1、,,Christorph Reeve , known as the star actor of “Superman”（超人） , fell from horse when riding and became tetraplegia（四肢瘫） in 1995， and died in 2007,Similar accident took place when Chinese gymnastics athlete, Sanlan（桑兰） , was exercising in the 4th Goodwill Games in New York on 21st July , 1998. The c
2、ervical spine injury led to tetraplegia .,Zhanghaidi（张海迪）, she had hemangioma(血管瘤） in T2, broke up in her five years, the bleeding compressed the spinal cord caused paralysis (截瘫),Lou Gehrig(19031941), one of the best baseball player in the world, was such a ALS （肌萎缩侧索硬化）patient.（ Lou Gehrig disease
3、),Stephen Hawking , a genius physicist , is another case of ALS .,Chapter 4 Spinal Cord Diseases (脊髓疾病),Purpose ：1) Comprehend: The general picture of spinal cord diseases ;2) Acquaint: Clinical manifestation, diagnosisand differential diagnosis, treatment principleof acute myelitis （急性脊髓炎）& spinal
4、cord compression （脊髓压迫症）3) Grasp: three main symptoms &localization (定位) of Spinal Cord DiseasesTeaching hour： 2 lecturing hours,CONTENTS,Part 1 AnatomyPart 2 ManifestationsPart 3 Lesion LocalizationPart 4 Acute myelitisPart 5 Compressive myelopathyPart 6 Vascular MyelopathiesPart 7 Syringomyelia&,P
5、ART ONE,ANATOMY,Spinal Cord Anatomy Relevant to Clinical Signs,Lies within the vertebral canal Medulla oblongataforamen magnum level of the first lumbar vertebra Lower endconus medullaris（圆锥） filum terminale（终丝）coccyx,All the spinal nerves below the fisrt lumbar forming the cauda equina(马尾）,two enla
6、rgements: Cervical (C5-T2) Lumbar (L1-S2),31 pairs of spinal nerves (dorsal root and ventral root),Spinal segments do not correspond numerically with enclosed vertebra.,31 segments of spinal cord: eight cervical, twelve dorsal or thoracic, five lumbar, five sacral, one coccygeal.,The length of spina
7、l cord: about 2/3 of the vertebras.,Spinal Cord Levels Relative to the Vertebral Body,Three Meningies,Pia mater（软脑膜）: forms the immediate covering of the cord Arachnoid（珠网膜）: lies superfically to the pia mater Dura mater（硬脑膜） : outside thearachnoid,Arachnoid space: contains cerebrospinal fluid(CSF)（
8、脑脊液） Epidural space: contains fatty tissue,venous plexus,Two spaces,Two anterior horns-motor cells Two posterior horns-sensory cells Lateral horns-autonomic cells,The Structure Inside the Spinal Cord,Two anterior column Two posterior column Two lateral columnAll fibers,Peripheral white matter:,Ascen
9、ding Pathways,Lateral spinothalamic tract （脊髓丘脑侧束）: conduct superficial sensation Ventral spinothalamic tract（脊髓丘脑前束） Tracts of Gracilis and Cuneatus（薄束和楔束）: conduct deep sensation,Descending Pathways,the important one is :Corticospinal tract (皮质脊髓束）or pyramidal tract（锥体束）,convey motor impulses from
10、 cerebral cortex to spinal cord,Blood Supply,Two posterior spinal arteries supply the blood to posterior column and posterior horn (1/3),Supply the blood to central grey matter, anterior columns, pyramidal tract(2/3),Single anterior spinal artery,Unites the spinal arteries to supply the white matter
11、 and most part of the posterior horn.,Arterial corona,PART TWO,MANIFESTATIONS （临床表现）,Three Main Symptoms of spinal cord diseases,1. Motor disturbanceUpper Motor Neuron Paralysis (Spastic paralysis )（ 痉挛性瘫） caused by : Pyramidal tract lesionLower Motor Neuron Paralysis (Flaccid paralysis（弛缓性瘫） caused
12、 by : anterior horn / ventral root lesion Sensation disturbance, caused by : spinothalamic, gracilis and cuneatus tracts lesion; posterior horn / posterior root lesion Autonomic function disturbance : sphincterdysfunction，lack of sweating, skin ulcer,Three types of lesion of spinal cord,Selective le
13、sion (Local lesion) （局灶性损害） 2. Semitransverse lesion（半横贯性损害） (Brown-Sequard syndrome) 3. Complete transverse lesion （完全性横贯性损害）,1. Selective Lesion (Local Lesion) (including six groups),（1）Anterior Horn Lesion,Symptom: flaccid paralysis(弛缓性麻痹）(lower motor neuron lesion),Diseases: Acute poliomyelitis（
14、急性脊髓灰质炎，也称小儿麻痹症） Progressive spinal muscular atrophy （进行性脊肌萎缩症）,（2）Pyramidal Tract lesion,Symptom: Spastic paralysis(Upper motor neuron lesion),Disease: Primary lateral sclerosis (原发性侧索硬化）,（3）Anterior horn+Pyramidal tract,Symptom:( cervical enlargement lesion) Flaccid paralysis+spastic paralysis on
15、the hands； spastic paralysis on the legs,Disease: Amyotrophic lateral sclerosis (ALS)（肌萎缩性侧索硬化）,（4）Posterior Column Lesion,Symptom: Deep sensation disturbance,Disease: Tabes dorsalis （脊髓痨）,(5) Posterior Column+Pyramidal Tract,Symptom: deep sensation disturbance + spastic paralysis,Disease: Subacute
16、combined degeneration of the spinal cord （脊髓亚急性联合变性）,（6）Lesion In The Gray Matter,Symptom: dissociated （分离性）sensory disturbance ，segmental sensory loss， muscles wasting in the hands Nutrition disturbance,Disease: Syringomyelia （脊髓空洞症） Spinal hemorrhage （脊髓出血）,2. Semitransverse lesion（半横贯损害）(Brown-Se
17、quard syndrome),On the side of the lesion:limb(s) spastic paralysis, deep sansation lost On the opposite side of the lesion: superficial sansation lost,3. Complete transverse lesion （完全性横贯性损害）,Acute myelitis, trauma Below the level of the lesion ： Spastic paralysis(痉挛性截瘫) Complete loss of all modali
18、ties sensation Sphincter disturbances,PART THREE,Lesion localization(病灶定 位）,The upper cervical region (C1-4),Pyramidal tract signs (锥体束征) in four limb-slight damage Tetraplegia(quadriplegia) (四肢瘫)-severe damagePain in the neck and occiput,2. The cervical enlargement(C5-T2),Flaccid & spastic paralysi
19、s + segmental sensory disturbance in the upper limbs Spastic paralysis in the lower limbs,3. The thoracic region,Spastic paralysis in the lower limbs Sensation lost below the level of the lesion,4. The lumbar enlargement(L1-S2),in the lower limbs: Flaccid paralysis Segmental sensory disturbance,5. T
20、he conus medullaris(L3-5) and coccyx:,Sensation loss in the perineum （会阴）and buttocks （臀部）in “saddle shaped”（马鞍型）distribution, sphincter disturbance,6. The cauda equina,Atrophic paralysis below the knee, saddle-shaped sensation disturbance , pain in the lower limbs, disturbance of the bladder and bo
21、wel,PART FOUR,ACUTE MYELITIS （急性脊髓炎）,DEFINITION,A nonspecific Inflammation of the spinal cord, including :transverse(横贯性) myelitisascending (上升性) myelitisdisseminate(播散性) myelitis,ETIOLOGY,Still unknown, may be: an indirect autoimmune attack triggered by infection or recent vaccination, causes the i
22、nflammation of the spinal cord.,PATHOLOGY,The site of Inflammation: edema and hyperemia. The leptomeninges: congested and infiltrated with inflammatory cells. The substance of the cord: congestion, perivascular inflammatory Infiltration.,The cells of the grey matter: Degeneration The white matter:De
23、myelinated of the myelin sheaths(髓鞘)Degeneration of the axis cylinders(轴索),Acute myelitis 急性脊髓炎,MRI T1,T2,MANIFESTATION,Age of onset: most 2040 years old. Both sexes occur Onset is acute, an upper respiration infection (URI) 23 days before, a pain at the back corresponding to the lesion (T3-5) Initi
24、al symptom: weakness and numbness in lower limbs,Symptoms and signs of a transverse lesion of spinal cord occur rapidly Motor symtoms: paraplegia Early stage : spinal shock (脊髓休克）similar to that of flaccid paralysis . After a few days or more, gradually change to spastic paralysis., sensory loss: be
25、low the lesion , all modalities sensation complete or incomplete loss, exhibiting an upper level corresponding to the affected segment site., impairment of sphincter control: retention in the urine and feces, later changing to automatic empty（自动膀胱）. automatic symptoms: over the parts of paralysis, l
26、ack of sweating, edema, etc.,After 34 weeks or more, recover gradually. Three complications should be stressed: urinary tract infection, bed sore（褥疮）, pneumonia, prevention is very important.,Auxiliary Examination,Peripheral blood WBC count elevates slightly in acute stage. CSF: Both protein(0.5-1.2
27、g/L) and white cells (20-200)106/L increase slightly sometimes moderately. No obstruction found in the vertebral canal. CT or MRI reveals the lesion.,DIAGNOSIS,Rapid onset of the symptoms and signs of a transverse lesion of the spinal cord. Changes of CSF. MRI abnormal signal.,Differential diagnosis
28、,Acute epidural abscess(急性硬膜外脓肿):Severe pain, high fever, highWBC, primary infectious lesion found elsewhere.,Some fever, fatigue, tenderness and deformity of the diseased vertebra. This disease confirmed by the X-ray check, CT or MRI,Tuberculous spinal osteitis(结核性脊椎炎),Metastases of the spine：Sever
29、e root pain appears early, primary lesion found in other part of the body. Aged person is favorable to have this disorder, distinguishing by the X-ray 、CT or MRI.,胸椎转移瘤（肝脏转移）,胸 椎 转 移 瘤,. Neuromyelitis optica (Devic disease) (视神经脊髓炎):prominant symptom of optic neuritis occurring before or after the m
30、yelitis, occasional simultaneously.,Hematomyelia(脊髓出血): An acute painful transverse myelopathy, the central grey matter is much damaged than the white matter. Diagnosis is best made by CT or MRI.,血 管 畸 形 并 出 血,Treatment,Adrenal Glucocorticoid Steroid(肾上腺糖皮质激素)(AGCS) pulse therapy(冲击疗法): Initial:meth
31、yprednisolone(甲强龙)500-1000mg, i.v.drip in 3-5 days, following by medrol(美卓乐) or prednisone(泼尼松) oral for several weeks or months. Antibiotics 3. Vitamins(B1,B6,B12) 4. Intravenous immunoglobulin(IVIg),General measures including care of the skin and urinary tract particularly. Early institution of ph
32、ysical therapy, such as massage, acupuncture, and other measures-rehabilitation.,Antibiotics(抗生素）,Steriod(激素）,Vitamin(维生素）,Diaper(尿布）,+,PART FIVE,Compressive myelopathy,(spinal cord compression),（压迫性脊髓病）,Definition,A group of diseases caused by the occupied(占位性) lesions within the vertebral canal, l
33、eads to compress the spinal cord, occurring relevant symptoms and signs.,Etiology,Disease of the vertebral column： (1)Trauma vertebra fracture with spinal cord cut off,(2) Tuberculous osteitis,(3) Tumor of the vertebra,Disease of the meninges ：Arachnoiditis（蛛网膜炎）, leukemia infiltrated（白血病浸润）Epidura
34、abscess,Epidura abscess (硬 膜 外 脓 肿),Astrocytoma of the spinal cord (脊 髓 星 形 细 胞 瘤),Disease of extramedullay(脊髓外）or intramedullay（脊髓内),Schwannoma (神 经 鞘 瘤),Lipoma(脂眆瘤),Gd-DTPA,T1WI,T1WI,Meningioma (脊 膜 瘤),Effects of compression upon the cord,Direct pressure interferes with conduction in the spinal ro
35、ots and in the cord. Compression of the arteries leads to ischemia of the segments of the cord.,Pressure upon the spinal veins leads to edema of the cord below the site of compression. Obstruction of the subarachnoid space leads to changes of CSF,MANIFESTATION,Mode of onset :Acute : injury subacute
36、: arachnoiditischronic : extramedullary tumor,2. Sensory symptoms,Pains radiating in the distribution of one or more spinal roots, unilateral or bilateral. Paresthesia in the limbs.,Compression of spinothalamic tract located in the affected side impairment of appreciation of pain, heat and cold on t
37、he opposite side of the body. (Brown-Sequard Syndrome),Compression of corticospinal tract spastic paresis of the limb / limbs below the level of the lesion. Compression of the ventral roots/ anterior horna progressive lower motor neuron lesion.,3. Motor symptoms,4. The reflexes:,Compression of the s
38、pinal cord at a given segmental leveldiminution or loss of reflexes.,the tendon reflexes below the level of the lesion are hyperactive;pathological reflexes positive;cremasteric(提睾) & abdominal reflexes can not be elicited.,Compression of the corticospinal tract,5. Autonomic symptoms:,The sphincters
39、 disturbance later occur,6. The spine:,deformity, tenderness,Auxiliary Examination, Radiography Myelography (脊髓造影） CT scan, MRI CSF,Diagnosis and Differential Diagnosis,1. Differentiate from the non-compressive diseases:Acute onset : occurring complete or incomplete transverse lesionsChronic onset :
40、 occurring root pain, Brown-Sequard syndrome,Differential diagnosis:,Root pain: Pleurisy,(胸膜炎）, angina pectoris（心绞痛）, cholecystitis（胆囊炎）, etc. Cord transverse lesion:multiple sclerosis, syringmyelia, motor neuron disease, etc.,Localization of the affected segmental level:,root pain, Segmental atroph
41、ic muscles, change of reflexes, the upper limit of sensory loss.,To determine the location of the lesion,4. Diagnosis of the causes of compression,According to: mode of onset, symptoms and signs of the cord, Change of CSF, symptoms develop, X-ray, CT, MRI.,Treatment,The appropriate treatment of the
42、source. For example: Tuberculous spinal osteitis (antituberculous therapy + appropriate operation), extradural abscess(early operation + adequate antibiotics therapy) , spinal tumor (operation) .,2. Rehabilitation,Part Five,Vascular Myelopathies脊髓血管病,Types of vascular myelopathies,1. Infarction of t
43、he Spinal Cord 2. Hematomyelia(脊髓出血) 3. Arteriovenous malformation (AVM) （动静脉畸形）,Zhanghaidi, she had hemangioma(血管瘤) in T2, broke up in her five years, the bleeding compressed the spinal cord caused paralysis.,Hematomyelia(脊髓出血): An acute painful transverse myelopathy, the central grey matter is muc
44、h damaged than the white matter. Diagnosis : best made by CT or MRI.Treatment : conservative therapy or operation,血 管 畸 形 并 出 血,PART SIX,SYRINGOMYELIA,（脊髓空洞症）,Syringomyelia,Definition,A cavity expansion of the spinal cord produces a progressive myelopathy. If the cavity extends to the medullar oblon
45、gata -syringobulbia (延髓空洞症),Etiology,Developmental disorders of the posterior fossa(后颅窝） and foramina magnum（枕骨大孔） Congenital malformation of the central canal of the spinal cord Obstruction of the foramina magnum.,Pathology,Cavity fills with liquor similar to CSF. Cavity expansion first affects the
46、 posterior horn anterior hornlateral horn desending and ascending pathways.,Manifestations,Disease occurs in 2030 years old, developing insidiously.,2. Classical symptomsDissociated（分离性） sensory disturbance (pain and temperature sensations lost, deep and touch sensation preserved, if the lesion : sy
47、mmatrical: the ditribution like a cape(背心) asymmetrical: like half of a cape.,Hyporeflexes Muscles wasting in the hands Nutrition disturbance: skin ulcers, sweating abnomalCharcots joints (enlargement, deformity without pain),Classical syndromes (continued),Auxiliary examination,DMCT （延迟性CT造影）MRI,Diagnosis and Differential diagnosis, Intramedullary tumor Amyotrophic lateral sclerosis (ALS)（肌萎缩侧索硬化） Leprosy (麻风),Treatment,The drugs for this disease are limited Large cavityoperation,THANK YOU,
