脊髓造影对椎管内肿瘤定位定性诊断探讨

本文回顾性分析并总结30例椎管肿瘤的临床,X线及病理资料,占同期椎管造影病例的10％。所有病人依据临床表现均确定了病变的位置,但定性诊断较难。通过脊髓造影而清晰显示了病变位置、范围及分界关系,基本上可以提示初步的定性诊断。因此脊髓造影仍是诊断椎管内肿瘤主要检查方法,具有实用性和普及性。     

15例低位椎管内肿瘤误诊误治分析

目的 探索提高椎管内肿瘤的诊断准确率及疗效。方法 对收治曾被误诊的胸10椎体节段以下的低位椎管内肿瘤15例患者的临床特征、影像学检查结果、误诊误治经过等进行总结和分析。结果 对椎管内肿瘤的症状、体征缺乏认识，体检不够细致，影像学检查选择不当是造成误诊的主要原因。结论 以临床特征为基础。配合X线片、腰穿脑脊液检查以及MRI检查可降低低位椎管内肿瘤的误诊率。MRI是诊断椎管内肿瘤的最佳手段。     

椎管内肿瘤38例临床分析

目的　总结外科治疗椎管内肿瘤的经验。方法　回顾性分析 2年来应用MRI及显微外科技术 ,对 38例椎管内肿瘤的手术疗效。结果　MRI及显微外科技术的应用 ,是提高椎管内肿瘤的诊断及手术效果的关键。结论　椎管内肿瘤以良性居多 ,手术效果好 ;MRI检查及显微外科技术的应用大大提高了椎管内肿瘤的治疗效果。     

椎管内肿瘤38例临床分析

目的 总结外科治疗椎管内肿瘤的经验。方法 回顾性分析2年来应用MRI及显微外科技术,对38例椎管内肿瘤的手术疗效。结果 MRI及显微外科技术的应用,是提高椎管内肿瘤的诊断及手术效果的关键。结论 椎管内肿瘤以良性居多,手术效果好;MRI检查及显微外科技术的应用大大提高了椎管内肿瘤的治疗效果。     

哑铃型椎管肿瘤的临床诊治分析

目的　探讨哑铃型椎管肿瘤的临床特征以及诊疗方法。方法　回顾性分析我院自１９９８至２００８年１０年间收治的２８例哑铃型椎管肿瘤患者的临床资料。结果　２８例哑铃型椎管肿瘤患者均经ＭＲＩ和术后组织病理学检查明确诊断,临床特征主要为椎管内压迫症状（根性疼痛、感觉异常、肌无力）和椎管外压迫症状（椎体周围发现包块）。所有病例均行Ⅰ期手术切除,无手术死亡,２３例获得随访,随访７个月～１０年,１８例恢复正常工作。结论　对椎管肿瘤患者应重视临床病史和体格检查;ＭＲＩ检查在哑铃型椎管内肿瘤的诊断和手术方式的选择上占重要地位;早期诊断、Ⅰ期手术完全切除肿瘤是优选有效的治疗方法。     

哑铃型纵隔神经源性肿瘤的临床诊治分析

目的探讨哑铃型纵隔神经源性肿瘤的临床表现、诊断及外科治疗方法。方法回顾性分析6例哑铃型纵隔神经源性肿瘤的临床表现、影像学检查、病理学检查及治疗方法。结果患者临床症状主要有长期慢性胸背痛,多伴有双下肢的感觉和运动障碍,个别病例无症状。所有病例术前均行胸部MRI检查,结果与术中情况吻合。肿瘤均由胸外科医师与神经外科医师协作一期完全切除。术后胸背痛及感觉和运动障碍明显改善或消失,异常神经系统体征消失。恢复顺利,治愈出院。术后病理:神经鞘瘤4例,神经纤维瘤2例。结论胸部MRI对肿瘤的诊断及指导手术治疗具有重要价值。手术治疗应由胸外科医师与神经外科医师协作一期切除椎管内外肿瘤,先切除椎管内肿瘤,然后再切除椎旁胸内肿瘤,根据病变的位置、形态、大小采取不同的手术方式。     

椎管内肿瘤的临床诊断及症状分析

目的：探讨椎管内肿瘤的临床表现，提高早期诊断水平。方法：回顾性分析81例椎管内肿瘤患者的临床症状、体征、影像学检查及病理类型。结果：椎管内肿瘤早期主要症状是疼痛（75％）、感觉异常（24％）和肌无力（49％），特别是夜间休息时疼痛加重，活动后症状减轻是主要临床特点。核磁共振是重要的检查诊断手段。结论：重视椎管内肿瘤的临床表现，完善体格检查，及时进行核磁共振等影像学手段的检查是提高早期诊断水平的关键。     

75例椎管内神经鞘瘤的手术治疗

目的:探讨椎管内神经鞘瘤的临床诊断和手术治疗经验。方法:总结我院自1993年2月～2004年10月收治的75例椎管内肿瘤的临床表现、影像学资料、手术方式以及手术前后患者脊髓或神经功能改善的情况。结果:MRI检查显示对病变性质和部位诊断有重要意义;75例患者肿瘤均完整切除、病理证实,所有患者术后神经功能均有明显恢复。结论:影像学检查对神经鞘瘤有较高的诊断率,最终确诊依赖于病理诊断;椎管内神经鞘瘤治愈率高,早诊断、早手术、临床效果好。     

椎管内成熟性实性畸胎瘤1例

成熟性实性畸胎瘤十分少见，发生于椎管内者则更为少见，兹报告1例如下。患者，男，25岁。因排尿困难1年，腰痛1月，双下肢功能障碍伴大便失禁半月，于1996年1月21日入院。查体：双小腿感觉减退，股前肌肌力IV级，右踝阵挛征（＋）。MR示：L。、。椎管内脂肪瘤。临床诊断：椎管内脂肪瘤。术中见：LZ、3椎管内硬膜下马尾神经背侧有一6cmX3cmX3cm圆型形肿物，包膜完整，似脂肪组织。遂行肿瘤切除，术后病人恢复良好，痊愈出院。随访1年，患者症状逐渐缓解，现功能基本恢复正常，CT检查：椎管内未见肿瘤。病理检查巨检：扁圆形肿物1个，体…     

中枢神经系统肿瘤

中枢神经系统肿瘤中85％生长于颅内;15％生长于椎管内。颅内肿瘤以胶质瘤最多(占42％),椎管内肿瘤以神经鞘膜瘤最多(占48％);脑膜瘤次之(占15～18％),垂体腺瘤、先天性肿瘤、血管性肿瘤及其他肿瘤均在10％以下。 一、胶质瘤 亦称神经胶质瘤,是来源于各种神经胶质的肿瘤,现分述如下: (一)星形胶质瘤 来源于星形胶质细     

Detection of unsuspected spinal cord compression in melanoma patients by 18F-fluorodeoxyglucose-positron emission tomography.

AIM: Positron emission tomography (PET) using (18)F-fluorodeoxyglucose can detect early or small metastatic deposits of melanoma and guide subsequent correlative anatomical imaging and treatment. The aim of this study was to assess the value of PET in demonstrating spinal cord compression by otherwise unsuspected metastatic disease. METHODS: Reports of 1365 PET studies performed on patients with melanoma were reviewed. Fifty patients considered to be at risk of spinal cord compression on the basis of PET were identified and 35 patients were analysed. Magnetic resonance imaging and computed tomography were used to confirm or refute the diagnosis. The symptoms and signs at the time of PET and follow-up status were compared between patients with and without confirmed spinal cord compression. RESULTS: In nine patients (26%) compression of the spinal cord or adjacent neurological structures was confirmed and eight of these patients had immediate treatment. Survival was poor in both patient groups, but three patients with confirmed compression maintained good neurological functional status following treatment. CONCLUSION: PET can detect imminent, unsuspected spinal cord compression in patients with metastatic melanoma. Immediate anatomical imaging of the spine is recommended in patients who have evidence of spinal cord compression on PET.     

Comparison of CSF cytology and spinal magnetic resonance imaging in the detection of leptomeningeal disease in pediatric medulloblastoma or primitive neuroectodermal tumor.

PURPOSE: Leptomeningeal disease (LMD) significantly affects the prognosis and treatment of pediatric patients with medulloblastoma or primitive neuroectodermal tumor (PNET). Examination of CSF for malignant cells, detection of LMD on spinal magnetic resonance imaging (MRI), or both are the methods routinely used to diagnose LMD. A recent study suggested 100% correlation between CSF and MRI findings in children with medulloblastoma. To determine the validity of this hypothesis, we compared the rate of detection of LMD between concurrent lumbar CSF cytology and spinal MRI performed at diagnosis in patients with medulloblastoma or PNET. PATIENTS AND METHODS: As a part of diagnostic staging, 106 consecutive patients newly diagnosed with medulloblastoma or PNET were evaluated with concurrent lumbar CSF cytology and spinal MRI. CSF cytology was examined for the presence of malignant cells and spinal MRI was reviewed independently for the presence of LMD. RESULTS: Thirty-four patients (32%) were diagnosed with LMD based on CSF cytology, spinal MRI, or both. There were 21 discordant results. Nine patients (8.5%) with positive MRI had negative CSF cytology. Twelve patients (11.3%) with positive CSF cytology had negative MRIs. The exact 95% upper bounds on the proportion of patients with LMD whose disease would have gone undetected using either CSF cytology or MRI as the only diagnostic modality were calculated at 14.4% and 17.7%, respectively. CONCLUSION: With the use of either CSF cytology or spinal MRI alone, LMD would be missed in up to 14% to 18% of patients with medulloblastoma or PNET. Thus, both CSF cytology and spinal MRI should routinely be used to diagnose LMD in patients with medulloblastoma or PNET.     

Role of spinal MRI in the follow-up of children treated for medulloblastoma

BACKGROUND: The purpose of the current study was to describe the usefulness of spinal magnetic resonance imaging (MRI) in children with medulloblastoma or primitive neuroectodermal tumor (PNET) of the posterior fossa. METHODS: Children consecutively diagnosed with medulloblastoma/PNET and followed in the Hospital for Sick Children/Toronto were identified. A homogenous cohort of children treated with craniospinal irradiation as part of their initial treatment was considered. Contrast-enhanced spinal MRIs done concomitantly with cranial MRIs (doublets) were reviewed. Recurrence was defined as any new abnormal lesion (in the brain or in the spine) in symptomatic or asymptomatic patients. Doublets after the first recurrence were excluded in the final analysis. The utility of a spinal MRI in the presence of a negative cranial MRI was assessed. RESULTS: In all, 73 patients (21 females and 52 males; median age, 6.6 years, median follow-up time, 4.3 years) had at least 1 evaluable doublet during the follow-up period. Since concomitant cranial and spinal MRI was introduced as the standard evaluation for medulloblastoma/PNET in 1991, 286 doublets were evaluable. Fourteen spinal MRIs and 25 cranial MRIs showed new nodular or leptomeningeal lesions. In 2 patients, repeat MRIs ruled out recurrence (false-positive). All confirmed spinal recurrences were associated with intracranial recurrence. Of 261 doublets with negative cranial MRI, no new lesion was identified on spinal MRI. CONCLUSIONS: An absence of progression on cranial MRI is highly predictive of absence of progression on spinal MRI. There is little evidence that surveillance spinal MRI (in children who underwent craniospinal radiation as part of their initial treatment) improves the detection of recurrences in children with medulloblastoma.     

Radiotherapy of primary intracranial germinomas: the case against routine craniospinal irradiation

A retrospective study was performed on all patients with biopsy-proven intracranial germinomas and unbiopsied suprasellar or pineal region tumors treated during the past 30 years in the Department of Radiation Oncology, University of California, San Francisco. A total of 33 patients were treated: 13 with biopsy-proven germinomas, and 20 others who were unbiopsied. All patients were treated with megavoltage equipment; total dose varied between 40-55 Gy. Only two patients were treated with prophylactic spinal irradiation. No patient received initial or adjuvant chemotherapy. Follow-up times for biopsy-proven patients ranged from 0.5 to 16.7 years with a median 5.3 years. No biopsy-proven patient had a recurrence of the tumor or died; thus, actuarial relapse-free and determinate survivals at 5 years were 100%. Although only one patient in this group received prophylactic spinal irradiation, no patient failed in the spinal axis. The 20 unbiopsied patients had follow-up times ranging from 0.1 to 27.5 years with a median of 5.5 years. Six unbiopsied patients died: two from recurrent disease at the primary site, one from distant peritoneal metastases, two from complications of treatment, and one from intercurrent disease. For this group, actuarial relapse-free survival at 5 years was 72%; the corresponding determinate survival was 73%. Nineteen unbiopsied patients were treated without craniospinal irradiation. Only one developed spinal metastases. The results from this and other series indicate that the risk of spinal metastases from intracranial germinoma is too low to warrant routine prophylactic spinal irradiation. However, patients with gross tumor spill causing contamination of the CSF, malignant CSF cytology, or documented subependymal or subarachnoid metastases presumably are at higher risk for leptomeningeal failure. Craniospinal irradiation is recommended for these patients.     

Leptomeningeal metastases: evaluation by gadolinium enhanced spinal magnetic resonance imaging

Background: Leptomeningeal metastases are common in patients with metastatic systemic cancer or certain primary brain tumors. They may be unsuspected clinically and may be missed by cerebrospinal fluid (CSF) cytology. We undertook a retrospective study of the diagnostic value of gadolinium enhanced spinal MR imaging in patients with known or at high risk for leptomeningeal metastases (LM). Material and methods: Ninety-six gadolinium enhanced MR examinations of the whole spine were performed in 61 patients (26 primary central nervous system tumors, 20 solid tumors and 15 lymphoproliferative neoplasms). All patients had detailed neurological evaluation and concomitant CSF examination. Results: Sixty-one MR's (62%) were positive, mostly in the lumbar spine. MR's were positive in 92% of patients with positive initial CSF cytology and in 60% of patients with negative CSF cytology. The MR examination was positive in 49% of those without clinical findings related to the spinal region. It showed disease beyond the symptomatic level in 42% of patients with spinal symptomatology. Multi-level spinal involvement was present in 57% of positive MR exams. Conclusion: Enhanced spinal MR is sensitive for the detection of neoplastic spinal seeding. It detects LM in about 50% of high risk patients with negative initial CSF cytology or no spinal symptoms.     

骨盆参数在老年脊柱矢状位平衡性判定中的意义

目的 通过研究骨盆参数包括骶骨角、骨盆倾斜度、骨盆指数与老年脊柱矢状位平衡性的相关性,探讨骨盆参数在判定老年脊柱平衡性方面的价值。方法 选取2010年９月至2011年９月北京大学第一医院骨科诊治的26例老年脊柱矢状位曲线不良的病例（包括老年退变性胸腰椎侧弯后凸畸形14例、老年骨质疏松性压缩骨折胸腰椎后凸畸形12例）;男９例、女17例,平均年龄69.2岁（56～79岁）。判定脊柱矢状位平衡性,判定标准包括：（1）患者站立位时不需要双髋过伸及双膝屈曲代偿为脊柱矢状位平衡,如需代偿则为脊柱矢状位失衡;（2） SVA值：侧位像上脊柱矢状面的C7铅垂线位于距S1后上角的±2.5 cm之内为脊柱矢状位平衡,否则为脊柱矢状位失衡。对脊柱矢状位平衡性判定的一致性和可重复性进行分析。根据脊柱矢状位平衡性分为平衡组和非平衡组,测定两组病例骶骨角（sacral slope,SS）、骨盆倾斜度（pelvic tilt,PT）和骨盆指数（pelvic incidence,PI）,应用独立样本 t 检验比较两组SS、PT和PI有无差异。结果 脊柱平衡性判定的一致性为92.3%,Kappa系数为0.861;对脊柱平衡性判定的可重复性为96.1%,Kappa系数为0.938。分为平衡组14例,非平衡组12例;平衡组中SS为（37±11）°,PT为（22±10）°,PI为（63±13）°,非平衡组病例中SS为（26±12）°,PT为（21±13）°,PI为（47±14）°;两组病例中SS和PI差异有统计学意义（P＜0.01）;PT差异无统计学意义。结论 老年脊柱矢状位曲线不良病例的脊柱矢状位平衡性与SS和PI相关,其中SS为主要影响因素可作为脊柱矢状位平衡性和手术策略制订的参考依据。     

Image-guided and intensity-modulated radiosurgery for patients with spinal metastasis

BACKGROUND: Radiosurgery can deliver a single, large radiation dose to a localized tumor using a stereotactic approach and hence, requires accurate and precise delivery of radiation to the target. Of the extracranial organ targets, the spine is considered a suitable site for radiosurgery, because there is minimal or no breathing-related organ movement. The authors studied spinal radiosurgery in patients with spinal metastases to determine its accuracy and precision. METHODS: The spinal radiosurgery program was based on an image-guided and intensity-modulated, shaped-beam radiosurgical unit. It is equipped with micromultileaf collimators for beam shaping and radiation intensity modulation and with a noninvasive, frameless positioning device that uses infrared, passive marker technology together with corroborative image fusion of the digitally reconstructed image from computed tomography (CT) simulation and orthogonal X-ray imagery at the treatment position. These images were compared with the port films that were taken at the time of treatment to determine the accuracy of the isocenter position. Clinical feasibility was tested in 10 patients who had spinal metastasis with or without spinal cord compression. The patients were treated with fractionated external beam radiotherapy followed by single-dose radiosurgery as a boost (6-8 grays) to the most involved portion of the spine or to the site of spinal cord compression. RESULTS: The accuracy for the isocenter was within 1.36 mm +/- 0.11 mm, as measured by image fusion of the digitally reconstructed image from CT simulation and the port film. Clinically, the majority of patients had prompt pain relief within 2-4 weeks of treatment. Complete and partial recovery of motor function also was achieved in patients with spinal cord compression. The radiation dose to the spinal cord was minimal. The maximum dose of radiation to the anterior edge of the spinal cord within a transverse section, on average, was 50% of the prescribed dose. There was no acute radiation toxicity detected clinically during the mean follow-up of 6 months. CONCLUSIONS: Image-guided, shaped-beam spinal radiosurgery is accurate and precise. Rapid clinical improvement of pain and neurologic function also may be achieved. The results indicate the potential of spinal radiosurgery in the treatment of patients with spinal metastasis, especially those with solitary sites of spine involvement, to increase the prospects of long-term palliation.     

Image-guided robotic radiosurgery for spinal metastases.

BACKGROUND AND PURPOSE: To determine the effectiveness and safety of image-guided robotic radiosurgery for spinal metastases. MATERIALS/METHODS: From 1996 to 2005, 74 patients with 102 spinal metastases were treated using the CyberKnife at Stanford University. Sixty-two (84%) patients were symptomatic. Seventy-four percent (50/68) of previously treated patients had prior radiation. Using the CyberKnife, 16-25 Gy in 1-5 fractions was delivered. Patients were followed clinically and radiographically for at least 3 months or until death. RESULTS: With mean follow-up of 9 months (range 0-33 months), 36 patients were alive and 38 were dead at last follow-up. No death was treatment related. Eighty-four (84%) percent of symptomatic patients experienced improvement or resolution of symptoms after treatment. Three patients developed treatment-related spinal injury. Analysis of dose-volume parameters and clinical parameters failed to identify predictors of spinal cord injury. CONCLUSIONS: Robotic radiosurgery is effective and generally safe for spinal metastases even in previously irradiated patients.     

Diagnosis and management of spinal cord sarcoidosis

BACKGROUND: Sarcoidosis of the spinal cord is very rare, affecting less than 1% of patients with sarcoidosis. METHODS: We retrospectively reviewed the charts of all patients with biopsy proven sarcoidosis and spinal cord involvement seen in our Interstitial Lung Disease and Sarcoidosis Clinic at the University of Cincinnati over a nineteen year period. Presentation of disease, method of diagnosis, and response to immunosuppressive therapy (methotrexate, azathioprine, or cyclophosphamide) were noted. RESULTS: Seventeen patients with spinal cord sarcoidosis were identified. All patients presented with insidious parethesias or weakness. Diagnosis was confirmed by biopsy of spinal cord lesions in two patients, dural biopsy in three patients, mediastinoscopy in eight patients, bronchoscopy in two patients, skin biopsy in one patient, and liver biopsy in one patient. Only four patients were diagnosed with sarcoidosis prior to spinal cord involvement. Cytotoxic therapy was initiated to reduce the daily dose of prednisone to less than 10 mg. Fourteen patients were evaluated at least six months after starting cytotoxic therapy. Of these evaluable patients, ten patients received methotrexate plus low dose prednisone and five responded. One patient received azathioprine plus low dose prednisone and responded. One patient received azathioprine, methotrexate, and low dose prednisone and responded. All seven patients that received cyclophosphamide responded. CONCLUSIONS: Spinal cord sarcoidosis should be considered in any patient presenting with gradual onset of paresthesias or weakness regardless of the diagnosis of sarcoidosis. Prompt treatment is important in long term outcome. Cyclophosphamide was an effective, well tolerated corticosteroid-sparing agent for patients with spinal cord sarcoidosis.