脊柱腫瘤講座

脊柱腫瘤的影像學(xué)診斷脊柱大體解剖脊柱檢查技術(shù)脊柱影像解剖脊柱良性腫瘤和腫瘤樣病變脊柱惡性腫瘤脊柱大體解剖頸段：7個頸椎胸段：12個胸椎腰段：5個腰椎骶段：5個骶椎尾段：4個尾骨椎間盤、椎間關(guān)節(jié)、椎旁韌帶等胸段椎骨:椎體、椎弓和7個骨性突起組成椎弓:椎板、椎弓根，相鄰椎弓根間構(gòu)成椎間孔椎管:各椎骨的椎孔共同連成頸椎環(huán)椎:前后弓及兩側(cè)塊樞椎:齒狀突、椎體及棘突第3至第7椎體：逐漸增大，椎孔三角形，椎間關(guān)節(jié)面近呈水平位，鉤椎關(guān)節(jié)（Luscka關(guān)節(jié)）胸椎：逐漸增大，椎孔心形，關(guān)節(jié)突關(guān)節(jié)面呈冠狀位腰椎：椎體逐漸增大，椎孔呈三角形，關(guān)節(jié)突關(guān)節(jié)面呈矢狀位骶骨：骶骨倒立扁三角形，5個骶椎融合而成尾骨:4個尾椎融合而成

骨性椎管的特點

骨間連接椎體間連接前縱韌帶、后縱韌帶、椎間盤

椎板及附件間連接黃韌帶、棘間韌帶、棘上韌帶、項韌帶橫突間韌帶、關(guān)節(jié)突關(guān)節(jié)環(huán)樞關(guān)節(jié)、環(huán)椎橫韌帶posteriorAnteriorRlateralLlateralC1-2C3-7TLSCo檢查技術(shù)

ExaminationMethods檢查技術(shù)常規(guī)X線:最主要和首選的檢查方法

CT:解決臨床和X線診斷疑難的第二步檢查方法MRI:示X線甚至CT不能顯示和顯示不佳的某些組織結(jié)構(gòu)核素掃描:一種全身骨骼檢查，但缺乏特異性影像解剖

RadiologicAnatomy常規(guī)X線

CTLA-PLateralL-obliqueCT解剖T重建LCT解剖MRI解剖C

脊柱良性腫瘤和腫瘤樣病變

BenignSpinalTumorandTumorlikeLesion脊柱良性腫瘤和腫瘤樣病變骨血管瘤骨軟骨瘤骨巨細(xì)胞瘤骨樣骨瘤骨母細(xì)胞瘤動脈瘤樣骨囊腫骨嗜酸性肉芽腫內(nèi)生骨疣其它：軟骨黏液樣纖維瘤、纖維骨瘤、血管外皮細(xì)胞瘤和血管內(nèi)皮細(xì)胞瘤等骨血管瘤Hemangioma最常見的脊柱原發(fā)良性腫瘤低血壓慢血流血管組成，摻雜于骨小梁和脂肪間，易出血病理上分毛細(xì)血管型和海綿狀血管型多胸椎椎體,多單椎體病變?nèi)魏文挲g均可發(fā)生，一般無癥狀，多女性對放射線有相當(dāng)?shù)拿舾行怨茄芰雠R床病理

骨血管瘤影像表現(xiàn)X線一為受累骨體積擴(kuò)張，骨小梁廣泛的吸收、增生和增厚，椎體呈柵欄狀特征性表現(xiàn)一為受累骨質(zhì)有肥皂泡沫樣的破壞和擴(kuò)張骨血管瘤影像表現(xiàn)

CT椎體部分或全部松質(zhì)骨密度減低病變區(qū)骨小梁減少，變粗致密冠狀面或矢狀面重建顯示柵欄狀表現(xiàn)增強掃描，病變常不強化或輕度強化

MRIT1WI和T2WI上均呈高信號增強掃描，中度至明顯強化Plainfilm

CTT骨血管瘤T骨血管瘤Fig.Athickenedtrabeculae(corduroysign)ofavertebralbodyhemangiomacanbeseenonthislateralview,whichisconeddowntotheL2vertebralbodyFig.BT1WIandFig.CT2WIshowthetypicalincreasedsignalintensityofavertebralbody

ABC骨血管瘤骨軟骨瘤Osteochondroma臨床病理由骨質(zhì)組成的基底和瘤體、透明軟骨組成的帽蓋和纖維組成的包膜三種不同組織構(gòu)成,又稱外生骨疣發(fā)生于脊椎少見，發(fā)生于脊柱單發(fā)1.3～1.4%，多發(fā)者9%約50%于頸椎，其次胸椎及腰椎;常見于附件兒童期生長緩慢，青春期迅速近1％病人的骨軟骨瘤發(fā)生惡變多兒童和青年男性，一般無癥狀治療應(yīng)徹底手術(shù)切除骨軟骨瘤骨軟骨瘤影像表現(xiàn)X線僅21%的起于棘突的較大病變被明確診斷小病變和突入椎管內(nèi)的腫瘤很難診斷15%顯示正常骨軟骨瘤影像表現(xiàn)CT附件骨性腫塊，皮質(zhì)與椎板皮質(zhì)相連可伴脊髓受壓

MRI病灶中心T1WI呈高信號，T2WI呈中等信號邊緣皮質(zhì)均呈低信號軟骨帽常既薄又小，T1WI呈低至中等信號，T2WI呈高信號成人如軟骨帽明顯增厚（大于1-2cm）則應(yīng)懷疑惡變38,yr,Mof

CHereditarymultipleexostosiswithseveralspinalosteochondromasFigA:LateralradiographofthecervicalspineshowsaC-4spinousprocessosteochondromawithpathognomonicmarrowandcorticalcontinuitysolidarrow).OsteochondromaatC-1isseenasanossifiedregion(openrrow)AxialFigBandsagittalFigCreconstructedCTscansrevealcortexandmarrowoftheosteochondroma(arrows),impingementonthespinalcanal,extrinsicerosionofC-2(arrowheadsinb),andcontinuitywiththeC-1spinousprocess(*inc).ABC骨軟骨瘤SagittalT1-weightedFigDandT2*gradient-echoFigEMRimagesrevealthesignalintensitycharacteristicofyellowmarrowwithintheosteochondromaandtheimpressionofthetumoronthespinalcanal(arrows),althoughthemarrowandcorticalcontinuityisnotwellseen.骨軟骨瘤DEFigF:

Photographofthegrossspecimenshowsthemarrowandcortexoftheosteochondromaandasmallcartilagecapatitsperiphery(arrowheads).

35yr，F(xiàn)OsteochondromaofsacrummalignanttransformationFigAVaguesclerosis(solidarrows)overtheleftsacrumandwideningofthesacroiliacjoint(openarrow).FigAFigCAxialCTscanshowsthethickcartilagecap(arrows)andsacroiliacjointinvasion,whichrepresentsmalignanttransformation.FigB

CoronalreconstructedCTscanshowsthecortexandmarrowcanaloftheosteochondroma(arrows)andcontinuitywiththesacrum(arrowheads).FigBFigCmultiplehereditaryexostoses.Notethatthelargesacrallesionhasnormalcortexaswellasmarrowarisingfromtheunderlyingbone.Thisappearancedefinesanexostosis.Welookforathickcartilagecaptosuggestdegenerationofanexostosistoachondrosarcoma.Inthiscase,thereisnospaceforathickcapbecausetheedgeoftheexostosisextendstothesubcutaneoustissue.Ifthereisanyquestion,MRimagingcandemonstratethecartilagethickness.Inthiscase,werecognizedmultipleexostosesbecauseofthepresenceofsessilelesionsattheanteriorsuperioriliacspines.10,yr,MMultiplehereditaryexostoses骨巨細(xì)胞瘤GiantCellTumor,GCT骨巨細(xì)胞瘤臨床病理由軟而脆且易出血的肉芽樣組織所構(gòu)成，無纖維包膜，可出血和壞死組織學(xué)分三級：Ⅰ級為良性，Ⅱ級為過渡類型，Ⅲ級為惡性患者多女性，發(fā)病年齡多20-40歲約1/3發(fā)生于脊柱，最常累及骶骨，其次為胸椎、頸椎和腰椎；多見于附件絕大多數(shù)為良性，約25%為惡性臨床癥狀主要為局部疼痛、無力和感覺異常治療多全切治療，若僅刮除術(shù)會出現(xiàn)40-60%％復(fù)發(fā)骨巨細(xì)胞瘤影像表現(xiàn)X線典型呈膨脹性偏心性多房性骨質(zhì)破壞，骨殼較薄，輪廓一般完整，內(nèi)見纖細(xì)骨嵴構(gòu)成分房狀幾點提示惡性a，較明顯的侵襲性表現(xiàn)b，骨膜增生顯著c，軟組織腫塊較大，患者年齡較大，疼痛持續(xù)加重，腫瘤突然生長迅速CT椎體局限性膨脹性溶骨性破壞,皮質(zhì)連續(xù)若為侵襲性可侵犯數(shù)個椎體椎弓椎間盤，皮質(zhì)破壞，軟組織腫塊形成發(fā)生于骶骨時，一般位于骶髂關(guān)節(jié)附近，皮質(zhì)可中斷增強掃描低密度區(qū)散在強化MRIT1WI上呈低、中等信號；T2WI上呈不均勻中等信號?？梢娋植砍鲅盘栐鰪姾竺黠@強化核素掃描顯示腫瘤呈彌漫性的濃聚骨巨細(xì)胞瘤影像表現(xiàn)FigAandFigB

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

FigCthelesionhasonlyintermediatesignalintensity,28,yr,FGCTofT-3andT-4Sag.T1WIAxi.T1WI+cSag.T2WIACBT4骨巨細(xì)胞瘤Intraoperativephotographobtainedafterincisionoftheskinshowsabulging,solidparaspinalmass(*)

FigD骨巨細(xì)胞瘤sacralGCT.A-PLateraLFigAFigbAxialCTSag.T2WI

soft-tissueextension.Cor.T2WIFigCFigDFigEFigF骨巨細(xì)胞瘤GCTofS4-521yr,FA-PLateraLAB骨巨細(xì)胞瘤FigC:CTshowing

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

26,yr,FGCTofthesacrum.骨巨細(xì)胞瘤GCTofC-7

posteriorelements

16ymale骨巨細(xì)胞瘤TI

骨巨細(xì)胞瘤骨樣骨瘤OsteoidOsteoma骨樣骨瘤

臨床病理由成骨性纖維組織及骨樣組織、編織骨構(gòu)成，腫瘤本身為瘤巢直徑約1.5cm，很少超過2厘米,周圍由增生致密的反應(yīng)性骨質(zhì)包繞

10%發(fā)生于脊柱，多腰椎，最常起于椎弓，其次椎板，小關(guān)節(jié)面和椎弓根單發(fā)性，腫瘤發(fā)展極慢多為青少年和成年人，多男性，多小于30歲患骨疼痛，夜間加重，服用水楊酸類藥物可緩解為其特點?；颊咭蚣∪獐d攣而引起側(cè)彎治療以用手術(shù)切除最為適宜,預(yù)后良好骨樣骨瘤影像表現(xiàn)X線腫瘤所在部位骨質(zhì)破壞周圍不同程度的反應(yīng)性骨硬化偶見內(nèi)鈣化/骨化分皮質(zhì)型、松質(zhì)型、骨膜下型骨樣骨瘤影像表現(xiàn)CT類圓形的低密度骨破壞區(qū)，中央見不規(guī)則的鈣化骨化影周圍不同程度的反應(yīng)性骨硬化環(huán)MRI腫瘤未鈣化部分T1WI呈低至中等信號，T2WI呈高信號鈣化及周圍硬化帶均呈低信號增強后，病變強化明顯。核素掃描腫瘤顯示明顯核素濃聚FigA:Radiographrevealsasubtlelucentarea(arrow)inarightarticularmass.FigB:CTscanshowsthenidus(largearrowheads)withasmallcentralareaofcalcification(smallarrowhead)andminimalsurroundingsclerosis.FigC:Radiographoftheresectedspecimenshowsthattheniduswasentirelyremoved(arrows).FigD:Posteriorbonescanshowsintenseuptakeoftheradionuclidebythenidus(arrow)

17,yr,MOsteoidosteomaoflaminaatT-11ABCD骨樣骨瘤瘤巢FigE:Photographofthegrossspecimenrevealsthenidus(*)extendingtothefacetcartilage(arrows)骨樣骨瘤瘤巢AxialCTscan(left)revealingthatatumorarisingfromtheleftC-5pedicleiscompressingtheleftC-5root.Bonescan(center)displayshighuptakeofcontrastmaterial.AxialCTscan(right)demonstratingthatlefthemilaminectomywassufficienttoremovethetumor.16,yr,MOsteoidosteomaoflaminaatC-5骨樣骨瘤骨母細(xì)胞瘤Osteoblastoma骨母細(xì)胞瘤臨床病理多量骨母細(xì)胞增生形成骨樣組織和編織骨為特點。典型病變直徑為1.5cm～2cm不等腫瘤境界清楚，血管豐富，腫瘤體積較大時出現(xiàn)囊變，合并動脈瘤樣骨囊腫時則多數(shù)含血囊腔。少數(shù)腫瘤可發(fā)生惡變約30～40%發(fā)生于脊柱,頸椎、胸椎和腰椎發(fā)病率相近,腫瘤常累及附件男性多于女性，男:女＝2:1，發(fā)病年齡90%20～30歲患骨局部疼痛不適，脊髓和神經(jīng)壓迫癥狀。水楊酸類藥物無緩解和無明顯夜間疼痛與骨樣骨瘤鑒別。治療應(yīng)手術(shù)切除，病變復(fù)發(fā)率為10-15%X線三種表現(xiàn)a：中心低密度破壞區(qū)，周圍骨硬化，病灶直徑大于1.5cmb：有多發(fā)小鈣化的膨脹性破壞，周圍伴硬化緣c：為侵襲性表現(xiàn)，骨膨脹破壞，及周圍軟組織浸潤和混雜性鈣化骨母細(xì)胞瘤影像表現(xiàn)CT對腫瘤內(nèi)鈣/骨化影顯示高于平片,尤其對復(fù)雜部位腫瘤顯示較好類圓形膨脹性骨質(zhì)破壞，周圍有不同程度增生硬化破壞區(qū)骨殼可中斷,周圍軟組織可局限性腫脹MRI非鈣/骨化部分T1WI呈低至中等信號,T2WI呈高信號,鈣/骨化部分呈低信號病灶周圍骨髓和軟組織反應(yīng)性充血水腫，為長T1長T2信號可顯示骨殼中斷，椎管內(nèi)延伸和脊髓受壓合并動脈瘤樣骨囊腫時可見囊腔及液液平面

核素掃描腫瘤顯示明顯核素濃聚

骨母細(xì)胞瘤影像表現(xiàn)Fig.Ashowsamarkedlyexpansilelesioninvolvingthespinousprocessandlaminae(arrows),withvaguesclerosissuggestiveofmineralization.Fig.BCTscanrevealsthemarkedexpansionofthelesion,whichhasadefinedscleroticrim(arrows),anditsencroachmentonthespinalcanal.Matrixmineralization(arrowheads),16,yr,M.osteoblastoma

of

C-3

Fig.ALradiographFig.BCT骨母細(xì)胞瘤Axi.T1WIFigC

andSag.T2WI

FigD

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

Axi.T1WISag.T2WIFigCFigD:骨母細(xì)胞瘤FigE骨母細(xì)胞瘤FigA:CTscanshowsadestructive,expansilelesionoftheleftlateralsideofC-1(arrows)withsmallfociofmineralizedmatrixperipherally(arrowheads)andinvasionofthesurroundingsofttissuesandforamentransversarium.FigB:CoronalT2-weightedMRimageshowshighsignalintensitywithinthemass(arrows).FigC:Digitalsubtractionangiogramrevealstumorstain(straightarrows)andobstructionoftheleftvertebralartery(curvedarrow).

9,yr,M.Aggressive

osteoblastomaof

C1ABC骨母細(xì)胞瘤

(侵襲性)CTMRIDSALeft:AnteroposteriorradiographrevealingasubtlyexpandedlesionthatisnearthemidlineatS4-5(arrows).Right:AxialCTscandemonstratingbonematrixwithinthelesion,notaggressiveinappearance.16,yr,Mosteoblastoma

of

S4-5

骨母細(xì)胞瘤Left:

bonescanrevealinganeccentricallylocatedareaofincreaseduptakeinthesacrum.Right:

TheCTscandemonstratesaminimallyexpandedlesioncontainingdensebonematrixintherightsideofthelowersacrum.16,yr,M.osteoblastoma

of

S4-5

骨母細(xì)胞瘤Lateralx-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

骨母細(xì)胞瘤動脈瘤樣骨囊腫AneurysmalBoneCyst,ABC動脈瘤樣骨囊腫臨床病理原因不明的腫瘤樣病變，分原發(fā)和繼發(fā)兩種病變由大小不等的海綿狀血池組成，外壁為薄壁囊狀骨殼繼發(fā)者發(fā)生原有病變基礎(chǔ)上，包括骨巨細(xì)胞瘤、骨母細(xì)胞瘤、軟骨母細(xì)胞瘤和骨肉瘤等好發(fā)于青少年，多10～20歲，女性略多脊柱占12-30％，胸椎最常受累，其次腰椎和頸椎，骶骨罕見；病變位于椎弓及其突起臨床癥狀主要為病變侵犯椎管引起相應(yīng)部位疼痛和神經(jīng)壓迫癥狀可行刮除植骨術(shù)，還可栓塞治療和放療；總的復(fù)發(fā)率為20-30%。

動脈瘤樣骨囊腫影像表現(xiàn)X線典型表現(xiàn)為脊柱附件骨顯著膨脹的囊狀透亮區(qū)，外側(cè)為薄的骨殼，呈“氣球狀”囊內(nèi)有或粗或細(xì)的骨小梁狀分隔或骨嵴動脈瘤樣骨囊腫影像表現(xiàn)CT多呈囊狀膨脹性骨破壞，骨殼菲薄軟組織密度腫塊內(nèi)見斑片樣、條索狀及不定形鈣化，邊緣可有硬化有時可見液液平面，下部密度高于上部，隨體位而改變。MRI檢出液－液平面更敏感液－液平面是本病的重要特點，T2WI上層一般為高信號，可能為漿液或高鐵血紅蛋白，下層為低信號，可能有含鐵血黃素成分。核素掃描常表現(xiàn)為外周部位的核素攝取增加，呈“油炸圈餅”征Fig.A

andafterFig.B

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

SagittalT2-weightedMRimageshowsthattheentirelesioncontainsfluid-fluidlevels(arrows)resultingfromhemorrhagicspacesandshowstheextentofspinalcanalnarrowing.8yr,MABCofT3ABC動脈瘤樣骨囊腫T1WIC+T1WIT2WI液-液平面(血竇)Photographofthesagittallysectionedgrossspecimendemonstratesthemultipleblood-filledspaces(arrows)inthelesion.Fig.D血竇動脈瘤樣骨囊腫Fig.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(血竇)動脈瘤樣骨囊腫neurysmalBoneCystFig.AComputedtomographicscanshowingalyticlesionintheposteriorelementsofthevertebraeattheT10-T12level,withexpansiontothevertebralbodyfromtheleft.Thisprocesswithathinperiostealborderentersthespinalcanal,pressingthecordforwardandtotheright

Fig.BMagneticresonanceimagingafterinjectionwithgadoliniumshowsanonhomogeneousmultilobularlesionatT10-T12level,extradurallypressingthespinalcordforwardandtotheright,destroyingthepedicleandthelaminaofthevertebra.

Fig.AFig.B動脈瘤樣骨囊腫T1WIC+骨嗜酸性肉芽腫EosinophilicGranuloma骨嗜酸性肉芽腫臨床病理本病屬網(wǎng)狀內(nèi)皮系統(tǒng)類脂質(zhì)沉積病，稱朗罕氏細(xì)胞組織細(xì)胞病（Langerhanscellhistiocytosis）包括三種病變：勒－雪病、韓－薛－柯病和嗜酸性肉芽腫。其孤立形式為嗜酸性肉芽腫，為良性局限性組織細(xì)胞增生，為最輕型。椎體為主要原發(fā)部位，多單發(fā)，可多發(fā)。肉芽組織位于骨髓腔伴出血壞死和囊變；晚期常有結(jié)締組織增生，纖維化骨化好發(fā)于兒童及青年，男多于女患部輕微疼痛，壓痛，伴有功能障礙治療方案：保守治療、固定、刮除、瘤內(nèi)注射激素，放療和切除等骨嗜酸性肉芽腫影像表現(xiàn)生長迅速的溶骨性病變，常導(dǎo)致椎體變扁和硬化，稱扁平椎。平片即可容易診斷，CT及MRI對確定病變范圍很有幫助病變延伸到周圍軟組織時，CT及MRI不典型，需組織學(xué)證實vertebraplanacanbeseen(arrow)inthethoracicspine,whichisconsistentwithLangerhan'scellhistiocytosis.8,yr,Mof

T扁平椎骨嗜酸性肉芽腫內(nèi)生骨疣Enostosis內(nèi)生骨疣臨床病理內(nèi)生骨疣通常指骨島，也稱鈣化性骨髓缺損、內(nèi)生骨瘤組織學(xué)上骨疣為板層骨，哈佛氏系統(tǒng)包埋在髓管內(nèi)。病變較出生時進(jìn)展，并被認(rèn)為也會產(chǎn)生損害的病變。好發(fā)于中軸骨傾向，特別是骨盆、脊柱和肋骨。脊柱骨島發(fā)生率僅1%。尸檢14%脊柱內(nèi)生骨疣好發(fā)于胸椎(T1～T7)和腰椎（L2和L3），胸椎病變常位于中線右側(cè)，而腰椎常位于中線左側(cè)。病變常位于皮質(zhì)下，其周圍常常伴有放射狀骨針。病變大小約2mmX2mm到6mmX10mm，大于2cm為巨大內(nèi)生骨疣常無癥狀，偶然發(fā)現(xiàn)內(nèi)生骨疣影像表現(xiàn)X線平片和CT常具有特征性表現(xiàn)，為圓形或橢圓形成骨性病變，邊界清楚,邊緣呈“棘狀放射”征或“毛刷狀邊緣”。周圍骨小梁正常MRI在各序列均為低信號，棘狀邊緣顯示清楚。周圍骨髓信號正常核素掃描絕大多數(shù)內(nèi)生骨疣顯示為正常，無異常放射性核素濃聚。少數(shù)出現(xiàn)濃聚的病變通常為巨大內(nèi)生骨疣，占33％病變自然病史不同，絕大多數(shù)病變變化不大，部分可緩慢生長或體積減?。?1.9％）。6個月內(nèi)病變直徑增加25%或1年內(nèi)50%時應(yīng)考慮該病Fig.ALateralradiographshowsascleroticfocusintheanteriorportionofL-3(arrowhead).Fig.BCTscanrevealsadenselyscleroticlesionwithanirregularspiculatedborderjustbeneaththeanteriorcortextotheleftofmidline(arrowheads)66-yr-oldMEnostosisofL-3Fig.AFig.B內(nèi)生骨疣毛刷狀邊緣Fig.ALateralradiographrevealsascleroticfocus(largearrows)withareasofspiculatedthornlikemargins(smallarrows).Fig.BPhotomicrograph(originalmagnification,X150;hematoxylin-eosinstain)showscorticalbone(arrows)withirregularmargins(arrowheads).35-yr-oldFGiantenostosisofL-2Fig.BFig.B脊柱惡性腫瘤MalignantTumor脊柱惡性腫瘤脊索瘤轉(zhuǎn)移性骨腫瘤骨髓瘤軟骨肉瘤骨肉瘤未分化網(wǎng)狀細(xì)胞肉瘤和PNET淋巴瘤白血病綠色瘤其它：間質(zhì)軟骨肉瘤、纖維肉瘤均罕見脊索瘤

Chordoma脊索瘤

臨床病理少見，起源于脊索殘余，占骨病變不到4%50%于骶骨（主要S4-S5），其次35%斜坡，15%椎體（主要C2）.也為骶骨最常見的原發(fā)骨腫瘤

腫瘤呈分葉狀，有纖維假包膜，內(nèi)含灰白或淺黃色膠狀物；可出血、假囊腔以及肉芽樣組織腫瘤生長緩慢，局部侵襲性，不轉(zhuǎn)移,偶遠(yuǎn)處轉(zhuǎn)移,主要為肺、淋巴結(jié)、蛛網(wǎng)膜下腔和脊髓多男性，男：女=2-3:1；30-60歲，高峰年齡50歲癥狀多由腫瘤擴(kuò)大侵犯或壓迫鄰近重要組織或器官所引起治療以手術(shù)切除為主脊索瘤影像表現(xiàn)X線腫瘤為溶骨性破壞，伴大的軟組織腫塊骶椎患骨常膨脹，瘤內(nèi)50-70%見鈣化鈣化多無定形，位于病變周圍骶椎以上節(jié)段患骨較少膨脹改變，并可出現(xiàn)硬化呈“象牙椎”表現(xiàn)脊索瘤影像表現(xiàn)CT主要呈溶骨性破壞腫瘤分葉狀，囊實性混雜密度，可見不規(guī)則鈣化軟組織腫塊增強，輕至中度強化不易與轉(zhuǎn)移瘤鑒別脊索瘤影像表現(xiàn)MRT1WI：中等信號（占75%）

；低信號（占25%）T2WI：呈高信號，信號高于CSF增強：明顯強化MRI在顯示病變侵及的范圍方面優(yōu)于CTCT在確定腫瘤的性質(zhì)特點方面優(yōu)于MRIFig.ALateralradiographshowsdestructionofthedistalsacrumandcoccyxwithcalcification(arrow).Fig.BCTscanalsodemonstratesthebonedestructionandasoft-tissuemass(arrowheads)containingcalcifications(arrow)..Chordomaoflowersacrum48-year-oldmanFig.AFig.B脊索瘤Fig.CT1WISagittalandaxialT2WIFig.DMRimagesrevealtheexpansilesacrococcygeallesion(arrowheads),whichhashighsignalintensityonD.Fig.CFig.D脊索瘤Fig.E

Asseeninthissagittalsectionofthegrossspecimen,theMRimagingappearancecorrelateswiththeexpansilelesion(arrowheads)andcalcification(arrow).Theuppersacrum(*)isspared脊索瘤Fig.ALateralradiographshowsadensevertebralbody(arrows)atL-3.Fig.BSagittalreconstructedCTscanobtainedafterinitialopenbiopsyrevealsnotonlytheL-3sclerosisbutalsosimilarfindingsinthesuperioraspectofL-4(arrowheads).ChordomaofL13-year-oldman1-yrhistoryofintermittentlowbackpain.Fig.AFig.B脊索瘤SagittalT1WI

Fig.CandT2WIFig.DMRimagesbetterdelineatethemarrowinvolvementatL-3andL-4withextensionthroughthedisk(arrows).Themasshasmarkedhighsignalintensityond.Fig.CFig.DFig.Egrossspecimendepictstheextentoftheneoplasm,withdiffuseinvolvementofL-3(arrowheads),theadjacentdisk(*),andthesuperioraspectofL-4(arrows).Fig.E脊索瘤UpperLeftandRight:AxialCTscansdemonstratingalargesoft-tissuemassextendinganteriorlytoinvolvetherectumandposteriorlytoinvadethebuttocks;calcificationisseenwithinthemass.

LowerLeftandRight:SagittalfastspinechoT2-weightedandaxialT2-weightedMRimagesdemonstratingthelesioninfiltratingthepresacralregion,extendingtosurroundtherectumandtheperivesicalfatbutnotinvadingthebladder.24-yrMchordomainvolvingS3-5脊索瘤

Fig.

AandB:PreoperativeaxialCTscanandMRimagerevealingasacralchordoma.Fig.

C:Photographofahemisectionofgrosspathologicalspecimendemonstratingcompleteenblockresectionofthesacrum.

Fig.DandE:Postoperativeanteroposteriorandlateralradiographs.Fig.脊索瘤chordomaFig.AFig.B脊索瘤

轉(zhuǎn)移性骨腫瘤

SecondaryTumororMetastaticTumor臨床病理脊柱轉(zhuǎn)移常見轉(zhuǎn)移途徑主要是血行轉(zhuǎn)移，少數(shù)直接蔓延原發(fā)腫瘤常包括：前列腺癌、腎癌、甲狀腺癌、乳癌、肺癌和鼻咽癌等。骨肉瘤、尤文瘤和淋巴瘤也可發(fā)生骨轉(zhuǎn)移患者51～60歲最多臨床表現(xiàn)為疼痛、持續(xù)性、夜間加重?？沙霈F(xiàn)腫塊、病理骨折和壓迫癥狀治療可選用對原發(fā)瘤有效的化學(xué)治療(包括激素)和中藥治療，放療可試用于單發(fā)轉(zhuǎn)移轉(zhuǎn)移性骨腫瘤轉(zhuǎn)移性骨腫瘤影像表現(xiàn)X線分為溶骨型、成骨型和混合型溶骨型：椎體廣泛或局限性骨質(zhì)破壞，椎體常變扁，椎間隙多保持完整。椎弓根常受侵蝕破壞成骨型：少見。大多前列腺癌引起，少數(shù)為乳癌、鼻咽癌、肺癌和膀胱癌。呈斑片狀、結(jié)節(jié)狀高密度，位于松質(zhì)骨內(nèi)，邊界清楚或不清。骨皮質(zhì)多完整，骨輪廓多無改變混合型轉(zhuǎn)移兼有溶骨型和成骨型轉(zhuǎn)移的骨質(zhì)改變轉(zhuǎn)移性骨腫瘤影像表現(xiàn)CT較X線敏感能顯示局部軟組織腫塊的范圍、大小及鄰近臟器的關(guān)系溶骨型為松質(zhì)骨和或皮質(zhì)骨的低密度缺損區(qū)，常伴軟組織腫塊成骨型為松質(zhì)骨內(nèi)斑點狀、片狀、棉團(tuán)狀或結(jié)節(jié)狀邊緣模糊的高密度灶，一般無軟組織腫塊混合型兼有兩者改變MRI能檢出X線CT甚至核素顯像不易發(fā)現(xiàn)的病灶多數(shù)腫瘤T1WI呈低信號，T2WI呈程度不高的高信號脂肪抑制序列顯示更清楚Magneticresonanceimagingstudyofthespineshowsadestructivelesioninthesecondlumbarvertebrawithextensionintothespinalcanal.Abdominalcomputedtomographicscanshowshepaticmetastasesandanirregularmassintheregionofthepancreas.

Fig.AFig.BFig.BFig.AscleroticmetastasesFigure.SagittalT1-weightedMRimageofthelumbosacralspineshowsmultiplehypointensefociwithinthesacrumandlumbarvertebrae.TheselesionsremainedhypointensewithalloftheMRimagingsequencesanddidnotexhibitenhancement.Plainradiographyrevealedscleroticmetastases.77-yrFMetastaticbreastcancerFractureFracturestenosismassExtensiveosseousmetastasesfromlungcarcinoma.Anterior(left)andposterior(right)wholebodybonescintigramsshowmultiple,randomlydistributedfociofabnormalradiotraceruptake.Thefocivaryinsizeandintensity.Fig.A:SagittalT2-weightedMRimagedemonstratinginvolvementoftheposteriorelementsofL-3(arrow).

Fig.B:AxialT1-weightedMRimagerevealingtheL-3spinousprocessandlaminainfiltratedbytumor,withanteriorstructuresintact(arrow).

Fig.E:Bonescandemonstratingnumerousadditionalsitesofmetastaticdisease(ribs,skull,andscapula)inadditiontoL-3(arrow).Thepatientunderwentsimpleposteriordecompression.

54-yrMmetastaticrenalcellcarcinomaABCSag.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)50-yrFbreastcarcinomamastectomy5yrsearlierLeft:PostoperativeplainnteroposteriorradiographobtainedafterT-2corpectomyandT1-3stabilizationperformedviaamediansternotomyapproach(notethesternalwires(arrow)Right:PostoperativeaxialCTscandemonstratinggoodspinaldecompression,structuraliliaccrestautograftstrut,andananteriorplate.62-yrMlargecellCaofthelung

NeuroimagesdemonstratingreconstructionafterC-4corpectomyforarenalcellmetastasis;stabilizationwasachievedusingatitaniummeshinterbodycageandchesttubeconstructfilledwithPMMA,supplementedbyananteriorcervicalplate.

Left:PreoperativeT2-weightedmagneticresonanceimage,sagittalview,revealingVBcollapseatC-4.Right:Postoperativecervicalx-rayfilm,lateralview.

Fig.A

Preoperativeplainx-rayfilmshowingmarkeddestructionoftheC-3VBandassociatedkyphoticeformity.

Fig.B

Postoperativex-rayfilmshowingplacementoftheTPSdeviceintotheC-3corpectomydefect,restoringanteriorcolumnheight.

Fig.C

IllustrationsoftheTPSdevice.Theapparatusisexpandabletofitthesizeofthecorpectomydefectandcanbefilledwithboneautograftifdesired.SquamouscellcarcinomaofthelungmetastatictoC-3.ABC骨髓瘤Myeloma骨髓瘤臨床病理骨髓瘤，又稱漿細(xì)胞瘤。起源于骨髓網(wǎng)織細(xì)胞的惡性腫瘤，為圓而脆軟的實質(zhì)新生物椎體為其好發(fā)部位，絕大多數(shù)為多發(fā)；單發(fā)少見，且約1/3可轉(zhuǎn)變?yōu)槎喟l(fā)。晚期可廣泛轉(zhuǎn)移。老幼均可發(fā)病，40歲以上常見，男:女＝2:1表現(xiàn)為骨骼疼痛，軟組織腫塊，病理性骨折化學(xué)治療對多發(fā)性骨髓瘤具有一定療效；嚴(yán)重貧血者可輸血；截癱者施行椎板切除術(shù)；病理骨折者施用適當(dāng)?shù)耐夤潭ǎ惶弁磭?yán)重者可施行放射線治療骨髓瘤影像表現(xiàn)X線廣泛性骨質(zhì)疏松：脊柱有壓縮骨折。多發(fā)性骨質(zhì)破壞：穿鑿狀、鼠咬狀骨質(zhì)破壞，邊緣清楚，無硬化邊和骨膜反應(yīng)骨質(zhì)硬化：少見，又稱硬化型骨髓瘤。表現(xiàn)為單純硬化和/破壞與硬化并存。破壞區(qū)周圍有硬化緣，病變周圍有放射狀骨針及彌漫性多發(fā)性硬化。骨髓瘤治療后也可出現(xiàn)硬化軟組織腫塊：位于破壞區(qū)周圍，很少跨越椎間盤水平至鄰近椎旁平片約10%正常表現(xiàn)骨髓瘤影像表現(xiàn)CT較X線平片更能早期顯示骨質(zhì)細(xì)微破壞和骨質(zhì)疏松典型表現(xiàn)為松質(zhì)骨內(nèi)呈彌漫性分布、邊緣清楚的溶骨性破壞區(qū)常見軟組織腫塊脊柱常病理性骨折，并硬膜外侵犯MRI