脊柱腫瘤的影像學診斷 (2)

1、脊柱腫瘤的影像學診斷,上海中醫(yī)藥大學龍華醫(yī)院放射科 王 嵩,,脊柱腫瘤的影像學診斷,脊柱大體解剖脊柱檢查技術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:前后弓及兩側塊

2、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，椎間關節(jié)面近呈水平位，鉤椎關節(jié)（Luscka 關節(jié)）胸椎：逐漸增大，椎孔心形，關節(jié)突關節(jié)面呈冠狀位腰椎：椎體逐漸增大，椎孔呈三角形，關節(jié)突關節(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、關節(jié)突關節(jié)環(huán)

3、樞關節(jié)、環(huán)椎橫韌帶,posterior,Anterior,R lateral,L lateral,C1-2,C3-7,T,L,S,Co,檢 查 技 術,Examination Methods,檢查技術,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構 核素掃描 :一種全身骨骼檢查，但缺乏特異性,影 像 解 剖,Radiologic

4、Anatomy,常 規(guī) X 線,C,T,L,A-P,Lateral,L- oblique,CT解剖,T,重建,L,CT解剖,MRI解剖,C,脊柱良性腫瘤和腫瘤樣病變,Benign Spinal Tumor and Tumorlike Lesion,脊柱良性腫瘤和腫瘤樣病變,骨血管瘤骨軟骨瘤骨巨細胞瘤骨樣骨瘤骨母細胞瘤動脈瘤樣骨囊腫骨嗜酸性肉芽腫內生骨疣其它：軟骨黏液樣纖維瘤、纖維骨瘤、血管外皮細胞瘤和血管內皮細胞瘤

5、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，一般無癥狀，多女性對放射線有相當的敏感性,骨血管瘤 臨床病理,骨血管瘤 影像表現,X線一為受累骨體積擴張，骨小梁廣泛的吸收、增生和增厚，椎體呈柵欄狀特征性表現一為受累骨質有肥皂泡沫樣的破壞和擴張,骨血管瘤 影像表現,CT椎體部分或全

6、部松質骨密度減低病變區(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,Plain film,CT,T,骨血管瘤,T,骨血管瘤,Fig. A thickened trabeculae (corduroy sign) of a vertebral body hemangioma can be seen on this la

7、teral 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 body,,,,A,B,C,骨血管瘤,骨軟骨瘤,Osteochondroma,臨床病理,由骨質組成的基底和瘤體、透明軟骨組成的帽蓋和纖維組成的包膜

8、三種不同組織構成,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，一般無癥狀治療應徹底手術切除,骨軟骨瘤,骨軟骨瘤 影像表現,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的腫瘤很難診斷15%顯示正常,骨軟骨瘤 影像表現,CT附件骨性腫塊，皮質與椎板皮質相連可伴脊

9、髓受壓 MRI病灶中心T1WI呈高信號，T2WI呈中等信號邊緣皮質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）則應懷疑惡變,38, yr, M of C,Hereditary multiple exostosis with several spinal osteochondromas,FigA: Lateral radiograph of the cervical

10、 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

11、 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).,,,,,,A,B,C,骨軟骨瘤,Sagitt

12、al 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 mar

13、row and cortical continuity is not well seen.,骨軟骨瘤,D,E,FigF: Photograph of the gross specimen shows the marrow and cortex of the osteochondroma and a small cartilage cap at its periphery (arrowheads).,35yr，F Osteochondr

14、oma of sacrummalignant transformation,FigAVague sclerosis (solid arrows) over the left sacrum and widening of the sacroiliac joint (open arrow).,FigA,FigCAxial CT scan shows the thick cartilage cap (arrows) and sacroi

15、liac 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 B,Fig

16、C,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

17、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

18、 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 exostoses,骨巨細胞瘤,Giant Cell Tumor,

19、 GCT,骨巨細胞瘤 臨床病理,由軟而脆且易出血的肉芽樣組織所構成，無纖維包膜，可出血和壞死組織學分三級：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，若僅刮除術會出現40-60%％復發(fā),骨巨細胞瘤 影像表現,X線典型呈膨脹性偏心性多房性骨質破

20、壞，骨殼較薄，輪廓一般完整，內見纖細骨嵴構成分房狀幾點提示惡性a，較明顯的侵襲性表現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,皮質連續(xù)若為侵襲性可侵犯數個椎體椎弓椎間盤，皮質破壞，軟組織腫塊形成發(fā)生于骶骨時，一般位于骶髂關節(jié)附近，皮質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?/p>

21、明顯強化核素掃描顯示腫瘤呈彌漫性的濃聚,骨巨細胞瘤 影像表現,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 l

22、esion enhances markedly with the contrast agent. FigC the lesion has only intermediate signal intensity,,28,yr,FGCT of T-3 and T-4,Sag.T1WI,Axi.T1WI +c,Sag.T2WI,,,,A,C,B,T4,骨巨細胞瘤,Intraoperative photograph obtained

23、after incision of the skin shows a bulging, solid paraspinal mass (*),FigD,骨巨細胞瘤,sacral GCT.,A-P,LateraL,,,Fig A,Fig b,Fig C,Fig D,Fig E,Fig F,骨巨細胞瘤,GCT of S4-5,21 yr ,F,A-P,LateraL,A,B,,,骨巨細胞瘤,FigC:CTshowing large ma

24、ss 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 in

25、tensity; 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 featu

26、re in GCTs,,Axial CT,Sag. T1WI,Axi. FSE T2WI,Sag. FS T1WI +C,骨巨細胞瘤,Upper Left: Anteroposterior radiograph emonstrating the expanded lytic lesion ccupying the sacrum. Upper Right and Center Left: Axial CT scans obtained

27、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 (

28、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.,26,

29、yr, F GCT of the sacrum,.,骨巨細胞瘤,GCT of C-7 posterior elements,16 y male,骨巨細胞瘤,T,I,骨巨細胞瘤,骨樣骨瘤,Osteoid Osteoma,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性骨質包繞 10%發(fā)生于脊柱，多腰椎，最常起于椎弓，其次椎板，小關節(jié)面和椎弓根單發(fā)

30、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攣而引起側彎治療以用手術切除最為適宜,預后良好,,骨樣骨瘤 影像表現,X線腫瘤所在部位骨質破壞周圍不同程度的反應性骨硬化偶見內鈣化/骨化分皮質型、松質型、骨膜下型,骨樣骨瘤 影像表現,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性骨硬化環(huán)MRI 腫瘤未鈣化部分

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

32、l 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

33、of the radionuclide by the nidus (arrow),17, yr, M Osteoid osteoma of lamina at T-11,,,A,B,C,D,,骨樣骨瘤,瘤巢,FigE: Photograph of the gross specimen reveals the nidus (*)extending to the facet cartilage (arrows),骨樣骨瘤,瘤巢,Axi

34、al 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) demonstrating that left he

35、milaminectomy was sufficient to remove the tumor.,16, yr, M Osteoid osteoma of lamina at C-5,骨樣骨瘤,骨母細胞瘤,Osteoblastoma,,骨母細胞瘤 臨床病理,多量骨母細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囊變，合并動脈瘤樣骨囊腫時則多數含血囊腔。少數腫

36、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。治療應手術切除，病變復發(fā)率為10-15%,X線三種表現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，骨膨脹破壞，及周圍軟組織浸潤

37、 和混雜性鈣化,骨母細胞瘤 影像表現,CT對腫瘤內鈣/骨化影顯示高于平片,尤其對復雜部位腫瘤顯示較好類圓形膨脹性骨質破壞，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性充血水腫，為長T1長T2信號可顯示骨殼中斷，椎管內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

38、示明顯核素濃聚,骨母細胞瘤 影像表現,Fig.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,

39、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 radiograph,Fig.B CT,骨母細胞瘤,Axi. T1WI FigC and Sag. T2

40、WI 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. T

41、1WI,Sag. T2WI,FigC,FigD:,骨母細胞瘤,FigE,骨母細胞瘤,FigA: 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 s

42、urrounding soft tissues 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

43、 obstruction of the left vertebral artery (curved arrow).,9, yr, M. Aggressive osteoblastoma of C1,,,,A,B,C,骨母細胞瘤 (侵襲性),CT,MRI,DSA,Left: Anteroposterior radiograph revealing a subtly expanded lesion that is near the m

44、idline 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,骨母細胞瘤,Left: bone scan revealing an eccentrically located area o

45、f increased 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,骨母細胞瘤,Lateral x-ray f

46、ilms (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 C1–6.Axial CT scan (d) demonstrating a typical o

47、steoid 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 ap

48、proach (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,

49、骨母細胞瘤,動脈瘤樣骨囊腫,Aneurysmal Bone Cyst, 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)生原有病變基礎上，包括骨巨細胞瘤、骨母細胞瘤、軟骨母細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部位疼

50、痛和神經壓迫癥狀可行刮除植骨術，還可栓塞治療和放療；總的復發(fā)率為20-30%。,動脈瘤樣骨囊腫 影像表現,X線典型表現為脊柱附件骨顯著膨脹的囊狀透亮區(qū)，外側為薄的骨殼，呈“氣球狀”囊內有或粗或細的骨小梁狀分隔或骨嵴,動脈瘤樣骨囊腫 影像表現,CT多呈囊狀膨脹性骨破壞，骨殼菲薄軟組織密度腫塊內見斑片樣、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

51、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。核素掃描常表現為外周部位的核素攝取增加，呈“油炸圈餅”征,Fig.A and after Fig.B administration of gadopentetate dimeglumine reveal a markedly expansile lesion involving the laminae of T-3 (larg

52、e 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 that the entire lesion contains

53、fluid-fluid levels (arrows) resulting from hemorrhagic spaces and shows the extent of spinal canal narrowing.,8yr, M ABC of T3,,,A,B,C,動脈瘤樣骨囊腫,T1WI C+,T1WI,T2WI,液-液平面(血竇),Photograph of the sagittally sectioned gross

54、 specimen demonstrates the multiple blood-filled spaces (arrows) in the lesion.,Fig.D,血竇,動脈瘤樣骨囊腫,Fig.A The anteroposterior radiograph can be easily misread as normal because of the overlying bowel gas obscuring the sa

55、crumFig.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 demonstra

56、tes 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

57、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 the sagittal exam would then be expected to appear vertic

58、al, 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 o

59、ther 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 S,,,A,D,C,B,液-液平面(血竇),動脈瘤樣骨囊腫,neu

60、rysmal Bone Cyst,Fig.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 perio

61、steal border enters the spinal canal, pressing the cord forward and to the right,Fig.B Magnetic resonance imaging after injection with gadolinium shows a nonhomogeneous multilobular lesion at T10-T12 level, extradurally

62、pressing the spinal cord forward and to the right, destroying the pedicle and the lamina of the vertebra.,Fig.A,Fig.B,動脈瘤樣骨囊腫,T1WI C+,骨嗜酸性肉芽腫,Eosinophilic Granuloma,骨嗜酸性肉芽腫 臨床病理,本病屬網狀內皮系統(tǒng)類脂質沉積病，稱朗罕氏細胞組織細胞?。↙angerhans ce

63、ll 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、瘤內注射激素，放療和切除等,骨嗜酸性肉芽腫 影像表現,生長迅速的溶骨性病變，常導致椎體

64、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，需組織學證實,vertebra plana can be seen (arrow) in the thoracic spine, which is consistent with Langerhan's cell histiocytosis.,8, yr, M of T,扁平椎,骨嗜酸性肉芽腫,內生骨疣,En

65、ostosis,內生骨疣 臨床病理,內生骨疣通常指骨島，也稱鈣化性骨髓缺損、內生骨瘤組織學上骨疣為板層骨，哈佛氏系統(tǒng)包埋在髓管內。病變較出生時進展，并被認為也會產生損害的病變。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，而腰椎常位于中線左側。病變常位于皮質下，其周圍常常伴有放射狀骨針。病變大小約2mmX2mm 到6mmX

66、10mm，大于2cm為巨大內生骨疣常無癥狀，偶然發(fā)現,內生骨疣 影像表現,X線平片和CT常具有特征性表現，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內生骨疣顯示為正常，無異常放射性核素濃聚。少數出現濃聚的病變通常為巨大內生骨疣，占33％病變自然病史不同，絕大多數病變變化不大，部分可緩慢生長或體積減?。?/p>

67、31.9％）。6個月內病變直徑增加25%或1年內50%時應考慮該病,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 be

68、neath the anterior cortex to the left of midline (arrowheads),66-yr-old M Enostosis of L-3,Fig.A,Fig.B,內生骨疣,毛刷狀邊緣,Fig.A Lateral radiograph reveals a sclerotic focus (large arrows) with areas of spiculated thornlike mar