脊髓疾病-中英对照.ppt

脊髓疾病DiseasesoftheSpinalCord,肖波中南大学湘雅医院神经内科,第一节概述,overview,Overview,AnatomyInternalStructureBloodSupplyClinicalFeaturesofDifferentLesions,Overview,脊髓的解剖Anatomyofspinalcord,脊髓的外形Externalfeatures31对脊神经:脊髓的节段与脊柱的不一致，由于胚胎时期脊髓的生长比脊柱慢,Overview,Overview,C(cervical)-8T(thoracic)-12L(lumbar)-5S(sacral)-5Co(coccygeal)-1,脊髓的膨大Enlargementofspinalcord,颈膨大Cervicalenlargement:C5T2腰膨大Lumbarenlargement:L1S2马尾Caudaequina由腰2至尾节共10对神经根组成,Overview,脊髓的三膜二腔Meningesandspaceofthespinalcord,脊髓硬膜外腔硬脊膜硬膜下腔蛛网膜蛛网膜下腔软脊膜,Overview,易受感染易破裂形成硬膜外血肿,可反映脑的病变注药入内进行治疗,意义不大,epiduralcavity,subduralcavity,subarachnoidcavity,脊髓内部结构InternalStructure,灰质Greymatter：前角Anteriorhorn:andmotorneuron后角Posteriorhorn:secondarysensoryneuron侧角Lateralhorn:C8L2交感神经低级中枢SympatheticnucleusS2S4脊髓副交感中枢Parasympatheticnucleus,Overview,白质Whitematter：,前索Anteriorfuniculus：皮质脊髓前束主要为下行纤维侧索Lateralfuniculus：后索Posteriorfuniculus：主要为上行纤维,Overview,薄束楔束,脊髓丘脑束脊髓小脑束皮质脊髓侧束,Overview,后索,侧索,前索,1薄束2楔束3脊髓小脑后束4皮质脊髓束5脊髓丘脑侧束6脊髓小脑前束9皮质脊髓前束14脊髓丘脑前束,后角,侧角,前角,脊髓的血液供应BloodSupply,脊髓前动脉Anteriorspinalartery：easytobeischemia根动脉Radicularartery：T4andL1aretheboundaryareas,andeasytobeischemia脊髓后动脉Posteriorspinalartery：rareischemia,Overview,Overview,脊髓损害的临床表现ClinicalFeaturesofDifferentLesions,运动障碍motordisturbance:前角和/或锥体束损害：运动神经元病感觉障碍sensorydisturbance：后角和前连合损害出现分离性感觉障碍自主神经功能障碍functionaldisturbance：大、小便障碍等,Overview,脊髓半切综合征Brown-SequardSyndrome,脊髓病变平面以下同侧的上运动神经元瘫痪同侧深感觉丧失对侧的痛、温觉丧失,Overview,脊髓横贯性损害Transverselesions,原因Majorcause:AcutemyelitisSpinalcordtraumaSpinalcordcompressionHematomyelia,表现Majorsigns:Uppermotorneuronparalysis(spinalshock)LossofallsenseAutonomicdysfunction,脊髓休克SpinalShock,Overview,脊髓休克SpinalShock,脊髓受到急性严重的横贯性损害时，出现受损平面以下脊髓反射活动完全消失，表现为肢体软瘫、肌张力低、腱反射消失和病理征阴性，一般持续16周。Intheacutestageofspinalcordlesions,thereisflaccidparalysiswithlossoftendonandotherreflexes,accompaniedbysensoryandbyurinaryandfecalretention.Thisisthestageofspinalshock,andoftenlast2to6weeks.,Overview,脊髓横贯性损害Transverselesions,损害平面的确立节段性肌萎缩根痛感觉平面反射改变,中指C7胸骨角T2乳头T4剑突T6肋弓T8脐部T10腹股沟T12,Overview,脊髓横贯性损害Transverselesions,高颈段（C1-4）SpasticparalysisofallextremitiesSenselossbelowneck，rootpainUrinaryandfecalretention，AbsentsweatingDiaphragmaticparalysis，dyspnea（C3-5）,Overview,脊髓横贯性损害Transverselesions,颈膨大（C5T2）SpasticparalysisoflowerlimbsandflaccidparalysisinupperlimbsSenselossbelowshoulder，RootpaininupperlimbsandshoulderUrinaryandfecalretentionAutonomicdysfunction(Hornersyndrome),Overview,霍纳（Horner）综合征：瞳孔缩小，眼球内陷，眼裂变小，面部出汗减少。,Overview,脊髓横贯性损害Transverselesions,胸段（T3-12）SenselossbelowchestorbellySpasticparalysisoflowerlimbsUrinaryandfecalretentionAutonomicdysfunctionRootpaininbackSegmentalAbdominalreflexvanish,Overview,脊髓横贯性损害Transverselesions,腰膨大（L1S2）SenselossoflowerlimbsandperineumFlaccidparalysisoflowerlimbsUrinaryandfecalretentionAutonomicdysfunctionRootpainingroin,Overview,第二节,急性脊髓炎Acutemyelitis,Acutemyelitis,DefinitionandclassificationClinicalmanifestationDiagnosisandDifferentialdiagnosisTreatmentPronosis,Acutemyelitis,概念Definition：是由于非特异性炎症引起脊髓白质脱髓鞘或坏死，导致急性横贯性脊髓损害，也称急性横贯性脊髓炎。Acutemyelitisisanacuteinflammationofoneormoresegmentsofthespinalcord,whichisassociatedwithinfectionsandvaccinationsdisorders.,Acutemyelitis,病因Etiology：InfectionandvaccinationVirusParasiteBacteriaFungusUnclear,分类Classification：postinfectiousmyelitisPostvaccinalmyelitisDemyelinatingmyelitisParaneoplasticmyelitis,Acutemyelitis,临床表现ClinicalManifestation（一）,发病年龄Age:youth(4y83y)性别Sex：malefemale起病形式Episode:acute;days诱因Cause:postvaccinalandpostinfectious好发部位Levels:MostcommonT3toT5;CervicaluptoC1,Acutemyelitis,ClinicalManifestation（二）,运动障碍motordisturbance：脊髓休克SpinalShock感觉障碍sensorydisturbance：损害平面以下所有感觉消失自主神经功能障碍autonomicdysfunction：大、小便障碍，皮肤干燥,Acutemyelitis,ClinicalManifestation（三）,上升性脊髓炎Acuteascendingmyelitis1.起病急骤2.病变常在12天甚至数小时上升到延髓3.瘫痪由下肢迅速累及上肢或延髓支配肌群出现吞咽困难，构音不清，呼吸肌麻痹，甚至死亡。,Acutemyelitis,辅助检查Laboratory,脑脊液Cerebrospinalfluid：ColorlessandtransparentWhitecellsandproteinnormalorslightlyincreasedGlucoseandchloridenormalMRI：Enlargedspinalcord,Acutemyelitis,鉴别诊断DifferentialDiagnosis（一）,视神经脊髓炎Neuromyelitisoptica有视力下降Vision病变常不完全对称Lesionsarecommonlyincompletesymmetry病情常有缓解及复发Remission-relapse可出现多灶性体征Multifocalsign,Acutemyelitis,DifferentialDiagnosis（二）,急性硬膜外脓肿Acuteepiduralabscess有化脓感染史focusofinfection发热、根痛明显fever,rootpain椎管阻塞明显obstructionofvertebralcanal脑脊液细胞和蛋白增高whitecellandproteinMRI可帮助鉴别MRIusedforidentify,Acutemyelitis,DifferentialDiagnosis（三）,脊髓出血Hematomyelia起病更急sudden剧烈背痛severebackpain血性脑脊液bloodyCSFMRIMRIormyelography,Acutemyelitis,治疗Treatment,精心护理Carefulnursing防褥疮，保持呼吸道通畅药物治疗Drugtreatment糖皮质激素、维生素B族、抗病毒药等康复治疗Earlyrehabilitativemanagement,Acutemyelitis,预后Prognosis,36个月内能恢复生活自理1/3病人基本恢复1/3病人能行走，但步态异常、大小便障碍1/3病人持续瘫痪、尿失禁,Acutemyelitis,第三节,脊髓压迫症Compressivemyelopathy,Compressivemyelopathy,DefinitionandEtiologyClinicalmanifestationLaboratoryfindingsDiagnosisTreatment,Acutemyelitis,概念Definition：,是由于椎管内的占位性病变引起脊髓受压的临床综合征，病变进行性发展，导致不同程度的脊髓横贯性损害和椎管阻塞。Compressivemyelopathyisasymptomresultfromcompressionofspinalcordbyoccupyinglesioninspinalcollum,withprogressiveofthelesion,itcanresultvarietydegreeoftransverselesionofspinalcordandspinalcolummobstruction.,Compressivemyelopathy,病因Etiology,肿瘤Tumor：胶质瘤、神经鞘瘤、转移瘤先天性异常Congenitalabnormality：颅底凹陷症外伤Trauma：椎间盘突出、脱位、骨折炎症Inflammation：脊柱结核、硬膜外脓肿、蛛网膜炎症脊髓出血Myelorrhagia,Compressivemyelopathy,临床表现ClinicalManifestation（一）,多表现为慢性脊髓压迫,以占位病变较多见.起病形式Episode:隐袭,进展缓慢根性疼痛Rootpain:髓外压迫,Compressivemyelopathy,ClinicalManifestation（二）,感觉障碍Sensorydisturbance：脊髓丘脑束:受损平面以下对侧躯体痛温觉消失后索:受损平面以下同侧躯体深感觉消失马鞍回避:髓内病变鞍区（S3-5）感觉最后受累,髓外压迫时,感觉障碍自下肢向上发展髓内压迫时,感觉障碍自病变节段向下发展,Compressivemyelopathy,ClinicalManifestation（三）,运动障碍Motordisturbance:锥体束同侧上运动神经元瘫痪前角或前根相应节段肌束颤动、肌束萎缩反射异常Abdominalreflex自主神经功能障碍Autonomicdysfunction,Compressivemyelopathy,辅助检查La