2023年Diseasesofthespinalcord（教学课件）.ppt

脊 髓 疾 病(Diseases of the spinal cord)Department of Neurology,The 2nd affiliated hospital,Harbin Medical University Diseases of the spinal cord Outline Acute myelitis Compressive myelopathy Syringomyelia Subacute combined degeneration of the spinal cord Motor neuron disease The anatomy of the spinal cord 1.External components:The upper and lower boundary of the cord The capsule The spinal nerves The relation between the cord and spine The anatomy of the spinal cord 1.External components:The upper and lower bourn of the cord Length:4245cm,It is the continuation of medulla(occipital foramen).The lower end forms terminal cone.It occupies 2/3 length of the spine.Lumbar enlargement:L1S2,cervical enlargement:C5T2 Terminal filament end on the periosteum of the 1st coccygeal vertebra The anatomy of the spinal cord 1.External components:Spinal nerves:31pairs of nerves were sent out:C8,T12,L5,S5 The segmental distribution of cutaneous sensory innervation 见图1 图2 The anatomic base of the spinal cord 1.External components The capsule:图例 Three layer capsule:spinal dura mater,arachnoid,tenuis mater Three spaces:epidural space:venous plexus and adipose subdural space subarachnoid space:CSF The anatomy of the spinal cord 1.External components:The cord of C18 is one segment higher than the correspond spine respectively,T18 is two segment higher,T912 is three higher,the count-part of lumbar is the 1012th thoracic vertebra,sacral cord lies in the 12th thoracic vertebra and the 1st lumbar.The anatomy of the spinal cord 2.Internal components:Gray matter:shape like H.Anterior horn:motor neuron.The fibers are anterior root Posterior horn:Lateral horn in the myelon of C8L2 and S24 White matter:anterior column,lateral column,posterior column The anatomy of the spinal cord 3.Blood supply Anterior spinal artery:which supplies the anterior two-thirds of the cord 供给脊髓全长和脊髓横断面前2/3区域。Posterior spinal arteries:供给脊髓全长及脊髓后柱、后索，脊髓横断面后1/3区域。Radicular arteries:根动脉与脊髓前、后动脉吻合，构成冠状动脉(coronary artery)环围绕脊髓外表，分出无数小支供给脊髓外表结构及脊髓实质外周局部的供血。C6、T9和L2处最大，T4和L1为交界。见图 Cord impairments-Clinical features Motor deficits:spastic or flaccid paralysis Disorders of somatic sensation:见图 posterior horn&root:节段性感觉障碍 posterior horn:节段性别离性感觉障碍 anterior white commissure:感觉别离现象 spinalthalamic tract:传导束性感觉障碍:Sphincter dysfunctions:paruria and dysporia incontinence or retention(including urination and defecation)Autonomic nervous imbalance Cord impairments-Clinical features 脊髓半侧损害(hemi-transverse impairments):Brown-Sequard syndrome 脊髓横贯损害(transverse impairments):spinal shock 1)高颈髓(C14):cervical myelon 2)颈膨大(C5T2):cervical enlargement 3)胸髓(T3T12):thoracic myelon 4)腰膨大(L1S2):lumbar myelon 5)脊髓圆锥(S35和尾节):terminal cone 6)马尾(cauda equina)判定脊髓病灶上界依据 根性病症：最上位根痛、根性感觉缺失、节段性肌无力或肌萎缩部位。传导束性感觉缺失平面：皮肤感觉支配三根定律。见图 Cutaneous sensation is in a segmenttal pattern because of overlap there is no loss of sensation unless three adjacent segments are affected.判定脊髓病灶上界依据 Tendon reflex change：C56,biceps and brachioradialis C78,triceps L24,knee jerk S12,ankle 自主神经征：反射性皮肤划纹症(reflective dermatography)头颈部立毛反射(pilomotor reflex)阿司匹林发汗试验(Aspirins weating test)中断处，均为脊髓病变上界。脊髓横贯性损害推算脊柱节段 分三步走：脊髓病变上界=皮节1，如皮节即感觉障碍平面，T7脊髓病变，上界T6。病变上界脊柱节段=脊髓病变上界n。(C14,n=0;C58,n=1；T18,n=2；T912,n=3)本例病变上界脊柱节段T62=T4。病变中心层面脊柱节段=病变上界脊柱节段+1 (向下1个层面)。本例为T5。急性脊髓炎(Acute myelitis)Concept Acute transverse impairments caused by demyelination or necrosis on white matter of the myeline.Such as:myelitis following infection,myelitis following vaccine inoculation,demyelinative myelitis,necrosis myelitis,para-tumor myelitis.Acute myelitis-Pathogeny unclear auto-immune reaction in association with a viral infection or vaccine inoculation 14 weeks ago.But there were no detective virus in nervous tissues,also no antibodies in CSF detected.Acute myelitis-Pathology Every segment may be involved,Range:T35,cervical or lumbar segment.Focal or transverse lesions,Findings under naked eyes:脊髓肿胀，质地变软，软膜充血渗出，切面灰白质不清，变性。Findings under microscope:髓内血管扩张、充血，血管周围炎性细胞侵润，神经细胞肿胀，破裂，消失，白质脱髓鞘，轴突变性，胶质增生。Acute myelitis-Clinical features Characters:1.The youth&post adolescent,No difference between the two sex.Infection or vaccine inoculation history Inducement of cold,overfatigue,trauma Acute myelitis-Clinical features 2.Acute onset,gets to the peak after several hours or 23 days.The initial symptoms:Numbness and weakness Backache and girdle sensation The most frequent sites:T3-5,Acute myelitis-Clinical features Dyskinesia:spinal shock 24weeks upper motor neuron paralysis Sensory disturbance:损伤以下所有感觉障碍，恢复较运动慢。Autonomic nerves dysfunction:早期尿潴留(无张力性神经原性膀胱)。膀胱充盈300400 ml即自动排s尿(反射性神经原性膀胱)。损害平面以下无汗、少汗、皮肤脱壳、角化。Acute myelitis-Clinical features 3.Acute ascending myelitis:危重型，起病急感觉平面数h或12d天上升至高颈髓，瘫痪迅速涉及上肢及延髓支配肌群，出现吞咽困难、构音不清和呼吸肌麻痹而死亡。4.Demyelinative myelitis:脊髓内有两个以上散在病灶，横贯性损害多不完全。Acute myelitis-investigation 1.Blood routine test:急性期周围血白细胞计数正常或稍高。2.Examination of the CSF:normal pressure,normal or increased white cell count,slightly increased protein concentration,normal glucose and