Pediatric emergency medicine trisk 2639 2639
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Dysfunction of the spinal cord may result from any of a variety of disorders,
either intrinsic or extrinsic to the spinal cord, with a great deal of overlap in their
clinical presentation. Spinal cord dysfunction from any cause is characterized by
paraplegia and hyporeflexia below the level of involvement; sensory symptoms,
such as band-like pain at the level of compression; and sensory loss or
paresthesias below the area of damage. If the lower spinal cord is involved (the
conus), there is usually early loss of bowel and bladder control. Compression of
the cauda equina usually results in asymmetric symptoms, radicular pain, and
focal lower-extremity motor and sensory abnormalities.
Transverse myelitis is an intramedullary disorder, involving both halves of the
cord over a variable length, with involvement of motor and sensory tracts. It
occurs in children and adults, although it is rare in the first year of life. Transverse
myelitis is believed to be caused by an autoimmune process, with demyelinating
lesions found in the spinothalamic and pyramidal tracts as well as posterior
columns of the spinal cord. During the course of the illness, the area of spinal
cord inflammation may extend rostrally and caudally to involve an extensive
portion of the spinal cord. Transverse myelitis may occur after a number of
infections, among those commonly reported are Epstein–Barr virus,
cytomegalovirus, measles, mumps, Campylobacter jejuni, and M. pneumoniae.
Transverse myelitis may also result from systemic autoimmune disorders such as
lupus erythematosus or scleroderma. In some older children and adolescents,
transverse myelitis is a first manifestation of multiple sclerosis.
Transverse myelitis may affect any level of the spinal cord, but thoracic
involvement is the most common. Initial symptoms include lower-extremity
paresthesia, local back pain, unilateral or bilateral lower-extremity weakness, and
urinary retention. A preceding respiratory or gastrointestinal illness is usually
reported, and at the time of diagnosis, fever and meningismus are sometimes seen
in children. Characteristically, the insidious onset of paresthesia or weakness of
the lower extremities progresses over days or, rarely, weeks and then is replaced
by the abrupt occurrence of static paraplegia or quadriplegia and, in the
cooperative child, a detectable sensory level. In other children, the course of
progression may be less than 12 hours. The sensory loss generally involves all
modalities, although a spinothalamic deficit (pain) may occur without posterior
column dysfunction (vibration). The weakness is usually symmetric but may be
asymmetric. After a variable interval, initial flaccidity may be replaced by
spasticity. Sphincter disturbance of the bowel and bladder occurs in most patients,
bladder distention being the most common initial sign of damage.
