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在 d/d 神內疾病時
總是要想到是
- Pure motor / sensory 還是 mixed
- Localized or generalized
- Central or peripheral
- UMN / LMN
Muscle (Myopathy)
NMJ (MG, Lambert eaton)
Peripheral nerve, root, plexus, Cord
Motor neuron disease
polyneuropathy ? demyelinating diease ?
* Cord : 3 major incomplete spinal cord syndromes :
Transverse cord : 截面以下全面喪失
脊髓病變以下部位雙側疼痛 + 溫度 + 本體感覺 + 運動功能都發生障礙
同時常伴隨排便及勃起等自主神經功能障礙
臨床上常見病因為感染後脊髓炎、多發性硬化症、外傷、及其他病因
Hemicord (Brown-Séquard syndrome) :
臨床症狀為所影響脊髓病灶位置同側以下部位
本體感覺及運動功能障礙 (伴隨上運動神經病變徵象)
而病灶位置對側以下部位之疼痛溫度感覺障礙
臨床上常見病因為外傷、輻射傷害、及潛水夫病
- The most common cause of this syndrome is penetrating injury.
- It can also be caused by lateral cord compression secondary to disk protrusion,
hematomas, spine fractures, infections, spinal cord infarctions, multiple sclerosis, or tumors.
Central cord syndrome
範圍較小時只影響 lateral spinalthalamic 溫痛
從內側的 C spine 開始影響
範圍較大時也幾乎是全部
解剖學位置的影響是在脊索中央
根據病灶大小的不同
由僅影響脊索中央側脊髓視丘徑交叉處到前角運動神經元及後索都有可能
故臨床症狀為所影響脊髓位置相關皮節感覺疼痛及溫度感覺障礙
而本體感覺完整或較輕程度影響，有時候相關肌節肌肉也會呈現無力甚至萎縮
臨床上常見疾病為外傷、脊髓空洞症、腫瘤、骨硬化性脊髓病變 (Spondylitic myelopathy)
- Usually seen in older patients with preexisting cervical spondylosis who sustain a hyperextension injury.
- Involves the central portion of the cord more than the peripheral.
- The neural tracts providing function to the upper extremities are most medial in position
- Decreased strength and, to a lesser degree, decreased pain and temperature sensation,
more in the upper than the lower extremities.
- Vibration and position sensation are usually preserved. 震動本體感覺通常還好
- Spastic paraparesis or spastic quadriparesis can also be seen.
Anterior cord : 以下全面運動, 溫痛喪失
解剖學位置的影響是在脊索橫切面前三分之二
包括兩側側皮質脊髓徑、側脊髓視丘徑、以及前角運動神經元
故臨床症狀為所影響脊髓位置以下部位之運動及疼痛溫度感覺障礙
而本體感覺完整或較輕程度影響；其運動障礙會伴隨上運動神經病變徵象
臨床上常見疾病為前脊髓動脈阻塞 (Anterior spinal artery occlusion)
- Results from damage to the corticospinal and spinothalamic pathways
- 只有 Posterior column 是好的
Posterior cord :
以下雙側本體震動
臨床症狀為所影響脊髓位置以下部位之本體感覺障礙
而運動及疼痛溫度感覺相對良好。
臨床上常見疾病為 B12 缺乏、神經性梅毒、外傷、腫瘤及後脊髓動脈阻塞
* 脊髓病變可依可能治療策略分為兩大類 :
A. 內科性：
a. 發炎性：感染後脊髓炎、多發性硬化症、免疫疾病相關脊髓炎（以 SLE 最多）
b. 感染性：疱疹病毒、HIV 病毒、HTLV-1 病毒、梅毒、結核菌
c. 營養性：維生素 B12 或 E 的缺乏、銅的缺乏
d. 中毒性：有機磷、笑氣質(N2O), Clioquinol、Hexacarbon(n-Hexane)、Zinc
Methotrexate、Cytosine arabinoside、Amphoterecin B。
d. 其他：前脊髓動脈阻塞、Hereditary spastic paraparesis、
放射傷害和電傷害性脊髓病變、paraneoplastic myelopathy。
B. 外科性：
a. 骨刺 、脊椎相關韌帶鈣化、及椎間盤突出所造成壓迫性脊髓病變。
b. 脊髓內(intramedullary)或其外硬腦膜內外(intradural or extradural) 原發或轉移性腫瘤
動靜脈異常
c. 脊髓外硬腦膜上膿瘍、血腫、脂肪沉積
d.急性脊髓外傷
e.脊髓空洞症
* Peripheral nerve :
症狀可不可以單用一條 peripheral nerve 解釋
症狀會比 root 更 localized
( ex : 不會是一整片 dermatome 感覺問題 )
- 常見的狀況 :
Radial nerve :
上臂背側, 前臂背側, 手背外側, 手腹外側 感覺異常
Drop hand 垂腕
- Humerus shaft fx, 拐杖 crutch palsy, Saturday night syndrome
Median nerve :
手心 3.5 掌指感覺 ( 包含手掌) , 手背 3.5 指 ( only 手指 )
Ape hand 魚際肌萎縮, 無法對指動作
- Carpal tunnel syndrome
Ulnar nerve :
手心手背 1.5 掌指感覺,
Claw hand
* Root :
神經根病變, Radiculopathy
最常見原因就是 herniated disc, 骨刺, 韌帶退化
少數情形如外傷造成神經根撕裂傷
meningeal carcinomatosis, 疱疹病毒及梅毒感染
壓到的神經根 :
該 dermatome 感覺異常
該 myotome muscle LMN sign
weakness, atrophy, fasciculation
該 DTR 下降
要做兩個 Test, 腳當然就是 SLRT
手的話要做Foraminal compression test (Spurling test)
把病人的頭前後左右推一推壓一壓
看會不會症狀更嚴重
The Spurling test is a medical maneuver used to assess nerve root pain (also known as radicular pain).
The examiner turns the patient's head to the affected side while extending and applying downward pressure to the top of the patient's head.
A positive Spurling's sign is when the pain arising in the neck radiates in the direction of the corresponding dermatome ipsilaterally.
It is a type of cervical compression test.
Patients with a positive Spurling's sign can present with a variety of symptoms,
including pain, numbness and weakness.
In addition to the clinical history, the neurological examination may show signs suggesting a cervical radiculopathy.
C6 :
Pain in the trapezius ridge and tip of the shoulder, often radiating to the thumb
with paresthesias and sensory impairment in the same areas
Weakness of biceps
Decreased biceps brachii and brachioradialis reflexes
C7 :
Pain in the shoulder blade and axilla, radiating to the middle finger
Weakness of triceps
Decreased triceps brachii reflex
T (any) :
Bandlike dysesthesias around the thorax
L5 :
Pain in the buttock, posterior lateral thigh, calf, and foot
Footdrop with weakness of the anterior tibial, posterior tibial, and peroneal muscles (但我覺得應該是 big toe extension)
Sensory loss over the shin and dorsal foot
S1 :
Pain along the posterior aspect of the leg and buttock
Weakness of the medial gastrocnemius muscle with impaired ankle plantar flexion
Loss of ankle jerk
Sensory loss over the lateral calf and foot
* Plexus :
多條 peripheral nerve ?
Trauma, pancoast tumor
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