脊柱损伤PPT课件.ppt

脊柱和脊髓损伤Spinefracture&spinalcordinjury（SCI）,桑宏勋,1,Gymnast-SangLanSportsinjury,2,Outline,IncidenceTypesClinicalsignsRadiologicalsignsSpinalshockManagement,3,Incidence,10-15permillion18-35yearsMale-3:1RTA51%-carsDomestic16%Industrial11%Sports16%-divingincidentsSelfharm5%occupation&naturaldisaster!,4,Types,Cervical40%Thoracic10%Lumbar3%Dorsolumbar35%Any14%About5-7%ofthetotalbodyfractures,5,Anatomy,脊椎骨spinecolumn,颈椎7胸椎12腰椎5骶锥5（1）尾椎4（1）33（26）,脊髓节段Cordlevel,颈髓8胸髓12腰髓5骶髓5尾髓131,6,Vertebralbody+Annex,7,Spineanatomy,Anteriorcolumn-Anteriorlongitudinalligament+AnteriorannularligamentandanteriorhalfofVB.MiddlecolumnPosteriorlong.Lig.+Posteriorannularligament+PosteriorhalfofVB.PosteriorColumnLigflavum+superior&Interspinouslig+intertransversecapsularlig+neuralarch+pedicle&spinousprocess.,8,Armstrong-DenisClassification,前柱前纵韧带、椎体及椎间盘的前半部中柱椎体及椎间盘的后半部及后纵韧带后柱椎体附件及其韧带,9,LevelofSpinalinjury,Neurologicallevelisatthemostlowestsegmentwithnormalmotor&sensoryfunctionDifficulttodetermine:-asmostmuscleefferentsreceivefibresfrommorethanonelevel-Closedcordlesionsmayextendoverseveralcms.-Dermatomeshaveimpreciseboundaries.,10,VertebralnumberandCordlevel,C2C7=add+1forcordlevelT1T3=add+1T4T6=add+2T7T9=add+3T10=L1,L2levelT11=L3,L4levelL1=sacrococcygealsegments,11,脊椎序数与脊髓节段对应关系：,颈椎17+1颈髓28胸椎1.2.3+1胸髓2.3.4胸椎4.5.6+2胸髓6.7.8胸椎7.8.9+3胸髓10.11.12胸椎10.11.12腰髓15腰椎1骶尾髓腰椎2以下马尾神经根,12,颈n椎下为颈n+1神经根胸n椎下为胸n神经根腰n椎下为腰n神经根骶n椎下为骶n神经根,VertebralbodyandSpinalNeverRoot,13,Flexion屈曲型：前方受压、后方拉开Extension伸直型：前方拉开、后方受压Flexionwithrotation屈曲旋转型：屈曲型基础旋转受力Compression垂直压缩型：前方、后方同时受压,Typesofbonyinjury,14,粉碎骨折（不稳定型）骨折脱位（不稳定型）,StabilityoftheFracture,椎体骨折,附件骨折,关节突、椎弓根骨折（不稳定型）,棘突、横突、椎板骨折（稳定型）,压缩骨折,椎体压缩1/3（不稳定型）,15,脊髓休克（Spinalshock）伤后损伤平面以下运动、感觉、括约肌功能完全丧失，数周自行恢复脊髓挫伤（contusionofspinalcord）脊髓出血、水肿脊髓裂伤（lacerationofspinalcord）脊髓部分或完全断裂脊髓受压（compressionofspinalcord）脊髓被压迫,脊髓损伤病理及类型,16,Spinalshock,Transientphysiologicalreflexdepressionofcordfunctionconcussionofspinalcord（脊髓震荡）Lossanaltone（紧张性）,reflexes,autonomiccontrolwithin24-72hrFlaccidparalysis（弛缓性麻痹）bladder&bowelandsustainedPriapismLastsevendaystillreflexneuralarcsbelowthelevelrecovers.,17,Degreesofinjury,Complete-flaccidparalysis（弛缓性麻痹）totallossofsensory&motorfunctionsIncomplete-mixedloss-Anteriorscsyndrome-Posteriorscsyndrome-Centralcordsyndrome-Brownsequardssyndrome-Caudaequinasyndrome,18,Anteriorspinalcordsyndrome,FlexionrotationalforcetospineDuetocompressionfractureofvertebralbodyoranteriordislocationAnteriorspinalarterycompressionLossofpower,reducedpainandtemperaturebelowthelesion.,19,Posteriorcordsyndrome,HyperextensioninjuriesPosteriorvertebralbodyfractureLossofproprioception(本体感受)andvibrationsense(振动觉）Severeataxia（共济失调）,20,Centralcordsyndrome,OlderagewithcervicalspondylosisHyperextensionwithminortraumaCordiscompressedbyosteophytesfromvertebralbodyagainstthickligamentumflavum.DamagesthecentralcervicaltractUMN（uppermotorneuron）lesiontolegs(spastic)LMN（lowermotorneuron）toarms(flaccidparalysis),21,Brownsequardssyndrome半脊髓损伤综合症,HemisectionofthecordStabinjuryandlateralmassfracturesUninjuredsidehasgoodpowerbutabsentpinprickandtemperature（痛温觉）.Spinothalamictracts（脊髓丘脑束）crosstooppositesideofthecordthreesegmentsbelow.,22,前部损伤：运动、痛温觉丧失，深感觉存在后部损伤：运动、痛温觉存在，深感觉丧失中央损伤：上肢运动丧失，下肢运动存在半侧损伤：对侧痛温觉丧失，同侧运动、深感觉存在,脊髓不完全损伤,23,病史症状外伤史、痛、活动受限,体征,畸形、肿胀、压痛神经功能障碍异常动度、骨擦音、骨传导音,辅助检查X线、CT、MRI、SEP,临床表现及诊断,Clinicalfeaturesandassesment,24,WhatHappenstoSpinalCord?,InitialInjuryduetocompressionbybonedisplacement,interruptionofbloodsupplytothecord,ortractionPrimaryinjuryinitialmechanicaldisruptionofaxons(轴突)asresultoflaceration(裂伤)Secondary-ongoing,progressivedamage(ischemia,hypoxia,edema）（缺血、缺氧、水肿),25,感觉sensibility,运动,括约肌sphincter,植物神经,休克期：软瘫休克后：软/硬瘫,-腹胀、腹痛,神经功能障碍,-大小便失禁,autonomicnerve,26,括约肌功能障碍(sphincterdysfunction)休克期:尿潴留，膀胱逼尿肌麻痹形成无张力性膀胱所致骶髓平面以上损伤，可形成自动反射膀胱，残余尿少于100毫升，但不能随意排尿脊髓园锥部骶髓或骶神经根平面损伤，则出现尿失禁，膀胱的排空需通过增加腹压（腹部用手挤压）或用导尿管来排空尿液大便也同样可出现便秘和失禁,27,脊髓运动水平肌肉标志CordLevelandthemusclelesions,28,X线检查常规正侧位(AP)、必要时斜位(obliqueview)。X片基本可确定骨折部位及类型CT检查判定移位骨折块侵犯椎管程度和发现突入椎管的骨块或椎间盘MRI核磁共振检查对判定脊髓损伤状况极有价值,Radiology,29,Whyshouldyouknowaboutallthisstuff?,30,CervicalSpineFracture:CSF环椎atlas可发生爆裂性骨折(Jefferson骨折)枢椎odontoidvertebra可发生齿状突dens骨折及伸展型绞刑者骨折(Hangmans骨折)C1-2的脱位,31,IntervertebralDiscSpaces,DecreasedIVDspacemayindicateherniateddisc,32,Anterior-PosteriorView,Symmetry/size对称性/AlignmentofspinousprocessesSmooth,rollinglateraledges,33,Odontoid齿突(Openmouth)View,34,OdontoidViewClose-up,35,36,37,38,39,40,41,TreatmentofSpinalInjuries,NoCurrentEffectiveTreatmentPreventionisKeyallcurrentmedicalandsurgicaltreatmentsaimedtopreventfurtherinjurytothespinalcord.,42,SystemOrientedApproach-ABC,AirwayBreathingCirculatoryNeurologicClassificationSpinalImagingGastroIntestinalSystemGenitourinarySystem（泌尿生殖系统）Skin,43,44,由于急救和搬运不当可使脊腨损伤平面上升或由不完全损伤变为完全性脊髓损伤,急救和搬运,Pre-hospitaltransfer,45,危重损伤：应首先抢救,搬运时保持纵向牵引头颈部，切忌头颈部转动,搬运时应平抬平放，切忌使脊柱过屈、过伸和扭转,颈椎骨折：,胸腰骨折：,46,47,48,Treatmentofsimplespinalfracture,胸腰骨折,压缩轻度：（1/3）,粉碎及脱位：开放复位内固定术,卧硬床，腰背肌锻炼复位，1m厚支具行走,两桌法过伸复位，石膏背心固定,49,胸腰段骨折轻度椎体压缩(1/3)，稳定型,50,胸腰段重度压缩超过50%。应予以闭合复位,两桌法过伸复位,双踝悬吊法复位,51,52,53,Cervicalspinefracture/dislocation压缩移位轻者，颌枕吊带牵引复位。牵引重量3-5kg。复位后用头胸石膏固定3个月压缩移位重者，用持续颅骨牵引复位。牵引重量可增加到6-10kg。摄X线片复查，复位后用头胸石膏固定3个月,54,55,Halo-Vest牵引固定,头-颈-胸石膏固定,56,头-盆环牵引Painful?!,57,脊柱的复位并维持脊柱的稳定性预防未损伤的神经组织功能丧失促进已损伤但未死亡的神经组织恢复早期康复训练，减少卧床并发症,AimofSurgerytreatmentalignmentreductionanddecompression,58,IndicationofSurgicalTreatment,开放性脊柱脊髓损伤影像检查有明确的椎管内占位，脊髓受压关节突有脱位、绞锁伤后脊髓损伤进行性加重其它不稳定性骨折,59,颈椎前路减压、植骨融合、固定术颈椎后路减压、植骨融合、固定术胸腰前路、侧前方减压、植骨融合、固定术胸腰后路减压、植骨融合、固定术,手术治疗,MethodsofSurgicalTreatment,60,X,61,62,63,Combinedtherapy,神经营养治疗：维生素B类等促进脊髓功能恢复,脱水治疗：甘露醇减轻脊髓水肿反应,自由基清除治疗：维生素A、C、E等减轻脊髓继发损害,激素治疗：甲基羟基松龙、地塞米松减轻脊髓创伤反应,支持治疗：保持水电平衡，补充能量全身支持营养,64,PreventionofComplications,褥疮：decubitalul