中樞脊柱教材講義

CentralNervousSystem

南京醫(yī)科大學(xué)一附院放射科洪汛寧hongxunning@2/3/20231脊柱和脊髓MRI組織分辨率高準(zhǔn)確顯示各解剖結(jié)構(gòu)顯示多種病理改變MRI多平面多參數(shù)成像MRI是診斷脊髓病變的最佳選擇2/3/20232腰椎矢狀位T1WI,T2WI2/3/202332/3/202342/3/20235正常影像表現(xiàn)脊椎和椎間盤椎管椎管內(nèi)結(jié)構(gòu)2/3/20236Normalanatomyoflumbarspine2/3/20237Spinalcanal脊椎腔Neuroforamen神經(jīng)孔bonediscDuralsac2/3/20238脊髓病變椎管內(nèi)腫瘤脊髓外傷脊柱脊髓先天畸形和發(fā)育障礙2/3/20239spinalcordneoplasmsIntramedullaryspinalcordneoplasmsarerare,accountingforabout4%－10%ofallcentralnervoussystemtumors.Despitetheirrarity,theselesionsareimportanttotheradiologistbecauseMRIisthepreoperativestudyofchoicetonarrowthedifferentialdiagnosisandguidesurgicalresection.2/3/202310椎管內(nèi)腫瘤分類髓內(nèi)腫瘤室管膜瘤星形膠質(zhì)細(xì)胞瘤髓外硬膜內(nèi)腫瘤神經(jīng)鞘瘤、神經(jīng)纖維瘤脊膜瘤硬膜外腫瘤轉(zhuǎn)移瘤、淋巴瘤、脂肪瘤2/3/202311SnakeinHouseNormalAnatomy2/3/202312ThreeLocationsIntramedullaryIntraduralextramedullaryExtradural2/3/202313Intramedullary2/3/202314

IntraduralExtramedullary2/3/202315Extradural2/3/2023162/3/202317LEARNINGOBJECTIVESListtheessentialimagingfeaturesofintramedullaryspinalcordneoplasms.Identifythecharacteristicimagingappearancesofthedifferenttypesofintramedullaryspinalcordneoplasmsthatallowaspecificdiagnosistobefavored.2/3/202318ThreeImportantTenetsCordexpansionAtleastsomeenhancementCystsareacommonassociatedfindinginthesettingofanintramedullaryspinaltumor2/3/202319室管膜瘤Ependymoma占髓內(nèi)腫瘤60%起源于脊髓中央管室管膜細(xì)胞或室管膜殘留物好發(fā)部位：腰骶段、脊髓圓錐、終絲良性，呈膨脹性生長2/3/202320CT脊髓密度均勻性降低，不規(guī)則膨大邊緣模糊，常見囊變輕度強(qiáng)化或不強(qiáng)化2/3/202321Intramedullary

astrocytomainan18-year-oldwomanwithprogressiveparesis,paresthesiaofthelowerextremities,anddifficultyvoiding.CTmyelogramshowsanear-competeblockofintrathecalcontrastmaterial(arrowheads)secondarytoanintramedullarymass.

2/3/202322MRI表現(xiàn)脊髓明顯局限性增粗T1WI為均勻低信號(hào)T2WI為均勻高信號(hào)可發(fā)生出血、囊變或合并脊髓空洞增強(qiáng)后均勻強(qiáng)化，囊變區(qū)無強(qiáng)化2/3/202323Ependymoma2/3/202324Ependymoma2/3/202325Ependymoma2/3/202326Ependymoma2/3/202327Ependymoma2/3/202328星形細(xì)胞瘤Astrocytoma占髓內(nèi)腫瘤40%，以胸頸段為多病變一般局限，可浸潤生長脊髓增粗，與正常無明顯界限2/3/202329CT平掃呈略低密度，少數(shù)高密度邊界不清增強(qiáng)后強(qiáng)化不均一囊變常見2/3/202330MRIT1WI低信號(hào)T2WI高信號(hào)，由于水腫T2范圍＞T1出血、壞死、囊變，信號(hào)不均實(shí)質(zhì)部分明顯強(qiáng)化2/3/202331A:irregularexpansionofthecervicalspinalcordextendingfromC3toC7(arrows),slightlyhypointense,expansionofthespinalcanal.B:abnormalareaofhighsignalintensitythroughouttheexpandedregion.

2/3/202332C:irregular,intense,homogeneousenhancementoftheinferiorportionoftheexpandedcord(arrows).D:Axialgradient-echoMRI,expansionofthecordwiththemasseccentricallylocatedalongitsrightmargin(arrows).

2/3/202333髓內(nèi)轉(zhuǎn)移瘤metastasis乳癌髓內(nèi)轉(zhuǎn)移2/3/202334Intramedullaryspinallymphoma.A：anill-definedregionofslightlyhighsignalintensity(arrows)inthemidthoracicspinalcord.B：abnormalhighsignalintensity(arrow)inthesameregion.Extensivecordedema(arrowheads)isalsoseen.

2/3/202335神經(jīng)鞘瘤neurinoma最常見椎管內(nèi)腫瘤髓外硬膜內(nèi)腫瘤神經(jīng)鞘瘤起源于神經(jīng)鞘膜的雪旺細(xì)胞2/3/202336CT圓形實(shí)質(zhì)性腫塊，密度較脊髓略高，脊髓受壓移位中等強(qiáng)化椎間孔擴(kuò)大，椎弓根骨質(zhì)吸收啞鈴狀2/3/202337MRI表現(xiàn)脊髓受壓、移位、患側(cè)蛛網(wǎng)膜下腔擴(kuò)大邊緣光滑、境界銳利的圓形、卵圓形或啞鈴狀腫塊影多位于脊髓背側(cè)T1WI低信號(hào)，T2WI為高信號(hào)可發(fā)生囊變、信號(hào)不均勻2/3/2023382/3/2023392/3/202340T1WI2/3/202341PDWIandT2WI2/3/2023422/3/202343脊膜瘤spinalmeningioma髓外硬膜內(nèi)腫瘤，多位于胸段起源于蛛網(wǎng)膜細(xì)胞呈寬基底與硬脊膜粘連較緊2/3/202344CT胸段蛛網(wǎng)膜下腔后方實(shí)質(zhì)性腫塊，局限，橢圓形或圓形，有完整包膜中等率強(qiáng)化2/3/202345MRI表現(xiàn)病變處脊髓受壓移位類圓形腫塊，境界清楚T1WI呈低信號(hào)或等信號(hào)，T2WI呈高信號(hào)或等信號(hào)合并囊變或鈣化，信號(hào)可不均勻顯著強(qiáng)化，可出現(xiàn)脊膜尾征2/3/202346脊膜瘤spinalmeningioma2/3/202347脊膜瘤2/3/202348脊膜瘤矢狀位MRI平掃、增強(qiáng)2/3/202349脊膜瘤2/3/202350脊髓外傷trauma非常嚴(yán)重?fù)p傷占0.2-0.5%車禍、工傷、運(yùn)動(dòng)、火器傷2/3/202351脊髓外傷脊柱損傷椎體骨折：正常結(jié)構(gòu)喪失，椎體信號(hào)不均勻脊椎脫位：椎體前緣、椎管前緣及后緣的平滑連線中斷2/3/202352脊髓損傷閉合損傷病理上分為：脊髓震蕩、脊髓挫裂傷、脊髓壓迫或橫斷、椎管內(nèi)血腫脊髓挫裂傷示脊髓腫脹、膨大，信號(hào)混雜脊髓壓迫示脊髓、硬膜囊受壓變形，脊髓內(nèi)出現(xiàn)水腫、壞死2/3/2023532/3/2023542/3/2023552/3/202356頸椎外傷骨折、椎間盤突出2/3/2023572/3/2023582/3/2023592/3/202360L3M/43AcuteburstfractureofL3,causingseverestenosisofspinalcanalX-rayCT3-D2/3/202361影像能改變治療方法并改善

預(yù)后及療效嗎？2/3/2023622/3/2023632/3/2023642/3/2023652/3/2023662/3/2023672/3/2023682/3/202369C2、3椎體骨折伴脊髓橫斷傷2/3/202370C5、6術(shù)后，頸髓軟化2/3/202371脊柱脊髓先天畸形和發(fā)育障礙脊膜膨出和脊髓脊膜膨出脊髓空洞征2/3/202372脊膜膨出meningocele和脊髓脊膜膨出meningomyelocele脊膜通過脊椎缺損部位向外呈囊袋狀膨出脊髓脊膜膨出是脊髓、脊神經(jīng)、馬尾與囊壁粘連并同時(shí)突出于椎管外腰骶部最常見，頸椎次之2/3/202373腰骶部脊柱裂、脊膜膨出2/3/202374脊髓空洞癥syringomyelia病理特征脊髓內(nèi)出現(xiàn)空洞洞壁由增生的膠質(zhì)組織構(gòu)成交通性脊髓空洞癥脊髓積水、空洞伴有Chiari畸形無腫瘤、外傷或蛛網(wǎng)膜炎伴有腫瘤的脊髓空洞癥外傷后脊髓空洞癥特發(fā)性脊髓空洞癥2/3/202375交通性脊髓空洞癥MRI表現(xiàn)空洞位于脊髓中央，呈管狀囊腔空洞內(nèi)見水樣信號(hào)脊髓增粗，脊髓實(shí)質(zhì)變薄2/3/