1、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大體解剖頸段：7個(gè)頸椎胸段：12個(gè)胸椎腰段：5個(gè)腰椎骶段：5個(gè)骶椎尾段：4個(gè)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(gè)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(gè)骶椎融合而成尾骨: 4個(gè)尾椎融合而成 椎體間連

2、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(xiàng)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Examination Methods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 Radiologic Anatomy T重建重建LC Benign Spinal Tumor and Tumorlike Lesion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(dòng)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)

3、胞瘤和血管內(nèi)皮細(xì)胞瘤等Hemangioma臨床病理 最常見(jiàn)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 任何年齡均可發(fā)生，一般無(wú)癥狀，多女性對(duì)放射線有相當(dāng)?shù)拿舾行?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(qiáng)掃描，病變常不強(qiáng)化或輕度強(qiáng)化 MRIT1WI和T2WI上均呈高信號(hào)增強(qiáng)掃描，中度至明顯強(qiáng)化Fig. A thickened trab

4、eculae (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 bodyABCOsteochondroma 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(jiàn)，發(fā)生于

5、脊柱單發(fā)1.31.4%，多發(fā)者9%約50%于頸椎，其次胸椎及腰椎;常見(jiàn)于附件兒童期生長(zhǎng)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(wú)癥狀治療應(yīng)徹底手術(shù)切除影像表現(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 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(hào)，T2WI呈中等信號(hào)邊緣皮質(zhì)均呈低信號(hào)軟骨帽常既薄又小，T1WI呈低至中等信號(hào)，T2WI呈高信號(hào)成人如軟骨帽明顯增厚（大于1-2cm）則應(yīng)懷疑惡變38, yr, M of CHereditary multiple exostosis wit

6、h 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)Axial FigB and sagittal FigC reconstructed CT scans

7、 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). Sagittal T1-weighted FigDand T2* gradient-echo FigEMR images reveal the signal intensity characteristic of yell

8、ow 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. FigF: Photograph of the gross specimen shows the marrow and cortex of the osteochondroma and a small cartilage cap at its periphery (arrowhe

9、ads).35yr，F(xiàn) 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 sacroiliac joint invasion, which represents malignant transformation.

10、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 as well as marrow arising from the underlying bone. This appeara

11、nce 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 there is any question, MR imaging can demonstrate the cart

12、ilage 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 exostosesGiant Cell Tumor, GCT臨床病理由軟而脆且易出血的肉芽樣組織所構(gòu)成，無(wú)纖維包膜，可出血和壞死組織學(xué)分三級(jí)：級(jí)為良性，級(jí)為過(guò)渡類型，級(jí)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

13、椎、頸椎和腰椎；多見(jiàn)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(wú)力和感覺(jué)異常治療多全切治療，若僅刮除術(shù)會(huì)出現(xiàn)40-60%復(fù)發(fā)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(jiàn)纖細(xì)骨嵴構(gòu)成分房狀幾點(diǎn)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(zhǎng)迅速影像表現(xiàn)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(gè)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(shí)，一般位于骶髂關(guān)節(jié)附近，皮質(zhì)可中斷增強(qiáng)掃描低密度區(qū)散在強(qiáng)化MRIT1WI上呈低、中等信號(hào)；T2WI上呈不均勻中等信號(hào)。可見(jiàn)局部

14、出血信號(hào)增強(qiáng)后明顯強(qiáng)化核素掃描顯示腫瘤呈彌漫性的濃聚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 markedly with the contrast agent. FigC the lesion has only intermediate si

15、gnal intensity, 28,yr,FGCT of T-3 and T-4Sag.T1WIAxi.T1WI +cSag.T2WIIntraoperative photograph obtained after incision of the skin shows a bulging, solid paraspinal mass (*)FigDsacral GCT.A-PLateraLFig AFig bAxial CTSag.T2WI soft-tissue extension.Cor.T2WIFig CFig DFig EFig FGCT of S4-521 yr ,FA-PLate

16、raLABFigC: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: revealing that the lesion is of low signal intensity; the large presacral mass displacing the rectum

17、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 T2WISag. FS T1WI +CUpper Left: Anteroposterior radiograph emonstrating the expanded lytic lesion ccupy

18、ing 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 rim unable to contain the expansive lesion. Center Right: Sagittal T1-weighted MR image (TR/TE 450/10

19、 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.26, yr, F GCT of the sacrum.GCT of C-7 posterior elements16 y maleOsteoid Osteoma 臨床病理由成骨性纖維組織及骨樣組

20、織、編織骨構(gòu)成，腫瘤本身為瘤巢直徑約1.5cm，很少超過(guò)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(diǎn)。患者因肌肉痙攣而引起側(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(jiàn)內(nèi)鈣化/骨化 分皮質(zhì)型、松質(zhì)型、骨膜下型影像表現(xiàn)CT類圓形的低密度骨破壞區(qū)，中央見(jiàn)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(hào)，T2WI呈高信號(hào) 鈣化及

21、周圍硬化帶均呈低信號(hào) 增強(qiáng)后，病變強(qiáng)化明顯。核素掃描腫瘤顯示明顯核素濃聚FigA: Radiograph reveals a subtle lucent area (arrow) in a right articular mass.FigB: CT scan shows the nidus (large arrowheads) with a small central area of calcification (small arrowhead) and minimal surrounding sclerosis. FigC: Radiograph of the resected specim

22、en 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 FigE: Photograph of the gross specimen reveals the nidus (*)extending to the facet cartilage (arrows)Axial CT scan

23、 (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) demonstrating that left hemilaminectomy was sufficient to remove the tumor.16, yr, M Osteoid osteoma of lamina at C-5

24、Osteoblastoma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(diǎn)。典型病變直徑為1.5cm2cm不等腫瘤境界清楚，血管豐富，腫瘤體積較大時(shí)出現(xiàn)囊變，合并動(dòng)脈瘤樣骨囊腫時(shí)則多數(shù)含血囊腔。少數(shù)腫瘤可發(fā)生惡變約3040%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% 2030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(wú)緩解和無(wú)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%影像表現(xiàn)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

25、膨脹破壞，及周圍軟組織浸潤(rùn) 和混雜性鈣化影像表現(xiàn)CT對(duì)腫瘤內(nèi)鈣/骨化影顯示高于平片,尤其對(duì)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(hào),T2WI呈高信號(hào), 鈣/骨化部分呈低信號(hào)病灶周圍骨髓和軟組織反應(yīng)性充血水腫，為長(zhǎng)T1長(zhǎng)T2信號(hào)可顯示骨殼中斷，椎管內(nèi)延伸和脊髓受壓合并動(dòng)脈瘤樣骨囊腫時(shí)可見(jiàn)囊腔及液液平面 核素掃描腫瘤顯示明顯核素濃聚 Fig.Ashows a markedly expansile lesion involving the spinous process and laminae

26、 (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 encroachment on the spinal canal. Matrix mineralization (arrowheads), 16, yr, M. osteoblastoma of C-3 Fig.A L radiographFig.B CTA

27、xi. 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 mass has relatively low signal intensity on the T2-weighted image. Axi. T1WISag. T2WIFigCFigD:FigEFigA: CT scan shows a destructiv

28、e, 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 tissues and foramen transversarium. FigB: Coronal T2-weighted MR image shows high signal intensity within the mass (arrows). FigC: Digital

29、 subtraction angiogram reveals tumor stain (straight arrows) and obstruction of the left vertebral artery (curved arrow).9, yr, M. Aggressive osteoblastoma of C1Left: Anteroposterior radiograph revealing a subtly expanded lesion that is near the midline at S4-5 (arrows). Right: Axial CT scan demonst

30、rating bone matrix within the lesion, not aggressive in appearance.16, yr, M osteoblastoma of S4-5 Left: bone scan revealing an eccentrically located area of increased uptake in the sacrum. Right: The CT scan demonstrates a minimally expanded lesion containing dense bone matrix in the right side of

31、the lower sacrum. 16, yr, M. osteoblastoma of S4-5 Lateral x-ray films (a) showed a soft-tissue swelling in the retropharyngeal space. Lateral (b) and coronal (c) 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 wit

32、h 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 excision via an anterolateral retropharyngeal approach (f) occipitocervical fixation by using two axis plates and titanium wires (g). Lateral x-r

33、ay films obtained immediately after (h) and 2 years postsurgery (i) showing solid fusion.10, yr, M osteoblastoma of C2 Aneurysmal Bone Cyst, ABC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1020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(jiàn)；病變位于椎弓及其突起臨床癥狀主要為病變侵犯椎管

34、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%。 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(jiàn)斑片樣、條索狀及不定形鈣化，邊緣可有硬化有時(shí)可見(jiàn)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(diǎn)，T2WI上層一般為高信號(hào)，可能為漿液或高鐵血紅蛋白，下層為低信號(hào)，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?cái)z取增加，呈“油炸圈餅”征Fig.A and after Fig.B a

35、dministration of gadopentetate dimeglumine reveal a markedly expansile lesion involving the laminae of T-3 (large arrowheads) and encroaching on the spinal canal (small arrowheads). Enhancement occurs largely in the periphery and septations of the lesion. Fig.C Sagittal T2-weighted MR image shows th

36、at the entire lesion contains fluid-fluid levels (arrows) resulting from hemorrhagic spaces and shows the extent of spinal canal narrowing. 8yr, M ABC of T3ABC動(dòng)脈瘤樣骨囊腫動(dòng)脈瘤樣骨囊腫液-液平面(血竇)Photograph of the sagittally sectioned gross specimen demonstrates the multiple blood-filled spaces (arrows) in the le

37、sion. Fig.D血竇血竇動(dòng)脈瘤樣骨囊腫動(dòng)脈瘤樣骨囊腫Fig.A The anteroposterior radiograph can be easily misread as normal because of the overlying bowel gas obscuring the 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

38、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 surrounding 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 ar

39、row) 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 the 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,

40、ABCs contain fluid levels. Conversely, most lesions with substantial fluid levels are ABCs, but such levels may occur in other lesions as well. Note 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

41、 of SADCB液-液平面(血竇)動(dòng)脈瘤樣骨囊腫動(dòng)脈瘤樣骨囊腫neurysmal Bone CystFig.A Computed tomographic scan showing alytic lesion in the posterior elements of the vertebrae 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 t

42、he cord forward and to the rightFig.B Magnetic resonance imaging after injection with gadolinium shows a nonhomogeneous multilobular lesion at T10-T12 level, extradurally pressing the spinal cord forward and to the right, destroying the pedicle and the lamina of the vertebra.Fig.AFig.B動(dòng)脈瘤樣骨囊腫動(dòng)脈瘤樣骨囊腫

43、Eosinophilic Granuloma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（Langerhans cell histiocytosis）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，放療和切除等影像表現(xiàn) 生長(zhǎng)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(duì)確定病

44、變范圍很有幫助病變延伸到周圍軟組織時(shí)，CT及MRI不典型，需組織學(xué)證實(shí)vertebra plana can be seen (arrow) in the thoracic spine, which is consistent with Langerhans cell histiocytosis.8, yr, M of TEnostosis 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(shí)進(jìn)展，并被認(rèn)為也會(huì)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(T1T7)和

45、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(wú)癥狀，偶然發(fā)現(xiàn)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(hào)，棘狀邊緣顯示清楚。周圍骨髓信號(hào)正常核素掃描絕大多數(shù)內(nèi)生骨疣顯示為正常，無(wú)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(zhǎng)或體積減小（31.9）。6個(gè)月內(nèi)病變直徑增加25%或1年內(nèi)

46、50%時(shí)應(yīng)考慮該病Fig.A Lateral radiograph shows a sclerotic focus in the anterior portion of L-3 (arrowhead). Fig.B CT scan reveals a densely 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.BFig.A L

47、ateral radiograph reveals a sclerotic focus (large arrows) with areas of spiculated thornlike margins (small arrows). Fig.B Photomicrograph (original magnification, X150; hematoxylin-eosin stain) shows cortical bone (arrows) with irregular margins (arrowheads). 35-yr-old FGiant enostosis of L-2Fig.B

48、Fig.BMalignant Tumor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(jiàn) Chordoma臨床病理少見(jiàn)，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(jiàn)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(zhǎng)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

49、所引起治療以手術(shù)切除為主影像表現(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(jiàn)鈣化鈣化多無(wú)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)影像表現(xiàn)CT主要呈溶骨性破壞腫瘤分葉狀，囊實(shí)性混雜密度，可見(jiàn)不規(guī)則鈣化軟組織腫塊增強(qiáng)，輕至中度強(qiáng)化不易與轉(zhuǎn)移瘤鑒別影像表現(xiàn)MRT1WI：中等信號(hào)（占75% ） ；低信號(hào)（占25% ） T2WI：呈高信號(hào)，信號(hào)高于CSF增強(qiáng)：明顯強(qiáng)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(diǎn)方面優(yōu)于MRIFig.ALateral radiograph shows destruction of the d

50、istal sacrum and coccyx with calcification (arrow). Fig.BCT scan also demonstrates the bone destruction and a soft-tissue mass (arrowheads) containing calcifications (arrow). . Chordoma of lower sacrum 48-year-old manFig.AFig.B脊索瘤Fig.C T1WI Sagittal and axial T2WI Fig.DMR images reveal the expansile

51、 sacrococcygeal lesion (arrowheads), which has high signal intensity on D. Fig.CFig.D脊索瘤脊索瘤Fig.E As seen in this sagittal section of the gross specimen, the MR imaging appearance correlates with the expansile lesion (arrowheads) and calcification (arrow). The upper sacrum (*) is spared脊索瘤Fig.ALatera

52、l radiograph shows a dense vertebral body (arrows) at L-3. Fig.BSagittal reconstructed CT scan obtained after initial open biopsy reveals not only the L-3 sclerosis but also similar findings in the superior aspect of L-4 (arrowheads). Chordoma of L 13-year-old man1-yr history of intermittent low bac

53、k pain.Fig.AFig.B脊索瘤Sagittal T1WIFig.Cand T2WIFig.D MR images better delineate the marrow involvement at L-3 and L-4 with extension through the disk (arrows). The mass has marked high signal intensity on d. Fig.CFig.DFig.Egross specimen depicts the extent of the neoplasm, with diffuse involvement of

54、 L-3 (arrowheads), the adjacent disk (*), and the superior aspect of L-4 (arrows).Fig.E脊索瘤Upper Left and Right: Axial CT scans demonstrating a large soft-tissue mass extending anteriorly to involve the rectum and posteriorly to invade the buttocks; calcification is seen within the mass. Lower Left a

55、nd Right: Sagittal fast spin echo T2-weighted and axial T2-weighted MR images demonstrating the lesion infiltrating the presacral region, extending to surround the rectum and the perivesical fat but not invading the bladder. 24-yr Mchordoma involving S3-5脊索瘤Fig.A and B: Preoperative axial CT scan an

56、d MR image revealing a sacral chordoma. Fig. C: Photograph of a hemisection of gross pathological specimen demonstrating complete en block resection of the sacrum. Fig. D and E: Postoperative anteroposterior and lateral radiographs.Fig.脊索瘤chordomaFig.AFig.B脊索瘤脊索瘤 Secondary Tumoror Metastatic Tumor 臨

57、床病理脊柱轉(zhuǎn)移常見(jiàn)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5160歲最多臨床表現(xiàn)為疼痛、持續(xù)性、夜間加重。可出現(xiàn)腫塊、病理骨折和壓迫癥狀治療可選用對(duì)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(jiàn)。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(wú)改變混合型轉(zhuǎn)移兼有溶骨型

58、和成骨型轉(zhuǎn)移的骨質(zhì)改變影像表現(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(diǎn)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(wú)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(hào)，T2WI呈程度不高的高信號(hào)脂肪抑制序列顯示更清楚Magnetic resonance imaging study of the spine shows a destructive lesion in the second lumbar vertebra with extension

59、into the spinal canal.Abdominal computed tomographic scan shows hepatic metastases and an irregular mass in the region of the pancreas.Fig.AFig.BFig.BFig.Asclerotic metastasesFigure. Sagittal T1-weighted MR image of the lumbosacral spine shows multiple hypointense foci within the sacrum and lumbar v

60、ertebrae. These lesions remained hypointense with all of the MR imaging sequences and did not exhibit enhancement. Plain radiography revealed sclerotic metastases.77-yr FMetastatic breast cancerExtensive osseous metastases from lung carcinoma. Anterior (left) and posterior (right) wholebodybone scin