王嵩脊柱肿瘤的影像学诊断

脊柱肿瘤的影像学诊断Ø

上海中医药大学龙华医院放射科

王

嵩第一页，共一百五十九页。脊柱肿瘤的影像学诊断脊柱大体解剖脊柱检查技术脊柱影像解剖脊柱良性肿瘤和肿瘤样病变脊柱恶性肿瘤第二页，共一百五十九页。脊

柱Ø大体解剖第三页，共一百五十九页。颈段：7个颈椎胸段：12个胸椎腰段：5个腰椎骶段：5个骶椎尾段：4个尾骨

椎间盘、椎间关节、椎旁韧带等胸段第四页，共一百五十九页。椎骨:椎体、椎弓和7个骨性突起组成椎弓:椎板、椎弓根，相邻椎弓根间构成椎间孔椎管:各椎骨的椎孔共同连成颈椎F

环椎:前后弓及两侧块F

枢椎:齿状突、椎体及棘突F

第3至第7椎体：逐渐增大，椎孔三角形，椎间关节面近呈水平位，钩椎关节（Lus关节）胸椎：逐渐增大，椎孔心形，关节突关节面呈冠状位腰椎：椎体逐渐增大，椎孔呈三角形，关节突关节面呈矢状位骶骨：骶骨倒立扁三角形，5个骶椎融合而成尾骨:4个尾椎融合而成骨性椎管的特点第五页，共一百五十九页。骨间连接椎体间连接F

前纵韧带、后纵韧带、椎间盘椎板及附件间连接F黄韧带、棘间韧带、棘上韧带、项韧带横突间韧带、关节突关节环枢关节、环椎横韧带第六页，共一百五十九页。posteriorAnterior第七页，共五十九页。R

lateralL

lateral页，共一五十九。C1-2第九页，共一百五十九页。C3-7第十页，共一百五十九页。T第十一页，共一百五十九页。L第十二页，共一百五十九页。SC第十三页，共一百五十九页。第十四页，共一百五十九页。第十五页，共一百五十九页。检

查

技

术ØExaminationMethods第十六页，共一百五十九页。检查技术常规X线:最主要和首选的检查方法CT:解决临床和X线诊断疑难的第二步检查方法MRI:示X线甚至CT不能显示和显示不佳的某些组织结构核素扫描:一种全身骨骼检查，但缺乏特异性第十七页，共一百五十九页。影

像

解

剖ØRadiologicAnatomy第十八页，共一百五十九页。常规X线C第十九页，共一百五十九页。T第二十页，共一百五十九页。LA-PLateral第二十一页，共一百五十九页。L-

oblique第二十二页，共一百五十九页。CT解剖T重建第二十三页，共一百五十九页。CT解剖L第二十四页，共一百五十九页。MRI解剖C第二十五页，共一百五十九页。脊柱良性肿瘤和肿瘤样病变ØBenign

Spinal

TumorØand

Tumorlike

Lesion第二十六页，共一百五十九页。脊柱良性肿瘤和肿瘤样病变骨血管瘤骨软骨瘤骨巨细胞瘤骨样骨瘤骨母细胞瘤动脉瘤样骨囊肿骨嗜酸性肉芽肿内生骨疣

其它：软骨黏液样纤维瘤、纤维骨瘤、血管外皮细胞瘤和血管内皮细胞瘤等第二十七页，共一百五十九页。骨血管瘤ØHemangioma第二十八页，共一百五十九页。最常见的脊柱原发良性肿瘤低血压慢血流血管组成，掺杂于骨小梁和脂肪间，易出血病理上分毛细血管型和海绵状血管型多胸椎椎体,多单椎体病变任何年龄均可发生，一般无症状，多女性对放射线有相当的敏感性骨血管瘤临床病理第二十九页，共一百五十九页。骨血管瘤影像表现X线F一为受累骨体积扩张，骨小梁广泛的吸收、增生和增厚，椎体呈栅栏状特征性表现F

一为受累骨质有肥皂泡沫样的破坏和扩张第三十页，共一百五十九页。骨血管瘤影像表现CTF

椎体部分或全部松质骨密度减低F

病变区骨小梁减少，变粗致密F

冠状面或矢状面重建显示栅栏状表现F

增强扫描，病变常不强化或轻度强化

MRIF

T1WI和T2WI上均呈高信号F

增强扫描，中度至明显强化第三十一页，共一百五十九页。Plain

filmCTT骨血管瘤第三十二页，共一百五十九页。骨血管瘤T第三十三页，共一百五十九页。Fig.

A

thickened

trabeculae(corduroy

sign)of

a

vertebral

body

hemangiomacan

beseen

on

this

lateral

view,

which

isconed

downto

the

L2

vertebral

bodyFig.

B

T1WI

and

Fig.

C

T2WIshow

the

typicalincreased

signal

intensity

of

avertebral

bodyABC骨血管瘤第三十四页，共一百五十九页。骨软骨瘤ØOsteochondroma第三十五页，共一百五十九页。临床病理

由骨质组成的基底和瘤体、透明软骨组成的帽盖和纤维组成的包膜种不同组织构成,又称外生骨疣发生于脊椎少见，发生于脊柱单发1.3～1.4%，多发者9%约50%于颈椎，其次胸椎及腰椎;常见于附件儿童期生长缓慢，青春期迅速近1％病人的骨软骨瘤发生恶变多儿童和青年男性，一般无症状治疗应彻底手术切除骨软骨瘤第三十六页，共一百五十九页。骨软骨瘤影像表现X线F

仅21%的起于棘突的较大病变被明确诊断F

小病变和突入椎管内的肿瘤很难诊断F

15%显示正常第三十七页，共一百五十九页。骨软骨瘤影像表现CTF

附件骨性肿块，皮质与椎板皮质相连F

可伴脊髓受压MRIF

病灶中心T1WI呈高信号，T2WI呈中等信号F

边缘皮质均呈低信号F软骨帽常既薄又小，T1WI呈低至中等信号，T2WI呈高信号F

成人如软骨帽明显增厚（大于1-2cm）则应怀疑恶变第三十八页，共一百五十九页。38,

yr,

M

of

CHereditary

multiple

exostosiswith

several

spinal

osteochondromasFigA:

Lateral

radiograph

of

the

cervical

spine

shows

a

C-4spinous

process

osteochondroma

with

pathognomonic

marrowand

cortical

continuity

solid

arrow).

Osteochondroma

at

C-1

isseen

as

an

ossified

region

(open

rrow)Axial

FigB

and

sagittalFigC

reconstructed

CT

scans

reveal

cortex

and

marrow

of

theosteochondroma

(arrows),

impingement

on

the

spinal

canal,

extrinsic

erosion

of

C-2(arrowheads

in

b),

and

continuity

with

the

C-1

spinous

process

(*

in

c).ABC骨软第三十九页，共一百五十九页。Sagittal

T1-weighted

FigDand

T2*

gradient-echo

FigEMR

images

revealthe

signal

intensity

characteristic

of

yellow

marrow

within

theosteochondroma

and

the

impression

of

the

tumor

on

the

spinal

canal(arrows),

although

the

marrow

and

cortical

continuity

is

not

well

seen.骨软骨瘤DE第四十页，共一百五十九页。FigF:

Photograph

of

the

gross

specimen

sh

the

marrow

and

cortex

of

the

osteochondro

and

a

small

cartilage

cap

at

its

peripher

(arrowheads).第四十一页，共一百五十九页。35yr，FOsteochondroma

of

sacrummalignant

transformatFigAVague

sclerosis(solid

arrows)over

theleft

sacrum

andwidening

of

thesacroiliac

joint(open

arrow).FigA第四十二页，共一百五十九页。FigCAxial

CT

scan

shows

the

thickcartilage

cap

(arrows)

and

sacroiliacinvasion,which

represents

malignanttransformation.FigB

Coronal

reconstructed

CT

scan

shows

the

cortexand

marrow

canal

ofthe

osteochondroma

(arrows)

and

continuity

with

the

sacrum(arrowheads).Fig

BFigC第四十三页，共一百五十九页。10,

yrMultiplehereditaryexostosesmultiple

hereditary

exostoses.

Note

that

the

large

sacral

lesion

has

normal

cortex

as

well

as

marrow

arising

from

the

underlyingbone.

This

appearance

defines

an

exostosis.

We

look

for

a

thick

cartilage

cap

to

suggest

degeneration

of

an

exostosis

to

a

chondrosarcoma.

In

this

case,

there

is

no

space

for

a

thick

cap

because

the

edge

of

the

exostosis

extends

to

the

subcutaneous

tissue.If

there

is

any

question,

MR

imaging

can

demonstrate

the

cartilage

thickness.

In

this

case,

we

recognized

multiple

exostoses

becauseof

the

presence

of

sessile

lesions

at

the

anterior

superior

iliac

spines.第四十四页，共一百五十九页。骨巨细胞瘤ØGiant

Cell

Tumor,

GCT第四十五页，共一百五十九页。骨巨细胞瘤临床病理由软而脆且易出血的肉芽样组织所构成，无纤维包膜，可出血和坏死组织学分三级：Ⅰ级为良性，Ⅱ级为过渡类型，Ⅲ级为恶性患者多女性，发病年龄多20-40岁

约1/3发生于脊柱，最常累及骶骨，其次为胸椎、颈椎和腰椎；多见于附件绝大多数为良性，约25%为恶性临床症状主要为局部疼痛、无力和感觉异常治疗多全切治疗，若仅刮除术会出现40-60%％复发第四十六页，共一百五十九页。骨巨细胞瘤影像表现X线F典型呈膨胀性偏心性多房性骨质破坏，骨壳较薄，轮廓一般完整，内见纤细骨嵴构成分房状F

几点提示恶性ü

a，较明显的侵袭性表现ü

b，骨膜增生显著üc，软组织肿块较大，患者年龄较大，疼痛持续加重，肿瘤然生长迅速第四十七页，共一百五十九页。CTF

椎体局限性膨胀性溶骨性破坏,皮质连续F

若为侵袭性可侵犯数个椎体椎弓椎间盘，皮质破坏，软组织肿块形成F

发生于骶骨时，一般位于骶髂关节附近，皮质可中断F

增强扫描低密度区散在强化MRIF

T1WI上呈低、中等信号；T2WI上呈不均匀中等信号。可见局部出血信号F

增强后明显强化核素扫描F

显示肿瘤呈弥漫性的浓聚骨巨细胞瘤影像表现第四十八页，共一百五十九页。Fig

A

and

Fig

B

a

la

expansile

lesion

of

vertebral

body

(arrwith

extension

intoposterior

elements

and

T-4

and

the

post

soft

tissues

(arrow

The

lesion

enhancesmarkedly

with

the

coagent.FigC

the

lesion

hasintermediatesignal

intensity28,yr,FGCT

of

T-3

and

T-4Sag.T1WIAxi.T1WI

+cSag.T2WIACT4B骨巨细胞瘤第四十九页，共一百五十九页。Intraoperativephotograph

obtainafter

incision

of

thskin

shows

a

bulgisolid

paraspinal

mas(*)FigD骨巨细胞瘤第五十页，共一百五十九页。sacral

GCT.A-PLateraLFig

AFig

b第五十一页，共一百五十九页。Axial

CTSag.T2WIsoft-tissueextension.Cor.T2WIFig

CFig

DFigEFig

F第五十二页，共一百五十九页。21

yGCT

ofA-PLateraLAB骨巨细胞瘤第五十三页，共一百五十九页。FigC:CTshowing

large

mass

of

SFigD:

demonstrating

an

inhomogeneousmass

that

containsseveral

areas

of

low

signal

intensity

(arrowscontrast

this

signalto

the

very

high

signal

intensityFigE:

revealing

that

the

lesion

is

osignal

intensity;

the

large

presacradisplacing

the

rectum

is

confirmed.FigF:revealing

only

mild

enhancemenagain

with

several

areas

of

relativesignal

intensity.

These

low-signal

rrepresent

a

common

feature

in

GCTsCDEFAxial

CTSag.

T1WIAxi.

FSE

T2WISag.FS

T1WI

+C骨巨细胞瘤第五十四页，共一百五十九页。Upper

Left:

Anteroposterior

radiograph

emonstratingthe

expanded

lytic

lesion

ccupying

the

sacrum.UpperRight

and

Center

Left:

Axial

CT

scansobtained

several

months

later,

demonstrating

therather

featureless

lytic

lesion

occupying

theentire

sacrum,

with

attempted

thin

cortical

rimunable

to

contain

the

expansive

lesion.Center

Right:

Sagittal

T1-weighted

MR

image(TR/TE

450/10

msec)

demonstrating

intensitypresacral

soft-tissue

extensionLower

Left

and

Right:

Sagittal

T2WI

and

axial

FSET2WI

revealing

the

inhomogeneous

mixed

high

and

lowsignal

intensity

mass,

typical

of

GCT.26,

yr,

FGCT

of

the

sacrum.骨巨细胞瘤第五十五页，共一百五十九页。16

y

maleGCT

of

C-7posterior

elemen骨巨细胞瘤第五十六页，共一百五十九页。TI骨巨细胞瘤第五十七页，共一百五十九页。骨样骨瘤ØOsteoid

Osteoma第五十八页，共一百五十九页。骨样骨瘤

临床病理

由成骨性纤维组织及骨样组织、编织骨构成，肿瘤本身为瘤巢直径1.5cm，很少超过2厘米,周围由增生致密的反应性骨质包绕

10%发生于脊柱，多腰椎，最常起于椎弓，其次椎板，小关节面和椎弓根单发性，肿瘤发展极慢多为青少年和成年人，多男性，多小于30岁

患骨疼痛，夜间加重，服用水杨酸类药物可缓解为其特点。患者因肌痉挛而引起侧弯治疗以用手术切除最为适宜,预后良好第五十九页，共一百五十九页。骨样骨瘤

影像表现X线ü

肿瘤所在部位骨质破坏ü

周围不同程度的反应性骨硬化ü

偶见内钙化/骨化ü

分皮质型、松质型、骨膜下型第六十页，共一百五十九页。骨样骨瘤

影像表现CTF

类圆形的低密度骨破坏区，中央见不规则的钙化骨化影F

周围不同程度的反应性骨硬化环

MRI肿瘤未钙化部分T1WI呈低至中等信号，T2WI呈高信号钙化及周围硬化带均呈低信号增强后，病变强化明显。核素扫描F

肿瘤显示明显核素浓聚第六十一页，共一百五十九页。FigA:

Radiograph

reveals

a

subtle

lucent(arrow)

in

a

right

articular

mass.FigB:

CT

scan

shows

the

nidus

(large

arrowheads)a

small

central

area

of

calcification

(small

arrowand

minimal

surrounding

sclerosis.FigC:

Radiograph

of

the

resected

specimenthat

the

nidus

was

entirely

removed

(arrows).FigD:

Posterior

bone

scan

shows

intense

uptake

ofradionuclide

by

the

nidus

(arrow)17,

yr,

MOsteoid

osteoma

oflamina

at

T-11ABCD骨样骨瘤瘤巢第六十二页，共一百五十九页。FigE:

Photograph

of

thegross

specimen

revealthe

nidus

(*)extendinthe

facet

cartilage

(a骨样骨瘤瘤巢第六十三页，共一百五十九页。Axial

CT

scan

(left)

revealing

that

a

tumor

arising

from

the

left

C-5

pedicle

is

compressingthe

left

C-5

root.Bone

scan

(center)

displays

high

uptake

of

contrast

material.Axial

CT

scan

(right)

demonstrating

that

left

hemilaminectomy

was

sufficient

to

removethe

tumor.16,

yr,

MOsteoid

osteoma

oflamina

at

C-5骨样骨瘤第六十四页，共一百五十九页。骨母细胞瘤ØOsteoblastoma第六十五页，共一百五十九页。骨母细胞瘤临床病理

多量骨母细胞增生形成骨样组织和编织骨为特点。典型病变直径为1.5cm～2cm不等

肿瘤境界清楚，血管丰富，肿瘤体积较大时出现囊变，合并动脉瘤样骨则多数含血囊腔。少数肿瘤可发生恶变约30～40%发生于脊柱,颈椎、胸椎和腰椎发病率相近,肿瘤常累及男性多于女性，男:女＝2:1，发病年龄90%20～30岁

患骨局部疼痛不适，脊髓和神经压迫症状。水杨酸类药物无缓解和夜间疼痛与骨样骨瘤鉴别。治疗应手术切除，病变复发率为10-15%第六十六页，共一百五十九页。X线三种表现F

a：中心低密度破坏区，周围骨硬化，病灶直径大于1.5F

b：有多发小钙化的膨胀性破坏，周围伴硬化缘F

c：为侵袭性表现，骨膨胀破坏，及周围软组织浸润和混杂性钙化骨母细胞瘤影像表现第六十七页，共一百五十九页。CTF

对肿瘤内钙/骨化影显示高于平片,尤其对复杂部位肿瘤显示较好F

类圆形膨胀性骨质破坏，周围有不同程度增生硬化F

破坏区骨壳可中断,周围软组织可局限性肿胀MRIF

非钙/骨化部分T1WI呈低至中等信号,T2WI呈高信号,钙/骨化部分呈低信号F

病灶周围骨髓和软组织反应性充血水肿，为长T1长T2信号F

可显示骨壳中断，椎管内延伸和脊髓受压F

合并动脉瘤样骨囊肿时可见囊腔及液液平面核素扫描F

肿瘤显示明显核素浓聚骨母细胞瘤影像表现第六十八页，共一百五十九页。Fig.Ashows

a

markedly

expansile

lesion

involving

theprocess

and

laminae

(arrows),

with

vague

sclerosissuggestive

of

mineralization.Fig.BCT

scan

reveals

the

marked

expansion

of

the

lesion,

wa

defined

sclerotic

rim

(arrows),

and

its

encroachment

on

tcanal.

Matrix

mineralization

(arrowheads),16,

yr,

M.osteoblastoma

of

C-3Fig.A

L

radiographFig.B

CT骨母细胞瘤第六十九页，共一百五十九页。Axi.

T1WI

FigCand

Sag.

T2WI

FigD

show

the

mass

(arrows)

and

its

degree

of

encroachment

on

thespinal

canal

(arrowheads

in

c).

Because

of

its

extensive

mineralization,

the

mass

has

relatively

losignal

intensity

on

the

T2-weighted

image.Axi.

T1WI

Sag.

T2WIFigCFigD:骨母细胞瘤第七十页，共一百五十九页。骨母细胞瘤FigE第七十一页，共一百五十九页。FigA:

CT

scan

shows

a

destructive,

expansile

lesion

of

the

left

lateral

side

of

C-1

(arrows)

with

small

foci

of

mineralizedmatrix

peripherally

(arrowheads)

and

invasion

of

thesurrounding

soft

tissues

and

foramen

transversarium.FigB:

Coronal

T2-weighted

MR

image

shows

high

signal

intensitywithin

the

mass

(arrows).FigC:

Digital

subtraction

angiogram

reveals

tumor

stainartery

(curved

arrow).9,

yr,

M.Aggressive

osteoblastoma

ofC1ABC骨母细胞瘤(straight

arrows)and

obstruction

of

the

left

vertebral

(侵袭性)CTMRIDSA第七十二页，共一百五十九页。Left:

Anteroposterior

radiograph

revealing

a

subtly

expandedlesion

that

is

near

the

midline

at

S4-5

(arrows).Right:

Axial

CT

scan

demonstrating

bone

matrix

within

the

lesion,not

aggressive

in

appearance.16,

yr,

Mosteoblastoma

of

S4-5骨母细胞瘤第七十三页，共一百五十九页。Left:

bone

scan

revealing

an

eccentrically

located

area

of

increased

uptake

in

thesacrum.Right:

The

CT

scan

demonstrates

a

minimally

expanded

lesion

containing

dense

bonematrix

in

the

right

side

of

the

lower

sacrum.16,

yr,

M.osteoblastoma

of

S4-5骨母细胞瘤第七十四页，共一百五十九页。Lateral

x-ray

films

(a)

showed

a

soft-tissue

swelling

ithe

retropharyngeal

space.

Lateral

(b)

and

coronal

(c)

MRimages

demonstrating

tumor

in

the

C-2

body

and

asoft-tissue

mass

from

C1–6.Axial

CT

scan

(d)

demonstrating

a

typical

osteoid

niduswith

peritumoral

sclerotic

rim

on

the

right

side

of

the

C-2

body.Technetium

bone

scan

(e)

also

displays

pronounceduptake

in

this

region.

We

performed

tumor

excision

viaan

anterolateral

retropharyngeal

approach

(f)occipitocervical

fixation

by

using

two

axis

plates

andtitanium

wires

(g).Lateral

x-ray

films

obtained

immediately

after

(h)

andyears

postsurgery

(i)

showing

solid

fusion.10,

yr,

Mosteoblastoma

of

C2骨母细胞瘤第七十五页，共一百五十九页。动脉瘤样骨囊肿ØAneurysmal

Bone

Cyst,

ABC第七十六页，共一百五十九页。动脉瘤样骨囊肿临床病理原因不明的肿瘤样病变，分原发和继发两种病变由大小不等的海绵状血池组成，外壁为薄壁囊状骨壳继发者发生原有病变基础上，包括骨巨细胞瘤、骨母细胞瘤、软骨母细胞瘤和骨等好发于青少年，多10～20岁，女性略多脊柱占12-30％，胸椎最常受累，其次腰椎和颈椎，骶骨罕见；病变位于椎弓及突起临床症状主要为病变侵犯椎管引起相应部位疼痛和神经压迫症状可行刮除植骨术，还可栓塞治疗和放疗；总的复发率为20-30%。第七十七页，共一百五十九页。动脉瘤样骨囊肿影像表现X线F典型表现为脊柱附件骨显著膨胀的囊状透亮区，外侧为薄的骨壳，呈“气球状”F

囊内有或粗或细的骨小梁状分隔或骨嵴第七十八页，共一百五十九页。动脉瘤样骨囊肿影像表现CTF

多呈囊状膨胀性骨破坏，骨壳菲薄F

软组织密度肿块内见斑片样、条索状及不定形钙化，边缘可有硬化F

有时可见液液平面，下部密度高于上部，随体位而改变。MRIF

检出液－液平面更敏感F

液－液平面是本病的重要特点，T2WI上层一般为高信号，可能为浆液或高铁血红蛋白，下层为低信号，可能有含铁血黄素成分。核素扫描F

常表现为外周部位的核素摄取增加，呈“油炸圈饼”征第七十九页，共一百五十九页。Fig.A

and

after

Fig.Bof

gadopentetate

dimreveal

a

markedly

exinvolving

the

laminaarrowheads)

and

encrthe

spinal

canal

(smarrowheads).

Enhanclargely

in

theperiphery

and

seplesion.Fig.C

Sagittal

T2image

shows

that

tlesion

containsfluid-fluid

levels

(arrfrom

hemorrhagic

spacesthe

extent

of

spinnarrowing.8yr,

M

ABCBAC动脉瘤样骨T1WI

C+T1WIT2WI液-液平面(血窦)第八十页，共一百五十九页。Fig.DPhotograph

of

thesagittally

sectiongross

specimendemonstrates

thmultiple

blood-filled

spaces(arrows)

in

thelesion.血窦动脉瘤样骨囊肿第八十一页，共一百五十九页。Fig.A

The

anteroposterior

radiograph

can

be

easily

mnormal

because

of

the

overlying

bowel

gas

obscuring

thFig.B

A

lateral

radiograph

demonstrates

only

obscurthe

S-3

posterior

elements

(arrows)Fig.CThe

lesion

is

more

readily

seen

on

the

CT

scan

obtainedpatient

in

a

prone

position.

This

scan

demonstrates

a

lytic

lesithe

left

S-3

ala,

with

a

thin

cortical

rim

surrounding

the

majoriNote

that

the

more

lucent

regions

in

the

center

of

the

lesion

actrepresent

fluid

levels.Fig.DFluid

levels

(short

arrow)

are

more

readily

ob

sagittal

T1-weighted

MR

image;

remember

that

the

pati

in

the

imager

and

that

the

fluid

levels

on

the

sagittal

be

expected

to

appear

vertical,

as

in

this

case.

The

hi

intensity

portion

of

the

fluid

is

blood.

Most,

but

not

fluid

levels.

Conversely,

most

lesions

with

substanti

ABCs,

but

such

levels

may

occur

in

other

lesions

as

wel

Note

also

in

this

case

that

there

is

a

substantial

component

of

tlocated

anteriorly

to

the

fluid

levels

that

is

solid

(long

arrow14,

yr,

MABC

of

SADCB液-液平面(血窦)动脉瘤样骨囊肿第八十二页，共一百五十九页。nneeuurryyssmmaall

BBoonneeCCyyssttFig.A

Computed

tomographic

scan

showing

alytic

lesion

in

the

posterior

elements

of

thevertebrae

at

the

T10-T12

level,

with

expansion

to

thevertebral

body

from

the

left.

This

process

with

a

thinperiosteal

border

enters

the

spinal

canal,

pressing

the

cordforward

and

to

the

rightFig.BMagnetic

resonance

imaging

after

injectiogadolinium

shows

a

nonhomogeneous

multilobular

leat

T10-T12

level,

extradurally

pressing

the

spinaforward

and

to

the

right,

destroying

the

pedicle

alamina

of

the

vertebra.Fig.AFig.B动脉瘤样骨囊肿T1WI

C+第八十三页，共一百五十九页。骨嗜酸性肉芽肿ØEosinophilic

Granuloma第八十四页，共一百五十九页。骨嗜酸性肉芽肿临床病理本病属网状内皮系统类脂质沉积病，称朗罕氏细胞组织细胞病（Langerhans

cell

histiocytosis）

包括三种病变：勒－雪病、韩－薛－柯病和嗜酸性肉芽肿。其孤立形式为嗜酸性肉芽肿，为良性局限性组织细胞增生，为最轻型。

椎体为主要原发部位，多单发，可多发。肉芽组织位于骨髓腔伴出血坏和囊变；晚期常有结缔组织增生，纤维化骨化好发于儿童及青年，男多于女

患部轻微疼痛，压痛，伴有功能障碍治疗方案：保守治疗、固定、除、瘤内注射激素，放疗和切除等第八十五页，共一百五十九页。骨嗜酸性肉芽肿影像表现生长迅速的溶骨性病变，常导致椎体变扁和硬化，称平椎。平片即可容易诊断，CT及MRI对确定病变范围很有帮助

病变延伸到周围软组织时，CT及MRI不典型，需组织学证实第八十六页，共一百五十九页。vertebra

plana

cseen

(arrow)

inthoracic

spine,consistent

withLangerhan"s

celhistiocytosis.8,

yr,

M

of扁平椎骨嗜酸性肉第八十七页，共一百五十九页。内生骨疣ØEnostosis第八十八页，共一百五十九页。内生骨疣临床病理内生骨疣通常指骨岛，也称钙化性骨髓缺损、内生骨瘤组织学上骨疣为板层骨，哈佛氏系统包埋在髓管内。病变较出生时进，并被认为也会产生损害的病变。好发于中轴骨倾向，特别是骨盆、柱和肋骨。脊柱骨岛发生率仅1%。尸检14%

脊柱内生骨疣好发于胸椎(T1～T7)和腰椎（L2和L3），胸椎病变常位于中线右侧，而腰椎常位于中线左侧。病变常位于皮质下，周围常常伴有放射状骨针。病变大小约2mmX2mm到6mmX10mm，于2cm为巨大内生骨疣常无症状，偶然发现第八十九页，共一百五十九页。内生骨疣影像表现X线平片和CTF

常具有特征性表现，为圆形或椭圆形成骨性病变，边界清楚,边缘呈“棘状放射”征或毛刷状边缘”。周围骨小梁正常MRIF

在各序列均为低信号，棘状边缘显示清楚。周围骨髓信号正常核素扫描F

绝大多数内生骨疣显示为正常，无异常放射性核素浓聚。少数出现浓聚的病变常为巨大内生骨疣，占33％病变自然病史不同，绝大多数病变变化不大，部分可缓慢生长或体积减小（31.9％）个月内病变直径增加25%或1年内50%时应考虑该病第九十页，共一百五十九页。hetheds)66-yr-old

M

Enostosis

of

LFig.AFig.A

Lateral

radiograph

shows

a

sclerotic

focus

in

tanterior

portion

of

L-3

(arrowhead).Fig.B

CT

scan

reveals

a

densely

sclerotic

lesionwith

an

irregular

spiculated

border

just

beneathanterior

cortex

to

the

left

of

midline

(arrowheaFig.B内生骨疣毛刷状边缘第九十一页，共一百五十九页。Fig.A

Lateral

radiograph

reveals

a

sclerotic

focwith

areas

of

spiculated

thornlike

margins

(smalFig.B

Photomicrograph

(original

magnification,

X150;

hematostain)

shows

cortical

bone

(arrows)

with

irregular

margins

(a35-yr-old

FGiant

enostosis

of

L-2Fig.BFig.B第九十二页，共一百五十九页。脊柱恶性肿瘤ØMalignant

Tumor第九十三页，共一百五十九页。脊柱恶性肿瘤脊索瘤转移性骨肿瘤骨髓瘤软骨肉瘤骨肉瘤未分化网状细胞肉瘤和PNET淋巴瘤白血病绿色瘤其它：间质软骨肉瘤、纤维肉瘤均罕见第九十四页，共一百五十九页。脊索瘤Chordoma第九十五页，共一百五十九页。脊索瘤

临床病理少见，起源于脊索残余，占骨病变不到4%

50%于骶骨（主要S4-S5），其次35%斜坡，15%椎体（主要C2）.也为骶骨最常见的原发骨肿瘤

肿瘤呈分叶状，有纤维假包膜，内含灰白或浅黄色胶状物；可出血、假腔以及肉芽样组织

肿瘤生长缓慢，局部侵袭性，不转移,偶远处转移,主要为肺、淋巴结网膜下腔和脊髓多男性，男：女=2-3:1；30-60岁，高峰年龄50岁

症状多由肿瘤扩大侵犯或压迫邻近重要组织或器官所引起治疗手术切除为主第九十六页，共一百五十九页。脊索瘤

影像表现X线F

肿瘤为溶骨性破坏，伴大的软组织肿块F

骶椎患骨常膨胀，瘤内50-70%见钙化F

钙化多无定形，位于病变周围F

骶椎以上节段患骨较少膨胀改变，并可出现硬化呈

“象牙椎”表现第九十七页，共一百五十九页。脊索瘤

影像表现CTF

主要呈溶骨性破坏F

肿瘤分叶状，囊实性混杂密度，可见不规则钙化F

软组织肿块F

增强，轻至中度强化F

不易与转移瘤鉴别第九十八页，共一百五十九页。脊索瘤

影像表现MRT1WI：中等信号（占75%）；低信号（占25%）T2WI：呈高信号，信号高于CSF增强：明显强化MRI在显示病变侵及的范围方面优于CTCT在确定肿瘤的性质特点方面优于MRI第九十九页，共一百五十九页。Chordoma

of

lower

sacrum48-year-old

manFig.AFig.B脊索瘤Fig.ALateral

radiograph

shows

destruction

of

the

distal

sacrum

and

coccyx

with

calcification

(arrow).

Fig.BCT

scan

alsodemonstrates

the

bone

destruction

and

a

soft-tissue

mass

(arrowheads)

containing

calcifications(arrow)..第一百页，共一百五十九页。Fig.C

T1WI

Sagittal

and

axial

T2WI

Fig.DMR

images

reveal

the

expansile

sacrococcygeal

lesion(arrowheads),

which

has

high

signal

intensity

on

D.Fig.CFig.D脊索瘤第一百零一页，共一百五十九页。Fig.E

As

seen

in

thissagittal

section

of

tgross

specimen,

the

Mimaging

appearancecorrelates

with

theexpansile

lesion(arrowheads)

andcalcification

(arrowThe

upper

sacrum

(*)

isspared脊索瘤第一百零二页，共一百五十九页。Fig.ALateral

radiograph

shows

a

dense

vertebral

body

(arrow3.Fig.BSagittal

reconstructed

CT

scan

obtained

after

initialbiopsy

reveals

not

only

the

L-3

sclerosis

but

also

similar

finthe

superior

aspect

of

L-4

(arrowheads).Chordoma

of

L13-year-old

man1-yr

history

ofintermittent

low

back

pain.Fig.AFig.B脊索瘤第一百零三页，共一百五十九页。Sagittal

TFig.CandT2WIFig.DMR

images

bdelineatethe

marrowinvolvemenand

L-4

witextensionthrough

the(arrows).

Thas

markedhigh

signintensityFig.CFig.D第一百零四页，共一百五十九页。Fig.Egross

spedepicts

tof

the

newith

diffinvolveme(arrowheaadjacentand

the

saspect

of(arrows).脊索Fig.E第一百零五页，共一百五十九页。Upper

Left

and

Right:

A

CT

scans

demonstratinglarge

soft-tissue

massextending

anteriorly

ttherectum

and

posterioinvade

the

buttocks;calcification

is

seen

wmass.Lower

Left

and

Right:fast

spin

echo

T2-weighaxial

T2-weighted

MR

imdemonstrating

the

lesiinfiltrating

the

presaextending

to

surround

trectum

and

the

perivesibut

not

invading

the

bl24-yr

Mchordoma

involving

S3-5脊索瘤第一百零六页，共一百五十九页。Fig.Preoperand

MR

isacral

cPhotogrhemisecpatholodemonstblock

resacrum.Fig.PostopeanteropradiogrFig.脊第一百零七页，共一百五十九页。Fig.AFichordoma脊索瘤第一百零八页，共一百五十九页。转移性骨肿瘤Ø

Secondary

TumorØor

Metastatic

Tumor第一百零九页，共一百五十九页。临床病理脊柱转移常见转移途径主要是血行转移，少数直接蔓延

原发肿瘤常包括：前列腺癌、肾癌、甲状腺癌、乳癌、肺癌和鼻咽癌等。骨肉瘤、尤文瘤和淋巴瘤也可发生骨转移患者51～60岁最多

临床表现为疼痛、持续性、夜间加重。可出现肿块、病理骨折和压迫症状

治疗可选用对原发瘤有效的化学治疗(包括激素)和中药治疗，放疗可用于单发转移转移性骨肿瘤第一百一十页，共一百五十九页。转移性骨肿瘤影像表现X线F

分为溶骨型、成骨型和混合型F溶骨型：椎体广泛或局限性骨质破坏，椎体常变扁，椎间隙多保持完整。椎弓根常受侵蚀破坏F

成骨型：少见。大多前列腺癌引起，少数为乳癌、鼻咽癌、肺癌和膀胱癌。呈斑片状、结节状高密度，位于松质骨内，边界清楚或不清。骨皮质多完整，骨轮廓多无改变F

混合型转移兼有溶骨型和成骨型转移的骨质改变第一百一十一页，共一百五十九页。转移性骨肿瘤影像表现CTF

较X线敏感F

能显示局部软组织肿块的范围、大小及邻近脏器的关系F溶骨型为松质骨和或皮质骨的低密度缺损区，常伴软组织肿块F成骨型为松质骨内斑点状、片状、棉团状或结节状边缘模糊的高密度灶，一般无软组织肿块F

混合型兼有两者改变MRIF

能检出X线CT甚至核素显像不易发现的病灶F

多数肿瘤T1WI呈低信号，T2WI呈程度不高的高信号F

脂肪抑制序列显示更清楚第一百一十二页，共一百五十九页。second

lumbavertebra

witextension

inthe

spinalcanal.Abdominal

computed

tomographicscan

shows

hepatic

metastases

andan

irregular

mass

in

the

region

of

thepancreas.Fig.AFig.BFig.BMagneticresonanceimaging

studof

the

spineshows

adestructivelesion

in

theFig.A第一百一十三页，共一百五十九页。sclerotic

metastas第一百一十四页，共一百五十九页。77-yr

FMetastatic

breast

cancerFigure.

Sagittal

T1-weighted

MRimage

of

the

lumbosacral

spineshows

multiple

hypointense

fociwithin

the

sacrum

and

lumbarvertebrae.

These

lesions

remainedhypointense

with

all

of

the

MRimaging

sequences

and

did

notexhibit

enhancement.

Plainradiography

revealed

scleroticmetastases.第一百一十五页，共一百五十九页。Fracture第一百一十六页，共一百五十九页。Fr

st第一百一十七页，共一百五十九页。mass第一百一十八页，共一百五十九页。Extensive

osseousmetastases

from

lungcarcinoma.

Anterior

(leand

posterior

(right)wholebodybone

scintigrams

showmultiple,

randomly

distrifoci

of

abnormal

radiotrauptake.

The

focivary

in

siand

intensity.第一百一十九页，共一百五十九页。Fig.A

:

Sagittal

T2-weighted

MRimage

demonstratinginvolvement

of

the

posterior

elementsof

L-3

(arrow).Fig.B

:

Axial

T1-weighted

MR

imagerevealing

the

L-3

spinous

processand

lamina

infiltrated

by

tumor,

wianterior

structures

intact

(arrow).Fig.E

:

Bone

scan

demonstrating

numerousadditional

sites

of

metastatic

disease

(ribsskull,

and

scapula)

in

addition

to

L-3

(arroThe

patient

underwentsimple

posterior

decompression.54-yr

Mmetastatic

renal

cell

carcinomaACB第一百二十页，共一百五十九页。Sag.MRI

of

the

lower

T

and

upper

T

ar(A)hypointense

on

T1WI

and

(B)hyperintense

onT2

WI).

On

DW

EPI

(C,

b

vaof

440

sec/mm2;

D,

b

value

of

880sec/mm2),

the

vertebral

metastasisvertebral

compression

fractures

apphyperintense.E,

ADC

map

shows

both

vertebral

metasand

acute

pathologic

vertebral

compfractures

with

low

ADCs,

which

indichindered

diffusion

of

water

protonspathologic

nature

of

these

findingshyperintense

area

located

centrallyfracture

of

L1,

which

possibly

indicunhindered

diffusion

in

an

area

of

d63-yr

Fwith

breasM

at

L1

(arrows)

fractures

at

T11-12

(arrow第一百二十一页，共一百五十九页。50-yr

Fmastectomy

5

yrs

earlierbreast

carcinoma第一百二十二页，共一百五十九页。Left:Postoperativnteroposteriradiograph

obafter

T-2

corand

T1-3

stabperformed

viamedian

sternoapproach

(notsternal

wiresRight:

PostopeCT

scan

demonstraspinal

decompresstructural

iliacstrut,

and

an

ant62-yr

Mlarge

cell

Caof

the

lung第一百二十三页，共一百五十九页。Neuroimagesdemonstratingreconstructioncorpectomy

formetastasis;

stawasachieved

using

a

tmesh

interbody

cagchest

tube

construPMMA,

supplementeanterior

cervicalLeft:

Preoperatimagneticresonancsagittal

view,

revcollapse

at

C-4.

RPostoperativeray

film,

late第一百二十四页，共一百五十九页。Fig.A

Preoperative

plain

x-ray

film

showing

destruction

of

the

C-3

VB

and

associated

kyp

eformity.Fig.B

Postoperative

x-ray

film

showingplacement

of

the

TPS

device

into

the

C-3corpectomy

defect,

restoring

anterior

columheight.Fig.C

Illustrations

of

the

TPS

device.

Theapparatus

is

expandable

to

fit

the

size

of

thcorpectomy

defect

and

can

be

filled

with

bonautograft

if

desired.Squamous

cell

carcinomaof

the

lung

metastatic

to

C-3.ABC第一百二十五页，共一百五十九页。骨髓瘤ØMyeloma第一百二十六页，共一百五十九页。骨髓瘤

临床病理

骨髓瘤，又称浆细胞瘤。起源于骨髓网织细胞的恶性肿瘤，为圆而脆软的实质新生物

椎体为其好发部位，绝大多数为多发；单发少见，且约