Miyelopatiya — the generalized concept used in neurology for designation of the damages of a spinal cord, various on the etiology, which usually have a chronic current. Clinically they can be shown by violations of force and a tone of muscles, various touch frustration, dysfunction of pelvic bodies. A problem of diagnostic search at a miyelopatiya is detection of a causal disease. The X-ray analysis of a backbone, MRT, EMG, ENG, an angiography, the analysis of a likvor, biochemical blood tests, PTsR-diagnostics, etc. is for this purpose carried out. Medical tactics is based on therapy of the main disease, symptomatic treatment and rehabilitation by means of LFK, mechanotherapy, massage, acupuncture and physical therapy.
Miyelopatiya is the complex concept including any dystrophic changes of a spinal cord, is not dependent on their etiology. As a rule, it is the chronic or subsharp degenerate processes resulting from violation of blood supply and metabolism of separate spinal segments. Often the miyelopatiya acts as a complication of degenerate and dystrophic diseases of a backbone, vascular pathology, toxic influence, a spine injury, dismetabolichesky changes or infectious processes. Therefore in the specified diagnosis the instruction on the nature of damage of a spinal cord by all means has to face the term "miyelopatiya". For example, "an ischemic miyelopatiya", "a compression miyelopatiya" etc.
Etiology and pathogenesis of a miyelopatiya
In the prevailing majority of cases the pathological processes leading to development of a miyelopatiya are localized out of a spinal cord. First of all it is degenerate changes of a backbone (osteochondrosis, , , involute ) and injuries (a vertebra fracture, an incomplete dislocation or dislocation of vertebras, compression spinal fracture). They are followed by vascular diseases (atherosclerosis, thrombosis of spinal vessels), anomalies of development of a backbone, tumoral processes in a backbone, metabolic violations (at a disproteinemiya, diabetes, a fenilketonuriya, lizosomalny diseases of accumulation), tuberculosis and osteomyelitis of a backbone. Can lead radioactive and toxic impact on an organism to pathological changes of a spinal cord.
Less often the miyelopatiya caused by direct defeat of substance of a spinal cord meet. The prime cause of their emergence can be: vertebral and spinal trauma, infectious damages and tumors of a spinal cord, gematomiyeliya, demiyelinization. The last can carry hereditary (at Russi-Levi's syndrome, Refsum's disease and so forth) or acquired (at multiple sclerosis) character. In exceptional cases the miyelopatiya develops as a complication of a lyumbalny puncture.
Among pathogenetic mechanisms of emergence of a miyelopatiya compression prevails. The compression a hernia nuclei pulposi, osteofita, otlomka is possible at a change, a tumor, the post-traumatic hematoma displaced by a vertebra. At the same time occurs both a direct sdavleniye of a spinal cord, and perezhaty spinal vessels, the hypoxia and violation of food, and then a degeneration and death of nervous cages of the struck spinal segment is a consequence of what. Emergence and development of pathological changes is implemented gradually with increase in a compression. Result — loss of function of neurons of this segment and blocking of carrying out through it of the impulses going on the carrying-out ways of a spinal cord.
Classification of a miyelopatiya
In modern neurology the miyelopatiya is traditionally classified by the etiologichesky principle.
- Spondilogenny (including diskogenny) — it is connected with various degenerate processes of a spine column.
- Ischemic (distsirkulyatorny, atherosclerotic, vascular) — develops against the background of chronic violation of spinal blood circulation.
- Post-traumatic — is caused as a direct injury of a spinal cord (concussion, a bruise), and with compression influence of a hematoma, the displaced vertebras or their parts at a change.
- Kartsinomatozny — is manifestation of paraneoplastic defeat of TsNS at leukemia, a lymphoma, a limfogranulematoza, lung cancer, etc. oncological pathology.
- Infectious — occurs at HIV, syphilis (neurosyphilis), Lyme's disease, an enteroviral infection at children.
- Toxic — is caused by toxic impact on TsNS. It can be observed at diphtheria.
- Radiation — depends on a dose and time of radiation exposure. The radiation miyelopatiya can arise after radiation therapy of malignant new growths.
- Metabolic — seldom found complication of endocrine and metabolic frustration.
- Demiyeliniziruyushchy — result of the hereditary or acquired demiyeliniziruyushchy processes in TsNS.
Clinically the miyelopatiya is shown by a number of neurologic symptoms which have practically no the specifics reflecting its etiology and entirely depend on level and extent of damage of a spinal cord. In general the miyelopatichesky simptomokompleks includes the peripheral paresis / paralysis with muscular hypotonia and a hyporeflection developing at the level of the struck segments; the central paresis / paralysis with a muscular hyper tone and a hyper reflection, the extending lower than the level of localization of pathological changes; and a paresteziya both at the level of defeat, and below it; pelvic violations (delay or incontience of urine and calla).
Spinal vessels are exposed to formation of atherosclerotic plaques and thrombosis much less often, than cerebral (brain vessels). As a rule, it occurs at persons 60 years are more senior. The motor-neurons which are in forward horns of a spinal cord are the most sensitive to ischemia. For this reason in a clinical picture of a vascular miyelopatiya the leading place is taken by motive violations that reminds manifestations the BASS. Frustration of the sensitive sphere are minimum and come to light only at careful neurologic survey.
Represents the spinal syndrome developing depending on weight of a trauma and a current of the next post-traumatic period. On clinical manifestations often has much in common with a siringomiyeliya, in particular the dissociated type of sensitive frustration: loss superficial (temperature, painful and tactile) sensitivity at safety deep (musculoarticulate and vibration). Usually post-traumatic miyelopatiya has irreversible character and makes a basis of the residual (residual) phenomena of a trauma. Its progrediyentny current with progressing of touch violations is in some cases noted. Often the post-traumatic miyelopatiya is complicated by interkurrentny infections of urinary tract (cystitis, uretrity, pyelonephritis); sepsis is possible.
It is most often observed in cervical spinal segments at the patients who underwent radiation therapy of cancer of throat or throat cancer; in chest department — at the patients receiving radiation concerning sredosteniye tumors. Develops in the period from 6 months to 3 years after beam loadings; on average 1 year later. In such cases the miyelopatiya needs differential diagnostics with spinal metastasises of the available tumor. Typically slow progressing of clinic caused by a gradual necrosis of tissues of spinal cord. At neurologic survey Broun-Sekar's syndrome can come to light. In tserebrospinalny liquid of change are not observed.
It is caused by toxic influence of a tumor and influence of biologically active agents synthesized by it that finally leads to necrotic changes of spinal structures. The clinical simptomokompleks in many respects repeats neurologic violations at a side amyotrophic sclerosis. Therefore some authors carry this type of a miyelopatiya to the BASS special form. In a likvor can come to light and moderated .
Diagnostics of a miyelopatiya
The diagnostic algorithm at identification of signs of a miyelopatiya is directed to an exception of another, similar on clinical symptoms, pathology of TsNS and establishment of the etiologichesky factor which is the cornerstone of dystrophic changes of a spinal cord. It includes the general and biochemical blood test, a X-ray analysis of a backbone, backbone MRT, an electromyography (EMG), an elektroneyrografiya (ENG), a research of the caused potentials, MR-or the KT-angiography of a spinal cord, a lyumbalny puncture.
According to indications in the absence of a possibility of carrying out MRT the miyelografiya and a discography can be in some cases executed. At suspicion on the infectious nature of a miyelopatiya blood test on sterility, the RPR-test, PTsR-researches, crops of cerebrospinal fluid is conducted.
During diagnostic search the neurologist can involve in joint consultation of other experts: vertebrologa, phthisiatrician, oncologist, venereologist; at the assumption of a demiyeliniziruyushchy hereditary miyelopatiya — genetics.
Treatment of a miyelopatiya
Tactics of treatment of a miyelopatiya depends on its etiology and a clinical form. It includes therapy of a causal disease and symptomatic treatment.
At a compression miyelopatiya elimination of a compression is prime. Removal of a wedge of Urban, drainage of a cyst, removal of a hematoma and tumor can be for this purpose shown. When narrowing the vertebral channel the patient goes to the neurosurgeon for the solution of a question of possible carrying out decompressive operation: laminektomiya, fasetektomiya or punktsionny decompression of a disk. If the compression miyelopatiya is caused by hernia of an intervertebral disk, then depending on degree of a protrusion and a condition of a disk the mikrodiskektomiya or a diskektomiya is carried out.
Treatment of an ischemic miyelopatiya consists in elimination of factors of a compression of vessels and performing vascular therapy. As the vascular component is present at pathogenesis practically of any miyelopatiya, similar treatment is included into complex therapy of most of patients. It includes spazmolitichesky and vasodilating means (, a ksantinola , a papaverine, ), medicines the improving microcirculation and rheological properties of blood ().
At a toxic miyelopatiya the basis of treatment is made by desintoxication, at infectious — antibacterial therapy adequate to an etiology. Great difficulties are presented by treatment of a hereditary demiyeliniziruyushchy miyelopatiya and kantseromatozny miyelopatiya at gemoblastoza. Often it comes down to performing symptomatic therapy.
In treatment of a miyelopatiya the medicines improving metabolism of nervous tissue and reducing its susceptibility to a hypoxia are obligatory. Neuroprotectors, metabolites and vitamins (a hydrolyzate of a brain of a pig, piracetam, a haemo derivative of blood of calfs, Vit of B1, Vit of B6) concern to them. Consultation of the physiotherapist for optimum selection of methods of physiotherapeutic influence is shown to many patients: diathermies, galvanization, UVCh, parafinoterapiya and so forth.
For the purpose of increase in volume of physical activity, development of skills of self-service, the prevention of development of complications (muscular atrophies, contractures of joints, decubituses, stagnant pneumonia) from early terms of a disease of the patient with a miyelopatiya carrying out LFK, massage and rehabilitation physical therapy is shown (electrostimulation, an electrophoresis with neostigminy, reflexotherapy, SMT of paretichny muscles, balneotherapy). At deep paresis of LFK consists in performance of passive exercises and mechanotherapy.
Forecast and prevention of a miyelopatiya
In case of timely elimination of a sdavleniye the compression miyelopatiya has a favorable current: at the corresponding treatment its symptoms can be reduced substantially. The ischemic miyelopatiya often has the progressing current; repeated courses of vascular therapy can stabilize a state for a while. The post-traumatic miyelopatiya is, as a rule, stable: its symptoms are not reduced and do not progress. The adverse forecast and steadily progressing current have a radiation, demiyeliniziruyushchy and kartsinomatozny miyelopatiya.
Prevention of a miyelopatiya consists in the prevention of the diseases capable to lead to its development. This timely identification and treatment of pathology of a backbone and vascular diseases; stable compensation of endocrine and metabolic frustration; injury prevention, infectious diseases, intoxications lead, cyanides, hexachlorohair dryer, etc.