脊柱腫瘤影像學(xué)診斷講座PPT學(xué)習(xí)教案

1、會(huì)計(jì)學(xué)1脊柱腫瘤影像學(xué)診斷講座脊柱腫瘤影像學(xué)診斷講座第1頁(yè)/共159頁(yè)第2頁(yè)/共159頁(yè)胸段第3頁(yè)/共159頁(yè) 第4頁(yè)/共159頁(yè)第5頁(yè)/共159頁(yè)第6頁(yè)/共159頁(yè)第7頁(yè)/共159頁(yè)第8頁(yè)/共159頁(yè)第9頁(yè)/共159頁(yè)第10頁(yè)/共159頁(yè)第11頁(yè)/共159頁(yè)第12頁(yè)/共159頁(yè)第13頁(yè)/共159頁(yè)第14頁(yè)/共159頁(yè)第15頁(yè)/共159頁(yè)第16頁(yè)/共159頁(yè)第17頁(yè)/共159頁(yè)第18頁(yè)/共159頁(yè)第19頁(yè)/共159頁(yè)第20頁(yè)/共159頁(yè)第21頁(yè)/共159頁(yè)T重建重建第22頁(yè)/共159頁(yè)L第23頁(yè)/共159頁(yè)C第24頁(yè)/共159頁(yè)第25頁(yè)/共159頁(yè)第26頁(yè)/共159頁(yè)第27頁(yè)/共159頁(yè)第28

2、頁(yè)/共159頁(yè)第29頁(yè)/共159頁(yè)第30頁(yè)/共159頁(yè)第31頁(yè)/共159頁(yè)第32頁(yè)/共159頁(yè)Fig. 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 bodyABC第33頁(yè)/共

3、159頁(yè)第34頁(yè)/共159頁(yè)第35頁(yè)/共159頁(yè)n15%顯示正常第36頁(yè)/共159頁(yè)n成人如軟骨帽明顯增厚（大于1-2cm）則應(yīng)懷疑惡變第37頁(yè)/共159頁(yè)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 sol

4、id arrow). Osteochondroma at C-1 is seen as an ossified region (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 proc

5、ess (* in c). 第38頁(yè)/共159頁(yè)Sagittal T1-weighted FigDand T2* gradient-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. 第39頁(yè)/

6、共159頁(yè)FigF: Photograph of the gross specimen shows the marrow and cortex of the osteochondroma and a small cartilage cap at its periphery (arrowheads).第40頁(yè)/共159頁(yè)35yr，F(xiàn) Osteochondroma of sacrummalignant transformationFigAVague sclerosis (solid arrows) over the left sacrum and widening of the sacroilia

7、c joint (open arrow).FigA第41頁(yè)/共159頁(yè)FigCAxial CT scan shows the thick cartilage cap (arrows) 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 (arr

8、owheads).Fig BFigC第42頁(yè)/共159頁(yè)multiple hereditary exostoses. Note that the large sacral lesion has normal 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 t

9、his 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 cartilage thickness. In this case, we recognized multiple exostoses because of the presence of sessile lesions at the anterior su

10、perior iliac spines.10, yr, M Multiple hereditary exostoses第43頁(yè)/共159頁(yè)第44頁(yè)/共159頁(yè)第45頁(yè)/共159頁(yè)第46頁(yè)/共159頁(yè)第47頁(yè)/共159頁(yè)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

11、enhances markedly with the contrast agent. FigC the lesion has only intermediate signal intensity, 28,yr,FGCT of T-3 and T-4Axi.T1WI +c第48頁(yè)/共159頁(yè)Intraoperative photograph obtained after incision of the skin shows a bulging, solid paraspinal mass (*)FigD第49頁(yè)/共159頁(yè)sacral GCT.A-PLateraLFig AFig b第50頁(yè)/共

12、159頁(yè)Axial CTSag.T2WI soft-tissue extension.Cor.T2WIFig CFig DFig EFig F第51頁(yè)/共159頁(yè)GCT of S4-521 yr ,FA-PLateraLAB第52頁(yè)/共159頁(yè)FigC: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

13、intensity FigE: revealing 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

14、. T1WIAxi. FSE T2WISag. FS T1WI +C第53頁(yè)/共159頁(yè)Upper 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, wit

15、h attempted thin cortical rim 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 in

16、tensity mass, typical of GCT.26, yr, F GCT of the sacrum.第54頁(yè)/共159頁(yè)GCT of C-7 posterior elements16 y male第55頁(yè)/共159頁(yè)第56頁(yè)/共159頁(yè)第57頁(yè)/共159頁(yè)第58頁(yè)/共159頁(yè)第59頁(yè)/共159頁(yè)n核素掃描n腫瘤顯示明顯核素濃聚第60頁(yè)/共159頁(yè)FigA: Radiograph reveals a subtle lucent area (arrow) in a right articular mass.FigB: CT scan shows the nidus (large ar

17、rowheads) with a small central area 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 Ost

18、eoid osteoma of lamina at T-11 第61頁(yè)/共159頁(yè)FigE: Photograph of the gross specimen reveals the nidus (*)extending to the facet cartilage (arrows)第62頁(yè)/共159頁(yè)Axial 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 upta

19、ke 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 第63頁(yè)/共159頁(yè)第64頁(yè)/共159頁(yè)第65頁(yè)/共159頁(yè)第66頁(yè)/共159頁(yè)第67頁(yè)/共159頁(yè)Fig.Ashows a markedly expansile lesion involving the spinous process and laminae (arr

20、ows), with vague sclerosis suggestive of mineralization. CT 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 CT第68頁(yè)/共159頁(yè)A

21、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:第69頁(yè)/共159頁(yè)FigE第70頁(yè)/共159頁(yè)FigA: CT sca

22、n 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 tissues and foramen transversarium. FigB: Coronal T2-weighted MR image shows high signal intensity within the mass (ar

23、rows). FigC: Digital subtraction angiogram reveals tumor stain (straight arrows) and obstruction of the left vertebral artery (curved arrow).9, yr, M. Aggressive osteoblastoma of C1第71頁(yè)/共159頁(yè)Left: Anteroposterior radiograph revealing a subtly expanded lesion that is near the midline at S4-5 (arrows)

24、. Right: Axial CT scan demonstrating bone matrix within the lesion, not aggressive in appearance.16, yr, M osteoblastoma of S4-5 第72頁(yè)/共159頁(yè)Left: bone scan revealing an eccentrically located area of increased uptake in the sacrum. Right: The CT scan demonstrates a minimally expanded lesion containing

25、 dense bone matrix in the right side of the lower sacrum. 16, yr, M. osteoblastoma of S4-5 第73頁(yè)/共159頁(yè)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

26、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 excision via an anterolateral retropharyngeal approach (f) occipitocervical fixation by using t

27、wo 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 第74頁(yè)/共159頁(yè)第75頁(yè)/共159頁(yè)第76頁(yè)/共159頁(yè)骨嵴第77頁(yè)/共159頁(yè)第78頁(yè)/共159頁(yè) and after administration of gadopentetate dimeglumine reveal a markedly expans

28、ile 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. Sagittal T2-weighted MR image shows that the entire lesion contains fluid-fluid levels (arrows) resulting from

29、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)第79頁(yè)/共159頁(yè)P(yáng)hotograph of the sagittally sectioned gross specimen demonstrates the multiple blood-filled spaces (arrows) in the lesion. 血竇血竇動(dòng)脈瘤樣骨囊腫動(dòng)脈瘤樣骨囊腫第80頁(yè)/共159頁(yè) The anteroposterior radiogra

30、ph can be easily misread as normal because of the overlying bowel gas obscuring the sacrum 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 demonstrate

31、s 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 arrow) are more readily observed on a sagittal T1-weighted MR image; r

32、emember 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, ABCs contain fluid levels. Conversely, most lesions with substantial

33、 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 of SADCB液-液平面(血竇)動(dòng)脈瘤樣骨囊腫動(dòng)脈瘤樣骨囊腫第81頁(yè)/共159頁(yè)neurysmal Bone Cyst Comput

34、ed 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 the cord forward and to the right Magnetic resonance imaging aft

35、er 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.動(dòng)脈瘤樣骨囊腫動(dòng)脈瘤樣骨囊腫第82頁(yè)/共159頁(yè)第83頁(yè)/共159頁(yè)第84頁(yè)/共159頁(yè)第85頁(yè)/共159頁(yè)vertebra plana can be seen (arrow) in

36、the thoracic spine, which is consistent with Langerhans cell histiocytosis.8, yr, M of T第86頁(yè)/共159頁(yè)第87頁(yè)/共159頁(yè)第88頁(yè)/共159頁(yè)第89頁(yè)/共159頁(yè)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 b

37、order just beneath the anterior cortex to the left of midline (arrowheads)66-yr-old M Enostosis of L-3Fig.AFig.B第90頁(yè)/共159頁(yè)Fig.A Lateral radiograph reveals a sclerotic focus (large arrows) with areas of spiculated thornlike margins (small arrows). Fig.B Photomicrograph (original magnification, X150;

38、hematoxylin-eosin stain) shows cortical bone (arrows) with irregular margins (arrowheads). 35-yr-old FGiant enostosis of L-2Fig.BFig.B第91頁(yè)/共159頁(yè)第92頁(yè)/共159頁(yè)第93頁(yè)/共159頁(yè)第94頁(yè)/共159頁(yè)第95頁(yè)/共159頁(yè)第96頁(yè)/共159頁(yè)第97頁(yè)/共159頁(yè)第98頁(yè)/共159頁(yè)Fig.ALateral radiograph shows destruction of the distal sacrum and coccyx with calcifi

39、cation (arrow). CT scan also demonstrates the bone destruction and a soft-tissue mass (arrowheads) containing calcifications (arrow). . Chordoma of lower sacrum 48-year-old man脊索瘤第99頁(yè)/共159頁(yè)Fig.C T1WI Sagittal and axial T2WI MR images reveal the expansile sacrococcygeal lesion (arrowheads), which has

40、 high signal intensity on D. 脊索瘤脊索瘤第100頁(yè)/共159頁(yè) 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脊索瘤第101頁(yè)/共159頁(yè)Fig.ALateral radiograph shows a dense vertebral bo

41、dy (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 back pain.脊索瘤第102頁(yè)/共159頁(yè)Sagittal T1WIFig.C

42、and T2WI 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. 第103頁(yè)/共159頁(yè)gross specimen depicts the extent of the neoplasm, with diffuse involvement of L-3 (arrowheads), the adjacent disk (*), and t

43、he superior aspect of L-4 (arrows).脊索瘤第104頁(yè)/共159頁(yè)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 and Right: Sagittal fast spin echo T2-weig

44、hted 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脊索瘤第105頁(yè)/共159頁(yè)Fig.A and B: Preoperative axial CT scan and MR image revealing a sacral

45、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.脊索瘤第106頁(yè)/共159頁(yè)chordoma脊索瘤脊索瘤第107頁(yè)/共159頁(yè)第108頁(yè)/共159頁(yè)第109頁(yè)/共159頁(yè)n變第110頁(yè)/共159頁(yè)n現(xiàn)的病灶n多數(shù)腫瘤T1WI呈低信號(hào)，T

46、2WI呈程度不高的高信號(hào)n脂肪抑制序列顯示更清楚第111頁(yè)/共159頁(yè)Magnetic resonance imaging study of the spine shows a destructive lesion in the second lumbar vertebra with extension into the spinal canal.Abdominal computed tomographic scan shows hepatic metastases and an irregular mass in the region of the pancreas.第112頁(yè)/共159頁(yè)s

47、clerotic metastases第113頁(yè)/共159頁(yè)Figure. Sagittal T1-weighted MR image of the lumbosacral spine shows multiple hypointense foci within the sacrum and lumbar vertebrae. These lesions remained hypointense with all of the MR imaging sequences and did not exhibit enhancement. Plain radiography revealed scl

48、erotic metastases.77-yr FMetastatic breast cancer第114頁(yè)/共159頁(yè)第115頁(yè)/共159頁(yè)第116頁(yè)/共159頁(yè)第117頁(yè)/共159頁(yè)Extensive osseous metastases from lung carcinoma. Anterior (left) and posterior (right) wholebodybone scintigrams show multiple, randomly distributed foci of abnormal radiotracer uptake. The focivary in size

49、 and intensity.第118頁(yè)/共159頁(yè) : Sagittal T2-weighted MR image demonstrating involvement of the posterior elements of L-3 (arrow). : Axial T1-weighted MR image revealing the L-3 spinous process and lamina infiltrated by tumor, with anterior structures intact (arrow). : Bone scan demonstrating numerous a

50、dditional sites of metastatic disease (ribs, skull, and scapula) in addition to L-3 (arrow). The patient underwent simple posterior decompression.54-yr Mmetastatic renal cell carcinomaABC第119頁(yè)/共159頁(yè)Sag.MRI of the lower T and upper T are (A)hypointense on T1WI and (B) hyperintense onT2 WI). On DW EPI

51、 (C, b value of 440 sec/mm2; D, b value of 880 sec/mm2), the vertebral metastasis and vertebral compression fractures appear hyperintense.E, ADC map shows both vertebral metastasis and acute pathologic vertebral compression fractures with low ADCs, which indicate hindered diffusion of water protons

52、and the pathologic nature of these findings. Note the hyperintense area located centrally in the fracture of L1, which possibly indicates unhindered diffusion in an area of debris.63-yr F with breast Ca.M at L1 (arrows)fractures at T11-12 (arrowheads)第120頁(yè)/共159頁(yè)50-yr Fbreast carcinomamastectomy 5 yr

53、s earlier第121頁(yè)/共159頁(yè)Left: Postoperative plain nteroposterior radiograph obtained after T-2 corpectomy and T1-3 stabilization performed via a median sternotomy approach (note the sternal wires (arrow) Right: Postoperative axial CT scan demonstrating good spinal decompression, structural iliac crest a

54、utograft strut, and an anterior plate. 62-yr Mlarge cell Caof the lung 第122頁(yè)/共159頁(yè)Neuroimages demonstrating reconstruction after C-4 corpectomy for a renal cell metastasis; stabilization was achieved using a titanium mesh interbody cage and chest tube construct filled with PMMA, supplemented by an a

55、nterior cervical plate. Left: Preoperative T2-weighted magnetic resonance image, sagittal view, revealing VB collapse at C-4. Right: Postoperative cervical x-ray film, lateral view.第123頁(yè)/共159頁(yè) Preoperative plain x-ray film showing marked destruction of the C-3 VB and associated kyphotic eformity. Po

56、stoperative x-ray film showing placement of the TPS device into the C-3 corpectomy defect, restoring anterior column height. Illustrations of the TPS device. The apparatus is expandable to fit the size of the corpectomy defect and can be filled with bone autograft if desired. Squamous cell carcinoma

57、 of the lung metastatic to C-3. ABC第124頁(yè)/共159頁(yè)第125頁(yè)/共159頁(yè)第126頁(yè)/共159頁(yè)n軟組織腫塊：位于破壞區(qū)周?chē)苌倏缭阶甸g盤(pán)水平至鄰近椎旁n平片約10%正常表現(xiàn)第127頁(yè)/共159頁(yè)nT2WI上呈高信號(hào)nSTIR序列病變高信號(hào)較T2WI更明顯第128頁(yè)/共159頁(yè)Left: Anteroposterior radiograph revealing a highly destructive lytic lesion involving both the left iliac wing and left sacrum. Right: Axia

58、l CT scan confirming involvement of both of these bones, as well as a moderate-sized soft-tissue mass. Plasmacytomas may be very large and elicit no osseous reaction, as in this case. This case also demonstrates the propensity of aggressive lesions to cross the sacroiliac joint. 61-year-old man with

59、 multiple myeloma.第129頁(yè)/共159頁(yè)Lytic expansile mass of C5. TransverseCT image at level of C5 shows expansilesoft-tissue mass along right side of C5 vertebral body, with associated bone destruction.第130頁(yè)/共159頁(yè)Comparative images from sagittal reformatted CT data set (left) and sagittal STIR MRI(right) o

60、f thoracic spine show multiple compression fractures of thoracic vertebral bodies, with severethoracic kyphosis and marked osteolysis of the T1 vertebral body(arrow).Multiple compression fractureson CT and MRMRCT骨溶解第131頁(yè)/共159頁(yè)Fig. Multiple plasmacytomas with cord compression.a Sagittal T1WI (left) a