脊髓疾病中英對(duì)照ppt課件

1、脊 髓 疾 病 Diseases of the Spinal Cord,肖 波 中南大學(xué)湘雅醫(yī)院神經(jīng)內(nèi)科,第一節(jié) 概述,overview,Overview,,Anatomy Internal Structure Blood Supply Clinical Features of Different Lesions,Overview,脊髓的解剖 Anatomy of spinal cord,脊髓的外

2、形 External features 31對(duì)脊神經(jīng): 脊髓的節(jié)段與脊柱的不一致，由于胚胎時(shí)期脊髓的生長(zhǎng)比脊柱慢,Overview,Overview,,C(cervical)-8 T(thoracic)-12L (lumbar)-5 S (sacral)-5Co (coccygeal)-1,脊髓的膨大 Enlargement of spinal cord,頸膨大 Cervical enlarge

3、ment:C5→T2 腰膨大 Lumbar enlargement:L1→S2 馬尾 Cauda equina 由腰2至尾節(jié)共10對(duì)神經(jīng)根組成,Overview,脊髓的三膜二腔 Meninges and space of the spinal cord,脊髓 硬膜外腔 硬脊膜 硬膜下腔 蛛網(wǎng)膜 蛛網(wǎng)膜下腔

4、 軟脊膜,Overview,,,,易受感染易破裂形成硬膜外血腫,,可反映腦的病變注藥入內(nèi)進(jìn)行治療,,,意義不大,epidural cavity,subdural cavity,subarachnoid cavity,,,,,脊髓內(nèi)部結(jié)構(gòu) Internal Structure,灰質(zhì) Grey matter ： 前角 Anterior horn: αand γmotor neuron 后角 Posterior ho

5、rn: secondary sensory neuron 側(cè)角 Lateral horn: C8－L2 交感神經(jīng)低級(jí)中樞 Sympathetic nucleus S2－S4 脊髓副交感中樞 Parasympathetic nucleus,,,,Overview,白質(zhì) White matter：,前索

6、Anterior funiculus：皮質(zhì)脊髓前束 主要為下行纖維 側(cè)索 Lateral funiculus：

7、 后索 Posterior funiculus： 主要為上行纖維,,,Overview,薄束楔束,脊髓丘腦束脊髓小腦束皮質(zhì)脊髓側(cè)束,,,,Overview,后索,側(cè)索,前索,1 薄束 2 楔束 3 脊髓小腦后束 4

8、 皮質(zhì)脊髓束 5 脊髓丘腦側(cè)束 6 脊髓小腦前束 9 皮質(zhì)脊髓前束 14 脊髓丘腦前束,后角,側(cè)角,前角,脊髓的血液供應(yīng) Blood Supply,脊髓前動(dòng)脈 Anterior spinal artery： easy to be ischemia 根動(dòng)脈 Radicular artery ： T4 and L1 are the boundary areas, and easy

9、 to be ischemia 脊髓后動(dòng)脈 Posterior spinal artery： rare ischemia,Overview,,,,Overview,脊髓損害的臨床表現(xiàn)Clinical Features of Different Lesions,運(yùn)動(dòng)障礙 motor disturbance:前角和/或錐體 束損害：運(yùn)動(dòng)神經(jīng)元病感覺(jué)障礙 sensory disturbance：后角和前

10、連 合損害出現(xiàn)分離性感覺(jué)障礙自主神經(jīng)功能障礙 functional disturbance： 大、小便障礙等,Overview,脊髓半切綜合征 Brown-Sequard Syndrome,脊髓病變平面以下同側(cè) 的上運(yùn)動(dòng)神經(jīng)元癱瘓同側(cè)深感覺(jué)喪失對(duì)側(cè)的痛、溫覺(jué)喪失,Overview,脊髓橫貫性損害Transverse lesions,原因 Major cause:A

11、cute myelitisSpinal cord traumaSpinal cord compressionHematomyelia,表現(xiàn)Major signs :Upper motor neuron paralysis (spinal shock)Loss of all senseAutonomic dysfunction,脊髓休克 Spinal Shock,Overview,脊髓休克 Spinal Shock,脊髓受

12、到急性嚴(yán)重的橫貫性損害時(shí)，出現(xiàn)受損平面以下脊髓反射活動(dòng)完全消失，表現(xiàn)為肢體軟癱、肌張力低、腱反射消失和病理征陰性，一般持續(xù)1－6周。In the acute stage of spinal cord lesions, there is flaccid paralysis with loss of tendon and other reflexes, accompanied by sensory and by urinary and fe

13、cal retention. This is the stage of spinal shock, and often last 2 to 6 weeks.,Overview,脊髓橫貫性損害 Transverse lesions,損害平面的確立節(jié)段性肌萎縮根痛感覺(jué)平面反射改變,中指 C7 胸骨角 T2 乳頭 T4 劍突 T6 肋弓 T8 臍部

14、 T10 腹股溝 T12,Overview,脊髓橫貫性損害 Transverse lesions,高頸段（C1-4）Spastic paralysis of all extremitiesSense loss below neck，root painUrinary and fecal retention，Absent sweating Diaphragmatic paralysis，dyspnea（ C3-5 ）,Ov

15、erview,脊髓橫貫性損害 Transverse lesions,頸膨大（ C5－T2 ）Spastic paralysis of lower limbs and flaccid paralysis in upper limbsSense loss below shoulder， Root pain in upper limbs and shoulderUrinary and fecal retentionAutonomic

16、dysfunction (Horner syndrome),Overview,,霍納（Horner）綜合征：瞳孔縮小，眼球內(nèi)陷，眼裂變小，面部出汗減少。,Overview,脊髓橫貫性損害 Transverse lesions,胸段（T3-12）Sense loss below chest or belly Spastic paralysis of lower limbsUrinary and fecal retentionAut

17、onomic dysfunction Root pain in backSegmental Abdominal reflex vanish,Overview,脊髓橫貫性損害 Transverse lesions,腰膨大（ L1－S2 ）Sense loss of lower limbs and perineumFlaccid paralysis of lower limbsUrinary and fecal retentio

18、nAutonomic dysfunctionRoot pain in groin,Overview,第二節(jié),急性脊髓炎 Acute myelitis,Acute myelitis,Definition and classification Clinical manifestation Diagnosis and Differential diagnosis Treatment Pronosis,Acute

19、 myelitis,概念 Definition ： 是由于非特異性炎癥引起脊髓白質(zhì)脫髓鞘或壞死，導(dǎo)致急性橫貫性脊髓損害，也稱(chēng)急性橫貫性脊髓炎。 Acute myelitis is an acute inflammation of one or more segments of the spina

20、l cord, which is associated with infections and vaccinations disorders.,Acute myelitis,,病因 Etiology ：Infection and vaccinationVirusParasiteBacteriaFungusUnclear,分類(lèi) Classification：postinfectious myelitisPostvaccin

21、al myelitisDemyelinating myelitisParaneoplastic myelitis,Acute myelitis,臨床表現(xiàn) Clinical Manifestation（一）,發(fā)病年齡 Age: youth (4 y~ 83y)性別 Sex：male ≈female起病形式 Episode: acute; days誘因 Cause: postvaccinal and

22、postinfectious好發(fā)部位 Levels: Most common T3 to T5;Cervical up to C1,Acute myelitis,Clinical Manifestation（二）,運(yùn)動(dòng)障礙 motor disturbance ： 脊髓休克 Spinal Shock 感覺(jué)障礙 sensory disturbance ： 損害平面以下所有感覺(jué)消失

23、自主神經(jīng)功能障礙 autonomic dysfunction ： 大、小便障礙，皮膚干燥,Acute myelitis,Clinical Manifestation（三）,上升性脊髓炎 Acute ascending myelitis 1.起病急驟 2.病變常在1－2天甚至數(shù)小時(shí)上升到延髓 3.癱瘓由下肢迅速累及上肢或延髓支配肌群出現(xiàn)吞咽困難，構(gòu)音不清，呼吸肌麻痹，甚至死亡。,Acute myelitis,輔助檢查

24、Laboratory,腦脊液 Cerebrospinal fluid：Colorless and transparentWhite cells and protein normal or slightly increased Glucose and chloride normalMRI： Enlarged spinal cord,Acute myelitis,鑒別診斷 Differential Diagnosis（一）,視神經(jīng)

25、脊髓炎 Neuromyelitis optica有視力下降 Vision↓病變常不完全對(duì)稱(chēng) Lesions are commonly incomplete symmetry病情常有緩解及復(fù)發(fā) Remission-relapse可出現(xiàn)多灶性體征 Multifocal sign,Acute myelitis,Differential Diagnosis（二）,急性硬膜外膿腫 Acute epidural abscess有化膿感染史

26、 focus of infection發(fā)熱、根痛明顯 fever, root pain椎管阻塞明顯 obstruction of vertebral canal腦脊液細(xì)胞和蛋白增高 white cell and protein↑MRI可幫助鑒別 MRI used for identify,Acute myelitis,Differential Diagnosis（三）,脊髓出血 Hematomyelia 起病更急sudden

27、劇烈背痛 severe back pain血性腦脊液 bloody CSFMRI MRI or myelography,Acute myelitis,治療 Treatment,精心護(hù)理 Careful nursing 防褥瘡，保持呼吸道通暢 藥物治療 Drug treatment 糖皮質(zhì)激素、維生素B族、抗病毒藥等 康復(fù)治療 Early rehabilitative ma

28、nagement,Acute myelitis,預(yù)后 Prognosis,3－6個(gè)月內(nèi)能恢復(fù)生活自理 1/3病人基本恢復(fù) 1/3病人能行走，但步態(tài)異常、大小 便障礙 1/3病人持續(xù)癱瘓、尿失禁,Acute myelitis,第三節(jié),脊髓壓迫癥 Compressive myelopathy,Compressive myelopathy,Definition and Etiology Clinical manifesta

29、tion Laboratory findings Diagnosis Treatment,Acute myelitis,概念 Definition ：,是由于椎管內(nèi)的占位性病變引起脊髓受壓的臨床綜合征，病變進(jìn)行性發(fā)展，導(dǎo)致不同程度的脊髓橫貫性損害和椎管阻塞。 Compressive myelopathy is a symptom result from compression of spinal cord by

30、 occupying lesion in spinal collum, with progressive of the lesion, it can result variety degree of transverse lesion of spinal cord and spinal columm obstruction.,Compressive myelopathy,病因 Etiology,腫瘤 Tumor：膠質(zhì)瘤、神經(jīng)鞘瘤、轉(zhuǎn)移瘤

31、先天性異常 Congenital abnormality： 顱底凹陷癥外傷 Trauma：椎間盤(pán)突出、脫位、骨折炎癥 Inflammation：脊柱結(jié)核、硬膜外 膿腫、蛛網(wǎng)膜炎癥脊髓出血 Myelorrhagia,,Compressive myelopathy,臨床表現(xiàn) Clinical Manifestation（一）,多表現(xiàn)為慢性脊髓壓迫,以占位病變較多見(jiàn)

32、. 起病形式 Episode:隱襲,進(jìn)展緩慢 根性疼痛 Root pain:髓外壓迫,Compressive myelopathy,Clinical Manifestation（二）,感覺(jué)障礙 Sensory disturbance ： 脊髓丘腦束:受損平面以下對(duì)側(cè)軀體痛溫覺(jué)消失 后索:受損平面以下同側(cè)軀體深感覺(jué)消失 馬鞍回避:髓內(nèi)病變鞍區(qū)（S3-5）感覺(jué)最后受累,,,髓外壓迫

33、時(shí),感覺(jué)障礙自下肢向上發(fā)展髓內(nèi)壓迫時(shí),感覺(jué)障礙自病變節(jié)段向下發(fā)展,,Compressive myelopathy,Clinical Manifestation（三）,運(yùn)動(dòng)障礙 Motor disturbance : 錐體束 同側(cè)上運(yùn)動(dòng)神經(jīng)元癱瘓 前角或前根 相應(yīng)節(jié)段肌束顫動(dòng)、肌束 萎縮反射異常 Abdominal reflex 自主神經(jīng)功能障礙 Autonomic

34、 dysfunction,,,Compressive myelopathy,輔助檢查 Laboratory,腦脊液 Cerebrospinal fluid： pressure ，protein ，Queckenstedt test (be careful)脊柱X線攝片 X-rayMRI或CT脊髓造影 Myelography,,,,Compressive myelopathy,診斷步驟 Diagnosis steps,是否

35、脊髓病變？（三主征）確定脊髓是否為壓迫性確定脊髓壓迫的節(jié)段確定髓內(nèi)、髓外、硬膜內(nèi)或硬膜外的病變明確病因和病變性質(zhì),Compressive myelopathy,,Compressive myelopathy,治療 Treatment,治療原則:盡早去除導(dǎo)致壓迫的原因Surgical treatmentEtiological treatment: Antibiotics：epidural abscess

36、 Antiuberculotic：spinal tuberculosis Radiotherapy：tumor,Compressive myelopathy,病例和MRI,例1：男，35歲，發(fā)熱10天，頭痛、四肢乏力。診斷：,,急性脊髓炎,病例和MRI,,例2：男，31歲，確診為結(jié)核性腦膜炎住院治療。查體：下肢截癱，T5以下平面痛覺(jué)消失。診斷：,,結(jié)核性腦脊髓炎,病例和MRI,例3：女，35歲，左手無(wú)力、萎縮