脊髓肿瘤诊治指南

脊髓肿瘤诊治指南 疾病简介: 椎管内肿瘤(Intra-spinal canal tumors)，又称为脊髓肿瘤，包括发生于脊髓本身及椎管内与脊髓临近的各种组织(如神经根、硬脊膜、血管、脂肪组织、先天性胚胎残余组织等)的原发性肿瘤或转移性肿瘤的总称。 发病原因原发脊髓肿瘤每年每10万人口发病2.5人。男女发病率相近，但脊膜瘤女性多见，室管膜瘤男性多见。胸段脊髓发生率较高，但按各段长度比例计算，发生率大致相同。 椎管内肿瘤的性质，成人以神经鞘瘤最多见;其次是脊膜瘤;余依次为先天性肿瘤、胶质瘤和转移瘤。儿童多为先天性肿瘤(皮样囊肿、上皮样囊肿及畸胎瘤)和脂肪瘤;其次为胶质瘤;第三位是神经鞘瘤。" 疾病分类 椎管肿瘤按部位可以分为:髓内肿瘤及髓外肿瘤。其中髓外肿瘤包括髓外硬膜下肿瘤及硬膜外肿瘤。 脊髓内肿瘤主要为星形细胞瘤及室 1、髓内肿瘤(Intramedullary tumor) 管膜瘤，约占全部脊髓肿瘤的20%。髓内肿瘤常侵犯多节段脊髓，累及后根入髓区可引起根性痛，但较少见。多能见有肌萎缩， 肌束震颤，锥体束征出现较晚，多不显著。括约肌功能障碍可早期出现，脊髓半切综合征少见，脑脊液改变多不明显，压颈试验多不显示蛛网膜下腔梗阻。 2、髓外肿瘤(Medullary tumor outside) 包括硬膜下及硬膜外肿瘤。前者常见的是神经鞘瘤(包括神经纤维瘤)、脊膜瘤，约占全部脊髓肿瘤的55%。后者占25%。髓外肿瘤累及脊髓节段一般较少。多 无肌肉萎缩，但马尾区肿瘤晚期下肢肌萎缩明显。括约肌障碍多在晚期出现，常有脊髓半切综合征，脑脊液改变出现较早，压颈试验多显示蛛网膜下腔梗阻，阻塞越 完全，蛋白增高越显著。 临床表现 脊髓位于椎管内，呈圆柱形，全长约42-45cm。自上而下共分出31对脊神经根;颈段8对，胸段12对，腰段5对，骶段5对，尾神经1对。脊 髓是肌肉、腺体和内脏反射的初级中枢，将身体各部的活动与脑的各部分活动密切联系的中间单位。脊髓病变引起的主要临床表现为:运动障碍、感觉障碍、括约肌 功能障碍和植物神经功能的障碍。主要表现为肿瘤所在平面的神经根损害及该水平以下的锥体束受累的症状和体征。 ncluding based life support (BLS), and senior heart life support (ACLS), and based trauma life support (BTLS) and senior trauma life support (ATLS) of based knowledge; common emergency technology of application; common emergency of causes identification, and clinical performance and the processing specification; common emergency auxiliary check of select refers to levy, and results judge and the clinical meaning; Indications, effects of common emergency drugs, side effects, as well as specific applications (medicine, for expansion of vasoactive drugs, cardiac diuretic, antispasmodic and anti-asthmatic drugs, analgesic drugs, Hemostatic, antiarrhythmic drugs, such as Cortina). Understand: the new development of the theory of life support; cardiac respiratory and cardiopulmonary resuscitation after cardiac syndrome etiology, pathophysiology, clinical manifestations, diagnosis, and treatment. 2. basic requirements (1) species and cases of study requirements: disease disease fever acute abdominal pain chest pain and difficulty breathing faint coma shock in acute poisoning with cardiac respiratory arrest bleeding (hemoptysis, hematemesis, hematuria, etc) requires at least 45 cases of arrhythmia. (2) basic skills requirements name name heart lung (1)神经根性疼痛(Nerve root pain):为神经根或硬脊膜的刺激所致。部位较固定、常局限于一处并沿受累神经根分布区放射，性质如刀割针刺或烧灼样，常呈间歇性发作，在用力咳嗽或打喷嚏时加重或诱发。 (2)感觉障碍(Sensory disorder):表现为受损脊髓平面以下的感觉减退或感觉异常(麻木或蚁走感)。 (3)运动障碍(Movement disorders):颈髓病变可出现四肢肌力减弱;胸腰段损害表现为下肢无力、肌张力增高及病理反射阳性等;腰骶段病变表现为马尾神经受损体征、肌张力及腱反射低下等;部分患者可伴有肌肉萎缩。 (4)直肠和膀胱功能障碍:表现为括约肌功能损害，便秘、小便急促甚至大小便失禁。 疾病体征 神经定位体征:这里是指纵向定位，即不同节段病变的神经系统体征。 (一)颈椎管肿瘤上颈髓区病变可有枕、颈区痛及感觉异常。病变节段以下可有痉挛性四肢瘫，肱二头肌腱反射亢进。第5颈髓病变可致三角肌、肱二头 肌，旋后肌萎缩性瘫。感觉障碍延伸至臂外侧，肱二头肌及旋后肌反射消失。第6颈髓病变致肱三头肌及腕伸肌瘫，部分性垂腕，相应皮节以及有感觉障碍。第七颈 髓病变出现腕屈肌和指屈指伸肌瘫，感觉障碍涉及臂中线偏尺侧。第8颈髓病变引起手内在肌萎缩性瘫，爪形手畸形，可有horner征，感觉障碍累及臂内侧， 第4、5指。 二)胸椎管肿瘤临床定位通常依赖感觉障碍水平，难以凭借肋间肌力判断。 ( 下腹肌瘫痪，上腹肌正常可出现beevor征，即患者、仰卧，对抗胸部所加阻力坐起时，脐向上移动。下腹壁反射消失。可有明显的胸腹部束带感。 (三)腰椎管肿瘤累及第1、2腰髓会引起提睾反射丧失。第3、4腰髓病变，未累及马尾神经根时，股四头肌减弱，膝反射消失，而跟腱反射亢进，踝 阵挛出现。该水平马尾神经受累引起小腿驰缓性瘫痪，膝踝反射消失。如果脊髓马尾同时受累可表现为一侧小腿痉挛瘫，另一侧驰缓性瘫痪。 (四)圆锥和马尾区早期症状可有腰痛，鞍区及下肢痛或麻木，常被诊断为坐骨神经痛。括约肌功能障碍出现较早。可出现下肢驰缓性瘫痪，肌萎缩，足下垂，腰骶皮节特别是鞍区可有感觉丧失，偶尔出现腰骶、臀、髋或足跟溃疡。 鉴别诊断 一、其他神经外科疾病 ncluding based life support (BLS), and senior heart life support (ACLS), and based trauma life support (BTLS) and senior trauma life support (ATLS) of based knowledge; common emergency technology of application; common emergency of causes identification, and clinical performance and the processing specification; common emergency auxiliary check of select refers to levy, and results judge and the clinical meaning; Indications, effects of common emergency drugs, side effects, as well as specific applications (medicine, for expansion of vasoactive drugs, cardiac diuretic, antispasmodic and anti-asthmatic drugs, analgesic drugs, Hemostatic, antiarrhythmic drugs, such as Cortina). Understand: the new development of the theory of life support; cardiac respiratory and cardiopulmonary resuscitation after cardiac syndrome etiology, pathophysiology, clinical manifestations, diagnosis, and treatment. 2. basic requirements (1) species and cases of study requirements: disease disease fever acute abdominal pain chest pain and difficulty breathing faint coma shock in acute poisoning with cardiac respiratory arrest bleeding (hemoptysis, hematemesis, hematuria, etc) requires at least 45 cases of arrhythmia. (2) basic skills requirements name name heart lung 1.脊髓空洞症(Syringomyelia):其临床表现与脊髓髓内肿瘤类似，在MRI上，由于某些髓内肿瘤可继发脊髓空洞形成，故有时会发 生误诊。(1)脊髓空洞症有典型浅、深感觉分离症状，常伴有chiari畸形或其他颅颈交界处畸形;MRI上脊髓空洞多位于脊髓中央、形态规则、空洞壁较 光滑，无肿瘤结节影可见;而脊髓髓内肿瘤伴发脊髓空洞的患者，具有典型痛、触觉分离性障碍者少见，罕有伴发chiari畸形和其他颅颈交界处畸形，MRI 上肿瘤继发的脊髓肿瘤性空洞多偏中心存在，形态不规则，空洞壁欠光滑，在平扫及增强MRI上，均可见肿瘤影。 2.脊髓血管畸形(Spinal cord vascular malformations):(1)脊髓血管畸形大多突然起病，而肿瘤患者多缓慢发病;(2)在MRI上，脊髓血管畸形一般不伴有脊髓空洞或仅伴有细小 的长管状空洞，若注射gd-dtpa后扫描，无强化肿瘤影;(3)在出血病例的随访MRI上，脊髓粗细因出血被吸收而渐趋正常，而在脊髓髓内肿瘤时，则常 伴有继发空洞形成，在增强MRI上，可见强化的肿瘤影，脊髓增粗与肿瘤异常信号影持续存在;(4)如行脊髓血管dsa，脊髓血管畸形可在病灶内显示单根血 管，以及动静脉瘘及异常回流静脉的存在。 二、 骨科退变性疾病 1.颈椎病(Cervical spondylosis):也有颈肩部疼痛及感觉异常等表现，但感觉障碍平面往往不规则，少见有括约肌功能障碍。x线平片或MRI扫描显示颈椎骨质增生或有椎间盘脱出。 腰椎间盘脱出(Slipped disk):青、壮年多见，患者多有腰部外伤史，以 2. 腰l4-5或l5-s1椎间盘脱出最常见。患者有单侧坐骨神经痛，直腿抬高试验阳性，直立或活动时疼痛 加重，卧床休息后疼痛减轻。脊柱有代偿性侧弯。脊柱x线平片可见椎间隙变窄;MRI特征性地显示椎间盘呈鸟嘴状向后突出或髓核脱入椎管内而使神经根受压。 三、神经内科疾病 1.多发性硬化(Multiple sclerosis):患者症状波浪形进展，激素治疗有效，除了仔细询问病史和查体，以了解病程呈波浪式进行性加重和发现感觉障碍外，还在于临床医师的高度警惕性，对疑诊患者进一步作MRI。 2. 肌萎缩性侧索硬化(Amyotrophic lateral sclerosis):病变主要累及脊髓前角细胞、延髓运动神经核及椎体束。因此以运动障碍为主，一般无感觉障碍。早期可有根痛，其特征性表现是上肢手部 肌肉萎缩和舌肌萎缩，严重者有构音困难。病变以上运动神经元为主时，腱反射亢进。蛛网膜下腔无阻塞，脑脊液常规、生化检查正常。 3.脊髓蛛网膜炎(Spinal cord arachnoiditis):患者存在结核性脑膜炎史或病前感染发热史，病程较长，脊髓受累范围广而不规则，症状多样化，csf中蛋白质轻度增高和白细 胞增多，以及MRI上脊髓呈轻、中度增粗，而无明显脊 ncluding based life support (BLS), and senior heart life support (ACLS), and based trauma life support (BTLS) and senior trauma life support (ATLS) of based knowledge; common emergency technology of application; common emergency of causes identification, and clinical performance and the processing specification; common emergency auxiliary check of select refers to levy, and results judge and the clinical meaning; Indications, effects of common emergency drugs, side effects, as well as specific applications (medicine, for expansion of vasoactive drugs, cardiac diuretic, antispasmodic and anti-asthmatic drugs, analgesic drugs, Hemostatic, antiarrhythmic drugs, such as Cortina). Understand: the new development of the theory of life support; cardiac respiratory and cardiopulmonary resuscitation after cardiac syndrome etiology, pathophysiology, clinical manifestations, diagnosis, and treatment. 2. basic requirements (1) species and cases of study requirements: disease disease fever acute abdominal pain chest pain and difficulty breathing faint coma shock in acute poisoning with cardiac respiratory arrest bleeding (hemoptysis, hematemesis, hematuria, etc) requires at least 45 cases of arrhythmia. (2) basic skills requirements name name heart lung3 髓空洞形成，增强MRI上病灶无强化时，需考虑脊髓蛛网膜炎诊断。 4.急性脊髓炎(Acute myelitis): 起病较急，常有全身不适、发热、肌肉酸痛等前驱症状。脊髓损害症状往往骤然出现，数小时至数天内便发展到高峰。受累平面较清楚，肢体多呈弛缓性瘫痪，合并 有感觉和括约肌功能障碍。脊髓蛛网膜下腔无阻塞，脑脊液白细胞数增多，以单核及淋巴细胞为主，蛋白质含量亦有轻度增高。若细菌性所致者以中性粒细胞增多为 主，蛋白质含量亦明显增高。MRI除可见脊髓肿胀外，无脊髓压迫征象，由于急性脊髓炎在4,6周内病变呈进行性发展，故发病6周左右复查，可见脊髓病变范 围缩小，信号强度减低。 疾病护理护理 方法 快递客服问题件处理详细方法山木方法pdf计算方法pdf华与华方法下载八字理论方法下载 1.搬动患者时要保持脊柱呈水平位，尤其是高颈位手术，必须加用围领固定后搬动，应留意搬动时颈部不能过伸过屈，以免加重脊髓损伤导致严重后果。 2.手术后体位，高颈段手术取半卧位，脊胸段髓手术取侧卧位，腰骶部手术取俯卧位压沙袋。术后翻身时留意保持脊柱水平位，勿扭曲。 麻醉清醒后可进流质或半流质，出现呕吐暂不进食。 3. 4.术后24小时注意观察脊髓肿瘤患者肢体活动，每2小时1次。以及早发现可能出现的硬膜外血肿。 (1)高颈位手术:麻醉清醒后观察四肢肌力活动，特别要留意呼吸幅度、频率情况。 (2)胸椎手术:上肢不受影响。术后观察下肢肌力活动及感觉平面变化。在观察过程中如发现感觉障碍平面上升或肢体活动力量有减退，应考虑迟发椎管内出血或脊髓水肿，应立即通知医师采取紧急措施。 (3)马尾部手术:观察下肢肌力活动度情况及肛周皮肤感觉，有否便意。马尾区手术术后容易出现大便干结，必要时灌肠处理。 5.截瘫患者按截瘫护理。 6.椎管内肿瘤术后6—8h不能排尿的患者给予导尿并保留，3d后须继续保存的，应定时冲洗，按保存导尿护理常规。 想了解更多关于脊髓肿瘤的医学常识请点击链接: ncluding based life support (BLS), and senior heart life support (ACLS), and based trauma life support (BTLS) and senior trauma life support (ATLS) of based knowledge; common emergency technology of application; common emergency of causes identification, and clinical performance and the processing specification; common emergency auxiliary check of select refers to levy, and results judge and the clinical meaning; Indications, effects of common emergency drugs, side effects, as well as specific applications (medicine, for expansion of vasoactive drugs, cardiac diuretic, antispasmodic and anti-asthmatic drugs, analgesic drugs, Hemostatic, antiarrhythmic drugs, such as Cortina). Understand: the new development of the theory of life support; cardiac respiratory and cardiopulmonary resuscitation after cardiac syndrome etiology, pathophysiology, clinical manifestations, diagnosis, and treatment. 2. basic requirements (1) species and cases of study requirements: disease disease fever acute abdominal pain chest pain and difficulty breathing faint coma shock in acute poisoning with cardiac respiratory arrest bleeding (hemoptysis, hematemesis, hematuria, etc) requires at least 45 cases of arrhythmia. (2) basic skills requirements name name heart lung 脊髓肿瘤手术治疗流程 检查项目 检查项目 检查指征 有30%,40%的椎管内肿瘤可引起相应节段椎骨骨质的改变，包括 椎管直径增加，椎弓根变窄;根间距增大;椎间孔扩张;椎体后缘x线脊柱平片检查 受压吸收、椎体及邻近骨质吸收和破坏、椎管内钙化斑及椎旁软组 织(肿瘤)影。以椎间孔和椎弓根改变最常见。 静脉注射增强对比剂可清楚显示肿瘤影像。椎管造影ct扫描 (CTM):髓内肿瘤表现为脊髓增粗、蛛网膜下腔变窄;髓外硬脊CT扫描检查 膜下肿瘤显示脊髓移位、变形，蛛网膜下腔在肿瘤侧明显扩大，在 肿瘤对侧变窄;硬脊膜外肿瘤显示脊髓移位、变形及双侧蛛网膜下 腔变小。 目前最有诊断价值的辅助检查方法，不仅能从矢状位、冠状位、轴 位三个方向立体观察病变，对病变进行精确定位，还能观察到病变 与脊髓、神经、脊柱 骨性结构的关系。经过注射顺磁性造影剂脊髓磁共振(MRI)检查 gd-dtpa后，根据某些肿瘤自身的影像学特点就能作出定性诊断，这 样术前就能对肿瘤做出定位诊断，甚至可确定部 分肿瘤的性质，对 手术方法的选择及综合治疗帮助很大。 治疗流程: 对于椎管内肿瘤目前唯一有效的方法就是手术治疗。约3/4可手术切除治愈。因此，对椎管内肿瘤的手术应持积极态度。 手术细则 具体实施 存在神经系统受损的症状体征、放射学检查肿瘤定位明确，无手术禁忌证的手术指征 椎管内肿瘤患者，均适宜手术治疗。 原则上讲，对于髓外肿瘤，一旦诊断明确，即应尽快手术;脊髓髓内肿瘤患 者，也宜尽早、在神经系统功能进展至中度障碍前施行手术。此外，手术时手术时机 机还应参照肿瘤的病理性质、部位与大小，以及患者的年龄、症状、全身状 态和患者家属的意愿等共同商定。 手术入路 1、绝大多数椎管内肿瘤，取后正中入路即可;对于少数巨大的椎管内外肿瘤， ncluding based life support (BLS), and senior heart life support (ACLS), and based trauma life support (BTLS) and senior trauma life support (ATLS) of based knowledge; common emergency technology of application; common emergency of causes identification, and clinical performance and the processing specification; common emergency auxiliary check of select refers to levy, and results judge and the clinical meaning; Indications, effects of common emergency drugs, side effects, as well as specific applications (medicine, for expansion of vasoactive drugs, cardiac diuretic, antispasmodic and anti-asthmatic drugs, analgesic drugs, Hemostatic, antiarrhythmic drugs, such as Cortina). Understand: the new development of the theory of life support; cardiac respiratory and cardiopulmonary resuscitation after cardiac syndrome etiology, pathophysiology, clinical manifestations, diagnosis, and treatment. 2. basic requirements (1) species and cases of study requirements: disease disease fever acute abdominal pain chest pain and difficulty breathing faint coma shock in acute poisoning with cardiac respiratory arrest bleeding (hemoptysis, hematemesis, hematuria, etc) requires at least 45 cases of arrhythmia. (2) basic skills requirements name name heart lung5 需联合胸外科、骨科、泌尿外科、妇产科等医师行同期同台手术切除。 2、1. 全椎板切除时，既要有相对宽的椎板切除，以充分显露，又应尽可能不 损伤两侧小关节突，以保持脊柱的稳定。2. 当肿瘤位于一侧时，可取选择性 半椎板切除人路;3. 对于病变范围较广、特别是儿童患者，宜作椎板成形术， 或脊柱固定融合术。 原文地址: ncluding based life support (BLS), and senior heart life support (ACLS), and based trauma life support (BTLS) and senior trauma life support (ATLS) of based knowledge; common emergency technology of application; common emergency of causes identification, and clinical performance and the processing specification; common emergency auxiliary check of select refers to levy, and results judge and the clinical meaning; Indications, effects of common emergency drugs, side effects, as well as specific applications (medicine, for expansion of vasoactive drugs, cardiac diuretic, antispasmodic and anti-asthmatic drugs, analgesic drugs, Hemostatic, antiarrhythmic drugs, such as Cortina). Understand: the new development of the theory of life support; cardiac respiratory and cardiopulmonary resuscitation after cardiac syndrome etiology, pathophysiology, clinical manifestations, diagnosis, and treatment. 2. basic requirements (1) species and cases of study requirements: disease disease fever acute abdominal pain chest pain and difficulty breathing faint coma shock in acute poisoning with cardiac respiratory arrest bleeding (hemoptysis, hematemesis, hematuria, etc) requires at least 45 cases of arrhythmia. (2) basic skills requirements name name heart lung