脊髓疾病(年制)课件

SpinalDiseases

脊髓疾病

汕头大学医学院第二附属医院神经内科张尤桥

AnatomyandPhysiology

解剖生理

Theexternalstructure:

外部结构

Theinternalstructure:

内部结构Theexternalstructure:

外部结构1.theupperandlowerbound(上下界)2.thespinalduramater(硬膜)

thearachnoid(蛛网膜)

thepiamater(软膜)thesubduralspace(硬膜下腔)thesubarachnoidspace:CSF(蛛网膜下腔:脑脊液)3.anatomicalsegmemnts(解剖分段)4.functiongnalsegmemnts(功能分段)5.thesegmentsensation:(感觉平面/节段)6.therelationshipofspinalsegmentstothevertebralbodies:

(髓节与椎骨对应关系)anatomicalsegmemnts解剖分段：

31segments:C8,T12,L5,S5,Co1;functiongnalsegmemnts功能分段：thehighcervicalsegment:C1-4;

高颈段thecervicalintumescentia:C5-T2;

颈膨大thethoracicsegment:T3-12;

胸段thelumbarintumescentia:L1-S2;

腰膨大themedullaryconus:S3-Co1圆锥thecaudaequina:L2-Co1(10).

马尾NTheinternalstructure

内部结构（1）1.thegraymatter:灰质2.thewhitemater:

白质thegraymatter:

灰质①theanteriorhorn;前角；②theposteriorhorn;

后角③thelateralhorn:侧角;a.C8-L2:thesympatheticnerve;C8-T1;

交感Nb.S2-4:theparasympatheticnerve;付交感N④thecentralcanal中央管:a.theanteriorcommissure前联合；b.theposteriorcommissre.后联合thewhitemater:

白质a.theanteriorfuniculus;前索theposteriorfuniculus;后索thelateralfuniculus.侧索b.thepyramidaltract(thecorticospinaltract);

椎体束thespinothalamictract;

脊髓丘脑束thefasciculusgracilisandthefasciculuscuneatus.簿束、楔束c.thearrangementoffibers:

纤维排列：interior→outside:C,T,L,S.Fig9.内→外Spinalreflex

脊髓反射1.

Strechreflex牵张反射２．Flexorreflex屈曲反射３．Spinalshock脊髓休克(脊髓反射消失)ClinicalManefestationforthedamageofspinalcord

脊髓损害临床表现

1、运动障碍

2、感觉障碍

3、自主神经功能障碍ClinicalManefestationforthedamageofspinalcord

脊髓损害临床表现

damageofthegraymater

灰质损害damageoftheconductiontract

传导束损害damageofonehalfofthespinalcord

半切损害transversedamageofthespinalcord横贯性损害damageofthegraymater

灰质损害

1.damageofspinalanteriorhorn:

前角损害2.damageofspinaldorsalhorn:后角损害3.damageofspinalanteriorcommissure:前连合损害4.damageofspinallateralhorn:侧角损害1、damageofspinalanteriorhorn:

前角损害segmentalparalysisoflowermotorneuron节段性下运动神经元性瘫痪

lowtension肌张力降低，

weaktendonreflex腱反射减弱，muscularatrophy肌萎缩，

nopathogicsigns无病理反射。2、damageofspinaldorsalhorn:

后角损害segmentalsensoryabnormalitylikedorsalrootdamage

类似后根损害的节段性分离性感觉异常abnormalpainandtemperaturesensation

痛、温觉异常，normaltouchanddeepsensation

触觉、深感觉正常3、damageofspinallateralhorn

侧角损害involvesautonomicnerve累及自主神经resultingin:引起abnomalvascularmovement血管运动异常、excessivesweating出汗、malnutritionoferecthairskinandnails

竖毛、皮肤、指甲营养障碍damageoftheconductiontract

传导束损害damageofthecorticospinaltract:pyramidalsign:皮层脊髓束损害：椎体束征damageofthespinothalamictract:

脊髓丘脑束损害damageofspinaldorsalcolumn:

后索损害damageofthecorticospinaltract:

皮层脊髓束损害：pyramidalsign:椎体束征Paralysis瘫痪、Manifestinghypertonia肌张力增高、hyperreflexia腱反射亢进、pathologicsigns病理反射阳性damageofthespinothalamictract:

脊髓丘脑束损害abnomalsuperficialsensation浅感觉异常damageofspinaldorsalcolumn:

后索损害

abnormalityofdeepsensation,深感觉异常、

damageofonehalfofthespinalcord

半切损害

BrownSequardSyndrome.

Ipsilateralspasticparalysis同侧痉挛性瘫痪、anddeepsensorydysfunction和深感觉障碍contralateralsuperficialsensorydysfunction对侧浅感觉障碍mostwithnoobviousdysfunctionofthetouchsensation大多数没有触觉障碍transversedamageofthespinalcord

横贯性损害(1)

highcerveicalspinaltransversedamage:

高颈段损害

cervicalintumescentiatransversedamage:颈膨大损害

transversedamageofthoracicspinalcord:

胸段损害abdominalreflex(腹壁反射)↓，Beeversign.

lumbarintumescentiatransversedamage:

腰膨大损害

cremasteric,knee,ankleandplantarreflex↓.

提睾反射、膝反射、踝反射、跖反射↓

transversedamageofthespinalcord

横贯性损害(2)

(5)transversedamageofconus:

圆锥损害

saddle-likesensorydecreaseorlossinanusandperineum肛门会阴部鞍区感觉减弱或消失、andrareofslightrootpain少有根痛sexualdysfunction:性功能障碍lossofanusreflex;.肛门反射消失

retentionofurineandstools.大小便失禁(incontinence潴留)(6)transversedamageofcaudaequina:

马尾N损害

severelegpain;剧烈腿痛

flaccidparalysisofbothlegs;双腿弛缓性瘫

lossofkneeandanklereflex;膝反射、踝反射消失incontinenceandretentionofurineandstools大小便潴留和失禁

AcuteMyelitis

急性脊髓炎

Definition定义EtiologyandPathology病因病理ClinicalManifestation临床表现LaboratoryFindings辅助检查Diagnosis诊断要点DifferentialDiagnosis鉴别诊断Treatment治疗Prognosis:预后Definition

定义Acutetransversemyelitis;急性横贯性脊髓炎

Postinfectiousmyelitis;

感染后脊髓炎Postvaccinalmyelitis；

疫苗接种后脊髓炎2EtiologyandPathology

病因病理

Unknown;病因未明。

Postinfectiousallergicreaction;

感染后变态反应。T3-5spinalsegmentsmaybeswollenorslightlyenlarged;脊髓肿胀/增粗3ClinicalManifestation临床表现(1)

1.respiratoryinfectionorvaccination;呼吸道感染/接种史2.tocatchacold,fatigue,injury;受凉、疲劳、外伤3.rootpainatthelesionlevel,受损平面根痛，numbnessandweaknessofthefeetandlegs双下肢麻木、乏力(lessoftenofthehandsandarms)(手和臂常少受累)4.belowthelesionlevel.病变平面以下theparalysisofextremities,肢体瘫痪，lossofsensation,各种感觉障碍，dysfunctionsofbowelandbladder大小便障碍7ClinicalManifestation临床表现(2)5.involvesautonomicnerve,自主神经功能障碍resultingin:abnormalvascularmovement,血管运动异常、excessivesweating,出汗少、无汗malnutritionoferecthair,skinandnails.

坚毛、皮肤、指甲营养障碍6.spinalshock:1～2week;2～4week.脊髓休克7.return:恢复3～4week;3～6months

8.ascendantmyelitis:上升性脊髓炎LaboratoryFindings

辅助检查

1.CSF脑脊液;2.MRI磁共振;Diagnosis:

诊断要点1.2.3.4.

DifferentialDiagnosis鉴别诊断

neuromyelitisoptica;

视N脊髓炎2.spinalhaemorrhage(bleeding)脊髓出血3.缺血性脊髓血管病4.spinalcordcompression:

脊髓压迫症：spinalepiduralabscess硬膜外脓肿、tumor肿瘤脊柱结核5.Guillain-Barresyndrome格巴急性脊髓炎

格巴病变部位

胸段脊髓

N根、周围N瘫痪截瘫、硬瘫(休克期软瘫)四肢软瘫感觉障碍明显、传导束型轻或无、末梢型大小便障碍明显、早出现一般无、轻或短暂颅N障碍无有CSF

多数正常，少数蛋白/细胞数轻↑蛋白～细胞分离电生理

SSCV↓MCV↓、H反射、F波↓

Treatment

治疗（1）

1.drugs（药物）:①DXM,prednisone;甲强龙地塞米松、强的松

②免疫球蛋白

③VitB;维生素B④Dibazone,nimodipine;地巴唑、尼莫地平⑤20%mannitol;

甘露醇⑥antibiotic;

抗菌素Treatment治疗（2）

2.nursing护理：skin,respiratorytract,urine,stool.皮肤，呼吸道，尿，大便。3.nutrition;营养

4.support;支持5.recoveredtreatment:康复治疗Prognosis:

预后Whataretheclinicalmanifestationsoftheacutemyelitis?

Compressive

myelopathy

压迫性脊髓病

Difinition:

定义refertoanumberofneurologicdiseaseswithspinaldysfunction,causedbysomeoccupationsinthevertebralcavitywhichresultedinthecompressedinjuryofthespinalcord,rootsofspinalnervesandtheirbloodvessels.由于椎骨椎管内占位性病变而产生的脊髓受压的一大组病征

Etiology:

病因:1.肿瘤

2.炎症

3.脊柱外伤

4.脊柱退行性病变

5.先天性疾病

pathogenesis：发病机制

脊髓受压早期可代偿,外形有明显改变,但传导径路并未中断,不出现神经功能受损.后期失代偿,出现明显症状和体征.

受压病变的性质和速度可影响代偿机制.

病变部位对损伤影响.ClinicalManifestation

临床表现(1)分型：acutespinalcordcompression:

急性脊髓压迫症(1)

transversedamageofthespinalcord;

(2)

spinalshock.chronicspinalcordcompression慢性脊髓压迫症

progressive进行性;Threestages三个期:

rootpains;(stimulantperiod)根痛(刺激期)

partialcompressionofspinalcord部分受压期

(Brown-Sequard’ssyndrome).finallycompletecompressionofthecord

(transversedamageofspinalcord)横贯性损害期

ClinicalManifestation

临床表现(2)表现：Radicularsymptomsandsigns:神经根症状和体征Sensorydisturbances:感觉障碍(髓内病变,髓外病变)Motordisturbances：运动障碍Thereflexes：反射Autonomicsymptoms:自主神经症状Irritativesymptomsofspinalmeninges:脊膜刺激症状LaboratoryFindings

辅助检查

1.lumbarpuncture:

腰穿①thepressureistested:itisraised压力↑(80-180mmH2Oisnormal).②cellcountisnormal细胞数正常；③proteinisraised,xanthochromia,Froinsign.蛋白↑黄变④Queckenstedttest:(+)奎根试验(压颈试验)2.X-ray3.vertebraltubeangiography:

椎管造影4.CTorMRDiagnosis

诊断yesornot?

是不是？whereitis?

在哪里？Whichdiseaseitis?

什么病？Diagnosis诊断(1)1.Thefoundationofdiagnosis(basisfordiagnosis):

根据①manifestationofthespinalcordcompression:

临床表现②vertebraltubeblocked;

椎管阻塞③CT/MR;2.toshowthepositionofthecompression:

定位

verticalsection;

纵向

crosssection:

横向insideoroutsideofthespinalcord:12髓内与外insideoroutsideofthespinalduramater:4硬膜内与外3.toshowthenature;

定性

3.定性诊断:急性压迫:多为外伤性.慢性压迫:髓内和髓外硬膜内以肿瘤常见.脊髓蛛网膜炎硬膜外病变以转移瘤多见,椎间盘突