脊柱肿瘤的影像学诊断课件.ppt

1、1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

2、5 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6789101112131415Examination Methods16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 17Radiologic Anatomy18 19202122T重建重建23L24C25Benign Spinal Tumor and Tumorlike Lesion26骨血管瘤骨软骨瘤骨巨细胞瘤骨样骨瘤骨母

3、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27Hemangioma28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

4、MRIT1WI和T2WI上均呈高信号增强扫描，中度至明显强化313233Fig. 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 bodyABC34Osteochondroma3

5、5 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1.31.4%，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36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

6、显增厚（大于1-2cm）则应怀疑恶变3838, 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 re

7、gion (open rrow)Axial 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). 39Sagittal T1-weighted FigDand T2* gradient-

8、echo 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. 40FigF: Photograph of the gross specimen shows the marrow and cortex of

9、 the osteochondroma and a small cartilage cap at its periphery (arrowheads).4135yr，F Osteochondroma of sacrummalignant transformationFigAVague sclerosis (solid arrows) over the left sacrum and widening of the sacroiliac joint (open arrow).FigA42FigCAxial CT scan shows the thick cartilage cap (arrows

10、) and sacroiliac 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 BFigC43multiple hereditary exostoses. Note that the large sacral lesion has n

11、ormal cortex as 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 subcu

12、taneous tissue. If 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 exostoses44Giant Cell Tumor, GCT45临床病理由软而脆且易出血的肉

13、芽样组织所构成，无纤维包膜，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46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

14、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48Fig 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 les

15、ion enhances markedly with the contrast agent. FigC the lesion has only intermediate signal intensity, 28,yr,FGCT of T-3 and T-4Sag.T1WIAxi.T1WI +cSag.T2WI49Intraoperative photograph obtained after incision of the skin shows a bulging, solid paraspinal mass (*)FigD50sacral GCT.A-PLateraLFig AFig b51

16、Axial CTSag.T2WI soft-tissue extension.Cor.T2WIFig CFig DFig EFig F52GCT of S4-521 yr ,FA-PLateraLAB53FigC:CTshowing large mass of SFigD: demonstrating an inhomogeneous mass that contains several areas of low signal intensity (arrows; contrast this signal to the very high signal intensity FigE: reve

17、aling that the lesion is of low signal intensity; the large presacral mass displacing the rectum is confirmed. FigF:revealing only mild enhancement, again with several areas of relatively low signal intensity. These low-signal regions represent a common feature in GCTsAxial CTSag. T1WIAxi. FSE T2WIS

18、ag. FS T1WI +C54Upper Left: Anteroposterior radiograph emonstrating the expanded lytic lesion ccupying the sacrum. Upper Right and Center Left: Axial CT scans obtained several months later, demonstrating the rather featureless lytic lesion occupying the entire sacrum, with attempted thin cortical ri

19、m unable to contain the expansive lesion. Center Right: Sagittal T1-weighted MR image (TR/TE 450/10 msec) demonstrating intensity presacral soft-tissue extensionLower Left and Right: Sagittal T2WI and axial FSE T2WI revealing the inhomogeneous mixed high and low signal intensity mass, typical of GCT

20、.26, yr, F GCT of the sacrum.55GCT of C-7 posterior elements16 y male5657Osteoid Osteoma58 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影像表现X线 肿瘤所在部位骨质破坏 周围不同程度

21、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61FigA: Radiograph reveals a subtle lucent area (arrow) in a right articular mass.FigB: CT scan shows the nidus (large arrowheads) with a small central a

22、rea of calcification (small arrowhead) and minimal surrounding sclerosis. FigC: Radiograph of the resected specimen shows that the nidus was entirely removed (arrows).FigD: Posterior bone scan shows intense uptake of the radionuclide by the nidus (arrow) 17, yr, M Osteoid osteoma of lamina at T-11 6

23、2FigE: Photograph of the gross specimen reveals the nidus (*)extending to the facet cartilage (arrows)63Axial CT scan (left) revealing that a tumor arising from the left C-5 pedicle is compressing the left C-5 root.Bone scan (center) displays high uptake of contrast material. Axial CT scan (right) d

24、emonstrating that left hemilaminectomy was sufficient to remove the tumor.16, yr, M Osteoid osteoma of lamina at C-5 64Osteoblastoma65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1.5cm2cm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3040%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% 2030岁患骨局部疼痛不适，脊髓和

25、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，

26、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 68Fig.Ashows a markedly expansile lesion involving the spinous process and laminae (arrows), with vague sclerosis suggestive of mineralization. Fig.BCT scan reveals the marked expansion of the lesion, which has a defined sclerotic rim (arrows), and its en

27、croachment on the spinal canal. Matrix mineralization (arrowheads), 16, yr, M. osteoblastoma of C-3 Fig.A L radiographFig.B CT69Axi. T1WI FigCand Sag. T2WI FigD show the mass (arrows) and its degree of encroachment on the spinal canal (arrowheads in c). Because of its extensive mineralization, the m

28、ass has relatively low signal intensity on the T2-weighted image. Axi. T1WISag. T2WIFigCFigD:70FigE71FigA: CT scan shows a destructive, expansile lesion of the left lateral side of C-1 (arrows) with small foci of mineralized matrix peripherally (arrowheads) and invasion of the surrounding soft tissu

29、es and foramen transversarium. FigB: Coronal T2-weighted MR image shows high signal intensity within the mass (arrows). FigC: Digital subtraction angiogram reveals tumor stain (straight arrows) and obstruction of the left vertebral artery (curved arrow).9, yr, M. Aggressive osteoblastoma of C172Left

30、: Anteroposterior radiograph revealing a subtly expanded lesion 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, M osteoblastoma of S4-5 73Left: bone scan revealing an eccentrically located area of incre

31、ased uptake in the sacrum. Right: The CT scan demonstrates a minimally expanded lesion containing dense bone matrix in the right side of the lower sacrum. 16, yr, M. osteoblastoma of S4-5 74Lateral x-ray films (a) showed a soft-tissue swelling in the retropharyngeal space. Lateral (b) and coronal (c

32、) MR images demonstrating tumor in the C-2 body and a soft-tissue mass from C16.Axial CT scan (d) demonstrating a typical osteoid nidus with peritumoral sclerotic rim on the right side of the C-2 body. Technetium bone scan (e) also displays pronounced uptake in this region. We performed tumor excisi

33、on via an anterolateral retropharyngeal approach (f) occipitocervical fixation by using two axis plates and titanium wires (g). Lateral x-ray films obtained immediately after (h) and 2 years postsurgery (i) showing solid fusion.10, yr, M osteoblastoma of C2 75Aneurysmal Bone Cyst, ABC76临床病理原因不明的肿瘤样病

34、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1020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

35、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79Fig.A and after Fig.B administration of gadopentetate dimeglumine reveal a markedly expansile lesion involving the laminae of T-3 (large arrowheads) and encroaching on the sp

36、inal canal (small arrowheads). Enhancement occurs largely in the periphery and septations of the lesion. Fig.C Sagittal T2-weighted MR image shows that the entire lesion contains fluid-fluid levels (arrows) resulting from hemorrhagic spaces and shows the extent of spinal canal narrowing. 8yr, M ABC

37、of T3ABC动脉瘤样骨囊肿动脉瘤样骨囊肿液-液平面(血窦)80Photograph of the sagittally sectioned gross specimen demonstrates the multiple blood-filled spaces (arrows) in the lesion. Fig.D血窦血窦动脉瘤样骨囊肿动脉瘤样骨囊肿81Fig.A The anteroposterior radiograph can be easily misread as normal because of the overlying bowel gas obscuring the

38、sacrumFig.B A lateral radiograph demonstrates only obscuration of the S-3 posterior elements (arrows)Fig.CThe lesion is more readily seen on the CT scan obtained with the patient in a prone position. This scan demonstrates a lytic lesion occupying the left S-3 ala, with a thin cortical rim surroundi

39、ng the majority of the lesion. Note that the more lucent regions in the center of the lesion actually represent fluid levels. Fig.DFluid levels (short arrow) are more readily observed on a sagittal T1-weighted MR image; remember that the patient is supine in the imager and that the fluid levels on t

40、he sagittal exam would then be expected to appear vertical, as in this case. The high signal intensity portion of the fluid is blood. Most, but not all, ABCs contain fluid levels. Conversely, most lesions with substantial fluid levels are ABCs, but such levels may occur in other lesions as well. Not

41、e also in this case that there is a substantial component of the lesion located anteriorly to the fluid levels that is solid (long arrows). 14, yr, M ABC of SADCB液-液平面(血窦)动脉瘤样骨囊肿动脉瘤样骨囊肿82neurysmal Bone CystFig.A Computed tomographic scan showing alytic lesion in the posterior elements of the vertebr

42、ae at the T10-T12 level, with expansion to the vertebral body from the left. This process with a thin periosteal border enters the spinal canal, pressing the cord forward and to the rightFig.B Magnetic resonance imaging after injection with gadolinium shows a nonhomogeneous multilobular lesion at T1

43、0-T12 level, extradurally pressing the spinal cord forward and to the right, destroying the pedicle and the lamina of the vertebra.Fig.AFig.B动脉瘤样骨囊肿动脉瘤样骨囊肿83Eosinophilic Granuloma84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

44、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86vertebra plana can be seen (arrow) in the thoracic spine, which is consistent with Langerhans cell his

45、tiocytosis.8, yr, M of T87Enostosis 88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(T1T7)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

46、，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90Fig.A Lateral radiograph shows a sclerotic focus in the anterior portion of L-3 (arrowhead). Fig.B CT scan reveals a den

47、sely sclerotic lesion with an irregular spiculated border just beneath the anterior cortex to the left of midline (arrowheads)66-yr-old M Enostosis of L-3Fig.AFig.B91Fig.A Lateral radiograph reveals a sclerotic focus (large arrows) with areas of spiculated thornlike margins (small arrows). Fig.B Pho

48、tomicrograph (original magnification, X150; hematoxylin-eosin stain) shows cortical bone (arrows) with irregular margins (arrowheads). 35-yr-old FGiant enostosis of L-2Fig.BFig.B92Malignant Tumor93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 Chordoma95临床病理少见，起源于脊索残余，占骨病变不到4%5

49、0%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影像表现CT主要呈溶骨性破坏肿瘤分叶状

50、，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MRI99Fig.ALateral radiograph shows destruction of the distal sacrum and coccyx with calcification (arrow). Fig.BCT scan also demonstrates the bone destruction and a s