脊柱肿瘤的影像学诊断课件

脊柱肿瘤的影像学诊断1脊柱肿瘤的影像学诊断1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2脊柱肿瘤的影像学诊断脊柱大体解剖2脊柱大体解剖3脊柱大体解剖3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4颈段：7个颈椎胸段4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环椎:前后弓及两侧块枢椎:齿状突、椎体及棘突第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（Luscka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5椎骨:椎体、椎弓和7个骨性突起组成骨性椎管的特点5

骨间连接椎体间连接前纵韧带、后纵韧带、椎间盘

椎板及附件间连接黄韧带、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6骨间连接椎体间连接6posteriorAnterior7posteriorAnterior7RlateralLlateral8RlateralLlateral8C1-29C1-29C3-710C3-710T11T11L12L12SCo13SCo1314141515检查技术

ExaminationMethods16检查技术ExaminationMethods16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17检查技术常规X线:最主要和首选的检查方法17影像解剖

RadiologicAnatomy18影像解剖RadiologicAnatomy18常规X线

C19常规X线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

脊柱良性肿瘤和肿瘤样病变

BenignSpinalTumorandTumorlikeLesion26脊柱良性肿瘤和肿瘤样病变BenignSpinal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27脊柱良性肿瘤和肿瘤样病变骨血管瘤27骨血管瘤Hemangioma28骨血管瘤Hemangioma28骨血管瘤临床病理

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29骨血管瘤临床病理最常见的脊柱原发良性肿瘤29骨血管瘤影像表现X线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一为受累骨质有肥皂泡沫样的破坏和扩张30骨血管瘤影像表现X线30骨血管瘤影像表现

CT椎体部分或全部松质骨密度减低病变区骨小梁减少，变粗致密冠状面或矢状面重建显示栅栏状表现增强扫描，病变常不强化或轻度强化

MRIT1WI和T2WI上均呈高信号增强扫描，中度至明显强化31骨血管瘤影像表现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骨软骨瘤Osteochondroma35骨软骨瘤Osteochondroma35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三种不同组织构成,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36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骨软骨瘤影像表现X线仅21%的起于棘突的较大病变被明确诊断小病变和突入椎管内的肿瘤很难诊断15%显示正常37骨软骨瘤影像表现X线37骨软骨瘤影像表现CT附件骨性肿块，皮质与椎板皮质相连可伴脊髓受压

MRI病灶中心T1WI呈高信号，T2WI呈中等信号边缘皮质均呈低信号软骨帽常既薄又小，T1WI呈低至中等信号，T2WI呈高信号成人如软骨帽明显增厚（大于1-2cm）则应怀疑恶变38骨软骨瘤影像表现CT3838,yr,Mof

CHereditarymultipleexostosiswithseveralspinalosteochondromasFigA:LateralradiographofthecervicalspineshowsaC-4spinousprocessosteochondromawithpathognomonicmarrowandcorticalcontinuitysolidarrow).OsteochondromaatC-1isseenasanossifiedregion(openrrow)AxialFigBandsagittalFigCreconstructedCTscansrevealcortexandmarrowoftheosteochondroma(arrows),impingementonthespinalcanal,extrinsicerosionofC-2(arrowheadsinb),andcontinuitywiththeC-1spinousprocess(*inc).ABC骨软骨瘤3938,yr,MofCHereditarymultiSagittalT1-weightedFigDandT2*gradient-echoFigEMRimagesrevealthesignalintensitycharacteristicofyellowmarrowwithintheosteochondromaandtheimpressionofthetumoronthespinalcanal(arrows),althoughthemarrowandcorticalcontinuityisnotwellseen.骨软骨瘤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.骨巨细胞瘤GiantCellTumor,GCT45骨巨细胞瘤GiantCellTumor,GCT45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46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，无骨巨细胞瘤影像表现X线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几点提示恶性a，较明显的侵袭性表现b，骨膜增生显著c，软组织肿块较大，患者年龄较大，疼痛持续加重，肿瘤突然生长迅速47骨巨细胞瘤影像表现X线47骨巨细胞瘤影像表现CT椎体局限性膨胀性溶骨性破坏,皮质连续若为侵袭性可侵犯数个椎体椎弓椎间盘，皮质破坏，软组织肿块形成发生于骶骨时，一般位于骶髂关节附近，皮质可中断增强扫描低密度区散在强化MRIT1WI上呈低、中等信号；T2WI上呈不均匀中等信号。可见局部出血信号增强后明显强化核素扫描显示肿瘤呈弥漫性的浓聚48骨巨细胞瘤影像表现CT48FigAandFigB

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

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

FigD骨巨细胞瘤50IntraoperativeFigD骨巨细胞瘤50sacralGCT.A-PLateraLFigAFigb51sacralGCT.A-PLateraLFigAFigAxialCTSag.T2WI

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

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

26,yr,FGCTofthesacrum.骨巨细胞瘤55UpperLeft:AnteroposteriorraGCTofC-7

posteriorelements

16ymale骨巨细胞瘤56GCTofC-7posteriorelementsTI

骨巨细胞瘤57TI骨巨细胞瘤57骨样骨瘤OsteoidOsteoma58骨样骨瘤OsteoidOsteoma58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约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。患者因肌肉痉挛而引起侧弯治疗以用手术切除最为适宜,预后良好59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，骨样骨瘤影像表现X线肿瘤所在部位骨质破坏周围不同程度的反应性骨硬化偶见内钙化/骨化分皮质型、松质型、骨膜下型60骨样骨瘤影像表现X线60骨样骨瘤影像表现CT类圆形的低密度骨破坏区，中央见不规则的钙化骨化影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。核素扫描肿瘤显示明显核素浓聚61骨样骨瘤影像表现CT61FigA:Radiographrevealsasubtlelucentarea(arrow)inarightarticularmass.FigB:CTscanshowsthenidus(largearrowheads)withasmallcentralareaofcalcification(smallarrowhead)andminimalsurroundingsclerosis.FigC:Radiographoftheresectedspecimenshowsthattheniduswasentirelyremoved(arrows).FigD:Posteriorbonescanshowsintenseuptakeoftheradionuclidebythenidus(arrow)

17,yr,MOsteoidosteomaoflaminaatT-11ABCD骨样骨瘤瘤巢62FigA:RadiographrevealsasubFigE:Photographofthegrossspecimenrevealsthenidus(*)extendingtothefacetcartilage(arrows)骨样骨瘤瘤巢63FigE:PhotographofthegrossAxialCTscan(left)revealingthatatumorarisingfromtheleftC-5pedicleiscompressingtheleftC-5root.Bonescan(center)displayshighuptakeofcontrastmaterial.AxialCTscan(right)demonstratingthatlefthemilaminectomywassufficienttoremovethetumor.16,yr,MOsteoidosteomaoflaminaatC-5骨样骨瘤64AxialCTscan(left)revealing骨母细胞瘤Osteoblastoma65骨母细胞瘤Osteoblastoma65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，合并动脉瘤样骨囊肿时则多数含血囊腔。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,肿瘤常累及附件男性多于女性，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无明显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%66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骨母细胞瘤影像表现X线三种表现a：中心低密度破坏区，周围骨硬化，病灶直径大于1.5cmb：有多发小钙化的膨胀性破坏，周围伴硬化缘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67骨母细胞瘤影像表现X线67骨母细胞瘤影像表现CT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类圆形膨胀性骨质破坏，周围有不同程度增生硬化破坏区骨壳可中断,周围软组织可局限性肿胀MRI非钙/骨化部分T1WI呈低至中等信号,T2WI呈高信号,钙/骨化部分呈低信号病灶周围骨髓和软组织反应性充血水肿，为长T1长T2信号可显示骨壳中断，椎管内延伸和脊髓受压合并动脉瘤样骨囊肿时可见囊腔及液液平面

核素扫描肿瘤显示明显核素浓聚

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

of

C-3

Fig.ALradiographFig.BCT骨母细胞瘤69Fig.AshowsamarkedlyexpansilAxi.T1WIFigC

andSag.T2WI

FigD

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

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

9,yr,M.Aggressive

osteoblastomaof

C1ABC骨母细胞瘤

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

of

S4-5

骨母细胞瘤73Left:AnteroposteriorradiograLeft:

bonescanrevealinganeccentricallylocatedareaofincreaseduptakeinthesacrum.Right:

TheCTscandemonstratesaminimallyexpandedlesioncontainingdensebonematrixintherightsideofthelowersacrum.16,yr,M.osteoblastoma

of

S4-5

骨母细胞瘤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

骨母细胞瘤75Lateralx-rayfilms(a)showed动脉瘤样骨囊肿AneurysmalBoneCyst,ABC76动脉瘤样骨囊肿AneurysmalBoneCyst,A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、软骨母细胞瘤和骨肉瘤等好发于青少年，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；病变位于椎弓及其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%。

77动脉瘤样骨囊肿临床病理原因不明的肿瘤样病变，分原发和继发动脉瘤样骨囊肿影像表现X线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”囊内有或粗或细的骨小梁状分隔或骨嵴78动脉瘤样骨囊肿影像表现X线78动脉瘤样骨囊肿影像表现CT多呈囊状膨胀性骨破坏，骨壳菲薄软组织密度肿块内见斑片样、条索状及不定形钙化，边缘可有硬化有时可见液液平面，下部密度高于上部，随体位而改变。MRI检出液－液平面更敏感液－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。核素扫描常表现为外周部位的核素摄取增加，呈“油炸圈饼”征79动脉瘤样骨囊肿影像表现CT79Fig.A

andafterFig.B

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

SagittalT2-weightedMRimageshowsthattheentirelesioncontainsfluid-fluidlevels(arrows)resultingfromhemorrhagicspacesandshowstheextentofspinalcanalnarrowing.8yr,MABCofT3ABC动脉瘤样骨囊肿T1WIC+T1WIT2WI液-液平面(血窦)80Fig.AandafterFig.BadministPhotographofthesagittallysectionedgrossspecimendemonstratesthemultipleblood-filledspaces(arrows)inthelesion.Fig.D血窦动脉瘤样骨囊肿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(血窦)动脉瘤样骨囊肿82Fig.ATheanteroposteriorradineurysmalBoneCystFig.AComputedtomographicscanshowingalyticlesionintheposteriorelementsofthevertebraeattheT10-T12level,withexpansiontothevertebralbodyfromtheleft.Thisprocesswithathinperiostealborderentersthespinalcanal,pressingthecordforwardandtotheright

Fig.BMagneticresonanceimagingafterinjectionwithgadoliniumshowsanonhomogeneousmultilobularlesionatT10-T12level,extradurallypressingthespinalcordforwardandtotheright,destroyingthepedicleandthelaminaofthevertebra.

Fig.AFig.B动脉瘤样骨囊肿T1WIC+83Fig.AComputedtomographicsca骨嗜酸性肉芽肿EosinophilicGranuloma84骨嗜酸性肉芽肿EosinophilicGranuloma8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（Langerhanscellhistiocytosis）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死和囊变；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、刮除、瘤内注射激素，放疗和切除等85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，称扁平椎。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86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vertebraplanacanbeseen(arrow)inthethoracicspine,whichisconsistentwithLangerhan'scellhistiocytosis.8,yr,Mof

T扁平椎骨嗜酸性肉芽肿87vertebraplanacanbeseen(ar内生骨疣Enostosis88内生骨疣Enostosis88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。病变较出生时进展，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、脊柱和肋骨。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，其周围常常伴有放射状骨针。病变大小约2mmX2mm到6mmX10mm，大于2cm为巨大内生骨疣常无症状，偶然发现89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、内生骨疣影像表现X线平片和CT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MRI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通常为巨大内生骨疣，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％）。6个月内病变直径增加25%或1年内50%时应考虑该病90内生骨疣影像表现X线平片和CT90Fig.ALateralradiographshowsascleroticfocusintheanteriorportionofL-3(arrowhead).Fig.BCTscanrevealsadenselyscleroticlesionwithanirregularspiculatedborderjustbeneaththeanteriorcortextotheleftofmidline(arrowheads)66-yr-oldMEnostosisofL-3Fig.AFig.B内生骨疣毛刷状边缘91Fig.ALateralradiographshowsFig.ALateralradiographrevealsascleroticfocus(largearrows)withareasofspiculatedthornlikemargins(smallarrows).Fig.BPhotomicrograph(originalmagnification,X150;hematoxylin-eosinstain)showscorticalbone(arrows)withirregularmargins(arrowheads).35-yr-oldFGiantenostosisofL-2Fig.BFig.B92Fig.ALateralradiographrevea脊柱恶性肿瘤MalignantTumor93脊柱恶性肿瘤MalignantTumor93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94脊柱恶性肿瘤脊索瘤94脊索瘤

Chordoma95脊索瘤Chordoma95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、假囊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、蛛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以手术切除为主96脊索瘤临床病理少见，起源于脊索残余，占骨病变不到4%96脊索瘤影像表现X线肿瘤为溶骨性破坏，伴大的软组织肿块骶椎患骨常膨胀，瘤内50-70%见钙化钙化多无定形，位于病变周围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97脊索瘤影像表现X线97脊索瘤影像表现CT主要呈溶骨性破坏肿瘤分叶状，囊实性混杂密度，可见不规则钙化软组织肿块增强，轻至中度强化不易与转移瘤鉴别98脊索瘤影像表现CT98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MRI99脊索瘤影像表现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

转移性骨肿瘤

SecondaryTumororMetastaticTumor109转移性骨肿瘤SecondaryTumo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，放疗可试用于单发转移转移性骨肿瘤110临床病理脊柱转移常见转移性骨肿瘤110转移性骨肿瘤影像表现X线分为溶骨型、成骨型和混合型溶骨型：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，骨轮廓多无改变混合型转移兼有溶骨型和成骨型转移的骨质改变111转移性骨肿瘤影像表现X线111转移性骨肿瘤影像表现CT较X线敏感能显示局部软组织肿块的范围、大小及邻近脏器的关系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，一般无软组织肿块混合型兼有两者改变MRI能检出X线CT甚至核素显像不易发现的病灶多数肿瘤T1WI呈低信号，T2WI呈程度不高的高信号脂肪抑制序列显示更清楚112转移性骨肿瘤影像表现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1/3可转变为多发。晚期可广泛转移。老幼均可发病，40岁以上常见，男:女＝2:1表现为骨骼疼痛，软组织肿块，病理性骨折化学治疗对多发性骨髓瘤具有一定疗效；严重贫血者可输血；截瘫者施行椎板切除术；病理骨折者施用适当的外固定；疼痛严重者可施行放射线治疗127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骨髓瘤影像表现X线广泛性骨质疏松：脊柱有压缩骨折。多发性骨质破坏：穿凿状、鼠咬状骨质破坏，边缘清楚，无硬化边和骨膜反应骨质硬化：少见，又称硬化型骨髓瘤。表现为单纯硬化和/破坏与硬化并存。破坏区周围有硬化缘，病变周围有放射状骨针及弥漫性多发性硬化。骨髓瘤治疗后也可出现硬化软组织肿块：位于破坏区周围，很少跨越椎间盘水平至邻近椎旁平片约10%正常表现128骨髓瘤影像表现X线128骨髓瘤影像表现CT较X线平片更能早期显示骨质细微破坏和骨质疏松典型表现为松质骨内呈弥漫性分布、边缘清楚的溶骨性破坏区常见软组织肿块脊柱常病理性骨折，并硬膜外侵犯MRI对检出病变、确定病变范围非常敏感T1WI上，骨破坏区或骨髓浸润区呈低信号。“椒盐状”为特征性表现T2WI上呈高信号STIR序列病变高信号较T2WI更明显129骨髓瘤影像表现CT129

Left:Anteroposteriorradiographrevealingahighlydestructivelyticlesioninvolvingboththeleftiliacwingandleftsacrum.Right:AxialCTscanconfirminginvolvementofbothofthesebones,aswellasamoderate-sizedsoft-tissuemass.Plasmacytomasmaybeverylargeandelicitnoosseousreaction,asinthiscase.Thiscasealsodemonstratesthepropensityofaggressivelesionstocrossthesacroiliacjoint.61-year-oldmanwithmultiplemyeloma.多发骨髓瘤130Left:AnteroposteriorradiogrLyticexpansilemassofC5.TransverseCTimageatlevelofC5showsexpansilesoft-tissuemassalongright