中英061推理副肿瘤性脊髓病施清晓黄
A64-year-oldright-handedwomanpresentedtoanoutsidehospitalwitha1-weekhistoryofweaknessnotedwhilewalking.Shereportedbilateralweaknessgreaterontheright,andseveralfalls.Shedeniedlowerextremitynumbness.Hermedicalhistorywassignificantforlower-backosteoarthritisanda20pack-yearsmokinghistory.Shedeniedconstitutionalsymptoms.Herexaminationonadmissionwasnotablefor4/5rightgastrocnemiusstrengthandunsteadygait.
64岁右利手女性以行走时乏力1周为主诉就诊于外院。患者双侧肢体乏力，以右侧为著，并有数次跌倒。否认双下肢麻木。患者有下背部骨关节炎病史，吸烟量为20包年。否认有全身症状。入院查体示右侧腓肠肌肌力4级，步态不稳。
Duringhospitalization,herright-sidedweaknessprogresseduntilshecollapsed.Shealsonotedhandweaknessandintensifiedbackpain,andrequiredbladdercatheterizationbecauseofdifficultyurinating.Upontransfertoourhospital,thepatient’svitalswerestableandherexaminationwassignificantformildankleedema.Neurologicexaminationdemonstrated4/5weaknessinherarmsbilaterallyand2/5weaknessinherlegsbilaterally;sensorydeficitswereabsent.Reflexeswerediminishedthroughoutandabsentintheleftleg.
住院期间，患者右侧肢体乏力出现进展。患者出现双手乏力和背部疼痛加剧，因排尿困难而留置导尿。患者转诊至我院时生命征平稳，查体发现脚踝轻度水肿。神经系统检查示双上肢肌力4级，双下肢肌力2级，无感觉障碍，左下肢腱反射完全消失。
Questionsforconsideration:
1.Wheredoesthisprocesslocalize?
2.Withwhatsyndromedoesthispatientpresent?
3.Whatisyourfirstdiagnosticstep?
需要考虑的问题：
1.病变的定位在哪里？
2.患者表现的是什么综合征？
3.确立诊断第一步应该做什么？
SECTION2第二部分Thispatientpresentedwithsignsofasubacuteprogressivemyelopathy.Quadriparesisandbladderdysfunctionindicatealesionatthelevelofthemidcervicalspinalcordaffectingventral/lateralspinalcordorspinalnerveroots.Withoutupperextremityinvolvement,thelesionwouldlocalizetothelowerspinalcordorcaudaequina.Bycontrast,apatternofdistalweaknesswithhyporeflexiaandnosensorydeficitistypicalofamotorneurondisorder.ItiscrucialtodistinguishmyelopathyfromGuillain-Barrésyndrome.Althoughreflexesmaybelostinbothsyndromes,myelopathyhasauniquepatternoffunctionalloss,urinarydysfunction,spasticity,andMRIfindings.
该患者表现为亚急性进展性脊髓病。四肢瘫和排尿障碍提示病变累及颈中段脊髓腹/外侧或脊神经根。没有上肢受累的话，病变则可定位于脊髓下段或马尾。反之，远端乏力、反射减退不伴有感觉障碍是运动神经元病的表现。脊髓病与GBS鉴别是很重要的。虽然两者都会出现腱反射减退，但脊髓病有独特的功能障碍、排尿障碍、肌强直和MRI表现。
Acarefulhistoryandexaminationguidethetypeandlocationofdiagnosticimaging,typicallyanMRIwithgadoliniumofthespinalregionofinterest.CTmyelogramisanalternativemodality.Thesemayreveal北京治白癜风那里好一点白癜风如何治疗最好
