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1、Christorph Reeve , known as the star actor of “Superman”（超人超人） , fell from horse when riding and became tetraplegia（四肢瘫四肢瘫） in 1995， and died in 2007Similar accident took place when Chinese gymnastics athlete, Sanlan（桑兰桑兰） , was exercising in the 4th Goodwill Games in New York on 21st July , 1998. T
2、he cervical spine injury led to tetraplegia .Zhanghaidi（张海迪张海迪）, she had hemangioma(血管瘤）血管瘤） in T2, broke up in her five years, the bleeding compressed the spinal cord caused paralysis (截瘫截瘫)Lou Gehrig(19031941), one of the best baseball player in the world, was such a ALS （肌萎缩侧索硬化）（肌萎缩侧索硬化）patient.
3、（ Lou Gehrig disease)Stephen Hawking , a genius physicist , is another case of ALS .Chapter 4 Spinal CordDiseases (脊髓疾病脊髓疾病) Purpose ： 1) Comprehend: The general picture of spinal cord diseases ; 2) Acquaint: Clinical manifestation, diagnosis and differential diagnosis, treatment principle of acute
4、myelitis （急性脊髓炎）（急性脊髓炎）& spinal cord compression （脊髓压迫症）（脊髓压迫症） 3) Grasp: three main symptoms & localization (定位定位) of Spinal Cord Diseases Teaching hour： 2 lecturing hoursCONTENTS Part 1 Anatomy Part 2 Manifestations Part 3 Lesion Localization Part 4 Acute myelitis Part 5 Compressive myelopathy Par
5、t 6 Vascular Myelopathies Part 7 Syringomyelia& ANATOMY Spinal Cord Anatomy Relevant to Clinical SignsLies within the vertebral canalMedulla oblongataforamen magnum level of the first lumbar vertebraLower endconus medullaris（圆锥） filum terminale（终（终丝）丝）coccyxAll the spinal nerves below the fisrt lumb
6、ar forming the cauda equina(马尾）马尾）two enlargements: 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 sac
7、ral, one coccygeal.The length of spinal cord: about 2/3 of the vertebras.Spinal Cord Levels Relative to the Vertebral BodySpinal Cord Levels Relative to the Vertebral BodySpinal cord levelSpinal cord levelCorresponding Vertebral BodyCorresponding Vertebral BodyCervical (For ex:C6)Cervical (For ex:C6
8、)C6-1=C5C6-1=C5Upper thoracic(T16)(For ex:T5)Upper thoracic(T16)(For ex:T5)T5-2=T3T5-2=T3Lower Lower thoracic(T712)(For thoracic(T712)(For ex:T9)ex:T9)T9-3=T6T9-3=T6LumbarLumbarT1012T1012SacralSacralT12L1T12L1CoccygealCoccygealL1L1 Three MeningiesPia mater（软脑膜）（软脑膜）: forms the immediate covering of
9、the cordArachnoidArachnoid（珠网膜）（珠网膜）（珠网膜）（珠网膜）: lies : lies superficallysuperfically to to the the piapia mater materDuraDura mater mater（硬脑膜）（硬脑膜）（硬脑膜）（硬脑膜） : outside the: outside the arachnoidarachnoidArachnoid space: contains cerebrospinal fluid(CSF)（脑脊液脑脊液脑脊液脑脊液）Epidural space: contains fatty ti
10、ssue,venous plexusTwo spacesTwo anterior horns-motor cellsTwo posterior horns-sensory cellsLateral horns-autonomic cellsThe Structure Inside the Spinal CordTwo anterior columnTwo posterior columnTwo lateral column All fibersPeripheral white matter:Ascending Pathways Lateral spinothalamic tract （脊髓丘脑
11、侧束）（脊髓丘脑侧束）: conduct superficial sensationVentral spinothalamic tract（脊（脊髓丘脑前束）髓丘脑前束）Tracts of Gracilis and Cuneatus（薄束和楔束（薄束和楔束）: conduct deep sensation DescendingPathwaysthe important one is :Corticospinaltract (皮质脊髓束）皮质脊髓束）or pyramidal tract（锥体束）锥体束）,convey motor impulses from cerebral cortex to
12、spinal cordBlood SupplyTwo posterior spinal arteriessupply 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 arteryUnites the spinal arteries to supply the white matter and most part of the post
13、erior horn.Arterial coronaMANIFESTATIONS （临床表床表现） Three Main Symptoms of spinal cord diseases1. Motor disturbance Upper Motor Neuron Paralysis (Spastic paralysis ) （ 痉挛性瘫）痉挛性瘫） caused by : Pyramidal tract lesion Lower Motor Neuron Paralysis (Flaccid paralysis（弛弛缓性瘫缓性瘫） caused by : anterior horn / ve
14、ntral root lesion2.Sensation disturbance, caused by : spinothalamic, gracilis and cuneatus tracts lesion; posterior horn / posterior root lesion 3.Autonomic function disturbance : sphincter dysfunction，lack of sweating, skin ulcerThree types of lesion of spinal cord1.Selective lesion (Local lesion)
15、（局灶性损害）（局灶性损害）2. Semitransverse lesion（半横贯性（半横贯性 损害）损害） (Brown-Sequard syndrome)3. Complete transverse lesion （完全性完全性横贯性损害）横贯性损害） （1）Anterior Horn LesionSymptom: flaccid paralysis(弛缓性麻痹）弛缓性麻痹）弛缓性麻痹）弛缓性麻痹） (lower motor neuron lesion)Diseases: Acute poliomyelitis（急性脊髓灰（急性脊髓灰（急性脊髓灰（急性脊髓灰质炎，也称小儿麻痹症）质炎，也
16、称小儿麻痹症）质炎，也称小儿麻痹症）质炎，也称小儿麻痹症）Progressive spinal muscular atrophy（进行性脊肌萎缩症）进行性脊肌萎缩症）进行性脊肌萎缩症）进行性脊肌萎缩症）（2）Pyramidal Tract lesionSymptom: Spastic paralysis (Upper motor neuron lesion)Disease: Primary lateral sclerosis(原发性侧索硬化）原发性侧索硬化）（3）Anterior horn+Pyramidal tractSymptom:( cervical enlargement lesion
17、)Flaccid paralysis+spastic paralysis on the hands；spastic paralysis on the legsDisease: Amyotrophic lateral sclerosis(ALS)（肌萎缩性侧索硬化）（肌萎缩性侧索硬化）（4）Posterior Column LesionSymptom: Deep sensation disturbanceDisease: Tabes dorsalis（脊髓痨）脊髓痨）(5) Posterior Column+Pyramidal TractSymptom: deep sensation distu
18、rbance + spastic paralysisDisease: Subacute combined degeneration of the spinal cord（脊髓亚急性联合变性）脊髓亚急性联合变性）（6）Lesion In The Gray MatterSymptom: dissociated （分离性）（分离性）sensory disturbance ，segmental sensory loss， muscles wasting in the hands Nutrition disturbance Disease: Syringomyelia（脊髓空洞症）脊髓空洞症） Spin
19、al hemorrhage（脊髓出血）脊髓出血）2. Semitransverse lesion（半横贯损害）半横贯损害） (Brown-Sequard 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（完全性横贯性损害）全性横贯性损害）Acute myelitis, traumaBelo
20、w the level of the lesion ： Spastic paralysis(痉挛性截瘫痉挛性截瘫)Complete loss of all modalities sensation Sphincter disturbances Lesion localization (病灶定病灶定 位）位）1.The upper cervical region (C1-4)Pyramidal tract signs (锥体锥体束征束征) in four limb-slight damageTetraplegia(quadriplegia) (四肢瘫四肢瘫)-severe damage Pain
21、 in the neck and occiput2. The cervical enlargement(C5-T2)Flaccid & spastic paralysis + segmental sensory disturbance in the upper limbsSpastic paralysis in the lower limbs3. The thoracic regionSpastic paralysis in the lower limbs Sensation lost below the level of the lesion4. The lumbar enlargement
22、(L1-S2)in the lower limbs:Flaccid paralysis Segmental sensory disturbance5. The conus medullaris(L3-5) and coccyx:Sensation loss in the perineum （会阴会阴）and buttocks （臀部臀部）in “saddle shaped”（马马鞍型）鞍型）distribution, sphincter disturbance6. The cauda equinaAtrophic paralysis below the knee, saddle-shaped
23、sensation disturbance , pain in the lower limbs, disturbance of the bladder and bowelACUTE MYELITIS（急性脊髓炎）急性脊髓炎）DEFINITIONA nonspecific Inflammation of the spinal cord, including : transverse(横横贯性性) myelitis ascending (上升性上升性) myelitis disseminate(播散性播散性) myelitisETIOLOGYStill unknown, may be: an in
24、direct autoimmune attack triggered by infection or recent vaccination, causes the inflammation of the spinal cord.PATHOLOGYThe site of Inflammation: edema and hyperemia.The leptomeninges: congested and infiltrated with inflammatory cells.The substance of the cord: congestion, perivascular inflammato
25、ry Infiltration.The cells of the grey matter: DegenerationThe white matter: Demyelinated of the myelin sheaths(髓鞘髓鞘) Degeneration of the axis cylinders(轴索索)Acute myelitis 急性脊髓炎急性脊髓炎 MRI T1T2MANIFESTATION1.Age of onset: most 2040 years old. Both sexes occur2.Onset is acute, an upper respiration infec
26、tion (URI) 23 days before, a pain at the back corresponding to the lesion (T3-5)3.Initial symptom: weakness and numbness in lower limbs4.Symptoms and signs of a transverse lesion of spinal cord occur rapidly Motor symtoms: paraplegia Early stage : spinal shock (脊脊髓髓休休克克）similar to that of flaccid pa
27、ralysis . After a few days or more, gradually change to spastic paralysis. sensory loss: below 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, l
28、ater changing to automatic empty（自（自动膀胱）膀胱）. automatic symptoms: over the parts of paralysis, lack of sweating, edema, etc.5. After 34 weeks or more, recover gradually.6.Three complications should be stressed: urinary tract infection, bed sore（褥褥疮）, pneumonia, prevention is very important.Auxiliary
29、Examination1.Peripheral blood WBC count elevates slightly in acute stage.2.CSF: Both protein(0.5-1.2g/L) and white cells (20-200)106/L increase slightly sometimes moderately.3.No obstruction found in the vertebral canal. 4.CT or MRI reveals the lesion.DIAGNOSISRapid onset of the symptoms and signs o
30、f a transverse lesion of the spinal cord.Changes of CSF.MRI abnormal signal.Differential diagnosisAcute epidural abscess(急急 性性硬硬 膜膜 外外 脓 肿):Severe pain, high fever, high WBC, primary infectious lesion found elsewhere. Some fever, fatigue, tenderness and deformity of the diseased vertebra. This disea
31、se confirmed by the X-ray check, CT or MRITuberculous spinal osteitis (结核性脊椎炎核性脊椎炎) Metastases of the spine： Severe 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（肝脏转移）
32、胸胸 椎椎 转转 移移 瘤瘤. Neuromyelitis optica (Devic disease) (视神经脊髓炎视神经脊髓炎):prominant symptom of optic neuritis occurring before or after the myelitis, occasional simultaneously. Hematomyelia(脊髓出血脊髓出血): An acute painful transverse myelopathy, the central grey matter is much damaged than the white matter. Di
33、agnosis is best made by CT or MRI.Treatment1.Adrenal Glucocorticoid Steroid(肾上上腺腺糖糖皮皮质激素激素)(AGCS) pulse therapy(冲击疗法冲击疗法):2.Initial:methyprednisolone(甲甲 强 龙 )500-1000mg, i.v.drip in 3-5 days, following by medrol(美美卓卓乐) or prednisone(泼尼尼松松) oral for several weeks or months.2.Antibiotics 3. Vitamins(B
34、1,B6,B12)3.4. Intravenous immunoglobulin(IVIg)4.General measures including care of the skin and urinary tract particularly.5.Early institution of physical therapy, such as massage, acupuncture, and other measures-rehabilitation.+Compressive myelopathy（压迫性脊髓病（压迫性脊髓病）DefinitionA group of diseases caus
35、ed by the occupied(占占位位 性性 ) lesions within the vertebral canal, leads to compress the spinal cord, occurring relevant symptoms and signs.EtiologyDisease of the vertebral column：(1)Trauma vertebrafracturewith spinal cord cut off(2) Tuberculous osteitis(3) Tumor of the vertebraDisease of the meninges
36、 ：Arachnoiditis（蛛网膜炎）蛛网膜炎）蛛网膜炎）蛛网膜炎）, leukemia infiltrated（白血病浸润）白血病浸润）白血病浸润）白血病浸润）Epidura abscessEpidura abscess (硬硬 膜膜 外外 脓脓 肿肿)Astrocytoma of the spinal cord (脊脊 髓髓 星星 形形 细细 胞胞 瘤瘤)Disease of extramedullay(脊髓外）脊髓外）or intramedullay（脊髓内（脊髓内) Schwannoma (神神 经经 鞘鞘 瘤瘤)Lipoma(脂脂眆瘤眆瘤)Gd-DTPAT1WI T1WIMeni
37、ngioma(脊脊 膜膜 瘤瘤)Effects of compression upon the cordDirect pressure interferes with conduction in the spinal roots 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.Obstruc
38、tion of the subarachnoid space leads to changes of CSFMANIFESTATION Mode of onset : Acute : injury subacute : arachnoiditis chronic : extramedullary tumor2. Sensory symptoms Pains radiating in the distribution of one or more spinal roots, unilateral or bilateral. Paresthesia in the limbs. Compressio
39、n of spinothalamic tract located in the affected side impairment of appreciation of pain, heat and cold on the 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/ an
40、terior horna progressive lower motor neuron lesion.3. Motor symptoms4. The reflexes:Compression of the spinal 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(提提睾睾) & abdominal
41、 reflexes can not be elicited.Compression of the corticospinal tract5. Autonomic symptoms: The sphincters disturbance later occur 6. The spine:deformity, tendernessAuxiliary Examination Radiography Myelography (脊髓造影）脊髓造影） CT scan, MRI CSFDiagnosis and Differential Diagnosis 1. Differentiate from the
42、 non-compressive diseases: Acute onset : occurring complete or incomplete transverse lesions Chronic onset : occurring root pain, Brown-Sequard syndromeDifferential diagnosis:Root pain: Pleurisy,(胸膜炎）胸膜炎）, angina pectoris（心（心绞痛）痛）, cholecystitis（胆囊炎）（胆囊炎）, etc. Cord transverse lesion: multiple scler
43、osis, syringmyelia, motor neuron disease, etc.2.Localization of the affected segmental level: root pain, Segmental atrophic muscles, change of reflexes, the upper limit of sensory loss.ManifestionExtradural（硬膜外（硬膜外）Extramedullary(脊髓外脊髓外)Intramedullary（髓内）（髓内）Root painsocccur earlyearlyless frequentS
44、ymptoms developbilaterall,symmetricalUnilateral to bilateralbilareral, symmetricalMotor symptomsappear firstearlierearlierSensory changeslateearlyearlySphincter disturbanceslaterlaterearlyProtein contentof CSFslight increasedhighlower3.To determine the location of the lesion4. Diagnosis of the cause
45、s of compressionAccording to: mode of onset, symptoms and signs of the cord,Change of CSF, symptoms develop, X-ray, CT, MRI. Treatment1.The appropriate treatment of the source. For example: Tuberculous spinal osteitis (antituberculous therapy + appropriate operation), extradural abscess(early operat
46、ion + adequate antibiotics therapy) , spinal tumor (operation) .2. RehabilitationPart FiveVascular Myelopathies 脊髓血管病脊髓血管病Types of vascular myelopathies1. Infarction of the Spinal Cord 2. Hematomyelia(脊髓出血脊髓出血)3. Arteriovenous malformation (AVM) （动静脉畸形）（动静脉畸形）Zhanghaidi, she had hemangioma(血管瘤血管瘤) i
47、n T2, broke up in her five years, the bleeding compressed the spinal cord caused paralysis. Hematomyelia(脊髓出血脊髓出血): An acute painful transverse myelopathy, the central grey matter is much damaged than the white matter. Diagnosis : best made by CT or MRI. Treatment : conservative therapy or operation
48、（脊髓空洞症）（脊髓空洞症）SyringomyeliaDefinition A cavity expansion of the spinal cord produces a progressive myelopathy. If the cavity extends to the medullar oblongata -syringobulbia (延髓空洞症延髓空洞症)Etiology 1.Developmental disorders of the posterior fossa(后后颅窝） and foramina magnum（枕骨大孔）（枕骨大孔）2.Congenital malfor
49、mation of the central canal of the spinal cord3.Obstruction of the foramina magnum. PathologyCavity fills with liquor similar to CSF. Cavity expansion first affects the posterior horn anterior hornlateral horn desending and ascending pathways.Manifestations1. Disease occurs in 20 30 years old, devel
50、oping insidiously.2. 2. Classical symptoms Dissociated（分离性） sensory disturbance (pain and temperature sensations lost, deep and touch sensation preserved, if the lesion : symmatrical: the ditribution like a cape(背背心心) asymmetrical: like half of a cape.HyporeflexesMuscles wasting in the handsNutritio
51、n disturbance: skin ulcers, sweating abnomal Charcots joints (enlargement, deformity without pain) Classical syndromes (continued) Auxiliary examinationDMCT（延迟性延迟性CT造影）造影）MRIDiagnosis and Differential diagnosis Intramedullary tumor Amyotrophiclateral sclerosis (ALS)（肌萎（肌萎缩侧索硬索硬化）化） Leprosy (麻麻风)TreatmentThe drugs for this disease are limitedLarge cavityoperation
