上海交通大学医学院

1、上海交通大学医学院课程名称：spinal disease第次课教师姓名Ma jia nfang职称atte ndant教研室Neurology教学时数4授课题目Spinal disease教学对象Grade 2003, En glish class授课地点Science and educati on buildi ng Room309教学方式MultimediaKeypo ints and difficulties一、Keypoints1. Relationship between spinal cord and spinal column 掌握脊髓与脊柱的关系2. Chief manifes

2、tation of the spinal cord lesion at different level掌握脊髓不同节段损害的主要表现3. Manifestation of the acute myelitis 掌握急性脊髓炎的临床表现4. Etiology, mani festati on, diag no sis and differe nt diag no sis of compressive spinal disease 掌握脊髓压迫症的病 因、临床表现、诊断及鉴别诊断5. The procedure and the clinical relevances of lumbar punct

3、ure 掌握腰穿动力试验的方法及意义二、Difficulties:1. The an atomy, physiological and pathophysiological releva nces of spinal cord脊髓解剖、生理及病理意义2. Diag no sis and differe nt diag no sis of compressive spinal disease 脊髓压迫症的诊断及鉴另 U诊断Educatio methods本次课应用的教具：multimedia多媒体Main content of class主要教学内容：(可另附页)脊髓疾病(Spinal Dise

4、ase)Chaptor 1 overviews 第一节 概述 80'一、The an atomy and physiology of spi nal cord 脊髓的解剖和生理 30'(一) Outlines of spinal cord 脊髓的外部结构 15'1. connected with medulla oblongata superiorsly and conus medullaries inferiorly上端与延髓相连下端形成脊髓圆锥2. Meninges and spaces of spinal cord 脊髓被膜及腔隙Spinal pia mater

5、内软膜Isubarach noid space cerebral spinal fluid蛛网膜下腔 脑脊液I arachnoid mater 蛛网膜Isubdural space硬膜下腔I dura mater 硬膜J epidural space venous plexus and lipid硬膜外腔静脉丛和脂肪3. 31 pairs of spinal nerves, 31 segments 31对脊神经，31 个节段Cervical 颈(C)8 ,Thoracic 胸(T)12 ,Lumbar腰(L)5 ,Sacral骶(S)5,Coccygeal 尾(Co)14. two enlar

6、gement 两个膨大cervical enlargement 颈膨大(C5T2)lumbar enlargement 腰膨大(L1S2)5. Cauda equina 马尾10 pairs from L 2Co 共 10 对6. the relatio nship betwee n spinal cord and spinal colu mn脊髓与脊柱的关系Cervical segment-1= certival vertebrae颈髓节段 -1=颈椎节段Thoracic segment-2=thoracic vertebrae (upper and middle) 上中胸髓节段 -2=胸椎

7、节段Thoracic segment-3=thoracic vertebrae (lower) 下胸髓节段 -3=胸椎节段Lumbar segment=thoracic 10-12 verterbrae 腰髓=第 1012 胸椎Sacral= thoracic 12 and lumbar 1 骶髓=第 12 胸椎及第 1 腰椎(二) Internal structure of spinal cord 脊髓的内部结构 15'1. grey matter nerve cell bodies 灰质 神经细胞核团(1) Anterior hornmotor neuron (low motor

8、neuron) 前角 运动神经细胞(下运动神经元 )(2) Posterior hornsecondary sensory neuron 后角 II 级感觉神经元 lateral hornC8L2 sympathetic neuron 侧角C8L2 交感神经细胞S2S4 parasympathetic neuronS2S4 副交感神经细胞(4) An terior grey commissi on 灰质前联合Bilateral crossed spinothalamic tract双侧脊髓丘脑束的交叉纤维2. white matterbundles of axonsconducting the

9、 sensory and motor tract 白质 上下行传导束(1) Corticosp inal tract con duct ing con tralateral involun tary moveme nt from cotex to con tralateral spinalanterior horn皮质脊髓束传导对侧大脑运动冲动至同侧脊髓前角细胞(2) Sp ino thalamic tractconducting con tralateral sen sory from con tralateral skin sen sati on to cortex 脊髓丘脑束 传导对侧身

10、体皮肤痛、温、触觉至大脑(3) Sp ino cerebellar tractcon dut ing propriocepti on to cerebellum 脊髓小脑束传导本体感觉至小脑(4) Posterior tract (fasciculus gracile, fasciculus cun eatus) con duct ing ipsilateral deep sen sati on and discriminative touch sensation后束(薄束、楔束)传导同侧深感觉和识别性触觉至脑部二、Main presentation of spinal cord lesion

11、 脊髓损害的主要表现50'(一) Grey matter lesion脊髓灰质节段性损害10'1. anterior horn lesion low motor neuron paralysis at the level of lesion 前角损害病灶同侧相应节段下运动神经元瘫痪2. posterior horn lesiondissociated sensory loss below the level of the lesion (pain and temperature senseloss with the presevation of the touch and de

12、ep sensation)后角损害病灶同侧相应节段痛、温觉障碍，触觉和深感觉保留(分离性感觉障碍)3. an terior commissi on lesi ondissociatted sense loss bilaterally below the level of the lesi on前联合损害病灶两侧相应节段分离性感觉障碍4. lateral horn lesionvegetative nerve dysfunction (autonomic nerve dysfunction) 侧角损害植物神经功能障碍*vasoco ntrol , sweat, sk in and n ail m

13、al nutritio nal and血管运动、出汗、皮肤指甲营养*ipsilateral Horner sig ns 同侧 Horner 征(C8 及)(二) transducting lesion 传导束性损害 10'1. pyramidal tract lesionipsilaterl upper motor neuron paralysis below the level of lesion锥体束 病灶平面以下同侧上运动神经元瘫痪2. spinothalamic tract lesion contralateral pain and temperature loss below

14、 the level of lesion脊髓丘脑束病灶平面以下对侧痛、温觉障碍3. posterior tract ipsilateral deep sensation loss below the level of lesion 后束病灶平面以下同侧深感障碍(三) Brown-Sequard Syndrome 脊髓半切损害 10'1. ipsilateral upper motor neuron paralysis below the level of lesion病灶平面以下同侧上运动神经元瘫痪2. ipsilateral deep sense loss below the lev

15、el of lesion 病灶平面以下同侧深感觉障碍3. con tralateral pa in and temperature loss below the level of lesi on 病灶平面以下对侧痛、温觉障碍4. con tralateral segme ntal pa in and hyperaesthesia 病灶同侧相应节段根痛和感觉过敏带(四) Transverse spinal cord lesion 脊髓横贯性损害 30'1. common features各节段病变的共同特点10'(1) moveme nt dysfu ncti onbilater

16、al paralysis below the level of lesi on (paraplegia or quadriplegia) 运动障碍病灶平面以下双侧性瘫痪(截瘫或四肢瘫)(2) sensory dysfunctionbilateral deep and superficial sense loss below the level of lesion (transductionarysense loss)感觉障碍病灶平面以下双侧所有深、浅感觉障碍(传导束型)(3) autonomic nerve dysfunctionsphinctor dysfunction and change

17、s of skin and nail 植物神经功能障碍括约肌功能障碍、皮肤指甲营养障碍2. characteristic features of every segment 各节段病变的主要不同点20'(1) H igh cervical level 高颈段(C1 T2)Quadriplegia (upper motor n euro n paralysis) 四肢上运动神经元瘫痪Dyspnea呼吸困难Occipital and cervical pai n 枕颈部疼痛 Cervical enlargement 颈膨大(C5T2)Low motor neuron paralysis o

18、f upper limbs 上肢下运动神经元瘫痪Upper motor neuron paralysis of low limbs下肢上运动神经元瘫痪Horner 'sig ns Horner 氏征(3) Thoracic part 胸段(T3T12)Upper motor neuron paralysis of both legs双下肢上运动神经元瘫痪Ban d-like sensory loss at the level of lesi on 受损节段束带感Lumbar part 腰段(LiS2)Low motor neuron paralysis of both legs双下肢下

19、运动神经元瘫痪Sense loss of both legs and peria nal双下肢及会阴部感觉减退或消失(5) Conus medullaris 圆锥(S3S5,Co) Sphincter dysfunction大小便功能障碍Perianal sensory loss(saddle-shaped)会阴及肛门部(马鞍状)感觉障碍Loss of Anal reflex 肛门反射消失Sexual dysfunction 性功能障碍Without paralysis and pyrami nal sig ns 常无肢体瘫痪和锥体束征(6) Cauda equina 马尾神经根(L2Co)S

20、imilar to conus medullaris but asymmetricl 与圆锥病变相似但不对称Root pain of peilanal下肢会阴部根痛Wasting of legs下肢肌肉萎缩Chapter 2 acute myelitis 第二节急性脊髓炎 40'一、Etiology and pathophysiology 病因和病理： 5'Possible related to inflammatory reaction induced by viral infection and vaccination可能与病毒感染或疫苗接种不变态反应有关二、Clinica

21、l manifestations 临床表现 12'1. age of on set 发病年龄 2.precipitatory factor 诱因 3. prodromal symptoms 前期症状 4.on set symptoms 首发症状 5.spinal shock 脊休克 6.conservative period 恢复期 7.ascending myelitis 上升性脊髓炎三、Lab investigations 辅助检查：6'Lumbar puncture, queckenstedt test, CSF, routine and biochemical test

22、 腰穿、三叉动力试验，脑脊液， 生化常规四、Differe ntial diag no sis 鉴别诊断：7'1. acute epidural abscess 急性硬膜外脓肿 2.metastastic tumor of spi nal cord 脊髓转移性肿瘤3. G-B-S4. Neuormyelitis optica 视神经脊髓炎 5. spinal haemorrhage 脊髓出血五、Treatment 治疗：8'1. corticosteroid 激素 2.lmmuno glob in 免疫球蛋白3. complicatio n preve nti on 防治并发症

23、 4.Vitam ine Bsupplement B 族维生素 5.supportive treatmenta and rehabilitation 支持疗法和功能锻炼六、prog no sis 预后 2'Chapter 3 compressive spinal cord 第三节 脊髓压迫症40'一、etiology 病因：5'classified by the n ature of the disease 1. tumor 2.in flammati on 3. trauma 4.vascular. 5.b one and joi ntdisease 6.chroni

24、c dieseases(syringomyelia)按病变性质分类 1.肿瘤2.炎症3.损伤4.血管病变5.骨关节 病6.慢性疾病(脊髓空洞症)二、clinical manifestation 临床表现：12'1. acute compressive spin al cord 急性脊髓压迫症2. chronic compressive spinal cord (1) stimulating period (2)partly compression of spinal cord (3)transverse spinal cord lesion presented with root pa

25、in, motor and sensory dysfunction and autonomic dysfunction慢性脊髓压迫症(1)刺激期 脊髓部分受压期 脊髓横贯性损害，表现为神经根痛，运动感觉、植物神经功能异常。三、lab investigation 实验室检查 6'1. lumbar acup unctu re+quecke nsedt test+CSF test2. image exams such as plain film, CT and MRI 腰穿 + 动力试验 +CSF 检查 2.X 线影像学 MRI四、Diag no sis and differe ntial

26、 diag nosis 诊断与鉴别诊断12'（一） 1. Iongitudinal level of the lesion in spinal cord 节段平面的定位2. transverse leve of lesion（intramedullary, epimedullary and extramedullary）横位定位（髓内，髓外硬膜下，髓外硬膜外）3.etiology diag no sis 定性诊断（二）Differe ntial diag no sis 1. acute myelitis 2. arach onoid in flammati on 3. extrasp

27、inal diseases 4. i ntraspi nal non-occupying lesion鉴别诊断1.急性脊髓炎2.蛛网膜炎3.锥管外疾病4.椎管内非占位病变五、treatment 治疗5'1. cause treatme nt- surgery 对因治疗一手术2. rehabilitation 康复治疗1. We aim to help the stude nt to un dersta nd the an atomy and physiology of spinal cord, especially the relati on ship betwee n the spi

28、nal cord and spinal colum, the internal structure of spinal cord(grey matter and white matter); the cli nical man ifestatio n of spinal cord, in cludi ng the lesi on of grey matter, tran sduct ionary lesi on and Braw n-sequard syn drome and tran sverse spinal lesio n.脊髓疾病要求学习复习和掌握脊髓的解剖和生理，尤其是脊髓与脊柱的关

29、系。脊髓的内部结构(灰质和白质)。掌握脊髓损害的主要表现包括脊髓灰质节段性损害、传导束型 损害，半切损害和横贯性损害的特点和不同点。2. Acute myelitis is non-specific in flammatroy react ion in duced by virus infection, prese nted by the transverse lesion features of spinal cord, for example, paraplegia and quadriplegia, tran ducti onary sen sory loss and aut ono m

30、ic dysfu nction( sph in ctor dysfu nction), the quecke nselt test is usually normal, the CSF is normal with protein level slightly elevated, high doses of corticosteroid and vitamine B are the main medication in acute treatment and rehabilitation in long term treatment.急性脊髓炎是由于病毒感染引发的脊髓的非特异性炎症，临床表现为脊髓横贯性复损，出现双下肢瘫或四肢瘫，传导束型感染障碍和植物神经功能障碍(二便障碍)，腰穿检查一般通畅，CSF可正常或轻度细胞蛋白增高，治疗主要给予大剂量皮质激素抗炎和大剂量B族维生素及必要的护理。3. Spinal cord compression is a group of diseases presented w