Hematoma Epidural Spinal ati Abscess vs Orifidi-Epidural Post: Irora Pada ati Paralysis Awọn asia Pupa¶

Lẹhin epidural iṣẹ ibimọ, akuniloorun ọpa ẹhin, aisan lumbar puncture (tap spinal), tabi abẹrẹ sitẹriọdu epidural, awọn alaisan nigbagbogbo ni iriri ọgbẹ kekere ti agbegbe ni aaye abẹrẹ tabi Ayebaye ** post-dural puncture orififo (“ifọwọra-tẹ” orififo ọpa ẹhin)** ti o fa fifalẹ jijo ti cerebrospinal ti o fa fifalẹ tabi orififo CS ti o duro. patapata laarin 15 iṣẹju ti eke alapin. Sibẹsibẹ, ajalu meji, awọn pajawiri neurosurgical le kọlu aaye apọju ti ọpa ẹhin lẹhin ilana ilana ẹhin (tabi lairotẹlẹ ni awọn alaisan ti o mu awọn tinrin ẹjẹ tabi ti o jiya lati inu ẹjẹ ti o ni kokoro arun): ** (1) Spinal Epidural Hematoma (SEH) , nibiti iṣọn epidural ruptured ti nṣan sinu ẹhin rigidi ati awọn wakati ẹhin ọpa ẹhin, o le fa fifun paṣan 2 ti ọpa ẹhin ati awọn wakati ẹhin ẹhin. Epidural Abscess (SEA), nibiti apo kan ti kokoro-arun (* Staphylococcus aureus*) ti gbooro si inu ọpa ẹhin fun awọn ọjọ. Nitoripe ọpa ẹhin ara eniyan jẹ tube egungun ti ko ni irẹwẹsi pẹlu yara odo fun imugboroja, didi ti o gbooro tabi abscess strangles awọn ipese ẹjẹ ti ọpa ẹhin ati ki o fa aiyipada ** paraplegia tabi quadriplegia *** ayafi ti awọn neurosurgeons ṣe pajawiri ** decompressive laminectomy laarin 8 si 12 wakati ti ibẹrẹ ailera ***. Ti ẹnikan ti o ṣẹṣẹ ni epidural, tẹ ni kia kia ọpa ẹhin, abẹrẹ ẹhin, iwọn tinrin ẹjẹ, tabi ikolu to ṣẹṣẹ ndagba ** irora ẹhin aarin aarin nla, irora ina-mọnamọna ti n ta isalẹ awọn ẹsẹ tabi ni ayika awọn egungun, numbness ninu ikun / buttocks (anesthesia gàárì), iṣoro ito, tabi awọn ẹsẹ ti o wuwo / alailagbara **, pe agbegbe rẹ pajawiri awọn nọmba lẹsẹkẹsẹ. Lakoko ti o n duro de gbigbe ọkọ alaisan, ṣe atunyẹwo awọn itọsọna ti o jọmọ lori cauda equina dídùn ati ki o ńlá ọpa-funmorawon, isun ẹjẹ subarachnoid ati orififo thunderclap, ati idaduro ito nla ati ailagbara lati urinate.

Nitoripe awọn nọọsi imularada ibimọ ati awọn idile nigbagbogbo asise ni kutukutu funmorawon ọpa ẹhin lẹhin iṣẹgun iṣẹ fun “ipalara deede lati inu oogun epidural” tabi “ọgbẹ ibi-iṣan ibi-iṣan lẹhin ibimọ,” awọn ofin aabo meji ti o ṣe pataki julọ ni ** Ilana 4-to-6-wakati Epidural Motor Recovery Ofin *** (ẹnikẹni ti agbara ẹsẹ ati imọlara rẹ ko ti pada ni kikun laarin wakati 6) tabi ti ẹsẹ rẹ numbness ba pada * lẹhin * wọ ni pipa, nilo pajawiri lẹsẹkẹsẹ Spine MRI) ati ** Idanwo 15-Minute Flat-Lie Headache Headache ** (orififo kan ti ko dara dara julọ nigbati o dubulẹ patapata kii ṣe orififo ọpa ẹhin ti o rọrun ati pe o gbọdọ ṣe iṣiro fun iṣọn-ẹjẹ iṣọn-ẹjẹ cerebral sinus thrombosis, hematoma subdural).

Ṣe eyi ni bayi¶

1. *Pe nọmba pajawiri ti agbegbe rẹ lẹsẹkẹsẹ ti ẹhin tabi irora ọrun ba wa pẹlu ailera ẹsẹ, numbness ẹsẹ, numbness ikun / buttock, tabi ailagbara lati ito. pajawiri awọn nọmba. Sọ kedere: * "Irora ti o ni ifura ti hematoma ẹhin ọpa ẹhin tabi ọpa ẹhin: irora aarin aarin ti o lagbara pẹlu ailera ẹsẹ tuntun / numbness / idaduro ito lẹhin ti epidural / ọpa ẹhin / lori awọn tinrin ẹjẹ. O nilo lẹsẹkẹsẹ Spine MRI ati Neurosurgery."
2. ** Ṣe Igbeyewo Flat-Lie 15-Minute lati ṣe iyatọ orififo puncture Post-Dural lati inu Intracranial tabi Spinal Catastrophe.** Ti aami aisan akọkọ ba jẹ orififo nla lẹhin ti epidural tabi lumbar puncture, jẹ ki alaisan naa dubulẹ ** 100 ogorun fifẹ lori ẹhin wọn laisi irọri *** fun iṣẹju 15:
3. Classic Benign Post-Dural Puncture orififo ("Wet Tap"): Orififo iwaju-occipital ati lile ọrun ni ilọsiwaju nipasẹ **80 si 100 ogorun laarin iṣẹju 15 si 30 ti irọba irọlẹ **, ati pada laarin iṣẹju 15 ti ijoko tabi dide.
4. ** FLAG RED (Intracranial Subdural Hematoma, Cerebral Venous Thrombosis, Meningitis, or Preeclampsia):** Orififo ma duro ni gbigbọn ati ti o lagbara paapaa nigba ti o ba dubulẹ patapata, o ji alaisan naa lati orun, lu bi 1-aaya thunderclap, tabi ti o tẹle pẹlu iba, iporuru, ailera tabi ipadanu ọkan. Pe 911 lẹsẹkẹsẹ.
5. Ṣayẹwo "Aago Imukuro Ẹsẹ-wakati 4" ati idanwo igbiyanju ẹsẹ ti nṣiṣe lọwọ. Lẹhin ti a ti da catheter epidural kan duro tabi fa jade, numbness anesitetiki agbegbe ati ailera gbọdọ ni ilọsiwaju ni imurasilẹ ati yanju patapata laarin wakati 4 si 6 **. Beere lọwọ alaisan lati **(1) Gbe ẹsẹ taara kọọkan kuro ni ibusun ***, **(2) Tẹ awọn ẽkun mejeeji tẹ **, ati **(3) Fa ẹsẹ mejeeji soke si imu wọn ki o tẹ si isalẹ bi ẹsẹ gaasi. Ti ẹsẹ kan tabi mejeeji ba wuwo, alailagbara, tabi kuku kọja wakati 4 si 6, tabi ti alaisan kan ti o le rin ni iṣaaju lojiji padanu agbara ẹsẹ (“ipadabọ idilọ mọto biphasic”), beere fun pajawiri ** Gbogbo-Spine MRI **.
6. **Mu GBOGBO awọn tinrin ẹjẹ ati awọn oogun antiplatelet mu lẹsẹkẹsẹ (maṣe gba iwọn lilo atẹle ti apixaban, rivaroxaban, enoxaparin/Lovenox, warfarin, clopidogrel, tabi aspirin). alfa, idarucizumab, 4-ifosiwewe PCC, tabi protamine sulfate **) ṣaaju ki o to decompression neurosurgical.
7. ** Jeki alaisan naa dubulẹ ati ki o tun wa ni ibusun, ki o si fi agbara mu NPO ti o muna (ko si ohun ti ẹnu) ti awọn asia pupa eyikeyi ba wa.** Ti o ba jẹ pe hematoma epidural spinal hematoma tabi abscess wa, alaisan yoo lọ taara lati scanner MRI si yara iṣẹ fun akuniloorun gbogbogbo pajawiri ati laminectomy decompressive; fifi ikun silẹ ni ṣofo ṣe idilọwọ ifẹkufẹ lakoko intubation. (Ti alaisan naa ba ni * nikan * orififo ipo-ọgbẹ lẹhin-dural puncture pẹlu odo ti iṣan tabi awọn asia pupa, wọn le dubulẹ pẹlẹbẹ ki wọn mu omi ẹnu ati kafeini lakoko ti o n ṣeto patch ẹjẹ apọju ** pẹlu Anesthesia).
8. ** rọra percuss (tẹ ni kia kia) si isalẹ aarin ti awọn ọpa ẹhin ati ki o ṣayẹwo awọn iwọn otutu ti ara.** Ni ** Spinal Epidural Abscess ***, fifọwọ ba rọra pẹlu ika kan lori awọn ilana iṣan egungun ni isalẹ arin ti ẹhin ṣe afihan igbadun, pinpoint ** ifọkanbalẹ midline ** taara lori vertebrae ti o ni arun, paapaa ti alaisan ko ba ni ibà 50 si ibà (**0) awọn alaisan abscess ko ni iba ni ifihan ibẹrẹ).

Igi ipinnu: lẹhin-epidural tabi irora ẹhin nla, orififo, ati paralysis triage¶

flowchart TD
    Start["Irora Ẹhin/Ọrun ti o lera TABI Ẹfọrifori nla ti o tẹle Arun, Ifun Lumbar, Abẹrẹ ọpa ẹhin, Tinrin Ẹjẹ, tabi Ikolu."] --> CheckSymptom{"Igbesẹ 1: Njẹ Ẹdun Alakọbẹrẹ Ṣe Pada/Ẹsẹ/ Awọn aami aisan Atọpa TABI Ẹfọrifori nla bi?"}

    CheckSymptom -->|"Pada tabi Irora Ọrun, Ipa ẹsẹ/Ailagbara, Irora Ibon, tabi Idaduro Atọpa"| CheckCordRedFlags{"Igbesẹ 2: Ṣayẹwo Imudanu Ọpa Ọpa Awọn asia pupa: 1. Irẹwẹsi ẹsẹ tabi iwuwo (lori 4 hrs lẹhin ti epidural pa, tabi pada lẹhin ti o wọ), 2. Numbness Saddle (groin / buttocks), 3. Ailagbara lati urinate tabi ailagbara, 4. Sharp midline back irora + ibon irora radicular?"}

    CheckCordRedFlags -->|"BẸẸNI si Asia pupa KANKAN (Paapa pẹlu Arun aipẹ/LP tabi Tinrin Ẹjẹ)"| CheckFeverRisk{"Igbesẹ 3: Ibẹrẹ ni kiakia (Awọn iṣẹju si Awọn wakati) la. Ibẹrẹ Subacute (Awọn ọjọ) pẹlu Ewu Arun (Lilo Oògùn IV, Àtọgbẹ, Sise Awọ, Ilana ọpa ẹhin)?"}

    CheckFeverRisk -->|"Ọbẹ-Dabi Ìrora Pada ti o yori si ailagbara iyara ni iṣẹju si awọn wakati (Yiyọkuro Catheter Lẹhin-Epidural tabi Lilo Anticoagulant)"| SEH["IFURA SPINAL EPIDURAL HEMATOMA (SEH): Pe 911 / 112 / 999 Lẹsẹkẹsẹ; Mu Awọn Tinrin Ẹjẹ Mu, NPO ti o muna, Stat Spine MRI + Iyipada Anticoagulant + Laminectomy Decompressive Laarin 8 si Awọn wakati 12"]

    CheckFeverRisk -->|"Ilọsiwaju Focal Midline Pada Irora Lori Awọn Ọjọ + Iba / Chills tabi ESR giga / CRP + Irora Ibon Radicular"| SEA["AWỌN ỌJỌ EPIDURAL ỌPINAL ti a fura si (okun): Pe Awọn iṣẹ pajawiri Lẹsẹkẹsẹ; Stat Gadolinium-Imudara Gbogbo-Ọpa-ẹhin MRI + Awọn aṣa Ẹjẹ + IV Vancomycin & Ceftriaxone/Cefepime + Imudanu Iṣẹ abẹ Pajawiri"]

    CheckSymptom -->|"Ẹrifori ti o lewu (Ilẹyin ibimọ, puncture Post-Lumbar, tabi Lẹhin-Epidural)"| FlatTest{"Igbesẹ 4: Ṣe Idanwo Alapin-Laba-iṣẹju 15-iṣẹju: Njẹ irọra 100% Alapin Laisi Irọri Tu 80% si 100% ti orififo laarin awọn iṣẹju 15 si 30?"}

    FlatTest -->|"BẸẸNI: Iwa-ori ti o wa ni ipo to muna (Ti lọ Nigbati Filati, Lile Laarin 15 Mins ti Joko/Iduro) + Gigun Ọrun / Tinnitus / Photophobia, Awọn aipe Neuro ZERO tabi iba"| PDPH["ORIFẸRẸ PUNCTURE POST-DURAL ('WET TAP' CSF Leak): Lie Flat, Hydrate, Caffeine Oral (200 si 300 mg), Acetaminophen/NSAIDs; Kan si Anesthesiology fun Patch Ẹjẹ Arun Arun Aifọwọyi Ijuwe (90% si 98% Oṣuwọn imularada)"]

    FlatTest -->|"RÁRA: Ọgbẹ orififo duro Nigbati o ba dubulẹ ni pẹlẹbẹ, Ibẹrẹ Thunderclap, Fever, Seizures, BP giga, Awọn iyipada Iran, tabi Aala / Ẹsẹ"| IntracranialRedFlag["Idẹruba INTRACRANIAL Idẹruba aye (Subdural Hematoma, Cerebral Venous Sinus Thrombosis, Bacterial Meningitis, or Postpartum Preeclampsia): Pe 911 Lẹsẹkẹsẹ fun Brain CT/MRV"]

Ipo 1: Orififo Puncture Lẹhin-Dural ("Tẹ ni kia kia tutu") ati nigbati jijo CSF kan yipada si Hematoma Subdural¶

Lakoko iwadii aisan ** lumbar puncture (tẹ ni kia kia ọpa ẹhin) ** tabi ** akuniloorun ọpa ẹhin , abẹrẹ kekere kan mọọmọ gun inu awọ ara lile ti o yika ito ọpa ẹhin ( dura mater and arachnoid membrane**). Lakoko ** epidural laala ** tabi ** abẹrẹ sitẹriọdu apọju **, anesthesiologist ni ero lati da duro nikan * ita * dura ni aaye epidural, ni lilo iwọn ** 17-giga tabi abẹrẹ Tuohy-18-18 *; ni aijọju ** 0.5 si 1.5 ogorun ** ti awọn aaye epidural, abẹrẹ ti o gbooro (tabi catheter ti o rọ) ba dura lairotẹlẹ lairotẹlẹ (airotẹlẹ “tẹ ni kia kia tutu”).

1. Ẹkọ aisan ara: Kini idi ti jijo CSF n fa orififo ti o tọ¶

Ọpọlọ agbalagba n ṣanfo ni iwuwo laisi iwuwo ni aijọju ** 150 milimita (ounun 5) ** ti omi ti n pese omi cerebrospinal (CSF). Nigbati CSF ba n jo jade nigbagbogbo nipasẹ iho kan ninu dura lumbar sinu awọn sẹẹli rirọ ti ẹhin isalẹ ni iyara ju plexus choroid ti ọpọlọ le ṣe agbejade omi tuntun (-20 mL/hour), lapapọ intracranial CSF iwọn didun silẹ (** intracranial hypotension**). - ** Ikun ọpọlọ ati isunmọ meningeal:** Ni akoko ti alaisan ba joko tabi dide, agbara walẹ fa ọpọlọ si isalẹ nipasẹ ọpọlọpọ awọn milimita inu agbọn (** caudal brain sag**). Nitoripe ọpọlọ parenchyma funrararẹ ko ni awọn olugba irora, irora wa lati ọpọlọ ti o sagging ti nfa ni agbara lori ** awọn membran dural ti o ni irora, awọn ara cranial (CN V, IX, ati X), ati didi awọn iṣọn cerebral ** ti o duro si oke ti agbọn. - ** Compensatory Monro-Kellie venous engorgement:** Nitoripe timole jẹ apoti ti o ni pipade (** ẹkọ Monro-Kellie **), nigbati iwọn didun CSF ba lọ silẹ, awọn iṣọn ati awọn sinuses iṣọn inu inu timole ati ọpa ẹhin oke cervical ti o lọra pẹlu ẹjẹ lati kun awọn igbale ti iṣan laarin awọn iṣẹju diẹ, ti o nfa titẹ ẹjẹ ti iṣan laarin iṣẹju diẹ.

2. Awọn Ẹya Ile-iwosan Hallmark ti Ẹrififo Ilẹ-ipin-igbẹhin-iwa-iwakọ Alailẹgbẹ (PDPH)¶

1. ** Akoko: ** Ni igbagbogbo bẹrẹ ** 12 si awọn wakati 72 ** lẹhin puncture lumbar tabi epidural (90 ogorun laarin awọn ọjọ 3, o fẹrẹ jẹ gbogbo laarin awọn ọjọ 5).
2. Ilana Orthostatic ti o muna: *** Alaisan naa ni itunu patapata tabi 80 si 100 laisi irora ninu ogorun nigbati wọn ba dubulẹ patapata lori ẹhin wọn ***, ṣugbọn laarin awọn iṣẹju 15 ti joko ni titọ tabi duro **, ti o lagbara, ṣigọgọ, lilu tabi orififo bii orififo lu kọja awọn ẹgbẹ mejeeji ti ẹhin (ori mejeji ti ẹhin) fronto-occipital) ***, radiating si isalẹ sinu ọrun ati ejika.
3. ** Nerve Cranial VI & VIII Awọn aami aiṣan:** Nitori irẹwẹsi ọpọlọ n na aifọkanbalẹ cranial kẹfa (** nafu abducens**) ti o si fa omi jade lati inu cochlea eti inu nipasẹ aqueduct cochlear, awọn alaisan nigbagbogbo ni iriri ** igbọran muffled (“etí labẹ omi”), kekere-pitched ramúramù tinnitus, ina, dizziness lẹẹkọọkan, dizziness. iran ***.

3. Iyipada Ewu naa: Nigbati “orififo Ọpa Ọpa Rọrun” kan Ya omije iṣọn Asopọ (Intracranial Subdural Hematoma)¶

4. Itọju Pataki fun PDPH: Idi ti Autologous Epidural Blood Patch (EBP) jẹ Standard Gold¶

• ** Awọn wakati 24 akọkọ ti awọn aami aiṣan ipo kekere:** Duro pẹlẹbẹ nigbakugba ti orififo ba bẹrẹ, mu iwọn deede ti awọn olomi ẹnu (fifi agbara mu overhydration ti o pọ ju ongbẹ deede ko mu iṣelọpọ CSF pọ si, botilẹjẹpe gbigbẹ mimu buru si irora), mu ** caffeine oral (200 to 300 mg lẹẹkan tabi lẹmeji lojoojumọ, tabi iṣan caffeine sodium benzoate 500 mg IV)** (eyiti o ṣe idinamọ awọn iṣọn inu inu ati dina awọn olugba adenosine), pẹlu acetaminophen ati ibuprofen. Awọn bulọọki apaniyan ti o ni ilọsiwaju bi ** transnasal sphenopalatine ganglion (SPG) Àkọsílẹ *** tun le pese iderun iyara.
• Gold-Standard arowoto (Autologous Epidural Blood Patch): Fun eyikeyi iwọntunwọnsi-si-àdájú efori puncture post-dural (paapaa lẹhin ti o tobi-bore epidural abẹrẹ tutu tẹ ni kia kia, tabi eyikeyi orififo pípẹ 24 to 48 wakati), anesthesiologists ṣe kan ** Patch Ẹjẹ. Labẹ awọn ipo aibikita, onimọ-jinlẹ fa ** 15 si 20 milimita ti ẹjẹ iṣọn ara alaisan *** lati apa wọn ki o fi sii laiyara sinu aaye epidural lumbar tabi aaye kan ni isalẹ aaye puncture atilẹba. Eyi ṣe awọn iṣẹ-iyanu meji: (1) iwọn didun ẹjẹ lẹsẹkẹsẹ tẹ apo dural lumbar, titari CSF pada si ori ati fifun orififo naa ** laarin awọn iṣẹju lori tabili **, ati (2) eje didi lori omije ni dura bi Band-Aid ti ibi, lilẹ jijo naa patapata ni ** 85 si 98 ogorun awọn alaisan.

Ipo 2: Hematoma Epidural Spinal (SEH) ati Ẹgẹ Anticoagulant / Catheter-Removal Pakute¶

A ** Spinal Epidural Hematoma (SEH)** jẹ ikojọpọ nla ti iṣọn-alọ ọkan tabi ẹjẹ iṣọn inu ẹhin ọpa ẹhin ti o rọ ọpa-ẹhin tabi cauda equina.

1. Kini idi ti Yiyọ Kateta Epidural kan jẹ Ewu Bi fifi sii¶

Otitọ pataki kan ti a tẹnumọ nipasẹ ** American Society of Regional Anesthesia and Pain Medicine (ASRA) *** awọn itọnisọna ni pe ** fere 50 ogorun gbogbo awọn hematomas ti ọpa ẹhin akuniloorun ti o ni ibatan ko waye KO nigbati abẹrẹ epidural ti kọkọ fi sii, ṣugbọn awọn ọjọ lẹhinna nigbati a fa jade catheter ṣiṣu epidural ṣiṣu ti o rọ. - Sisun catheter epidural jade kuro ni ẹhin le ṣe irẹrun iṣan iṣọn kekere kan ninu iṣọn iṣọn-ẹjẹ Batson. - ** Ilana Aago Anticoagulant: ** Ni awọn alaisan ti o wa ni ile iwosan (gẹgẹbi awọn alaisan orthopedic orthopedic / hip rirọpo awọn alaisan, awọn alaisan ti iṣan ti iṣan / thoracic, tabi awọn alaisan C-apakan ti n gba awọn iṣan ẹjẹ prophylactic bi ** enoxaparin [Lovenox], heparin ti a ko ni ida, apixaban, tabi rivaroxaban ***), ti nfa ẹjẹ ti nfa ẹjẹ ti nfa lakoko ti o nfa ẹjẹ ti nfa ẹjẹ. iwọn lilo ti ẹjẹ tinrin ju laipẹ lẹhin ti o ba fa catheter jade) ṣe idiwọ iṣọn kekere yẹn lati didi. Laarin awọn wakati 1 si 12 ***, didi ẹjẹ ti o ga pupọ ti o kun inu ọpa ẹhin. - * Akiyesi lori SEH lẹẹkọkan: * Awọn hematomas epidural spinal tun waye ** laipẹ laisi eyikeyi abẹrẹ ọpa ẹhin ** ni awọn alaisan ti o mu awọn abẹrẹ ẹjẹ (warfarin, DOACs, antiplatelet meji) lẹhin titẹ kekere, iwúkọẹjẹ, gbigbe, tabi ifọwọyi ti chiropractic.

2. Ilọsiwaju ile-iwosan ti Hematoma Epidural Epidural¶

1. ** lojiji, bi ọbẹ, irora aarin aarin tabi irora ọrun ("Irora Ọgbẹ Ọpa-ọpa")** ọtun ni ipele ti ẹjẹ, nigbagbogbo tẹle pẹlu didasilẹ ** didasilẹ irora ibon ni ayika àyà/inu tabi isalẹ awọn ẹsẹ mejeeji **.
2. ** Pipadanu ifarako ti o ni ilọsiwaju ni kiakia ati ailera motor (laarin awọn iṣẹju 30 si awọn wakati diẹ):** Numbness ati tingling dide soke awọn ẹsẹ si laini petele ti o yatọ lori ẹhin mọto (** ipele ifarako ), tabi numbness ninu ikunra, awọn ara, ati awọn buttocks ( anesthesia gàárì,), tẹle ni kiakia nipasẹ eru, clumparsy ese ( paraplegia**).
3. ** Idaduro ito ati isonu ti iṣakoso ifun:** Nitori awọn okun autonomic sacral ti n ṣakoso iṣan detrusor àpòòtọ joko lori alailagbara ni ita ti conus medullaris ati cauda equina, ** ailagbara lati urinate (tabi ikun omi ti ko ni irora lati inu àpòòtọ distended)** jẹ ọkan ninu awọn ami akọkọ ti titẹkuro okun.

Ipo 3: Ọgbẹ Epidural Abscess (SEA) ati Ilọsiwaju 4-Ipele Alailẹgbẹ¶

A ** Spinal Epidural Abscess (SEA)** jẹ ikolu kokoro-arun pyogenic (eyiti o fa ni ** 60 si 70 ogorun awọn iṣẹlẹ nipasẹ * Staphylococcus aureus **, pẹlu MRSA, atẹle nipasẹ * Streptococcus , * Escherichia coli , ati * Pseudomonas ) idẹkùn laarin egungun dura mater ati. Awọn kokoro arun de aaye apọju ti ọpa ẹhin boya nipasẹ ẹjẹ ( irugbin hematogenous ** lati inu õwo awọ / cellulitis, abscess ehín, ikolu urinary tract, catheter inu iṣọn, tabi lilo oogun abẹrẹ) tabi nipasẹ itẹsiwaju taara lati inu catheter epidural, iṣẹ abẹ ọpa ẹhin, tabi ti o wa nitosi vertebral disc infection ( discelitis/oste).

Awọn ipele Isẹgun 4 lẹsẹsẹ ti Abscess Epidural ti Ọpa-ẹhin (Awọn ipele Heusner)¶

Nitoripe abscess spinal spinn runs spinal cord nipasẹ mejeeji funmorawon ẹrọ ati **septic thrombophlebitis (didi ti awọn iṣọn ọpa ẹhin) ***, alaisan kan le fo lati Ipele 2 tabi 3 si ipele 4 paralysis ti ko ni iyipada ni ** wakati kan ***:

• ** Ipele 1 (Focal Midline Back or Neck Pain + Spine Percussion Tenderness):** Àìdá, àìdánilójú, ìrora àbílẹ̀ tàbí ìrora líle ní àárín ẹhin tabi ọrun ti o buru sii nigbati o ba dubulẹ ni alẹ, ti o tẹle pẹlu ifarabalẹ pinpoint nigbati ika kan ba tẹ awọn ilana ti o wa ni ẹhin. (Akiyesi: Iba ko si ni iwọn 50 ogorun ti awọn alaisan Ipele 1, eyiti o yori si aiṣedeede igbagbogbo bi “iṣan ti o fa sẹhin”).
• ** Ipele 2 (Irun Irritation Nerve / Radicular Shooting Pain):** Ina-mọnamọna, sisun, tabi irora ibon ti n tan lati ọpa ẹhin si isalẹ ẹsẹ kan (sciatica), isalẹ apa, tabi yipo ni ayika ribcage tabi ikun (nigbagbogbo ti a ṣe ayẹwo bi awọn shingles, awọn okuta kidinrin, tabi irora gallbladder), ti o tẹle pẹlu awọn iṣan ọrun / ẹhin.
• Ipele 3 (Ailagbara Moto Tete, Pipadanu Senssory, ati Atọpa/Ifun Ifun): Awọn ẹsẹ ti o wuwo, ikọsẹ ikọsẹ, sisọ ẹsẹ silẹ, numbness labẹ ọgbẹ tabi ni agbegbe gàárì, ati ** idaduro ito nla *** (iwọn àpòòtọ ti o ku lẹhin-ofo). >100 to 200 mL). ** Eyi ni ferese igbala iṣẹ abẹ ti o kẹhin. ***
• Ipele 4 (Pipe Paralysis): Lapapọ ipadanu gbigbe ati rilara ni isalẹ ipele ti abọ. Ni kete ti Ipele 4 to gun ju ** 24 si awọn wakati 36 ***, ṣiṣan iṣẹ-abẹ ṣọwọn ṣe atunṣe ririn.

Iyatọ Orififo Puncture Post-Dural, Hematoma Epidural Spinal, Abscess Spinal Epidural Abscess, ati Meningitis¶

Lo tabili afiwe ibusun yii lati ṣe iyatọ ni iyara lati ṣe iyatọ awọn aami aiṣan lẹhin ilana ilana lati iṣẹ abẹ ati awọn ajalu ajakale-arun:

Ayẹwo ile-iwosan ti o daju ati awọn ilana ilana neurosurgical¶

Nigbati alaisan kan ba de ile-iṣẹ pajawiri pẹlu ifura ọpa-ẹhin funmorawon, awọn ile-iwosan ṣe ipa ọna neurosurgical ti akoko kan:

1. ** Lẹsẹkẹsẹ Gbogbo-Ọpa ẹhin MRI (NOT Plain X-ray or CT Only):** Awọn egungun X-ray ti ọpa ẹhin jẹ deede ni hematoma nla ati abscess ni kutukutu, ati awọn ọlọjẹ CT ti kii ṣe iyatọ ti o ṣe deede padanu awọn didi asọ-ara ati pus inu odo odo. Iwọn goolu jẹ ** Aworan Resonance Magnetic Emergent (MRI) ti Gbogbo Spine ** (pẹlu iyatọ gadolinium fun abscess ti a fura si; ​​T1/T2 ti kii ṣe iyatọ fun hematoma), aworan cervical, thoracic, ati awọn ipele lumbosacral lati mu ** 10 si 15 ogorun oṣuwọn ti awọn egbo foo **. (Ti o ba jẹ pe ẹrọ afọwọsi kan ṣe idiwọ MRI, pajawiri **CT Myelography *** ti ṣe).
2. ** Ṣiṣayẹwo olutirasandi Bedside Bed (Ayeku Post-Void):** Awọn nọọsi ṣe olutirasandi àpòòtọ iṣẹju-aaya 30 ni kete lẹhin ti alaisan gbiyanju lati di ofo. A ** post-ofo aloku (PVR) iwọn didun lori 100 to 200 mL** jẹrisi idaduro iṣan neurogenic lati inu okun tabi cauda equina funmorawon, ti o nfa lẹsẹkẹsẹ ** catheterization Foley ***.
3. ** Iyipada Anticoagulant + Laminectomy Decompressive Pajawiri:**
4. ** Fun Ẹjẹ Epidural Hematoma (SEH): ** Awọn olutọpa ẹjẹ jẹ iyipada lẹsẹkẹsẹ (** 4-factor PCC + IV vitamin K ** fun warfarin; ** andexanet alfa ** tabi 4-factor PCC fun apixaban / rivaroxaban; **idarucizumab *** fun dabigatran; ** nopprotalate sulfarin; <100,000/uL), atẹle nipasẹ ** laminectomy decompressive ati yiyọ kuro didi ** laarin <8 to 12 hours.
5. Fun Ọgbẹ Ẹjẹ Ẹjẹ (SEA): Awọn ipilẹ meji ti ** awọn aṣa ẹjẹ ** ni a fa, a ti bẹrẹ awọn oogun aporo IV empiric (** IV vancomycin.15 to 20 mg/kgPLUS IV cefepime [2 g q8htabi ceftriaxone [2 g q12h]**), ati neurosurgeons ṣe ** laminectomy abẹ ni kiakia ati pus drainage ** atẹle nipa 4 si 8 ọsẹ ti awọn egboogi ìfọkànsí.

Awọn nọmba pajawiri agbegbe ati awọn ilana ile-ibẹwẹ¶

Hematoma ti o ni ifura ọpa ẹhin epidural tabi abscess spinal nilo gbigbe ọkọ alaisan lẹsẹkẹsẹ lọ si ile-iwosan giga ti o ni ipese pẹlu ** 24-wakati MRI pajawiri pajawiri ati On-Call Neurosurgery / Orthopedic Spine Surgery ***:

• ** Orilẹ Amẹrika ati Kanada: *** Tẹ ** 911 *. Sọ fun awọn alamọdaju lati gbe lọ si ile-iwosan pataki kan pẹlu ** 24/7 MRI ati Iṣẹ abẹ Ọpa-ẹhin ** (lilọ si ile-iwosan agbegbe kekere kan laisi MRI-alẹ-alẹ tabi neurosurgery npadanu awọn wakati iyebiye ni gbigbe laarin ile-iwosan lakoko window paralysis 8-wakati). Ṣakoso labẹ ** American Society of Regional Anesthesia and Pain Medicine (ASRA) ati Awọn Arun Arun Awujọ ti Amẹrika (IDSA) awọn itọnisọna.
• ** United Kingdom: ** Pipe ** 999 *** fun ọkọ alaisan lẹsẹkẹsẹ si ile-iwosan nla nla kan ** Ẹka pajawiri (A&E) ** pẹlu agbegbe ** Iṣẹ abẹ Ọpa-ọpa ati awọn iṣẹ MRI ** (ti o tẹle ** GIRFT National Suspected Cauda Equina Syndrome & Spinal Cord Compression Pathway ** ati ** Association of AA [Association / Aestestists] awọn itọnisọna).
• European Union: Titẹ 112. Ṣakoso labẹ ** European Society of Anaesthesiology and Intensive Care (ESAIC)** ati European Society of Regional Anesthesia (ESRA) awọn itọnisọna ailewu neuraxial.
• ** Australia ati Ilu Niu silandii: *** Tẹ ** 000 *** ni Australia tabi ** 111 *** ni Ilu Niu silandii. Ṣakoso labẹ ** Australian ati New Zealand College of Anesthetists (ANZCA) *** awọn itọnisọna idena neuraxial.
• India ati Asia-Pacific: Titẹ 112 (tabi 108 ni India), 995 ni Singapore, 119 ni Japan ati South Korea, tabi 999 ni Malaysia ati Hong Kong. Beere ile-ẹkọ giga kan pẹlu MRI-wakati 24 ati neurosurgery.

Awọn ibeere ti a beere nigbagbogbo¶

Bawo ni MO ṣe le sọ iyatọ laarin orififo ọpa ẹhin “tutu-tẹ” deede lẹhin apọju ati ẹjẹ ọpọlọ ti o lewu tabi didi?¶

Ṣe Idanwo Flat-Lie Minute 15-Minute: puncture post-dural Ayebaye kan (“tutu-tẹ ni kia kia”) orififo ọpa ẹhin jẹ nitori titẹ ito ọpa ẹhin kekere nigbati o tọ, nitorinaa irọri 100 ogorun alapin lori ẹhin rẹ laisi irọri kan tu 80 si 100 ogorun ti orififo laarin awọn iṣẹju 15 si 30, ati orififo wa laarin iṣẹju 15 ti o duro soke. Ti orififo rẹ KO ba dara pupọ nigbati o ba dubulẹ patapata, ti orififo ti o lo lati wa ni ipo lojiji yipada nigbagbogbo paapaa nigba ti o dubulẹ, tabi ti o ba ni titẹ ẹjẹ ti o ga, awọn iyipada wiwo, rudurudu, ikọlu, iba, tabi ailera ni apa tabi ẹsẹ, pe 911 lẹsẹkẹsẹ lati ṣe akoso hematoma intracranial subdural hematoma, cerebral venous prethromboosis, postrombosis meningitis.

Bawo ni o yẹ ki o pẹ to fun awọn ẹsẹ mi lati ni rilara ni kikun ati agbara lẹhin ti a ti pa epidural ibimọ kan?¶

Labẹ awọn itọnisọna aabo akuniloorun ti kariaye (gẹgẹbi Ẹgbẹ Awọn Anaesthetists' Obstetric ati awọn ilana ASRA), ni kete ti idapo epidural ti duro ati yọ catheter kuro, anesitetiki agbegbe n wọ ni imurasilẹ ati pe agbara ẹsẹ ati itara yẹ ki o jẹ 100 ogorun pada si deede laarin awọn wakati 4 (ati pe ko gun ju wakati mẹfa lọ). Ti o ko ba le gbe awọn ẹsẹ ti o tọ kuro ni ibusun lẹhin awọn wakati 4, ti awọn ẹsẹ rẹ ba ni rilara ti o pọ sii tabi numbness, ti o ba ni numbness ninu ikun rẹ tabi awọn ẹhin nigbati o ba npa, tabi ti awọn ẹsẹ rẹ ba ṣiṣẹ daradara ni iṣaaju ati lẹhinna tun lọ numb tabi ailera lẹẹkansi, tọju rẹ bi pajawiri lẹsẹkẹsẹ ati beere fun iṣiro Spine MRI lati ṣe akoso hematoma ọpa-ẹhin.

Kini idi ti yiyọ catheter epidural kan le fa hematoma ti ọpa ẹhin awọn ọjọ lẹhin ilana naa?¶

Aaye epidural ọpa ẹhin ni oju opo wẹẹbu ti o nipọn ti ẹlẹgẹ, awọn iṣọn ogiri tinrin (Batson's plexus). Sisun catheter pidural ṣiṣu ti o rọ lati ẹhin ni ipari iṣẹ tabi lẹhin iṣẹ abẹ le fa ọkan ninu awọn iṣọn kekere wọnyẹn, eyiti o jẹ iṣiro fere idaji gbogbo hematomas epidural. Ti alaisan naa ba ti gba iwọn lilo ti tinrin ẹjẹ (gẹgẹbi enoxaparin/Lovenox, heparin, apixaban, tabi rivaroxaban) ti o sunmọ akoko ti o ti fa catheter jade, tabi ni awọn platelets kekere (bii ninu iṣọn HELLP), iṣọn ti o ni kekere ko le didi ati ẹjẹ sinu rigidi laarin awọn wakati ọpa ẹhin.

Kini “patch ẹjẹ apọju” ati kilode ti o ko yẹ ki o jẹ ki orififo ọpa-ẹhin lile kan lọ lai ṣe itọju fun awọn ọsẹ?¶

Patch eje epidural autologous jẹ ilana iṣẹju 15-iṣẹju ibusun ti o ṣe nipasẹ onimọran akuniloorun ti o fa 15 si 20 milimita ti ẹjẹ aibikita lati iṣọn apa rẹ ti o si fi sinu aaye epidural ti ẹhin isalẹ rẹ lati di omije pinhole ninu apo ito ọpa ẹhin. O ṣe iwosan 85 si 98 ogorun ti awọn efori puncture lẹhin-dural fere lẹsẹkẹsẹ. Ni ikọja imukuro irora irora ki iya tuntun tabi alaisan le joko si oke ati ṣiṣẹ, lilẹ jijo CSF ​​ti o lagbara ṣe aabo fun ọpọlọ: ti ọpọlọ ba lọ silẹ si isalẹ inu agbọn fun awọn ọjọ tabi awọn ọsẹ lati jijo ti a ko ṣe itọju, o le na ati fa awọn iṣọn didan ẹlẹgẹ lori oke ti ọpọlọ, ti o nfa igbesi aye eewu intracranioma subdu.

Njẹ ẹnikan le ni abscess ọpa-ẹhin paapaa ti wọn ko ba ni iba?¶

Bẹẹni, ati idaduro fun iba ni nọmba-ọkan idi ti awọn abscesses spinal epidural ti wa ni padanu titi paralysis yoo waye. Awọn iwadii ile-iwosan fihan pe nikan 50 si 60 ida ọgọrun ti awọn alaisan ti o ni ifẹsẹmulẹ ọpa-ẹjẹ epidural ti o ni ibà nigba ti wọn kọkọ de yara pajawiri, ati pe o kere ju 15 ogorun ni pipe “triad Ayebaye” ti irora ẹhin, iba, ati awọn aipe iṣan-ara gbogbo ni akoko kanna. Dipo, wa fun àìdá, ẹhin aarin ti agbegbe tabi irora ọrun ti o dun nigba ti a tẹ pẹlu ika kan, titu irora nafu si isalẹ awọn ẹsẹ tabi awọn egungun, ati awọn okunfa ewu bi àtọgbẹ, ikolu awọ ara laipe, ilana ehín, abẹrẹ ọpa ẹhin, tabi laini IV, ati beere fun idanwo ẹjẹ ESR / CRP ati itansan Spine MRI.

Kilode ti ferese 8-si-12-wakati jẹ pataki ni kete ti ailera ẹsẹ tabi idaduro ito bẹrẹ?¶

Nitoripe eegun vertebral ti egungun ko le na isan, didi ẹjẹ apọju ti o gbooro tabi apo ti pus kii ṣe pinches awọn ọpa ẹhin ni ọna ẹrọ, o tun fọ awọn iṣọn titẹ kekere ti o nfa ọpa ẹhin, ti o nfa iṣọn-ẹjẹ iṣọn-ẹjẹ (infarction) ti iṣan ọpa ẹhin. Awọn data neurosurgical fihan pe ti awọn oniṣẹ abẹ ba ṣii ẹhin (laminectomy decompressive) ti o si yọ didi tabi pus laarin 8 si wakati 12 ti ibẹrẹ ailera ẹsẹ, ọpọlọpọ awọn alaisan tun gba agbara ti nrin ni kikun ati iṣakoso àpòòtọ; ni kete ti paralysis pipe ti pẹ diẹ sii ju wakati 24 si 36, awọn iwe afọwọya ara eegun ọpa ẹhin ku patapata.

Awọn orisun ati osise itoni¶

• ** Awujọ Amẹrika ti Akuniloorun Ẹkun ati Oogun Irora (ASRA, Orilẹ Amẹrika): *** Anesthesia agbegbe ni Alaisan Ngba Antithrombotic tabi Itọju Ẹjẹ: Awọn Itọsọna orisun-Ẹri ASRA (Ẹya Karun)* (* Anesthesia agbegbe & Oogun irora *, awọn ofin akoko fun yiyọkuro epidural, gbigbe awọn apo-itọju anticotheatheatheatheatheathesia ati awọn aarun ayọkẹlẹ 4. kakiri, ati <8 to 12 hour Ferese laminectomy decompressive fun hematoma epidural ti ọpa ẹhin).
• ** Multi-Society International Working Group on Post-Dural Puncture Headache (ASRA, ESRA, OAA, SOAP, International):** * Awọn Itọsọna Iṣẹ iṣegun ti o da lori Ẹri lori orififo puncture Postdural * (* Anesthesia agbegbe & oogun Irora / JAMA Network *, awọn ami ami aisan ẹjẹ ti o wa ni ipo ipo, ati awọn ami ami-ẹjẹ ẹjẹ ti o wa ni abẹlẹ, awọn ami ami aisan ti o wa ni ipo, ati ilana ilana patch epidural autologous).
• ** Association Anaesthetists 'Association (OAA) & Association of Anesthetists (United Kingdom):** * Ilana Aabo: Abojuto Neurological ti o ni nkan ṣe pẹlu Dina ti Neuraxial Obstetric * ("Gbilẹ ẹsẹ ti o tọ ni Awọn wakati 4" ofin ati ọna MRI lẹsẹkẹsẹ fun gigun tabi pada Àkọsílẹ motor).
• ** Awujọ Arun Arun ti Amẹrika (IDSA, Orilẹ Amẹrika): ** * Awọn Itọsọna Iṣeduro Iṣegun IDSA fun Ayẹwo ati Itoju ti Native Vertebral Osteomyelitis ati Spinal Arun Arun Arun ninu Awọn agbalagba pẹlu cephalosporin kẹta/kẹrin).
• ** NHS Ngba Ni Titun Akoko (GIRFT) & Society of British Neurological Surgeons (SBNS, United Kingdom):** *Aisan ti orilẹ-ede ti a fura si Cauda Equina Syndrome ati Ipa-ọna Pajawiri Ipapa Ọpa Ọpa Arun *.

Jẹmọ awọn itọsọna¶

• Cauda equina dídùn ati ńlá ọpa-ẹhin funmorawon awọn asia pupa
• Ijẹ ẹjẹ Subarachnoid, orififo thunderclap, ati aneurysm ọpọlọ ruptured
• Eclampsia imulojiji, HELLP dídùn, ati postpartum preeclampsia
• Meningitis ati meningococcal septicemia ti kii-blanching sisu triage
• Idaduro ito nla, ailagbara lati ito, ati idinamọ catheter