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1、The Spinal tremor due to nerve lesion. 不随意运动常由基底结或脑干损伤引起 颤动常由神经损伤所致 Palpation 触诊 Look for tenderness, symptom of myositis. 肌肉触痛常为肌炎的表现,Strength of Individual Muscle Groups肌群组的强度变化,Patterns of weakness can help localize lesion. 肌力降低的类型有助于确定病变部位 Test strength of each muscle group and record. 检查记录每组肌群的
2、强度 Pair testing of contralateral muscle groups to see asymmetry. 检查对侧相应肌群确定不对称性 Tests muscle, LMN, peripheral nerves and roots 检查肌肉 中枢和周围神经 Lower Motor Neuron 下位运动神经元,Clinical Character临床特征,Acute UMN lesions often show flaccid paralysis, after hrs/days hypertonia/hyperreflexia. 急性上运动神经元损伤常表现为软瘫 数小时或
3、数天后转为肌张力增高 Slow/awkward foot tapping/finger movements can indicate corticospinal, cerebellar, basal ganglia lesions. 缓慢笨拙的手足运动 提示脊髓 脑干或基底部损伤,Sensory function感觉功能,fleet sensory 浅感觉 deep sensory 深感觉 complex sensory 复合感觉,Introduction概述,fleet sensory: bodies feelings to stimulus including sense of pain,
4、 touch and temperature 浅感觉: 机体对刺激的感受 包括痛觉 触觉 温度觉 deep sensory: bodies distinguishing to sense of moving, place and tremble 深感觉: 机体对刺激的识别 包括运动觉 位置觉 震动觉 complex sensory: feelings by cortex synthesis analysed, including sense of skin orientation, deuce distinguish, form and structure, surface delineati
5、on 复合感觉: 综合分析后的皮质感觉 包括皮肤定位觉 两点辨别觉 形体觉 体表图形觉 Caution: close eyes when pass in review 注意: 被检查者闭目,Fleet Sensory浅感觉,Sense of pain: stick skin with pin tip lightly, sense obstacle of pain seen in damage of side bind of spinal cord and thalamencephalon 痛觉: 用大头针针尖轻刺皮肤 痛觉障碍见于脊髓丘脑侧束损害 Sense of touch: touch s
6、kin or membrane with cotton sticker, sense obstacle of touch seen in damage of back bind of spinal cord 触觉: 用棉签轻触皮肤或黏膜 触觉障碍见于脊髓后索病损 Sense of temperature: test skin with hot or cold water, sense obstacle of temperature seen in damage of side bind of spinal cord and thalamencephalon 温度觉: 用热水或冷水试管测试皮肤
7、温度觉障碍见于脊髓丘脑侧束损害,Deep Sensory深感觉,Sense of movement: nip lightly and move finger or toe, cant distinguish seen in damage of back bind 运动觉: 轻夹被检查者手指或足趾移动 不能辨别见于后索病损 Sense of position: put limb in some position, cant distinguish seen in damage of back bind 位置觉: 将被检查者肢体放于某一位置 不能辨别见于后索病损 Sense of tremor:
8、put vibrating tuning fork in follicle, no tremor feelings seen in damage of back bind 震动觉: 将震动的音叉置于骨突起处 无震动感见于后索病损,Complex Sensory复合感觉,Sense of skin orientation: touch skin with cotton sticker, no orientation seen in cortex disorders 皮肤定位觉: 用棉签轻触皮肤 定位感缺失见于皮质病变 Sense of two point distinguish: stimula
9、te two point in skin with dull , make sure the space feeling from two to one point, space increased seen in front lobe damage 两点辨别觉: 钝脚分规刺激皮肤两点 确定缩小至感觉为一点的间距 间距增大见于额叶病变 Sense of entity: touch familiar body such as coin with one hand, cant say names seen in cortex disorders 实体觉: 单手触摸熟悉物体(如硬币) 说不出名称见于
10、皮质病变 Sense of delineation in body surface: draw simple graph in skin, cant distinguish seen in disorders upwards thalamencephalon 体表图形觉: 在皮肤上画简单图形 不能识别见于丘脑以上病变,Nervous Reflexes神经反射,hysical reflex 生理反射 pathological reflex 病理反射 meningeal stimulation sign 脑膜刺激征 nerve root stimulus sign 神经根刺激征,Fiber Tra
11、cts in White Matter脑皮质神经通路,Innervation of Spinal Cord脊神经分布,The Reflex Arc神经反射,Reflex: rapid, predictable, and involuntary responses to stimuli 反射: 对刺激快速 可预测 不随意的反应 Reflex arc: direct route from a sensory neuron, to an interneuron, to an effector 反射弧: 从感觉神经元至中间神经元到效应器的直接通路,Simple Reflex Arc神经反射弧,感受器
12、传入神经元 中枢 传出神经元 效应器 sensory afferent integration association effector receptors neuron center neuron,Physical Reflex生理反射,Superficial reflex: induced by the stimulation of mucocutaneous receptors 浅反射: 刺激皮肤粘膜感受器引起反应 Included: corneal reflex, abdominal reflex, cremasteric reflex, plantar reflex 包括: 角膜反射
13、 腹壁反射 提睾反射 跖反射 Deep reflex: induced by the stimulation of periosteal and tendon receptors 深反射: 刺激骨膜肌腱感受器引起反应 Included: biceps reflex, triceps reflex, brachioradialis reflex, patellar reflex, achilles tendon reflex 包括: 肱二头肌反射 肱三头肌反射 桡骨骨膜反射 膝(腱)反射 跟腱反射,Corneal Reflex角膜反射,Centre: pons 中枢: 桥脑 Afferent n
14、erve: trigeminal nerve 传入: 三叉神经 Efferent nerve: facial nerve 传出: 面神经 Technique: using cotton touch cornea 方法: 棉花轻触角膜 Response: close eyes 反应: 闭眼,Abdominal Reflex腹壁反射,Centre 中枢 coastal margin: T78 上腹壁: 胸髓7,8节 umbilicus: T910 中腹壁: 胸髓9,10节 above groin: T1112 下腹壁: 胸髓11,12节 Technique: pull abdominal wall
15、 using stick 方法: 竹签划腹壁 Response: local muscle contract 反应: 局部腹肌收缩,Cremasteric Reflex提睾反射,Centre: L12 中枢: 腰髓1,2节 Technique: pull inner side of thigh using stick 方法: 竹签划大腿内侧 Response: same side testicle ascending 反应: 睾丸上提,Plantar Reflex跖反射,Centre: S12 中枢: 骶髓1,2节 Technique: pull foot thenar using stick
16、 检查: 划足底 Response: foots thenar flection 反应: 足跖屈曲,Anus Reflex肛门反射,Centre: S45 中枢: 骶髓4,5节 Technique: pull crissum skin using stick 检查: 轻划肛周皮肤 Response: perianus sphincter contract 反应: 肛门外括约肌收缩,Biceps Reflex肱二头肌反射,Centre: C56 中枢: 颈髓5,6节 Technique: beat tendon of brachial biceps 检查:叩击肱二头肌肌腱 Reaction: r
17、apid flexion of the forearm 反应: 前臂快速屈曲,Triceps Reflex肱三头肌反射,Centre: C78 中枢: 颈髓7,8节 Technique: beat tendon of brachial triceps superior in olecranon 检查: 叩击鹰嘴突上方 肱三头肌肌腱 Reaction: extension of the forearm 反应: 前臂稍伸展,Brachioradialis Reflex桡骨骨膜反射,Centre: C58 中枢: 颈髓58节 Technique: beat styloid process of ra
18、dius 检查: 叩击桡骨茎突 Reaction: flexion and pronation (moving the palm downward) of the forearm 反应: 前臂旋前屈肘,Patellar Reflex膝(腱)反射,Centre: L24 中枢: 腰髓24节 Technique: beat tendon of quadriceps below patella 检查: 叩击髌骨下方 股四头肌肌腱 Reaction: extension of the knee 反应: 小腿伸展,Achilles Tendon Reflex跟腱反射,Centre: S12 中枢: 骶髓
19、1, 2节 Technique: beat Achilles tendon 检查: 叩击跟腱 Reaction: plantar flexion of the ankle 反应: 足向跖面屈曲,Site of Pathological Changes病变定位,Superficial reflex 浅反射 Unilateral absence: pyramidal tract diseases 单侧消失: 锥体束病损 Bilateral absence: regional damage in spinal cord 双侧消失: 脊髓局部病损 Deep reflex 深反射 Hyperactive
20、: disease of central nerves 增强: 中枢病变 Absent or hypoactive: reflex arc abnormality 减弱消失: 局部病变,Clinical Meanings临床意义,Asymmetry of tendon reflex is important orientation sign of nerve lesion. 腱反射不对称是神经损害的重要定位体征 Decreased or disappeared tendon reflex usually seen in peripheral nerve injury such as perip
21、heral nervitis, radiculoneuritis, anterior polimyelitis etc. 腱反射减弱或消失多系周围神经病变所致 如末梢神经炎 神经根炎 脊髓前角灰质炎等 There is spinal shock duration in brain or spinal injury initial stages, deep reflex decreased or disappeared in this duration, after this deep reflex increasing. 在脑或脊髓损伤初期有一段脊髓休克期 此时深反射亦减弱或消失 休克期过后出
22、现深反射加强,Pathological Reflex病理反射,Abnormal reflex induced by pyramidal tract diseases made brain loose control of brain-stem and spinal cord. 指锥体束病损时 大脑失去对脑干和脊髓的抑制作用 而出现的异常反射 Pathological reflex can appear in infant within one and half year, caused by nerve system incompletely growth and not belong to
23、pathologic. 一岁半以内婴儿神经系统发育未完善 可出现这种反射 不属于病理性,Pyramidal Sign锥体束征,Upper limbs pathological reflex: Hoffmann Sign usually seen in cervical region disorders of spinal cord 上肢病理反射: 霍夫曼征 多见于颈髓病变 Lower limbs pathological reflex: Babinski sign, Chaddock sign, Oppenheim sign, Gordon sing 下肢病理反射: 巴宾斯基征 查多克征 奥本
24、海姆征 戈登征 Clonus: rhythmical contraction of the muscle made the limb or foot movement by stimulation 阵挛: 刺激使肌肉有节奏的收缩致肢体运动,Hoffmann Sign霍夫曼征,Technique: flip nail of middle finger 检查: 弹刮中指指甲 Positive: other four fingers bend to palm lightly 阳性: 四指轻微屈掌,Pyramidal Sign in Lower Limbs下肢锥体束征,Babinski sign: u
25、sing stick pull thenar along outer side to small toe and entad 巴宾斯基征: 用竹签划足底 沿外侧缘至小趾根部转向内侧 Chaddock sign: using stick pull foot back from outer ankle to small toe and entad 查多克征: 用竹签划足背 自外踝至小趾根部转向内侧 Oppenheim sign: press and slip downward along front of shinbone 奥本海姆征: 向下方滑压胫骨前缘 Gordon sign: pinch g
26、astrocnemius 戈登征: 捏压腓肠肌,Positive Sign阳性征象,Findings: the big toe shows dorsiflexion and the other toes show fanning. 表现: 拇趾背伸 余四趾扇形展开 Babinski sign is the highest positive rate in these signs 巴宾斯基征的阳性率最高,Clonus阵挛,Ankle clonus: forcibly made anklebone extend excessively 踝阵挛: 用力使踝关节过伸 Patellar clonus:
27、drive patella downwards 髌阵挛: 向远端推动髌骨 Positive: contract rhythmical in local 阳性: 局部有节奏的收缩,踝阵挛检查法,Meningeal Stimulation Sign脑膜刺激征,Definition: signs induced by disorders with meninges such as pathological changes, inflammation, arachnoid low cavity bleeding, encephalic hypertension, etc. 定义: 脑膜病变 脑膜炎 蛛
28、网膜下腔出血 颅内压增高等(除外颈椎疾患) Neck rigidity: resisting in raise neck 颈项强直: 抬颈抵抗 Kernig sign: angle of knees joint can be drived up less than 135 degree with bended thigh 克匿格征: 屈腿抬高135(正常可达135) Brudzinski sign: going down on knees when raise neck 布鲁金斯基征: 抬颈时屈膝,Technique检查方法,neck rigidity 颈项强直,Kernig sign 克匿格
29、征,Brudzinski sign 布鲁金斯基征,Nerve Root Stimulus Sign神经根刺激征,straight leg raise (Lasague) test 直腿抬高(拉塞格)试验 When the leg is passively flexed at the hip, the patient complains of pain in the low back. 正常下肢抬高可达6090 抬高30出现痛感为阳性 Clinical significance: help confirm the presence of a herniated nucleus pulposus 意义: 神经根受刺激 见于坐骨神经痛 腰椎间盘突出 腰骶神经根炎,70,Sign of Upper and Lower Motor Neuron Lesions上下运动神经元损伤征象比较,foreshow next content预告下次内容,症状学 symptomatology 发热 fever 水肿 edema 疼痛 pain,