脊柱腫瘤的影像學診斷課件

脊柱腫瘤的影像學診斷1脊柱腫瘤的影像學診斷1脊柱腫瘤的影像學診斷脊柱大體解剖脊柱檢查技術脊柱影像解剖脊柱良性腫瘤和腫瘤樣病變脊柱惡性腫瘤2脊柱腫瘤的影像學診斷脊柱大體解剖2脊柱大體解剖3脊柱大體解剖3頸段：7個頸椎胸段：12個胸椎腰段：5個腰椎骶段：5個骶椎尾段：4個尾骨椎間盤、椎間關節(jié)、椎旁韌帶等胸段4頸段：7個頸椎胸段4椎骨:椎體、椎弓和7個骨性突起組成椎弓:椎板、椎弓根，相鄰椎弓根間構成椎間孔椎管:各椎骨的椎孔共同連成頸椎環(huán)椎:前后弓及兩側塊樞椎:齒狀突、椎體及棘突第3至第7椎體：逐漸增大，椎孔三角形，椎間關節(jié)面近呈水平位，鉤椎關節(jié)（Luscka關節(jié)）胸椎：逐漸增大，椎孔心形，關節(jié)突關節(jié)面呈冠狀位腰椎：椎體逐漸增大，椎孔呈三角形，關節(jié)突關節(jié)面呈矢狀位骶骨：骶骨倒立扁三角形，5個骶椎融合而成尾骨:4個尾椎融合而成

骨性椎管的特點5椎骨:椎體、椎弓和7個骨性突起組成骨性椎管的特點5

骨間連接椎體間連接前縱韌帶、后縱韌帶、椎間盤

椎板及附件間連接黃韌帶、棘間韌帶、棘上韌帶、項韌帶橫突間韌帶、關節(jié)突關節(jié)環(huán)樞關節(jié)、環(huán)椎橫韌帶6骨間連接椎體間連接6posteriorAnterior7posteriorAnterior7RlateralLlateral8RlateralLlateral8C1-29C1-29C3-710C3-710T11T11L12L12SCo13SCo1314141515檢查技術

ExaminationMethods16檢查技術ExaminationMethods16檢查技術常規(guī)X線:最主要和首選的檢查方法

CT:解決臨床和X線診斷疑難的第二步檢查方法MRI:示X線甚至CT不能顯示和顯示不佳的某些組織結構核素掃描:一種全身骨骼檢查，但缺乏特異性17檢查技術常規(guī)X線:最主要和首選的檢查方法17影像解剖

RadiologicAnatomy18影像解剖RadiologicAnatomy18常規(guī)X線

C19常規(guī)X線C19T20T20LA-PLateral21LA-PLateral21L-oblique22L-oblique22CT解剖T重建23CT解剖T重建23LCT解剖24LCT解剖24MRI解剖C25MRI解剖C25

脊柱良性腫瘤和腫瘤樣病變

BenignSpinalTumorandTumorlikeLesion26脊柱良性腫瘤和腫瘤樣病變BenignSpinal脊柱良性腫瘤和腫瘤樣病變骨血管瘤骨軟骨瘤骨巨細胞瘤骨樣骨瘤骨母細胞瘤動脈瘤樣骨囊腫骨嗜酸性肉芽腫內生骨疣其它：軟骨黏液樣纖維瘤、纖維骨瘤、血管外皮細胞瘤和血管內皮細胞瘤等27脊柱良性腫瘤和腫瘤樣病變骨血管瘤27骨血管瘤Hemangioma28骨血管瘤Hemangioma28骨血管瘤臨床病理

最常見的脊柱原發(fā)良性腫瘤低血壓慢血流血管組成，摻雜于骨小梁和脂肪間，易出血病理上分毛細血管型和海綿狀血管型多胸椎椎體,多單椎體病變任何年齡均可發(fā)生，一般無癥狀，多女性對放射線有相當的敏感性29骨血管瘤臨床病理最常見的脊柱原發(fā)良性腫瘤29骨血管瘤影像表現X線一為受累骨體積擴張，骨小梁廣泛的吸收、增生和增厚，椎體呈柵欄狀特征性表現一為受累骨質有肥皂泡沫樣的破壞和擴張30骨血管瘤影像表現X線30骨血管瘤影像表現

CT椎體部分或全部松質骨密度減低病變區(qū)骨小梁減少，變粗致密冠狀面或矢狀面重建顯示柵欄狀表現增強掃描，病變常不強化或輕度強化

MRIT1WI和T2WI上均呈高信號增強掃描，中度至明顯強化31骨血管瘤影像表現CT31Plainfilm

CTT骨血管瘤32PlainfilmCTT骨血管瘤32T骨血管瘤33T骨血管瘤33Fig.Athickenedtrabeculae(corduroysign)ofavertebralbodyhemangiomacanbeseenonthislateralview,whichisconeddowntotheL2vertebralbodyFig.BT1WIandFig.CT2WIshowthetypicalincreasedsignalintensityofavertebralbody

ABC骨血管瘤34Fig.Athickenedtrabeculae(c骨軟骨瘤Osteochondroma35骨軟骨瘤Osteochondroma35臨床病理由骨質組成的基底和瘤體、透明軟骨組成的帽蓋和纖維組成的包膜三種不同組織構成,又稱外生骨疣發(fā)生于脊椎少見，發(fā)生于脊柱單發(fā)1.3～1.4%，多發(fā)者9%約50%于頸椎，其次胸椎及腰椎;常見于附件兒童期生長緩慢，青春期迅速近1％病人的骨軟骨瘤發(fā)生惡變多兒童和青年男性，一般無癥狀治療應徹底手術切除骨軟骨瘤36臨床病理由骨質組成的基底和瘤體、透明軟骨組成的帽蓋和骨軟骨瘤影像表現X線僅21%的起于棘突的較大病變被明確診斷小病變和突入椎管內的腫瘤很難診斷15%顯示正常37骨軟骨瘤影像表現X線37骨軟骨瘤影像表現CT附件骨性腫塊，皮質與椎板皮質相連可伴脊髓受壓

MRI病灶中心T1WI呈高信號，T2WI呈中等信號邊緣皮質均呈低信號軟骨帽常既薄又小，T1WI呈低至中等信號，T2WI呈高信號成人如軟骨帽明顯增厚（大于1-2cm）則應懷疑惡變38骨軟骨瘤影像表現CT3838,yr,Mof

CHereditarymultipleexostosiswithseveralspinalosteochondromasFigA:LateralradiographofthecervicalspineshowsaC-4spinousprocessosteochondromawithpathognomonicmarrowandcorticalcontinuitysolidarrow).OsteochondromaatC-1isseenasanossifiedregion(openrrow)AxialFigBandsagittalFigCreconstructedCTscansrevealcortexandmarrowoftheosteochondroma(arrows),impingementonthespinalcanal,extrinsicerosionofC-2(arrowheadsinb),andcontinuitywiththeC-1spinousprocess(*inc).ABC骨軟骨瘤3938,yr,MofCHereditarymultiSagittalT1-weightedFigDandT2*gradient-echoFigEMRimagesrevealthesignalintensitycharacteristicofyellowmarrowwithintheosteochondromaandtheimpressionofthetumoronthespinalcanal(arrows),althoughthemarrowandcorticalcontinuityisnotwellseen.骨軟骨瘤DE40SagittalT1-weightedFigDandTFigF:

Photographofthegrossspecimenshowsthemarrowandcortexoftheosteochondromaandasmallcartilagecapatitsperiphery(arrowheads).

41FigF:Photographofthegross35yr，FOsteochondromaofsacrummalignanttransformationFigAVaguesclerosis(solidarrows)overtheleftsacrumandwideningofthesacroiliacjoint(openarrow).FigA4235yr，FFigAFigA42FigCAxialCTscanshowsthethickcartilagecap(arrows)andsacroiliacjointinvasion,whichrepresentsmalignanttransformation.FigB

CoronalreconstructedCTscanshowsthecortexandmarrowcanaloftheosteochondroma(arrows)andcontinuitywiththesacrum(arrowheads).FigBFigC43FigCAxialCTscanshowsthethmultiplehereditaryexostoses.Notethatthelargesacrallesionhasnormalcortexaswellasmarrowarisingfromtheunderlyingbone.Thisappearancedefinesanexostosis.Welookforathickcartilagecaptosuggestdegenerationofanexostosistoachondrosarcoma.Inthiscase,thereisnospaceforathickcapbecausetheedgeoftheexostosisextendstothesubcutaneoustissue.Ifthereisanyquestion,MRimagingcandemonstratethecartilagethickness.Inthiscase,werecognizedmultipleexostosesbecauseofthepresenceofsessilelesionsattheanteriorsuperioriliacspines.10,yr,MMultiplehereditaryexostoses44multiplehereditaryexostoses.骨巨細胞瘤GiantCellTumor,GCT45骨巨細胞瘤GiantCellTumor,GCT45骨巨細胞瘤臨床病理由軟而脆且易出血的肉芽樣組織所構成，無纖維包膜，可出血和壞死組織學分三級：Ⅰ級為良性，Ⅱ級為過渡類型，Ⅲ級為惡性患者多女性，發(fā)病年齡多20-40歲約1/3發(fā)生于脊柱，最常累及骶骨，其次為胸椎、頸椎和腰椎；多見于附件絕大多數為良性，約25%為惡性臨床癥狀主要為局部疼痛、無力和感覺異常治療多全切治療，若僅刮除術會出現40-60%％復發(fā)46骨巨細胞瘤臨床病理由軟而脆且易出血的肉芽樣組織所構成，無骨巨細胞瘤影像表現X線典型呈膨脹性偏心性多房性骨質破壞，骨殼較薄，輪廓一般完整，內見纖細骨嵴構成分房狀幾點提示惡性a，較明顯的侵襲性表現b，骨膜增生顯著c，軟組織腫塊較大，患者年齡較大，疼痛持續(xù)加重，腫瘤突然生長迅速47骨巨細胞瘤影像表現X線47骨巨細胞瘤影像表現CT椎體局限性膨脹性溶骨性破壞,皮質連續(xù)若為侵襲性可侵犯數個椎體椎弓椎間盤，皮質破壞，軟組織腫塊形成發(fā)生于骶骨時，一般位于骶髂關節(jié)附近，皮質可中斷增強掃描低密度區(qū)散在強化MRIT1WI上呈低、中等信號；T2WI上呈不均勻中等信號?？梢娋植砍鲅盘栐鰪姾竺黠@強化核素掃描顯示腫瘤呈彌漫性的濃聚48骨巨細胞瘤影像表現CT48FigAandFigB

alargeexpansilelesionoftheT-4vertebralbody(arrows),withextensionintotheposteriorelementsofT-3andT-4andtheposteriorsofttissues(arrowheads).Thelesionenhancesmarkedlywiththecontrastagent.

FigCthelesionhasonlyintermediatesignalintensity,28,yr,FGCTofT-3andT-4Sag.T1WIAxi.T1WI+cSag.T2WIACBT4骨巨細胞瘤49FigAandFigBalargeexpansIntraoperativephotographobtainedafterincisionoftheskinshowsabulging,solidparaspinalmass(*)

FigD骨巨細胞瘤50IntraoperativeFigD骨巨細胞瘤50sacralGCT.A-PLateraLFigAFigb51sacralGCT.A-PLateraLFigAFigAxialCTSag.T2WI

soft-tissueextension.Cor.T2WIFigCFigDFigEFigF骨巨細胞瘤52AxialCTSag.T2WIsoft-tissueeGCTofS4-521yr,FA-PLateraLAB骨巨細胞瘤53GCTofS4-521yr,FA-PLateraLAFigC:CTshowing

largemassofSFigD:demonstratinganinhomogeneousmassthatcontainsseveralareasoflowsignalintensity(arrows;contrastthissignaltotheveryhighsignalintensityFigE:revealingthatthelesionisoflowsignalintensity;thelargepresacralmassdisplacingtherectumisconfirmed.FigF:revealingonlymildenhancement,againwithseveralareasofrelativelylowsignalintensity.Theselow-signalregionsrepresentacommonfeatureinGCTsCDEFAxialCTSag.T1WIAxi.FSET2WISag.FST1WI+C骨巨細胞瘤54FigC:CTshowinglargemassofSUpperLeft:Anteroposteriorradiographemonstratingtheexpandedlyticlesionccupyingthesacrum.UpperRightandCenterLeft:AxialCTscansobtainedseveralmonthslater,demonstratingtheratherfeaturelesslyticlesionoccupyingtheentiresacrum,withattemptedthincorticalrimunabletocontaintheexpansivelesion.CenterRight:SagittalT1-weightedMRimage(TR/TE450/10msec)demonstratingintensitypresacralsoft-tissueextensionLowerLeftandRight:SagittalT2WIandaxialFSET2WIrevealingtheinhomogeneousmixedhighandlowsignalintensitymass,typicalofGCT.

26,yr,FGCTofthesacrum.骨巨細胞瘤55UpperLeft:AnteroposteriorraGCTofC-7

posteriorelements

16ymale骨巨細胞瘤56GCTofC-7posteriorelementsTI

骨巨細胞瘤57TI骨巨細胞瘤57骨樣骨瘤OsteoidOsteoma58骨樣骨瘤OsteoidOsteoma58骨樣骨瘤

臨床病理由成骨性纖維組織及骨樣組織、編織骨構成，腫瘤本身為瘤巢直徑約1.5cm，很少超過2厘米,周圍由增生致密的反應性骨質包繞

10%發(fā)生于脊柱，多腰椎，最常起于椎弓，其次椎板，小關節(jié)面和椎弓根單發(fā)性，腫瘤發(fā)展極慢多為青少年和成年人，多男性，多小于30歲患骨疼痛，夜間加重，服用水楊酸類藥物可緩解為其特點?；颊咭蚣∪獐d攣而引起側彎治療以用手術切除最為適宜,預后良好59骨樣骨瘤臨床病理由成骨性纖維組織及骨樣組織、編織骨構成，骨樣骨瘤影像表現X線腫瘤所在部位骨質破壞周圍不同程度的反應性骨硬化偶見內鈣化/骨化分皮質型、松質型、骨膜下型60骨樣骨瘤影像表現X線60骨樣骨瘤影像表現CT類圓形的低密度骨破壞區(qū)，中央見不規(guī)則的鈣化骨化影周圍不同程度的反應性骨硬化環(huán)MRI腫瘤未鈣化部分T1WI呈低至中等信號，T2WI呈高信號鈣化及周圍硬化帶均呈低信號增強后，病變強化明顯。核素掃描腫瘤顯示明顯核素濃聚61骨樣骨瘤影像表現CT61FigA:Radiographrevealsasubtlelucentarea(arrow)inarightarticularmass.FigB:CTscanshowsthenidus(largearrowheads)withasmallcentralareaofcalcification(smallarrowhead)andminimalsurroundingsclerosis.FigC:Radiographoftheresectedspecimenshowsthattheniduswasentirelyremoved(arrows).FigD:Posteriorbonescanshowsintenseuptakeoftheradionuclidebythenidus(arrow)

17,yr,MOsteoidosteomaoflaminaatT-11ABCD骨樣骨瘤瘤巢62FigA:RadiographrevealsasubFigE:Photographofthegrossspecimenrevealsthenidus(*)extendingtothefacetcartilage(arrows)骨樣骨瘤瘤巢63FigE:PhotographofthegrossAxialCTscan(left)revealingthatatumorarisingfromtheleftC-5pedicleiscompressingtheleftC-5root.Bonescan(center)displayshighuptakeofcontrastmaterial.AxialCTscan(right)demonstratingthatlefthemilaminectomywassufficienttoremovethetumor.16,yr,MOsteoidosteomaoflaminaatC-5骨樣骨瘤64AxialCTscan(left)revealing骨母細胞瘤Osteoblastoma65骨母細胞瘤Osteoblastoma65骨母細胞瘤臨床病理多量骨母細胞增生形成骨樣組織和編織骨為特點。典型病變直徑為1.5cm～2cm不等腫瘤境界清楚，血管豐富，腫瘤體積較大時出現囊變，合并動脈瘤樣骨囊腫時則多數含血囊腔。少數腫瘤可發(fā)生惡變約30～40%發(fā)生于脊柱,頸椎、胸椎和腰椎發(fā)病率相近,腫瘤常累及附件男性多于女性，男:女＝2:1，發(fā)病年齡90%20～30歲患骨局部疼痛不適，脊髓和神經壓迫癥狀。水楊酸類藥物無緩解和無明顯夜間疼痛與骨樣骨瘤鑒別。治療應手術切除，病變復發(fā)率為10-15%66骨母細胞瘤臨床病理多量骨母細胞增生形成骨樣組織和編織骨為骨母細胞瘤影像表現X線三種表現a：中心低密度破壞區(qū)，周圍骨硬化，病灶直徑大于1.5cmb：有多發(fā)小鈣化的膨脹性破壞，周圍伴硬化緣c：為侵襲性表現，骨膨脹破壞，及周圍軟組織浸潤和混雜性鈣化67骨母細胞瘤影像表現X線67骨母細胞瘤影像表現CT對腫瘤內鈣/骨化影顯示高于平片,尤其對復雜部位腫瘤顯示較好類圓形膨脹性骨質破壞，周圍有不同程度增生硬化破壞區(qū)骨殼可中斷,周圍軟組織可局限性腫脹MRI非鈣/骨化部分T1WI呈低至中等信號,T2WI呈高信號,鈣/骨化部分呈低信號病灶周圍骨髓和軟組織反應性充血水腫，為長T1長T2信號可顯示骨殼中斷，椎管內延伸和脊髓受壓合并動脈瘤樣骨囊腫時可見囊腔及液液平面

核素掃描腫瘤顯示明顯核素濃聚

68骨母細胞瘤影像表現CT68Fig.Ashowsamarkedlyexpansilelesioninvolvingthespinousprocessandlaminae(arrows),withvaguesclerosissuggestiveofmineralization.Fig.BCTscanrevealsthemarkedexpansionofthelesion,whichhasadefinedscleroticrim(arrows),anditsencroachmentonthespinalcanal.Matrixmineralization(arrowheads),16,yr,M.osteoblastoma

of

C-3

Fig.ALradiographFig.BCT骨母細胞瘤69Fig.AshowsamarkedlyexpansilAxi.T1WIFigC

andSag.T2WI

FigD

showthemass(arrows)anditsdegreeofencroachmentonthespinalcanal(arrowheadsinc).Becauseofitsextensivemineralization,themasshasrelativelylowsignalintensityontheT2-weightedimage.

Axi.T1WISag.T2WIFigCFigD:骨母細胞瘤70Axi.T1WIFigCandSag.T2WIFFigE骨母細胞瘤71FigE骨母細胞瘤71FigA:CTscanshowsadestructive,expansilelesionoftheleftlateralsideofC-1(arrows)withsmallfociofmineralizedmatrixperipherally(arrowheads)andinvasionofthesurroundingsofttissuesandforamentransversarium.FigB:CoronalT2-weightedMRimageshowshighsignalintensitywithinthemass(arrows).FigC:Digitalsubtractionangiogramrevealstumorstain(straightarrows)andobstructionoftheleftvertebralartery(curvedarrow).

9,yr,M.Aggressive

osteoblastomaof

C1ABC骨母細胞瘤

(侵襲性)CTMRIDSA72FigA:CTscanshowsadestructLeft:AnteroposteriorradiographrevealingasubtlyexpandedlesionthatisnearthemidlineatS4-5(arrows).Right:AxialCTscandemonstratingbonematrixwithinthelesion,notaggressiveinappearance.16,yr,Mosteoblastoma

of

S4-5

骨母細胞瘤73Left:AnteroposteriorradiograLeft:

bonescanrevealinganeccentricallylocatedareaofincreaseduptakeinthesacrum.Right:

TheCTscandemonstratesaminimallyexpandedlesioncontainingdensebonematrixintherightsideofthelowersacrum.16,yr,M.osteoblastoma

of

S4-5

骨母細胞瘤74Left:bonescanrevealinganeLateralx-rayfilms(a)showedasoft-tissueswellingintheretropharyngealspace.Lateral(b)andcoronal(c)MRimagesdemonstratingtumorintheC-2bodyandasoft-tissuemassfromC1–6.AxialCTscan(d)demonstratingatypicalosteoidniduswithperitumoralscleroticrimontherightsideoftheC-2body.Technetiumbonescan(e)alsodisplayspronounceduptakeinthisregion.Weperformedtumorexcisionviaananterolateralretropharyngealapproach(f)occipitocervicalfixationbyusingtwoaxisplatesandtitaniumwires(g).

Lateralx-rayfilmsobtainedimmediatelyafter(h)and2yearspostsurgery(i)showingsolidfusion.10,yr,Mosteoblastoma

of

C2

骨母細胞瘤75Lateralx-rayfilms(a)showed動脈瘤樣骨囊腫AneurysmalBoneCyst,ABC76動脈瘤樣骨囊腫AneurysmalBoneCyst,A動脈瘤樣骨囊腫臨床病理原因不明的腫瘤樣病變，分原發(fā)和繼發(fā)兩種病變由大小不等的海綿狀血池組成，外壁為薄壁囊狀骨殼繼發(fā)者發(fā)生原有病變基礎上，包括骨巨細胞瘤、骨母細胞瘤、軟骨母細胞瘤和骨肉瘤等好發(fā)于青少年，多10～20歲，女性略多脊柱占12-30％，胸椎最常受累，其次腰椎和頸椎，骶骨罕見；病變位于椎弓及其突起臨床癥狀主要為病變侵犯椎管引起相應部位疼痛和神經壓迫癥狀可行刮除植骨術，還可栓塞治療和放療；總的復發(fā)率為20-30%。

77動脈瘤樣骨囊腫臨床病理原因不明的腫瘤樣病變，分原發(fā)和繼發(fā)動脈瘤樣骨囊腫影像表現X線典型表現為脊柱附件骨顯著膨脹的囊狀透亮區(qū)，外側為薄的骨殼，呈“氣球狀”囊內有或粗或細的骨小梁狀分隔或骨嵴78動脈瘤樣骨囊腫影像表現X線78動脈瘤樣骨囊腫影像表現CT多呈囊狀膨脹性骨破壞，骨殼菲薄軟組織密度腫塊內見斑片樣、條索狀及不定形鈣化，邊緣可有硬化有時可見液液平面，下部密度高于上部，隨體位而改變。MRI檢出液－液平面更敏感液－液平面是本病的重要特點，T2WI上層一般為高信號，可能為漿液或高鐵血紅蛋白，下層為低信號，可能有含鐵血黃素成分。核素掃描常表現為外周部位的核素攝取增加，呈“油炸圈餅”征79動脈瘤樣骨囊腫影像表現CT79Fig.A

andafterFig.B

administrationofgadopentetatedimegluminerevealamarkedlyexpansilelesioninvolvingthelaminaeofT-3(largearrowheads)andencroachingonthespinalcanal(smallarrowheads).Enhancementoccurslargelyintheperipheryandseptationsofthelesion.Fig.C

SagittalT2-weightedMRimageshowsthattheentirelesioncontainsfluid-fluidlevels(arrows)resultingfromhemorrhagicspacesandshowstheextentofspinalcanalnarrowing.8yr,MABCofT3ABC動脈瘤樣骨囊腫T1WIC+T1WIT2WI液-液平面(血竇)80Fig.AandafterFig.BadministPhotographofthesagittallysectionedgrossspecimendemonstratesthemultipleblood-filledspaces(arrows)inthelesion.Fig.D血竇動脈瘤樣骨囊腫81PhotographofthesagittallysFig.A

TheanteroposteriorradiographcanbeeasilymisreadasnormalbecauseoftheoverlyingbowelgasobscuringthesacrumFig.B

AlateralradiographdemonstratesonlyobscurationoftheS-3posteriorelements(arrows)Fig.CThelesionismorereadilyseenontheCTscanobtainedwiththepatientinaproneposition.ThisscandemonstratesalyticlesionoccupyingtheleftS-3ala,withathincorticalrimsurroundingthemajorityofthelesion.Notethatthemorelucentregionsinthecenterofthelesionactuallyrepresentfluidlevels.Fig.DFluidlevels(shortarrow)aremorereadilyobservedonasagittalT1-weightedMRimage;rememberthatthepatientissupineintheimagerandthatthefluidlevelsonthesagittalexamwouldthenbeexpectedtoappearvertical,asinthiscase.Thehighsignalintensityportionofthefluidisblood.Most,butnotall,ABCscontainfluidlevels.Conversely,mostlesionswithsubstantialfluidlevelsareABCs,butsuchlevelsmayoccurinotherlesionsaswell.Notealsointhiscasethatthereisasubstantialcomponentofthelesionlocatedanteriorlytothefluidlevelsthatissolid(longarrows).

14,yr,MABCofSADCB液-液平面(血竇)動脈瘤樣骨囊腫82Fig.ATheanteroposteriorradineurysmalBoneCystFig.AComputedtomographicscanshowingalyticlesionintheposteriorelementsofthevertebraeattheT10-T12level,withexpansiontothevertebralbodyfromtheleft.Thisprocesswithathinperiostealborderentersthespinalcanal,pressingthecordforwardandtotheright

Fig.BMagneticresonanceimagingafterinjectionwithgadoliniumshowsanonhomogeneousmultilobularlesionatT10-T12level,extradurallypressingthespinalcordforwardandtotheright,destroyingthepedicleandthelaminaofthevertebra.

Fig.AFig.B動脈瘤樣骨囊腫T1WIC+83Fig.AComputedtomographicsca骨嗜酸性肉芽腫EosinophilicGranuloma84骨嗜酸性肉芽腫EosinophilicGranuloma8骨嗜酸性肉芽腫臨床病理本病屬網狀內皮系統(tǒng)類脂質沉積病，稱朗罕氏細胞組織細胞?。↙angerhanscellhistiocytosis）包括三種病變：勒－雪病、韓－薛－柯病和嗜酸性肉芽腫。其孤立形式為嗜酸性肉芽腫，為良性局限性組織細胞增生，為最輕型。椎體為主要原發(fā)部位，多單發(fā)，可多發(fā)。肉芽組織位于骨髓腔伴出血壞死和囊變；晚期常有結締組織增生，纖維化骨化好發(fā)于兒童及青年，男多于女患部輕微疼痛，壓痛，伴有功能障礙治療方案：保守治療、固定、刮除、瘤內注射激素，放療和切除等85骨嗜酸性肉芽腫臨床病理本病屬網狀內皮系統(tǒng)類脂質沉積病，稱骨嗜酸性肉芽腫影像表現生長迅速的溶骨性病變，常導致椎體變扁和硬化，稱扁平椎。平片即可容易診斷，CT及MRI對確定病變范圍很有幫助病變延伸到周圍軟組織時，CT及MRI不典型，需組織學證實86骨嗜酸性肉芽腫影像表現生長迅速的溶骨性病變，常導致椎體vertebraplanacanbeseen(arrow)inthethoracicspine,whichisconsistentwithLangerhan'scellhistiocytosis.8,yr,Mof

T扁平椎骨嗜酸性肉芽腫87vertebraplanacanbeseen(ar內生骨疣Enostosis88內生骨疣Enostosis88內生骨疣臨床病理內生骨疣通常指骨島，也稱鈣化性骨髓缺損、內生骨瘤組織學上骨疣為板層骨，哈佛氏系統(tǒng)包埋在髓管內。病變較出生時進展，并被認為也會產生損害的病變。好發(fā)于中軸骨傾向，特別是骨盆、脊柱和肋骨。脊柱骨島發(fā)生率僅1%。尸檢14%脊柱內生骨疣好發(fā)于胸椎(T1～T7)和腰椎（L2和L3），胸椎病變常位于中線右側，而腰椎常位于中線左側。病變常位于皮質下，其周圍常常伴有放射狀骨針。病變大小約2mmX2mm到6mmX10mm，大于2cm為巨大內生骨疣常無癥狀，偶然發(fā)現89內生骨疣臨床病理內生骨疣通常指骨島，也稱鈣化性骨髓缺損、內生骨疣影像表現X線平片和CT常具有特征性表現，為圓形或橢圓形成骨性病變，邊界清楚,邊緣呈“棘狀放射”征或“毛刷狀邊緣”。周圍骨小梁正常MRI在各序列均為低信號，棘狀邊緣顯示清楚。周圍骨髓信號正常核素掃描絕大多數內生骨疣顯示為正常，無異常放射性核素濃聚。少數出現濃聚的病變通常為巨大內生骨疣，占33％病變自然病史不同，絕大多數病變變化不大，部分可緩慢生長或體積減小（31.9％）。6個月內病變直徑增加25%或1年內50%時應考慮該病90內生骨疣影像表現X線平片和CT90Fig.ALateralradiographshowsascleroticfocusintheanteriorportionofL-3(arrowhead).Fig.BCTscanrevealsadenselyscleroticlesionwithanirregularspiculatedborderjustbeneaththeanteriorcortextotheleftofmidline(arrowheads)66-yr-oldMEnostosisofL-3Fig.AFig.B內生骨疣毛刷狀邊緣91Fig.ALateralradiographshowsFig.ALateralradiographrevealsascleroticfocus(largearrows)withareasofspiculatedthornlikemargins(smallarrows).Fig.BPhotomicrograph(originalmagnification,X150;hematoxylin-eosinstain)showscorticalbone(arrows)withirregularmargins(arrowheads).35-yr-oldFGiantenostosisofL-2Fig.BFig.B92Fig.ALateralradiographrevea脊柱惡性腫瘤MalignantTumor93脊柱惡性腫瘤MalignantTumor93脊柱惡性腫瘤脊索瘤轉移性骨腫瘤骨髓瘤軟骨肉瘤骨肉瘤未分化網狀細胞肉瘤和PNET淋巴瘤白血病綠色瘤其它：間質軟骨肉瘤、纖維肉瘤均罕見94脊柱惡性腫瘤脊索瘤94脊索瘤

Chordoma95脊索瘤Chordoma95脊索瘤

臨床病理少見，起源于脊索殘余，占骨病變不到4%50%于骶骨（主要S4-S5），其次35%斜坡，15%椎體（主要C2）.也為骶骨最常見的原發(fā)骨腫瘤

腫瘤呈分葉狀，有纖維假包膜，內含灰白或淺黃色膠狀物；可出血、假囊腔以及肉芽樣組織腫瘤生長緩慢，局部侵襲性，不轉移,偶遠處轉移,主要為肺、淋巴結、蛛網膜下腔和脊髓多男性，男：女=2-3:1；30-60歲，高峰年齡50歲癥狀多由腫瘤擴大侵犯或壓迫鄰近重要組織或器官所引起治療以手術切除為主96脊索瘤臨床病理少見，起源于脊索殘余，占骨病變不到4%96脊索瘤影像表現X線腫瘤為溶骨性破壞，伴大的軟組織腫塊骶椎患骨常膨脹，瘤內50-70%見鈣化鈣化多無定形，位于病變周圍骶椎以上節(jié)段患骨較少膨脹改變，并可出現硬化呈“象牙椎”表現97脊索瘤影像表現X線97脊索瘤影像表現CT主要呈溶骨性破壞腫瘤分葉狀，囊實性混雜密度，可見不規(guī)則鈣化軟組織腫塊增強，輕至中度強化不易與轉移瘤鑒別98脊索瘤影像表現CT98脊索瘤影像表現MRT1WI：中等信號（占75%）

；低信號（占25%）T2WI：呈高信號，信號高于CSF增強：明顯強化MRI在顯示病變侵及的范圍方面優(yōu)于CTCT在確定腫瘤的性質特點方面優(yōu)于MRI99脊索瘤影像表現MR99Fig.ALateralradiographshowsdestructionofthedistalsacrumandcoccyxwithcalcification(arrow).Fig.BCTscanalsodemonstratesthebonedestructionandasoft-tissuemass(arrowheads)containingcalcifications(arrow)..Chordomaoflowersacrum48-year-oldmanFig.AFig.B脊索瘤100Fig.ALateralradiographshowsFig.CT1WISagittalandaxialT2WIFig.DMRimagesrevealtheexpansilesacrococcygeallesion(arrowheads),whichhashighsignalintensityonD.Fig.CFig.D脊索瘤101Fig.CT1WISagittalandaxialFig.E

Asseeninthissagittalsectionofthegrossspecimen,theMRimagingappearancecorrelateswiththeexpansilelesion(arrowheads)andcalcification(arrow).Theuppersacrum(*)isspared脊索瘤102Fig.EAsseeninthissagittalFig.ALateralradiographshowsadensevertebralbody(arrows)atL-3.Fig.BSagittalreconstructedCTscanobtainedafterinitialopenbiopsyrevealsnotonlytheL-3sclerosisbutalsosimilarfindingsinthesuperioraspectofL-4(arrowheads).ChordomaofL13-year-oldman1-yrhistoryofintermittentlowbackpain.Fig.AFig.B脊索瘤103Fig.ALateralradiographshowsSagittalT1WI

Fig.CandT2WIFig.DMRimagesbetterdelineatethemarrowinvolvementatL-3andL-4withextensionthroughthedisk(arrows).Themasshasmarkedhighsignalintensityond.Fig.CFig.D104SagittalT1WIFig.CandT2WIFigFig.Egrossspecimendepictstheextentoftheneoplasm,withdiffuseinvolvementofL-3(arrowheads),theadjacentdisk(*),andthesuperioraspectofL-4(arrows).Fig.E脊索瘤105Fig.EFig.E脊索瘤105UpperLeftandRight:AxialCTscansdemonstratingalargesoft-tissuemassextendinganteriorlytoinvolvetherectumandposteriorlytoinvadethebuttocks;calcificationisseenwithinthemass.

LowerLeftandRight:SagittalfastspinechoT2-weightedandaxialT2-weightedMRimagesdemonstratingthelesioninfiltratingthepresacralregion,extendingtosurroundtherectumandtheperivesicalfatbutnotinvadingthebladder.24-yrMchordomainvolvingS3-5脊索瘤106UpperLeftandRight:AxialCT

Fig.

AandB:PreoperativeaxialCTscanandMRimagerevealingasacralchordoma.Fig.

C:Photographofahemisectionofgrosspathologicalspecimendemonstratingcompleteenblockresectionofthesacrum.

Fig.DandE:Postoperativeanteroposteriorandlateralradiographs.Fig.脊索瘤107Fig.AandB:PreoperativeaxchordomaFig.AFig.B脊索瘤108chordomaFig.AFig.B脊索瘤108

轉移性骨腫瘤

SecondaryTumororMetastaticTumor109轉移性骨腫瘤SecondaryTumo臨床病理脊柱轉移常見轉移途徑主要是血行轉移，少數直接蔓延原發(fā)腫瘤常包括：前列腺癌、腎癌、甲狀腺癌、乳癌、肺癌和鼻咽癌等。骨肉瘤、尤文瘤和淋巴瘤也可發(fā)生骨轉移患者51～60歲最多臨床表現為疼痛、持續(xù)性、夜間加重?？沙霈F腫塊、病理骨折和壓迫癥狀治療可選用對原發(fā)瘤有效的化學治療(包括激素)和中藥治療，放療可試用于單發(fā)轉移轉移性骨腫瘤110臨床病理脊柱轉移常見轉移性骨腫瘤110轉移性骨腫瘤影像表現X線分為溶骨型、成骨型和混合型溶骨型：椎體廣泛或局限性骨質破壞，椎體常變扁，椎間隙多保持完整。椎弓根常受侵蝕破壞成骨型：少見。大多前列腺癌引起，少數為乳癌、鼻咽癌、肺癌和膀胱癌。呈斑片狀、結節(jié)狀高密度，位于松質骨內，邊界清楚或不清。骨皮質多完整，骨輪廓多無改變混合型轉移兼有溶骨型和成骨型轉移的骨質改變111轉移性骨腫瘤影像表現X線111轉移性骨腫瘤影像表現CT較X線敏感能顯示局部軟組織腫塊的范圍、大小及鄰近臟器的關系溶骨型為松質骨和或皮質骨的低密度缺損區(qū)，常伴軟組織腫塊成骨型為松質骨內斑點狀、片狀、棉團狀或結節(jié)狀邊緣模糊的高密度灶，一般無軟組織腫塊混合型兼有兩者改變MRI能檢出X線CT甚至核素顯像不易發(fā)現的病灶多數腫瘤T1WI呈低信號，T2WI呈程度不高的高信號脂肪抑制序列顯示更清楚112轉移性骨腫瘤影像表現CT112Magneticresonanceimagingstudyofthespineshowsadestructivelesioninthesecondlumbarvertebrawithextensionintothespinalcanal.Abdominalcomputedtomographicscanshowshepaticmetastasesandanirregularmassintheregionofthepancreas.

Fig.AFig.BFig.BFig.A113Magneticresonanceimagingstuscleroticmetastases114scleroticmetastases114Figure.SagittalT1-weightedMRimageofthelumbosacralspineshowsmultiplehypointensefociwithinthesacrumandlumbarvertebrae.TheselesionsremainedhypointensewithalloftheMRimagingsequencesanddidnotexhibitenhancement.Plainradiographyrevealedscleroticmetastases.77-yrFMetastaticbreastcancer115Figure.SagittalT1-weightedMFracture116Fracture116Fracturestenosis117Fracture117mass118mass118Extensiveosseousmetastasesfromlungcarcinoma.Anterior(left)andposterior(right)wholebodybonescintigramsshowmultiple,randomlydistributedfociofabnormalradiotraceruptake.Thefocivaryinsizeandintensity.119ExtensiveosseousmetastasesfFig.A:SagittalT2-weightedMRimagedemonstratinginvolvementoftheposteriorelementsofL-3(arrow).

Fig.B:AxialT1-weightedMRimagerevealingtheL-3spinousprocessandlaminainfiltratedbytumor,withanteriorstructuresintact(arrow).

Fig.E:Bonescandemonstratingnumerousadditionalsitesofmetastaticdisease(ribs,skull,andscapula)inadditiontoL-3(arrow).Thepatientunderwentsimpleposteriordecompression.

54-yrMmetastaticrenalcellcarcinomaABC120Fig.A:SagittalT2-weightedMSag.MRIofthelowerTandupperTare(A)hypointenseonT1WIand(B)hyperintenseonT2WI).OnDWEPI(C,bvalueof440sec/mm2;D,bvalueof880sec/mm2),thevertebralmetastasisandvertebralcompressionfracturesappearhyperintense.E,ADCmapshowsbothvertebralmetastasisandacutepathologicvertebralcompressionfractureswithlowADCs,whichindicatehindereddiffusionofwaterprotonsandthepathologicnatureofthesefindings.NotethehyperintensearealocatedcentrallyinthefractureofL1,whichpossiblyindicatesunhindereddiffusioninanareaofdebris.63-yrFwithbreastCa.MatL1(arrows)fracturesatT11-12(arrowheads)121Sag.MRIofthelowerTandupp50-yrFbreastcarcinomamastectomy5yrsearlier12250-yrFbreastcarcinomamastectLeft:PostoperativeplainnteroposteriorradiographobtainedafterT-2corpectomyandT1-3stabilizationperformedviaamediansternotomyapproach(notethesternalwires(arrow)Right:PostoperativeaxialCTscandemonstratinggoodspinaldecompression,structuraliliaccrestautograftstrut,andananteriorplate.62-yrMlargecellCaofthelung123Left:62-yrMlargecellCa123

NeuroimagesdemonstratingreconstructionafterC-4corpectomyforarenalcellmetastasis;stabilizationwasachievedusingatitaniummeshinterbodycageandchesttubeconstructfilledwithPMMA,supplementedbyananteriorcervicalplate.

Left:PreoperativeT2-weightedmagneticresonanceimage,sagittalview,revealingVBcollapseatC-4.Right:Postoperativecervicalx-rayfilm,lateralview.

124NeuroimagesdemonstratingrecFig.A

Preoperativeplainx-rayfilmshowingmarkeddestructionoftheC-3VBandassociatedkyphoticeformity.

Fig.B

Postoperativex-rayfilmshowingplacementoftheTPSdeviceintotheC-3corpectomydefect,restoringanteriorcolumnheight.

Fig.C

IllustrationsoftheTPSdevice.Theapparatusisexpandabletofitthesizeofthecorpectomydefectandcanbefilledwithboneautograftifdesired.SquamouscellcarcinomaofthelungmetastatictoC-3.ABC125Fig.APreoperativeplainx-ray骨髓瘤Myeloma126骨髓瘤Myeloma126骨髓瘤臨床病理骨髓瘤，又稱漿細胞瘤。起源于骨髓網織細胞的惡性腫瘤，為圓而脆軟的實質新生物椎體為其好發(fā)部位，絕大多數為多發(fā)；單發(fā)少見，且約1/3可轉變?yōu)槎喟l(fā)。晚期可廣泛轉移。老幼均可發(fā)病，40歲以上常見，男:女＝2:1表現為骨骼疼痛，軟組織腫塊，病理性骨折化學治療對多發(fā)性骨髓瘤具有一定療效；嚴重貧血者可輸血；截癱者施行椎板切除術；病理骨折者施用適當的外固定；疼痛嚴重者可施行放射線治療127骨髓瘤臨床病理骨髓瘤，又稱漿細胞瘤。起源于骨髓網織細胞的骨髓瘤影像表現X線廣泛性骨質疏松：脊柱有壓縮骨折。多發(fā)性骨質破壞：穿鑿狀、鼠咬狀骨質破壞，邊緣清楚，無硬化邊和骨膜反應骨質硬化：少見，又稱硬化型骨髓瘤。表現為單純硬化和/破壞與硬化并存。破壞區(qū)周圍有硬化緣，病變周圍有放射狀骨針及彌漫性多發(fā)性硬化。骨髓瘤治療后也可出現硬化軟組織腫塊：位于破壞區(qū)周圍，很少跨越椎間盤水平至鄰近椎旁平片約10%正常表現128骨髓瘤影像表現X線128骨髓瘤影像表現CT較X線平片更能早期顯示骨質細微破壞和骨質疏松典型表現為松質骨內呈彌漫性分布、邊緣清楚的溶骨性破壞區(qū)常見軟組織腫塊脊柱常病理性骨折，并硬膜外侵犯MRI對檢出病變、確定病變范圍非常敏感T1WI上，骨破壞區(qū)或骨髓浸潤區(qū)呈低信號?！敖符}狀”為特征性表現T2WI上呈高信號STIR序列病變高信號較T2WI更明顯129骨髓瘤影像表現CT129

Left:Anteroposteriorradiographrevealingahighlydestructivelyticlesioninvolvingboththeleftiliacwingandleftsacrum.Right:AxialCTscanconfirminginvolvementofbothofthesebones,aswellasamoderate-sizedsoft-tissuemass.Plasmacytomasmaybeverylargeandelicitnoosseousreaction,asinthiscase.Thiscasealsodemonstratesthepropensityofaggressivelesionstocrossthesacroiliacjoint.61-year-oldmanwithmultiplemyeloma.多發(fā)骨髓瘤130Left:AnteroposteriorradiogrLyticexpansilemassofC5.TransverseCTimageatlevelofC5showsexpansilesoft-tissuemassalongright