脊柱肿瘤的影像学诊断

脊柱肿瘤的影像学诊断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脊柱恶性肿瘤脊柱大体解剖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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posteriorAnteriorRlateralLlateralC1-2C3-7TLSCo检查技术ExaminationMethods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，但缺乏特异性影像解剖RadiologicAnatomy常规X线CTLA-PLateralL-obliqueCT解剖T重建LCT解剖MRI解剖C脊柱良性肿瘤和肿瘤样病变BenignSpinalTumorandTumorlikeLesion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骨血管瘤Hemangioma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MRIT1WI和T2WI上均呈高信号增强扫描，中度至明显强化PlainfilmCTT骨血管瘤T骨血管瘤Fig.Athickenedtrabeculae(corduroysign)ofavertebralbodyhemangiomacanbeseenonthislateralview,whichisconeddowntotheL2vertebralbodyFig.BT1WIandFig.CT2WIshowthetypicalincreasedsignalintensityofavertebralbodyABC骨血管瘤骨软骨瘤Osteochondroma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,yr,MofCHereditarymultipleexostosiswithseveralspinalosteochondromasFigA:LateralradiographofthecervicalspineshowsaC-4spinousprocessosteochondromawithpathognomonicmarrowandcorticalcontinuitysolidarrow).OsteochondromaatC-1isseenasanossifiedregion(openrrow)AxialFigBandsagittalFigCreconstructedCTscansrevealcortexandmarrowoftheosteochondroma(arrows),impingementonthespinalcanal,extrinsicerosionofC-2(arrowheadsinb),andcontinuitywiththeC-1spinousprocess(*inc).ABC骨软骨瘤SagittalT1-weightedFigDandT2*gradient-echoFigEMRimagesrevealthesignalintensitycharacteristicofyellowmarrowwithintheosteochondromaandtheimpressionofthetumoronthespinalcanal(arrows),althoughthemarrowandcorticalcontinuityisnotwellseen.骨软骨瘤DEFigF:Photographofthegrossspecimenshowsthemarrowandcortexoftheosteochondromaandasmallcartilagecapatitsperiphery(arrowheads).35yr，FOsteochondromaofsacrummalignanttransformationFigAVaguesclerosis(solidarrows)overtheleftsacrumandwideningofthesacroiliacjoint(openarrow).FigAFigCAxialCTscanshowsthethickcartilagecap(arrows)andsacroiliacjointinvasion,whichrepresentsmalignanttransformation.FigBCoronalreconstructedCTscanshowsthecortexandmarrowcanaloftheosteochondroma(arrows)andcontinuitywiththesacrum(arrowheads).FigBFigCmultiplehereditaryexostoses.Notethatthelargesacrallesionhasnormalcortexaswellasmarrowarisingfromtheunderlyingbone.Thisappearancedefinesanexostosis.Welookforathickcartilagecaptosuggestdegenerationofanexostosistoachondrosarcoma.Inthiscase,thereisnospaceforathickcapbecausetheedgeoftheexostosisextendstothesubcutaneoustissue.Ifthereisanyquestion,MRimagingcandemonstratethecartilagethickness.Inthiscase,werecognizedmultipleexostosesbecauseofthepresenceofsessilelesionsattheanteriorsuperioriliacspines.10,yr,MMultiplehereditaryexostoses骨巨细胞瘤GiantCellTumor,GCT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MRI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增强后明显强化核素扫描显示肿瘤呈弥漫性的浓聚FigAandFigBalargeexpansilelesionoftheT-4vertebralbody(arrows),withextensionintotheposteriorelementsofT-3andT-4andtheposteriorsofttissues(arrowheads).Thelesionenhancesmarkedlywiththecontrastagent.FigCthelesionhasonlyintermediatesignalintensity,28,yr,FGCTofT-3andT-4Sag.T1WIAxi.T1WI+cSag.T2WIACBT4骨巨细胞瘤Intraoperativephotographobtainedafterincisionoftheskinshowsabulging,solidparaspinalmass(*)FigD骨巨细胞瘤sacralGCT.A-PLateraLFigAFigbAxialCTSag.T2WIsoft-tissueextension.Cor.T2WIFigCFigDFigEFigF骨巨细胞瘤GCTofS4-521yr,FA-PLateraLAB骨巨细胞瘤FigC:CTshowinglargemassofSFigD:demonstratinganinhomogeneousmassthatcontainsseveralareasoflowsignalintensity(arrows;contrastthissignaltotheveryhighsignalintensityFigE:revealingthatthelesionisoflowsignalintensity;thelargepresacralmassdisplacingtherectumisconfirmed.FigF:revealingonlymildenhancement,againwithseveralareasofrelativelylowsignalintensity.Theselow-signalregionsrepresentacommonfeatureinGCTsCDEFAxialCTSag.T1WIAxi.FSET2WISag.FST1WI+C骨巨细胞瘤UpperLeft:Anteroposteriorradiographemonstratingtheexpandedlyticlesionccupyingthesacrum.UpperRightandCenterLeft:AxialCTscansobtained