chapter17-1脊髓
脊髓-最新PPT课件
Anterolateral sulcus
后外侧沟
Posterolateral sulcus
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脊髓节段
Segments of spinal cord
每对脊神经所连属的 一段脊髓，叫一个脊髓 节段。胚胎3个月与椎管等长， 新生儿脊髓末端平L3， 成人脊髓末端平L1体下缘
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脊髓起源于神 经管的后部， 是中枢神经的 低级部分。上 与各级脑中枢 有广泛联系， 下借31对脊神 经分布到躯干 四肢和胸腹腔 脏器。
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主要内容
脊髓位置与外形 脊髓的内部结构 脊髓的主要功能 脊髓的损伤类型
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第一部分
脊髓位置和外形
Location and appearance of the spinal cord
传导非意识性本体感觉冲动
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脊髓丘脑束(spinothalamic tract)
脊髓丘脑侧束：外侧索的前半 脊髓丘脑前束：前索
起于 Ⅲ－IV层的后角固有核（脊神经节细胞中 枢支入脊髓先上升1～2脊髓节后入后角固有核）， 纤维斜经白质前连合交叉后在对侧的外侧索和前 索上行，止于丘脑，故称脊髓丘脑束。 脊髓丘脑侧束功能是传导痛觉和温度觉的冲动。 脊髓丘脑前束功能是传导粗略触觉冲动。
皮质脊髓侧束：外侧索
皮质脊髓前束：前索
控制骨骼肌的随意运动。
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皮 质 脊 髓 束
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皮质脊髓侧束：
起于中央前回 在延髓交叉 行于外侧索 终于脊髓前角 管理同侧上下肢肌 损伤后表现为痉挛性瘫痪 （硬瘫）：无明显的肌萎 缩、 肌张力和腱反射亢进。
脊髓疾病-中英对照
Overview
脊髓横贯性损害 Transverse lesions
腰膨大（ L1－S2 ）
Sense
loss of lower limbs and perineum Flaccid paralysis of lower limbs Urinary and fecal retention Autonomic dysfunction Root pain in groin
Acute myelitis
病因 Etiology ：
Infection
分类 Classification：
postinfectious
and vaccination Virus Parasite Bacteria Fungus Unclear
myelitis Postvaccinal myelitis Demyelinating myelitis Paraneoplastic myelitis
前角 Anterior horn: αand γmotor neuron 后角 Posterior horn: secondary sensory
neuron
侧角 Lateral horn:
C8－L2 交感神经低级中枢 Sympathetic nucleus S2－S4 脊髓副交感中枢 Parasympathetic nucleus
脊髓横贯性损害 Transverse lesions
高颈段（C1-4）
Spastic paralysis of all extremities
Sense loss below neck，root pain
Urinary and fecal retention，Absent
镇痛药 (1)
– 身体依赖性(physical dependence) – 精神依赖性(psychological dependence)
停药后出现戒断症状
(withdrawal syndrome)，至意识 丧失，病人精神出现变态，有明 显强迫性觅药行为等。
药物滥用（drug abuse）
戒断症状(withdrawal syndrome)
异喹啉类 – 罂粟碱，无镇痛作 用，有松弛平滑肌、 Papaverine 舒张血管的作用。
第二节
阿片受体激动药
阿片生物碱类镇痛药
吗啡 Morphine
Morphine是阿片类镇痛药的经典代表
药，镇痛作用强大，抑制呼吸、镇静和 欣快等中枢作用明显，长期用药易产生 耐受性和依赖性。
一、构效关系
痛觉感受器
边缘系统 (情绪反应)
脊
大脑皮质 (疼痛)
病理生理意义：
a. 保护机体; b. 剧烈疼痛可带给病人极大痛苦。 临床意义： 对病症的诊断有意义； 注意：对诊断未明的疼痛不宜过早 用药物止痛，以免掩盖病情，贻误 诊断
镇痛药与解热镇痛药的区别
镇痛药
– 主要作用于中枢神经系统，镇痛作用较 强。在不影响意识的情况下，选择性地 消除或缓解痛觉，减轻由疼痛引起的紧 张、焦虑等情绪。
精神状态，同时也包括身体状态，它表现出一种
强迫性地要连续或定期用该药的行为和其它反应， 为的是要感受它的精神效应，或是为了避免由于 断药所引起的不舒适；可以发生或不发生耐受性； 同一人可以对一种以上药物产生依赖性。
药物依赖性分类 – 身体依赖性(physical dependence)
绝大部分同时兼有身体和精神依 赖性，后者是造成滥用者不断追 求用药的最主要因素。多数依赖 性药物具有耐受性。
脊髓疾病ppt课件
四、辅助检查
呈无张力性神经源性膀胱，膀胱
膀胱功能障碍 充盈过度出现充盈性尿失禁；随
着脊髓功能恢复，膀胱容量缩小
，尿液充盈到300-400ml时自主排
尿，称反射性神经源性膀胱。
-----------------------------------------休克期无直肠运动出现大便潴留，
直肠功能障碍
有时由于肛门括约肌功能松弛， 也可出现大便失禁，随着功能的
瘫痪，深感觉障碍，对侧痛、温觉障碍。 多见于脊髓外伤和脊髓肿瘤的早期
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2.脊髓横贯性损害 主要临床表现：截瘫
感觉障碍 大小便障碍 休克期—软瘫（3~4周）spinal shock 恢复期—硬瘫
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3.脊髓各节段横贯性损害临床表现
高颈髓 颈膨大 胸髓 腰膨大 圆锥 马尾
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脊髓炎 ：
指各种感觉或变态反应
所引起的脊髓炎症
脊髓病 ：
由外伤、压迫、血管、放
射、代谢、营养和遗传所 引起的脊髓病变
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急性脊髓炎
脊髓蛛网膜炎
各
急 性 运脊动 髓神 经炎元 病
论
脊髓空洞症
脊髓压迫症
脊髓亚急性联合变性
脊髓血管病
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皮质脊髓前束
侧索：位于前根和后根之间 主要有皮质脊髓侧束
脊髓丘脑侧束
后索：位于后正中沟和后根之间
主要有薄束、楔束
白质
（White Matter）
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脊髓解剖(英文图文课件)
MENINGES
3 layers: dura mater, arachnoid mater and pia mater. • 1. Dura mater: outer layer, is tough, single layered membrane is
deep to the epidural space and superficial to the archnoid mater. • 2. Arachnoid mater: middle layer, made of collagen fibers and
• The lateral horns contain autonoe the activity of smooth muscle, cardiac muscle and glands.
White matter: • The white matter is organized into regions. • The anterior and posterior gray horns divide the white mater on
Spinal cord （脊髓）
Part of human spinal cord. 1 – central canal; 2 – posterior median sulcus; 3 – gray matter; 4 – white matter; 5 – dorsal root + dorsal root ganglion; 6 – ventral root; 7 – fascicles; 8 – anterior spinal artery; 9 – arachnoid mater; 10 – dura mater
each side into 3 broad areas called columns: ◦ Anterior (ventral) white
ICF在脊髓损伤的应用-励建安
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功能与残疾的综合模式
慢性膝关节不稳 M 23.5
身体功能与 身体结构
活动
参与
环境因素
个人因素 相关因素
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身体功能与身体结构
• 身体功能指身体的生理功能，包括 心理功能 • 身体结构指身体的解剖结构，例如 器官、肢体和相关部件
– 相当于障碍Impairments
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功能与残疾的综合模式
慢性膝关节不稳 M 23.5
Chapter 2 Chapter 3 Chapter 4
身体结构 (s)
Structures of the nervous system
The eye, ear and related structures
Mental functions
Sensory functions and pain
声音和言语功能
s1 – s8
d1 – d9
e1 – e5
பைடு நூலகம்
Chapters
b110 – b899
s110 – s899
d110 – d999
e110 – e599
2nd Level
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第二级结构 – 举例
章节 b1 脑高级功能 Mental function
整体脑高级功能 (b110 – b139)
b110 b114 b117 b122 b126 b130 b134 b139 意识 定向 智力 整体心理功能 个性 主观能动性 睡眠 非特指的整体心理功能
特定的脑高级功能Specific mental functions (b140 – b189)
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ICF – 三级结构
The higher the more precise
神经病学总结
Chapter1.2.3 神经病学概论1.神经系统的解剖以及病损的定位诊断（1）内囊以及丘脑内囊损害引起三偏——偏瘫、偏盲、偏身感觉障碍丘脑—对侧感觉缺失，深感觉和精细感觉障碍重于浅感觉，伴感觉异常和自发性疼痛（2）脑干1）延髓延髓背外侧综合症（wallenberg syndrome）：交叉性感觉障碍，同侧面部浅感觉丧失，对侧偏身痛，浅感觉丧失；同侧软腭、咽喉肌瘫痪，表现为吞咽困难、构音困难、咽反射消失等2）脑桥脑桥腹外侧综合征（Millard-Gulber syndrome）：同侧展神经、面神经麻痹，对侧中枢性偏瘫，对侧偏身感觉障碍。
脑桥腹内侧综合征（Foville syndrome）：两眼向病灶对侧凝视，同侧展神经、面神经麻痹，对侧中枢性偏瘫闭锁综合征：又称去传出状态，是双侧脑桥基底部病变，典型临床症状为意识清醒，咽部、四肢不能活动，仅以眼部的某些动作与外界交流（2）中脑大脑脑脚综合症（weber syndrome）：动眼神经交叉瘫，病侧动眼神经麻痹，对侧中枢性面舌瘫和上下肢瘫（3）脊髓1）不完全性脊髓损害•脊髓前角损害：节段性下运动神经元瘫痪，表现为下运动神经元瘫痪如肌肉萎缩、腱反射消失，无感觉障碍和病理反射。
•后角损害：同侧痛温觉缺失、触觉保留的分离性感觉障碍，常见于脊髓空洞症。
•侧角损害：C8~L2是脊髓交感神经中枢，受损出现血管舒缩功能障碍、泌汗障碍和营养障碍等，C8~T1病变时出现Horner综合征；S2~4侧角为副交感中枢，损害时产生膀胱直肠功能障碍和性功能障碍。
•前联合型：见于脊髓中央部病变（肿瘤、脊髓空洞症），双侧对称性节段性分离性感觉障碍（对称性、节段性、浅感觉障碍，而深感觉保留）•前索损害:对侧病变水平以下粗触觉障碍，刺激性病变出现病灶对侧水平以下弥散性疼痛•后索损害：振动觉、位置觉障碍，感觉性共济失调、精细触觉障碍。
•侧索损害：对侧肢体病变水平以下上运动神经元瘫痪和痛温觉障碍•脊髓束性损害：以选择性侵犯脊髓个别传导束为特点•脊髓半切综合征（Brown-Sequard Syndrome)：表现为病变对侧浅感觉丧失，同侧深感觉丧失和上运动神经元瘫痪。
脊髓解剖与功能图ppt课件
三、脊髓反射和损伤表现
脊髓的功能：（1）传导
上行：
感受器 脊髓 脑
下行： 脑
脊髓
躯干四肢肌运动 大部分内脏运动
三、脊髓反射和损伤表现
脊髓的功能：（2）反射
躯体反射：牵张反射：骨骼肌被牵引时， 引起肌肉的收缩和肌张力的增高。屈曲 反射：当机体受到伤害性刺激时，屈肌 收缩，以逃避这种刺激
内脏反射：排尿反射、竖毛反射、排便反射
灰质
1、后角 后角边缘核
胶状质 后角固有核
二、脊髓的内部结构
灰质
3、前角 前角运动神经元 α运动神经元
γ运动神经元 中间抑制神经元源自二、脊髓的内部结构白质
后索
外侧索
前索
C5 白质前联合
L3
T8
S3
二、脊髓的内部结构
白质 主要由长的上行纤维束和下行纤维束
以及短的固有束组成
二、脊髓的内部结构
二、脊髓的内部结构
灰质
Rexed板层结构
Ⅰ层 后角缘层
Ⅱ层 胶状质
Ⅲ、Ⅳ层 后角固有核
Ⅴ层 后角颈、网状核
Ⅵ层 后角基部
Ⅶ层 中间带
Ⅷ层 前角基部
Ⅸ层 前角运动细胞群
Ⅹ层 中央管周围
灰质：有神经细胞核团和部分胶质细胞 白质： 中央管：
二、脊髓的内部结构
• 一、灰质：前角、后角及C8-L2、S2-4的侧 角，还包括中央管前后的灰质前联合和后 联合，合称中央灰质。前角：主要与躯干 及四肢的运动有关。后角：参与感觉信息 的中转。侧角： C8-L2是交感神经中枢，支 配血管、内脏急腺体的活动（C8-T1支配同 侧的瞳孔扩大肌、睑板肌、眼眶肌、面部 的血管和汗腺；S2-4副交感神经，支配直肠、 膀胱和性腺。）
脊髓疾病的诊断思路 ppt课件
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五 脊髓的常见疾病
• 急性脊髓炎 • 脊髓压迫症 • 脊髓空洞症 • 脊髓亚急性联合变性
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（一）急性脊髓炎
Myelitis
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急性脊髓炎是指非特异性局限
于数个节段的急性横贯性脊髓炎， 绝大多数在感染后或疫苗接种后 发病。如病变迅速上升, 称为上 升性脊髓炎;如脊髓内有两个以上 散在病灶，则称为播散性脊髓炎。
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脊髓髓内结核
• 结核肉芽肿映像 • T1低信号环,强化呈环状强化 • T2等或低信号环, • 干酪样坏死呈圆形稍高信号
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颈椎间盘突出
• 一位51岁的女性患者，主要表现为双手中 指、环指、小指麻木，后渐出现双足趾麻 木疼痛，行走时足底疼痛感明显加重。查 体可见双侧中指、环指、小指感觉迟钝， 双侧霍夫曼征明显阳性，双侧膝健反射亢 进,双病理征阳性。在核磁片上，我们可 以看到，颈6、7椎间盘突出，相应平面脊 髓受压。
• “不怕太阳晒，也不怕那风雨狂，只怕先生骂我 笨，没有学问无颜见爹娘 ……”
• “太阳当空照，花儿对我笑，小鸟说早早早……”
一。脊髓解剖
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（一）脊髓的起止
• 上端与延髓在枕骨 大孔水平相连。
• 下端形成圆锥，生出 终丝，附着于第1/2 尾骨体。
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（二）脊髓与脊椎的关系
• 脊髓位于椎管内，圆锥末端约在L1 下缘水平，因而脊髓各节段的位置比 相应的脊椎为高。
剑突 肋缘 平脐 腹股沟 • 腹壁反射消失：节段 T7~8 上 T9~10 中
人卫九版神经病学PPT课件11-脊髓疾病
脊髓的血液供应
• *脊髓的动脉：节段动脉、脊髓前动脉、脊 髓后动脉。 脊髓前动脉:供应脊髓前3/4的血液。 脊髓后动脉:供应脊髓后1/4的血液。
脊髓的功能
• 传导功能 • 反射功能：躯体反射：牵张（伸肌）反射
和屈肌反射。内脏反射：血管张力、发汗、 排尿、排便、勃起、瞳孔反射。 • 躯体神经营养功能
• *后中间沟把后索分为内侧的薄束和外侧的 楔束。
• *脊髓节：每对脊神经根与脊髓相对应的部 分。脊髓共有31节，颈8、胸12、腰5、骶5、 尾1。
脊髓的大体解剖
• *颈膨大：颈4-胸1。 •பைடு நூலகம்*腰骶膨大：腰2-骶3或腰1-骶2 。 • 锥体和脊髓节段的对应关系：上颈段与锥
体相同，下颈段和上胸段平上1节锥体，中 胸段平上2节锥体，下胸段平上3节锥体， 全部腰节平10、11、12锥体，骶尾节平腰1 锥体。
各种脊髓病变的临床特点
• 脊髓横断：首先出现脊髓休克，原因是失 去高级中枢的控制，下行传导束的易化和 抑制均消失。人类的休克期最长，平均3-6 周。横断面以下出现：运动、反射、躯体 感觉、内脏感觉、肌张力消失。膀胱功能 障碍：尿潴留—尿失禁—自动膀胱（骶髓 受损除外）。
各种脊髓病变的临床特点
• *脊髓半切（Brown-Sequard）综合征： 病变同侧：1、损伤平面以下痉挛性瘫痪。
脊髓的传导束（上行）
• 脊髓丘脑束：传导痛、温、触、压等浅感觉，对 它的走行了解不是完全清楚。皮肤、粘膜等的感 觉神经末梢---脊神经节细胞---中枢突触经后根外 侧---脊髓的背外侧束(Lissauer束），在同节或上 下1-3节---部分纤维止于后角Ⅰ-Ⅲ层，主要是后 角边缘核---发出纤维经白质前连合交叉---*对侧脊 髓的外侧索和前索---脊髓丘脑（侧、前）束---丘 脑腹后外侧核---中央后回
2013脊髓损伤指南 17.Management_of_Acute_Combination_Fractures_of_the
Management of Acute Combination Fractures of the Atlas and Axis in AdultsRECOMMENDATIONSLevel III:The treatment of combination atlas-axis frac-tures based primarily on the specific charac-teristics of the axis fracture is recommended.•External immobilization of most C1-C2com-bination fractures is recommended.•C1-type II odontoid combination fractures with an atlanto-dental ratio of $5mm and C1-Hangman combination fractures with C2-C3angulation of $11should be considered for surgical stabilization and fusion.RATIONALEThe unique anatomy and relationship of the atlas and axis vertebra result in a variety of fracture patterns in the setting of significant cervical trauma.Although each of these vertebral bodies is subjected to isolated fractures,combination fractures occur with sufficient frequency to warrant special consid-eration.Recommendations for the management of acute combination fractures of the atlas and axis were published by the guidelines author group of the Joint Section on Disorders of the Spine and Peripheral Nerves of the American Association of Neurological Surgeons and the Congress of Neuro-logical Surgeons in 2002.1The previous guideline was based on Class III medical evidence and recom-mended that management decisions for combina-tion C1-C2fractures be based on the fracture characteristics of the axis fracture.The purpose of the current review is to update the medical evidence on the management of acute combination fractures of the atlas and axis in adults.SEARCH CRITERIAA National Library of Medicine (PubMed)computerized literature search from 1966to 2011was undertaken using Medical Subject Headings in combination with “vertebral fracture ”:“atlas,”“axis,”and “human.”This strategy yielded 202references.The abstracts were reviewed,and articles focusing on clinical management and follow-up of combination fractures of the atlas and axis were selected for inclusion.The relative infrequency of these fractures,the small number of case series,and the numerous case reports with pertinent information required rather broad inclusion criteria.The bibliographies of the selected papers were reviewed to provide addi-tional references.These efforts resulted in 47manuscripts describing the clinical features and the manage-ment of acute traumatic atlas and axis combina-tion fractures and are summarized in Evidentiary Table format.All provide Class III medical evidence.SCIENTIFIC FOUNDATIONThe historic series of 46atlas fractures described by Sir Geoffrey Jefferson 2contained 19fractures that were actually combination fractures of the atlas and the axis (Table 1).The incidence of concurrent atlas and odontoid fracture ranges from 5%to 53%in the literature,and the incidence of combination atlas and Hangman fractures ranges from 6%to 26%.Gleizes et al 3compiled incidence data over a 14-year period on combination fracture injuries in the upper cervical spine.The authors con-cluded that combination fractures are relatively common and require a high level of surveillance to detect.They identified 784cervical spine injuries,including 116upper cervical spine injuries.Of these,31were combined C1-C2fractures,representing 4%of the total.The most frequent C1-C2fracture combinations included combined bipedicular fracture of the axis andTimothy C.Ryken,MD,MS*Mark N.Hadley,MD ‡Bizhan Aarabi,MD,FRCSC§Sanjay S.Dhall,MD¶Daniel E.Gelb,MD k R.John Hurlbert,MD,PhD,FRCSC#Curtis J.Rozzelle,MD**Nicholas Theodore,MD ‡‡Beverly C.Walters,MD,MSc,FRCSC ‡§§*Iowa Spine &Brain Institute,University of Iowa,Waterloo/Iowa City,Iowa;‡Division of Neurological Surgery and **Division of Neurological Surgery,Children’s Hospital of Alabama,University of Alabama at Birmingham,Birmingham,Alabama;§Department of Neurosurgery and;k Department of Orthopaedics,University of Maryland,Baltimore,Maryland;¶Department of Neurosurgery,Emory Uni-versity,Atlanta,Georgia;#Department of Clinical Neurosciences,University of Calgary Spine Program,Faculty of Medicine,Uni-versity of Calgary,Calgary,Alberta,Canada;‡‡Division of Neurological Surgery,Barrow Neurological Institute,Phoenix,Arizona;§§Department of Neurosciences,Inova Health System,Falls Church,Virginia Correspondence:Mark N.Hadley,MD,FACS,UAB Division of Neurological Surgery,510–20th St S,FOT 1030,Birmingham,AL 35294-3410.E-mail:mhadley@Copyright ª2013by theCongress of Neurological Surgeons1313odontoid fracture,combined fracture of the posterior arch of C1 and odontoid fracture,combined Jefferson fracture with odontoid fracture,and C2articular pillar fracture with odontoid fracture.The authors observed that70%of atlas fractures,30%of odontoid fractures,and30%of C2traumatic spondylolistheses(Hangman fractures)were involved in a combination fracture injury.It has been suggested that the likelihood of a neurological deficit is greater with combination fractures than with either atlas or axis fractures alone.4-6Historically,combination fractures of C1and C2have been managed sequentially,as proposed by Levine and Edwards,7 allowing1fracture to heal(usually the atlas)before attempting definitive management of the axis injury.In1989,Dickman et al8reported their experience with25cases of acute atlas-axis combination fractures from an overall series of 860patients with acute cervical spinal fracture injuries(3%). They identified an incidence of neurological deficit of12%.Four combination atlas-axis fracture types were identified:C1-type II odontoid(10cases,40%),C1-miscellaneous axis fracture(7 cases,28%),C1-type III odontoid(5cases,20%)and C1-Hangman fracture(3cases,12%).Rigid immobilization was the initial management strategy in20of25of patients(84%)for a median duration of12weeks(range,10-22weeks).The reported fusion rate of was95%(19of20).Five patients were treated surgically,and all achieved fusion(100%).Four were treated with early surgery based on an atlantoaxial interval of$6 mm,and1patient with an initial atlantoaxial interval of5mm failed halo treatment requiring posterior C1-C2fusion.The authors recommend computed tomography in all patients with either a C1or a C2fracture to evaluate for a combination injury.They recommend that atlas fractures in combination with type II or III odontoid fractures with an atlantoaxial interval of$5mm be considered for early surgical management. Guiot and Fessler9in1999described a series of10patients with combination atlas-axis fractures ultimately treated with surgical stabilization with anterior odontoid fixation.Five had failed a previous attempt at halo immobilization.There were9 C1-type II odontoid fractures and1C1-type III odontoid combination fracture injury.There was1death unrelated to surgery.All surviving patients achieved fusion.The authors recommended that surgery be considered in patients with fractures that were irreducible or could not be maintained with external immobilization and for unstable fractures with a high likelihood of nonunion.Treatment of Combination C1-Type IIOdontoid FracturesThe treatment of specific C1-C2fracture combinations has been the subject of numerous reports.Similar to the literature on isolated type II odontoid fracture management(see Management of Isolated Axis Fractures in Adults),the C1-type II odontoid fracture combination fracture injury has generated the most controversy.Options for management of C1-type II odontoid combination fractures include traction followed by immobiliza-tion,semirigid immobilization(collar),rigid immobilization (halo,Minerva,sterno-occipital mandibular immobilizer),poste-rior C1-C2fusion with and without instrumentation,and ante-rior odontoid screw fixation.Several authors have described traction followed by semirigid immobilization as treatment for acute combination C1-C2 fractures.10,11Esses et al12described the successful treatment of a C1-type II odontoid combination fracture managed in a cervical collar.The decreased union rate reported for type II odontoid fractures managed with nonrigid immobilization must be considered.The majority of reports of combination C1-C2 fractures have described treatment with rigid external immobi-lization,including the halo,sterno-occipital mandibular immo-bilizer,and Minerva devices.8,13-15,47,49Dickman et al8treated6 patients with,6-mm atlanto-dens interval with halo immobi-lization and reported an83%success rate(5of6).The single treatment failure had an atlantoaxial interval of5mm and underwent posterior C1-C2fusion at12weeks after injury.Segal et al,14Andersson et al,13and Seybold and Bayley15described a total of7additional cases of C1-type II odontoid combination fractures successfully treated with halo immobilization.Three contemporary case series presenting conflicting argu-ments on the role of halo immobilization in the treatment of cervical spinal fracture injuries are summarized in Table2.16-18 None of these citations contain exclusively C1-C2combination fractures,thus limiting their use for specific recommendations. They are included to provide perspective on the role of halo immobilization in upper cervical spine fracture management. Longo et al17conducted an extensive systematic review on halo vest management of cervical spine injuries.They identified47 reports describing a total of1078patients with cervical spine fractures,including50patients with combination C1-C2fracture injuries(4.6%).Although the specifics of outcome with this subgroup were not presented,the authors concluded after review that the management of upper cervical spine injuries,including combination fracture injuries,with halo immobilization is a safe and effective treatment option.Daentzer and Flörkemeier16 retrospectively reviewed29patients with upper cervical spine injuries treated in a halo vest.They divided the patients into 2groups:patients,65years of age(n=18)and patients$65 years of age(n=11).The fracture subtypes were as follows:type II odontoid fracture(6patients),type III odontoid fracture (6patients),combination C1-C2fractures(6patients),and other subaxial cervical fractures(11patients).The outcomes of interest were the clinical and radiological results,treatment complica-tions,and rate of nonunion requiring surgery.Only2patients required surgery:1patient with an isolated type II odontoid fracture and1patient with a type II odontoid fracture in com-bination with a C1arch fracture.Both were.65years of age. The clinical and radiological results were not statistically signifi-cantly different between the2patient groups.The incidence of complications and the time interval for fracture healing were greater in the older patient group but were not statistically significant.RYKEN ET ALIn a more focused study,Tashjian et al18reviewed78patients .65years of with odontoid fractures:isolated type II(n=50) or isolated type III odontoid fractures(n=17)and combination C1-C2odontoid fractures(n=11)treated with halo immobili-zation.Treatment included collar(n=27),halo(n=34),and operative(n=17)(4operation plus halo).Combination fracture outcomes were not specifically described.There were24deaths (31%)during the initial hospitalization.Of those patients treated with a halo vest,42%died compared with a20%mortality rate among patients not treated in a halo device(P=.03).The incidence of major complications in the halo-treated group was 66%compared with36%in the nonhalo group(P=.003).The authors concluded that odontoid fractures in the elderly are associated with significant morbidity and mortality and appear to be magnified with the use of a halo immobilization device.C1-type II odontoid combination fractures considered to be unstable have been successfully managed with surgical stabilization and fusion.Techniques have included posterior C1-C2fixation (with or without transarticular screws),anterior odontoid screw fixation,and occipitocervical fusion.Dickman et al,8Andersson et al,13Coyne et al,19and Lee et al20treated a total of8patients with C1-type II odontoid combination fractures with early surgical fusion based on an atlantoaxial interval of$6mm.Six patients had posterior C1-C2fusion,and1patient underwent occipital-cervical fusion for multiple fractures of the posterior atlantal arch. Occipitocervical fixation has been used to treat C1-C2combination fractures by other authors in cases of C1posterior arch incompetence or gross C1-C2instability.8,13Guiot and Fessler9 described2patients with this combination injury pattern treated posteriorly with C1-C2transarticular screw fixation and fusion. Multiple authors have reported anterior odontoid fixation with fusion rates exceeding90%.Montesano et al,21Berlemann and Schwazenbach,55Guiot and Fessler,9Henry et al,22and Apostolides et al23have reported a combined total of25patients with C1-C2 combination fractures treated successfully with anterior odontoid fixation.Cases reported by Guiot and Fessler9and Apostolides et al23describe the use of anterior transarticular fixation for combination C1-C2fracture injuries.More recently,Ben Aïicha et al24described the surgical management of4patients with combination fractures of the type II odontoid and C1arch.Two patients were treated with posterior transarticular C1-2fusion,1patient with occipitocervical fusion, and1patient with anterior odontoid screw fixation.The authors recommended that the management of patients with C1-C2 combination fracture injuries be based on the type of odontoid fracture and the presence of neurological injury.Agrillo and Mastronardi25reported the successful use of triple anterior screws(odontoid and bilateral transarticular C1-C2)in the management of a combination C1arch-type II odontoid fracture in a92-year-old man.The authors concluded that in presence of a potentially unstable type II odontoid fracture with a fractured posterior atlas arch,triple anterior screw fixation is an option,even in the elderly.Omeis et al26described their surgical series of29elderly patients with odontoid fractures(type II alone,n=24;type II in combination with C1fractures,n=5)with a mean follow-up of18months postoperatively.Twenty-seven patients(93%)were neurologically intact,and2patients(7%)presented with a central cord syndrome. Anterior odontoid screw fixation was the treatment offered to16 patients(55%).Fusion occurred in6patients(37.5%);stability occurred in9patients(56.2%);and1patient(6.3%)required subsequent posterior stabilization and fusion.Posterior fixation and fusion were the initial treatment in13patients(45%).Fusion occurred in4patients(30.7%),and stability was achieved in9 patients(69%).The authors reported1death and3other perioperative complications(10%).Twenty-five of29patients (86%)reportedly returned to their previous level of activity.The authors concluded that odontoid fractures in the elderly can be treated surgically with acceptable morbidity and mortality and that the majority of patients can return to their previous level of independence. In summary,treatment options for C1-type II odontoid combination fractures include external orthoses(both nonrigid and rigid)and surgical fixation with fusion.C1-C2instability defined by an atlantal-dens interval of$5mm or the failure of external immobilization warrants consideration for surgical treatment by one of several acceptable means.Treatment of Combination C1-Type IIIOdontoid FracturesDickman et al8described5patients with C1-type III odontoid combination fractures.All were successfully treated with halo immobilization for an average of12weeks.Ekong et al27 identified2similar cases.One was managed successfully in a halo device;the second failed halo immobilization and required a delayed posterior C1-C2fusion.Omeis et al26reported a patient with a C1-type III odontoid-Hangman combination fracture that they successfully treated with ventral odontoid screw fixation followed by posterior pedicle screw fixation and fusion.It appears that external immobilization is effective in the management of these injuries in the majority of patients.fractures Collar,haloCOMBINATION ATLAS AXIS FRACTURESPosterior wiring is not indicated arch fracture.16Retrospective review of6combination C1-odontoid fractures examining effect ofage on management III If the conditions for conservativecervical spine injuries withfavorable,the clinical andsimilar in patients regardlessa tendency for more complicationspatients.Retrospective review of5elderly patients with combination C1-odontoid fractures III Elderly patients with combinationfractures can be treated surgicallymorbidity and mortality rates.these patients can be mobilizedtheir previous levels of independence.Case report of a92-year-old patients witha C1-type II odontoid fracture treated with a combination of odontoid and bilateral transarticular C1-C2anterior screw fixation III Triple anterior screw fixationfracture is an option,evenRetrospective review of11elderly patients with combination C1-C2fractures managed with cervical immobilization III Odontoid fractures are associated morbidity and mortality inworse with the use of a haloRetrospective review of3elderly patients withcombination C1-type II odontoid fracturesIII Either halo or posterior fusionRetrospective review of784cervical spine injuries including31C1-C2combination fractures III C1posterior arch-odontoidcommon pattern.70%of C1fractures and30%were associated with a secondfracture.Retrospective review of combination C1-Hangman fracturesIII Nonoperative managementRetrospective review of10patients undergoing surgical fixation for combination C1-C2 fractures III Surgical fusion with either anteriorposterior transarticular screwsuccessful.(Continues)RYKEN ET ALwith combination C1-C2fractures resulted in high rates of fusion,tolerated in the elderly.Nonrigidresulted in lower fusion rates.Retrospective review of7patients witha combination of C1-Hangman fractures III Nonoperative managementdisplacement was.6mm,successful.Retrospective review of3patients of C1-miscellaneous axis body fracturesIII Nonoperative managementRetrospective review of5patients with C1-C2fracturesIII Nonoperative management Retrospective review of1patient witha combination C1-C2fractureIII Posterior stabilization was successful.Retrospective review of247admissions with upper cervical spine fractures including82 patients with neurological deficit III In patients with combined injury neurological deficit occurredposterior arch fracture,burstor body fracture of the axisan odontoid fracture or aDisorders,Case report of a70-year-old man with fracturedislocation of C1-C2with20-mm atlantoaxialdisplacementIII Successfully treated with O-C4internal fixation,and posteriorcomplete recovery. Retrospective review of2patients.80y of agewith C1-odontoid fracturesIII Nonoperative managementsurvived the initial postinjury1992Retrospective review of a patient with C1burstand vertical C2body fracture treated witha cervical collarIII Nonoperative management1992Retrospective review of2patients with C1arch and type II odontoid fractures III Nonoperative managementO-C2fusion was performedDisorders,Retrospective review of2patients withcombination C1-type II or III odontoid fracturesIII The integrity of the posteriorconsidered in planning surgicalEpidemiological report of717cervical spinefracturesIII Atlas fractures occurred with(53%)and with Hangman(Continues)COMBINATION ATLAS AXIS FRACTURESa combination fracture of both C1and C2type of C2fracture.Surgery with either anteriorcan be considered if failuretherapy or displacementof.6mm.Retrospective review of15patients with a combination C1-Hangman fractures III Management should be basedAnterior C2-3fusion shouldthose patients with C2-3angulationthis group has an85%nonunionimmobilization.Retrospective review of2patients withcombination C1-odontoid fracturesIII Nonoperative therapy successful.Retrospective review of7patients withcombination C1-odontoid fracturesIII Nonoperative therapy successful.Retrospective review of1patient with C1-type IIodontoid fractures managed in a halo orthosesIII Nonoperative therapy successful.Bone American Retrospective review of6cases with combinationC1-2fractures managed with immobilizationIII Nonoperative therapy was successful.North Review article on management of C1-C2traumatic fracturesIII Comments on combined injuries:1.The presence of3injuriesassociated with a high likelihoodinjury.2.If find1injury or fracture,another.3.Mechanism of injury usuallyinjury observed.4.Each injury needs to be evaluatedthe presence of2fracturesindicate instability(posterior(Continues)RYKEN ET ALTreatment of Combination C1-Hangman Fractures The combination of C1-Hangman fractures has been successfully treated with external immobilization in the majority of reported cases.Successful treatment with immobilization has been reported with a cervical collar,28the halo device,and the sterno-occipital mandibular immobilizer-type orthosis.4,8,29-31The report by Fielding et al32included15patients with combination C1-Hangman fractures.They reported that when the combination Hangman fracture was associated with C2-3angulation.11°, they considered these C1-C2combination injuries unstable. Surgical stabilization and fusion were recommended. Treatment of Combination C1-MiscellaneousC2Body FracturesThe recommended initial treatment of C1-C2body fractures as reported in the literature is nonoperative.Both rigid immobilization and nonrigid immobilization have been described with nearly universal success.6,20,33-35The Dickman et al8series,which included7patients with combination C1-C2body fractures were all successfully treated with either halo or sterno-occipital mandibular immobilizer immobilization.SUMMARYCombination fractures of the atlas and axis occur relatively frequently and are associated with an increased incidence of neurological deficit compared with either isolated C1or isolated C2fractures.C1-type II odontoid combination fractures are the most common C1-C2combination fracture injury pattern,followed by C1-miscellaneous axis body fractures,C1-type III odontoid fractures,and C1-Hangman combination fractures.Class III medical evidence addressing the management of patients with acute traumatic combination atlas and axis fractures describes a variety of treatment strategies for these unique fracture injuries based primar-ily on the specific characteristics of the axis fracture injury subtype.The type of axis fracture present generally dictates the manage-ment strategy for the C1-C2combination fracture injury.Rigidexternal immobilization is typically recommended as the initial management for the majority of patients with these injuries.Combination atlas-axis fractures with an atlantoaxial interval of $5mm or angulation of C2on C3of$11°have been considered for and successfully treated with surgical stabilizationand fusion.Surgical options in the treatment of combination C1-C2fractures include posterior C1-2internal fixation and fusion orcombination anterior odontoid and C1-2transarticular screwfixation with fusion.Fractures of the posterior ring of the atlas cancomplicate the surgical treatment of unstable C1-C2combinationfracture injuries.If the posterior arch of C1is incompetent anda dorsal operative procedure is indicated,occipitocervical internal fixation and fusion,posterior C1-C2transarticular screw fixation and fusion,and C1lateral mass-C2pars/pedicle screw fixation and fusion techniques have been reported to be successful.KEY ISSUES FOR FUTURE INVESTIGATION Review of the available literature highlights the lack of pro-spective data and comparison studies to help guide appropriate treatment of combination atlas-axis fractures.Although immobi-lization has been recommended as the initial management of choice,the increased morbidity and mortality of halo use in the elderly,the increased rate of nonunion of type II odontoid fractures, and patient preferences all raise the question of the benefit of early surgical fixation and fusion for these injuries.Prospective data derived from appropriately designed comparative studies would assist in determining the most favorable outcome strategies and would provide Class II medical evidence on this topic.DisclosureThe authors have 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RJ,Pepin J,Hensinger R.Traumaticspondylolisthesis of the axis.Clin Orthop Relat Res.1989;239:47-52.33.Polin RS,Szabo T,Bogaev CA,Replogle RE,Jane JA.Nonoperative managementof types II and III odontoid fractures:the Philadelphia collar versus the halo vest.Neurosurgery.1996;38(3):450-456;discussion456-457.34.Craig JB,Hodgson BF.Superior facet fractures of the axis vertebra.Spine(Phila Pa1976).1991;16(8):875-877.35.Bohay D,Gosselin RA,Contreras DM.The vertical axis fracture:a report on threecases.J Orthop Trauma.1992;6(4):416-419.36.Müller EJ,Wick M,Muhr G.Traumatic spondylolisthesis of the axis:treatmentrationale based on the stability of the different fracture types.Eur Spine J.2000;9(2):123-128.37.Morandi X,Hanna A,Hamlat A,Brassier G.Anterior screw fixation of odontoidfractures.Surg Neurol.1999;51(3):236-240.38.Greene KA,Dickman CA,Marciano FF,Drabier JB,Hadley MN,Sonntag VK.Acute axis fractures:analysis of management and outcome in340consecutive cases.Spine(Phila Pa1976).1997;22(16):1843-1852.39.Weller SJ,Malek AM,Rossitch E Jr.Cervical spine fractures in the elderly.SurgNeurol.1997;47(3):274-280;discussion280-281.40.Pedersen AK,Kostuik plete fracture-dislocation of the atlantoaxialcomplex:case report and recommendations for a new classification of dens fractures.J Spinal Disord.1994;7(4):350-355.41.Hanigan WC,Powell FC,Elwood PW,Henderson JP.Odontoid fractures inelderly patients.J Neurosurg.1993;78(1):32-35.42.Hays MB,Alker GJ Jr.Fractures of the atlas vertebra:the two-part burst fracture ofJefferson.Spine(Phila Pa1976).1988;13(6):601-603.43.Jeanneret B,Magerl F.Primary posterior fusion C1/2in odontoid fractures:indications,technique,and results of transarticular screw fixation.J Spinal Disord.1992;5(4):464-475.44.Ryan MD,Henderson JJ.The epidemiology of fractures and fracture-dislocationsof the cervical spine.Injury.1992;23(1):38-40.45.Kesterson L,Benzel E,Orrison W,Coleman J.Evaluation and treatment of atlasburst fractures(Jefferson fractures).J Neurosurg.1991;75(2):213-220.46.Levine AM,Edwards CC.Fractures of the atlas.J Bone Joint Surg Am.1991;73(5):680-691.ender S,Charles RW.Fracture of the dens in ankylosing spondylitis.Injury.1987;18(3):213-214.48.Hanssen AD,Cabanela ME.Fractures of the dens in adult patients.J Trauma.1987;27(8):928-934.49.Lind B,Nordwall A,Sihlbom H.Odontoid fractures treated with halo-vest.Spine(Phila Pa1976).1987;12(2):173-177.50.Levine AM,Edwards CC.The management of traumatic spondylolisthesis of theaxis.J Bone Joint Surg Am.1985;67(2):217-226.51.Pepin JW,Bourne RB,Hawkins RJ.Odontoid fractures,with special reference tothe elderly patient.Clin Orthop Relat Res.1985;193:178-183.52.Effendi B,Roy D,Cornish B,Dussault RG,Laurin CA.Fractures of the ring of theaxis:a classification based on the analysis of131cases.J Bone Joint Surg Br.1981;63-B(3):319-327.53.Lipson SJ.Fractures of the atlas associated with fractures of the odontoidprocess and transverse ligament ruptures.J Bone Joint Surg Am.1977;59(7): 940-943.54.Anderson LD,D’Alonzo RT.Fractures of the odontoid process of the axis.J BoneJoint Surg Am.1974;56(8):1663-1674.55.Berlemann U,Schwarzenbach O.Dens fractures in the elderly.Results of anteriorscrew fixation in19elderly patients.Acta Orthop Scand.1997;68(4):319-224.56.Fujimura Y,Nishi Y,Kobayashi K.Classification and treatment of axis bodyfractures.J Orthop Trauma.1996;10(8):536-540.RYKEN ET AL。
系统解剖学笔记之__脊髓
一、位置和外形图17－1
脊髓外形简图
脊髓位于椎管内，上端平枕骨大孔处与延髓相连，下端在成人平第1腰椎体下缘（新生儿可达第3腰椎下缘平面），全长约42~45cm，最宽处横径为1~1.2cm。脊髓呈前、后稍扁的圆柱形，全长粗细不等，有两个梭形的膨大，即颈膨大cervical enlargement和腰骶膨大lumbosacral enlargement。前者自第4颈节至第1胸节，后者自第2腰节至第3骶节。这两个膨大的形成是因为内部的神经元数量相对较多，与四肢的出现有关。脊髓末端变细，称为脊髓圆锥conus medullaris，自此处向下延为细长的无神经组织的终丝filum terminale (图17-1)，长约20cm，向上与软脊膜相连，向下在第2骶椎水平以下由硬脊膜包裹，止于尾骨的背面。
二、脊髓的内部结构
脊髓由灰质和白质两大部分组成。在脊髓的横切面（图17-3,4）上，可见中央有一细小的中央管central canal，围绕中央管周围是“H”形的灰质，灰质的外周是白质。
每侧的灰质，前部扩大为前角anterior horn或前柱；后部狭细为后角或后柱posterior column，它由后向前又可分为头、颈和基底三部分；在胸髓和上部腰髓（L1~L3），前、后角之间有向外伸出的侧角或侧柱lateral column；前、后角之间的区域为中间带intermediate zone；中央管前、后的灰质分别称为灰质前连合anterior gray commissure和灰质后连合posterior gray commissure，连接两侧的灰质。因灰质前、后连合位于中央管周围，又称中央灰质。
脊髓疾病——讲义
浅感觉区
9
感觉（ ）纤维束
脊髓白质
纤维束
薄束 楔束 脊髓丘脑束
脊髓小脑后束 脊髓小脑前束
运动（ ）纤维束
皮质脊髓侧束 皮质脊髓前束 Barne前外侧束 红核脊髓束
短（
顶盖脊髓束 前庭脊髓束 网状脊髓束 内侧纵束
）纤维束 固有束
躯体运动 肌张力 视听反射
深感觉 浅感觉 脊髓反射
10
脊髓灰质自主神经中枢 病损部位
33
慢性脊髓压迫症呈缓慢进行性发展，通常 表现三期:（1）根痛期:神经根痛及脊膜刺 激症状;（2）脊髓部分受压期:表现脊髓半 切综合征;（3）完全受压期:出现脊髓完全 横贯性损害。三期的表现并非绝对孤立， 常可相互重叠。
1· 神经根症状 2· 感觉障碍 3· 运动障碍
表现为根痛或局限性运动障碍。
肿瘤压迫示意图（1）：
29
肿瘤压迫示意图（2）：
30
肿瘤压迫示意图（3）：
31
肿瘤压迫示意图（4）：
32
2· 发病机制
病情程 度的相 关因素
①是否有代偿
②脊髓受压的速度：急性、慢性
③病变发生的部位：髓内还是髓外
３.
临床表现
急性脊髓压迫症病情进展迅速，脊髓功能可 于数小时至数日内完全丧失，多表现脊髓横 贯性损害，常有脊髓休克；
脊髓节段和椎骨的对应关系
脊髓节段和椎骨的对应关系
脊髓是人体的重要器官之一，位于脊柱内，由神经元和支持细胞组成。
脊髓从脑干下
端开始，一直延伸到第一腰椎水平，共有31个节段。
每个脊髓节段与相应的椎骨相对应，并分别支配不同的身体部分。
本文将介绍脊髓节段和椎骨的对应关系。
颈部
颈部是脊髓的最上部分，共有8个节段。
它对应着7个颈椎和第一胸椎。
这些节段支
配头部、颈部、肩部、手臂和胸部的一些肌肉和皮肤。
颈椎1节段（C1）：支配头部和颈部的肌肉，包括头部后伸肌、颈反曲肌等。
颈椎3节段（C3）：掌控后斜肌、前斜肌等颈部肌肉。
颈椎6节段（C6）：主要支配肩带下肌、尺肱骨伸肌和腕屈肌群。
胸部
胸椎1节段（T1）：支配第一肋间肌和小背肌等。
胸椎6节段（T6）：掌控胸大肌、腹直肌和股外侧肌等。
腰部
腰部是脊髓的下部，共有5个节段。
它对应着5个腰椎，支配着腰部肌肉、臀部肌肉、股部肌肉和部分下肢肌肉。
腰椎2节段（L2）：主要掌控宫韧带和股大肌等。
腰椎3节段（L3）：支配斜肌和股内收肌等。
尾骨
尾骨是脊髓的最下部分，对应着尾椎。
它控制着恒压反射和排泄功能。
尾骨和尾椎是
人体最下端的一部分骨骼结构，不参与支撑体重。
总之，脊髓节段和椎骨是人体解剖学上非常重要的组成部分。
了解它们之间的对应关系，可以更加清晰地认识到身体各部分受到神经支配和控制的方式，这对于生理学、神经
科学和医学研究都具有重要意义。
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前庭脊髓束
内侧纵束
脊髓丘脑前束
皮质脊髓前束
顶盖脊髓束
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1.上行纤维束
薄束
（1）薄束 T5 以下 楔束 T4 以上 —传导意识性本体感觉
薄束
脊神经节
颈部
腰部
-11-
（2）脊髓小脑束 1)脊髓小脑后束 2)脊髓小脑前束 —传导非意识性本体感觉
脊髓小脑后束 脊髓小脑前束
脊神经节
-12-
（3）脊髓丘脑束 脊髓丘脑前束 —传导粗触觉，压觉 脊髓丘脑侧束 —传导痛温觉
板层Ⅲ 板层Ⅳ
内有后角固有核
板层 Ⅴ 接受本体感觉传入纤维 板层Ⅵ 调节运动
中间内侧核——与内脏感觉有关
板层 Ⅶ
中间外侧核——与内脏运动有关 胸核（背核 Clarke柱）—非意识性本体感觉
骶副交感核—在S2 ~ 4节段相当于板层Ⅶ，内脏运动
板层 Ⅷ — 中间神经元，影响γ与α运动神经元
-7-
板层 Ⅸ— 前角运动神经元 前角内侧核：躯干肌 前角外侧核：四肢肌
⒊脊髓前角受损： 弛缓性瘫痪
⒋中央灰质周围病变： 感觉分离
-19-
练习题简答： 1 试述脊髓段与椎骨的对应关系。 2 胃大部切除术通常在剑突与脐之间做正中切
口，如果采用硬膜外麻醉，在何处进行穿刺， 为什么？ 3 试述下列传导束的起始、行程和功能。 名词解释： 薄束、楔束、脊髓丘脑束、脊髓小脑前束与后束、背外 侧束、皮质脊髓侧束、皮质脊髓前束、锥体束、固有束、 红核脊髓束、顶盖脊髓束、网状脊髓束、前庭脊髓束、 内侧纵束
神经系统
第十七章 中枢神经系统
第一节 脊 髓 一、位置和外形 二、内部结构 三、脊髓反射和损伤后表现
第二节 脑
-1-
第一节 脊 髓
一、位置和外形
前正中裂 前外侧沟
（一）位置：位于椎管内
上端平枕骨大孔处与延髓相连
下端(成人)平第1腰椎体下缘
（二）外形： 两个膨大：颈膨大 腰骶膨大
8条沟：前正中裂 1 后正中沟 1 前外侧沟 2 后外侧沟 2 后中间沟 2
-20-
重点和难点
重点： 1 脊髓节段与椎体对应关系 2 脊髓丘脑束 3 薄束与楔束 4 脊髓小脑前、后束 5 锥体束
难点： 1 脊髓灰质的板层 2 锥体外系的纤维束 3 脊髓损伤的病例分析
-21-
-2-
后正中沟 颈膨大
后中间沟 后外侧沟
腰骶膨大
终丝
脊髓圆锥 终丝 马尾 脊神经 （31对） 前根 （运动） 后根 （感觉）
后正中沟 脊髓圆锥
第一骶神经
后根
-3-
前根
终丝 马尾
终丝
后正中沟
传入神经
后根 传出神经
脊神经
-4-
前根
前正中裂
前外侧沟 脊神经节
（三）脊髓节段与椎骨的对应关系
脊髓节段:每一对脊神经及其前、后根的 根丝附着范围的脊髓构成一个脊髓节段。
脊髓丘脑侧束
脊髓丘脑前束
-13-
脊神经节
2 下行纤维束 （1）皮质脊髓束：躯体运动
1)皮质脊髓侧束 2)皮质脊髓前束 3)Barne 前外侧束
皮质脊髓侧束
前角运动元
-14-
皮质脊髓前束
（2）红核脊髓束：兴奋屈肌 （3）前庭脊髓束：兴奋伸肌 （4）网状脊髓束：躯干四肢近端肌的运动控制 （5）顶盖脊髓束：兴奋对侧颈肌，抑制同侧颈肌 （6）内侧纵束：调节眼球运动与头部姿势
α-运动神经元：支配跨关节的梭外肌纤维→关节运动 γ-运动神经元：支配梭内肌纤维→调节肌张力
Renshaw细胞：接受α-运动神经元轴突侧支并发分支 与其形成负反馈环路 板层 Ⅹ— 中央灰质：接受某些后根纤维
α -运动神经元 γ -运动神经元
-8-
肌梭
脊髓灰质板层与核团的对应关系
板层 Ⅰ Ⅱ Ⅲ、Ⅳ Ⅴ Ⅵ Ⅶ Ⅷ Ⅸ Ⅹ
等
-16-
1、牵张反射 （包括深反射和肌张力反射） 深反射（腱反射）：
肌肉、肌腱 脊神经后根 α-运动神经元 脊神经前根 肌肉收缩
-17-
2、屈曲反射
皮肤 脊神经后根
后角 中间神经元 α-运动神经元 脊神经前根
肌肉收缩
-18-
（二）脊髓损伤的一些表现
⒈脊髓全横断： 脊髓休克
⒉脊髓半横断： 布朗-色夸综合征
-5-
二、脊髓的内部结构
中央管 前角（前柱） 后角（后柱） 侧角（侧柱） 中间带 中央灰质：
灰质后连合 灰质前连合 白质 前索 外侧索 后索 白质前连合 网状结构
终室
灰质后连合 后角
前角 灰质前连合
-6-
后正中沟 后索
后外侧沟
外侧索
中央管
前正中裂
前索
前外侧沟
（一）灰质
Rexed 板层
板层 Ⅰ ——边缘层（海绵带） 板层 Ⅱ ——胶状质
内侧纵束
-15-
红核脊髓束
前庭脊髓束 网状脊髓束
三、脊髓反射和损伤表现 功能表现在两方面： ①上、下行传导径路的中继站； ②反射中枢。
（一）脊髓反射 1、单突触反射 2、躯体反射—骨骼肌的反射活动 牵张反射、屈曲反射、浅反射等
3、内脏反射—躯体内脏反射、内脏内脏反射和内脏躯体反 射，竖毛反射、膀胱排尿反射、直肠排便反射
对应的核团或部位 后角边缘核 胶状质 后角固有核 后角颈 网状核 后角基底部 中间带，背核 中间内侧核 中间外侧核 骶副交感核 前角底部，在颈、腰膨大处只占前角内侧部 前角内侧核 前角外侧核 中央灰质
-9-
（二）白质
楔束
薄束
皮质脊髓侧束 脊髓小脑后束 红核脊髓束
脊髓小脑前束 脊髓丘脑侧束
网状脊髓束