1、 Spinal Diseases 脊髓疾病 汕头大学医学院第二附属医院神经内科 张尤桥Anatomy and Physiology 解剖生理The external structure:外部结构 The internal structure:内部结构The external structure:外部结构v1.the upper and lower bound (上下界)v2.the spinal dura mater (硬膜)the arachnoid (蛛网膜)the pia mater (软膜)the subdural space(硬膜下腔)the subarachnoid space:C
2、SF (蛛网膜下腔:脑脊液)v3.anatomical segmemnts (解剖分段)v4.functiongnal segmemnts (功能分段)v5.the segment sensation:(感觉平面/节段)v6.the relationship of spinal segments to the vertebral bodies:v (髓节与椎骨对应关系)anatomical segmemnts 解剖分段：31 segments:C8,T12,L5,S5,Co1;functiongnal segmemnts 功能分段：the high cervical segment:C1-4;
3、高颈段the cervical intumescentia:C5-T2;颈膨大the thoracic segment:T3-12;胸 段 the lumbar intumescentia:L1-S2;腰膨大the medullary conus:S3-Co1圆 锥the cauda equina:L2-Co1(10).马尾NThe internal structure内部结构（1）1.the gray matter:灰质2.the white mater:白质the gray matter:灰质vthe anterior horn;前角；vthe posterior horn;后角vthe
4、lateral horn:侧角;a.C8-L2:the sympathetic nerve;C8-T1;交感N b.S2-4:the parasympathetic nerve;付交感Nvthe central canal 中央管:a.the anterior commissure前联合；b.the posterior commissre.后联合 the white mater:白质va.the anterior funiculus;前索 the posterior funiculus;后索 the lateral funiculus.侧索vb.the pyramidal tract(the
5、corticospinal tract);椎体束 the spinothalamic tract;脊髓丘脑束 the fasciculus gracilis and the fasciculus cuneatus.簿束、楔束vc.the arrangement of fibers:纤维排列：interior outside:C,T,L,S.Fig9.内外Spinal reflex脊髓反射1.Strech reflex 牵张反射Flexor reflex 屈曲反射Spinal shock 脊髓休克(脊髓反射消失)Clinical Manefestation for the damage of s
6、pinal cord 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Clinical Manefestation for the damage of spinal cord 脊髓损害临床表现 qdamage of the gray mater 灰质损害qdamage of the conduction tract 传导束损害 qdamage of one half of the spinal cord 半切损害 qtransverse damage of the spinal cord 横贯性损害 damage of the gray mater 灰质损害 v1.damag
7、e of spinal anterior horn:前角损害v2.damage of spinal dorsal horn:后角损害v3.damage of spinal anterior commissure:前连合损害v4.damage of spinal lateral horn:侧角损害 1、damage of spinal anterior horn:前角损害segmental paralysis of lower motor neuron 节段性下运动神经元性瘫痪 low tension 肌张力降低，weak tendon reflex 腱反射减弱，muscular atrophy
8、 肌萎缩，no pathogic signs 无病理反射。2、damage of spinal dorsal horn:后角损害 segmental sensory abnormality like dorsal root damage 类似后根损害的节段性分离性感觉异常abnormal pain and temperature sensation 痛、温觉异常，normal touch and deep sensation 触觉、深感觉正常 3、damage of spinal lateral horn 侧角损害 involves autonomic nerve 累及自主神经 resulti
9、ng in:引起abnomal vascular movement 血管运动异常、excessive sweating 出汗、malnutrition of erect hair skin and nails 竖毛、皮肤、指甲营养障碍 damage of the conduction tract传导束损害qdamage of the corticospinal tract:pyramidal sign:皮层脊髓束损害：椎体束征qdamage of the spinothalamic tract:脊髓丘脑束损害qdamage of spinal dorsal column:后索损害damage
10、of the corticospinal tract:皮层脊髓束损害：pyramidal sign:椎体束征Paralysis 瘫痪、Manifesting hypertonia 肌张力增高、hyperreflexia 腱反射亢进、pathologic signs 病理反射阳性damage of the spinothalamic tract:脊髓丘脑束损害abnomal superficial sensation 浅感觉异常damage of spinal dorsal column:后索损害 abnormality of deep sensation,深感觉异常、damage of one
11、 half of the spinal cord半切损害 Brown Sequard Syndrome.Ipsilateral spastic paralysis 同侧痉挛性瘫痪、and deep sensory dysfunction 和深感觉障碍contralateral superficial sensory dysfunction 对侧浅感觉障碍most with no obvious dysfunction of the touch sensation 大多数没有触觉障碍 transverse damage of the spinal cord横贯性损害(1)q high cerve
12、ical spinal transverse damage:高颈段损害q cervical intumescentia transverse damage:颈膨大损害q transverse damage of thoracic spinal cord:胸段损害 abdominal reflex(腹壁反射)，Beever sign.q lumbar intumescentia transverse damage:腰膨大损害 cremasteric,knee,ankle and plantar reflex.提睾反射、膝反射、踝反射、跖反射 transverse damage of the sp
13、inal cord横贯性损害(2)(5)transverse damage of conus:圆锥损害 saddle-like sensory decrease or loss in anus and perineum 肛门会阴部鞍区感觉减弱或消失、and rare of slight root pain 少有根痛 sexual dysfunction:性功能障碍 loss of anus reflex;.肛门反射消失 retention of urine and stools.大小便失禁 (incontinence 潴留)(6)transverse damage of cauda equin
14、a:马尾N损害 severe leg pain;剧烈腿痛 flaccid paralysis of both legs;双腿弛缓性瘫 loss of knee and ankle reflex;膝反射、踝反射消失 incontinence and retention of urine and stools 大小便潴留和失禁 Acute Myelitis 急性脊髓炎 qDefinition 定义qEtiology and Pathology 病因病理qClinical Manifestation 临床表现qLaboratory Findings 辅助检查qDiagnosis 诊断要点qDiffe
15、rential Diagnosis鉴别诊断qTreatment 治疗qPrognosis:预后Definition 定义qAcute transverse myelitis;急性横贯性脊髓炎 qPostinfectious myelitis;感染后脊髓炎qPostvaccinal myelitis；疫苗接种后脊髓炎2Etiology and Pathology病因病理 Unknown;病因未明。Postinfectious allergic reaction;感染后变态反应。T3-5 spinal segments may be swollen or slightly enlarged;脊髓肿
16、胀/增粗 3Clinical Manifestation 临床表现临床表现(1)v1.respiratory infection or vaccination;呼吸道感染/接种史v2.to catch a cold,fatigue,injury;受凉、疲劳、外伤v3.root pain at the lesion level,受损平面根痛，numbness and weakness of the feet and legs 双下肢麻木、乏力 (less often of the hands and arms)(手和臂常少受累)v4.below the lesion level.病变平面以下 t
17、he paralysis of extremities,肢体瘫痪，loss of sensation,各种感觉障碍，dysfunctions of bowel and bladder 大小便障碍 7Clinical Manifestation 临床表现临床表现(2)v5.involves autonomic nerve,自主神经功能障碍 resulting in:abnormal vascular movement,血管运动异常、excessive sweating,出汗少、无汗malnutrition of erect hair,skin and nails.坚毛、皮肤、指甲营养障碍v6.s
18、pinal shock:12 week;24 week.脊髓休克v7.return:恢复 34 week;36 months v 8.ascendant myelitis:上升性脊髓炎 Laboratory Findings辅助检查辅助检查 v1.CSF 脑脊液;v2.MRI 磁共振;Diagnosis:诊断要点1.2.3.4.Differential Diagnosis 鉴别诊断鉴别诊断 1.neuromyelitis optica;视N脊髓炎 2.spinal haemorrhage(bleeding)脊髓出血3.缺血性脊髓血管病4.spinal cord compression:脊髓压迫
19、症：spinal epidural abscess 硬膜外脓肿、tumor 肿瘤 脊柱结核5.Guillain-Barre syndrome 格巴 急性脊髓炎急性脊髓炎 格巴格巴病变部位 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（治疗（1 1）1.drugs（药物）:DXM,prednisone;甲强龙 地塞米松、强的松 免疫球蛋白 Vit B;维生素B Dibaz
20、one,nimodipine;地巴唑、尼莫地平 20%mannitol;甘露醇 antibiotic;抗菌素Treatment 治疗治疗（2）2.nursing 护理：skin,respiratory tract,urine,stool.皮肤，呼吸道，尿，大便。3.nutrition;营养 4.support;支持5.recovered treatment:康复治疗Prognosis:预后What are the clinical manifestations of the acute myelitis?Compressivemyelopathy压迫性脊髓病压迫性脊髓病 Difinition:
21、定义 refer to a number of neurologic diseases with spinal dysfunction,caused by some occupations in the vertebral cavity which resulted in the compressed injury of the spinal cord,roots of spinal nerves and their blood vessels.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 p
22、athogenesis：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.Clinical Manifestation临床表现(1)分型：acute spinal cord compression:急性脊髓压迫症 (1)transverse damage of the spinal cord;(2)spinal shock.chronic spinal cord compression 慢性脊髓压迫症 progressive 进行性;Three stages 三个期:v
23、 root pains;(stimulant period)根痛(刺激期)v partial compression of spinal cord 部分受压期 (Brown-Sequards syndrome).v finally complete compression of the cord (transverse damage of spinal cord)横贯性损害期 Clinical Manifestation临床表现(2)表现：qRadicular symptoms and signs:神经根症状和体征qSensory disturbances:感觉障碍(髓内病变,髓外病变)qMo
24、tor disturbances：运动障碍qThe reflexes：反射qAutonomic symptoms:自主神经症状qIrritative symptoms of spinal meninges:脊膜刺激症状 Laboratory Findings辅助检查 1.lumbar puncture:腰穿v the pressure is tested:it is raised 压力 (80-180 mmH2O is normal).v cell count is normal细胞数正常；v protein is raised,xanthochromia,Froin sign.蛋白黄变v Q
25、ueckenstedt test:(+)奎根试验(压颈试验)2.X-ray3.vertebral tube angiography:椎管造影4.CT or MR DiagnosisDiagnosis 诊断yes or not?是不是？where it is?在哪里？Which disease it is?什么病？Diagnosis 诊断(1)1.The foundation of diagnosis(basis for diagnosis):根据 manifestation of the spinal cord compression:临床表现 vertebral tube blocked;椎
26、管阻塞 CT/MR;2.to show the position of the compression:定位q vertical section;纵向q cross section:横向inside or outside of the spinal cord:12 髓内与外inside or outside of the spinal dura mater:4 硬膜内与外3.to show the nature;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 盘突出症.Diagnosis 诊断(2)髓内 髓外 1.N根
27、痛 晚 早 2.感觉分离 可有 无 3.瘫痪 肌萎缩 椎体束征 4.痛温觉障碍 上肢下 下肢上 5.侧别 双侧 一侧双 6.大小便 早 晚 7.CS旦白 +8.奎根 -+9.椎骨痛 -+10.X片 -+11.椎管造影 梭状缺损 杯状缺损 12.CT/MR 髓内 髓外Diagnosis 诊断(3)硬膜内 硬膜外 1.病程 慢 快 2.侧别 半切 横贯 3.CSF +4.X片 -+Differential Diagnosis 鉴别诊断v急性脊髓炎 v脊髓空洞症:病程长,多位于下颈部及上胸部.分离性感觉障碍,MR示脊髓内长条形空洞.Treatment治疗 1.operation;手术:椎板减压术2.antibiotic;抗菌素,抗痨治疗3.recovered treatment.康复治疗 What are the chief symptoms and signs of the cord compression?
