Symptom complexes of lesions of the cortico-muscular pathway at different levels. Spinal cord injury: symptoms and syndromes

Diseases of the spinal cord, at all times, were a fairly common problem. Even minor lesions of this most important structure of the central nervous system can lead to very sad consequences.
Spinal cord

This is the main part, along with the brain, of the human central nervous system. It is an oblong cord 41-45 cm long in adults. It performs two very important functions:

1. conductive - information is transmitted in a two-way direction from the brain to the limbs, namely along the numerous tracts of the spinal cord;
2. reflex - the spinal cord coordinates the movements of the limbs.

Diseases of the spinal cord, or myelopathy, is a very large group of pathological changes that differ in symptoms, etiology and pathogenesis.

They are united by only one thing - the defeat of various structures of the spinal cord. At the moment, there is no single international classification of myelopathy.

According to etiological signs, diseases of the spinal cord are divided into:

• vascular;
• compression, including those associated with intervertebral hernias and injuries of the spinal column;
• degenerative;
• infectious;
• carcinomatous;
• inflammatory.

The symptoms of diseases of the spinal cord are very diverse, since it has a segmental structure.

Common symptoms of spinal cord injury include pain in the back, aggravated by physical exertion, general weakness, dizziness.

The remaining symptoms are very individual, and depend on the damaged area of ​​the spinal cord.

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Symptoms of spinal cord injury at different levels

If the I and II cervical segment of the spinal cord is damaged, it leads to the destruction of the respiratory and cardiac center in the medulla oblongata. Their destruction leads in 99% of cases to the death of the patient, due to cardiac arrest and breathing.

Tetraparesis is always noted - a complete shutdown of all limbs, as well as most of the internal organs.
Damage to the spinal cord at the level of the III-V cervical segments is also extremely life-threatening.

The innervation of the diaphragm stops, and is possible only due to the respiratory muscles of the intercostal muscles. When the damage does not spread to the entire cross-sectional area of ​​the segment, individual tracts may be affected, thereby causing only paraplegia - disabling the upper or lower extremities.

Damage to the cervical segments of the spinal cord in most cases is caused by injuries: hitting the head while diving, as well as in an accident.

If the V-VI cervical segments are damaged, the respiratory center remains intact, weakness of the muscles of the upper shoulder girdle is noted.

The lower extremities still remain without movement and sensitivity with a complete lesion of the segments. The level of damage to the thoracic segments of the spinal cord is easy to determine. Each segment has its own dermatome.

The T-I segment is responsible for the innervation of the skin and muscles of the upper chest and armpit; segment T-IV - pectoral muscles and skin area in the nipple area; the thoracic segments from T-V to T-IX innervate the entire region of the chest, and from T-X to T-XII the anterior abdominal wall.

Consequently, damage to any of the segments in the thoracic region will lead to loss of sensitivity and limitation of movement at the level of the lesion and below. There is weakness in the muscles of the lower extremities, the absence of reflexes of the anterior abdominal wall. Severe pain is noted at the site of injury.

As for damage to the lumbar regions, this leads to loss of movement and sensitivity of the lower extremities.

If the lesion is located in the upper segments of the lumbar region, paresis of the thigh muscles occurs, and the knee reflex disappears.

If the lower lumbar segments are affected, then the muscles of the foot and lower leg suffer.

Lesions of various etiologies of the cerebral cone and cauda equina lead to dysfunction of the pelvic organs: urinary and fecal incontinence, erection problems in men, lack of sensitivity in the genital area and perineum.

Vascular diseases of the spinal cord

This group of diseases includes strokes of the spinal cord, which can be both ischemic and hemorrhagic.

Vascular diseases of the brain and spinal cord have a common etiology - atherosclerosis.

The main difference between the consequences of these diseases is a violation of higher nervous activity in vascular diseases of the brain, loss of various types of sensitivity and muscle paresis.

Hemorrhagic stroke of the spinal cord, or spinal cord infarction, is more common in young people as a result of vascular ruptures. Predisposing factors are increased tortuosity, fragility and vascular failure.

Most often, it occurs as a result of genetic diseases or disorders during embryonic development, which causes abnormal development of the spinal cord.

Rupture of a blood vessel can occur anywhere in the spinal cord, and symptoms can only be given according to the affected segment.

In the future, as a result of the movement of a blood clot with CSF through the subarachnoid spaces, it is possible for the lesions to spread to neighboring segments.

Ischemic stroke of the spinal cord occurs in the elderly, as a result of atherosclerotic changes in blood vessels. A spinal cord infarction can cause damage not only to the vessels of the spinal cord, but also to the aorta and its branches.

As in the brain, in the spinal cord, transient ischemic attacks can occur, which are accompanied by temporary symptoms in the corresponding segment.

Such passing attacks of ischemia in neurology are called intermittent myelogenous claudication. Unterharnscheidt syndrome is also distinguished as a separate pathology.

MRI diagnostics of limb vessels

Intermittent myelogenous claudication occurs during prolonged walking or other physical exertion. It manifests itself in sudden numbness and weakness of the lower extremities. After a short rest, the complaints disappear.

The cause of this disease is atherosclerotic changes in the vessels in the region of the lower lumbar segments, resulting in ischemia of the spinal cord.

The disease should be differentiated from damage to the arteries of the lower extremities, for which MRI is performed to diagnose the vessels of the extremities and aorta with a contrast agent.

Syndrome of Unterharnscheidt. This disease first manifests itself mainly at a young age.

Caused by vasculitis and malformation of the vessels of the vertebrobasilar basin.

Syndromes of lesions of the spinal cord in this disease: sharply there is tetraparesis, loss of consciousness, which disappear after a few minutes.

It should be diagnosed with hysterical personality disorders and an epileptic seizure.

Compression injuries of the spinal cord

Compression, or infringement of the spinal cord occurs for several reasons:

1. Vertebral hernias- the resulting hernial sac compresses the segment. Most often, it is not a complete clamping of the entire segment, but of its horns: anterior, lateral or posterior. If the anterior horns of the spinal cord are damaged, then there is a decrease in muscle tone and sensitivity in the corresponding segment or dermatome, since the anterior horns have sensory and motor fibers. When squeezing the lateral horns, there are violations of the autonomic nervous system in the corresponding segment. The manifestations of this disease are diverse: pupils dilate for no reason, sweating, mood swings, tachycardia, constipation, increased blood glucose and blood pressure. Often, when referring to therapists with such complaints, symptomatic treatment is prescribed, and a diagnostic search is directed to the affected organ. Only with the appearance of back pain, a correct diagnosis is made after an MRI. Compression of the posterior horns leads to a partial, or less often complete loss of sensation, also in a certain segment. Diagnosis in such cases does not cause any particular difficulties. The treatment of all intervertebral hernias is surgical. All non-traditional and traditional conservative methods of treatment only temporarily save from the symptoms of the disease.
2. Tumor in the spinal cord or vertebrae.Compression fracture of a vertebra
3. Vertebral compression fractures. These types of fractures most often occur when falling from a height on the legs, and less often on the back. Fragments of the vertebrae can compress or dissect the spinal cord. In the first case, the symptoms are the same as with hernias. In the second case, the forecasts are much worse. If the spinal cord is cut, the conduction system will be completely disrupted in the underlying sections. Unfortunately, the consequences of such injuries remain throughout life.
   Most often, incomplete dissection of the spinal cord occurs, that is, only some spinal tracts are damaged, which again leads to a variety of symptoms. Nowadays, computed or magnetic resonance imaging allows to determine the location of the lesion, with an accuracy of 0.1 mm.
4. Degenerative processes of the spine are the most common causes of spinal cord injury. Cervical spondylosis and lumbar (lumbar) osteoarthritis of the spine is the destruction of the bone tissue of the vertebrae, with the formation of connective tissue, as well as osteophytes. As a result of tissue growth, compression of the cervical spinal cord occurs. Symptoms in this disease are similar to hernial compression, but more often it has a concentric lesion, which contributes to damage to all the horns and roots of the spinal cord.
5. Infectious diseases of the spinal cord- a group of diseases of various etiologies. According to the duration of the course, acute, subacute and chronic myelitis are distinguished; according to the degree of prevalence: transverse, multifocal, limited.

Due to the occurrence, the following forms of myelitis are distinguished:

• Viral myelitis. The most common pathogens are viruses of poliomyelitis, herpes, rubella, measles, influenza, less often hepatitis and mumps. Neurological symptoms are diverse and depend on the affected segments and the spread of the infection. Common symptoms for all infectious lesions are fever, severe headaches and back pain, impaired consciousness, increased muscle tone in the limbs. The greatest danger is the involvement in the infectious process of the cervical spinal cord. In the cerebrospinal fluid, during a lumbar puncture, a high content of protein and neutrophils is found.
• bacterial myelitis. Occurs in acute meningococcal meningitis, as a result of the movement of cerebrospinal fluid along with bacteria, and also as a consequence of syphilis. Meningococcal meningitis of the spinal cord is very severe, with total inflammation of the membranes of the brain and spinal cord. Even against the background of modern treatment, mortality remains quite high. Currently, long-term consequences and complications of syphilis are quite rare, but still relevant. One such complication is the spinal cord. Tabes spinalis is a tertiary neurosyphilis that affects the spinal roots and posterior columns, leading to loss of sensation in certain segments. Tuberculosis of the spinal cord
• Tuberculosis of the spinal cord stands apart among the lesions of a bacterial nature. Tuberculosis enters the spinal cord in three ways: hematogenous - with primary tuberculosis complex and disseminated tuberculosis, lymphogenous - with tuberculosis of the lymph nodes, contact - with a close location of the infection, for example, in the spine. Destroying bone tissue, mycobacterium creates cavernous foci, which create a compression effect on the segments of the spinal cord. At the same time, the back hurts in the affected area, which undoubtedly facilitates the diagnostic task.
• Oncological diseases spinal cord is divided into malignant and benign. The former include ependymoma of the spinal cord and sarcoma. An ependymoma grows from cells lining the central canal of the spinal cord. With a significant increase, compression of the spinal tracts occurs, which leads primarily to visceral disorders and loss of segmental sensitivity, followed by paraplegia. Sarcoma grows from poorly differentiated connective tissue cells, i.e. from muscles, bones, dura mater. The greatest danger is presented by clear cell sarcoma, which competes with melanoma in terms of malignancy and metastasis, but is much less common. Benign neoplasms of the spinal cord include lipoma, hemangioma, and dermoid cyst of the spinal cord. Since these tumors are extramedullary, the treatment is surgical. Rapid and significant growth (dermoid cyst of the spinal cord reaches 15 cm in length), early manifestation of pain and radicular syndromes of the spinal cord, forces a laminectomy of the spine, with removal of the neoplasm, to decompress and prevent permanent paralysis. Meningioma of the spinal cord develops from cells of the arachnoid membrane. Meningioma, like a cyst and lipoma, can reach an impressive size, causing compression of the roots of the spinal cord. But a distinctive feature of meningioma is the frequent development of massive bleeding, which is quite difficult to stop. Treatment of meningioma is also surgical. Often, meningiomas are already present from birth, but due to slow growth, they appear already in adulthood. Inflammation of the spinal cord
• Inflammatory diseases spinal cord include most of the above. Inflammation of the spinal cord and meninges occurs with infectious diseases, with carcinomatosis, with degenerative changes. The reaction that occurs both in the brain itself and in the membranes and spine leads to inflammatory edema and compression compression of the roots, and sometimes the horns of the spinal cord.

Source: http://lechuspinu.ru/drugie_bolezni/zabolevaniya-spinnogo-mozga.html

Diseases of the spinal cord

Knowledge of the anatomical structure of the spinal cord (segmental principle) and spinal nerves extending from it allows neuropathologists and neurosurgeons to accurately determine the symptoms and syndromes of damage in practice.

During a neurological examination of the patient, descending from top to bottom, they find the upper limit of the onset of a disorder in the sensitivity and motor activity of the muscles. It should be remembered that the vertebral bodies do not correspond to the segments of the spinal cord located under them.

The neurological picture of spinal cord injury depends on its damaged segment.

As a person grows, the length of the spinal cord lags behind the length of the surrounding spine.

During its formation and development, the spinal cord grows more slowly than the spine.

In adults, the spinal cord ends at the level of the body of the first lumbar L1 vertebra.

The nerve roots extending from it will go further down to innervate the limbs or organs of the small pelvis.

The clinical rule used in determining the level of damage to the spinal cord and its nerve roots:

1. neck roots (except neck C8) leave the spinal canal through holes above their corresponding vertebral bodies,
2. thoracic and lumbar roots leave the spinal canal under the vertebrae of the same name,
3. the upper cervical segments of the spinal cord lie behind the vertebral bodies with the same numbers,
4. the lower cervical segments of the spinal cord lie one segment above their corresponding vertebra,
5. the upper thoracic segments of the spinal cord lie two segments higher,
6. the lower thoracic segments of the spinal cord lie three segments higher,
7. lumbar and sacral segments of the spinal cord (the latter form the brain cone (conus medullaris) are localized behind the vertebrae Th9–L1.

To clarify the distribution of various pathological processes around the spinal cord, especially in spondylosis, it is important to carefully measure the sagittal diameters (lumen) of the spinal canal. The diameters (lumen) of the spinal canal in an adult are normal:

• at the cervical level of the spine - 16-22 mm,
• at the thoracic level of the spine -16-22 mm,
• L1–L3- about 15-23 mm,
• at the level of the lumbar vertebrae L3–L5 and below - 16-27 mm.

Neurological syndromes of diseases of the spinal cord

With damage to the spinal cord at one level or another, the following neurological syndromes will be detected:

1. loss of sensation below the level of his spinal cord injury (sensitivity disorder level)
2. weakness in the limbs innervated by descending nerve fibers of the cortico-spinal tract from the level of spinal cord injury

Sensory disturbances (hypesthesia, paresthesia, anesthesia) may appear in one or both feet. Sensory disturbance may extend upward, mimicking peripheral neuropathy.

In the event of a complete or partial interruption of the corticospinal and bulbospinal tracts at the same level of the spinal cord, the patient develops paralysis of the muscles of the upper and/or lower extremities (paraplegia or tetraplegia).

In this case, the symptoms of central paralysis are revealed:

• increased muscle tone
• deep tendon reflexes are increased
• a pathological symptom of Babinsky is detected

During examination of a patient with spinal cord injury, segmental disorders are usually detected:

1. a band of sensitivity changes near the upper level of conductive sensory disorders (hyperalgesia or hyperpathia)
2. hypotension and muscle atrophy
3. isolated prolapse of deep tendon reflexes

The level of sensory disturbances according to the conduction type and segmental neurological symptoms roughly indicate the localization of the transverse lesion of the spinal cord in the patient.

An accurate localizing sign is pain felt along the midline of the back, especially at the thoracic level. Pain in the interscapular region may be the first symptom of spinal cord compression in a patient.

Radicular pain indicates the primary localization of the spinal cord lesion in the region of its outer masses. When the cone of the spinal cord is affected, pain is often noted in the lower back.

In the early stages of a transverse spinal cord injury, the limbs may show decreased muscle tone (hypotension) rather than spasticity due to the patient's spinal shock. Spinal shock can last for several weeks.

It is sometimes mistaken for an extensive segmental lesion. Later tendon and periosteal reflexes in the patient become elevated.

In transverse lesions, especially those caused by infarction, paralysis is often preceded by short clonic or myoclonic convulsions in the limbs.

Another important symptom of transverse spinal cord injury is dysfunction of the pelvic organs, which manifests itself in the form of retention of urine and feces in the patient.

Compression within (intramedullary) or around the spinal cord (extramedullary) may present clinically in a similar manner.

Therefore, one neurological examination of the patient is not enough to determine the localization of the spinal cord lesion.

Neurological signs that testify in favor of the localization of pathological processes around the spinal cord (extramedullary) include:

• radicular pain,
• half spinal Brown-Séquard syndrome,
• symptoms of damage to peripheral motor neurons within one or two segments, often asymmetrical,
• early signs of involvement of the cortico-spinal tract,
• a significant decrease in sensitivity in the sacral segments,
• early and pronounced changes in the cerebrospinal fluid (CSF).

Neurological signs that testify in favor of the localization of pathological processes within the spinal cord (intramedullary) include:

1. hard to localize burning pain,
2. dissociated loss of pain sensitivity while maintaining musculo-articular sensitivity,
3. preservation of sensitivity in the perineum and sacral segments,
4. late onset and less pronounced pyramidal symptoms,
5. normal or slightly altered composition of cerebrospinal fluid (CSF).

A lesion within the spinal cord (intramedullary) that involves the innermost fibers of the spinothalamic pathways but does not involve the outermost fibers that provide sensation to the sacral dermatomes will present with no signs of injury. The perception of pain and temperature stimuli in the sacral dermatomes (nerve roots S3–S5).

Brown-Séquard syndrome is a complex of symptoms of a half lesion of the diameter of the spinal cord. Brown-Sequard syndrome is clinically manifested by:

• on the side of the spinal cord injury - paralysis of the muscles of the arm and / or leg (monoplegia, hemiplegia) with loss of muscle-articular and vibrational (deep) sensitivity,
• on the opposite side - loss of pain and temperature (superficial) sensitivity.

The upper limit of pain and temperature sensitivity disorders in Brown-Séquard syndrome is often determined 1-2 segments below the site of spinal cord injury, since the fibers of the spinothalamic pathway after the formation of a synapse in the dorsal horn of the spinal cord pass into the opposite lateral funiculus, rising up. If there are segmental disorders in the form of radicular pain, muscle atrophy, extinction of tendon reflexes, then they are usually unilateral.

The spinal cord is supplied with blood by one anterior spinal and two posterior spinal arteries.

If the lesion of the spinal cord is limited to the central part or affects it, then it will mainly damage the gray matter neurons and segmental conductors that produce their decussation at this level. This is observed with a bruise during a spinal cord injury, syringomyelia, tumors and vascular lesions in the basin of the anterior spinal artery.

With a central lesion of the cervical spinal cord, there are:

1. weakness of the arm, which is more pronounced compared to the weakness of the leg,
2. dissociated sensory disorder (analgesia, i.e. loss of pain sensitivity with distribution in the form of a "cape on the shoulders" and lower neck, without anesthesia, i.e. loss of tactile sensations, and with the preservation of vibration sensitivity).

Lesions of the conus of the spinal cord, localized in the region of the vertebral body L1 or below, compress the spinal nerves that make up the cauda equina. This causes peripheral (flaccid) asymmetric paraparesis with areflexia.

This level of damage to the spinal cord and its nerve roots is accompanied by dysfunction of the pelvic organs (dysfunction of the bladder and intestines).

The distribution of sensory disorders on the patient's skin resembles the outlines of a saddle, reaches the L2 level and corresponds to the zones of innervation of the roots included in the cauda equina.

Achilles and knee reflexes in such patients are reduced or absent. Often, patients report pain that radiates to the perineum or thighs.

In pathological processes in the region of the cone of the spinal cord, pain is less pronounced than in lesions of the cauda equina, and disorders of the bowel and bladder function occur earlier. Achilles reflexes are extinguished.

Compression processes can simultaneously capture both the cauda equina and the conus of the spinal cord, which causes a combined syndrome of damage to peripheral motor neurons with an increase in reflexes and the appearance of a pathological symptom of Babinsky.

When the spinal cord is damaged at the level of the foramen magnum, patients experience weakness of the muscles of the shoulder girdle and arm, followed by weakness of the leg and arm on the opposite side on the side of the lesion. Volumetric processes of this localization sometimes give pain in the neck and neck, extending to the head and shoulders. Another evidence of a high cervical level (up to the segment Th1) lesion serves as Horner's syndrome.

Some diseases of the spine can cause sudden myelopathy without previous symptoms (similar to a spinal stroke).

These include epidural hemorrhage, hematomyelia, spinal cord infarction, prolapse (prolapse, extrusion) of the nucleus pulposus of the intervertebral disc, subluxation of the vertebrae.

Chronic myelopathy occurs with the following diseases of the spine or spinal cord:

Source: http://www.minclinic.ru/vertebral/bolezni_spinnogo_mozga.html

Major diseases of the spinal cord

The spinal cord belongs to the central nervous system. It is connected to the brain, nourishes it and the shell, transmits information. the function of the spinal cord is to correctly transmit incoming impulses to other internal organs.

It consists of various nerve fibers through which all signals and impulses are transmitted. Its basis is white and gray matter: white is made up of processes of nerves, gray contains nerve cells.

The gray matter is located in the core of the spinal canal, while the white matter completely surrounds it and protects the entire spinal cord.

Spinal cord diseases are all characterized by a great risk not only for health, but also for human life. Even minor deviations of a temporary nature sometimes cause irreversible consequences.

Thus, incorrect posture can doom the brain to starvation and trigger a number of pathological processes. It is impossible not to notice the symptoms of disorders in the functioning of the spinal cord.

Almost all the symptoms that can be caused by diseases of the spinal cord can be classified as severe manifestations.

Symptoms of spinal cord disease

The mildest symptoms of spinal cord disease are dizziness, nausea, periodic pain in muscle tissue.

The intensity in diseases can be moderate and variable, but more often the signs of damage to the spinal cord are more dangerous.

In many ways, they depend on which particular department has undergone the development of pathology and what disease is developing.

Common symptoms of spinal cord disease:

• loss of sensation in a limb or part of the body;
• aggressive back pain in the spine;
• uncontrolled emptying of the bowels or bladder;
• pronounced psychosomatics;
• loss or limitation of movement;
• severe pain in the joints and muscles;
• paralysis of the limbs;
• amyotrophy.

Symptoms may vary depending on which substance is affected. In any case, signs of damage to the spinal cord cannot be overlooked.

Spinal cord compression

The concept of compression means a process in which squeezing, squeezing the spinal cord occurs.

This condition is accompanied by multiple neurological symptoms that can cause some diseases. Any displacement or deformation of the spinal cord always disrupts its functioning.

Often, diseases that people consider safe cause severe damage not only to the spinal cord, but also to the brain.

So, otitis media or sinusitis can cause an epidular abscess. In diseases of the ENT organs, the infection can quickly enter the spinal cord and provoke infection of the entire spinal column.

Quite quickly, the infection reaches the cerebral cortex and then the consequences of the disease can be catastrophic. In severe otitis media, sinusitis, or a prolonged phase of the disease, meningitis and encephalitis occur.

The treatment of such diseases is complex, the consequences are not always reversible.

Read also: Cauda equina syndrome of the spinal cord and its treatment

Hemorrhages in the region of the spinal cord are accompanied by storm pains throughout the spine.

This happens more often from injuries, bruises, or in case of a serious thinning of the walls of the vessels surrounding the spinal cord.

Locality can be absolutely any, more often the cervical region suffers as the weakest and most unprotected from damage.

The progression of a disease such as osteochondrosis, arthritis can also cause compression. Osteophytes, as they grow, put pressure on the spinal cord, intervertebral hernias develop. As a result of such diseases, the spinal cord suffers and loses its normal functioning.

Tumors

As in any organ of the body, tumors can appear in the spinal cord. It is not even malignancy that matters, since all tumors are dangerous for the spinal cord. The value is given to the location of the neoplasm. They are divided into three types:

1. extradural;
2. intradural;
3. intramedullary.

Extradural are the most dangerous and malignant, have a tendency to rapid progression. Occur in the hard tissue of the brain membrane or in the vertebral body. The surgical solution is rarely successful, associated with a risk to life. This category also includes tumors of the prostate and mammary glands.

Intradural are formed under the hard tissue of the lining of the brain. These tumors are neurofibromas and meningiomas.

Intramedullary tumors are localized directly in the brain itself, in its main substance. Malignancy is critical.

For diagnosis, MRI is used more often as a study that gives a complete picture of spinal cord carcinoma. This disease is treated only surgically. All tumors have one thing in common: conventional therapy has no effect and does not stop metastases.

Therapy is appropriate only after a successful operation.

Intervertebral hernia

Intervertebral hernias occupy a leading position in a number of diseases of the spinal cord. Primary protrusions are formed, only over time it becomes a hernia.

With such a disease, deformation and rupture of the fibrous ring occurs, which serves as a fixator for the disc core. As soon as the ring is destroyed, the contents begin to flow out and often end up in the spinal canal.

If the intervertebral hernia has affected the spinal cord, myelopathy is born. The disease myelopathy means dysfunction of the spinal cord.

Sometimes the hernia does not manifest itself and the person feels normal. But more often the spinal cord is involved in the process and this causes a number of neurological symptoms:

• pain in the affected area;
• sensitivity change;
• depending on the locality, loss of control over the limbs;
• numbness, weakness;
• violations in the functions of internal organs, more often the pelvis;
• the pain spreads from the waist to the knee, capturing the thigh.

Such signs usually manifest themselves, provided that the hernia has reached an impressive size.

Treatment is often therapeutic, with the appointment of drugs and physiotherapy.

An exception is only in cases where there are signs of failure in the work of internal organs or in case of serious damage.

Myelopathy

Non-compressive myelopathy is a complex disease of the spinal cord. There are several varieties, but it is difficult to distinguish between them.

Even MRI does not always accurately establish the clinical picture.

The CT scan results always show the same picture: severe swelling of the tissues without any signs of compression of the spinal cord from the outside.

Necrotizing myelopathy involves several segments of the spine. This form is a kind of echo of significant carcinomas, removed by localization. Over time, it provokes the birth of paresis and problems with the pelvic organs in patients.

Carcinomatous meningitis is found in most cases when there is a progressive cancerous tumor in the body. Most often, primary carcinoma is located either in the lungs or in the mammary glands.

Prognosis without treatment: no more than 2 months. If the treatment is successful and on time, the life span is up to 2 years. Most deaths are associated with running processes in the central nervous system. These processes are irreversible, brain function cannot be restored.

Inflammatory myelopathy

Most often, arachnoiditis is diagnosed as one of the types of inflammatory process in the brain or spinal cord. It must be said that such a diagnosis is not always correct and clinically confirmed.

A detailed and qualitative examination is required. Occurs against the background of transferred otitis, sinusitis or against the background of severe intoxication of the whole organism.

Arachnoiditis develops in the arachnoid membrane, which is one of the three membranes of the brain and spinal cord.

A viral infection provokes a disease such as acute myelitis, which is similar in symptoms to those of other inflammatory diseases of the spinal cord.

Diseases such as acute myelitis require immediate intervention and identification of the source of infection.

The disease is accompanied by ascending paresis, severe and growing weakness in the limbs.

Infectious myelopathy is expressed more specifically. The patient cannot always understand and correctly assess his condition. More often, the cause of infection is herpes zoster, the disease is complex and requires long-term therapy.

spinal cord infarction

For many, even the concept is as unfamiliar as a spinal cord infarction.

But due to severe circulatory disorders, the spinal cord begins to starve, its functions are so upset that it leads to necrotic processes.

There are blood clots, the aorta begins to exfoliate. Almost always several departments are affected at once. A vast area is covered, a general ischemic infarction develops.

Also Read: Symptoms of Inflammation of the Spinal Cord

Even a minor bruise or injury to the spinal column can be the cause. If there is already an intervertebral hernia, then it can collapse in case of injury.

Then its particles enter the spinal cord. This phenomenon is unexplored and poorly understood, there is no clarity in the very principle of the penetration of these particles.

There is only the fact of detection of particles of the destroyed tissue of the nucleus pulposus of the disc.

It is possible to determine the development of such a heart attack according to the patient's condition:

1. sudden weakness to failure of the legs;
2. nausea;
3. temperature drop;
4. Strong headache;
5. fainting.

Diagnosis only with the help of MRI, treatment is therapeutic. A disease such as a heart attack, it is important to stop it in time and stop further damage. The prognosis is often positive, but the quality of life of the patient may worsen.

Chronic myelopathy

Osteochondrosis is recognized as a killer of the spinal column, its diseases and complications can rarely be reversed to a tolerable state.

This is due to the fact that 95% of patients never carry out prophylaxis, do not visit a specialist at the onset of the disease. Seek help only when the pain does not allow to live.

But at such stages, osteochondrosis already triggers processes such as spondylosis.

Spondylosis is the end result of degenerative changes in the structure of spinal cord tissues. Violations cause bone growths (osteophytes), which ultimately compress the spinal canal.

The pressure can be strong and cause stenosis of the central canal. Stenosis is the most dangerous condition, for this reason a chain of processes can start that involve the brain and central nervous system in the pathology.

Treatment of spondylosis is often symptomatic and is aimed at alleviating the patient's condition. The best result can be accepted if in the end it is possible to achieve a stable remission and delay the further progression of spondylosis. It is impossible to reverse spondylosis.

Lumbar stenosis

The concept of stenosis always means squeezing and narrowing of some organ, channel, vessel. And almost always stenosis poses a threat to human health and life.

Lumbar stenosis is a critical narrowing of the spinal canal and all its nerve endings. The disease can be both congenital pathology and acquired.

Stenosis can be caused by many processes:

• osteophytes;
• displacement of the vertebrae;
• hernia;
• protrusions.

Sometimes a congenital anomaly worsens an acquired one.

Stenosis can be in any department, it can cover part of the spinal column, and the entire spine. The condition is dangerous, the solution is often surgical.

I. Damage to the peripheral nerve - flaccid paralysis of the muscles innervated by this nerve. Occurs with damage to the peripheral and cranial nerves (neuritis, neuropathy). This type of distribution of paralysis is called neural.

II. Multiple lesions of the nerve trunks - signs of peripheral paralysis are observed in the distal extremities. This pattern is called polyneuritic distribution of paralysis. Such paralysis (paresis) is associated with the pathology of the distal parts of several peripheral or cranial nerves (polyneuritis, polyneuropathy).

III. The defeat of the plexus (cervical, brachial, lumbar, sacral) is characterized by the occurrence of flaccid paralysis in the muscles innervated by this plexus.

IV. Damage to the anterior horns of the spinal cord, anterior roots of the spinal cord, nuclei of the cranial nerves characterized by the occurrence of peripheral paralysis in the area of ​​the affected segment. The defeat of the anterior horns, in contrast to the defeat of the anterior roots, has clinical features:

Presence of fasciculations and fibrillations

- "mosaic" lesions within one muscle

Early and rapidly progressive atrophy with regeneration reaction.

V. The defeat of the lateral columns of the spinal cord is characterized by the occurrence of central paralysis below the level of the lesion on the side of the focus and the loss of pain and temperature sensitivity on the opposite side.

Due to pathologies of the lateral cortico-spinal tract. In this case, central paralysis is determined on the side of the focus in the muscles that receive innervation from the segments from the level of the lesion and below.

VI. Transverse spinal cord injury(bilateral defeat of the pyramidal bundles and gray matter).

· With lesions of the upper cervical segments of the spinal cord (C1-C4) the pyramidal tracts for the upper and lower extremities will be damaged - central paralysis of the upper and lower extremities will occur (spastic tetraplegia).

· With damage to the cervical thickening of the spinal cord the pyramidal tracts for the lower extremities will be damaged, as well as the motor neurons of the anterior horns that innervate the upper extremities - peripheral paralysis for the upper extremities and central paralysis for the lower extremities will occur (upper flaccid paraplegia, lower spastic paraplegia).

· With lesions at the level of the thoracic segments the pyramidal tracts for the lower extremities are interrupted, the upper extremities remain unaffected ( lower spastic paraplegia).

· With a lesion at the level of the lumbar thickening the motor neurons of the anterior horns that innervate the lower limbs are destroyed (lower flaccid paraplegia).

VII. Damage to the pyramidal bundle in the brain stem observed with lesions in one half of the trunk. It is characterized by the occurrence of central hemiplegia on the opposite side of the focus and paralysis of any cranial nerve on the side of the focus. This syndrome is called alternating.

VIII. Damage to the internal capsule characterized by the appearance of a contralateral "syndrome of three hemi-": hemiplegia, hemianesthesia, hemianopsia.

IX. Damage to the anterior central gyrus x characterized by the occurrence of central monoparesis, depending on the location of the lesion. For example, brachyfacial paralysis with damage to the lower part of the contralateral precentral gyrus.

Irritation of the anterior central gyrus causes epileptic seizures; seizures can be localized or generalized. With local convulsions, the patient's consciousness is preserved (such paroxysms are called cortical or Jacksonian epilepsy).

Clinical symptoms and diagnosis of movement disorders.

Diagnosis of movement disorders includes the study of a number of indicators of the state of the motor sphere. These indicators are:

1) motor function

2) visible muscle changes

3) muscle tone

4) reflexes

5) electrical excitability of nerves and muscles

motor function

It is checked by examining active (voluntary) movements in the striated muscles.

By severity Disorders of voluntary movements are divided into paralysis (plegia) and paresis. Paralysis- this is a complete loss of voluntary movements in certain muscle groups; paresis- incomplete loss of voluntary movements, manifested by a decrease in muscle strength in the affected muscles.

By prevalence paralysis and paresis distinguish the following options:

- monoplegia or monoparesis- disorder of voluntary movements in one limb;

- hemiplegia or hemiparesis- disorder of voluntary movements in the limbs of one half of the body;

- paraplegia or paraparesis- a disorder of voluntary movements in symmetrical limbs (in the hands - upper paraplegia or paraparesis, in the legs - lower paraplegia or paraparesis);

- triplegia or triparesis- motor disorders in three limbs;

- tetraplegia or tetraparesis - disorders of voluntary movements in all four limbs.

Paralysis or paresis due to damage to the central motor neuron is designated as central; paralysis or paresis caused by damage to a peripheral motor neuron is called peripheral.

Method for detecting paralysis and paresis includes:

1) external examination

2) study of the volume of active movements

3) study of muscle strength

4) conducting special samples or tests to detect mild paresis

1) External examination allows you to detect or suspect a particular defect in the state of motor function by the patient's facial expressions, his posture, the transition from a lying position to a sitting position, getting up from a chair. The paretic arm or leg often takes a forced position up to the development of contractures. So, a patient with central hemiparesis can be "recognized" by the Wernicke-Mann posture - flexion contracture in the arm and extensor contracture in the leg ("the arm asks, the leg mows").

Particular attention is paid to the gait of the patient. For example, "cock" gait and steppage with paresis of the peroneal muscle group.

2) Volume of active movements is defined as follows. On the instructions of the doctor, the patient himself makes active movements, and the doctor visually assesses their possibility, volume and symmetry (left and right). Usually, a series of basic movements are examined in order from top to bottom (head, cervical spine, trunk muscles, upper and lower limbs).

3) muscle strength explored in parallel with active movements. When examining muscle strength, the following method is used: the patient is asked to perform an active movement, then the patient holds the limb in this position with maximum strength, and the doctor tries to move in the opposite direction. At the same time, he evaluates and compares on the left and on the right the degree of effort that is required for this. The study is evaluated by five-point system: full muscle strength 5 points; slight decrease in strength (yielding) - 4 points; moderate decrease in strength (active movements in full under the action of gravity on the limb) - 3 points; the possibility of movement in full only after the elimination of gravity (the limb is placed on a support) - 2 points; preservation of movement (with barely noticeable muscle contraction) - 1 point. In the absence of active movement, if the weight of the limb is not taken into account, the strength of the studied muscle group is assumed to be zero. With muscle strength of 4 points, they talk about mild paresis, in 3 points - about moderate, in 2-1 - about deep.

4) Special samples and tests it is necessary to carry out in the absence of paralysis and clearly perceptible paresis. With the help of tests, it is possible to identify muscle weakness that the patient does not subjectively feel, i.e. the so-called "hidden" paresis.

Table No. 3. Samples for the detection of latent paresis

Spinal cord(medulla spinalis) - part of the central nervous system located in the spinal canal. The spinal cord has the appearance of a white cord, somewhat flattened from front to back in the area of ​​thickenings and almost round in other departments.

In the spinal canal, it extends from the level of the lower edge of the foramen magnum to the intervertebral disc between the 1st and 2nd lumbar vertebrae. At the top, the spinal cord passes into the brain stem, and at the bottom, gradually decreasing in diameter, it ends with a cerebral cone.

In adults, the spinal cord is much shorter than the spinal canal, its length varies from 40 to 45 cm. The cervical thickening of the spinal cord is located at the level of the III cervical and I thoracic vertebrae; the lumbosacral thickening is located at the level of the X-XII thoracic vertebra.

The anterior median (15) and posterior median sulcus (3) divide the spinal cord into symmetrical halves. On the surface of the spinal cord, at the exit points of the ventral (anterior) (13) and dorsal (posterior) (2) roots, two less deep furrows are revealed: anterior lateral and posterior lateral.

The section of the spinal cord corresponding to two pairs of roots (two anterior and two posterior) is called a segment. The anterior and posterior roots emerging from the segments of the spinal cord unite into 31 pairs of spinal nerves. The anterior root is formed by the processes of the motor neurons of the nuclei of the anterior horns of the gray matter (12). The composition of the anterior roots of the VIII cervical, XII thoracic, and two upper lumbar segments, along with the axons of motor somatic neurons, includes neurites of the cells of the sympathetic nuclei of the lateral horns, and the anterior roots of the II-IV sacral segments include the processes of neurons of the parasympathetic nuclei of the lateral intermediate substance of the spinal cord. The posterior root is represented by the central processes of pseudo-unipolar (sensitive) cells located in the spinal ganglion. The central canal passes through the gray matter of the spinal cord along its entire length, which, expanding cranially, passes into the IV ventricle of the brain, and in the caudal part of the cerebral cone forms the terminal ventricle.

The gray matter of the spinal cord, consisting mainly of nerve cell bodies, is located in the center. On transverse sections, it resembles the letter H in shape or has the form of a “butterfly”, the anterior, posterior and lateral sections of which form the horns of gray matter. The anterior horn is somewhat thickened and located ventrally. The posterior horn is represented by a narrow dorsal part of the gray matter extending almost to the outer surface of the spinal cord. The lateral intermediate gray matter forms the lateral horn.
Longitudinal accumulations of gray matter in the spinal cord are called pillars. Anterior and posterior columns are present throughout the spinal cord. The lateral column is somewhat shorter; it starts at the level of the VIII cervical segment and extends to the I-II lumbar segments. In the columns of gray matter, nerve cells are combined into more or less distinct groups-nuclei. Around the central canal is the central gelatinous substance.
White matter occupies the peripheral parts of the spinal cord and consists of processes of nerve cells. Furrows located on the outer surface of the spinal cord divide the white matter into the anterior, posterior and lateral cords. Nerve fibers, common in origin and function, inside the white matter are combined into bundles or tracts that have clear boundaries and occupy a certain position in the cords.

There are three systems of pathways in the spinal cord: associative (short), afferent (sensory) and efferent (motor). Short associative bundles connect segments of the spinal cord. Sensitive (ascending) tracts are sent to the centers of the brain. Descending (motor) tracts connect the brain with the motor centers of the spinal cord.

Along the spinal cord are the arteries supplying it: an unpaired anterior spinal artery and a paired posterior spinal artery, which are formed by large radiculomedullary arteries. The superficial arteries of the spinal cord are interconnected by numerous anastomoses. Venous blood flows from the spinal cord through the superficial longitudinal veins and anastomoses between them through the radicular veins into the internal vertebral venous plexus.

The spinal cord is covered with a dense sheath of the dura mater, the processes of which, extending from each intervertebral foramen, cover the root and the spinal ganglion.

The space between the hard shell and the vertebrae (epidural space) is filled with venous plexus and adipose tissue. In addition to the dura mater, the spinal cord is also covered with arachnoid and pia mater.

Between the pia mater and the spinal cord is the subarachnoid space of the spinal cord, filled with cerebrospinal fluid.

There are two main functions of the spinal cord: its own segmental-reflex and conductive, which provides communication between the brain, trunk, limbs, internal organs, etc. Sensory signals (centripetal, afferent) are transmitted through the posterior roots of the spinal cord, and motor signals are transmitted through the anterior roots ( centrifugal, efferent) signals.

The proper segmental apparatus of the spinal cord consists of neurons of various functional purposes: sensory, motor (alpha-, gamma-motoneurons), vegetative, intercalary (segmental and intersegmental interneurons). All of them have direct or indirect synaptic connections with the conduction systems of the spinal cord. Spinal cord neurons provide reflexes to muscle stretch - myotatic reflexes. They are the only reflexes of the spinal cord in which there is a direct (without the participation of intercalary neurons) control of motoneurons using signals coming through afferent fibers from muscle spindles.

RESEARCH METHODS

Myotatic reflexes are manifested by shortening of the muscle in response to its stretching when the neurological hammer strikes the tendon. They differ in locality, and according to their condition, the topic of the spinal cord lesion is established.

The study of superficial and deep sensitivity is important. When the segmental apparatus of the spinal cord is damaged, sensitivity in the corresponding dermatomes is disturbed (dissociated or total anesthesia, hypoesthesia, paresthesia), vegetative spinal reflexes (viscero-motor, vegetative-vascular, urinary, etc.) change.

According to the state of the motor function of the limbs (upper and lower), as well as muscle tone, the severity of deep reflexes, the presence of pathological carpal and foot signs, one can assess the safety of the functions of the efferent conductors of the lateral and anterior cords of the spinal cord. Determination of the zone of violation of pain, temperature, tactile, joint-muscular and vibration sensitivity allows us to assume the level of damage to the lateral and posterior cords of the spinal cord. This is facilitated by the study of dermographism, sweating, vegetative-trophic functions.

To clarify the topic of the pathological focus and its relationship with surrounding tissues, as well as to determine the nature of the pathological process (inflammatory, vascular, tumor, etc.), to resolve issues of therapeutic tactics, additional studies are carried out. During spinal puncture, the initial CSF pressure, the patency of the subarachnoid space (CSD tests) are assessed; cerebrospinal fluid is subjected to laboratory testing.

Important information about the state of the motor and sensory neurons of the spinal cord is obtained by electromyography, electroneuromyography, which make it possible to determine the speed of impulse conduction along the sensory and motor nerve fibers, and to record the evoked potentials of the spinal cord.

With the help of X-ray examination, lesions of the spine and the contents of the spinal canal (meninges of the spinal cord, vessels, etc.) are revealed.

In addition to survey spondylography, if necessary, tomography is performed, which allows detailing the structures of the vertebrae, the size of the spinal canal, detecting calcification of the meninges, etc. Highly informative methods of X-ray examination are pneumomyelography, myelography with radiopaque substances, as well as selective spinal angiography, venospondylography.

The anatomical contours of the spine, the structures of the spinal canal of the spinal cord are well visualized using computed tomography, magnetic resonance imaging.

The level of the subarachnoid space block can be determined using radioisotope (radionuclide) myelography. Thermography is used in the diagnosis of various lesions of the spinal cord.

Topical diagnostics

Spinal cord lesions are manifested by symptoms of irritation or loss of function of motor, sensory and autonomic-trophic neurons. Clinical syndromes depend on the localization of the pathological focus along the diameter and length of the spinal cord, the topical diagnosis is based on a combination of symptoms of impaired function of both the segmental apparatus and the conductors of the spinal cord. If the anterior horn or anterior root of the spinal cord is damaged, flaccid paresis or paralysis of the corresponding myotome develops with atrophy and atony of the innervated muscles, myotatic reflexes fade, fibrillation or “bioelectric silence” is detected on the electromyogram.

In the pathological process in the region of the posterior horn or posterior root, sensitivity in the corresponding dermatome is disturbed, deep (myotatic) reflexes decrease or disappear, the arc of which passes through the affected root and segment of the spinal cord. When the posterior root is damaged, radicular shooting pains first appear in the zone of the corresponding dermatome, then all types of sensitivity decrease or are lost. When the posterior horn is destroyed, as a rule, sensitivity disorders are of a dissociated nature (pain and temperature sensitivity drops out, tactile and joint-muscular sensitivity is preserved).

Bilateral symmetric dissociated sensitivity disorder develops when the anterior gray commissure of the spinal cord is affected.

With damage to the neurons of the lateral horns, vegetative-vascular, trophic disorders and disorders of sweating, pilomotor reactions occur (see Autonomic nervous system).

Damage to the conduction systems leads to more common neurological disorders. For example, with the destruction of the pyramidal conductors in the lateral funiculus of the spinal cord, spastic paralysis (paresis) of all muscles innervated by neurons located in the underlying segments develops. Deep reflexes increase, pathological carpal or foot signs appear.

With the defeat of the conductors of sensitivity in the lateral cord, anesthesia occurs downward from the level of the pathological focus and on the side opposite from the focus. The law of the eccentric arrangement of long conductors (Auerbach-Flatau) makes it possible to differentiate the development of intramedullary and extramedullary pathological processes in the direction of distribution of sensitivity disorders: an ascending type of sensitivity disorders indicates an extramedullary process, a descending type indicates an intramedullary one. The axons of the second sensory neurons (cells of the posterior horn) pass into the lateral funiculus of the opposite side through the two overlying segments of the spinal cord, therefore, when identifying the upper limit of conduction anesthesia, it should be assumed that the pathological focus is located two segments of the spinal cord above the upper limit of sensory disorders.

When the posterior cord is destroyed, the joint-muscular vibrational and tactile sensitivity on the side of the focus is disturbed, and sensitive ataxia appears.

If half of the diameter of the spinal cord is damaged, central paralysis occurs on the side of the pathological focus, and conduction pain and temperature anesthesia (Brown-Sekara syndrome) occurs on the opposite side.

Symptom complexes of spinal cord injury at its various levels

There are several main symptom complexes of the lesion at various levels. Damage to the entire diameter of the spinal cord in upper cervical region (I-IV cervical segments of the spinal cord) is manifested by flaccid paralysis of the neck muscles, paralysis of the diaphragm, spastic tetraplegia, anesthesia from the level of the neck and downward, dysfunction of the pelvic organs of the central type (urinary and fecal retention); possible radicular pain in the neck and neck.

A lesion at the level of the cervical thickening (CV-ThI segments) leads to flaccid paralysis of the upper extremities with muscle atrophy, the disappearance of deep reflexes in the arms, spastic paralysis of the lower extremities, general anesthesia below the level of the lesion, dysfunction of the pelvic organs of the central type.

Destruction of the lateral horn cells at the level of CVIII-ThI causes Bernard-Horner syndrome.

The defeat of the thoracic segments is characterized by lower spastic paraplegia, conduction paraanesthesia, the upper limit of which corresponds to the level of the location of the pathological focus, urinary and fecal retention.

When the upper and middle thoracic segments are affected, breathing becomes difficult due to paralysis of the intercostal muscles; the defeat of the TX-XII segments is accompanied by paralysis of the abdominal muscles. Atrophy and weakness of the back muscles are revealed. Radicular pains are girdle in nature.

The defeat of the lumbosacral thickening (segments LI-SII) causes flaccid paralysis and anesthesia of the lower extremities, retention of urine and feces, impaired sweating and pilomotor reaction of the skin of the lower extremities.

The defeat of the segments of the epiconus (Epiconus Minor's syndrome) is manifested by flaccid paralysis of the muscles of the LV-SII myotomes with the disappearance of the Achilles reflexes (with the preservation of the knees), anesthesia in the area of ​​the same dermatomes, urinary and fecal retention, and impotence.

The defeat of the segments of the cone (segments (SIII - SV) is characterized by the absence of paralysis, dysfunction of the pelvic organs according to the peripheral type with true incontinence of urine and feces, the absence of the urge to urinate and defecate, anesthesia in the anogenital zone (saddle anesthesia), impotence.

Horse tail (cauda equina) - its defeat gives a symptom complex, very similar to the defeat of the lumbar thickening and conus medullaris. There is a peripheral paralysis of the lower extremities with disorders of urination such as retention or true incontinence. Anesthesia on the lower extremities and in the perineum. Characterized by severe radicular pain in the legs and for the initial and incomplete lesions - asymmetry of symptoms.

When the pathological process destroys not everything, but only part of the diameter of the spinal cord, the clinical picture consists of various combinations of movement disorders, coordination, superficial and deep sensitivity, disorders of the function of the pelvic organs and trophism (bedsores, etc.) in the denervated zone.

The most common variants of incomplete lesions of the diameter of the spinal cord:

1) damage to the anterior (ventral) half of the diameter of the spinal cord, characterized by peripheral paralysis of the corresponding myotomes, central paralysis and conduction pain and temperature anesthesia below the level of the pathological focus, dysfunction of the pelvic organs (Preobrazhensky's syndrome);

2) damage to one half of the diameter of the spinal cord (right or left), clinically manifested by Brown-Sequard syndrome;

3) damage to the posterior third of the diameter of the spinal cord, characterized by a violation of deep, tactile and vibrational sensitivity, sensitive ataxia, conduction parasthesia (Williamson's syndrome);

4) damage to the anterior horns of the spinal cord, causing peripheral paralysis of the corresponding myotomes (polio syndrome);

5) damage to the centromedullary zone or the posterior horn of the spinal cord, manifested by dissociated segmental anesthesia in the corresponding dermatomes (syringomyelic syndrome).

In the topical diagnosis of lesions of the spinal cord, it is important to remember the discrepancy between the level of location of the segments of the spinal cord and vertebral bodies. It should be borne in mind that in acute lesions of the cervical or thoracic segments (trauma, hematomyelia, myeloischemia, etc.), the developing paralysis of the lower extremities is accompanied by muscle atony, the absence of knee and Achilles reflexes (Bastian's law). For the slow development of the process of such localization (for example, with a tumor), symptoms of spinal automatism with protective reflexes are characteristic.

With some lesions of the posterior cords at the level of the cervical segments of the spinal cord (tumor, plaque of multiple sclerosis, spondylogenic myeloischemia, arachnoiditis), at the moment the head is tilted forward, there is a sudden pain penetrating the entire body, similar to an electric shock (Lermitte's symptom). For topical diagnosis, the sequence of addition of symptoms of dysfunction of the structures of the spinal cord is important.

Determining the level of spinal cord injury

To determine the level of damage to the spinal cord, in particular its upper border, radicular pain, if any, is of great importance. When analyzing sensory disorders, it should be taken into account that each dermatome, as noted above, is innervated by at least 3 segments of the spinal cord (in addition to its own, by one more upper and one lower neighboring segments). Therefore, when determining the upper limit of anesthesia, it is necessary to consider the affected level of the spinal cord, which is 1-2 segments higher.

Equally used to determine the level of damage are changes in reflexes, the spread of segmental movement disorders and the upper limit of conduction. Sometimes it can also be useful to study sympathetic reflexes. So, for example, in areas of the skin corresponding to the affected segments, there may be a lack of reflex dermographism, piloarrectory reflex, etc.

The so-called “mustard” test can also be useful here: narrow strips of paper from dry mustard plasters are cut, moistened and applied to the skin (you can fix them with transversely glued strips of adhesive plaster), one below the other, along the length, with a continuous strip. Differences in vascular responses above the level of the lesion, at the level of segmental disorders and below them, on the territory of conduction disorders, can help clarify the topic of the spinal cord lesion.

In case of tumors of the spinal cord, the following methods can be used to determine the level of their location:

Symptom of herniation. During lumbar puncture, if there is a blockade of the subarachnoid space, as the cerebrospinal fluid flows out, a difference in pressure is created and it decreases in the lower part of the subarachnoid space, below the block. As a result, a “movement” downwards, “wedging” of the tumor is possible, which determines the intensification of radicular pain, worsening of conduction disorders, etc. These phenomena can be short-term, but sometimes they are persistent, determining the deterioration in the course of the disease. The symptom is more typical for subdural extramedullary tumors, for example, for neurinomas, which originate more often from the posterior roots and are usually somewhat mobile (Elsberg, I.Ya. Razdolsky).

close to described symptom of liquor shock(I.Ya. Razdolsky). Again, in the presence of a block, and more often also with subdural extramedullary tumors, there is an increase in radicular pain and worsening of conduction disorders when the head is tilted to the chest or when the jugular veins are pressed on both sides of the neck (as when taking Quekenstedt). The mechanism of the symptom is almost the same; only here it is not the decrease in fluid pressure in the subarachnoid space below the block that affects, but its increase above it due to venous stasis inside the skull.

Symptom of the spinous process(I.Ya. Razdolsky). Pain when tapping on the spinous process of the vertebra, at the level of which the tumor is located. The symptom is more typical for extramedullary, extradural tumors. It is best caused by shaking not with a hammer, but with the hand of the examiner (“pulp of a fist”). Sometimes, in this case, not only radicular pains appear (aggravate), but also peculiar paresthesias arise: “feeling of an electric discharge” (Cassirer, Lermitte,) - a feeling of electric current passing (or “goosebumps”) down the spine, sometimes in the lower limbs.

Also of some importance may be radicular position pains(Dandy - Razdolsky). In a certain position, which causes, for example, the tension of the posterior root, from which the neurinoma originates, radicular pains of the corresponding level arise or intensify.

Finally noteworthy Elsberg's symptom - Dyke(radiological) - an abnormal increase in the distance between the roots of the arches from 2 to 4 mm at the level of tumor localization (usually extradural).

When projecting the affected segments of the spinal cord onto the vertebrae, it is necessary to take into account the discrepancy between the length of the spinal cord and the spine, and the calculation should be made according to the instructions given above. For orientation in the spinous processes of the vertebrae, the following data can serve:

- the highest vertebra visible under the skin is the VII cervical, i.e. the lowest cervical vertebra;

- the line connecting the lower corners of the shoulder blades passes over the VII thoracic vertebra;

- the line connecting the tops of the iliac crests (cristae lliacae) passes between the III and IV lumbar vertebrae.

In processes leading to filling the cavity of the intravertebral canal (for example, with tumors) or causing adhesions in the subarachnoid space (with arachnoiditis), valuable data for the localization of the process can sometimes be obtained by myelography, i.e., radiography with the introduction of contrast solutions into the subarachnoid space. It is preferable to introduce by suboccipital puncture "heavy" or descending solutions (oily); the contrast agent, descending in the cerebrospinal fluid down, in case of impaired patency in the subarachnoid space, stops or temporarily lingers at the level of the block and is detected on radiography in the form of a shadow (“stop” contrast).

Less contrasting images are obtained with pneumomyelography, i.e., when air is injected through a lumbar puncture to a sitting patient; air, rising up through the subarachnoid space, stops under the "block" and determines the lower limit of the existing obstacle.

To determine the level of location of the “block” (for tumors, arachnoiditis, etc.), sometimes a “staircase” lumbar puncture is used, usually only in the intervals between the LIV - LIII - LII vertebrae (puncture of higher sections can be dangerous due to possible injury to the spinal brain). Below the blockade of the subarachnoid space, protein-cell dissociation is observed, above - the normal composition of the cerebrospinal fluid; below the blockade - the symptoms of Quekenstedt and Stukkei, above - their absence (normal).

Cylindrical strand located in the spinal canal. Two thickenings - cervical (C5-Th1 - innervation of the lower end) and lumbar (L1-2-Sv. lower end). 31-31 segments: 8 cervical (C1-C8), 12 thoracic (Th1-Th12), 5 lumbar (L1-L5), 5 sacral (S1-S5), and 1-2 coccygeal (Co1-Co2). The image is pointed below. the brain cone, which ended with the terminal thread, reached. coccygeal vertebrae. At the level of each segment, 2 pairs of anterior and posterior roots depart. On each side they merge into the brain cord. The gray thing has rear horns, sod. feelings. cells; front horns, sod. dvig. class, and lateral horns in the cat. dispersed vegetative. cute and parasimp. neurons. The white matter consists of nerve fibers and is divided into 3 cords: posterior, lateral and anterior. Upper cervical region (С1-С4)- paralysis or irritability. diaphragm, spastic paralysis of the end, loss of all kinds of sensations, urination of the urinary tract. Cervical thickening (C5-D2) – reph. upper paralysis. horse, spastic. lower; loss of sensation, urinary disorders, Horner's sim. thoracic region (D3- DVII) - spastic lower paraplegia. final, rstr-va urine-I, loss of feeling in the lower half of the body. Lumbar thickening (L1- S2)- reph. paralysis and anesthesia of the lower con-th, urinary tract. brain cone (S3- S5)- loss of feeling in the region. perineum, raster-va urine-I. Ponytail - perf. lower paralysis. con-th, raster. urine, anesthesia on the lower. con-x and crotch.

18. Sensitive and motor races in case of damage to the anterior and posterior roots, plexuses, peripheral nerves.

The defeat of the trunk periph. nerve- violation of all types of feelings in the area of ​​​​the skin innervation of this nerve, paresis, muscle atony, areflexia, hyporeflexia, atrophy. Defeat of trunks of textures- anesthesia, hypoesthesia of all kinds of feelings, pain, paresis, muscle atony, areflexia, hyporeflexia, atrophy. Cervical: n.occipitalis minor (CI-CIII) - small occipital nerve, severe pain (schatyl. neuralgia); n. auricularis magnus (CIII) - large ear nerve, sensory disturbances, pain; n. supraclavicularis (CIII-CIV) - supraclavicular nerves, sensory disturbances, pain; n. phrenicus (CIII-CIV) - diaphragm nerve, diaphragm paralysis, hiccups, shortness of breath, pain. Defeat. shoulders. plexus - flaccid atrophic. paralysis and anesthesia upper. horse with loss of extensor elbows. and flexion. reflexes. Damage to the posterior sense root- paresthesia, pain, loss of all kinds of sensations, segmental character: circular on the trunk, stripe-longitudinal on the extremities, muscle atony, areflexia, hyporeflexia, atrophy. Damage to the anterior roots- segmental distribution of paralysis.

19. Clinical manifestations of damage to half the diameter of the spinal cord. Brown Sicard Syndrome. Clinical examples.

Lesion on the side of the focus: loss of deep sensitivity, impaired articular-muscular feeling in the presence of central paralysis downward from the level of the lesion, on the opposite side. side - conduction pain and temperature anesthesia, disturbed. surface sensitivity. As a clinical forms of disorders of spinal circulation. according to the hemorrhagic type, hematomyelia is isolated (Brown-Sicard syndrome). Signs of damage to the spinal cord occur suddenly, after a physical load, injury. I observed a strong pain radicular syndrome with irradiation in all directions, often dagger girdle pain along the spine, headache, nausea, vomiting, slight stupor, lethargy. Def. Kernig's symptom, in combination with Lasegue's pain symptom, stiff neck muscles. May occur with myelitis, tumors of the spinal cord.

20. Ipair. olfactory nerve and olfactory system. Symptoms and syndromes of injury.n. olfactorii. The fibers start from the olfactory bipolar cells, in the mucous membrane of the superior nasal concha, the axons enter the cranial cavity through the ethmoid bone → 1st neuron ends in the olfactory bulb located in the anterior cranial fossa → 2nd neuron reach the olfactory triangle, anterior perforated plate and transparent septum → 3rd neuron parahippocampal gyrus, piriform gyrus, hippocampus. Defeat: ↓ - hyposmia ; exacerbation of the sense of smell - hyperosmi I; perversion of smell - dysosmia, smell. hallucinations - with psychoses and epilepsy. seizures . Research: give a sniff of various odorous substances.

21. IIpair. Optic nerve and visual system. Signs of damage at various levels.n. opticus. 1st neuron ganglion cells of the retina, through the foramen opticum enters the cranial cavity → along the base of the brain and anterior to the sella turcica intersect, forming a chiasma (internal fibers intersect, external or temporal fibers do not intersect) → optic tracts → brain stems → afferent part of the pupillary reflex arc, visual centers - superior colliculi 2nd neuron→ in the external geniculate bodies and the pillow of the thalamus "thalamic neuron". → external knee body → internal capsule → as part of the Graziole bundle → cortical area. Research: 1. visual acuity: ↓ - amblyopia ; total loss - amaurosis .2. color perception: complete flower blindness - achromatopsia; impaired perception of certain colors - dyschromatopsia; color blindness - inability to distinguish between green and red colors.3. fields of view: N - outward 90˚, inward 60˚, downward 70˚, upward 60˚.- concentric - narrowing of the field of view on both sides;- scotoma - loss of individual sections; - hemianopsia - loss of half of the vision. Homonymous hemianapsia - loss of the right and left visual fields of each eye. Heteronymous - loss of both internal and external visual fields: bitemporal - loss of temporal fields of vision; binasal - prolapse of internal half. When hit. retina or vision. nerve, blindness occurs, ↓ visual acuity, with damage. chiasma - heteronymous hemianopia, with lesions. sees. paths after the cross - homonymous lunge. of sight, at the center in zrit. tract - homonymous hemianopsia, with lesions. sees. bark - square hemianopsia.

22. III, IV, VI pairs. Oculomotor, trochlear and abducent nerves and oculomotor system. Eye innervation. Gaze paresis (cortical and stem). IIIpair -oculomotorius. Nuclei in the midbrain, along the bottom of the aqueduct of the brain, at the level of the superior colliculi → exit at the base of the brain → leaves the skull and divides into branches: superior inn-t superior rectus muscle, inferior inn-t three external muscles of the eye: inferior rectus, oblique, internal . Laterally, large cell nuclei, inn-t transverse bands. muscles (oculomotor-e, raising the upper eyelid). Paramedial small cell nuclei of Yakubovich - Edinger - Westphal, Inn-I muscles of the constrictor of the pupil. Defeat: 1) divergent strabismus and the impossibility of movements of the affected eyeball inwards and upwards; 2) exophthalmos - protrusion of the eye from the orbit; 3) ptosis - drooping of the upper eyelid; 4) mydriasis - dilation of the pupil due to paralysis of the muscles that narrow the pupil and the absence of a direct and concomitant reaction of the pupil to light; 5) accommodation paralysis - Decreased vision at close distances. IVpair -n. trochlearis. The nucleus at the bottom of the aqueduct at the level of the inferior hillocks → fibers go up, cross in the anterior cerebral velum → rounding the legs of the brain, exit it and pass along the base of the skull into the orbit (through the superior orbital fissure). Inn-t muscle turn the eyeball outward and down. Defeat: convergent strabismus, diplopia. VIpair -n. abducens. The nucleus lies at the bottom of the IV ventricle → wraps around the fibers of the facial nerve go to the base → exit at the border of the bridge and the medulla oblongata in the region of the cerebellar pontine angle → enters the cavity of the orbit through the superior orbital fissure. Inn-t lateral rectus muscle of the eye. Defeat: convergent strabismus, diplopia. With the defeat of all nerves - complete ophthalmoplegia. Innervation of the movements of the eyeballs impl. cortical center of gaze, located. in the posterior part of the middle frontal gyrus → ext. capsule and brain peduncles, decussation, through neurons of the reticular formation and medulla. bundles transmit impulses to the nuclei III, IV, VI nerves.

23. Vsteam. trigeminal nerve. Sensitive and moving parts. Damage symptoms.n. trigeminus. Nuclei in the brainstem → sensory fibers extend from the Gasser ganglion ( 1st neuron)→ enter the brain: the fibers of pain and tactile sensitivity end in n. tractus spinalis, and tactile and joint-muscular sensitivity end in the nucleus n. terminalis ( 2nd neuron) → fibers of the nuclei form a loop entering the opposite medial loop → thalamus ( 3rd neuron) → internal capsule → end in the posterior central gyrus. The dendrites of the Gasser node make up the sensory root: the ophthalmic nerve exits the skull through the superior orbital fissure, the maxillary nerve through the round hole, and the mandibular through the foramen ovale. The motor root, together with the maxillary nerve, goes to the masticatory muscle. in case of motor damage. fibers, the lower jaw, when the mouth is opened, deviates towards the lesions. muscles. With paralysis, everyone chews. muscles the lower jaw sags, with damage. Department. branches developed raster-va chvstvit. in the innervir zone. given nerve, fade correspondingly. reflexes. Defeat. orbital nerve leads to loss of the corneal and supraorbital reflex. When hit. gasser node or root, feeling drops out in the innervir zones. all branches of the 5th pair, pain, disease. when pressed, in places of exit on the face. with damage to the nuclei on the face of dissociators. raster of feelings (loss of pain and temperament).

Movement - a universal manifestation of vital activity, providing the possibility of active interaction of both the constituent parts of the body and the whole organism with the environment by moving in space. There are two types of movements:

1) involuntary- simple automated movements, which are carried out due to the segmental apparatus of the spinal cord, the brain stem as a simple reflex motor act;

2) arbitrary (purposeful)- arising as a result of the implementation of programs that are formed in the motor functional segments of the central nervous system.

In humans, the existence of voluntary movements is associated with the pyramidal system. Complex acts of human motor behavior are controlled by the cerebral cortex (middle sections of the frontal lobes), the commands of which are transmitted along the pyramidal path system to the cells of the anterior horns of the spinal cord, and from them through the peripheral motor neuron system to the executive organs.

The program of movements is formed on the basis of sensory perception and postural reactions from the subcortical ganglia. Correction of movements occurs according to the feedback system with the participation of the gamma loop, which starts from the spindle-shaped receptors of intramuscular fibers and closes on the gamma motor neurons of the anterior horns, which, in turn, are controlled by the overlying structures of the cerebellum, subcortical ganglia and cortex. The motor sphere of a person is developed so perfectly that a person is able to carry out creative activity.

3.1. Neurons and pathways

Motor pathways of the pyramidal system (Fig. 3.1) consist of two neurons:

1st central neuron - a cell of the cerebral cortex;

2nd peripheral neuron - motor cell of the anterior horn of the spinal cord or motor nucleus of the cranial nerve.

1st central neuron is located in the III and V layers of the cerebral cortex of the brain (Betz cells, middle and small pyramidal

Rice. 3.1.Pyramid system (diagram):

A)pyramidal path: 1 - cerebral cortex; 2 - internal capsule;

3 - leg of the brain; 4 - bridge; 5 - cross of pyramids; 6 - lateral corticospinal (pyramidal) path; 7 - spinal cord; 8 - anterior corticospinal path; 9 - peripheral nerve; III, VI, VII, IX, X, XI, XII - cranial nerves; b) convexital surface of the cerebral cortex (fields

4 and 6); topographic projection of motor functions: 1 - leg; 2 - torso; 3 - hand; 4 - brush; 5 - face; V) horizontal section through the internal capsule, the location of the main pathways: 6 - visual and auditory radiance; 7 - temporal-bridge fibers and parieto-occipital bridge bundle; 8 - thalamic fibers; 9 - cortical-spinal fibers to the lower limb; 10 - cortical-spinal fibers to the muscles of the body; 11 - cortical-spinal fibers to the upper limb; 12 - cortical-nuclear pathway; 13 - frontal bridge path; 14 - cortical-thalamic path; 15 - anterior leg of the inner capsule; 16 - knee of the inner capsule; 17 - rear leg of the inner capsule; G) anterior surface of the brain stem: 18 - pyramidal decussation

cells) in the area anterior central gyrus, posterior superior and middle frontal gyri, and paracentral lobule(4, 6, 8 cytoarchitectonic fields according to Brodmann).

The motor sphere has a somatotopic localization in the anterior central gyrus of the cerebral cortex: the centers of movement of the lower extremities are located in the upper and medial sections; upper limb - in its middle section; head, face, tongue, pharynx, larynx - in the middle lower. The projection of the movements of the body is presented in the posterior section of the superior frontal gyrus, the rotation of the head and eyes - in the posterior section of the middle frontal gyrus (see Fig. 3.1 a). The distribution of motor centers in the anterior central gyrus is uneven. In accordance with the principle of "functional significance", the most represented in the cortex are the parts of the body that perform the most complex, differentiated movements (the centers that ensure the movement of the hand, fingers, face).

The axons of the first neuron, going down, fan-shaped converge, forming a radiant crown, then pass in a compact bundle through the internal capsule. From the lower third of the anterior central gyrus, the fibers involved in the innervation of the muscles of the face, pharynx, larynx, and tongue pass through the knee of the internal capsule, in the trunk they approach the motor nuclei of the cranial nerves, and therefore this path is called corticonuclear. The fibers that form the corticonuclear pathway are sent to the motor nuclei of the cranial nerves (III, IV, V, VI, VII, IX, X, XI) of both their own and the opposite side. The exception is the corticonuclear fibers that go to the lower part of the nucleus VII and to the nucleus XII of the cranial nerves and carry out unilateral voluntary innervation of the lower third of the facial muscles and half of the tongue on the opposite side.

Fibers from the upper 2/3 of the anterior central gyrus, involved in the innervation of the muscles of the trunk and limbs, pass into anterior 2 / 3 posterior legs of the inner capsule and in the brain stem (corticospinal or actually pyramid path) (see Fig. 3.1 c), and the fibers are located outside to the muscles of the legs, inside - to the muscles of the arms and face. At the border of the medulla oblongata and spinal cord, most of the fibers of the pyramidal tract form a decussation and then pass as part of the lateral funiculi of the spinal cord, forming lateral (lateral) pyramidal path. A smaller, uncrossed part of the fibers forms the anterior funiculi of the spinal cord (anterior pyramidal

path). The crossing is carried out in such a way that the fibers located externally in the area of ​​the crossing, innervating the muscles of the legs, are inside after the crossing, and, conversely, the fibers to the muscles of the hands, located medially before the crossing, become lateral after moving to the other side (see Fig. 3.1 d ).

In the spinal cord, the pyramidal tract (anterior and lateral) gives off segmentally fibers to alpha large neurons of the anterior horn (second neuron), carrying out a direct connection with the working striated muscle. Due to the fact that the segmental zone of the upper extremities is the cervical thickening, and the segmental zone of the lower extremities is the lumbar, the fibers from the middle third of the anterior central gyrus end mainly in the cervical thickening, and from the upper third - in the lumbar.

Motor cells of the anterior horn (2nd, peripheral neuron) located in groups responsible for the contraction of the muscles of the trunk or limbs. Three groups of cells are distinguished in the upper cervical and thoracic sections of the spinal cord: the anterior and posterior medial cells, which provide contraction of the trunk muscles (flexion and extension), and the central, innervating muscle of the diaphragm, shoulder girdle. In the region of the cervical and lumbar thickenings, the anterior and posterior lateral muscles innervating the flexor and extensor muscles of the limbs join these groups. Thus, in the anterior horns at the level of the cervical and lumbar thickenings there are 5 groups of motor neurons (Fig. 3.2).

Within each of the groups of cells in the anterior horn of the spinal cord and in each motor nucleus of the cranial nerves, there are three types of neurons with different functions.

1. alpha large cells, conducting motor impulses with high speed (60-100 m/s), providing the possibility of fast movements, are associated mainly with the pyramidal system.

2. Alpha small neurons receive impulses from the extrapyramidal system and exert postural influences, providing postural (tonic) contraction of muscle fibers, perform a tonic function.

3. gamma neurons receive impulses from the reticular formation and their axons are sent not to the muscle itself, but to the proprioceptor enclosed in it - the neuromuscular spindle, affecting its excitability.

Rice. 3.2.Topography of the motor nuclei in the anterior horns of the spinal cord at the level of the cervical segment (diagram). Left - general distribution of cells of the anterior horn; on the right - nuclei: 1 - posteromedial; 2 - anteromedial; 3 - front; 4 - central; 5 - anterolateral; 6 - posterolateral; 7 - posterolateral; I - gamma-efferent fibers from small cells of the anterior horns to neuromuscular spindles; II - somatic efferent fibers, giving collaterals to the medially located Renshaw cells; III - gelatinous substance

Rice. 3.3.Cross section of the spine and spinal cord (scheme):

1 - spinous process of the vertebra;

2 - synapse; 3 - skin receptor; 4 - afferent (sensitive) fibers; 5 - muscle; 6 - efferent (motor) fibers; 7 - vertebral body; 8 - node of the sympathetic trunk; 9 - spinal (sensitive) node; 10 - gray matter of the spinal cord; 11 - white matter of the spinal cord

The neurons of the anterior horns are multipolar: their dendrites have multiple connections with various afferent and efferent systems.

The axon of a peripheral motor neuron emerges from the spinal cord as part of front spine, goes into plexuses and peripheral nerves, transmitting a nerve impulse to the muscle fiber (Fig. 3.3).

3.2. Syndromes of movement disorders (paresis and paralysis)

The complete absence of voluntary movements and a decrease in muscle strength to 0 points, due to damage to the cortico-muscular pathway, is called paralysis (plegia); limitation of range of motion and decrease in muscle strength up to 1-4 points - paresis. Depending on the distribution of paresis or paralysis, they are distinguished.

1. Tetraplegia / tetraparesis (paralysis / paresis of all four limbs).

2. Monoplegia / monoparesis (paralysis / paresis of one limb).

3. Triplegia/triparesis (paralysis/paresis of three limbs).

4. Hemiplegia / hemiparesis (one-sided paralysis / paresis of the arms and legs).

5. Upper paraplegia / paraparesis (paralysis / paresis of the hands).

6. Lower paraplegia / paraparesis (paralysis / paresis of the legs).

7. Crossed hemiplegia / hemiparesis (paralysis / paresis of the arm on one side - legs on the opposite side).

There are 2 types of paralysis - central and peripheral.

3.3. Central paralysis. Topography of the central motor neuron lesion Central paralysis occurs when the central motor neuron is damaged, i.e. with damage to Betz cells (layers III and V) in the motor zone of the cortex or pyramidal tract along the entire length from the cortex to the anterior horns of the spinal cord or motor nuclei of cranial nerves in the brain stem. The following symptoms are characteristic:

1. Muscular spastic hypertension, on palpation, the muscles are tense, compacted, jackknife symptom contractures.

2. Hyperreflexia and expansion of the reflexogenic zone.

3. Clonuses of the feet, kneecaps, lower jaw, hands.

4. Pathological reflexes.

5. defensive reflexes(reflexes of spinal automatism).

6. Decreased skin (abdominal) reflexes on the side of paralysis.

7. Pathological synkinesis.

Synkinesia - involuntary arising friendly movements during the performance of active movements. They are divided into physiological(e.g. waving arms while walking) and pathological. Pathological synkinesis occurs in a paralyzed limb with damage to the pyramidal tracts, due to the loss of inhibitory influences from the cerebral cortex on intraspinal automatisms. Global synkinesis- contraction of the muscles of the paralyzed limbs, which occurs when the muscle groups on the healthy side are tensed. For example, in a patient, when trying to rise from a prone position or get up from a sitting position on the paretic side, the arm is bent at the elbow and brought to the body, and the leg is unbent. Coordinator synkinesis- when you try to make a paretic limb any movement in it involuntarily

another movement appears, for example, when trying to flex the lower leg, dorsiflexion of the foot and thumb occurs (tibial synkinesis or Stryumpel's tibial phenomenon). Imitative synkinesis- involuntary repetition by the paretic limb of those movements that are performed by a healthy limb. Topography of central motor neuron lesion at different levels

Syndrome of irritation of the anterior central gyrus - clonic convulsions, motor Jackson's seizures.

Syndrome of lesions of the cortex, radiant crown - hemi/monoparesis or hemi/monoplegia on the opposite side.

Internal capsule knee syndrome (damage to the corticonuclear pathways from the lower third of the anterior central gyrus to the nuclei of the VII and XII nerves) - weakness of the lower third of the facial muscles and half of the tongue.

Syndrome of damage to the anterior 2 / 3 posterior femur of the internal capsule - Uniform hemiplegia on the opposite side, the Wernicke-Mann position with a predominance of spastic tone in the flexors of the arm and extensors of the leg (“the arm asks, the leg mows”) [Fig. 3.4].

Rice. 3.4.Wernicke-Mann Pose: A- on right; b- left

Pyramidal tract syndrome in the brainstem - damage to the cranial nerves on the side of the focus, on the opposite side of hemiparesis or hemiplegia (alternating syndromes).

Syndrome of lesions of the pyramidal tract in the area of ​​the decussation on the border of the medulla oblongata and spinal cord - cross hemiplegia or hemiparesis (lesion of the arm on the side of the focus, legs - contralaterally).

Syndrome of defeat of the pyramidal tract in the lateral funiculus of the spinal cord - Central paralysis below the level of the lesion homolaterally.

3.4. Peripheral paralysis. Topography of the defeat of the peripheral motor neuron

Peripheral (flaccid) paralysis develops when a peripheral motor neuron is damaged (cells of the anterior horns or motor nuclei of the brain stem, roots, motor fibers in the plexuses and peripheral nerves, neuromuscular synapse and muscle). It is manifested by the following main symptoms.

1. Muscle atony or hypotension.

2. Areflexia or hyporeflexia.

3. Muscular atrophy (hypotrophy), which develops as a result of damage to the segmental reflex apparatus after some time (at least a month).

4. Electromyographic signs of damage to the peripheral motor neuron, roots, plexuses, peripheral nerves.

5. Fascicular muscle twitches resulting from pathological impulses of a nerve fiber that has lost control. Fascicular twitches usually accompany atrophic paresis and paralysis with a progressive process in the cells of the anterior horn of the spinal cord or motor nuclei of the cranial nerves, or in the anterior roots of the spinal cord. Much less often, fasciculations are observed with generalized lesions of peripheral nerves (chronic demyelinating polyneuropathy, multifocal motor neuropathy).

Topography of the defeat of the peripheral motor neuron

Anterior horn syndrome characterized by atony and muscle atrophy, areflexia, electromyographic signs of damage to the peripheral motor neuron (at the level of the horns)

ENMG data. Typical asymmetry and mosaic lesions (due to possible isolated lesions of individual groups of cells), early onset of atrophy, fibrillar twitching in the muscles. According to stimulation electroneurography (ENG): the appearance of giant and repeated late responses, a decrease in the amplitude of the M-response at a normal or slightly slow rate of propagation of excitation, the absence of impaired conduction along sensitive nerve fibers. According to needle electromyography (EMG): denervation activity in the form of fibrillation potentials, positive sharp waves, fasciculation potentials, potentials of “neuronal” type motor units in muscles innervated by the affected segment of the spinal cord or brainstem.

Anterior root syndrome characterized by atony and muscle atrophy mainly in the proximal parts, areflexia, electromyographic signs of damage to the peripheral motor neuron (at the level of the roots) according to ENMG. Typically combined damage to the anterior and posterior roots (radiculopathy). Signs of radicular syndrome: according to stimulation ENG (impaired late responses, in the case of secondary damage to the axons of nerve fibers - a decrease in the amplitude of the M-response) and needle EMG (denervation activity in the form of fibrillation potentials and positive sharp waves in the muscles innervated by the affected root, fasciculation potentials are rarely recorded).

Peripheral nerve syndrome includes a triad of symptoms - motor, sensory and autonomic disorders (depending on the type of peripheral nerve affected).

1. Motor disorders characterized by muscle atony and atrophy (more often in the distal extremities, after some time), areflexia, signs of peripheral nerve damage according to ENMG data.

2. Sensory disorders in the zone of nerve innervation.

3. Vegetative (vegetative-vascular and vegetative-trophic) disorders.

Signs of a violation of the conduction function of motor and / or sensory nerve fibers, according to stimulation ENG, manifest themselves in the form of a slowdown in the rate of propagation of excitation, the appearance of chronodispersion of the M-response, blocks of conduction

arousal. In the case of axonal damage to the motor nerve, denervation activity is recorded in the form of fibrillation potentials, positive sharp waves. Fasciculation potentials are rarely recorded.

Symptom complexes of lesions of various nerves and plexuses

Radial nerve: paralysis or paresis of the extensors of the forearm, hand and fingers, and with a high lesion - and the long abductor muscle of the thumb, the “hanging hand” position, loss of sensitivity on the dorsal surface of the shoulder, forearm, part of the hand and fingers (dorsal surface of I, II and half of III ); loss of the reflex from the tendon of the triceps muscle, inhibition of the carporadial reflex (Fig. 3.5, 3.8).

Ulnar nerve: typical "clawed paw" - the impossibility of squeezing the hand into a fist, limiting palmar flexion of the hand, adducting and spreading the fingers, extensor contracture in the main phalanges and flexion in the terminal phalanges, especially the IV and V fingers. Atrophy of the interosseous muscles of the hand, worm-like muscles going to the IV and V fingers, muscles of the hypothenar, partial atrophy of the muscles of the forearm. Violation of sensitivity in the zone of innervation, on the palmar surface of the fifth finger, the back surface of the fifth and fourth fingers, the ulnar part of the hand and the third finger. Sometimes there are trophic disorders, pain radiating to the little finger (Fig. 3.6, 3.8).

median nerve: violation of palmar flexion of the hand, I, II, III fingers, difficulty in opposition of the thumb, extension of the middle and terminal phalanges of the II and III fingers, pronation, atrophy of the muscles of the forearm and tenar (“monkey hand” - the hand is flattened, all fingers are extended, the thumb is close brought to index). Violation of sensitivity on the hand, palmar surface of I, II, III fingers, radial surface of the IV finger. Vegetative-trophic disorders in the zone of innervation. With injuries of the median nerve - causalgia syndrome (Fig. 3.7, 3.8).

Femoral nerve: with a high lesion in the pelvic cavity - a violation of flexion of the hip and extension of the lower leg, atrophy of the muscles of the anterior surface of the thigh, the inability to walk up the stairs, run, jump. Sensitivity disorder on the lower 2/3 of the anterior surface of the thigh and the anterior inner surface of the lower leg (Fig. 3.9). Loss of the knee jerk, positive symptoms of Wasserman, Matskevich. At a low level

Rice. 3.5.Symptom of a "hanging hand" in case of damage to the radial nerve (a, b)

Rice. 3.6.Symptom of "clawed paw" in case of damage to the ulnar nerve (a-c)

Rice. 3.7.Symptoms of "monkey's hand" in lesions of the median nerve ("obstetrician's hand") [a, b]

Rice. 3.8.Innervation of the skin sensitivity of the upper limb (peripheral type)

Rice. 3.9.

lesions - an isolated lesion of the quadriceps femoris muscle.

Obturator nerve: violation of adducting the hip, crossing the legs, turning the hip outward, atrophy of the adductors of the hip. Sensitivity disorder on the inner surface of the thigh (Fig. 3.9).

External femoral cutaneous nerve: sensitivity disorder on the outer surface of the thigh, paresthesia, sometimes severe neuralgic paroxysmal pain.

Sciatic nerve: with a high complete lesion - loss of function of its main branches, the entire group of muscles of the flexors of the lower leg, the impossibility of bending the lower leg, paralysis of the foot and fingers, sagging of the foot, difficulty in

walking, atrophy of the muscles of the back of the thigh, all muscles of the lower leg and foot. Sensitivity disorder on the anterior, outer and posterior surfaces of the lower leg, dorsal and plantar surfaces of the foot, fingers, decrease or loss of the Achilles reflex, severe pain along the sciatic nerve, soreness of the Valle points, positive tension symptoms, antalgic scoliosis, vasomotor-trophic disorders, in case of injury sciatic nerve - causalgia syndrome.

Gluteal nerves: violation of hip extension and fixation of the pelvis, "duck gait", atrophy of the gluteal muscles.

Posterior femoral cutaneous nerve: sensory disturbance on the back of the thigh and lower buttocks.

Tibial nerve: violation of plantar flexion of the foot and fingers, rotation of the foot outward, inability to stand on toes, atrophy of the calf muscles, atrophy of the muscles of the foot,

Rice. 3.10.Innervation of the skin sensitivity of the lower limb (peripheral type)

Rice. 3.11.Symptom of the "horse foot" with damage to the peroneal nerve

retraction of the interosseous spaces, a peculiar appearance of the foot - "calcaneal foot" (Fig. 3.10), sensitivity disorder on the back of the leg, on the sole, plantar surface of the fingers, decrease or loss of the Achilles reflex, vegetative-trophic disorders in the zone of innervation, causalgia.

Peroneal nerve: limitation of dorsiflexion of the foot and toes, inability to stand on the heels, dangling of the foot down and rotation inward ("horse foot"), a kind of "cock's gait" (when walking, the patient raises his leg high so as not to hit the floor with his foot); atrophy of the muscles of the anterolateral surface of the lower leg, a disorder of sensitivity along the outer surface of the lower leg and the dorsum of the foot; pains are expressed unsharply (fig. 3.11).

With damage to the plexuses there are motor, sensory and autonomic disorders in the zone of innervation of this plexus.

Brachial plexus(C 5 -Th 1): persistent pain radiating throughout the arm, aggravated by movement, atrophic paralysis of the muscles of the entire arm, loss of tendon and periosteal reflexes. Violation of all types of sensitivity in the zone of innervation of the plexus.

- Superior brachial plexus(C 5 -C 6) - Duchenne-Erb palsy: predominant damage to the muscles of the proximal arm,

sensitivity disorder along the outer edge of the entire arm, loss of the reflex from the biceps of the shoulder. - Inferior brachial plexus(From 7 - Th1)- paralysis of Dejerine-Klumpke: disorder of movements in the forearm, hand and fingers with the preservation of the function of the muscles of the shoulder girdle, impaired sensitivity on the inner surface of the hand, forearm and shoulder, vasomotor and trophic disorders in the distal parts of the hand, prolapse of the carporadial reflex, Bernard-Horner syndrome.

Lumbar plexus (Th 12 -L 4): the clinical picture is due to a high lesion of three nerves arising from the lumbar plexus: the femoral, obturator and external cutaneous nerve of the thigh.

Sacral plexus (L 4 -S 4): loss of functions of the peripheral nerves of the plexus: the sciatic with its main branches - the tibial and peroneal nerves, the upper and lower gluteal nerves and the posterior cutaneous nerve of the thigh.

The differential diagnosis of central and peripheral paralysis is presented in Table. 1.

Table 1.Symptoms of central and peripheral paralysis

In practice, one has to meet with diseases (for example, amyotrophic lateral sclerosis), in which symptoms are revealed that are inherent in both central and peripheral paralysis: a combination of atrophy and roughly expressed hyperreflexia, clonuses, pathological reflexes. This is due to the fact that a progressive degenerative or acute inflammatory process mosaically, selectively affects the pyramidal tract and cells of the anterior horn of the spinal cord, as a result of which both the central motor neuron (central paralysis develops) and the peripheral motor neuron (peripheral paralysis develop) are affected. With further progression of the process, the motor neurons of the anterior horn are more and more affected. With the death of more than 50% of the cells of the anterior horns, hyperreflexia and pathological reflexes gradually disappear, giving way to symptoms of peripheral paralysis (despite the ongoing destruction of the pyramidal fibers).

3.5. Half spinal cord injury (Brown-Séquard syndrome)

The clinical picture of the Brown-Séquard syndrome is presented in Table. 2.

Table 2.Clinical symptoms of Brown-Sequard syndrome

Complete transverse lesion of the spinal cord characterized by the development