脊髓损伤后痉挛知多少？痉挛的分型与病理生理学特征

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                    <p style=""><span style="margin: 0px; padding: 0px; max-width: 100%; box-sizing: border-box !important; word-wrap: break-word !important;">反射亢进。上运动神经元起源于大脑和脑干，纤维投射到脑干和脊髓内的下运动神经元。下运动神经元起源于脊髓前角，包括：(1)支配梭外肌的α-运动神经元；(2)支配梭内肌的γ-运动神经元。</span><br style="margin: 0px; padding: 0px; max-width: 100%; box-sizing: border-box !important; word-wrap: break-word !important;"  /></p><p style=""><o:p style="margin: 0px; padding: 0px; max-width: 100%; box-sizing: border-box !important; word-wrap: break-word !important;"></o:p></p><p style=""><span style="margin: 0px; padding: 0px; max-width: 100%; box-sizing: border-box !important; word-wrap: break-word !important;">　　脊髓损伤（SCI）可导致上运动神经元向下运动神经元或中间神经元信息传递的中断。在SCI后的一段时间内，患者损伤平面以下的肌肉会出现迟缓性瘫痪和腱反射消失，这一阶段称为“脊髓休克”。研究发现，脊髓休克常于损伤后1到3天开始，可历时数周或数月，并伴随渐进性腱反射亢进、肌张力增加和不自主肌肉痉挛（统称为痉挛状态）。</span><o:p style="margin: 0px; padding: 0px; max-width: 100%; box-sizing: border-box !important; word-wrap: break-word !important;"></o:p></p><p style=""><span style="margin: 0px; padding: 0px; max-width: 100%; box-sizing: border-box !important; word-wrap: break-word !important;">　<strong style="margin: 0px; padding: 0px; max-width: 100%; box-sizing: border-box !important; word-wrap: break-word !important;">　痉挛状态主要表现为以下三种类型：</strong></span><o:p style="margin: 0px; padding: 0px; max-width: 100%; box-sizing: border-box !important; word-wrap: break-word !important;"></o:p></p><p style=""><strong style="margin: 0px; padding: 0px; max-width: 100%; box-sizing: border-box !important; word-wrap: break-word !important;">　　一、内因性强直痉挛状态（Intrinsic tonic spasticity）</strong></p><p style=""><span style="margin: 0px; padding: 0px; max-width: 100%; box-sizing: border-box !important; word-wrap: break-word !important;">　　<img data-s="300,640" data-type="jpeg" src="http://mmbiz.qpic.cn/mmbiz/dx3KibwtDhvdL3IgJzgDSVfo4mfRkXIADl0tHpCcSRRiaWhNv2Kmbdz4AR3ANo7tkglxFoOYHgiby6oUEChiaBqIsA/0?wx_fmt=jpeg" data-ratio="0.6463022508038585" data-w="311"  /><br  /></span><o:p style="margin: 0px; padding: 0px; max-width: 100%; box-sizing: border-box !important; word-wrap: break-word !important;"></o:p></p><p style=""><span style="margin: 0px; padding: 0px; max-width: 100%; box-sizing: border-box !important; word-wrap: break-word !important;">　　</span><img data-cke-saved-src="file:///C:\Users\ADMINI~1\AppData\Local\Temp\ksohtml\wps7C06.tmp.png" src="/mpres/htmledition/ueditor/themes/default/images/spacer.gif" word_img="file:///C:/Users/ADMINI~1/AppData/Local/Temp/ksohtml/wps7C06.tmp.png" data-ratio="1" data-w="1.3333332538604736" src="http://mp.weixin.qq.com/mpres/htmledition/ueditor/themes/default/images/spacer.gif" style="margin: 0px; padding: 0px; background-image: url(http://mp.weixin.qq.com/mpres/htmledition/ueditor/lang/zh_CN/images/localimage.png); border: 1px solid rgb(221, 221, 221); box-sizing: border-box !important; word-wrap: break-word !important; width: auto !important; visibility: visible !important; background-position: 50% 50%; background-repeat: no-repeat no-repeat;"  /><span style="margin: 0px; padding: 0px; max-width: 100%; box-sizing: border-box !important; word-wrap: break-word !important;">（图片仅供参考）</span><o:p style="margin: 0px; padding: 0px; max-width: 100%; box-sizing: border-box !important; word-wrap: break-word !important;"></o:p></p><p style=""><span style="margin: 0px; padding: 0px; max-width: 100%; box-sizing: border-box !important; word-wrap: break-word !important;">　　内因性强直痉挛状态（肌张力增高）是牵张反射亢进的主要表现。简单来说，牵张反射的刺激起源于肌梭，经Ia类传入纤维传入脊髓，其轴突末梢可与中间神经元连接或直接与α-运动神经元连接。牵张反射的主要作用为增加肌张力，保持肌肉的伸展。</span><o:p style="margin: 0px; padding: 0px; max-width: 100%; box-sizing: border-box !important; word-wrap: break-word !important;"></o:p></p><p style=""><span style="margin: 0px; padding: 0px; max-width: 100%; box-sizing: border-box !important; word-wrap: break-word !important;">　　牵张反射亢进表现为肌肉过度兴奋状态，这将导致肌张力的持续增加。这种肌张力增高常表现为速度依赖性，即牵伸速度越快，肌张力越高。强直性痉挛的异常兴奋状态可能是由于肌梭刺激阈值降低和/或牵张反射敏感性增加所致。其原因可能是由于肌肉的去神经增敏状态和肌肉功能属性改变的联合作用。去神经支配可导致损伤早期肌细胞膜神经受体表达下调，随后再上调，并会对神经递质的敏感性增加。SCI后，肌肉形态学变化也会逐渐出现，例如肌肉纤维化、肌纤维萎缩、弹性属性下降、肌小节数量减少、结缔组织堆积，以及肌肉的可收缩性向强直性特征转化等，这些可能促使了肌肉被动张力的进一步增加。</span><o:p style="margin: 0px; padding: 0px; max-width: 100%; box-sizing: border-box !important; word-wrap: break-word !important;"></o:p></p><p style=""><span style="margin: 0px; padding: 0px; max-width: 100%; box-sizing: border-box !important; word-wrap: break-word !important;">　<strong style="margin: 0px; padding: 0px; max-width: 100%; box-sizing: border-box !important; word-wrap: break-word !important;">　二、内因性阶段痉挛状态（Intrinsic phasic spasticity）</strong></span><o:p style="margin: 0px; padding: 0px; max-width: 100%; box-sizing: border-box !important; word-wrap: break-word !important;"></o:p></p><p style=""><img data-s="300,640" data-type="jpeg" src="http://mmbiz.qpic.cn/mmbiz/dx3KibwtDhvdL3IgJzgDSVfo4mfRkXIADoFV4x03Rp0gNWS1hsibe2XEu7fo8DMgr4CThp177LaibM4B5MNTnM60Q/0?wx_fmt=jpeg" data-ratio="0.6143344709897611" data-w="293"  /><br  /></p><p style=""><span style="margin: 0px; padding: 0px; max-width: 100%; box-sizing: border-box !important; word-wrap: break-word !important;">　　</span><img data-cke-saved-src="file:///C:\Users\ADMINI~1\AppData\Local\Temp\ksohtml\wps7C16.tmp.png" src="/mpres/htmledition/ueditor/themes/default/images/spacer.gif" word_img="file:///C:/Users/ADMINI~1/AppData/Local/Temp/ksohtml/wps7C16.tmp.png" data-ratio="1" data-w="1.3333332538604736" src="http://mp.weixin.qq.com/mpres/htmledition/ueditor/themes/default/images/spacer.gif" style="margin: 0px; padding: 0px; background-image: url(http://mp.weixin.qq.com/mpres/htmledition/ueditor/lang/zh_CN/images/localimage.png); border: 1px solid rgb(221, 221, 221); box-sizing: border-box !important; word-wrap: break-word !important; width: auto !important; visibility: visible !important; background-position: 50% 50%; background-repeat: no-repeat no-repeat;"  /><span style="margin: 0px; padding: 0px; max-width: 100%; box-sizing: border-box !important; word-wrap: break-word !important;">（图片仅供参考）</span><o:p style="margin: 0px; padding: 0px; max-width: 100%; box-sizing: border-box !important; word-wrap: break-word !important;"></o:p></p><p style=""><span style="margin: 0px; padding: 0px; max-width: 100%; box-sizing: border-box !important; word-wrap: break-word !important;">　　内因性阶段痉挛症状（如腱反射亢进与阵挛）是由于牵张反射阶段性亢进导致的。腱反射亢进是由外力施加到深肌腱引起的肌肉反射亢进。缺乏Ia类传入纤维的突触前抑制作用可能是这种反射亢进的主要原因。</span><o:p style="margin: 0px; padding: 0px; max-width: 100%; box-sizing: border-box !important; word-wrap: break-word !important;"></o:p></p><p style=""><span style="margin: 0px; padding: 0px; max-width: 100%; box-sizing: border-box !important; word-wrap: break-word !important;">　　阵挛可定义为：不自主节律性肌肉收缩，可导致远侧关节的抖动，常出现在踝关节。阵挛可经快速牵拉肌肉引出。目前较流行的理论认为，阵挛的可能机制是牵张反射的周期性激活。根据该理论，背屈踝关节可使小腿三头肌Ia类肌梭传入纤维的激活，引起小腿三头肌收缩，导致踝关节跖屈。这种反射性收缩历时短暂，并且会迅速停止。随后肌肉舒张，由于重力作用或检查者继续牵拉，踝关节将再次背屈。这将导致再一次牵张反射的激活。SCI后，由于下行纤维的中断，牵张反射会失去抑制作用，导致了阶段性牵张反射亢进，并最终导致了阵挛。</span><o:p style="margin: 0px; padding: 0px; max-width: 100%; box-sizing: border-box !important; word-wrap: break-word !important;"></o:p></p><p style=""><span style="margin: 0px; padding: 0px; max-width: 100%; box-sizing: border-box !important; word-wrap: break-word !important;">　　关于阵挛的第二个理论是脊髓中枢振荡器或发生器的激活。其能够节律性激活α-运动神经元，以对外界刺激做出反应。Beres-Jones等的观察可能支持了该理论：(1)踝关节、膝关节和腕关节可出现相似的振动频率；(2)阵挛频率不受施加频率的影响，这显示阵挛不单单是由牵张反射介导；(3)非牵张性刺激也可引起阵挛；(4)在阵挛EMG爆发之后的不应期阶段，敲击肌腱、H反射刺激和震动均不能引起传出冲动。总的来说，阵挛的可能机制尚有待进一步研究。</span><o:p style="margin: 0px; padding: 0px; max-width: 100%; box-sizing: border-box !important; word-wrap: break-word !important;"></o:p></p><p style=""><span style="margin: 0px; padding: 0px; max-width: 100%; box-sizing: border-box !important; word-wrap: break-word !important;">　　<strong style="margin: 0px; padding: 0px; max-width: 100%; box-sizing: border-box !important; word-wrap: break-word !important;">三、外因性痉挛状态（Extrinsic spasticity）</strong></span><o:p style="margin: 0px; padding: 0px; max-width: 100%; box-sizing: border-box !important; word-wrap: break-word !important;"></o:p></p><p style=""><img data-s="300,640" data-type="jpeg" src="http://mmbiz.qpic.cn/mmbiz/dx3KibwtDhvdL3IgJzgDSVfo4mfRkXIADLT9yS9M8ia8fhhpUcXZzytpcGUCP8WM5FicB4Xyb4VMicgDpEnIAh9QKw/0?wx_fmt=jpeg" data-ratio="0.6275" data-w="400"  /><br  /></p><p style=""><span style="margin: 0px; padding: 0px; max-width: 100%; box-sizing: border-box !important; word-wrap: break-word !important;">　　</span><img data-cke-saved-src="file:///C:\Users\ADMINI~1\AppData\Local\Temp\ksohtml\wps7C27.tmp.png" src="/mpres/htmledition/ueditor/themes/default/images/spacer.gif" word_img="file:///C:/Users/ADMINI~1/AppData/Local/Temp/ksohtml/wps7C27.tmp.png" data-ratio="1" data-w="1.3333332538604736" src="http://mp.weixin.qq.com/mpres/htmledition/ueditor/themes/default/images/spacer.gif" style="margin: 0px; padding: 0px; background-image: url(http://mp.weixin.qq.com/mpres/htmledition/ueditor/lang/zh_CN/images/localimage.png); border: 1px solid rgb(221, 221, 221); box-sizing: border-box !important; word-wrap: break-word !important; width: auto !important; visibility: visible !important; background-position: 50% 50%; background-repeat: no-repeat no-repeat;"  /><span style="margin: 0px; padding: 0px; max-width: 100%; box-sizing: border-box !important; word-wrap: break-word !important;">（图片仅供参考）</span><o:p style="margin: 0px; padding: 0px; max-width: 100%; box-sizing: border-box !important; word-wrap: break-word !important;"></o:p></p><p style=""><span style="margin: 0px; padding: 0px; max-width: 100%; box-sizing: border-box !important; word-wrap: break-word !important;">　　除了内因，外界有害刺激也可使肌肉产生痉挛症状、无意识肌肉痉挛，即称为外因性痉挛状态。外因性痉挛状态的最常见形式为“屈肌痉挛”，其主要由皮肤、肌肉、皮下组织和关节的传入信号（可共同称为“屈肌反射传入信号”）激发。这些屈肌反射传入信号调节的多突触反应参与了屈肌-回缩反射。SCI可中断中枢抑制作用，使这些反射过度兴奋。换句话说就是，屈肌-回缩反射正常情况下只出现在正常人群，而非SCI患者。SCI后，由于缺乏下行抑制作用，屈肌-回缩反射通路的刺激阈值可能会降低，且该系统的信号增益效应也会增加。节内多突触连接导致了屈肌反射被局部刺激激活，产生了广泛的屈肌痉挛，其可表现为下肢所有关节的整体屈曲状态。</span></p><p style=""><span style="margin: 0px; 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