脊髓损伤(香港)课件

1、脊髓(j su)損傷 臨床上的問題Spinal Cord InjuryThe Clinical ProblemKeith DK LukChair Professor & HeadDept of Orthopedics & TraumatologyUniversity of Hong Kong第一页，共五十九页。Anatomy 解剖(jipu)學 脊髓(j su) 中樞神經系統Spinal cord (central nervous system) vs 馬尾叢 周邊神經系統Cauda equina(peripheral nervous system)C1 to L1L2 to S4第二页，共五

2、十九页。脊髓(j su)損傷的發病率 Incidence of Spinal Cord Injury在美國，每百萬人口(rnku)約有40宗新病例 (每年10,000宗病例)40 new cases / million population in USA (about 10,000 cases per year)在歐洲, 台灣及香港，每百萬人口約有20宗新病例20 new cases / million population in Europe, Taiwan & Hong Kong National Spinal Injury Statistical Center, USA. 2004第三页

3、，共五十九页。一九九(ji ji)八至九九(ji ji)年度衛生署年報Department of Health Annual Report 1998/99脊髓(j su)損傷 365 病人Spinal Cord Injury 365 patients第四页，共五十九页。2000年衛生署資料Department of Health Website Information脊髓(j su)及神經受損 452 病人Injury to nerves and spinal cord 452 patients第五页，共五十九页。嚴重脊髓(j su)損傷 More Severe SCI二零零四年上半年共有(n

4、 yu)71個病例First 6 months/200471 cases第六页，共五十九页。常見脊髓(j su)損傷的原因Common causes of spinal cord injury交通意外(ywi)Motor vehicular accident高處墜下 Fall from height運動創傷 Sports & recreational injuries暴力 Violence 第七页，共五十九页。香港常見導致脊髓(j su)受損的原因Common Causes of Spinal Cord Impairment in Hong Kong退化(tuhu)病 Degenerative

5、 diseases創傷 Traumatic injuries腫瘤性疾病 Neoplastic diseases發炎性疾病 Inflammatory diseases第八页，共五十九页。第九页，共五十九页。第十页，共五十九页。第十一页，共五十九页。第十二页，共五十九页。第十三页，共五十九页。第十四页，共五十九页。第十五页，共五十九页。殘疾的程度(chngd)Disability relates to:受損水平(shupng) Level of injury四肢癱瘓 Quadriplegia下肢癱瘓 Paraplegia受損程度(chngd) Degree of injury部份受損 Incomp

6、lete完全受損 Complete第十六页，共五十九页。高位(o wi)脊髓受損High Spinal Cord Injury 依賴呼吸(hx)機 Ventilator dependent呼吸併發症 Respiratory complication完全依賴 Totally dependent第十七页，共五十九页。臨床問題 Clinical Problems生理(shngl)問題 Physical 心理問題 病人, 家屬 Psychological Patient, Family社交問題 就業, 參與社會活動 Socio-economical Employment, Community acce

7、ss第十八页，共五十九页。生理(shngl)問題Physical Problems喪失活動能力(nngl) Loss of motion失去感覺 Loss of sensation - Pressure ulcers 褥瘡 痛楚 Pain 第十九页，共五十九页。生理(shngl)問題Physical Problems 交感神經功能 Autonomic dysreflexia - 膀胱 尿滯留或小便(xiobin)失禁 Bladder retention or incontinence - 大腸 便秘或失禁 Bowel constipation or incontinence - 功能性障礙 S

8、exual dysfunction 痙攣 Spasticity第二十页，共五十九页。完全癱瘓者:一年內:約5-10%的病人約有兩節段的改善(gishn)90% 的病人有一節段的改善 少於1%的病人有兩節段以上的改善: For complete SCI:In one year:90% of SCI patients improve one level. 5-10% of SCI patients improve two levels. less than 1% of SCI patients improve more than two levels半癱瘓者: 比較難估計, 不過整體比完全癱瘓者優

9、勝For incomplete SCI less predictable, tends to be better than complete injuries NSCISC, 2004. Natural history 第二十一页，共五十九页。傳統的療法 Conventional management 脊髓是不能被修補或再生 Repair, regeneration of the spinal cord is not possible集中(jzhng)復康治療主流治療方向增強殘餘功能恢復功能 減低傷殘 Focus on rehabilitationMain stream managementM

10、aximize residual functionsFunctional restoration Minimize disabilities第二十二页，共五十九页。截癱性步行(bxng) Paraplegic walking第二十三页，共五十九页。半癱瘓 Incomplete Paraplegia第二十四页，共五十九页。 家居(jij)改善 Home modification第二十五页，共五十九页。公共(gnggng)交通工具 Transportation第二十六页，共五十九页。第二十七页，共五十九页。香港現有的服務Current Services in Hong Kong幾乎所有(suyu)

11、的脊髓復康服務均由醫院管理局提供 Nearly all spinal cord rehabilitation are provided by HA三間由醫管局提供的脊髓復康醫院 3 SCI units under the Hospital Authority香港區：麥理浩復康院, MacLehose Rehabilitation Centre 九龍區：九龍醫院, Kowloon Hospital新界區：大埔醫院, Tai Po Hospital高技術水準的設備 - FES, 矯具等State-of- the-art facilitiesFES, orthosis, etc第二十八页，共五十九页

12、。脊髓損傷的治療及再生(zishng)的可能Potential for spinal cord repair and regeneration 再生(zishng)療法Regenerative therapies第二十九页，共五十九页。脊髓(j su)損傷研究的重要性 Importance of Spinal Cord Injury (SCI) Research第三十页，共五十九页。 研究脊髓(j su)損傷的病理組織學 To investigate pathohistology of Spinal Cord Injury： 甚麼因素阻止了脊髓(j su)損傷後軸突的再生？ What stop

13、 axonal regeneration in Spinal Cord Injury? 如何促進脊髓損傷受損神經元的存活(cn hu)和再生？ How to enhance survival and regeneration of injured neurons in Spinal Cord Injury? 這些問題的答案將會給脊髓損傷病人提供新的療法。 Answer to these questions will contribute significantly for the new treatment methods for Spinal Cord Injury patients. 損傷

14、後神經元如何、為何死亡？ how and why neurons die after injury? 第三十一页，共五十九页。 確定已用於脊髓損傷病人(bngrn)臨床試驗的幹細胞、施萬細胞以及Oefactory Ensheathing Cells 細胞(OEC - 嗅鞘上皮細胞)移植等治療方法的機制。To confirm and prove mechanisms of treatment methods that have been used in clinical trial study for the Spinal Cord Injury patients, such as stem c

15、ell, Schwanns cell and OEC cell (Oefactory Ensheathing Cells) transplantations. 為脊髓(j su)損傷新藥的檢測提供動物模型。To provide animal models for testing effects of new drugs for Spinal Cord Injury.第三十二页，共五十九页。Neuroscience Exploring the Brain, Second Edition.Bear MF, Connors BW, Paradiso MA脊髓的主要(zhyo)功能（Main Func

16、tions of the Spinal Cord）將感覺訊息從外周傳向腦，運動訊息從腦傳向外周。 構成局部回路(hul)和反射。 To perform locomotion and reflex. To convey sensory impulses from periphery to the brain and to convey motor impulses from the brain to the periphery.第三十三页，共五十九页。神經细胞(xbo)死亡 （Neuronal cell death） a. 原發損傷 Primary injury (空洞cavity) b. 繼發

17、損傷 Secondary injury1a1b321234524,5,6脊髓(j su)損傷後有侍解決的問題2. 軸突切斷（Axotomy）3. 脱髓鞘（Demyelination）4. 膠質癍痕（Glial scar）5. 抑制性分子(fnz)（Inhibit molecules , NI-35, NI-250）6. 血液供應不良（Poor Blood supply）第三十四页，共五十九页。1a1b322524,5,6脊髓(j su)損傷的突破性研究 (一)（Breakthrough Studies on the Field of Spinal Cord Injury）1. 神經细胞死亡(s

18、wng)（Neuronal cell death）波尼松龍治療减少细胞死亡，利用嗅鞘上皮細胞或幹细胞移植替代死亡的细胞。Reduce cell death by therapy with methylprednisolone (Young 1990) and replace death cells with OEC transplantation (Li, J of Neurosci. 1998; Huang, 2003) or Stem cells transplantation (Harper, PNAS 2004).2. 軸突切断（Axotomy）的治療增强軸突切斷神經元的再生(zish

19、ng)能力。Enhance regeneration ability of axotomized neurons (Pears Nature Medicine, 2004; Yick, J Neurotrauma, 2004).第三十五页，共五十九页。1a1b321234524,5,6脊髓(j su)损傷的突破性研究(二)（Breakthrough Studies on the Field of Spinal Cord Injury）3. 去髓鞘（Demyelination）的治療通過施萬细胞移植(yzh)重建髓鞘 。Rebuild myelination by Schwanns cell t

20、ransplantation (Xu, EJN 1999; Sivasankaran, Nature Neurosci. 2004).4,5,6. 膠質癍痕及抑制性分子（Glial scar and Inhibit molecules）通過改變局部化學環境减少癍痕形成(xngchng)，去除抑制因子。Reduce glial scar and remove inhibitor molecules by changing the local chemical environment (Yick, Neuroreport, 2000; Moon, Nature Neurosci. 2001). 第

21、三十六页，共五十九页。用於治療脊髓(j su)損傷的幹細胞第三十七页，共五十九页。Clinical Trials CentreFaculty of MedicineThe University of Hong Kong8/F Clinical Pathology BuildingQueen Mary Hospital, Hong KongTel: (852) 2855 4664Fax: (852) 2974 1248E-mail: ctcentrehkucc.hku.hkwww.hku.hk/ctc香港大學醫學院臨床試驗中心(zhngxn)第三十八页，共五十九页。Symposium on Cl

22、inical Trial Central Laboratory Services due to the lack of investigators and patients in the established regions.Study sitesDrug development has become a global activity由於研究員及合適参與臨床試驗的病人(bngrn)在已發展地區均出現短缺，臨床試驗正趨向全球化。試驗場地第三十九页，共五十九页。Symposium on Clinical Trial Central Laboratory Services 19801990 19

23、96 ICH GCP Guideline良好(lingho)臨床試驗管理規範第四十页，共五十九页。Symposium on Clinical Trial Central Laboratory Services 已發出之臨床試驗證書第四十一页，共五十九页。Global clinical trialsInto China and HKfrom other regions吸引(xyn)世界各地之科研機構到中、港進行臨床試驗Our aim我們的目標第四十二页，共五十九页。Products from China and HK協助中、港之醫藥產品進軍國際市場Our aim我們的目標第四十三页，共五十九页。

24、Highly qualified clinical investigators 高質素之臨床研究員Scientific expertise 科學專業知識Experienced in clinical research 豐富之臨床研究經驗High population density 高人口密度Excellent infrastructure 優良之基建(jjin) and more 及其他有利條件Why Hong Kong? 為何選擇香港?第四十四页，共五十九页。Clinical Sciences Number of Publications (1991-2002)臨床科學 出版(chbn)數

25、目 (1991-2002)Clinical Trial / Research Experience 臨床試驗/研究(ynji)經驗第四十五页，共五十九页。Hong Kong Hospital Authority ClustersHA7 Clusters七個聯網43 Hospitals/Institutions四十三間醫院/機構29,022 Beds二萬九千零二十二個床位(chungwi)6.8 Million Population六百八十萬人口 香港醫院管理局聯網第四十六页，共五十九页。Hong Kong Hospital Authority ClustersCompliance with I

26、CH GCP 符合良好臨床試驗管理規範之標準Uniform operations 統一運作標準HA Guidelines 醫院管理局指引(zhyn)SOPs 標準運作程序Trained EC members 曾受訓之倫理委員會會員Ethics Committees 倫理委員會香港醫院管理局聯網第四十七页，共五十九页。Established in 1998 under the Faculty of Medicine of The University of Hong Kong (founded in 1887)於一九九八年在香港大學醫學院之下成立(chngl)The first full-ser

27、vice Academic Research Organization (ARO) in clinical trials in Asia亞洲首間一站式臨床試驗學術研究機構Clinical Trials Centre 臨床試驗中心(zhngxn)Objective: To offer one-stop solutions to clinical trial sponsors and investigators目標: 提供(tgng)一站式服務予臨床試驗贊助商及研究員第四十八页，共五十九页。Board of Directors 理事會Clinical Trials Centre 臨床試驗中心Bus

28、iness and Development 業務發展Project Management 項目管理Site Management 研究基地管理Data Management and Medical Statistics 數據處理及統計分析Laboratory and Research Pharmacy 實驗室及藥品管理Education 教育及培訓Research and Consultation 研究及諮詢Advisory Committee諮詢委員會Faculty of Medicine 醫學院Trial Network Management 試驗網絡管理Organization Stru

29、cture 組織架構第四十九页，共五十九页。Sponsors with a Master Clinical Trial Contract with HKU部份已與香港大學訂定標準合約之贊助商第五十页，共五十九页。Services 服務Research Consultation研究諮詢Contract & Budget合約及財務預算Regulatory Affairs法規事務Subject Recruitment受試者招募Site Management研究基地管理Trial Monitoring試驗監察Research Pharmacy藥品管理Project Management項目管理Data

30、 Management數據處理Medical Statistics統計分析Training & Education教育及培訓Laboratory Services實驗室服務第五十一页，共五十九页。Clinical Trials 臨床試驗CTC No. of Sponsored Trials Contracted Per Year受贊助之臨床試驗總數(每年(minin)第五十二页，共五十九页。Types of Trials by Therapeutic Area按專科分類Types of Trials by Trial Phase按臨床試驗期分類Type of clinical trials 臨

31、床試驗之種類CTC Types of Trials腫瘤科兒科泌尿科一期(y q)腸胃及肝臟科感染(gnrn)及傳染科血液科心臟科其他(qt)內分泌及新陳代謝科三期四期其他二期精神科第五十三页，共五十九页。5 clinical laboratories:Anatomical PathologyClinical BiochemistryClinical ImmunologyHaematologyMicrobiology五大臨床實驗室：組織及細胞病理臨床生化(shn hu)臨床免疫血液微生物學Fully accredited by the College of American Pathologis

32、ts (CAP) (under the category of large multidiscipline laboratory)Laboratory Facilities 實驗室設備得到美國病理(bngl)學家學會(CAP)之認証(隸屬大型多功能實驗室組別)第五十四页，共五十九页。Master of Medical Sciences / PgDip / PgCert 醫療科學碩士/研究院文憑/研究院證書- Clinical Trials Research Methodology 臨床試驗研究(ynji)方法學- Medical Statistics 統計分析GCP courses 良好臨床試驗管理規範課程EC members trainin