中枢脊柱教材讲义

CentralNervousSystem

南京医科大学一附院放射科洪汛宁hongxunning@2/3/20231脊柱和脊髓MRI组织分辨率高准确显示各解剖结构显示多种病理改变MRI多平面多参数成像MRI是诊断脊髓病变的最佳选择2/3/20232腰椎矢状位T1WI,T2WI2/3/202332/3/202342/3/20235正常影像表现脊椎和椎间盘椎管椎管内结构2/3/20236Normalanatomyoflumbarspine2/3/20237Spinalcanal脊椎腔Neuroforamen神经孔bonediscDuralsac2/3/20238脊髓病变椎管内肿瘤脊髓外伤脊柱脊髓先天畸形和发育障碍2/3/20239spinalcordneoplasmsIntramedullaryspinalcordneoplasmsarerare,accountingforabout4%－10%ofallcentralnervoussystemtumors.Despitetheirrarity,theselesionsareimportanttotheradiologistbecauseMRIisthepreoperativestudyofchoicetonarrowthedifferentialdiagnosisandguidesurgicalresection.2/3/202310椎管内肿瘤分类髓内肿瘤室管膜瘤星形胶质细胞瘤髓外硬膜内肿瘤神经鞘瘤、神经纤维瘤脊膜瘤硬膜外肿瘤转移瘤、淋巴瘤、脂肪瘤2/3/202311SnakeinHouseNormalAnatomy2/3/202312ThreeLocationsIntramedullaryIntraduralextramedullaryExtradural2/3/202313Intramedullary2/3/202314

IntraduralExtramedullary2/3/202315Extradural2/3/2023162/3/202317LEARNINGOBJECTIVESListtheessentialimagingfeaturesofintramedullaryspinalcordneoplasms.Identifythecharacteristicimagingappearancesofthedifferenttypesofintramedullaryspinalcordneoplasmsthatallowaspecificdiagnosistobefavored.2/3/202318ThreeImportantTenetsCordexpansionAtleastsomeenhancementCystsareacommonassociatedfindinginthesettingofanintramedullaryspinaltumor2/3/202319室管膜瘤Ependymoma占髓内肿瘤60%起源于脊髓中央管室管膜细胞或室管膜残留物好发部位：腰骶段、脊髓圆锥、终丝良性，呈膨胀性生长2/3/202320CT脊髓密度均匀性降低，不规则膨大边缘模糊，常见囊变轻度强化或不强化2/3/202321Intramedullary

astrocytomainan18-year-oldwomanwithprogressiveparesis,paresthesiaofthelowerextremities,anddifficultyvoiding.CTmyelogramshowsanear-competeblockofintrathecalcontrastmaterial(arrowheads)secondarytoanintramedullarymass.

2/3/202322MRI表现脊髓明显局限性增粗T1WI为均匀低信号T2WI为均匀高信号可发生出血、囊变或合并脊髓空洞增强后均匀强化，囊变区无强化2/3/202323Ependymoma2/3/202324Ependymoma2/3/202325Ependymoma2/3/202326Ependymoma2/3/202327Ependymoma2/3/202328星形细胞瘤Astrocytoma占髓内肿瘤40%，以胸颈段为多病变一般局限，可浸润生长脊髓增粗，与正常无明显界限2/3/202329CT平扫呈略低密度，少数高密度边界不清增强后强化不均一囊变常见2/3/202330MRIT1WI低信号T2WI高信号，由于水肿T2范围＞T1出血、坏死、囊变，信号不均实质部分明显强化2/3/202331A:irregularexpansionofthecervicalspinalcordextendingfromC3toC7(arrows),slightlyhypointense,expansionofthespinalcanal.B:abnormalareaofhighsignalintensitythroughouttheexpandedregion.

2/3/202332C:irregular,intense,homogeneousenhancementoftheinferiorportionoftheexpandedcord(arrows).D:Axialgradient-echoMRI,expansionofthecordwiththemasseccentricallylocatedalongitsrightmargin(arrows).

2/3/202333髓内转移瘤metastasis乳癌髓内转移2/3/202334Intramedullaryspinallymphoma.A：anill-definedregionofslightlyhighsignalintensity(arrows)inthemidthoracicspinalcord.B：abnormalhighsignalintensity(arrow)inthesameregion.Extensivecordedema(arrowheads)isalsoseen.

2/3/202335神经鞘瘤neurinoma最常见椎管内肿瘤髓外硬膜内肿瘤神经鞘瘤起源于神经鞘膜的雪旺细胞2/3/202336CT圆形实质性肿块，密度较脊髓略高，脊髓受压移位中等强化椎间孔扩大，椎弓根骨质吸收哑铃状2/3/202337MRI表现脊髓受压、移位、患侧蛛网膜下腔扩大边缘光滑、境界锐利的圆形、卵圆形或哑铃状肿块影多位于脊髓背侧T1WI低信号，T2WI为高信号可发生囊变、信号不均匀2/3/2023382/3/2023392/3/202340T1WI2/3/202341PDWIandT2WI2/3/2023422/3/202343脊膜瘤spinalmeningioma髓外硬膜内肿瘤，多位于胸段起源于蛛网膜细胞呈宽基底与硬脊膜粘连较紧2/3/202344CT胸段蛛网膜下腔后方实质性肿块，局限，椭圆形或圆形，有完整包膜中等率强化2/3/202345MRI表现病变处脊髓受压移位类圆形肿块，境界清楚T1WI呈低信号或等信号，T2WI呈高信号或等信号合并囊变或钙化，信号可不均匀显著强化，可出现脊膜尾征2/3/202346脊膜瘤spinalmeningioma2/3/202347脊膜瘤2/3/202348脊膜瘤矢状位MRI平扫、增强2/3/202349脊膜瘤2/3/202350脊髓外伤trauma非常严重损伤占0.2-0.5%车祸、工伤、运动、火器伤2/3/202351脊髓外伤脊柱损伤椎体骨折：正常结构丧失，椎体信号不均匀脊椎脱位：椎体前缘、椎管前缘及后缘的平滑连线中断2/3/202352脊髓损伤闭合损伤病理上分为：脊髓震荡、脊髓挫裂伤、脊髓压迫或横断、椎管内血肿脊髓挫裂伤示脊髓肿胀、膨大，信号混杂脊髓压迫示脊髓、硬膜囊受压变形，脊髓内出现水肿、坏死2/3/2023532/3/2023542/3/2023552/3/202356颈椎外伤骨折、椎间盘突出2/3/2023572/3/2023582/3/2023592/3/202360L3M/43AcuteburstfractureofL3,causingseverestenosisofspinalcanalX-rayCT3-D2/3/202361影像能改变治疗方法并改善

预后及疗效吗？2/3/2023622/3/2023632/3/2023642/3/2023652/3/2023662/3/2023672/3/2023682/3/202369C2、3椎体骨折伴脊髓横断伤2/3/202370C5、6术后，颈髓软化2/3/202371脊柱脊髓先天畸形和发育障碍脊膜膨出和脊髓脊膜膨出脊髓空洞征2/3/202372脊膜膨出meningocele和脊髓脊膜膨出meningomyelocele脊膜通过脊椎缺损部位向外呈囊袋状膨出脊髓脊膜膨出是脊髓、脊神经、马尾与囊壁粘连并同时突出于椎管外腰骶部最常见，颈椎次之2/3/202373腰骶部脊柱裂、脊膜膨出2/3/202374脊髓空洞症syringomyelia病理特征脊髓内出现空洞洞壁由增生的胶质组织构成交通性脊髓空洞症脊髓积水、空洞伴有Chiari畸形无肿瘤、外伤或蛛网膜炎伴有肿瘤的脊髓空洞症外伤后脊髓空洞症特发性脊髓空洞症2/3/202375交通性脊髓空洞症MRI表现空洞位于脊髓中央，呈管状囊腔空洞内见水样信号脊髓增粗，脊髓实质变薄2/3/