Clinical neuroanatimia
Figure 1 shows the transverse section of the spine, which shows the location of the main pathways. The main conductive motorway is the corticospinal tract originates in the opposite hemisphere, in the subsequent part of the fibers goes to the opposite direction. A spinctalamatic tract transfers similarly to the cross-information from the opposite side of the body, while the rear poles transmit ipsilateral information about the position of body elements in the space and the sense of vibration.
Fig. one.
Symptoms of defeat
Due to the features of the distribution of most conductive pathways in the spinal cord, most patients usually have a combination of motor, sensitive and vegetative disorders.
Motor disorders
Most patients have symptoms of the lesion of the central motioneerone of both legs ( spastic parapapere) or with the defeat of the top cervical department of all four limbs ( spastic tetrapareps). The damage to the cervical spinal cord can lead to the development of the lower spastic paraper in combination with mixed, symptoms of the lesion of central and peripheral motionones in the upper limbs due to the simultaneous lesion of conductive paths and roots in the cervical spinal cord.
Sensitivity disorders
A sign of damage to the spinal cord is the presence the level of sensitivity disorders, for example, the skin sensitivity is broken below some level, and above it is normal. In a patient with spastic parapaprem sensitivity impairment level Represents a certain value to confirm the presence of the spinal brain damage, but the diagnostic significance of this feature is limited to precisely anatomical localization of the lesion. So, the level of sensitivity impairment in the TH10 segment does not always talk about the damage directly the TH10, but rather about the defeat at the level or above the TH10. It is essential in clinical practice. For example, when examining the patient's neurovelization methods with acute squeezing of the spinal cord, which requires urgent treatment, and the level of sensitivity on TH10 (the area of \u200b\u200bvisualization is limited to the breast, the underlying foci of lesion leaning to surgical treatment may not be detected.
Vegetative violations
The involvement of the bladder is an early sign of the defeat of the spinal cord, patients complain about urgent urination and frequent cases of urinary incontinence. Symptoms associated with the digestive tract, in the initial stage of the disease, appear less often, although patients may complain about the incontinence of the chair. Often, sexual dysfunction is also found, in particular the erection violation.
Other manifestations of damage to the spinal cord include pain syndromes in the neck or lower back or indications of the injured injury.
Specific spinal syndromes
Extramedullary and intramedullary lesions syndromes
The external compression of the spinal cord is an extrapullary lesion (tumor or supposed an intervertebral disk), causes loss of sensitivity in sacral dermatomas ( sadlovoid anesthesia). The reason for this is that part of the spinal tract closest to the surface of the spinal cord (transmitting information from lumbosacral dermatomes) is most vulnerable to external compression (Fig. 2). In the internal (intramedullary) lesion, on the contrary, first of all, fibers are suffering, located in the center of the spinctalamic path, while the fibers from the sacrilate department remain throughout the intact time ( sressy release) Although it is not strict rule (Fig. 2).
Fig. 2. Extra and intramedullary damage to the spinal cord. The location of the conductive paths in the spinctalamatic path - the fibers from sacred dermatomes (S) are located the most laterally, followed by fibers from lumbar (L), chest (t), and, most centrally, from cervical dermatomes. External compression (a) is accompanied by a lesion of fibers from sacred dermatomes, whereas with intramedullary lesion (c) these fibers may remain intact
With unilateral damage to the spinal cord, the characteristic syndrome of motor and sensitive disorders is developing. In its most complete form arising with the full one-sided damage to the spinal cord, this state is called Brown-Secary Syndrome (Fig. 3). This case is exactly the situation in which the level of sensitivity disorders does not provide accurate information about the localization of the lesion.
Fig. 3. Brown-secarar syndrome. The defeat of the central motor mechanone on the same side of the same name (as the descending corticospinal routes have already made the cross in the oblong brain). The loss of deep sensitivity and the feelings of vibration is also observed on the side of the same name relative to the lesion to the focus (due to the fact that the fibers rise in the rear pilots do not intersect until the oblong brain is reached). The loss of pain and temperature sensitivity is observed on the side opposite to the lesion focus (since conducting paths crossed in the spinal cord at the level of root roots in the spinal cord or somewhat higher). A strip of hyptestesy is also possible (sometimes - in combination with spontaneous pain) at the level of the lesion due to damage to the fibers, which have not yet made the cross in the contralateral spinctalamatic path
A rare disease in which the cavity is formed in the spinal cord, filled with SMG ( syrinx - Cane) (Fig. 4). It is manifested by the development of a characteristic motor and sensitive neurological deficit (Fig. 5). Usually, the cavity is first developing in the lower cervical spinal cord, over time can spread all over long spinal cord. Patients develop lower spastic parapapapes with signs of damage to peripheral motioneerone in the upper limbs (due to the defeat of both the corticospinal path and the front horns of the cereal spinal cord). The deep sensitivity of the fibers of which are located in the rear pillars of the spinal cord, as a rule, is preserved, while painful sensitivity is violated due to the lesion of the intersecting fibers in the area of \u200b\u200bthe cavity. dissociated anesthesia). The loss of surface (pain and temperature) sensitivity is usually distributed by the type "Jacket" - the zones of anesthesia with the upper and lower levels determined by the volume of the cavity. In some patients, the cavity can spread into an oblong brain ( siringobulbia) With the development of bilateral lesion of the lower cranial nerves and the horner syndrome.
Fig. four. Siringomyelia. MRI of the cervical spinal cord, sagittal projection. Filled cavity (hypo intensive signal area - big arrow) and associated anomalid-kiari anomaly (small arrow)
Fig. five. Siringomyelia - Clinical manifestations
The pathogenesis of Siringomyelia is not sufficiently studied, most likely, the development of the disease is associated with violation of the hydrodynamics of the SMG. In many patients, there are violations of the development of the brain and cerebellum barrel (Annold-Kiari anomalia), under which the cerebellum almonds are elongated and roasted into a large occipital hole ( cerebelchik ectopia). Some patients show the surgical decompression of a large occipital opening and a cavity drainage through a siringth.
Other common syndromes
Spinal brain damage syndromes are common as a result of neurosifilis (spine dry tube) and vitamin B12 deficiency (towing the degeneration of the spinal cord). With a spinal cord infarction caused by thrombosis of the front spinal artery, the rear poles usually remain intact.
Patients over 50 years old most frequent cause of myelopathy is spondlissee of the cervical spine. In this case, the degenerative disease (osteoarthritis) of the cervical vertebrae may lead to the compression of the spinal cord due to the impact:
- calcification, degeneration and protrusion of intervertebral disks
- bone expansions ( osteophytes)
- calcification and thickening of the longitudinal bundle.
In patients under the age of 40 years old, the most common cause of the damage of the spinal cord is sclerosis. More rare causes are shown in Table 1.
Table 1.
Treatment
When examining a patient with acute myelopathy, the first thing should be eliminated by the compression of the spinal cord - MRI or myelography (Fig. 6). This allows you to identify a disease that requires urgent surgical intervention, or in the case of malignant neoplasms, determine the testimony for radiation therapy and the use of corticosteroids in order to reduce edema. After decreasing the severity of the spinal cord compression, treatment is carried out to eliminate the causes of the disease (Table 1).
Fig. 6. On the sagittal cut MRI visualized meningoma, causing a spinal cord. Benign tumors relatively rarely cause compresses, but early diagnosis increases the likelihood of successful surgical intervention
Defeating spinal roots (radiculopathy)
Clinical neuroanatomy and classification
The roots of the nerves leave the left and to the right of the spinal cord through the intervertebral holes, where the dorsal (sensory) and ventral (motor) roots are combined, forming spinal nerves. The spinal nerves are numbered in accordance with the sequence number of the vertebrae, between which they exit from the channel (Fig. 7). In the cervical department, each root number corresponds to the vertebral number below the outlet. Thus, the spore C7, which leaves between the vertebrae C6 and C7, may be damaged by the protrusion of the C6 / C7 intervertebral disk. However, the nerve between the vertebrae C7 and TH10 is numbered as C8. The roots in the chest, lumbar and sacralized departments are numbered in accordance with the vertebra's sequence number above the exit place. Despite this, when the lumbar intervertebral disk prolapse is usually damaged to the root with the same number as the underlying vertebra. For example, when the L4 / L5 disk prolapse is damaged by the nerve L5, despite the fact that L4 leaves the hole between the L4 / L5. The reason for this is the three-dimensional intraspinal organization of lumbosacral roots (horse tail).
Fig. 7.Practice of spinal cord segments, vertebral roots
Cervical radiculopathy
The prolapse of the modified intervertebral disk in the cervical sector of the steam area relative to the pair of normally located vertebrae can lead to the nerve compression at its exit from the opening. Other reasons for compression are spondylise and much less often - tumors.
The clinical manifestations of such a lesion are pain in the neck, irradiating hand, usually in the innervation zone of the corresponding Miotoma, less often - dermatoma. The weakness of the muscles innervated from the corresponding spinal cord segment, the loss of tendon reflexes and the sensitivity disturbance in the respective dermatomas are possible.
In most patients with diseases of intervertebral discs, an improvement in the conservative treatment occurs as a result of conservative treatment. Non-steroidal anti-inflammatory agents and muscle relaxants are used, a separate patient shows the wearing collar and the implementation of the recommendations of the physiotherapist to relieve pain. Few patients showed the conduct of MRI in order to determine the feasibility of operational intervention. Operations on the expansion of the outlet or removing the hernia of the intervertebral disk are more effective in the presence of neurological deficit and functional constraints than exclusively to relieve pain syndrome.
In some cases, the protrusion of the intervertebral disk or the change arising as complication of spondyleasis can simultaneously bring the spinal root and the spinal cord directly ( mieloradiculopathy). If the compression is observed at the level of closure of tendon reflexes of the upper limb, the valuable diagnostic criterion of the lesion level is to identify inversion of reflexes. For example, in the absence of a reflex patient with a biceps, a biceps tendon percussion causes a finger bending (inverted reflex from the biceps), which can be represented as follows:
This implies the presence of a lesion at the C5 level, which causes the interruption of the reflex arc from the biceps, but due to the fact that the spinal cord is also involved in the pathological process, the instrumental inhibition of the reflex arc disappears and the bending reflex of the finger of the brush is appeared, the arc of which is closed at the C8 segment level.
Ponytail
The spinal cord ends with a cone (Conus Medullaris) at the level of the bottom limit of the vertebra L1. Next, lumbar and sacral flares follow inside the spinal channel, before reaching the outlet and form a horse tail. The pathological processes in the art, for example - tumors, usually lead to simultaneous multiple asymmetric damage to the roots, which is manifested by impaired functions of peripheral motioneerone and loss of sensitivity. Often there is also a violation of the bladder functions, manifested by chronic urination delay with urinary incontinence during its overflow and the infections of the urethra. Similar symptoms develop when damaged the lower spinal cord department ( "Cones defeat"), the clinical feature of such a lesion is the simultaneous presence of signs of lesion of central and peripheral motionones. Thus, the patient may have no reflexes in combination with bilateral suspending pathological stop reflexes.
Intermittent chromoty horse-tail
Clinical syndrome occurring in the circulation disorders of a horse-tail due to the narrowing of the lumbal spinal canal with the degenerative spine damage. It is characterized by transient neurological symptoms in the form of pains in buttocks and thighs, motor and sensitive disorders in the lower limbs, which occur during the load and disappear alone, usually in a position with a bent back (in this situation, the surveillance of the spinal channel increases). The main direction of the differential diagnosis is to eliminate the true moving chromium, due to the ischemia of the muscles of the towers in case of insufficiency of peripheral blood circulation. From the spinal lesion, this condition is distinguished by the absence of sensorotor disorders, as well as the regression time of symptoms at rest (1-2 minutes with peripheral vascular failure, 5-15 minutes with a mixed chromotype of horse-tail). Decompression Laminectomy leads to an improvement in the condition during the stenosis of the lumbar channel, while the preliminary conduct of MRI or CT is mandatory.
PROLAPS Lumbar Intervertebral Disc
The prolapse of the altered intervertebral disc in the lumbar department usually leads to the compression of the roots, which are sent laterally to the intervertebral opening, the underlying roots are affected. So, the spine S1 may be composed of the hernia of the L5 / S1 disk. Characteristic manifestations - pain at the bottom of the back, propagating on the back surface of the leg from the buttock to the ankle ( sciatica), Paralysis and weakness of calbal and cambal muscles (most clearly noticeable when the patient is worth), loss of sensitivity in the S1 innervation zone and reduced Achilles Reflex. With the damage to the root L5 caused by the prolapse of the L4 / L5 disk, the pain spreads along the sedined nerve and is accompanied by the weakness of the extensors of the foot, in particular, the passage of the outer long extensor of the foot of the foot and the sensitivity disorders in the innervation zone of the Dermatoma L5. The passive tension of the lower lumbar sacral roots (lifting the disintegrated feet in the patient lying on the back) is limited due to the pain and muscle tension arising from this. The pain and tension of the muscles are enhanced with the ankle dorziflexia when the leg raised and dismissed in the knee joint. A similar feature of the lesion of the upper lumbar roots is a sample to straighten the hip, in which the pain and muscular stress limit the passive straightening of the thigh in a patient located in a bending position or heating.
Treatment of the patient with Ishias at the initial stage is conservative and implies bed regime with subsequent gradual mobilization. The introduction of anesthetics and corticosteroids to the surface of the root (under the control of CT) can also contribute to improving the state. Resistant neurological symptoms of compression of the root may be an indication for surgical intervention, such as decompression laminypes and discominations, is required to pre-establish a lesion level based on MRI data or CT (Fig. 8).
Fig. eight. Prolapse of the intervertebral disk of the lumbar spine. The lateral disk protrusion is visualized to the CT (shown by the arrow). The patient suffers from Ishias due to the compression of the root
Acute central disk prolapse
In this case, urgent neurosurgical assistance is required. The disk rolls in the central region, causing total compression of the horse-tail, less often there is a compression of individual roots. Patients experience strong sharp back pains, sometimes irradizing down on the legs, in combination with bilateral weakness of the muscles of the lower extremities (with the absence of agchyllated reflexes) and acute painless urination delay (an increase in the bladder is detected during palpation). Possible development of persistent constipation or incontinence of feces. The loss of sensitivity can be limited to the lower sacral dermato-moms (saddot anesthesia). The tone of the anal sphincter is reduced, the anal reflexes are absent (due to the damage to the roots S3 - S4 - S5). This reflex is caused by barn irritation of the skin near the anus and normally leads to a reduction in the sphincter. After the diagnosis is confirmed by the methods of neurovalization, an urgent decompression of the Laminectomy is necessary in order to prevent irreversible sphincter dysfunction.
Neurology for general practitioners. L. Ginsberg
Examination questions:
1.7. Segmental apparatus of the spinal cord: anatomy, physiology, symptoms of defeat.
1.8. Conductive spinal cord paths: lesion symptoms.
1.9. The cervical thickening of the spinal cord: anatomy, physiology, symptoms of defeat.
1.10. Spinal brain variation lesions syndrome (transverse mixture syndrome, brown-secoire).
1.11. Lumbar thickening, spinal cord cone, horse tail: anatomy, physiology, symptoms of damage.
1.12. The oblongable brain: anatomy, physiology, symptoms of the defeat of the caudal group (IX, X, XII pairs of cranial nerves). Bulbar and pseudobulberry paralysis.
1.15. Cork innervation of motor core nerve nuclei. Symptoms of lesion.
Practical skills:
1. Collecting anamnesis in patients with diseases of the nervous system.
4. Study of the functions of the cranial nerves
Anatomy-physiological features of the spinal cord
Spinal cord Anatomically is a cylindrical litigation, located in the spine, 42-46 cm long (in an adult).
1. The structure of the spinal cord (at different levels)
The basis of the structure of the spinal cord is segmental principle (31-32 segments): cervical (C1-C8), breast (TH1-TH12), lumbar (L1-L5), sacral (S1-S5) and coccopes (CO1-CO2). Thickening spinal cord: chine(C5-TH2, ensures the innervation of the upper extremities) and lumbar (L1 (2) -S1 (2), ensures the innervation of the lower extremities). Due to a special functional role (the location of the segmental center for regulating the function of the pelvic organs - see Tanning No. 2.) Eliminate cone (S3-CO2).
Due to the peculiarities of the ontogenesis of the spinal cord of the adult ends at the level of the LII vertebra, below this level of the root form ponytail(Fur segments L2-S5) .
The ratio of spinal cord segments and vertebrae ( skeletopia): C1-C8 \u003d C I.-C. VII, Th1-th12 \u003d th i -th x, l1-l5 \u003d th xi -th xii, S5-CO2 \u003d L I -L II.
- Places of exit Koreshkov: C1-C7 - over the vertebral name, C8 - under VII, Th1-CO1 - under the vertebral identity.
- Each segment The spinal cord has two pairs of front (motor) and rear (sensitive) roots. Each rear spinal cord root has a spinal gangli. The front and rear roots of each side merge, forming a spinal nerve.
2. The structure of the spinal cord (transverse section)
- Sine substance cm: Located in the center of the spinal cord and resembles a butterfly. The right and left half of the gray spinal cord substance is interconnected by a thin carcement (the median intermediate), in the center of which the hole of the central spinal cord channel passes. Histologically allocate the following layers: 1 - marginal; 2-3 - gelatin substance; 4-6 - own cores of the rear horns; 7-8 - Nucleus Intermedius; 9 - Motor motor rates of the front horns.
1) Rear Horn (columns) cm: Bodies of neurons of the paths of surface sensitivity and the cerebuline examination system
2) Side Horn (columns) cm: Segmental vegetative efferent neurons - sympathetic (C8-L3) and parasympathetic (S2-S4) nervous system.
3) Front Horn (columns) cm: Muscular cells (alpha-large motionones, Renshou brake cells) and extrapyramidal (alpha-small motionones, gamma neurons) systems.
- White substance cm: Located along the periphery of the spinal cord, there are amelinated fibers, connecting the segments of the spinal cord among themselves and with cerebral centers. In the white substance of the spinal cord distinguish the rear, front and side ropes.
1) Rear ropes cm: Contain ascending Conductors of deep sensitivity - medial (fasc.gracilis, thin, golay, from lower extremities) and lateral (Fasc.Cuneatus, Wedge-shaped, Burdach, from the upper extremities).
2) Side rope CM: Contain descending: 1) pyramid (lateral cortical-spinal path), 2) red-core-spinal (Dorsolateral extrapyramidal system); and rising paths: 1) spinno-cerebelchikovy (along the lateral edge of the side cordics) - front (Govers) and rear (Flexiga), 2) lateral spinatalamic (lateral - temperature, medial - pain).
3) Front rope cm: Contain descending:1) front pyramidy (Tube beam, non-restricted), 2) vestibulo-spinal out (Printromedial Extrapyramid System), 3) reticulo-spindy (Printromedial Extrapyramid System) ; 4) olivo-spindy , 5) trenchless-spindy ; and rising paths: 1) front spinatelamic (lateral - touch, medial - pressure), 2) spinno-olivarny (proprioceptive, to Lower Olive), 3) spinal-coatory (proprioceptive, to quadrochemia).
Spinal cord lesions syndromes
1. Defeat syndromes cm (across a scraper):
- front horns - 1) peripheral paralysis in the muscles of this segment (reduction of force, butreflection (interrupting efferent link), buttonia (gamma loop break), buttrophy muscles) + 2) Fascicular twitching;
- rear Rog - 1) dissociated sensitivity disorder (the surface of the surface while maintaining deep) on the side of the lesion in the segment zone ("half-curtain") + 2) aureflex (interruption of an affective link);
- side Horn - 1) violation of sweating, sawctic, vasomotor and trophic disorders in the segment zone;
- front gray spike - 1) dissociated sensitivity disorder (surface loss while maintaining deep) on both sides in the segment zone ("jacket");
- rear Katikov- 1) loss of deep sensitivity (poses, locomotion, vibration) ipsilateral + 2) sensitive attaxia is ipsilateral;
- side Canatians - 1) Central paresis is ipsilateral (with double-sided lesion - violation of the function of the pelvic organs in the central type) + 2) disruption of the temperature and pain sensitivity on the conductor type is controlled (on the 2 segment below the upper boundary of the focus - the prestrest is carried out at 2 segments);
- front spinal artery (Preobrazhensky) - the defeat of the front 2/3 of the spinal cord;
- half damage cm (brown-secarage) - 1) It is ipsilateral at the level of the segment, controlled - by 2-3 segments below the conductor type, 2) Ipsilaterally from the lesion level, 3) peripheral Partares Ipsilathly at the level of the segment, central Pares.ipsilathly below the lesion level, 4) trophic disorders Ipsilath at the segment level.
- full transverse damage cm: 1) surface sensitivity from the lesion level, 2) loss of deep sensitivity from the lesion level, 3) peripheral Partares at the segment level central Pares.below the lesion level, 4) vegetative calculation
2. Syndromes of full transverse lesions, see at different levels (Ging Riddoha, in length):
- craneospinal:
1) sensitive sphere:but) anesthesia On both sides in the caudal zones of the yard, on the back of the head, arms, body and legs, b) pain and paresthesia in the nape region;
2) motor sphere: a) central tetrapreza, b) disturbance of breathing (diaphragm);
3) Central pelvic violations;
4) vegetative sphere: bernard Gorn Syndrome (damage to the downward sympathetic pathway from the hypothalamus (body I)) - vegetative ptosis (narrowing of the eye slit), myiosis, enofalm;
5) Defeat caudal group of cranial nerves;
6) intracranial hypertension.
- upper segments (C2-C4):
1) sensitive sphere: on both sides on the back of the head, hands, body and legs;
2) motor sphere: a) Tetrapireps (VK-mixed, NK-central), b) disturbance of breathing (diaphragm paralysis) or ICTO (C4);
3) Central pelvic violations;
4) vegetative sphere: bernard Gorn Syndrome (damage to the path from the hypothalamus);
- cervical thickening (C5-TH1):
1) sensitive sphere:by conductor type spinal option on both sides on hand, body and legs;
2) motor sphere: Tetrapareps (VK-peripheral, NK-central);
3) Central pelvic violations;
4) vegetative sphere: but) bernard-Gunner syndrome (the defeat of the cilospinal center - the side horns of C8-Th1, body II sympathetic path); b) Vegetative violations on VK,
- breast Department (TH2-TH12):
1) sensitive sphere:by conductor type spinal option on both sides on the body and legs;
2) motor sphere: central lower parapapere;
3) Central pelvic violations;
4) vegetative sphere: but) vegetative violations on VK, b) Cardialgia (TH5).
- lumbar thickening (L1-S2):
1) sensitive sphere:by conductor type spinal option on both sides on the legs (pararasthesia) and in the perianal region;
2) motor sphere: peripheral lower parapareps;
3) Central pelvic violations;
4) vegetative sphere: vegetative violations on the NK.
- epicus (L4-S2):
1) sensitive sphere:by conductor type spinal option on both sides in the perianal area and on the back of the thigh, the legs;
2) motor sphere: peripheral Partares Stop (Flashing Achilles Reflex);
3) Central pelvic violations;
4) vegetative sphere: vegetative violations on the NK.
- cone (S3CO2):
1) sensitive sphere:anesthesia in the perianal area on both sides;
2) motor sphere: peripheral Partares crotch muscles;
3) peripherals pelvic violations (incontinence, paradoxical Ishuria);
4) vegetative sphere: vegetative violations Functions of pelvic organs.
- horse tail (rootL2-S5):
1) sensitive sphere:a) pain syndrome in the field of saddle and legs, b) asymmetric anesthesia in the field of saddle and legs on both sides;
2) motor sphere: peripheral Partares Muscles of the NK and the Crotch (L2-S5);
3) peripherals pelvic violations (incontinence).
3. Compression damage syndromes cm:
- intramedullar:1) more often in the area of \u200b\u200bthickening, 2) quickly progresses, 3) downward type of flow.
- extramedullar:1) more often in the chest department or horse tail, 2) slowly progresses, 3) ascending flow type, 4) block of liquor resistance, 5) changes in liquor (xanthromy, protein-cell dissociation), 6) spinal change (destruction, positive call symptom ).
General information about the brain barrel
1. Structural division of the brain stem:
- vertically:
1) the oblong brain;
2) Varoliviyev Bridge;
3) medium brain.
- horizontally:
1) base (basis): descending paths (corticospinal, corticobulbar, corticipant)
2) Tire (tegmentum):
1) Rising paths (spin- and bulbotlamic, deep sensitivity paths, medial loop, lateral loop),
2) core core nerves,
3) reticular formation,
4) Specifications.
3) Roof (tectum): Specifications.
2. Features of the structure of the cranial nerve systems (source in ontogenesis):
- Laundic somites:
1) afferent part - optic nerve (II),
2) Efferterent part - Overall nerve (III),
3) Vegetative (parasympathetic) part - Yakubovich kernel + eyelashes gangliy.
- Gwee Somiti(1 - maxigant, 2 - facial, 3 - Language, 4 - wandering):
1) afferent part - upper and lower jaw nerve, eye nerve (branches V),
2) the efferent part is the lower jaw nerve (branch V), facial nerve (VII), languagehilic nerve (IX),
3) Vegetative (parasympathetic) part is a salivaee and dorsal core + a picker, submandibular, ear ganglia, a ganglia of a vaga nerve.
3. Scheme of the motoring path of cranial nerves
- the lower part of the front central winding cerebral cortex (body i) - TRACTUS Corticonuclearis - cross-line directly over motor nuclei ( rule 1.5 kernels):
1) to the nuclei of 3,4,5,6,9,10,11 pairs of cranial nerves Corticonuclear journey makes incomplete crossing (bilateral innervation)
2) to the nuclei 7 (lower part) and 12 pairs of cranial nerves corticouclear path makes a full cross (Rule 1.5 cores)
- core trunk Brain (body II) - motor portion of the cranial nerve - cross-striped muscles.
4. Scheme of the sensitive path of the cranial nerves
Extero or proproporeceptor - cranial nerve;
- cranial node (body i) - sensitive portion of the cranial nerve;
Sensitive brain core gomolateral (body II) - Cross controlly (directly above the kernel) - a sensitive path in the composition of the medial loop;
- ventroleteral kernel Talamus (body III) - tamlamocortical path - through the back third of the back leg of the inner capsule - a rayan crown (Corona Radiata);
- the lower departments of the rear central winding and the upper dark area.
Brain Status: etiological factors of defeat
1. Diseases flowing with the selective damage of the gray matter of the trunk (core nerve nuclei):
- polyenenthephaliti(VII, IX, X, XI, XII): poliomyelitis, polio-like diseases (cokes, eco), western Nile fever,
- neurodegenerative diseases:motor neuron disease (progressive bulbarium paralysis)
Fazio-Londe syndrome (VII, VI, IV, III), spinal amyotrophy of Kennedy
2. Diseases occurring with the selective lesion of the white substance of the barrel:
- autoimmune diseases: multiple sclerosis,
- dysmetabolic diseases:central Pontane Melinolysis
- hereditary diseases and syndromes:hereditary spastic paraplegia, spinocelebellar atrophy
3. Diseases occurring with the lesion of white and gray substance of the barrel:
Brain circulation disorders
Inflammatory diseases: Orhem
Tumors
Anatomo-physiological features of the oblong brain
Medulla In the oral department, it borders with the bridge of the brain (bridge-cerebellar angle), and in the caudal department with the spinal cord (the conditional lower edge of the oblong brain is the crossing of the pyramid, the place of the exit the root C1, the top edge of the first spinal cord segment). In the middle of the ventral part there is a major furrow, where a.basilaris passes, the dorsal part is the bottom of the IV ventricle (the lower part of the diamond pummy).
1. Composite parts:
- base (basis) - pyramid Path (Pyramids) and lower olives;
- tire (tegmentum):
1) rising ways: spinctalamatic paths; Paths of deep sensitivity -\u003e Nucleic.gracilis cores (nucl.cuneatus) -\u003e Medial loop,
2) core cranial nerves (IX-XII),
3) reticular formation (vasomotory, respiratory, swallowing center, muscular tone regulation center, sleep center [Brain activity synchronization - hypnogenic effect]);
- roof (tectum) - It does not stand out (rear cerebral sail).
2. Card nerves
- XII Couple - N.Hypoglossus.
1) nucleiXII Couples and Function:
Motive - nucl.nn.HYPOGLOSSI (body II - muscle language)
2) Exitfrom the brain- Ventreated groove (between olive and pyramid),
3) Exitfrom turtle - CANALIS NN.HYPOGLOSSI
4) loss syndromes:
- Supported type (body and axon I neurona) - deviation in the opposite direction from the hearth, dysarthria (central paralysis);
- nuclear type (neuron body) - deviation towards the hearth, dysarthria, tongue atrophy, fasciculation (peripheral paralysis);
- root type (Akson II Neuron) - Deviation towards the hearth, dysarthria, language atrophy (peripheral paralysis);
6) research methods:
- Complaints:dysarthria
- Status:1) Position of the language in the oral cavity and 2) when pronouncing, 3) the presence of atrophy (hypotrophy) and fibrillary twitching in the muscles of the language
- XI Couple - N.Accessorius.
1) kernel XI pairs and function:
Motive - nucl.nn.Accessorii (body II - trapezoidal and breast-eyed-bed-like muscles)
2) Exitfrom the brain
3) Exitfrom turtle - From the skull - for.jugulare.
4) loss syndromes:
- Nuclear(neuron body) - the impossibility of raising the hand above horizontally, the difficulty of turning the head into the opposite heart of the side, lowering the shoulder (with double-sided lesion - "hanging" head), fasciculation in these muscles (peripheral paralysis);
- root type (Akson II neuron) - the impossibility of raising the hand above horizontally, the difficulty of turning the head into the opposite heart of the side, lowering the shoulder (peripheral paralysis);
5) irritation syndromes:
- Motor portion- attacks of clonic and quotation seizures (salaam of seizor), spastic Krivoshoya
6) research methods:
- Complaints:impaired head and hand moving
- Status:1) The position of the shoulders, blades and heads at rest and 2) movement, 3) the stress of the breast-curable-cottage and trapezoid muscle.
- X Couple - N.Vagus.
1) nucleiX Couples and feature:
Sensitive - NUCl.Solitarius (body II for taste sensitivity - the NASTOR), NUCL. Alae Cinerea (body II for interoceptive sensitivity - from hemo- and baroreceptors)
Vegetative - Nucl.Salivatorius Inferior (Easy Slying Iron), nucl.dorsalis nn.Vagi (internal organs)
2) Exitfrom the brain- Ventroleteral furrorous (forced olive),
3) Exitfrom turtle - FOR.jugulare (forms 2 gangliya - upper (special sensitivity) and lower (taste, peritone)).
4) loss syndromes:
- Nuclear(body II neuron) and root type (Akson II Neuron) - Dysphagia, Diephony, Reduced Reflex, Anesthesia, Troops, Trachea, Dry Mouth, Tachycardia, Dysfunction
- Neuropathy of the return gentle nerve(dysphonia)
5) irritation syndromes:
- Vegetative portion- attacks of heart rate disorders, bronchospasm, laryngospasm, pylorospasm, etc.
- neuralgia of the upper gentle nerve: 1) attacks of intense, short-term pain in the area of \u200b\u200blarynx and cough + 2) jacket zone under the thyroid cartilage (zone of hyperesthesia, the touch of which provokes the attack of pain)
- IX Couple - N. Glossopharingeus
1) nucleiIX Couples and Function:
Motive - Nucl.ambiguus (body II - Muscles of the pharynx and larynx)
Sensitive - nucl.Solitarius (body II for taste sensitivity-rear 1/3 language), NUCL. Alae Cinerea (body II for interoceptive sensitivity - from chemo and baroreceptors)
Vegetative - Nucl.Salivatorius Inferior (Easy Slear Iron)
2) Exitfrom the brain- Ventroleteral furrorous (forced olive),
3) Exitfrom turtle - for.jugulare (forms 2 gangliya - upper - (special sensitivity) and lower (taste).
4) loss syndromes:
- Nuclear(damage to the body II of the neuron) and root type (Axon's defeat II neuron) - dysphagia, dysphony, reduction of pharyngeal reflex, the anesthesia of the pharynx, the Ameffes of the rear 1/3 of the language, dry mouth
5) irritation syndromes:
- Sensitive portion- nellengia Language nerve- 1) attacks of intense, short-term pain in the field of pharynx, language, almond, outdoor auditory passage + 2) Women's zones (zones of hyperesthesia, touch to which pains the attack)
6) research methods:
- Complaints: 1) pain and paresthesia in the throat, 2) loss of taste, 3) disruption of the lamp, articulation, swallowing,
- Status:1) position and mobility of a soft sky and tongue (UVULA) at rest and 2) when pronouncing sounds, 3) swallowing, 4) articulation, 5) Saving, 6) flavor sensitivity, 7) Pipple reflex.
Syndromes lesions of the oblong brain
1. Alternating syndromes - one-sided focal lesion of half of the brain trunk at various levels with a homoolateral impaired of the function of cranial nerves and contralateral conductive disorders.
- Jackson syndrome (limited defeat in the field of the base of the oblong brain:
1) root (inner path from the kernel)XII nerve:
2) Pyramid Path:
- Dorsolateral lesion syndrome (damage to the rear lower cerebulic artery,top, medium, lower medullary, vertebral artery ) - Wallenberg-Zakharchenko:
1) sensitive coresV Nerva - Homolateral impaired surface sensitivity at half past
2) Double core and pathIX I.X nerves -homolateral Partares of Soft Sky Muscles and Voice Bundle With Swallowing and Lancture Disorders
3) Single kernel -homolateral violation (loss) taste sensitivity
4) the fibers of the sympathetic center -gomolateral Bernara Gunner Syndrome
5) Lower cerebellar leg - Homolateral hemiatax limbs
6) vestibular nuclei -nistagm, dizziness, nausea, vomiting
7) Spinolamic path: Contracting superficial hemiagesthesia
- Medial lesion syndrome (occlusion of the vertebral artery) - Deputy:
1) kernelXII nerve: Homolateral sluggish language paresis;
2) Lower Olive: Gomolateral Myoclonies Soft Sky
3) Pyramid Path: Contralateral spastic hemiplegia.
4) Medial Loop: Contralateral decrease in deep sensitivity.
- Syndrome Avellisa
1) Double core:
2) Pyramid Path: Contralateral spastic hemiplegia.
- Schmidt syndrome (Defeat in the field of motor cores of the IX-XI pairs of cranial nerves).
1) Double core: Homolateral Pares of Muscles of Soft Sky and Voice Bundle With Violation of Swallowing and Lancture;
2) kernelXi nerve:
3) Pyramid Path: Contralateral spastic hemiplegia.
- Topia syndrome (Defeat in the field of nuclei of the XI and XII nerves):
1) kernelXi nerve: Gomolateral Partares Trapezoid Muscle
2) kernelXII nerve: Homolateral sluggish language paresis;
3) Pyramid Path: Contralateral spastic hemiplegia.
- Syndrome Valenshtein (Defeat in the Nucleus Ambiguus area):
1) Double core -
2) spinctalamatic tract -contracting superficial hemiagesthesia.
- Glike syndrome (Extensive defeat of various brain stem departments):
1) visual centers - Gomolateral vision reduction (amblyopia, amavrosis)
2) kernelVII Nerva - Gomolateral paresis and spasm of mimic muscles,
3) sensitive kernelsV nerve -gomolateral pain in the supurabital region
4) Double core -homolateral paresis of soft sky muscles and voice bundles with violation of swallowing and lamp,
5) Pyramid Path: Contralateral spastic hemiplegia.
2. Bulbarium and pseudobulbar syndromes
- Bulbarium syndrome- peripheral paralysis It occurs with the defeat of the nuclei of IX, X, XII pairs of cranial nerves:
1) reduction of muscle strength ( dizaRTIRY, dISfonia, dIS
2) reduction of pharyngeal reflex,
3) Language atrophy, larynx muscles and soft sky, regeneration in the muscles of the ENMG language.
4) fibrillary and fascicular twitching (especially in the muscles of the language),
- Pseudobulbar syndrome- central Palsy, when bilateral damage to corticouclear pathways to the kernels IX, X, XII pairs of cranial nerves:
1) reduction of muscle strength ( dizaRTIRY, dISfonia, dISpharygetics, accumulation in food, pouring liquid food through the nose, Nicolalia),
2) Saving (revitalizing?) Piping reflex,
3) Reflexes of oral automatism.
4) violent laughter and crying.
Damage to the upper cervical segments at the CI-CIV level (injury of the top cervical vertebrae)
Spassky (Central) Tetraprez / Tetraplegia
Paralysis or diaphragm irritation (Ikota, shortness of breath)
Loss of all types of sensitivity by conductor
Central urination disorders (delay, periodic incontinence)
Root pain with irradiation in the neck area, nape, faces
Bulbar symptoms (dysphagia, dizziness, nystagm, bradycardia, diplopia)
Damage to the cervical SV-D1 (cervical thickening)
Top sluggish paraplegy
Lower spastic paraplegy
Loss of all kinds of sensitivity from damage to the book on the conductor type
Root pains in hands
Bernard-Gunner syndrome (in connection with the violation of the sympathetic center of innervation of the eye)
Traumatic shock (sharp decline in blood pressure, early central hyperthermia, violation of consciousness)
Damage to the thoracic DII-DXII (injury of the lower chest or upper lumbar vertebrae)
Central Lower Paraplegy
Segmental and conductive sensitivity disorders
Singing root pain in the chest or abdomen
Urination disorders in the central type
Loss of abdominal reflexes
Damage to lumbar thickening LI-SII (at the level of X-XII breast vertebrae)
Sluggy lower paralegia with a loss of knee, Achilles, cremaster reflexes
Loss of sensitivity from the level of groin fold, in the crotch area
Central urination disorders and defecation (delay, periodic incontinence)
Neuron, the value of its component parts. The arc of the knee reflex: the number of neurons where the receptor is located, the principle of its action.
NEURON
ABOUT: Structural and functional unit of the nervous system. An electrically excitable cell that processes, stores and transmits information using electrical and chemical signals.
The cell contains the kernel, the body of the cell and the process (dendrites and axons).
Depending on the function, allocate:
Sensitive Neurons perceive irritation, transform them into nerve impulses and transmit to the brain.
Effective- We produce and send commands to the working bodies.
Insert - communicate between sensitive and motor neurons, participate in the processing of information and generation of commands.
Akson - Long neuron proceeding. It is adapted for excitation and information from the neuron body to neuron or from neuron to the executive body.
Dendriti
transfer excitation to the neuron body.
Ball Reflex- This is an unconditional reflex, occurs with a short stretching of the four-headed thigh muscles caused by a slight blow on the tendon of this muscle under the patella.
The receptors are neuromuscular spindles located in the 4th thigh muscle. When tensile muscle spindles, nerve impulses according to dendrites are transmitted to the bodies of sensitive neurons located in the spinal gangles of the spinal roots of the spinal nerve.
From sensitive neurons, exciting signals are transmitted to alpha-motoneons, located in the front horns of the gray substance, and from alpha-motones - to muscle fibers of the same muscle (see fig).
In addition to the main (monosynaptic) component, the arc of the knee reflex include the path of signal transmission, which ensures the relaxation of the antagonist muscle (knee flexor). From the same sensitive neurons according to collaterals of their axons, the signal is transmitted to the braking interneurons of the side horns of the gray substance, and the brake signal is transmitted to the motionerons of the sweeper muscle.
Transverse damage to the spinal cord involve one or more segments and completely or partially interrupt the spinal cord. The complete crossing of the spinal cord on the cervical or chest causes the following symptoms:
1) full, ultimately spastic, tetrapalegia or, if only legs were injured, the lower paraplegia, which, if complete damage, acquires the character of paraplegia in the bending position;
2) total anesthesia conduit type below the lesion level;
3) violations of the functions of the pelvic organs;
4) violation of vegetative and trophic functions (breakdowns, etc.);
5) Segmental sluggish paralysis and muscle atrophy due to the involvement of the front horns at the level of one or more damaged segments.
More often is the syndrome of incomplete (partial) transverse lesion.
Clinical manifestations are different under the lesions of the spinal cord on the upper cervical level (segments Ci - C4), at the level of the cervical thickening, with the damage to the thoracic spinal cord, the upper-and-living department (Li - L3), epicusus (L4 - L5, S1 - S2) and cone (S3 - S5). Isolated damage to the spinal cord cone occurs less frequently than in combination with horse-tail lesion (in the latter case, cruel root pains, sluggish paralysis of the lower extremities, anesthesia in them, urination disorders of the type of delay or the "true" urinary incontinence) are observed.
Damage at the level of the lower spinal cord departments have their clinical features. Thus, the epicus syndrome (L4 - S2) is characterized by the damage to the muscles innervated by the sacral plexus with the predominant defeat of the Metober muscle and the relative preservation of the boltberry. Preserved bending thigh and knee extension. Slisse paralympus (va-riy in terms of severity) muscles of the jagged area, the back of the thigh, on the shin and foot (defective extension of the hips and the bending of the knee, the movement of the foot and fingers). Achilles reflexes fall out; Knee - Saved. Sensitivity disorders below the L4 segment. The functions of the bladder and the rectum ("autonomous bladder") deteriorate.
The spinal cord cone syndrome (S3 and more distal segments) is characterized by the absence of paralysis (with an isolated cone damage); the presence of saddot anesthesia, sluggish bladder paralysis and paralysis of the anal sphincter, the absence of anal and bull-convertible reflexes; tendon reflexes are saved; There are no pyramid signs.
Diseases that cause damage only on one half of the spinal cord lead to a known Brown-Sequard syndrome, which is not discussed in detail (in most cases, there are incomplete variants of Brown Secary syndrome).
With slowly developing lesions of the thoracic and cervical, the syndrome of spinal automatism with protective reflexes is possible, which can be used to determine the lower boundary of the spinal process, for example, tumor.
Main reasons:
2. Pathology of the vertebrae (spine).
3. Extramedullary and intramedullary tumor (emanating from spinal tissue, metastases, sarcoma, glioma, spinal-naya angioma, ependymoma, meningioma, neurinoma).
4. Neuming compression (hernia of an intervertebral disk, epidural abscess, epidural hemorrhage (hematoma), lumbar stenosis.
5. Melite, epidritis, abscess, demyelinizing diseases.
6. Radiation myelopathy.
7. Injury with spinal cord injury (contusion) and late traumatic spinal cord compression.
1. Occlusion of the front spinal artery.
The front spinal artery, which runs along the ventral surface of the spinal cord, bloodsput the front two-thirds of the spinal cord by means of numerous furillary-comuterural arteries included in the spinal cord in the ventridge. These arteries are blood supply to the front and side horns of the spinal cord, spinatelamic, front corticospinal and, most importantly, lateral corticospinal paths. The most important point is the absence of the rear cakes and rear horns. Based on these anatomical ratios, the front spinal artery syndrome (identical central spinal lesion syndrome) is represented by the following symptoms):
central lower parapareps (sometimes monopares of the leg), which in the acute phase of the disease can be sluggish (spinal shock) with areflexia, but then, after a few
for weeks, there is a gradual increase in muscle tone on spastic type, hyperreflexia develops, clones, symptom of Babinsky
urination delay, which is gradually moving into urine incontinence (hypereflex bladder) decreased pain and loss of temperature sensitivity. In contrast to the disturbed pain and temperature sensitivity, tactile sensitivity and the ability to localize the stimulus are saved, the same applies to vibration sensitivity. Often observe the root pains corresponding to the top level of the lesion. Sometimes the spinal cord heart attack is preceded by transient ischemic spinal attacks.
The cause of occlusion may be an embolism or a local agherosk-lardic process. Less than the cause of the spinal and the NFARCT, systemic diseases are becoming (for example, nodular periaryitis). The disease begins acutely. The incomplete transverse damage of the spinal cord occurs in the lower cervical or chest levels, large supply sucking supplies in the front spinal artery. The age of patients is predominantly elderly (but not always). Signs of common atherosclerosis are detected. With a radiographic study, there is no deviations. Likvor has not been changed. Sometimes, as under cerebral stroke, increased hemagocrit.
The infarction of the back of the spinal artery does not give the pattern of the transverse damage of the spinal cord.
* A rare cause of spinal cord compression syndrome - venous heart attack.
* See also the section "Spinal cord vascular syndromes". 2. Pathology of the vertebrae (spine).
The compression of the spinal cord can be caused by the pathology of the spine, (tumor, spondylitis, the prolapse of the intervertebral disk) at which the remittance of the distortic aligned tissues of the vertebra, neoplastic or inflammatory tissue in the spinal channel occurs. In history, there may be guidance on the root pain at the level of the defeat preceding the acute development of symptoms, but such information may be absent. Quite often, incomplete transverse damage syndrome develops without any precursors. With a neurological examination, it is possible to roughly define the lesion level. In general, it is possible to rely on the neurological examination in determining the transverse nature of the lesion, and not the level of damage to the spinal cord. The reason for this is the so-called eccentric arrangement of long ascending and downward fibers. Any focus, made
the spinal cord in the direction outside Knutrice will first of all be an effect on these long fibers, so the first clinical manifestations usually occur in the anatomical areas localized below the level of localization of the very focal lesion.
Certain useful information can be obtained with laboratory studies (for example, EE). Other necessary diagnostic tests at the time of the patient's arrival may not be available (for example, the study of the metabolism of bone tissue).
Additional research is needed to clarify the diagnosis. Traditional methods are x-ray and neurovalization in the visualization mode of bones, allowing to identify destructive changes in the vertebrals due to the local impact on them of the neoplasm or inflammatory process. In the absence of changes in radiography or neuro-visualization, scintigraphy of the spine is diagnostically valuable. A scintigraphic study performs the role of a search method, when the level of damage to the spinal column cannot be installed. In determining the level of defeat about the degree of compression of the spinal cord and the extraspinal exposure, they are judged by the results of myelography in combination with CT.
3. Extramedullary or intramedullary tumor.
To identify extrapullary intradural volumetric processes, myelography is most informative in combination with CT or MRI. The vertex pillar in such cases is often intact, at the same time there is a spinal cord compression. The advantage of myelography is its ability to well visualize the localization of the pathological process, in addition, you can simultaneously take a liquor for research and obtain diagnostically valuable information. The spectrum of extrumedullary pathological processes is wide: from the nute or meningoma (usually located on the posterior surface of the spinal cord and requiring surgical intervention) to lymphoma, which is better amenable to radiation therapy, and arachnoid cyst.
Intramedullary spinal cord tumors are rare. The foreground in the clinical picture comes out of pain, but paresthesia, paraparex and urination disorders. With such a symptomatics, if at all arise the assumptions about neurological pathology, then they are suspected primarily a spinal shape of multiple sclerosis. However, no polystagity, no flow with exacerbations and remissions at this state. The progressive course of spinal pathology with the involvement of different systems (sensitive, motor, vegetative) should
be the basis for finding a surround process.
4. Neumorous spinal cord compression.
The loss of the hernia of the intervertebral disk at the cervical level usually leads to the brown-secary syndrome, but the formation and syndrome of the front spinal artery is possible. It does not require any extraordinary impact to fallout: in most cases it occurs in completely inconspicuous situations, for example - when filming (pulling hands) in the position lying on the back. Among the additional methods of studying the method of choice is neurovalization.
Epidural abscess is characterized by an incomplete transverse lesion syndrome of a prugreviated spinal cord: Local, almost unbearable pain and tension of the stakeholder of the spinal column; local pain; and inflammatory blood changes. In this situation, there is no time for additional studies, with the exception of radiography and myelography. Urgent surgical intervention is necessary.
Epidurition requires a differential diagnosis with myelitis (see below). A crucial diagnostic value is MRI or myelography. Lumbar puncture with suspected epidurition is absolutely contraindicated.
The acute development of the cross-lesion syndrome of the spinal cord in a patient receiving anticoagulants is most likely due to hemorrhage in epidural space (epidural hematoma). In such patients, anticoagulant antagonists should immediately introduce, since in this situation, neurovalization research and myelography and urgent surgical intervention are necessary.
5. Mielitis and multiple sclerosis.
More or less complete transverse damage to the spinal cord occurs with inflammatory (viral, paraneplastic, demyelinizing, necrotizing, post-specific, mycoplasmic, syphilitic, tuberculosis, sar-koidozny, idiopathic myelitis) process in the spinal cord. In other words, both viral and other etiology of myelita are possible; Often it occurs as a post-infectious immune response that manifests itself in the form of a multi-grade perivozny demi-linization. This condition is sometimes not easy to differentiate from multiple sclerosis. The characteristic sign of the latter is the syndrome of the Atthantic paraward. However, the attactic syndrome in the acute stage may be absent.
Melite arises acutely or subacted, often against the background of general-infectious symptoms. Pains and paresthesia appear in the zone
innervations of amazed roots; They are joined by tet-rapilegia or lower parapiley (parapaperse), which in the acute period are sluggish. Characteristic violations of the functions of pelvic organs, trophic disorders (lying). The functions of the rear poles are not always violated.
The refinement of the etiology of myelitis requires a complex of clinical and paraklinic studies, including the study of liquor, MRI of the spinal cord caused by the potentials of different modality (including visual), serological diagnostics of viral infection, including HIV infection. At about half of the cases of insulated inflammation of the spinal cord, the reason for identifying cannot be detected.
6. Radiation myelopathy.
Radiation myelopathy can develop delayed (after 6-15 months) after radiation therapy of tumors in the chest and neck. Peripheral nerves are more resistant to this damage. Gradually appear paresthesias and dissecessia in the footsteps and the phenomenon of Lermitta; Then the weakness is developing in one or both legs with pyramid signs and symptoms of the involvement of spinctalamatic paths. There is a picture of a transverse myelopathy or brown-secarar syndrome. The liquor does not detect noticeable deviations from the norm, with the exception of an easy increase in protein content. MRI helps to see the vascular foci of reduced density in the parenchyma of the spinal cord.
7. Spinal injury and late traumatic spinal cord.
The diagnosis of acute injury of the spinal cord difficulties does not cause, as there is an appropriate anamnestic information. If the injury occurred many years ago, the patient may forget to report her to the doctor, because it does not suspect that this injury may cause existing progressive spinal symptoms. Therefore, chronic vascular myelopathy due to compression damage to the vertebral without the help of radiography to diagnose may be not easy.
Other (rare) causes of spinal cord compression syndrome: scheduling processes, hematomyiel, hematoreraft, spinal syphilis (gumma), cysticircosis, cysts.
* Electricalrah may also cause myelopathy.
* See also Sections "Lower Spassy Paraperex", "Myelopathy Chronic", "Spinal Current Vascular Syndromes".
The clinical picture of the damage to the spinal cord depends on the level of localization of the pathological process and its length along the longitudinal or transverse axis.
Front horns defeat syndrome: Peripheral paralysis with muscle atrophyes innervated by damaged motnelones of the corresponding segment - segmental (pet) paralysis, decreased or loss of reflexes and fascicular twitching in the innervation zone of affected muscles.
The lesion syndrome of the front roots: Peripheral paralysis with muscle atrophy in the innervation zone of roots.
Front gray spike lesion syndrome: Bilateral disorders of pain and temperature sensitivity while maintaining the muscular and articular sense, tactile and vibratory sensitivity (dissociated type) in the projection of damaged segments, while the reflexes in the damage zone.
Side Syndrome Side Roggers: Vasomotor and trophic disorders at the segmental level, and with a lesion at the level of segments with 8 -Th 1 (defeat centrum Ciliospinale) - Bernard's Claude Syndrome - Gorner: The narrowing of the pupil (MIOS) due to the paralysis of the muscle, expanding the pupil, the omission of the upper eyelid (PTOS) at the expense of the paralysis of the upper tarzal muscle (Muller's muscles) and the surface of the eyeball (enofalm) due to the pares .
Syndrome defeat rear horns: Reducing or loss of pain and temperature sensitivity in the preservation of muscular and articular feeling, vibration and tactile sensitivity (dissociated type of disorders), a decrease or inhibition of reflexes in the area of \u200b\u200baffected segments.
The lesion syndrome of the rear roots: Shocking, stuffing pains as symptoms of irritation root, disorder of all kinds of sensitivity, decreased or loss of reflexes in the area of \u200b\u200baffected roots as symptoms of falling out.
Syndrome Defeating side cords: The occurrence of conductive disorders is below the level of damage in the form of a spastic paralysis on the side of the focus and the loss of pain and temperature sensitivity on the opposite side from the level of 2-3 segments below; With double-sided lesions of the side cakes, in addition to bilateral conduction disorders of movements and sensitivity, there is a violation of the function of the pelvic organs in the central type (delay, periodic urinary incontinence).
Syndrome defeat rear cakes: Reduced or loss of muscular-articular feeling, vibration and partly tactile sensitivity on the side of the lesion from the hearth, sensitive ataxia.
Syndrome of the combined defeat of the front horns and the pyramidal path: A similar combination is included in the structure of the disease of the central and peripheral motor mechanone and is called the lateral amyotrophic sclerosis. The patient has a combination of peripheral (sluggish) and central (spastic) paralysis: atrophy of the muscles of the hands, primarily brushes, a decrease in muscle tone, fasciculation and fibrillation, while reflexes are increased, pathological signs are observed. One of the pathognomonic symptoms with lateral amyotrophic sclerosis is a sharp increase in mandibular reflex. In engaging in the process of nuclei of motor cranial nerves, symptoms of bulbar paralysis occur.
Syndrome Defeat Half Spinal Brain (Brown-Secary syndrome): Central paralysis, muscular-articular feeling disorder, vibration and partly tactile sensitivity on the side of the Book of the Book from the hearth; disorder of pain, temperature and partially tactile sensitivity on the opposite side below the lesion level; The development in the zone of the affected segments on the side of the focus of segmental disorders of sensitivity and peripheral paralysis (segmental disorders clearly actually protrude with the defeat of at least 2-3 neighboring segments). In accordance with the anatomy of damage, an ataxia may develop, but it is difficult to verify due to paralysis.
Syndrome of the damage to the ventral half of the spinal cord Developed by impaired blood circulation in the anterior spinal artery pool (Preobrovsky syndrome), is characterized by paralymps of legs and hands (type of motor disorders and the involvement of the limbs depend on the level of the hearth - see spinal cord lesions syndromes in ch. 5.3), bilateral conductive disorders of pain, temperature and Partially tactile sensitivity (dissociated type), often accompanied by a violation of the function of the pelvic organs in the central type.
Syndrome of full transverse damage to the spinal cord It may occur during myelitis (transverse mixer) or traumatic damage to the spinal cord. It is determined by the localization of the focus, characterized by tetraplegia or paraplegium, conductive sensitivity disorders below the level of damage, violation of the function of the pelvic organs. In the sudden traumatic sprinkling of the spinal cord develops the so-called so-called spinal shockcharacterized by the development of sluggish paralysis and violation of all types of sensitivity below the place of damage, loss of control over the function of pelvic organs. The sweating is most often disturbed and proligence develops in the area below the defeat. The mechanism of the spinal shock is associated with a sudden loss of stimulating influences from the head of the oversegment apparatus. Gradually appear spinal automatons. Thus, when painfully irritating below the level of damage, bending occurs in hip, knee and ankle joints, the unconserved reflex function of the bladder and the intestine appears. According to modern data, the period for the appearance of spinal automatism is 7-10 days. If this does not occur, it is necessary to carry out the audit of the damage zone to identify the objects of the spinal cord.
Syndromes of violations of the function of the pelvic organs They develop with the damage to conductors coming from the cortex (central type), spinal centers of pelvic organs or corresponding roots and nerves (peripheral type).
With acute bilateral defeat of the side pillars, as a rule, at first comes urine delay (Reentio Urinae), Up to the break of the bladder in the case of its overflow. Subsequently, the automatic, reflex type of functioning of the spinal centers and comes periodic urinary incontinence (Incontinentio Intermittens) - As the urinary bubble stretches the incoming urine there is an irritation of a detruder, which, achieving a certain extent, causes reflex emptying of the bladder, like in babies. Easy degree of periodic urinary incontinence is called imperative urination urgesIn such cases, the patient cannot delay the bladder emptying for a long time when the urination appears to urinate.
With the peripheral type of urination disorder, urine delay is also possible, but most typical true urine incontinence (Incontinentio Vera). There is a relaxation of sphincters and detrusive, and urine is continuously released dropwise as it arrives in the bladder, without accumulating in it, and there is always a residual urine. In cases of preservation of the activity of the lumbar sympathetic bubble center, the tone of the internal sphincter can be maintained, and then urine begins to stand out by drops only when the bladder is overflow and significant tension - the bladder - paradoxical incontinence of urine (Ishuria Paradoxa). The violation of the rectum function is as character.
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