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自发性椎管内硬膜外血肿1例

2018-12-03 陈士军 韩业福 付艳超 临床骨科杂志

患者,女,63岁,因突发双下肢麻木伴乏力14h余入院。主诉:在家弯腰洗衣服时突感胸腰背部疼痛,双下肢麻木、无力,不能站立及行走,无昏迷、恶心及低热、盗汗等伴随症状。急至当地医院行胸椎X线及CT检查,未见明显异常,予以局部康复理疗后未见好转,且症状逐渐加重。我院门诊以“不全瘫”收住我科。患病以来,患者精神尚可,大、小便未解。

临床资料

患者,女,63岁,因突发双下肢麻木伴乏力14h余入院。主诉:在家弯腰洗衣服时突感胸腰背部疼痛,双下肢麻木、无力,不能站立及行走,无昏迷、恶心及低热、盗汗等伴随症状。急至当地医院行胸椎X线及CT检查,未见明显异常,予以局部康复理疗后未见好转,且症状逐渐加重。我院门诊以“不全瘫”收住我科。患病以来,患者精神尚可,大、小便未解。

既往史:腰椎间盘突出症9年余,未行任何治疗,无高血压病、心脏病、糖尿病等内分泌及代谢性疾病史。查体:体温36.5℃,脉搏78次,呼吸20次,血压18.7/13.3kPa,心、肺、腹检查未见明显异常。专科检查:脊柱生理曲度变浅,局部皮肤未见明显红肿、破损等异常;胸腰背部重度按压无明显疼痛,左侧膝关节以下皮肤触觉、痛觉明显减退,右侧脐平面以下触觉、痛觉稍减退,双下肢位置觉存在;脊柱各方向活动范围减小,双下肢直腿抬高试验不能,被动直腿抬高试验(-),双下肢各关节被动活动未见明显异常;双下肢肌力约Ⅱ级,周径相等,双侧巴宾斯基征(+),双侧膝腱、跟腱反射未见明显异常,马鞍区及会阴部感觉未见明显异常。入院后血常规:WBC22.09×109/L,N0.91,RBC2.86×1012/L。

尿常规:潜血(+)。超敏C-反应蛋白10.8mg/L,葡萄糖8.71mmol/L。肝、肾功能、电解质未见明显异常。腰椎MRI(图1A、B)提示:①T10,11椎管内硬膜外异常信号,考虑占位?出血?建议行增强扫描进一步检查。②L2~3、L5~S1椎间盘突出。③L3~4、L4~5椎间盘膨出。④胸腰椎退行性变。腰椎MRI增强(图1C)提示:T10、T11椎管内硬膜外异常信号,未见明显强化,考虑血肿可能性大,建议复查。胸椎CT三维重建显示:胸椎退行性变。入院后予以绝对卧床休息,导尿、脱水、营养神经、活血及对症治疗。次日清晨查房,患者主诉胸腰背部疼痛略缓解,查体见双下肢可勉强抬离床面,肌力约Ⅲ级;经非手术治疗半个月后患者症状明显缓解,双下肢肌力约为Ⅳ级,皮肤浅感觉较之前好转。诊断为自发性椎管内硬膜外血肿(SSEH)。


讨论

SSEH是一种多以颈肩部或胸背部疼痛急性发作、伴进行性神经根或脊髓受压为特征的疾病,发病突然,病情进展较快,临床上极易误诊。多数认为SSEH是指非医源性及无明显外伤引起椎管内硬膜外血液的异常聚集,发病原因不明,可能与血管畸形、抗凝治疗、溶栓等有关;发病机制也不明确,主要推测是椎管内硬膜外静脉丛出血。

目前临床上认为MRI是诊断SSEH的金标准,尤其是T2加权像,增强扫描用于与肿瘤、感染的鉴别。SSEH是临床上少见的急症,病情变化快,如不能及早诊断、及时处理,容易出现脊髓或神经不可逆性损伤,造成严重后果。本病治疗以椎板切除减压血肿清除手术为主;如果患者症状较轻、血肿范围小、脊髓受压轻且临床表现逐渐缓解,可在患者及家属同意签字下行非手术治疗,并定期MRI复查脊髓;反之则建议及早进行手术治疗。

原始出处:

陈士军,韩业福,付艳超等.自发性椎管内硬膜外血肿1例[J].临床骨科杂志,2018,21(5):640.DOI:10.3969/j.issn.1008-0287.2018.05.053.

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    2019-08-07 bugit
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    2018-12-05 sodoo

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