1、Spinal cord disorders,The department of Neurology, Xuanwu hospital, Capital University of Medical Sciences,Words List（1）,Vertebra 椎体 Cervical 颈的 Thoracic 胸的 Lumbar 腰的 Sacral 骶的 Coccygeal 尾骨的 Conus medullaris 脊髓圆锥 Cauda equina 脊髓马尾 Afferent fiber 传入纤维 Efferent fiber 传出纤维 Ganglion 神经节 Dermatome 皮区/皮节
2、Myotome 肌节 Gray matter 灰质 White matter 白质 Anterior white commissure 前连合 Fasciculus gracilis 薄束 Fasciculus cuneatus 楔束,Words List（2）,Corticospinal tract 皮质脊髓束 Pyramidal tract 锥体束 Pyramidal decussation 锥体交叉 Axon 轴突 Synapse 突触 Dendrite 树突 Medial lemniscal system 内侧丘系 Proprioception 本体感觉 Lemniscal decus
3、sation 丘系交叉 Thalamus 丘脑 Vestibulospinal tract 前庭脊髓束 Rubrospinal tract 红核脊髓束 Reticulospinal system 网状脊髓系统 Spinothalamic tract 脊髓丘脑束 Spinocerebellar tract 脊髓小脑束 Ventral posterolateral nucleus 腹后外侧核（丘脑）,Contents of The Lecture,一、Anatomy of spinal cord (SP)二、Clinical manifestations of SP lesions三、Diseas
4、es of the spinal cord 四、Questions for homework五、Books recommended,Spinal cord is part of central neural system. Begin at the end of the brainstem End at the first lumber vertibrate.,Carry both incoming and outgoing messages between the brain and the rest of the body. It is also the center for reflex
5、es.,example,Brain spinal cord hand station hot water,Outline,The anatomy of spinal cordThe internal componentsExternal components The reflex of spinal cord The blood supply of spinal cord The clinical aspects of damaging spinal cord,The anatomy of spinal cord,External components:,The upper and lower
6、 boundary of the cord The spinal nerves: C1-8, T1-12, L1-5, S1-5 The relation between the cord and spine,How the Spinal cord Is Organized,The spinal cord are contained in the spinal canal. Spinal canal is longer than the spinal cord. In most adults, the spine is composed of 26 vertebrae, which are t
7、he individual bones of the back. vertebrae protect the spinal cord.,The upper and lower bound of the cord,Length: 4245cm, It is the continuation of medulla(occipital foramen). The lower end forms terminal cone（圆锥）. It occupies 2/3 length of the spine. cervical enlargement: C5T2 Lumbar enlargement: L
8、1S2, Terminal filament（终丝） end on the periosteum（骨膜） of the 1st coccygeal vertebra.,External components,Spinal nerves: 30pairs of nerves were sent out: C1-8, T1-12, L1-5, S1-5 The root in the front, the motor root, transmits impulses from the spinal cord to the muscles. The root in the back, the sen
9、sory root, carries sensory information (about touch, position, pain, and temperature) from the body to the spinal cord.,External components,The segmental distribution of cutaneous（皮肤的） sensory innervation,Spinal segment,Cervical cord C1-8 Thoracic cord T1-12 Lumbar cord L1-5 Sacral cord S1-5 Coccyge
10、al 1 Cauda equina,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.,Internal
11、components,Gray matter: shape like H.Anterior horn Posterior hornLateral horn ： C8L2 and S24,Internal components,White matter: anterior column, lateral column, posterior column Ascending transmit tracts Descending transmit tracts,Ascending fibers,Fasciculus gracilis（薄束） Fasciculus cuneatus（楔束） Spino
12、thalamic tract（脊髓丘脑束） Spinocerebellar tract（脊髓小脑束）,Ascending fibers,Fasciculus gracilis（薄束） contains fibers from sacral, lumbar, and lower thoracic dermatomes（皮肤感觉分布区） Fasciculus cuneatus（楔束） carries fibers from upper thoracic and cervical dermatomes Function: convey well-localized sensation of fine
13、 touch, vibration, two-point discrimination, and proprioception (position sense) from the skin and joints.,Ascending fibers,Spinothalamic tract： lateral spinothalamic tract :carries information about pain and temperature anterior spinothalamic tract:carries information about crude touch,Ascending fi
14、bers,Spinocerebellar tract posterior spinocerebellar tract anterior spinocerebellar tract,Coordinate the movement and posture of limbs,Descending fibers,corticospinal tract（皮质脊髓束） rubrospinal tract（红核脊髓束） vestibulospinal tract（前庭脊髓束） reticulospinal tract（网状脊髓束） tectospinal tract（顶盖脊髓束） medial longit
15、udinal fasciculus（内侧纵束）,Pyramidal system corticospinal tracts corticonuclear tracts,Descending fibers,corticospinal tract: lateral corticospinal tract anterior corticospinal tract,Carries information for volitional movement （随意运动）under direct cortical control,Arteries of spinal cord,Anterior spinal
16、artery provide blood to anterior 2/3spinal cord Posterior spinal artery provide blood to posterior 1/3 spinal cord Radicular artery connect the arterior spinal artery with posterior spinal artery,The reflex of spinal cord,Reflexes: A reflex is an automatic response to a stimulus. For example, the lo
17、wer leg jerks when the tendon below the kneecap is gently tapped with a small rubber hammer. The pathway that a reflex follows (reflex arc) is a complete circuit, without involvement of the brain.,Cord impairments-Clinical features,Motor deficits: Anterior horn or root damaging: low motor neuron (fl
18、accid) paralysis, muscles fasciculations and fibrillations, no sense disturblance. Pyramidal tract damaging: spastic paralysis below the level of the lesion. Both anterior horn and Pyramidal tract damaging: combine damaging with upper and low motor neuron disturblances,spinal shock（脊髓休克）,flaccid par
19、aplegia(迟缓性截瘫）, diminished or absent reflexes, without pyramidal sign, bladder and bowel are paralyzed, last 26 weeks. Cause: Loss of the tonic effect of corticospinal tract excitation on the the anterior horn cell.,Lower-versus upper-motor-neuron lesions,Sensation disturbances,posterior horn & root
20、: 节段性感觉障碍 anterior white commissure: 感觉分离现象loss of pain and temperature sensations,touch and deep sensations are keeped. spinalthalamic tract:传导束性感觉障碍loss of contralateral pain and temperature sensations,Sensation disturbances,Autonomic nervous imbalance,Sphincter(括约肌） dysfunctions:paruria （排尿异常）and
21、 dysuria(小便困难），incontinence or retention (including urination排尿 and defecation排便) Skin , finger, sweating, nutrition dysfunction,Lesions of the Spinal Cord,Sydrome of the posterior roots,Sydrome of the posterior column,Sydrome of the posterior horns,Sydrome of anterior white commissure: 感觉分离现象,Syndr
22、ome of combined degeneration ofposterior funiculi, corticospinal tracts Subacute combined degeneration of spinal cord,Syndrome of the anterior horns Acute poliomyelitis,Syndrome of the corticospinal tractsHereditary spastic paraplegia,Syndrome of combined disease of posterior funiculi, spinocerebell
23、ar pathways, and possibly pyramidal tracts,Friedreich Ataxia,Syndrome of hemisection of the spinal cordBrown-Sequard Syndrome,Complete transection of the spinal cord at different levels,Brown-Sequard syndrome,ipsilateral upper motor neuron damaging and loss of deep sensation below the lesion, contra
24、lateral loss of pain and temperature sensation below the lesion, compressive myelopathy,Transection damaging of spinal cord,Total transection damaging results in immediate permanent paralysis and loss of all sensations below the level of the lesion. Bladder/bowel disturbance Autonerve disturbance Tr
25、auma, inflammations,spinal hemorrhage,Acute transverse myelitis,Case report,Femal,23 years old, weakness, numbness associated with urinary and stool retention Sign: spastic paraplegia of both legs, sensory loss below T4, Bilateral Babinski sign(+),History of acute transverse myelitis,In 1922 , some
26、cases reported it was a rare complication of smallpox vaccination: inflammation of the spinal cord and brain . It was in 1948 that the term “acute transverse myelitis” was utilized in reporting a case of inflammatory myelopathy complicating pneumonia,Definition,Acute transverse myelitis is a localiz
27、ed inflammation of the spinal cord that blocks transmission of nerve impulses up and down the spinal cord. Such as: myelitis following infection, myelitis following vaccine inoculation, demyelinative myelitis, necrosis myelitis, para-tumor myelitis.,Pathogenesis,The cause of acute transverse myeliti
28、s is unknown, About 30 to 40% of people with this disorder develop it after an otherwise minor viral infection. 14 weeks ago, auto-immune reaction in association with a viral infection or vaccine inoculation; But there were no detective virus in nervous tissues, also no antibodies in CSF detected.,P
29、athology,Findings under naked eyes: swelling（肿胀）, hyperemia（充血）, seeping（渗出）. Findings under microscope: vascular enlargement(血管扩张）and hyperemia, inflammated cell erosion（侵润） ; nerve cell swelling, disappearing，demyelinating（脱髓鞘） in white mater，axon degeneration（轴索变性） and gliosis（胶质细胞增生） .,Clinical
30、features,1. Incidence have two peaks,1020, 3040 years.No difference between the gender. Infection or vaccine inoculation history ; Inducement of cold, overfatigue, trauma et al.,Clinical features,2. Acute onset, gets to the peak after several hours or 23 days. The most frequent sites: T3-5. The init
31、ial symptoms: Numbness and weakness in the legs Backache and a belt-like tightness is felt around the chest or stomach at the level affected,Clinical Manifestation,Motor deficits: para- quadriparesis , spinal shock in acute phase,spinal shock（脊髓休克）,flaccid paraplegia(迟缓性截瘫）, diminished or absent ref
32、lexes, without pyramidal sign, bladder and bowel are paralyzed, last 26 weeks. Cause: Loss of the tonic effect of corticospinal tract excitation on the the anterior horn cell.,Clinical Manifestation,Sensation deficits: lose all of the sensation below the level of spinal cord Automatic nerve deficits
33、: urinary, stool retention; dryness of skin; nails nutrition dysfunction,Clinical features,3. Acute ascending myelitis: repaidly advanced, sensation level ascends to high cervical cord or medulla from several hours to 12d， paralysis in upper extremity and muscles contorlled by medulla ， Dysphagia（吞咽
34、困难）、dysarthria（声音嘶哑） and dyspnea（呼吸困难）.,Investigation,1. Blood routine test: wbc are normal or slightly increased . 2. CSF: normal pressure, Queckenstedt test is normal. white cell ： normal or increased, protein ： slightly increasedglucose and chloride： normalElevated IgG index,Imaging,Among the var
35、ious imaging modalities, MR is the best technique due to its multiplanar capabilities and superior tissue sensitivity. It allows to answer the following questions:1) is the spinal cord normal or not ?2) is the lesion localized to the cord (focal or diffuse) or to the whole neuraxis (brain, nerve roo
36、ts)?,3) how is the signal, is there an enhancement or not?,Imaging finding,Acute lesions are hyperintense on T2-weighted images and hypointense on T1-weighted images and may demonstrate cord enlargement. Enhancement with gadolinium has been reported. Chronic lesions often show persistent hyperintens
37、e signal on T2 from gliosis. Severe cases may lead to cord atrophy.,Acute myelitis,Diagnose,Acute onset The history of infection and vaccine inoculation The symptoms of cord transverse impairment The examination of CSF MRI,Differential diagnosis:,(1) Acute epidural abscess （急性硬膜外脓肿） 1) Commonly have
38、 skin infection, severe fever; 2) Intense spinal root pain 3) Severe local tenderness in spine, 4)Rapidly advancing loss of neurological function below the lesion. 5) Blood wbc increased, 6) CSF wbc slight increased and protein increased, subaranoid space is blocked.7) CT scan and MRI is helpful.,Di
39、fferential diagnosis,(2) spine tuberclosis（脊柱结核） fever in afternoon, night sweat secondary compression of the cordmalformation in spineX ray of spine showed destruction in exact segments of spine, abscess shadow,Differential diagnosis,(3) carcinomatous metastases（转移癌） more in old people； rapid cours
40、e of disease ； nerve root pain in early stage； compression symptom, paraplegia , lossing sensation and urinating； X ray、CT、MRI: damaged in vertebrat，but no abscess shadow ； Idiocarcinoma,Differential diagnosis,(4) optica neuromyelitis（视神经脊髓炎） A subtype of multiple sclerosis,neuritis optica: decline
41、of eyesightsigns reflecting multiple focus, such as: nystagmus(眼球震颤）, diplopia（复视）, ataxia（共济失调）.,Differential diagnosis,(5) spinal cord hemorrhage（脊髓出血） because of truma or AVM in spinal cord severe back pain paraplegia and difficulty urinating rapidly. secondary subarachnoid hemorrahge CT scan sho
42、wed hyperdensitive in spinal cord DSA showed AVM,Treatment,Nursing is very important urethral catheterication for urinary retention artificial respiration for dyspnea Emphasis of nutrition, Emphasis of nursing, prevent complications.Drugs corticosteroid drugs antiviral drugs neurotrophic drugs Prope
43、r antibiotics to prevent infection Rehabilitative treatment passive activity, massage, intensive exercises.,脊髓压迫症 (compressive myelopathy),Concept: 椎管内占位性病变(occupy lesion)引起的脊髓受压表现的一组疾病，呈进行性发展，最后导致不同程度(in varying degree)脊髓横贯损害和椎管阻塞。,Pathogenesis,Causes: tumorsinflammationstrauma of the spine脊柱退行性变(d
44、egeneration)congenital abnormality,The warning signs of spinal cord compression,Progressive feeling of stiffness or fatigue in the legs More or less rapidly progressive impairment of gait Urinary dysfunction Sensory disturbances in one or both legs Band-like abnormal sensation around the thorax or a
45、bdomen Back pain,The distribution of the transmit tracts,Pathology and physiology,Factors influencing the compensation：1. Speed of compression: acute or chronic2. The relation between the cord and the lesions: Intramedullary or extramedullary,Pathology and physiology,Intramedullary lesions: 髓内的占位性病变
46、直接侵犯神经组织，症状出现较早. Extramedullary intradural lesions: 首先从一侧压迫脊髓, 症状进展缓慢 Extramedallary extradural lesions: 由于硬脊膜的阻挡，对脊髓的压迫作用相对轻微，症状往往发生在脊腔明显梗阻之后3. 根动脉受压:可引起分布区脊髓缺血，静脉高 压，局部脊髓组织水肿以及血浆蛋白渗出。,Clinical features,(1)Irritating and deficit symptoms of nerve roots(anterior/posterior root) (2)Sensation disturba
47、nce (spinalthalumas tract) ;(3)Dyskinasia(运动障碍）:extension spastic paralysis or paraplegia in flexion,Clinical features,(4) Reflex abnormal(anterior/posterior root,anterior horn,pyramidal tract, abdominal reflex(5)Sympotoms of autonomic nerves： sphincter dysfunction (extramedullary, intramedullary)(6
48、) 脊膜刺激症状：tendness,Examination,(1) Lumbar puncture：对诊断有重要意义。 压颈试验(Queckenstedt试验): block (2) Plain X ray of the spine: bone destruction, widening of the spinal canal, destruction of the laminae or spinous processes, or a vertebral hemangioma（血管瘤）(3) CT or MRI：清晰显示脊髓受压影像，MRI is of crucial diagnostic value.,Disk protrusion,Disk protrusion,Disk protrusion,Compressive myelopathy,Spinal tubercolosis,Spinal cord tumour,Spinal cord tumour,Spinal cord tumour,Diagnosis,
