脊柱肿瘤影像学诊断讲座

脊柱肿瘤的影像学诊断上海中医药大学龙华医院放射科王嵩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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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骨巨细胞瘤影像表现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:Axia