目的 研究超声评价脊柱情况的影像学改变对胎儿闭合性脊柱裂的诊断及与病理诊断的一致性。方法 选择2017年1月至2021年12月在保定市第一中心医院收治的产检孕妇505例，年龄20～40岁，平均年龄30。59岁;孕周6-12周，平均孕周8。93周;身体质量指数21。72～32。98 kg/m2，平均身体质量指数27。35 kg/m2;初中及以下学历157例，中专或高中学历213例，大专及以上学历135例。根据分娩结局将胎儿分成正常组472例和闭合性脊柱裂组33例。使用四维超声和MRI等影像学技术评估胎儿脊柱发育情况，以病理诊断为金标准，评估二者对闭合性脊柱裂的诊断效能;单因素和多因素Logistic分析确定闭合性脊柱裂的影响因素。结果 33例闭合性脊柱裂胎儿均进行引产或剖宫产，所有胎儿的脊髓和脊柱都有不同程度的畸形。脊柱裂范围从骶椎到颈椎不等，其中21例胎儿的闭合性脊柱裂范围在腰椎以下，9例在胸椎以上，3例在腰椎到胸椎之间。所有胎儿的脊髓都有不同程度的损伤。超声显示:椎体变形、缺损等，经过胎儿脊柱冠状背面扫查，脊柱背侧椎弓呈现平行串珠状，为强回声，间距变宽;横切面表示，椎管外围由椎弓和椎体构成的闭合性三角形;包块型中有脊膜膨出、脂肪脊髓裂及脂肪脊髓脊膜膨出;无包块型中存在脊髓纵裂、尾端退化综合征、皮毛窦、终丝脂肪瘤和脊膜膨出合并脊髓纵裂。MRI:可清晰显示腰骶部畸形的各类形态，矢状位可清晰显示高信号，脊髓和脊膜向背部膨出;T1和T2为高信号，脊髓圆锥和背部软组织粘连，椎管突出和膨出。根据受试者工作特性(ROC)曲线，四维超声诊断的灵敏度为81。82％，特异度为87。71％，ROC曲线下面积(AUC)为0。814(95％ CI 0。735～0。893);MRI诊断的灵敏度为90。91％，特异度为 89。83％，AUC 为 0。877(95％ CI 0。817～0。937);联合诊断的灵敏度为 96。97％，特异度为 87。08％，AUC为0。908(95％ CI 0。867～0。948)，联合检测的灵敏度和AUC明显高于单独检测(P＜0。05)。两组孕妇身体质量指数、胎儿位置、羊水量、前置胎盘及双顶径、腹围和股骨长等指标差异有统计学意义(P＜0。05)。Logistic回归分析显示，胎儿位置[比值比(OR)=1。351，95％ CI 1。113～1。641]、前置胎盘(OR=1。575，95％ CI 1。058～2。344)、双顶径(OR=1。831，95％ CI 1。021～3。284)及孕妇身体质量指数(OR=1。504，95％ CI 1。229～1。840)等是闭合性脊柱裂的影响因素。结论 四维超声可应用于闭合性脊柱裂的预测和诊断，且联合MRI影像学可提高闭合性脊柱裂的阳性检出率，以达到优生优育的目的。
Consistency of imaging diagnosis and pathological findings of fetal closed spina bifida
Objective To investigate the imaging changes of ultrasound evaluation of spinal conditions for the diagnosis of fe-tal closed spina bifida and its consistency with pathological diagnosis.Methods From January 2017 to December 2021,a to-tal of 505 pregnant women were enrolled,which aged 20-40 years old with mean age of 30.59 years old;gestational age was 6-12 weeks with mean of 8.93 weeks;body mass index(BMI)was 21.72-32.98 kg/m2 with mean BMI of 27.35 kg/m2.There were 157 cases with junior high school or below education,213 with secondary school or high school,and 135 cases with college or above.According to outcome of delivery,the fetuses were divided into normal group(n=472)and closed spina bifida group(n=33).The fetal spinal development was assessed using imaging techniques of four-dimensional ultra-sound and magnetic resonance imaging(MRI).The pathological diagnosis was used as the gold standard to evaluate diagnostic efficacy of the two methods in diagnosis of closed spina bifida,the univariate and multivariate Logistic analysis were used to determine the influencing factors of closed spina bifida.Results A total of 33 cases of closed spina bifida fetus underwent in-duced labor or cesarean section,all fetal spinal cord and spine showed different degrees of deformity.The extent of spina bifida ranged from sacral to cervical spine,with 21 cases below lumbar spine,9 above thoracic spine,and 3 between lumbar spine and thoracic spine,and all fetal spinal cords with different degrees of damage.The ultrasound images showed vertebral deformation and defect.The coronal back scan results of the spine showed that the dorsal vertebral arch of spine were parallel beaded with strong echo,and the spacing became wider.The transverse section showed that periphery of spinal canal was composed of verte-bral arch and vertebral body to form closed triangle.In mass type,there were meningocele,fat spinal cord fissure and fat spinal cord meningeal;in non-mass type,there were diastematomyelia,caudal degeneration syndrome,pilonidal sinus,filum terminale lipoma and meningocele combined with diastematomyelia.MRI results clearly showed various forms of lumbosacral deformity,sagittal clearly showed high signal,spinal cord and meninges bulged to back;T1 and T2 showed high signal,spinal cord cone and back soft tissue adhesion,spinal canal was protruded and bulged.According to receiver operating characteristic(ROC)curve,the sensitivity of four-dimensional ultrasound was 81.82％,specificity was 87.71％,the area under ROC curve(AUC)was 0.814[95％ confidence interval(CI)0.735-0.893].The sensitivity of MRI was 90.91％,specificity was 89.83％,and AUC was 0.877(95％ CI 0.817-0.937).The sensitivity of parallel combined detection was 96.97％,specificity was 87.08％,and AUC was 0.908(95％ CI 0.867-0.948).The sensitivity and AUC of combined detection were significantly higher than those of sin-gle detection(P＜0.05).There were significant differences in maternal BMI,fetal position,amniotic fluid volume,placenta previa and biparietal diameter,abdominal circumference and femur length between 2 groups(P＜0.05).Logistic regression analysis showed that fetal position[odds ratio(OR)=1.351,95％ CI 1.113-1.641],placenta previa(OR=1.575,95％ CI 1.058-2.344),biparietal diameter(OR=1.831,95％ CI 1.021-3.284)and maternal BMI(OR=1.504,95％ CI 1.229-1.840)were the influenc-ing factors of closed spina bifida.Conclusion It is demonstrated that four-dimensional ultrasound diagnosis could be used in prediction and diagnosis of spina bifida occulta,and combined with MRI may improve the positive detection rate,so as to achieve the role of eugenics.
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