Ataxia

Introduction The anterior horn cells of the spinal cord receive the regulation and control of the upward and downward conduction beams of the cerebral cortex, the cerebral cortex, the cerebellum, the vestibular labyrinth system, and the deep sensation, so that the human body maintains a certain posture to properly perform the random movement and maintain balance. If the above part of the lesion occurs, resulting in a coordination disorder, called ataxia. At present, there is no specific treatment for ataxia. In addition to general supportive therapy, acupuncture treatment, physical therapy and physical function training can also be used. Various B vitamins, citicoline intramuscular injection, oral lecithin, etc. can also be used. Patients with advanced disease should take care to prevent various infections. The arched foot can be used for orthopedic surgery or wearing orthopedic shoes.

Cause

Cause:

(a) cerebellar ataxia

1, cerebellar sacral lesions: common in the cerebellar sacral tumor, children with medulloblastoma, astrocytoma, ependymoma, adult metastases more common.

2, cerebellar hemisphere damage: common in tumors, metastases. Tuberculoma or abscess and vascular disease.

3, the whole cerebellar ataxia: common in cerebellar degeneration and atrophy.

(2) Deep feeling disorder ataxia

1, peripheral neuropathy: common in polyneuritis, lead, arsenic, mercury poisoning, alcoholism, metabolic diseases.

2, posterior root lesions: common in metastatic tumors.

3, posterior cord lesions: common in the spinal cord hernia combined degeneration. Alcoholism, spinal cord compression, etc.

4, thalamic lesions: common in cerebrovascular disease.

5, parietal lesions: common in cerebrovascular disease.

(C) cerebral ataxia

It is common in cerebrovascular diseases, tumors, inflammation, trauma, and degenerative diseases in the frontal, parietal, lobular, occipital, and filthy parts of the brain.

(four) vestibular ataxia

Common in acute labyrinthitis, inner ear hemorrhage, acute lesions of the vestibular nerve or vestibular nucleus.

mechanism:

(a) cerebellar ataxia

The cerebellum is located in the posterior cranial fossa, on the dorsal side of the pons and the medulla, and is the fourth ventricle. It is connected to the midbrain, pons, and medulla by three pairs of feet. The cerebellum is called the binding arm, which is mainly composed of the telecentric fibers from the cerebellum. The midbrain part is the bridge arm, which is composed of fibers from the pons nucleus. The cerebellum is mainly a rope-like body composed of fibers from the spinal cord and the medulla into the cerebellum. According to the occurrence of cerebellum, physiological function and fiber connection, the cerebellum is divided into three leaves:

1. The small knot of the pompon: It is the oldest part of the cerebellum. It is called the primitive cerebellum or the ancient cerebellum. It receives the fibers from the vestibular nerve and the vestibular nucleus. It is the integrated center of balance and regulation. When it is damaged, it causes the combination of the trunk and the lower limbs. Disorder.

2, the anterior lobe: in front of the cerebellum, the part before the first fissure, belongs to the old cerebellum in phylogenetics, mainly receives the anterior and posterior bundles of the spinal cerebellum. This bundle transmits deep sensation, its function is to regulate muscle tone and maintain body posture. .

3, the posterior lobe: the part after the first fissure, most of the posterior lobe is a newly-occurring structure, called the new cerebellum, which receives the cerebellar conduction of the cortical pons, mainly involved in the regulation of the delicate random movement from the cerebral cortex.

In addition to receiving proprioceptive impulses, the cerebellum also accepts the impulses of external sensation, hearing, vision, and visceral sensation. Therefore, the cerebellum not only affects exercise, but also affects feeling and brain function. Therefore, the most important manifestation of cerebellar lesions is ataxia. When standing, the body leans forward or shakes sideways. When sitting, the trunk is also swaying and unstable. When walking, you can't walk straight, and suddenly the left and right gait is drunk. Finger nose test, finger ear test, grasp test, rotation test, rebound test, knee-high test, intentional tremor, nystagmus may have a positive finding.

(2) Deep feeling disorder ataxia

The deep sensory conduction path is as follows:

Muscle, tendon, joint, peripheral nerve, spinal cord, posterior cord, posterior cord, thin bundle (lower branch), thin bundle nucleus, medullary cross, wedge bundle (upper limb), thin bundle nucleus, thalamic cortical bundle, internal capsule occipital, central posterior Go back to 2/3 and the parietal area.

A deep sense of the conduction path, any part of the damage can occur ataxia. The characteristics are that the ataxia is not obvious when blinking, and the deep eye is obviously enhanced with deep sensory disturbance (joint position sense, vibration party and sports party reduction or disappearance), closed eyes are difficult to stand positive, and wash basin sign is positive. In the early stage, there may be unstable roads, especially in dark places, where the ataxia is obvious. When walking, the foot is thrown forward, and the heel is forced to land (super step) to widen the base of the two feet. When the upper limbs extended and closed their eyes, the two upper limbs consciously fell, and the fingers were in a playing position. Checking the movement of the limbs ataxia is obvious, the knee gum test is not accurate, the finger test of the upper limbs, the finger test is not accurate. The static balance disorder is also obvious. For example, when the supine position is raised, the two feet are lifted up, and the two feet are kept still, and the shaking is unstable, and the eyes are more obvious when the eyes are closed.

(C) cerebral ataxia

Ataxia can occur in the frontal lobe, parietal lobe, lobes, occipital lobe, and abdominal cavity. Frontal lobe ataxia is caused by damage to the frontal pons cerebellar tract. It is characterized by standing or walking. High-level lesions should be considered when there is a disability in the lower extremities. Parietal ataxia is often accompanied by deep sensory disturbances, and the central lobular lesions in the parietal lobe exhibit cerebellar symptoms and urinary dysfunction. The collar leaf ataxia can be accompanied by other signs of the collar leaf.

(four) vestibular ataxia

Mainly based on balance obstacles, it is characterized by balance obstacles during exercise and at rest. May be accompanied by dizziness, nystagmus, vestibular labyrinth symptoms. Mistaken to test positive, closed eyes difficult to sign positive. This type of ataxia is shaken after a period of time after closing the eye, and gradually increases, and the direction of the dump is consistent with the direction of the eye movement. Found in acute labyrinthitis, inner ear hemorrhage, acute lesions of the vestibular nerve or vestibular nucleus.

an examination

Related inspection

Brain evoked potential brain ultrasound examination combined with flexion syndrome water cup test for brain CT examination

First, the history of illness

1, ataxia

Attention to the onset of illness and the course of the disease, generally acute onset of ataxia and paroxysmal, vestibular system lesions and vertigo epilepsy is more likely. The onset is more urgent, and those who deteriorate in a short period of time are more likely to have acute cerebellar lesions, central nervous system inflammation and brain trauma after treatment. Patients with more acute onset and rapid deterioration, sometimes life-threatening cerebrovascular disease, brain trauma, especially cerebellar hemorrhage. Alcoholism and vitamin deficiency-induced ataxia can improve ataxia after improving nutritional status. Arrhythmia with remission and recurrence is more common with multiple sclerosis.

2. Age and family history

It has great reference significance in the diagnosis of ataxia. Childhood is congenital cerebellar hypoplasia, hereditary diseases, childhood acute cerebellar ataxia, encephalitis and so on. Adolescent onset can be seen in juvenile spinal cord hereditary ataxia, hereditary ataxia, polyneuritis, osteomuscular atrophy, hypertrophic interstitial neuropathy, syringomyelia. Young and healthy people can be seen in dentate nucleus red atrophy, olive bridge cerebral degeneration, subacute combined degeneration, telangiectasia and ataxia. Middle-aged and elderly people are more common in cerebellar atrophy, vertebral-basal artery insufficiency, cerebellar hemorrhage, cerebrovascular disease and so on. Some of the ataxia disorders include genetic factors such as congenital cerebellar hypoplasia, childhood acute cerebellar ataxia, and juvenile spinal cord hereditary ataxia. Hereditary ataxia polyneuritis vertebral muscle atrophy ataxia, large interstitial neuropathy, dentate nucleus redness atrophy, olive bridge cerebellar degeneration, telangiectasia ataxia.

Second, physical examination

Correct and free exercise requires a lot of muscles, including active muscle, synergistic muscle, orange anti-muscle and fixed muscle to complete.

1, finger nose test

The paralyzed patient first straightens and abducts the upper limb, then touches the tip of the nose with the tip of the index finger, repeats in different directions, speeds, blinks, and closed eyes, and contrasts on both sides. In the case of ataxia, the behavior is light and heavy, and the speed is different. If you misunderstand or adjust, you can target the target. When the cerebellar hemisphere lesions are manifested, the more the ataxia is closer to the target, the more obvious the ataxia is, and the poor distance can often exceed the target. In the case of sensory ataxia, the eye-opening movement is barrier-free, but when the eyes are closed, there is a clear ataxia.

2, with the knee test

The patient is supine, and the following three actions are performed in sequence: one side of the lower limb is lifted and straightened, and the knee is placed on the knee of the lower limb of the contralateral side, and then the heel is lowered along the leading edge of the sacrum. Sliding, trying to make the movements accurately and consistently. Cerebellar damage caused by poor positioning and intentional tremor when lifting the leg and touching the knee, often swaying when moving down; when the sensory ataxia occurs, the patient's heel often cannot find the knee, and when moving down, the swing is uncertain and often cannot and The femur remains in contact.

3. Fast rotation test

The side of the hand is quickly and continuously beaten with one hand; or the forearm is quickly rotated before and after, or the palm and the back of the hand are alternately contacted with the tabletop; when the cerebellum is damaged, the above actions are awkward and the rhythm is uneven.

4, rebound test

The patient closed his eyes and flexed his fists on one side of the upper limbs. The doctor suddenly forced himself to relax during the process of pulling open, and the normal fragile protection action did not touch himself. When the cerebellum was damaged, the coordination function of the active muscle and the orange muscle was poor. Often cause excessive movement and attack yourself. Or maintain the posture of the arms extending forward. The examiner suddenly pushes down its arms separately or simultaneously, and then releases, and the normal person can accurately return to the original position. Patients with cerebellar ataxia do not normally control the coordination of the agonist muscle and the orange-anti-muscle, often causing excessive movement and excessive swinging time. When examining the lower limbs, the calf can be pushed while the patient maintains a 90o bend of the knee, and the meaning is the same as above.

5, over the finger test

The upper limb of the patient is stretched forward, and the finger is placed on the finger that the examiner is fixed. Then the patient lifts the hand to the vertical position and then descends to the examiner's finger. When the patient is examined, the patient always maintains the upper limb straight. Close your eye and check your eyes. When the vestibular ataxia occurs, the lower limbs tend to be lost to the side with the lesion; when the sensory ataxia occurs, the examiner's fingers are often not found when the eyes are closed, but the brain is not fixed in the direction of the skew. In the case of dysregulation, generally only the upper limb is deflected to the outside.

6, toe-finger test

The patient is lying on his back and lifting the big toe to reach the fingers of the Laker. The latter often changes position and requires the patient to track accurately.

7, sit-up test

The patient is supine, the two hands are placed on the chest without sitting and sitting up. The normal person can only press the two lower limbs to flex and not leave the bed surface. The cerebellar and the trunk of the cerebellar lesion are flexed at the same time, and the lower limbs are lifted up, called joint flexion. Sign.

Third, auxiliary inspection

1, cerebellar ataxia should be examined brain CT or MRI to exclude cerebellar tumors, metastases, tuberculoma or abscess and vascular disease and cerebellar degeneration and atrophy.

2, deep sensory ataxia such as localized lesions located in the peripheral nerve should be examined EMG, somatosensory evoked potential; such as in the posterior root lesion or posterior cord lesion should be examined EMG, evoked potential, MRI of the lesion, cerebrospinal fluid Check, or myelography. It is best to check brain CT or MRI when considering the thalamus or parietal lobe.

Differential diagnosis

The diagnosis should be differentiated from the following symptoms:

1. Cerebellar ataxia: caused by the cerebellum and its associated neurological pathology. Cerebellar ataxia can be observed through the daily activities of IAs patients, such as dressing, buttoning, water, writing, eating, speech, gait, etc. Unstable walking, gait squatting, inflexible movements, and wide legs when walking; adult patients cannot walk straight when walking. Suddenly left and right, the curve progresses, showing the pace of the scissors, showing a "Z" shape forward deflection, and trying to use the upper limbs to help maintain the stability of the body. The change in muscle tone can be changed to a sputum state as the lesion can be reduced, and the ataxia gait can also be transformed into a sacral ataxia gait. Standing unsteady, leaning forward or shaking sideways. When standing on the toes or standing on the heels, the shaking is more stable and the fall is often the patient's early complaint. Patients often say: "When walking a path or an uneven road, walking is more stable and more likely to fall." As the disease progresses, the patient may behave in an unstable or inability to stay in bed.

2. Vestibular ataxia: caused by damage to the vestibular system, with balance disorders. It is characterized by a balance disorder between static and exercise. It has the same points as cerebellar ataxia, such as wide base of the feet when standing, unstable body, dumping to the side or rear, and skew when walking. However, there are generally obvious dizziness, nystagmus and abnormal vestibular function tests.

3. Spinal ataxia: caused by deep sensory disturbances in the posterior root cord of the spinal cord. Vision can be compensated, so the Longbo sign is positive, and the knee test is not stable, accompanied by lower limb position and vibration. Found in spinal cord lesions, peripheral nervous system, Flidry disorders.

4. Cerebral ataxia: Ataxia can occur when the frontal lobe, parietal lobe, lobes, occipital lobe, and abdominal cavity are lesions. Frontal lobe ataxia is caused by damage to the frontal pons cerebellar tract. It is characterized by standing or walking. High-level lesions should be considered when there is a disability in the lower extremities. Parietal ataxia is often accompanied by deep sensory disturbances, and the central lobular lesions in the parietal lobe exhibit cerebellar symptoms and urinary dysfunction. The collar leaf ataxia can be accompanied by other signs of the collar leaf.

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