脊柱肿瘤的影像学诊断.ppt

1、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脊 柱柱大体解剖颈段：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

2、：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posterior posterior Anterior Anterior R lateral R lateralL lateralL lateralC1-2C3-7TLSCo检检 查查 技技 术术 Examination Methods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

3、织结构 核素扫描:一种全身骨骼检查，但缺乏特异性 影影 像像 解解 剖剖 Radiologic Anatomy常 规 X 线 CTLA-PLateralL-oblique CT解剖T重建重建LCTCT解剖解剖解剖解剖MRIMRI解剖解剖解剖解剖C 脊柱良性肿瘤和肿瘤样病变脊柱良性肿瘤和肿瘤样病变 Benign Spinal Tumor and Tumorlike Lesion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骨血管瘤Hemangioma骨血管瘤 临床病

4、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 MRIT1WI和T2WI上均呈高信号增强扫描，中度至明显强化Plain film CTT骨血管瘤骨血管瘤T骨血管瘤骨血管瘤Fig.

5、A thickened trabeculae(corduroy sign)of a vertebral body hemangioma can be seen on this lateral view,which is coned down to the L2 vertebral bodyFig.B T1WI and Fig.C T2WI show the typical increased signal intensity of a vertebral body ABC骨血管瘤骨血管瘤骨软骨瘤骨软骨瘤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

6、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1.31.4%，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骨软骨瘤骨软骨瘤骨软骨瘤 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

7、）则应怀疑恶变38,yr,M of CHereditary multiple exostosis with several spinal osteochondromasFigA:Lateral radiograph of the cervical spine shows a C-4 spinous process osteochondroma with pathognomonic marrow and cortical continuity solid arrow).Osteochondroma at C-1 is seen as an ossified region(open rrow)Ax

8、ial FigB and sagittal FigC reconstructed CT scans reveal cortex and marrow of the osteochondroma(arrows),impingement on the spinal canal,extrinsic erosion of C-2(arrowheads in b),and continuity with the C-1 spinous process(*in c).A AB BC C骨软骨瘤骨软骨瘤骨软骨瘤骨软骨瘤Sagittal T1-weighted FigDand T2*gradient-echo

9、 FigEMR images reveal the signal intensity characteristic of yellow marrow within the osteochondroma and the impression of the tumor on the spinal canal(arrows),although the marrow and cortical continuity is not well seen.骨软骨瘤骨软骨瘤DDE EFigF:Photograph of the gross specimen shows the marrow and cortex

10、 of the osteochondroma and a small cartilage cap at its periphery(arrowheads).35yr，F Osteochondroma of sacrummalignant transformationFigAVague sclerosis(solid arrows)over the left sacrum and widening of the sacroiliac joint(open arrow).FigAFigCAxial CT scan shows the thick cartilage cap(arrows)and s

11、acroiliac joint invasion,which represents malignant transformation.FigB Coronal reconstructed CT scan shows the cortex and marrow canal of the osteochondroma(arrows)and continuity with the sacrum(arrowheads).Fig BFigCmultiple hereditary exostoses.Note that the large sacral lesion has normal cortex a

12、s well as marrow arising from the underlying bone.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

13、there is any question,MR imaging can demonstrate the cartilage thickness.In this case,we recognized multiple exostoses because of the presence of sessile lesions at the anterior superior iliac spines.10,yr,M Multiple hereditary exostoses骨巨细胞瘤骨巨细胞瘤Giant Cell Tumor,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

14、，可出血和坏死组织学分三级：级为良性，级为过渡类型，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

15、，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Fig A and Fig B a large expansile lesion of the T-4 vertebral body(arrows),with extension into the posterior elements of T-3 and T-4 and the posterior soft tissues(arrowheads).The lesion enhances m

16、arkedly with the contrast agent.FigC the lesion has only intermediate signal intensity,28,yr,FGCT of T-3 and T-4Sag.T1WIAxi.T1WI +cSag.T2WIA AC CB BT4T4骨巨细胞瘤骨巨细胞瘤骨巨细胞瘤骨巨细胞瘤Intraoperative photograph obtained after incision of the skin shows a bulging,solid paraspinal mass(*)FigD骨巨细胞瘤骨巨细胞瘤sacral GCT.A-PLateraLFig AFig bAxial CTSag.T2WI soft-tissue extension.Cor.T2WIFig CFig DFig EFig F骨骨巨巨细细胞胞瘤瘤GCT of S4-521 yr,FA-PLateraLAB骨巨细胞瘤骨巨细胞瘤FigC:CTshowing large mass of SFigD:demonstrating an inhomogeneou