home Adviсe Symptom complexes of damage to the cortical-muscular tract at different levels. What type of sensitivity disorder is characteristic of damage to the dorsal horns of the spinal cord (1)

Symptom complexes of damage to the cortical-muscular tract at different levels. What type of sensitivity disorder is characteristic of damage to the dorsal horns of the spinal cord (1)

Cylindrical. cord located in the spinal canal. Two thickenings - cervical (C5-Th1 - innerv. lower end) and lumbar (L1-2-S 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 also sharpened below. the conus medullaris, which is connected by the filum terminale, has reached. coccygeal vertebrae. At the level of each segment, 2 pairs of anterior and posterior roots depart. On each side they merge into the medullary cord. The gray thing has hind horns, sod. feelings. cells; anterior horns, sod. engine class, and side horns in the cat. location veget. cute. and parasymp. neurons. The white matter consists of nerve fibers and is divided into 3 cords: posterior, lateral and anterior. Upper cervical region (C1-C4)- paralysis or irritation. diaphragm, spastic terminal paralysis, loss of all types of sensations, urinary dispersion. Cervical thickening (C5-D2) – transfer paralysis upper horse, spastic lower; loss of sensation, urinary disorders, Horner's sim. Thoracic region (D3- DVII) - spastic lower paraplegia final, loss of urine, loss of sensation in the lower half of the body. Lumbar thickening (L1- S2)- transfer paralysis and anesthesia of the lower parts, urination patterns. Conus medullaris (S3- S5)- loss of feeling in the region. perineum, urine dispersion. Ponytail - perf. lower paralysis con-th, raster. urine, anesthesia on the lower. con-x and perineum.

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

Peripheral trunk damage. nerve- disturbance of all types of senses in the area of cutaneous innervation of this nerve, paresis, muscle atony, areflexia, hyporeflexia, atrophy. Damage to the plexus trunks- anesthesia, hypoesthesia of all types of senses, 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 auricular nerve, senses, pain; n. supraclavicularis (CIII-CIV) – supraclavicular nerves, senses, pain; n. phrenicus (CIII-CIV) – nerve of the diaphragm, paralysis of the diaphragm, hiccups, shortness of breath, pain. Damage shoulders plexuses - flaccid atrophic. paralysis and anesthesia top. con-th with loss of elbow extension. and flexor muscles. reflexes. Damage to the posterior sensory root- paresthesia, pain, loss of all types of sensation, segmental character: circular on the trunk, strip-longitudinal on the limbs, 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 lesion: loss of deep sensitivity, impairment of articular-muscular sense in the presence of central paralysis downward from the level of the lesion, on the contrary. side – conduction pain and temperature anesthesia, violation. superficial sensitivity. As a clinical forms of spinal circulation disorders. According to the hemorrhagic type, hematomyelia is distinguished (Brown-Sicart syndrome). Signs of defeat spinal cord occur suddenly, after physical activity, injury. I observed a strong pain radicular syndrome with irradiation in all directions, dagger-like girdling pains along the spine, headache, nausea, vomiting, slight stupor, lethargy are not uncommon. Def. Kernig's symptom, in combination with Lasegue's pain symptom, stiffness of the neck muscles. May occur with myelitis, spinal cord tumors.

20. Ipair. olfactory nerve and olfactory system. Symptoms and syndromes of damage.n. olfactorii. The fibers begin from the olfactory bipolar cells, in the mucous membrane of the superior turbinate, 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, the anterior perforated plate and the septum pellucidum → 3rd neuron parahippocampal gyrus, piriformis gyrus, hippocampus. Loss: ↓ - hyposmia ; heightened sense of smell - hyperosmi I; perversion of smell - dysosmia, sense of smell. hallucinations – with psychosis and epilepsy. seizures . Research: allow you to smell various odorous substances.

21. IIpair. Optic nerve and visual system. Signs of damage at various levels.n. opticus. 1st neuron retinal ganglion cells enter the cranial cavity through the foramen opticum → at the base of the brain and anterior to the sella turcica they intersect, forming a chiasma (internal fibers intersect, external or temporal ones do not intersect) → optic tracts → cerebral peduncles → afferent part of the arc of the pupillary reflex, visual centers - superior colliculi 2nd neuron→ into the external geniculate bodies and the cushion of the visual thalamus "thalamic neuron". → external genicular body → internal capsule → as part of the Graziole bundle → cortical region. Research: 1. visual acuity: ↓ - amblyopia ; total loss - amaurosis .2. color vision: complete flower blindness – achromatopsia; impaired perception of individual colors - dyschromatopsia; color blindness – inability to distinguish between green and red colors.3. field 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 areas; - hemianopsia – loss of half of vision. Homonymous hemianapsia – loss of the right and left visual fields of each eye. Heteronymous – loss of both internal and external fields of vision: bitemporal – loss of temporal visual fields; binasal – loss of internal half When damaged retina or vision nerve blindness occurs, ↓ visual acuity, with damage. chiasmata - heteronymous hemianopsia, with lesions. sees paths after the cross - homonymous lunge. vision, with a lesion in the visual field. tract - homonymous hemianopsia, with lesions. sees cortex - square hemianopsia.

22. III, IV, VI pairs. Oculomotor, trochlear and abducens nerves and oculomotor system. Innervation of gaze. Gaze paresis (cortical and stem). IIIpair -oculomotorius. Nuclei in the midbrain, along the bottom of the cerebral aqueduct, at the level of the superior colliculus → emerge at the base of the brain → leaves the skull and is divided into branches: superior inn - superior rectus muscle, inferior inn - three external muscles of the eye: inferior rectus, oblique, internal . Laterally, large cell nuclei, inn-t transverse stripes. muscles (oculomotor, levator upper eyelid). Paramedial small cell nuclei of Yakubovich – Edinger – Westphal, Inn-I muscle of the constrictor pupil. Damage: 1) divergent strabismus and the inability to move the affected eyeball inward and upward; 2) exophthalmos – protrusion of the eye from the orbit; 3) ptosis – drooping upper eyelid; 4) mydriasis – dilation of the pupil due to paralysis of the muscles that constrict the pupil and the absence of a direct and friendly reaction of the pupil to light; 5) paralysis of accommodation – deterioration of vision at close distances. IVpair -n. trochlearis. The nucleus is at the bottom of the aqueduct at the level of the lower colliculi → the fibers go upward, cross in the anterior cerebral velum → going around the cerebral peduncles, exit it and along the base of the skull pass into the orbit (through the upper orbital fissure). Inn the muscle rotates the eyeball outward and downward. Damage: convergent strabismus, diplopia. VIpair -n. abducens. The nucleus lies at the bottom of the IV ventricle → bends around the fibers of the facial nerve and goes to the base → exits at the border of the pons and medulla oblongata in the region of the cerebellopontine angle → enters the orbital cavity through the superior orbital fissure. Inn-t lateral rectus muscle of the eye. Damage: convergent strabismus, diplopia. If all nerves are affected, complete ophthalmoplegia occurs. Innervation of eyeball movements is realized. cortical center of gaze, located V posterior section middle frontal gyrus → internal. capsule and cerebral peduncles, decussation, through neurons of the reticular formation and honey prot. the bundle transmits impulses to the nuclei of the III, IV, VI nerves.

23. Vsteam. Trinity nerve. Sensory and motor parts. Symptoms of lesions.n. trigeminus. Nuclei in the brainstem → sensory fibers arise from the gasserian ganglion ( 1st neuron)→ enter the cerebrum: 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) → nuclear fibers form a loop entering the opposite medial lemniscus → thalamus opticum ( 3rd neuron) → internal capsule → end in the posterior central gyrus. The dendrites of the Gasserian ganglion make up a sensitive root: the orbital nerve leaves the skull through the superior orbital fissure, the maxillary nerve through the foramen rotundum, the mandibular nerve through the foramen ovale. The motor root, together with the maxillary nerve, goes to the masticatory muscle. when the engine is damaged. fibers lower jaw when opening the mouth, it deviates towards the lesion. muscles. When paralyzed, they chew everyone. muscles, the lower jaw droops, when damaged. Department. the branches of the raster have developed. in the innervir zone. given nerve, the response fades away. reflexes. Damage eye socket nerve leads to loss of the corneal and supraorbital reflex. When damaged gasserian node or root, the feeling falls in the innerviral zones. all branches of the 5th pair, pain, illness. when pressed at the exit points on the face. when the nuclei on the face are damaged, they are dissociated. raster of feelings (loss of pain and temperature).

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 parts.

In the spinal canal it extends from the level of the lower edge of the foramen magnum to the intervertebral disc between the I and II lumbar vertebrae. At the top, the spinal cord passes into the brain stem, and at the bottom, gradually decreasing in diameter, it ends with the conus medullaris.

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 third cervical and first thoracic vertebra; 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 sites of the ventral (anterior) (13) and dorsal (posterior) (2) roots, two shallower grooves are revealed: anterior lateral and posterior lateral.

A segment of the spinal cord corresponding to two pairs of roots (two anterior and two posterior) is called a segment. The anterior and dorsal roots unite into 31 pairs of spinal nerves. The anterior root is formed by processes of motor neurons of the nuclei of the anterior horns of the gray matter (12). The anterior roots of the VIII cervical, XII thoracic, and two upper lumbar segments, along with the axons of somatic motor neurons, include 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 dorsal root is represented by the central processes of false 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 fourth ventricle of the brain, and in the caudal part of the conus medullaris forms the terminal ventricle.

The gray matter of the spinal cord, consisting mainly of bodies nerve cells, is located in the center. In cross sections, it resembles the shape of the letter H or has the appearance 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 dorsal 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 collections of gray matter in the spinal cord are called columns. The anterior and posterior columns are present throughout the entire length of the spinal cord. The lateral column is somewhat shorter, it begins 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 united into more or less distinct groups-nuclei. Around the central canal there is a central gelatinous substance.
White matter occupies the peripheral parts of the spinal cord and consists of processes of nerve cells. The grooves located on the outer surface of the spinal cord divide the white matter into anterior, posterior and lateral cords. Nerve fibers, uniform in origin and function, inside white matter are combined into bundles or tracts that have clear boundaries and occupy a specific position in the cords.

There are three systems of pathways functioning in the spinal cord: associative (short), afferent (sensitive) and efferent (motor). Short association fascicles connect segments of the spinal cord. Sensory (ascending) tracts are directed to the centers of the brain. The descending (motor) tracts provide communication between the brain and the motor centers of the spinal cord.

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

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

The space between the dura mater and the vertebrae (epidural space) is filled with venous plexus and fatty tissue. In addition to the dura mater, the spinal cord is also covered by the 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, providing communication between the brain, torso, limbs, internal organs etc. Sensitive signals (centripetal, afferent) are transmitted along the dorsal roots of the spinal cord, and motor (centrifugal, efferent) signals are transmitted along the anterior roots.

The spinal cord's own segmental apparatus consists of neurons for various functional purposes: sensory, motor (alpha, gamma motor neurons), autonomic, interneurons (segmental and intersegmental interneurons). All of them have direct or indirect synaptic connections with the conduction systems of the spinal cord. Neurons of the spinal cord provide muscle stretch reflexes - myotatic reflexes. They are the only spinal cord reflexes in which there is direct (without the participation of interneurons) control of motor neurons using signals transmitted along afferent fibers from muscle spindles.

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Myotatic reflexes are manifested by shortening of the muscle in response to its stretching when the tendon is struck with a neurological hammer. They differ in locality, and according to their condition, the topic of spinal cord damage is determined.

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 impaired (dissociated or total anesthesia, hypoesthesia, paresthesia), and vegetative spinal reflexes change (viscero-motor, vegetative-vascular, urinary, etc.).

According to the state of motor function of the extremities (upper and lower), as well as muscle tone, the severity of deep reflexes, the presence of pathological hand 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. Determining the zone of disturbance 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, and 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.), solutions to issues of therapeutic tactics are carried out additional research. During spinal tap evaluate the initial cerebrospinal fluid pressure, patency of the subarachnoid space (cerebrospinal fluid dynamic tests); cerebrospinal fluid is subjected to laboratory testing.

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

By using x-ray examination identify damage to the spine and contents spinal canal(spinal cord membranes, blood vessels, etc.).

In addition to survey spondylography, if necessary, tomography is performed, which makes it possible to detail the structures of the vertebrae, the size of the spinal canal, and detect calcification meninges etc. Highly informative methods of X-ray examination are pneumomyelography, myelography with radiocontrast agents, as well as selective spinal angiography, venospondylography.

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

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

Topical diagnostics

Lesions of the spinal cord 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 set of symptoms of dysfunction of both the segmental apparatus and the conductors of the spinal cord. In case of defeat anterior horn or the anterior root of the spinal cord develops flaccid paresis or paralysis of the corresponding myotome with atrophy and atony of the innervated muscles, myotatic reflexes fade, fibrillation or “bioelectric silence” is detected on the electromyogram.

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

Bilateral symmetrical dissociated sensitivity disorder develops with damage to the anterior gray commissure of the spinal cord.

When the neurons of the lateral horns are damaged, autonomic-vascular, trophic disorders and disturbances in sweating and pilomotor reactions occur (see Autonomic nervous system).

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

If sensory conductors in the lateral cord are damaged, anesthesia occurs downward from the level of the pathological focus and on the side opposite to the lesion. The law of eccentric arrangement of long conductors (Auerbach - Flatau) allows us to differentiate the development of intramedullary and extramedullary pathological processes in the direction of spread of sensitivity disorders: the ascending type of sensitivity disorders indicates an extramedullary process, the descending type indicates an intramedullary process. The axons of the second sensory neurons (dorsal horn cells) pass into the lateral cord of the opposite side through 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 sensitivity disorders.

When the posterior cord is destroyed, joint-muscular vibration and tactile sensitivity on the side of the lesion is disrupted, and sensitive ataxia appears.

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

Symptom complexes of spinal cord lesions at its various levels

There are several main symptom complexes of damage at different levels. Damage to the entire diameter of the spinal cord in upper cervical region (I-IV cervical segments of the spinal cord) appears flaccid paralysis neck muscles, paralysis of the diaphragm, spastic tetraplegia, anesthesia from the level of the neck and downwards, dysfunction of the pelvic organs of the central type (urinary and fecal retention); Possible radicular pain in the neck and back of the head.

A lesion at the level of the cervical thickening (segments CV-ThI) leads to flaccid paralysis of the upper extremities with muscle atrophy, 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 lateral horn cells at the CVIII-ThI level causes Bernard-Horner syndrome.

Damage to 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; damage to the TX-XII segments is accompanied by paralysis of the abdominal muscles. Atrophy and weakness of the back muscles are detected. Radicular pain is girdling in nature.

Damage to the lumbosacral thickening (segments LI-SII) causes flaccid paralysis and anesthesia of the lower extremities, urinary and fecal retention, impaired sweating and pilomotor reaction of the skin of the lower extremities.

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

Damage to the conus segments (segments (SIII - SV)) is characterized by the absence of paralysis, peripheral dysfunction of the pelvic organs with true urinary and fecal incontinence, absence of the urge to urinate and defecate, anesthesia in the anogenital zone (saddle anesthesia), impotence.

Horse's tail (cauda equina) - damage to it gives a symptom complex very similar to damage to the lumbar enlargement and conus medullaris. Arises peripheral paralysis lower limbs with urinary disorders such as retention or true incontinence. Anesthesia on the lower extremities and perineum. Severe radicular pain in the legs is characteristic and for initial and incomplete lesions - asymmetry of symptoms.

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

The most common types of incomplete damage to the diameter of the spinal cord are:

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 syndrome);

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

3) damage to the posterior third of the diameter of the spinal cord, characterized by impaired deep, tactile and vibration sensitivity, sensory ataxia, conduction parasthesias (Williamson syndrome);

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

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

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

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

Determining the level of spinal cord damage

To determine the level of damage to the spinal cord, in particular its upper border, great importance have radicular pain, if any. 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, another 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, located 1 - 2 segments higher.

Changes in reflexes, the spread of segmental movement disorders and upper limit conductive. Sometimes it can also be useful to study sympathetic reflexes. For example, in areas of the skin corresponding to the affected segments, there may be an absence of reflex dermographism, piloarrector reflex, etc.

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

For spinal cord tumors, the following techniques can be used to determine their level of location:

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

Close to described cerebrospinal fluid rush symptom(I.Ya. Razdolsky). Again, in the presence of a block, and more often also with subdural extramedullary tumors, increased radicular pain and worsening of conduction disorders occur when the head is tilted to the chest or when the jugular veins are pressed with hands on both sides of the neck (as with the Queckenstedt maneuver). The mechanism of occurrence 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 stagnation inside the skull.

Spinous process symptom(I.Ya. Razdolsky). Pain when tapping the spinous process of the vertebra, at the level of which the tumor is located. The symptom is more typical for extramedullary and extradural tumors. It is best caused by shaking not with a hammer, but with the hand of the examiner (“the flesh of the fist”). Sometimes, not only do radicular pains appear (exacerbate), but also peculiar paresthesias occur: “a feeling of electric discharge” (Cassirer, Lhermitte,) - a feeling of passing electric current(or “pins and needles”) down the spine, sometimes into the lower limbs.

May also have a known significance radicular positional pain(Dandy - Razdolsky). In a certain position, which causes, for example, tension in the posterior root from which the neuroma arises, radicular pain of the corresponding level arises or intensifies.

Finally worthy of attention Elsberg-Dyck sign(x-ray) - 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 in the length of the spinal cord and spine and carry out the calculation according to the instructions given above. For orientation in the spinous processes of the vertebrae, the following data can be used:

- 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 above the VII thoracic vertebra;

- the line connecting the tops of the iliac crests (cristae lliacae) runs in the space 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 localizing the process can sometimes be obtained by myelography, i.e., radiography when contrast solutions are introduced into the subarachnoid space. It is preferable to administer “heavy” or descending solutions (oil) by suboccipital puncture; the contrast agent, descending downwards in the cerebrospinal fluid, in case of obstruction in the subarachnoid space, stops or is temporarily delayed at the level of the block and is detected on radiography in the form of a shadow (“stop” contrast).

Less contrast images are obtained with pneumomyelography, i.e., when air is injected through a lumbar puncture in a sitting patient; the air, rising upward through the subarachnoid space, stops under the “block” and determines the lower border of the existing obstruction.

To determine the level of location of the “block” (for tumors, arachnoiditis, etc.), a “staircase” lumbar puncture is sometimes used, usually only in the spaces between the LIV - LIII - LII vertebrae (puncture more high departments may be dangerous due to possible needle injury to the spinal cord). Below the blockade of the subarachnoid space, protein-cell dissociation is observed, above - the normal composition of the cerebrospinal fluid; Below the blockade there are symptoms of Queckenstedt and Stuckey, above - their absence (the norm).

Spinal cord - component central nervous system. It is located in the spinal canal formed by the foramina of the vertebrae. It starts from the foramen magnum at the level of the articulation of the first cervical vertebra with the occipital bone. It ends at the border of the first and second lumbar vertebrae. There are two thickenings: cervical, responsible for controlling the upper limbs, lumbosacral, controlling the lower limbs.

There are 8 cervical or cervical, 12 thoracic or thoracic, 5 lumbar or lumbar, 5 sacral or sacral, 1–3 coccygeal segments. The spinal cord itself contains white matter (the pathways for impulses) and gray matter (the neurons themselves). The gray matter contains several groups of neurons, called horns because of their external similarity, responsible for certain functions: the anterior horns contain motor neurons that control muscle movements, the posterior ones are responsible for all types of sensitivity coming from the body and the lateral ones (only in thoracic region), giving commands to all internal organs.

Depending on the type of spinal cord lesion and the affected area, the signs of the disease may differ and have an extremely different clinical picture. It is customary to distinguish symptoms depending on the level of brain damage, its localization and the structures (white and gray matter) that it damaged. Moreover, if the damage does not cross the entire diameter, then sensitivity will disappear on the opposite side, and motor function on the affected side.

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By damaged groups of neurons

Damage to the motor neurons of the anterior horns leads to loss of motor function in the muscle groups controlled by these segments. Disturbances in the area of the posterior groups of neurons cause loss of sensitivity in the areas of the skin corresponding to these segments. Damage to the lateral horns causes dysfunction of the gastrointestinal tract and internal organs.

If pathological process touches the white matter, the paths along which impulses pass between the higher and lower-lying structures of the central nervous system are interrupted. Following this, it develops persistent disorder innervation of the underlying parts of the human body.

Symptoms of spinal cord damage at different levels

Contrary to popular belief, spinal cord injury is not always fatal. Fatal outcomes occur only in the case of a complete or half rupture of the diameter in the first five cervical segments - this is due to the location of the respiratory and cardiovascular centers in them. All complete ruptures are characterized by a total loss of sensitivity, motor activity below the damage site. Injuries to the coccygeal and last sacral segments will cause loss of control over the pelvic organs: involuntary urination, defecation.

Injuries

Trauma accounts for about 80–90% of all spinal cord diseases. They occur in everyday life, sports, accidents, and at work. As a result of exposure to a traumatic factor, compression, displacement or various fractures vertebrae Lifting excessive weights may cause a hernia. intervertebral disc– protrusion of cartilage into the spinal canal with subsequent compression of both the structures of the central nervous system and the nerve roots.

Depending on the severity of the injury, damage to the spinal column is formed to varying degrees. With minor traumatic impacts, a concussion is observed nerve tissue, which leads to motor and sensory disorders and resolves within 2–4 weeks. More serious injuries cause complete or partial rupture diameter of the SC with the corresponding symptom complex.

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Displacement of the vertebrae is characterized by the development of a long-term, weakly progressive disorder of all types of sensitivity and movement. Symptoms may worsen with certain body positions or with prolonged sedentary work.

Hernias and infections

Often, the resulting hernia compresses the dorsal roots of the spinal nerves, which leads to severe girdling pain without impairing movement. The pain intensifies when bending over, lifting heavy objects, or resting on an uncomfortable surface. With the development of inflammation of the membranes of the SM, symptoms spread to several, sometimes all, segments are observed. The clinical picture may be similar to radiculitis, but the symptoms extend over more than 2–3 segments. There is an increase in body temperature to 39–40 degrees, often accompanied by manifestations of cerebral meningitis, and the patient may experience delirium and loss of consciousness.

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The viral disease polio exclusively affects the anterior horns, which contain motor neurons, resulting in the inability to control skeletal muscles. And although after 4–6 months some restoration of innervation is possible due to preserved neurons, patients lose the ability to full movements for the rest of their lives.

Spinal strokes

A fairly rare disease associated with circulatory disorders. Each segment has its own artery. When it is blocked, the neurons of the corresponding area die. The clinical picture of spinal strokes may be similar to a rupture of half the diameter of the spinal column, but they are not preceded by trauma. The development of pathology in most cases occurs in older people with atherosclerotic lesion blood vessels, hypertension, possible previous heart attacks and strokes.

Thinking as an independent form cognitive activity is formed gradually and is one of the most recent psychological formations.

Experience in researching intellectual impairments from the technical point of view. theory of systemic dynamic localization of HMF showed that neuropsychological symptoms of thinking disorders have the same local significance as symptoms of other disorders cognitive processes. Luria, describing neuropsychological syndromes of damage to different parts of the left hemisphere of the brain (in right-handed people) - temporal, parieto-occipital, premotor and prefrontal - identifies several types of disorders of intellectual processes.

In case of defeat left temporal region against the background of sensory or acoustic-mnestic aphasia, intellectual processes do not remain intact. Despite the violation of the sound image of words, their semantic (meaning) sphere remains relatively intact. Verbal paraphasias in the speech of a patient with sensory aphasia arise according to the laws of categorical thinking. But they grossly violate those semantic operations that require constant indirect participation of speech connections or if you need to retain speech material in memory. Partial compensation of these disorders is possible only by relying on visual visual stimuli.

In case of defeat parieto-occipital regions of the brain : difficulties of spatial analysis and synthesis. There is a loss (or weakening) of the optical-spatial factor (visual signs and their spatial relationships are poorly visible). The intention to complete the task is preserved, they can draw up a general plan for the upcoming activity, but are not able to complete the task itself. Characteristic acalculia, difficulties in understanding certain logical-grammatical constructions reflecting spatial and “quasi-spatial” relations.

Defeat premotor parts of the left. half-me GM: premotor syndrome - difficulties in the temporary organization of all mental processes, including intellectual ones. Not only the disintegration of “kinetic patterns” of movements and difficulties in switching from one motor act to another are observed, but also disturbances in the dynamics of the thought process. The curtailed, automated nature of intellectual operations (“mental actions”) is disrupted. These violations are included in dynamic aphasia syndrome(the slowness of the process of understanding stories, fables, and arithmetic problems appears in patients already when listening to them). Consequence - violation of the dynamics of verbal-logical thinking(stereotypical responses when switching to a new operation).

Defeat frontal prefrontal regions of the brain: The disorders are very diverse: from gross defects to almost asymptomatic cases. This inconsistency is explained by the variety of “frontal” syndromes and the insufficient adequacy of the implementation techniques. Happening collapse of the structure of mental activity. The 1st stage of intellectual activity - the formation of an “indicative basis for action” - is either completely absent from them or sharply reduced when performing both non-verbal and verbal-logical tasks. Difficulties also arise when analyzing a complex literary text that requires active orientation and reflection (texts are misunderstood). Violation of selectivity logical operations with side connections (tasks on classifying objects): the logical principle is replaced by a situational one.

CARD No. 2

1. When the cervical thickening is affected, the following are observed (3):

1) peripheral paresis of the upper limbs

2) conductive type of sensitivity disorders

3) peripheral paresis of the lower extremities

4) dysfunction of the pelvic organs

5) cerebellar ataxia

2. A block of the subarachnoid space can be identified (2):

1) radiography of the spine

2) magnetic resonance imaging of the spinal cord

3) electromyography

4) electroneuromyography

5) lumbar puncture with liquorodynamic tests

3. The conduction type of deep sensitivity disorder occurs when there is damage to (1):

1) anterior cords

2) lateral cords

3) posterior cords

4) front horns

5) posterior horns

4. Urinary urgency occurs with bilateral lesions (5):

1) anterior horns of the cervical thickening

2) anterior horns of the lumbar enlargement

3) anterior cords

4) posterior cords

5) lateral cords

5. When the anterior horns of the spinal cord are damaged at the level of the cervical thickening, (1) occurs:

1) spastic tetraparesis

2) central paraparesis in the hands

3) peripheral paraparesis in the legs

4) peripheral paraparesis in the hands

CARD No. 3

Each question has one or more correct answers.

The number of correct answers is indicated in parentheses.

Each correct answer must be highlighted on your answer sheet.

1. When the lumbar enlargement is affected, the following are noted (3):

1) conduction-type deep sensitivity disorder

2) disorder of surface sensitivity of the segmental-radicular type

3) paresis of the lower extremities

4) loss of all abdominal reflexes

5) loss of knee and Achilles reflexes

2. Complete damage to the diameter of the spinal cord at the C2-C3 level is manifested (2):

1) spastic tetraparesis

2) peripheral tetraparesis

3) paresis of the diaphragm

4) bilateral symptom Horner

5) Brown-Séquard syndrome

3. A decrease in the flexion-elbow (biceps) reflex occurs when there is a lesion (2):

2) musculocutaneous nerve

3) median nerve

4) segments C7-C8 of the spinal cord

5) segments C5-C6 of the spinal cord

4. Missing when performing with eyes closed only the heel-knee test on the right is due to the lesion (1):

1) posterior columns of the spinal cord at the upper cervical level on the right

2) posterior pillars at the upper cervical level on the left

3) posterior columns at thoracic level on the right

4) posterior columns at the thoracic level on the left

5. Reflex arc The urinary detrusor closes through the spinal segments (1):

CARD No. 4

Each question has one or more correct answers.

The number of correct answers is indicated in parentheses.

Each correct answer must be highlighted on your answer sheet.

1. When the dorsal horns of the spinal cord are damaged, (1) occur:

1) deep sensitivity disorder of the conduction type

2) disorder pain sensitivity by conductor type

3) peripheral paresis

4) segmental-dissociated type of sensitivity disorders

2. Overflow Bladder occurs when affected (2):

1) cervical thickening

2) thoracic spinal cord

3) lumbar thickening

4) conus spinal cord

5) ponytail

3. Where are the cell bodies of peripheral motor neurons innervating upper limbs (1)?

1) in the anterior horns of the upper cervical spinal cord

2) in the anterior horns of the cervical thickening

3) in the dorsal horns of the upper cervical spinal cord

4) in the posterior horns of the cervical thickening

4. Fasciculations are characteristic of damage (1):

2) lateral cords of the spinal cord

3) peripheral nerves

4) neuromuscular synapse

5. Adamkiewicz’s artery is (1):

1) radicular-spinal artery of the cervical thickening

2) radicular spinal artery of the lumbar enlargement

3) anterior spinal artery

4) posterior spinal artery

CARD No. 5

Each question has one or more correct answers.

The number of correct answers is indicated in parentheses.

Each correct answer must be highlighted on your answer sheet.

1. When the posterior columns are affected at the thoracic level, (2) are noted:

1) central paresis of the lower extremities

2) peripheral paresis of the lower extremities

3) sensitive ataxia

4) conduction type of deep sensitivity disorders in the legs

What type of sensitivity disorder is characteristic of lesions of the dorsal horns of the spinal cord (1)?

1) radicular

2) conductive

3) segmentally dissociated

4) polyneuropathic

3. Muscle atrophy is characteristic of damage to the cortical-muscular tract in the area (2):

1) corona radiata

2) peripheral nerves

3) white matter of the spinal cord

4) anterior horns of the spinal cord

5) neuromuscular synapses

4. When the left half of the diameter of the spinal cord is damaged at the thoracic level, (3) occur:

1) central paresis of the right leg

2) central paresis of the left leg

3) decreased joint-muscular sensation in the left leg

4) decreased pain sensitivity in right leg

5) dysfunction of the pelvic organs

Symptom complexes of damage to the cortical-muscular tract at different levels. What type of sensitivity disorder is characteristic of damage to the dorsal horns of the spinal cord (1)

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

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

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 parts.

In the spinal canal it extends from the level of the lower edge of the foramen magnum to the intervertebral disc between the I and II lumbar vertebrae. At the top, the spinal cord passes into the brain stem, and at the bottom, gradually decreasing in diameter, it ends with the conus medullaris.

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 sites of the ventral (anterior) (13) and dorsal (posterior) (2) roots, two shallower grooves are revealed: anterior lateral and posterior lateral.

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

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

RESEARCH METHODS

Myotatic reflexes are manifested by shortening of the muscle in response to its stretching when the tendon is struck with a neurological hammer. They differ in locality, and according to their condition, the topic of spinal cord damage is determined.

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

Topical diagnostics

Bilateral symmetrical dissociated sensitivity disorder develops with damage to the anterior gray commissure of the spinal cord.

When the neurons of the lateral horns are damaged, autonomic-vascular, trophic disorders and disturbances in sweating and pilomotor reactions occur (see Autonomic nervous system).

When the posterior cord is destroyed, joint-muscular vibration and tactile sensitivity on the side of the lesion is disrupted, and sensitive ataxia appears.

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

Symptom complexes of spinal cord lesions at its various levels

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

Damage to 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.

Damage to the lumbosacral thickening (segments LI-SII) causes flaccid paralysis and anesthesia of the lower extremities, urinary and fecal retention, impaired sweating and pilomotor reaction of the skin of the lower extremities.

Damage to the conus segments (segments (SIII - SV)) is characterized by the absence of paralysis, peripheral dysfunction of the pelvic organs with true urinary and fecal incontinence, absence of the urge to urinate and defecate, anesthesia in the anogenital zone (saddle anesthesia), impotence.

The most common types of incomplete damage to the diameter of the spinal cord are:

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

3) damage to the posterior third of the diameter of the spinal cord, characterized by impaired deep, tactile and vibration sensitivity, sensory ataxia, conduction parasthesias (Williamson syndrome);

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

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

Determining the level of spinal cord damage

For spinal cord tumors, the following techniques can be used to determine their level of location:

May also have a known significance radicular positional pain(Dandy - Razdolsky). In a certain position, which causes, for example, tension in the posterior root from which the neuroma arises, radicular pain of the corresponding level arises or intensifies.

Finally worthy of attention Elsberg-Dyck sign(x-ray) - abnormal increase in the distance between the roots of the arches from 2 to 4 mm at the level of tumor localization (usually extradural).

- 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 above the VII thoracic vertebra;

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

Less contrast images are obtained with pneumomyelography, i.e., when air is injected through a lumbar puncture in a sitting patient; the air, rising upward through the subarachnoid space, stops under the “block” and determines the lower border of the existing obstruction.

By damaged groups of neurons

Symptoms of spinal cord damage at different levels

Injuries

Hernias and infections

Spinal strokes

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 parts.