脊柱损伤

脊柱和脊髓损伤Spinefracture&spinalcordinjury（SCI）桑宏勋Gymnast-SangLanSportsinjuryOutlineIncidenceTypesClinicalsignsRadiologicalsignsSpinalshockManagementIncidence10-15permillion18-35yearsMale-3:1RTA51%-carsDomestic16%Industrial11%Sports16%-divingincidentsSelfharm5%occupation&naturaldisaster!TypesCervical40%Thoracic10%Lumbar3%Dorsolumbar35%Any14%About5-7%ofthetotalbodyfracturesAnatomy脊椎骨spinecolumn颈椎7胸椎12腰椎5骶锥5（1）尾椎4（1）33（26）脊髓节段Cordlevel颈髓8胸髓12腰髓5骶髓5尾髓131Vertebralbody+AnnexSpineanatomyAnteriorcolumn-Anteriorlongitudinalligament+AnteriorannularligamentandanteriorhalfofVB.Middlecolumn–Posteriorlong.Lig.+Posteriorannularligament+PosteriorhalfofVB.PosteriorColumn–Ligflavum+superior&Interspinouslig+intertransversecapsularlig+neuralarch+pedicle&spinousprocess.Armstrong-DenisClassification前柱前纵韧带、椎体及椎间盘的前半部中柱椎体及椎间盘的后半部及后纵韧带后柱椎体附件及其韧带LevelofSpinalinjuryNeurologicallevelisatthemostlowestsegmentwithnormalmotor&sensoryfunctionDifficulttodetermine:-asmostmuscleefferentsreceivefibresfrommorethanonelevel-Closedcordlesionsmayextendoverseveralcms.-Dermatomeshaveimpreciseboundaries.VertebralnumberandCordlevelC2–C7=add+1forcordlevelT1–T3=add+1T4–T6=add+2T7–T9=add+3T10=L1,L2levelT11=L3,L4levelL1=sacrococcygealsegments脊椎序数与脊髓节段对应关系：颈椎1－7+1颈髓2－8胸椎1.2.3+1胸髓2.3.4胸椎4.5.6+2胸髓6.7.8胸椎7.8.9+3胸髓10.11.12胸椎10.11.12——腰髓1－5腰椎1——骶尾髓腰椎2以下——马尾神经根颈n椎下为颈n+1神经根胸n椎下为胸n神经根腰n椎下为腰n神经根骶n椎下为骶n神经根VertebralbodyandSpinalNeverRootFlexion屈曲型：前方受压、后方拉开Extension伸直型：前方拉开、后方受压Flexionwithrotation屈曲旋转型：屈曲型基础旋转受力Compression垂直压缩型：前方、后方同时受压Typesofbonyinjury粉碎骨折（不稳定型）骨折脱位（不稳定型）StabilityoftheFracture椎体骨折附件骨折关节突、椎弓根骨折（不稳定型）棘突、横突、椎板骨折（稳定型）压缩骨折椎体压缩1/3（稳定型）椎体压缩1/3（不稳定型）脊髓休克（Spinalshock）伤后损伤平面以下运动、感觉、括约肌功能完全丧失，数周自行恢复脊髓挫伤（contusionofspinalcord）脊髓出血、水肿脊髓裂伤（lacerationofspinalcord）脊髓部分或完全断裂脊髓受压（compressionofspinalcord）脊髓被压迫脊髓损伤病理及类型SpinalshockTransientphysiologicalreflexdepressionofcordfunction–‘concussionofspinalcord’（脊髓震荡）Lossanaltone（紧张性）,reflexes,autonomiccontrolwithin24-72hrFlaccidparalysis（弛缓性麻痹）bladder&bowelandsustainedPriapismLastsevendaystillreflexneuralarcsbelowthelevelrecovers.DegreesofinjuryComplete-flaccidparalysis（弛缓性麻痹）－totallossofsensory&motorfunctionsIncomplete-mixedloss-Anteriorscsyndrome-Posteriorscsyndrome-Centralcordsyndrome-Brownsequard’ssyndrome-CaudaequinasyndromeAnteriorspinalcordsyndromeFlexionrotationalforcetospineDuetocompressionfractureofvertebralbodyoranteriordislocationAnteriorspinalarterycompressionLossofpower,reducedpainandtemperaturebelowthelesion.PosteriorcordsyndromeHyperextensioninjuriesPosteriorvertebralbodyfractureLossofproprioception(本体感受)andvibrationsense(振动觉）Severeataxia（共济失调）CentralcordsyndromeOlderagewithcervicalspondylosisHyperextensionwithminortraumaCordiscompressedbyosteophytesfromvertebralbodyagainstthickligamentumflavum.DamagesthecentralcervicaltractUMN（uppermotorneuron）lesiontolegs(spastic)LMN（lowermotorneuron）toarms(flaccidparalysis)Brownsequardssyndrome半脊髓损伤综合症HemisectionofthecordStabinjuryandlateralmassfracturesUninjuredsidehasgoodpowerbutabsentpinprickandtemperature（痛温觉）.Spinothalamictracts（脊髓丘脑束）crosstooppositesideofthecordthreesegmentsbelow.前部损伤：运动、痛温觉丧失，深感觉存在后部损伤：运动、痛温觉存在，深感觉丧失中央损伤：上肢运动丧失，下肢运动存在半侧损伤：对侧痛温觉丧失，同侧运动、深感觉存在脊髓不完全损伤病史症状外伤史、痛、活动受限体征畸形、肿胀、压痛神经功能障碍异常动度、骨擦音、骨传导音辅助检查X线、CT、MRI、SEP临床表现及诊断ClinicalfeaturesandassesmentWhatHappenstoSpinalCord?InitialInjury–duetocompressionbybonedisplacement,interruptionofbloodsupplytothecord,ortractionPrimaryinjury–initialmechanicaldisruptionofaxons(轴突)asresultoflaceration(裂伤)Secondary-ongoing,progressivedamage－(ischemia,hypoxia,edema）（缺血、缺氧、水肿)感觉sensibility运动括约肌sphincter植物神经休克期：软瘫休克后：软/硬瘫-腹胀、腹痛神经功能障碍-大小便失禁autonomicnerve括约肌功能障碍(sphincterdysfunction)休克期:尿潴留，膀胱逼尿肌麻痹形成无张力性膀胱所致骶髓平面以上损伤，可形成自动反射膀胱，残余尿少于100毫升，但不能随意排尿脊髓园锥部骶髓或骶神经根平面损伤，则出现尿失禁，膀胱的排空需通过增加腹压（腹部用手挤压）或用导尿管来排空尿液大便也同样可出现便秘和失禁颈髓肌力减退腰髓肌力减退C3-4膈肌L2髂腰肌C5肱二头肌三角肌L3股四头肌C6伸腕肌C7肱三头肌L4胫骨前肌C8手固有肌L5背伸肌T1小指外展肌S1腓骨肌脊髓运动水平肌肉标志CordLevelandthemusclelesionsX线检查常规正侧位(AP)、必要时斜位(obliqueview)。X片基本可确定骨折部位及类型CT检查判定移位骨折块侵犯椎管程度和发现突入椎管的骨块或椎间盘MRI核磁共振检查对判定脊髓损伤状况极有价值RadiologyWhyshouldyouknowaboutallthisstuff?CervicalSpineFracture:CSF环椎atlas可发生爆裂性骨折(Jefferson骨折)枢椎odontoidvertebra可发生齿状突dens骨折及伸展型绞刑者骨折(Hangman’s骨折)C1-2的脱位IntervertebralDiscSpacesDecreasedIVDspacemayindicateherniateddiscAnterior-PosteriorViewSymmetry/size对称性/AlignmentofspinousprocessesSmooth,rollinglateraledgesSpinousProcessesOdontoid齿突(Openmouth)ViewOdontoidViewClose-upC1lateralmassC1lateralmassC2DensTreatmentofSpinalInjuriesNoCurrentEffectiveTreatmentPreventionisKeyallcurrentmedicalandsurgicaltreatmentsaimedtopreventfurtherinjurytothespinalcord.SystemOrientedApproach-ABCAirwayBreathingCirculatoryNeurologicClassificationSpinalImagingGastroIntestinalSystemGenitourinarySystem（泌尿生殖系统）Skin由于急救和搬运不当可使脊腨损伤平面上升或由不完全损伤变为完全性脊髓损伤急救和搬运Pre-hospitaltransfer危重损伤：应首先抢救搬运时保持纵向牵引头颈部，切忌头颈部转动搬运时应平抬平放，切忌使脊柱过屈、过伸和扭转颈椎骨折：胸腰骨折：Treatmentofsimplespinalfracture胸腰骨折压缩轻度：（1/3）压缩重度：（1/3）粉碎及脱位：开放复位内固定术卧硬床，腰背肌锻炼复位，1m厚支具行走两桌法过伸复位，石膏背心固定胸腰段骨折轻度椎体压缩(1/3)，稳定型胸腰段重度压缩超过50%。应予以闭合复位两桌法过伸复位双踝悬吊法复位Ce