Hc vin qun y

B mn phu thut thn kinh

phu thut thn kinh

gio trnh ging dy i hc

nh xut bn qun i nhn dn

h ni - 2003
nh xut bn mong c bn c gp kin ph bnh

hi ng bin son, bin tp, ti liu gio trnh,

gio khoa ca hc vin qun y

Thiu tng gs.ts. Phm Gia Khnh

Gim c Hc vin Qun y - Ch tch
i t bs. H Vn Ty
Ph Gim c Hc vin Qun y - Ph ch tch
i t gs.ts. Nguyn Vn Nguyn
Ph Gim c Hc vin Qun y - y vin
i t gs.ts. V c Mi
Ph Gim c Hc vin Qun y - y vin
i t GS.TS. L Bch Quang
Ph Gim c Hc vin Qun y - y vin
i t PGS.TS. ng Ngc Hng
Gim c Bnh vin 103 - y vin
i t GS.TS. Nguyn Vn Mi
Ph Gim c Bnh vin 103 - y vin
i t PGS.TS. L nm
Gim c Vin Bng Quc Gia - y vin
i t BS. phm quc ng
H trng h o to Trung hc - y vin
i t BS. Trn Lu Vit
Trng phng Thng tin Khoa hc
Cng ngh Mi trng - y vin
Trung t BS. Nguyn Vn CHnh
Trng ban Bin tp - Th k

355 - 61
1566 - 2002
QND - 2003
Ch bin :
PGS.TS. Bi quang tuyn
PGS.TS. nguyn th l

Tham gia bin son :

PGS.TS. Bi quang tuyn

Ch nhim B mn Phu thut thn kinh - HVQY.
Ch nhim khoa PTTK - Bnh vin 103.
Pgs. Ts. Nguyn th l
Cc ph Cc Qun Y.
Nguyn ch nhim B mn PTTK - Hc vin Qun Y.
PGS.TS. V hng lin
Ph ch nhim B mn PTTK - HVQY.
Nguyn ch nhim khoa PTTK - Bnh vin 103.
Th.s. ng nh nam
Ging vin B mn PTTK - HVQY.
Ph ch nhim Khoa PTTK - Bnh vin 103.
Ts. Nguyn hng minh
Ging vin B mn PTTK - HVQY.
Ts. V vn ho
Ging vin B mn PTTK - HVQY.
Ts. Bi ngc tin
Ch nhim khoa Phu thut thn kinh
Bnh vin 198 - B Cng an
 Li gii thiu

Gio trnh Phu thut thn kinh do B mn Phu thut thn

kinh bin son s gip cho sinh vin Y khoa khng nhng
nm c kin thc c bn trong chn on, cp cu v iu tr
chn thng h thn kinh m cn gip cho sinh vin nm c
bnh hc v iu tr mt s bnh c tnh cht chuyn su.
Cc bi ging c vit ngn gn, y v d hiu chc
chn s l ti liu qu gi gip cho sinh vin yu thch v say
sa hc tp mn chuyn ngnh ny.
Trn trng gii thiu bn c cun gio trnh Phu thut
thn kinh v rt mong nhn c kin ng gp gio trnh
ngy cng c hon thin.

Gim c Hc vin qun y

Thiu tng , GS.TS: phm gia khnh

 Li ni u

p ng vi nhu cu o to ngy cng cao ca HVQY v

ci tin phng php dy v hc ng thi b sung
nhng kin thc mi, cp nht cho ph hp vi yu cu hc tp
hin nay ca sinh vin, B mn Phu thut Thn kinh c
gng bin son cun gio trnh Phu thut thn kinh dnh cho
sinh vin y khoa. Gio trnh gm 4 chng:
Chng 1: Cc phng php chn on cn lm sng trong
Phu thut thn kinh.
Chng 2: Chn thng h thn kinh.
Chng 3: Bnh l h thn kinh trung ng.
Chng 4: Khm cp cu chn thng h thn kinh.
Gio trnh vit ngn gn, d hiu nhm gip cho sinh vin
nm c nhng kin thc c bn v hiu bit mt phn
chuyn su.
Mc d c nhiu c gng, song cun sch c th cn c
nhng thiu st, rt mong bn c gp xy dng ti bn
ln sau c tt hn.

Ch bin
PGS.TS. Bi quang tuyn
Ch nhim B mn Phu thut Thn kinh
 cc ch vit tt

ALNS : p lc ni s
ALTT : p lc thm thu
AVM : D dng mch mu no
BC : Bch cu
BN : Bnh nhn
BQ : Bng quang
CN : Chn ng no
CHT : Cng hng t
CLVT : Ct lp vi tnh
CS-TS : Ct sng-ty sng
CTSN : Chn thng s no
DMC : Di mng cng
DNT : Dch no ty
M : ng mch
MN : ng mch no
HAM : Huyt p ng mch
HC : Hng cu
MTNS : Mu t ni s
NMC : Ngoi mng cng
NT3 : No tht ba
NT4 : No tht bn
OSTL : ng sng tht lng
RLCG : Ri lon cm gic
RLHH : Ri lon h hp
RLTG : Ri lon tri gic
RLTT : Ri lon tiu tin
RLV : Ri lon vn ng
TK : Thn kinh
TKKT : Thn kinh khu tr
TKTV : Thn kinh thc vt
VTCS-TS : Vt thng ct sng-ty sng
VTSN : Vt thng s no
 b mn phu thut thn kinh

Mc lc

Trang
Li gii thiu 5
Li ni u 7
Chng 1: Cc phng php chn on cn lm sng
h thn kinh 13
- Chc ng sng tht lng. 15
- Chc no tht. 19
- Chp ty cn quang. 22
- Chp ng mch no. 24
- Chp ct lp vi tnh. 27
- Phng php chn on bng cng hng t. 33
Chng 2: Chn thng h thn kinh 37
- Chn thng s no. 39
- Vt thng s no do ho kh. 51
- Chn thng kn ct sng v ty sng. 57
- Vt thng ct sng-ty sng. 65
- Tn thng dy thn kinh ngoi vi. 72
Chng 3: Bnh l h thn kinh. 85
- U no. 87
- Hi chng tng p lc ni s. 91
- Chy mu trong no t pht. 97
- p xe no. 104
- U ty. 110
- Lao ct sng. 116
- Thot v a m ct sng c. 121
- Thot v a m vng tht lng. 133
- Gai i ct sng. 145
Chng 4: KHm cp cu chn thng h thn kinh. 151
- Khm v x tr cp cu chn thng s no. 153
- Cc phng php chn on bnh l ct sng - ty sng. 165
- iu tr ri lon tiu tin trong chn thng ct sng-ty sng. 172
- Thuc s dng trong phu thut thn kinh. 179
Chng 1
Cc phng php
Chn on cn lm sng h thn kinh

Chc ng sng tht lng

Bi Quang Tuyn

1. Ch nh.
Chc ng sng tht lng (OSTL) l k thut c ng dng trong nhiu
chuyn ngnh khc nhau nh Ni-Ngoi Thn kinh, Tm thn, Truyn nhim,
Nhi khoa. Chc OSTL c ch nh cho nhng mc ch sau:
+ Vi mc ch chn on:
- Nghin cu p lc, mu sc v thnh phn dch no ty (DNT) chn
on bnh l no v ty sng.
- Bm thuc cn quang chp ty, chp bao r thn kinh.
+ Vi mc ch iu tr:
- Rt bt DNT lm gim tm thi p lc ni s (ALNS) sau chn thng,
sau can thip phu thut bnh l no. Thng ly b 5 - 8 ml DNT.
- Ly b mu v sn phm phn hy ca hng cu sau chy mu di nhn
do chn thng hoc do tai bin mch mu no.
- a corticoide (depersolone) vo DNT iu tr vim ty, vim mng nhn
ty.
- Bm kh oxy iu tr tm thn, ng kinh.
- a khng sinh iu tr vim mng no, vim ty.
2. Chng ch nh.
+ Trong trng hp u hoc nghi ng u h s sau, u ln bn cu i no.
 + Ph no vi biu hin ph a th.
+ Lao ct sng-ty sng ang giai on tin trin.
+ Vim ty hoc lm m vng nh chc OSTL.
3. K thut chc OSTL.
3.1. V tr chc:
Khe lin gai sau ca t sng LIII-LIV hoc LIV-LV.
3.2. Dng c:
+ Mt khay men c tri sng v trng; gc, bng v gng tay v trng.
+ Mt khay qu u c bng cn Iode v bng cn 900.
+ Kim chc OSTL di 10 - 15 cm c thng nng (mandrin). Kim c ng
knh nng t 0,8 - 1mm.
+ p k Claude hoc ng thy tinh (ng pipet) o p lc DNT.
+ Bm tim v kim gy t.
+ Thuc gy t lidocain hoc novocain.
+ 2 ng nghim v mt vi dng c khc nh km cp sng; km cp bng
cn, bng dnh.
3.3. T th bnh nhn:
Bnh nhn (BN) c th ngi hoc nm. T th ngi nguy him nn t c p
dng. BN nm nghing, u gp vo ngc, hai i co ht mc vo bng (hnh 1).

Hnh 1: T th BN v v tr chc OSTL.

3.4. K thut:
+ nh du vng nh chc bng cch k mt ng lin mo chu hai bn,
ng k s i qua lin gai sau ca LIV-LV.
+ St trng v tr chc.
+ Gy t 2 - 3 ml lidocain 2% (th phn ng trc khi gy t).
 + Chc kim: mi kim phi vung gc vi ct sng. Kim s chc qua cc lp da
v di da; dy chng lin gai (lig. supraspinale); dy chng vng (lig. flavum);
lp t chc lng lo ngoi mng cng v cui cng l mng cng ty.
Khi kim chc qua dy chng vng, c cm gic st tay, mi kim nm
khoang ngoi mng cng (khi gy t ngoi mng cng ngi ta bm thuc
gy t vo khoang ny). Tip tc y nh kim vo su hn v khi kim chc
thng mng cng, xut hin cm gic st tay ln th hai, tc l mi kim
nm trong khoang di nhn ca ty.
+ Khi kim nm trong khoang di nhn ca ty, rt thng kim s thy
DNT chy ra. Nu cha thy c DNT, th xoay kim v y nh vo su hn
hoc va xoay kim va rt kim ra ngoi mt cht. i khi phi chc kim ti 2 - 3
ln mi c.
+ Khi rt thng kim thy DNT chy ra, tin hnh o p lc DNT bng p
k Claude hoc bng ng thy tinh. Nu khng c 2 dng c trn th c th
m s git, bnh thng p lc DNT l 60 - 80 git/pht hoc bng 10 - 15
mmHg t th nm ngang.
3.5. Kim tra lu thng DNT:
Khi nghi ng c s chn p ty (do u hoc cc cn nguyn khc) tin hnh
kim tra lu thng DNT bng nghim php Queckenstedt v Stockey.
+ Nghim php Queckenstedt:
Trong khi o p lc DNT, ngi ph tay ln tnh mch c ca bnh
nhn 2 bn trong 10 - 15 giy ri b tay ra. S p ny s gy cn tr dng
mu no v tim, mu tnh mch b li v gy tng p lc DNT, kt qu nh
sau:
- Lu thng DNT bnh thng: khi tay ln tnh mch c, p lc DNT c
th ln ti 25 - 30 mmHg v khi b tay ra p lc DNT tt xung rt nhanh v tr
v bnh thng. iu chng t khoang di nhn ca ty thng sut, khng
b chn p v gi l nghim php Queckenstedt (+) hay cn gi l lu thng
DNT bnh thng.
- Lu thng DNT b tc nghn hon ton.
Khi tay ln tnh mch c 2 bn nhng khng thy thay i p lc DNT;
nu m s git DNT khng thy tng ln, chng t c s chn p ty trn ch
chc, gi l nghim php Queckenstedt (-) hay lu thng DNT b tc nghn
hon ton.
+ Nghim php Stockey:
Khc vi nghim php Queckenstedt, ngi ph dng nm tay p mnh vo
thnh bng trc ca BN v pha ct sng trong thi gian 5 - 10 giy ri b tay
ra.
 Do cc tnh mch ngoi mng cng on tht lng-cng v tnh mch
ch di nn khi p tay vo thnh bng tc l gin tip p vo tnh mch ch
di, dng mu tnh mch ngoi mng cng b li s gy tng p lc DNT.
Nghim php Stockey ch lm h tr cho nghim php Queckenstedt
gip chn on v tr ty b chn p. V d mt trng hp u gy chn p
hon ton khoang di nhn ty on ngc, nu chc OSTL LIV-LV tc l
chc pha di u, nghim php Queckenstedt (-), nhng Stockey li (+).
Khng c lm 2 nghim php ni trn nu BN c biu hin tng p lc ni
s.
4. Tai bin v bin chng chc OSTL.
+ Tai bin nguy him c th xy ra khi chc OSTL l tt kt no: kt thy
thi dng vo khe Bichat hoc tt kt hnh nhn tiu no vo l chm.
Biu hin: ri lon nghim trng chc phn h hp v tim mch, c cn dui
cng t chi. trnh tai bin ni trn cn phi kim tra y mt trc khi chc
OSTL v nu chc phi BN nm u thp, dng kim c ng knh nng
< 0,8 mm v khi rt thng kim khng c DNT chy thnh tia m cho
chy tng git mt.
+ au u do thay i p lc DNT sau khi ly DNT xt nghim.
+ au vng chc kim do chc i chc li nhiu ln, i khi gy au do
chc phi r thn kinh.
+ Vim mng no hay phn ng mng no biu hin sau vi ngy chc
OSTL, BN au u, c cng, st, nn... trnh bin chng ny khi chc phi
m bo nguyn tc tuyt i v trng.
5. Thnh phn DNT bnh thng v bnh l.
Thng ly 5 - 8 ml DNT xt nghim sinh ho v t bo. Nhng thay
i thnh phn DNT ca mt s bnh l tm tt trong bng sau:

Thnh phn
Dch no ty p lc DNT Mu sc DNT
T bo Protein Glucose
DNT bnh 10 - 15 Trong vt 0-3 t bo 2,7 - 4,5
thng mmHg khng mu 15 - 45 mg% mmol/l

Vim mng > 500 t

no m. Tng cao Vn c bo (ch 1 - 3 gr/l Di
yu 2mmol/l
neutro)
 Vim mng Vi chc
no do lao. Tng cao Vng chanh n hng 70 - 80 mg/l Di
trm t 2 mmol/l
bo.

Bnh thng Tng nh

Vim no hoc tng Bnh thng Tng BC 70 - 100 mg/l Bnh thng
do virus nh lympho

U no Tng cao Trong Bnh Tng cao >1

Bnh thng
thng gr/l

Chy mu Sm (2-3 Sm:

di nhn ngy u): nhiu
do tai bin DNT pht HC, BC
mch mu Tng hng hoc Mun: Mun: tng Bnh thng
no mu BC neutro >100 mg/l
Mun hn: v lympho
DNT vng
sm v
snh.

Vng nht Bnh Tng 1 - 10

U ty sng Bnh thng nu u di gr/l u di Bnh thng
thng
mng cng mng cng

Vim a r
thn kinh
Bnh thng Bnh thng Bnh Tng nh Bnh thng
(bnh
thng 50 - 100mg/l
Guilaine-
Barre

chc no tht

Bi Quang Tuyn

1. i cng v h thng no tht.

1.1. Gii phu:
Magendie (1837) l ngi u tin m t y h thng cc bung no
v DNT. Cc bung no gm: no tht bn, no tht ba v no tht bn (hnh 1).
 Hnh 1: H thng no tht nhn t trn
xung (A) v nhn bn (B).
1. No tht bn; 2. L Monro; 3. Sng trn; 4. Sng thi dng; 5. Sng chm; 6. Cng Sylvius;
III. No tht ba; IV. No tht bn; L. L Luska; M. L Magendie.

+ No tht bn: mi bn cu i no c 1 no tht bn. No tht bn l bung

no ln nht cun quanh nhn ui, i th v cung no, gm c 3 sng: sng
trn, sng thi dng v sng chm.
+ No tht ba (NT3): NT3 thng vi no tht bn bi l Monro v thng
xung no tht bn (NT4) bi cng Sylvius. Cng Sylvius rt hp nn d b bt
tc do vim dnh hoc do u.
+ No tht bn: l ch phnh ca ng ty, nm gia hnh no, cu no
pha trc v tiu no pha sau.
NT4 c gc trn thng vi NT3 bi cng Sylvius; gc di thng vi ng ty; 2
gc bn l l Luska thng vi khoang di nhn ca no.
Mng mi NT4 mng, cng gia 2 cung tiu no trn v 2 cung tiu no
di, c 1 l gia mng mi thng vi khoang di nhn ca ty gi l l
Magendie.
1.2. Tun hon DNT:
DNT c sinh ra m ri mng mch trong no tht bn s qua l Monro
vo NT3; t NT3 qua cng Sylvius xung ha vi DNT ca NT4 ri sau
DNT qua l Luska ra khoang di nhn ca no v qua l Magendie ra
khoang di nhn ca ty.
2. Ch nh.
+ Vi mc ch chn on:
Trc y ngi ta a thuc cn quang vo no tht bn chn on u no
(u no tht, u thn no, u gc cu tiu no v u tiu no), hin nay khng p
dng.
+ Vi mc ch iu tr:
Vi mc ch iu tr cho ti nay vn c p dng rng ri trong phu
thut thn kinh, c th:
- Chc no tht cp cu nhm gii thot tm thi DNT cp tnh e do
tnh mng BN trong trng hp trn dch no hoc u no. Sau khi chc no tht
dn DNT ra ngoi, nu tnh trng BN kh ln sau 5 - 7 ngy s phu thut
gii quyt cn nguyn.
- Dn lu lu di DNT t no tht bn vo bng hoc vo tm nh phi
ca tim trong iu tr trn dch no, hoc nhng u no khng c kh nng ly
b.
- Dn lu tm thi khi tin hnh m u no hoc p xe no h s sau. Dn
lu mt vi ngy sau phu thut.
3. K thut chc no tht bn.
C 2 v tr chc vo no tht bn: chc sng trn v sng chm.
3.1. Chc sng trn no
tht bn:
+ V tr v t th chc:
BN nm nga. K ng ni lin
nh ca 2 vnh tai v k ng
chnh gia nh chy t gc mi n
chm ngoi. T giao im ca 2
ng, k ng phn gic v im
t mi khoan nm trn ng phn
gic ny, cch ng gia trn-nh l
3 cm (hnh 2).
+ Gy t ti ch. Rch da di 4 - 5
cm song song vi ng gia trn nh. Hnh 2: S chc no tht bn sng trn
y ct mc xng s ra 2 bn, t banh
t ng.
+ Khoan s: t mt l khoan ri
gm xng rng ra xung quanh, ng knh 1,5 - 2 cm.
+ t in mng no cng. Dng kim Troca chc vo sng trn ca no tht
bn. Mi kim hng v pha ui ngoi ca mt cng bn chc.
+ Khi kim qua thnh no tht bn, c cm gic lng tay. Rt thng kim s
thy DNT chy ra. Nu cha c DNT, tip tc y nh kim vo su hn
cho ti khi c DNT.
 Bnh thng kim vo su 5 - 6 cm l ti no tht bn. Nu no tht bn gin
to, khong cch ny s ngn hn v chc vo no tht bn rt d dng. Nu no
tht nh, i khi phi chc 3 - 4 ln mi c.
Sau khi ly DNT xt nghim, tin hnh theo mc ch yu cu
ra.
3.2. Chc sng chm no tht bn:
+ V tr v t th BN: BN nm sp hoc nm nghing, u quay ti a
sang bn.
+ Xc nh chm ngoi: k 1 ng chnh gia chm ngoi v gc
mi, v t im 3 cm cch chm ngoi v cch ng gia, tin hnh gy
t v rch da (hnh 3).
+ t khoan s v gm rng
xng ra xung quanh, ng knh 1,5
- 2 cm.
+ t in mng no cng ri tin
hnh chc kim Troca: mi kim hng
v cnh mi cng bn ca BN. Cm
gic lng tay khi chc qua thnh no
tht bn. Rt kim; ly 5 ml xt
nghim ri tin hnh th thut theo
mc ch ra.
4. Tai bin v bin chng.
+ Chy mu trong no do kim chc
gy t rch mch mu hoc kim
chc vo t chc u.
+ Vim no, vim mng no. Hnh 3: V tr chc sng chm no tht
+ p xe no...

chp ty cn quang

Bi Quang Tuyn
 C 2 k thut chp ty (myelography):
+ Chp ty bm kh.
+ Chp ty cn quang.
Chp ty bm kh (pneumomyelography - PMG) c Dandy tin hnh
u tin vo nm 1918 chn on u ty. Sau ny nh c thuc cn quang
tan trong nc, khng kch thch ty nn chp ty bng khng kh khng cn
c p dng. Do vy trong bi ny ch gii thiu v chp ty cn quang.
1. Thuc chp ty cn quang.
Chp ty c bm thuc cn quang tan trong du c Sicard v Forestier
lm u tin vo nm 1922. Thuc cn quang tan trong du loi lng cng nh
siu lng (lipiodol fluid) c nhc im l tn ti trong khoang di nhn ca ty
mt thi gian di, chng c hp thu i rt chm, c khi 6 thng sau chp li
ct sng vn thy cn lipiodol. Do vy chng d gy vim mng nhn ty.
Ngy nay lipiodol khng cn c dng chp ty.
Thuc cn quang tan trong nc c p dng rng ri hin nay chp ty
cn quang l omnipaque (Iohexol) (ca Php); iopamiron (iopamidol) (ca M)
v pamiray (ca c). Cc loi thuc ny tt nht hin nay, chng khng b ion
ha nn khng c, khng gy kch thch ty sng v no; c th chp kim
tra ton b ty sng m khng c bin chng g.
C 3 loi thuc trn c hm lng iode/ml khc nhau: loi 200; 240; 300; 350
mg iode/1ml. Tt c cc loi thuc trn Bnh vin 103 chp cho hng
nghn trng hp an ton m khng c bin chng g.
2. Ch nh v chng ch nh.
+ Ch nh: chn on u ty; thot v a m v chn p ty do
cc cn nguyn khc.
+ Chng ch nh: khi c tng p lc ni s do u h s sau; khi tnh trng
BN qu nng.
3. K thut.
+ Tin hnh chc OSTL nh trnh by trn.
+ Sau khi o p lc DNT, kim tra lu thng DNT v ly 5 ml xt nghim.
Bm thuc cn quang ni trn vo khoang di nhn ca ty. C 2 k thut sau:
3.1. Chp bao r thn kinh (sarco-radiculography):
chn on thot v a m tht lng-cng: bm 8 - 10 ml omnipaque
loi 300 mg/l; rt kim; iu chnh bn dc 30 - 400, u pha cao. Chp 3 -
4 phim: 1 phim thng, 1 phim nghing, 1 hoc 2 phim chch 3/4 tri hoc phi
(nu au mt chn).
3.2. Chp ty:
Bm vo khoang di nhn ty 10 - 15 ml omnipaque loi 300 mg iode/ml;
rt kim; iu chnh cho bn dc 30 - 40 0, u pha dc ca bn. Thuc cn
quang s t t di chuyn v pha ty ngc v ty c (s nhn thy r ct thuc
di chuyn trn mn v tuyn). t gi di u BN sao cho u cao thuc
cn quang khng ln no m tp trung ch ty b chn. Chng 3 pht sau, khi
thuc ti ch ty b chn, chp 1 phim thng xem kt qu trc. Sau 5
pht chp li phim th hai, nu thuc cn quang vn dng v tr nh phim
u th chc chn l v tr ty b chn. Sau chp thm phim nghing.
4. Mt s hnh nh bnh l.
4.1. Hnh nh u ty:
+ U gy tc hon ton khoang di nhn: thuc cn quang dng cc di
ca u c hnh chn chn hoc hnh cng cua. Hnh nh ny hay gp
trong u mng ty hoc u r thn kinh di mng cng.
Thuc dng cc di ca u c hnh rng lc, nhiu kh nng l u ngoi
mng cng ty.
+ U khng gy tc hon ton khoang di nhn: c hnh khuyt ct thuc
cn quang ch c u.
4.2. Hnh nh vim mng nhn ty:
Vim mng nhn ty (arachnoiditis) khng gy chn p ty nh u nhng
cng gy cn tr lu thng DNT. Do trn phim c th thy tc hon ton
hoc khng hon ton ct thuc cn quang. Hnh nh tng i c trng ca
vim mng nhn ty l thuc cn quang to thnh hnh di chy dc theo chiu
ca ty nh mt chui ht cm.
4.3. Hnh nh thot v a m:
Do nhn nhy a m li vo ng sng gy p mng cng bao cng,
trn phim thy hnh khuyt lm ct thuc ngang vi khoang gian t sng. C
th thy hnh nh chn tc hon ton hoc khng hon ton ct thuc (thot
v trung tm) hoc thot v lch bn thy hnh nh cc r thn kinh khng
ngm thuc.
Cc tai bin v bin chng sau chp ty cn quang khng c g c bit.
Mt s t BN sau chp c au u ko di mt vi ngy ri khi. Bnh vin
103 chp ty cn quang cho hng nghn trng hp u an ton v khng c
bin chng g c bit.
Chp ng mch no

Bi Quang Tuyn

Egas Monis l ngi u tin tin hnh chp ng mch no (MN) cn

quang vo nm 1927 chn on u no. Lohr (1936) p dng chp MN
chn on mu t ni s (MTNS) do chn thng.
Trc y thuc cn quang rt c v hay gy tai bin nn chp MN c
tin hnh khng nhiu. Mi sau ny, nh cng ngh pht trin, thuc cn
quang khng gy c, t gy tai bin nn chp MN c p dng rng ri
hn.
Thuc cn quang chp MN hay dng trong lm sng l visotrast; conray;
omnipaque; telebrix.
Chp MN gm c:
+ Chp ng mch cnh trong.
+ Chp ng mch t sng.
1. Chp ng mch cnh trong.
Chp ng mch (M) cnh trong s cho thy ng mch no trc v ng
mch no gia l cc nhnh chnh ca M cnh trong cung cp mu cho 2/3 trc
ca bn cu i no.
1.1. Ch nh:
+ Nghi ng u no, p xe no.
+ Nghi ng d dng mch mu no: phnh ng mch no; u mch mu no;
thng ng mch cnh trong - xoang hang.
+ Chn on mu t ni s cp tnh do chn thng; mu t t pht do tai
bin mch mu no; mu t ni s mn tnh.
1.2. Chng ch nh:
+ Bnh nhn trong tnh trng qu nng.
+ Bnh nhn c huyt p cao km theo c cn au tht ngc.
+ Bnh nhn suy gan, suy tim hoc suy thn giai on cui.
+ Vng nh chc b nhim trng, vim ty rng.
1.3. K thut:
C 2 k thut: chc kim trc tip vo ng mch cnh gc v thng ng
mch.
1.3.1. Chc kim trc tip:
+ Dng c:
- Kim di 7 - 10 cm, ng knh 1mm; u kim vt c thng nng
(mandrin).
- Bm tim thy tinh 20 ml.
 - Khay men c tri sng v trng; sng l; bng bng gc v trng; kim; bm
tim gy t.
+ T th bnh nhn v k thut tin hnh chc ng mch:
- Bnh nhn nm nga, k gi di vai
sao cho u n v pha sau (hnh 1).
- Trn b xng c 3 cm, pha trong c
c n chm, tin hnh gy t lidocain
2%. Gy t trong da, di da, hai bn v
pha sau ng mch.
- Tay tri xc nh v tr ng mch
bng ngn tr v gia, c nh ng mch
khi chc kim khng b trt kim trn Hnh 1:
thnh ng mch. Chc
- Tay phi chc kim qua da. Khi kim qua da
nm trn thnh ngoi ca ng mch cnh
gc th chc tht nhanh v mnh cho kim chp
xuyn qua c thnh trc v sau ca ng
ng
mch; hng mi kim chch 450 so vi M.
- Rt thng kim v rt kim t t. Khi kim rt ra khi thnh sau v nm trong
lng M, mu s pht ra thnh tia. Lp thng kim tr li v tin hnh lun kim
sao cho kim lun vo ng mch cnh trong. Khi lun hng mi kim chch ra
sau v ra ngoi.
- Rt thng kim m thy mu pht thnh tia l chc chn kim nm
trong lng M cnh trong.
- C nh kim v bm thuc cn quang. Mi ln bm 8 - 10 ml thuc cn
quang. C th bm 2 - 3 ln, mi ln cch nhau 5 - 10 pht. Sau mi ln bm
thuc, tin hnh chp phim.
- Sau khi chp xong, rt kim v p tay ln ch chc 5 - 10 pht trnh
mu chy ra to thnh khi mu t vng c, bng v trng. Bnh nhn v
bung cn c theo di ti ch v ton thn.
1.3.2. Thng ng mch:
Seldinger tin hnh thng ng mch u tin vo nm 1953 v c gi l
k thut Seldinger. K thut nh sau:
+ Chc kim vo ng mch i.
+ Lun ng thng (catheter) c un cong u ln quai M ch ri
qut u ng thng ln ng mch cnh gc (nu bn tri), hoc vo ng
mch cnh tay u (nu bn phi). Khi chc chn u ng catheter nm
trong lng ng mch ni trn th bm thuc cn quang v chp phim (c mn
hnh theo di ng i ca ng thng).
 + c kt qu: cn c vo s thay i v tr cc ng mch ngi ta c th
xc nh c v tr khi mu t hoc khi bnh l.
1.3.3. Chp ng mch s ho xo nn:
Chp M no trn my chp s ho xo nn (digital subtraction angiography)
cho php xc nh tn thng mch mu c 3 th ng mch, tnh mch v
mao mch. Cho bit v tr v hnh thi tn thng mch mu, c bit trong
cc d dng mch mu no. Do tc dng xo xng nn gip ngi ta xc nh r
cc tn thng mch mu mt cch y hn.
K thut tin hnh theo phng php Seldinger, chc kim vo ng mch
i, lun catheter, bm thuc cn quang bng tay hoc bng my ri tin hnh
chp chn lc ng mch cnh trong. Hin nay k thut ny c p dng ph
bin thay cho k thut chp ng mch no thng thng.
2. Chp ng mch t sng.
Chp M t sng cn quang s cho thy ng mch thn nn v 2 ng
mch no sau cung cp mu cho thy chm v tiu no.
2.1. Ch nh:
+ Chn on u no hoc p xe h s sau (tiu no, gc cu tiu no).
+ Mu t h s sau do chn thng hoc tai bin mch mu no.
+ Chn p ng mch t sng do thoi ho ct sng to thnh gai xng
gy thiu nng ng mch t sng-thn nn.
2.2. Chng ch nh:
+ Bnh nhn c huyt p cao km theo c cn au tht ngc.
+ Bnh nhn b suy thn, suy gan giai on cui.
+ Tnh trng chung bnh nhn qu nng, tui qu cao, yu.
2.3. K thut:
C 2 k thut chp ng mch t sng: chc kim trc tip qua da vo
ng mch t sng v thng M theo phng php Seldinger.
+ Chc kim trc tip vo ng mch t sng ngang t sng c CIV,CV
v CVI (hoc c th chc kim vo ng mch di n).
+ Thng ng mch: theo k thut Seldinger nh trnh by trn. K thut
ny c p dng rmg ri hn. Lun catheter ln quai ng mch ch ri qut
vo ng mch di n, a ln ng mch t sng. Khi u catheter nm
trong ng mch t sng th tin hnh bm 8 - 10 ml thuc cn quang v
chp phim.
3. Tai bin v bin chng.
Ni chung chp MN t c tai bin v bin chng, tuy nhin c th gp:
+ Phn ng vi thuc cn quang: mc nh, bnh nhn bun nn v nn;
mt tm ti, kh th, mch nhanh, ni mn nga ngoi da. Mc nng c
th try tim mch, ngng h hp, ngng tim v t vong.
 + Ph no tin trin t t sau mt vi gi chp MN. Bnh nhn au u
bun nn, nn, vt v, tri gic xu dn ri i vo hn m.
+ ng kinh; lit 1/2 ngi.
+ Ti ch: au, c th c mu t vng chc kim gy chn p kh qun.
phng tai bin, nn th phn ng thuc cn quang (tim 1 ml thuc
cn quang vo tnh mch trc khi chp MN). Tim khng histamin trc khi
bm thuc cn quang.
Chp ct lp vi tnh

Bi quang tuyn
1. i cng.
1.1. Nhng lp ct chun:
My chp ct lp vi tnh (CLVT) do Hounsfield nh vt l ngi Anh pht
minh nm 1973, nhn gii thng Nobel nm 1979.
Chp CLVT l phng php chn on hin i cho php chn on sm
cc tn thng s v no do chn thng v nhiu bnh l khc h thn
kinh trung ng.
Bnh thng ct 9 - 10 lp lin tip nhau, mi lp dy 10 mm. Lp ct u tin
song song vi ng chun ni gia ui mt v l tai (ng chun OM) (hnh
1).
1.2. Ch s hp thu tia X
ca t chc:
Bnh thng s hp thu tia X
(Rontgen) ca xng s, no lnh v t
chc bnh l l khc nhau nn ngi ta
c th phn bit c hnh nh t
chc trn phim chp CLVT.
Ch s hp thu tia X c tnh theo
n v Hounsfield. Ngi ta qui nh
hp thu tia X ca nc bng khng
Hnh 1: O. Nu t chc no c hp thu tia
Nhng lp X thp hn nc c coi l gi tr m (-
ct chun ) v t chc no c hp thu tia X ln
qua s v hn nc c coi l gi tr dng (+).
no. Ch s hp thu tia X ca xng s v cc
t chc khc c tr s khc nhau dao
ng t - 1000 n + 1000 n v Hounsfield (HU).
Thng thng c 7 cu trc nhn r trn nh CLVT vi hp thu tia X khc
nhau, v d:
Khng kh - 1000 HU.
M - 50 HU.
Dch no ty (DNT) + 4 n + 14 HU.
 Cht xm ca no + 32 n + 40 HU.
Cht trng ca no + 28 n + 32 HU.
Xng s + 1000 HU.
T chc vi ha + 60 HU.
1.3. Cch c phim CLVT s no:
Khi c phim CLVT cn ch nhng thay i bnh l sau:
+ S thay i hp thu tia X ca m no bnh l so vi m no lnh.
Vng bnh l s c hp thu tia X khc nhau, c th:
- Gim m (hypodense) hay cn gi l gim t trng so vi m no
lnh.
- Tng m (hyperdense) hay cn gi l tng t trng.
- C cng m (isodense) hay cn gi l ng t trng vi m no.
+ S thay i hnh dng no tht:
- Hai no tht bn gin to gp trong trng hp u no hoc vim dnh gy
chn tc cng Sylvius.
- Cc no tht bn thu nh u hai bn hoc b xo khng nhn thy, gp
trong ph no do chn thng; ph no sau phu thut.
- Cc no tht mo m, chn y khng u nhau, thng do u hoc khi
bnh l khc.
+ S dch chuyn ng gia:
ng gia c to nn do vch lin no tht, no tht III v lim i no. S
dch chuyn ng gia sang bn l do khi chon ch nh u, p xe, mu t, ph
no mt bn do gip no. S dch chuyn ng gia cng ln tin lng cng
nng.
2. Hnh nh CLVT trong chn thng s no.
2.1. Mu t ngoi mng cng (NMC):
Mu t ni s (MTNS) ng bnh, cn mi, c h s hp thu tia X cao,
t + 64 n + 88 HU. Trn nh CLVT s thy vng tng t trng (hyperdense),
cho hnh nh sng v d dng phn bit vi t chc xung quanh. iu ny
c gii thch l do trong bc mu t c cha nhiu ion canxi c trng lng
nguyn t cao (Ambrose, 1973).
+ Hnh nh c trng ca mu t NMC trn nh CLVT l hnh thu knh
hai mt li (biconvex). Nhng i khi mu t NMC c hnh thu knh mt
mt li (mt li pha xng s v mt mt phng v pha no). Chiu
dy ca mu t NMC c khi dy ti 4 - 5 cm.
+ No tht bn b chn y nn thu nh pha c mu t v y sang bn
gy dch chuyn ng gia.
+ C th thy gip no ngay di mu t, biu hin trn nh l vng ph
no, t trng m no gim, cho hnh ti.
2.2. Mu t di mng cng (DMC):
Mu t di mng cng c chia ra: cp tnh, bn cp tnh v mn tnh.
 2.2.1. Mu t di mng cng cp tnh:
L bc mu t hnh thnh 3 ngy u sau chn thng.
+ Trn nh CLVT, mu t DMC c hnh lim, tng t trng lan rng b
mt ca bn cu i no, c th chy di t trn-thi dng-nh. Chiu dy
ca mu t khng ln nh chiu dy ca mu t NMC.
+ Mu t DMC thng bao gi cng km theo gip no ngay di mu t, do
vy th tch khi chon ch tng, bao gm c mu t, no gip v ph no... gy
chn p no v dch chuyn ng gia. S dch chuyn ng gia c
ngha tin lng i vi ngi bnh, c th:
Mc I: dch chuyn 1 - 4 mm, tnh trng bnh nhn tng i nng.
Mc II: dch chuyn 4 - 8mm, tnh trng bnh nhn nng.
Mc III: dch chuyn 9 - 13mm, tnh trng bnh nhn rt nng
Mc IV: dch chuyn trn 13 mm, tnh trng bnh nhn cc k nng,
c kh nng t vong.
2.2.2. Mu t DMC bn cp:
L bc mu t hnh thnh t ngy th 4 n ngy th 14 sau chn thng (2
tun sau chn thng). giai on ny c s thay i mt trong bc mu
t, c th:
+ Trn nh CLVT thy mu t c mt khng thun nht, c ch tng,
c ch gim mt l do mu bt u dch ho v tiu i.
+ Hnh nh ph quanh mu t, biu hin l vng c t trng gim hn so vi
m no lnh.
+ Dch chuyn ng gia.
2.2.3. Mu t DMC mn tnh:
L bc mu t xut hin t ngy th 15 sau chn thng tr i (theo mt s
ti liu khc tnh t ngy th 21 tr i).
tun th 3 sau chn thng din ra qu trnh dch ho trong bc mu t,
l qu trnh phn hy hng cu v to thnh bao x. Trn nh CLVT, qu
trnh ny c biu hin bng s gim t trng (hypodense) trong bc mu t.
Bc mu t long dn v t trng mu t dn dn bng t trng ca m no,
ngha l ng t trng (isodense). Nhiu khi rt kh phn bit ranh gii
mu t mn tnh. nhn r hn, ngi ta phi tim thuc cn quang vo tnh
mch, khi s nhn r bao x ca bc mu t v d dng phn bit mu t
vi m no lnh.
Hnh nh mu t DMC mn tnh trn CLVT c th biu hin nh sau:
+ T trng ca mu t c th gp:
- Gim t trng ng u so vi m no: chng t mu t dch ho hon
ton.
- ng t trng so vi m no lnh.
 - T trng hn hp, biu hin: trong bc mu t c ch gim t trng, c ch
tng t trng v c ch ng t trng vi m no lnh; iu chng t mu
t ang dch ho, cha dch ho hon ton.
+ Khi chon ch gy dch chuyn ng gia.
+ No tht b chn y, mo m khng ng u hai bn.
+ Nhn r bao x ca bc mu t sau khi tim cn quang.
2.3. Mu t trong no:
+ Trn nh CLVT thy mt vng tng t trng thun nht, l mu t
nm trong cht no. mu t thng c ranh gii r vi t chc xung quanh v
thng khng c hoc c km theo gip no nhng khng nng.
+ Mu t trong no do chn thng, theo ti liu nc ngoi th a s c
iu tr ni khoa; phu thut ch tin hnh 39 - 52% cc trng hp.
2.4. Mu t trong no tht:
+ Trn nh CLVT, d dng phn bit mu t trong no tht tin pht hoc
th pht.
- Tin pht: l tn thng m ri mng mch trong no tht v to nn mu
t mt bn hoc c 2 no tht bn.
- Th pht: l mu t nm trong cht no st vi thnh no tht v chc
thng thnh no tht to nn mu t: mt phn nm trong no tht v mt
phn nm trong cht no.
+ Thng mu t trong no tht hay gy tc ng dn DNT (do tc l
Monro hoc cng Sylvius) gy nn trn dch no cp v trn nh CLVT nhn
thy 2 no tht bn gin to.
+ Tin lng i vi mu t trong no tht tin pht hoc th pht l cc k
nng, c t l t vong cao.
2.5. Gip no:
Trn nh CLVT c th thy cc hnh thi gip no nh sau:
+ gip no ngay di ch xng s b chn thng hoc pha i bn
vi lc chn thng (c ch i bn - contre coup).
+ gip no l vng ph lan rng c t trng gim so vi m no lnh, trn
nh CLVT thy hnh ti. C th thy vng ph no lan rng c xen k nhng
im tng t trng, l nhng chy mu nh, ngha l gip no chy mu
(gip no l chnh).
+ Ph no s gy chon ch, gy dch chuyn ng gia v bin dng no
tht.
2.6. Ph no:
Trn nh CLVT c th thy ph no cc b v ph no ton th.
+ Ph no cc b: l mt vng gim t trng, khng c ranh gii r rt. Ph no
cc b do chn thng l kt qu ca gip no, t nhiu gy nn tnh trng
chon ch v lm dch chuyn ng gia.
 + Ph no ton th: biu hin l s gim t trng ca ton b m no ni
chung; h thng no tht thu nh kch thc, thm ch cc no tht b xo
khng nhn thy; khoang di nhn b mt, khng nhn thy cc cun no v
khng cn ranh gii gia cht trng v cht xm v no; khng c dch chuyn
ng gia l do ph no ng u 2 bn.
2.7. T nc di mng cng (DMC):
c trng ca t nc DMC trn nh CLVT l khoang di nhn ca vng t
nc gin rng, khong cch gia b mt ca no vi mt trong xng s cch xa
nhau, biu hin trn CLVT l vng thun nht v mt v c t trng nh t
trng ca DNT.
T nc DMC c khi c 2 bn cu i no v hay gp vng trn, trn-thi
dng.
2.8. Tn thng si trc lan ta:
Tn thng si trc lan ta (diffuse axonal injury) do chn thng hay gp
tr em v ngi tr. Do c ch chn thng tng tc v gim tc t ngt gy
t rch cc si trc thn kinh ca cht trng bn cu i no. Trn CLVT
biu hin tn thng si trc lan ta nh sau:
+ Tng th tch bn cu i no hu qu ca ph no. Hp no tht bn v
no tht III, mt khoang di nhn.
+ C nhng tng t trng do chy mu nh (kch thc mt vi mm n 10
mm). Cc chy mu ny i khi khu tr th trai, hch di v no hoc cu
no.
+ Nu chp CLVT li sau 2 - 3 tun chn thng s thy ht du hiu ca
ph no; nhng chy mu trc y bin mt, thay vo l nhng gim
t trng.
+ V phng din lm sng nhn thy BN hn m su ngay sau chn
thng v ko di vi cc biu hin ri lon chc nng h hp, tim mch, chc
nng thc vt. Biu hin i sng thc vt ko di. Nu sng st s li di
chng nng n nh ri lon tm thn, nhng thiu ht thn kinh trm trng
v vn ng, tri gic hiu bit, ng kinh...
3. Hnh nh CLVT ca p xe no.
Nguyn nhn p xe no c th do vt thng s no cn d vt kim kh; do
chn thng s no; do vim tai xng chm; inh ru (mn nht quanh
ming) hoc mn nht u; hu bi vng c-gy. C th do vim nhim
t xa nh vim bng quang, vim b thn m; ct ty vim; nhim khun
huyt...
Hnh nh c trng i vi p xe no trn CLVT l du hiu vng trn
vnh xe. Vng trn chnh l v bao p xe, l t chc x c t trng cao hn
t trng ca m no lnh nn nhn r m khng phi tim thuc cn quang.
Nhng nu bao p xe mi c hnh thnh s nhn khng r trn CLVT, v th
phn bit ranh gii bao p xe vi t chc no ngi ta phi tim cn quang
tnh mch, vng trn bao p xe ngm thuc cn quang nhn thy r hn.
 Bn trong vng trn l dch m, c t trng thp hn so vi m no lnh.
C th thy vng ph quanh ra ca vng trn.
Du hiu chon ch ca bc p xe l y ng gia, thay i hnh
dng no tht.
Vng trn s thu nh li v mt i nu c iu tr bng khng sinh
mnh v sm ngay t u. Cn phn bit vng trn ca p xe vi vng trn c
th gp trong u no.
4. Hnh nh CLVT trong chn on u no.
Trn CLVT cho bit v tr, kch thc v tnh cht t chc hc ca u no.
4.1. Hnh nh trc tip:
S hp thu tia X ca cc loi u no l khc nhau. Theo Kazner (1981) chia 4
nhm u no c hp thu tia X nh sau:
+ Cc u no c hp thu tia X cao: trn CLVT khng tim cn quang (nh nativ)
cng d dng phn bit c vi t chc no xung quanh, l cc u mng no
(meningioma); u tuyn yn...
+ Cc u c hp thu tia X thp hn so vi m no lnh (u c t trng thp):
hay gp trong cc u t bo thn kinh m hnh sao (astrocytoma); u nguyn
bo mch mu; u hn hp...
+ cc u c hp thu tia X tng t nh t chc no, ngha l u c ng t
trng (isodense) vi m no, gp trong u dy thn kinh s VIII; u di cn t ni
khc n.
+ Cc u no c hp thu tia X hn hp, ngha l trong u c ch tng, c ch
gim v thm ch c ch ng t trng vi m no. Cc u ny thng c vng
ph xung quanh, c th pht hin d dng trn CLVT v hay gp trong u
nguyn bo thn kinh m (glioblastoma); u t bo thn kinh m t nhnh
(oligodendroglioma). U nguyn bo thn kinh m l loi u c tnh IV.
i vi u no c hp thu tia X thp, xc nh ranh gii u, ngi ta
thng tim thuc cn quang tnh mch. Sau 5 - 10 pht cht cn quang s tp
trung t chc u v nh vy c th nhn r ranh gii ca u vi t chc no.
4.2. Hnh nh gin tip:
Trn CLVT, hnh nh gin tip ca u no l khi chon ch gy dch
chuyn ng gia; lm bin dng no tht v ph quanh u. Theo Kazner
(1981) chia 3 mc ph quanh u:
- Ph mc I: ra ph quanh u ti 2 cm.
- Ph mc II: ra ph quanh u trn 2 cm, c th chim ti na bn cu i no.
- Ph mc III: vng ph lan rng ti na bn cu i no, thm ch ph c
sang bn cu i no i bn.
 4.3. Chn on t chc hc ca u no trn nh
CLVT:
Kh nng chn on t chc hc trn CLVT l kh cao, v d: i vi u
mng no xc nh ng trn CLVT l 84%; u nguyn bo thn kinh m
(glioblastoma) l 85%; u c tnh di cn l 80% v u tuyn yn trn 90%.
Di y l bng ni v m hp thu tia X ca t chc bnh thng v
t chc bnh l (nh nativ - khng tim thuc cn quang, theo Kaznerr, 1981).
hp thu tia X tnh theo n v Hounsfield (HU).
M no v t chc n v Hounsfield (HU)
Xng + 1000 HU.
Vi ho + 60 HU
Cht xm v cht trng ca no + 28 n + 40.
Dch no ty + 4 n + 14.
Mu t ni s (ng bnh, cn mi) + 64 n + 88.
Mu chy c + 30 n + 60.
U t bo thn kinh m + 18 n + 40.
U nguyn bo ty. + 36 n + 56.
U dy thn kinh s VIII. + 28 n + 40.
U tuyn yn. + 35 n + 50.
U m. - 120 n - 40.
U hn hp. - 120 n + 10.
U di cn. + 22 n + 50.
U nang. + 6 n + 22.
t qu chy mu cn mi. + 22 n + 26.
t qu chy mu c. + 10 n + 16.
V ca bao p xe. + 28 n + 34.
M trong bc p xe. + 19 n + 23.
T chc m trong hc mt. - 90 n - 70.
Khng kh. - 1000 HU.
Phng php chn on bng cng hng t

Bi Quang Tuyn

Felix Bloch v Purcell E. l ngi pht minh ra cng hng t (CHT) vo nm

1945-1946.
Jasper Jackson (1967) tin hnh th nghim CHT trn ng vt sng.
Nm 1972, Lauterbur P. to c nh CHT t mt mu nc Stony Brook
(M).
Mi ti nm 1978-1979, hnh nh CHT mi c chnh thc a vo s dng
chn on khi bnh l trong no. Ti nay phng php chn on bng
CHT (Magnetic Resonance Imaging - MRI) ngy cng c ng dng rng ri.
1. Cc bc tin hnh to nh cng hng t.
1.1. t ngi bnh vo mt t trng mnh:
T trng l mt khi nam chm c khong trng gia t bnh
nhn (BN) nm vo . Nam chm ca my c t lc t 0,2 T n 2 T (1T =
1Tesla = 10.000 Gauss).
Di tc dng ca t trng, cc proton (ht nhn nguyn t) trong c th
ngi bnh s quay cng hng vi t trng bn ngoi.
1.2. Pht sng v tuyn in (sng radio):
Sau khi t ngi bnh nm vo v tr, ngi ta cho pht sng radio.
y c s khc bit gia chp ct lp vi tnh (CLVT) v chp CHT. Trong
chp CLVT, to nh ngi ta dng nng lng pht ra l chm tia X (Rontgen);
cn to nh CHT ngi ta li dng nng lng pht ra l sng radio nhm cung
cp nng lng cho cc proton.
1.3. Tt sng radio:
Khi tt sng radio, cc proton trong c th mt nng lng dn dn tr v
trng thi ban u nh khi cha c pht sng radio, ng thi chng pht ra tn
hiu.
Ngi ta gi hin tng ny l thi gian th dui. Thi gian th dui (relaxation
times) gm:
+ Th dui dc (longitudial relaxation) hay cn gi l thi gian T2.
+ Th dui ngang (transversal relaxation) hay cn gi l thi gian T1.
1.4. To nh cng hng t:
Nh h thng my vi tnh m cc tn hiu pht ra khi tt sng radio ngi
ta to c nh CHT. S to nh CHT l nh thi gian th dui T1 v T2. Mi loi
m t chc trong c th c thi gian T1v T2 khc nhau v s khc nhau trn
nh T1 v T2 l s khc nhau v cng tn hiu. nh c to ra l T1W
v T2W.
2. Hnh nh t chc bnh thng trn nh CHT.
2.1. T chc no v dch no ty (DNT):
+ Cht xm v cht trng ca no trn CHT th hin r hn trn nh CLVT.
Trn CHT, cht xm biu hin sm hn cht trng.
+ Dch no ty: trn nh T1W, DNT cho cng tn hiu thp v biu
hin hnh ti. Trn nh T2W th ngc li, DNT c cng tn hiu cao v
cho hnh sng trng.
2.2. C v da u:
S tng phn trn T1W gia c, da u v t chc bnh thng l rt ln,
v th trn nh T1W cc t chc ny nhn thy rt r.
 2.3. Xng c:
V xng l t chc cha rt t nc v ch chim 23% proton/cm3, t
hn rt nhiu so vi ty xng. Do vy trn nh T1W cng nh trn nh T2W v
xng u cho cng tn hiu thp v biu hin l hnh ti, khng nhn
thy trn CHT.
Tri li, ty xng cho cng tn hiu cao, v th trn nh T1W v c
trn T2W nhn thy tu xng c hnh sng.
2.4. M v khng kh:
+ T chc m hc mt, ngoi mng cng ty hoc m di da v u m cho
cng tn hiu cao trn nh T1W v c trn T2W, nn c hnh sng trng.
+ Khng kh ( trong cc xoang trn cc hang chm...) cho tn hiu thp,
th hin trn nh T1W v T2W l hnh ti.
2.5. Mch mu no:
K thut to nh bng CHT c th thy c ton b h thng ng mach
no (ng mch cnh trong cng nh ng mch t sng thn nn), cho hnh
nh r nt nh trong k thut chp ng mch no thng thng m khng phi
bm thuc cn quang vo ng mch. Nh vy c th pht hin v tr cc
phnh mch mu no; thng ng mch cnh trong - xoang hang; nhng d dng
ng-tnh mch no (AVM).
Tm li:
- nh T1W: cho hnh nh v cu trc gii phu kh y v tht hn
i vi cu trc no cng nh ct sng v ty sng.
- V xng, DNT v khng kh trn nh T1W cho cng tn hiu thp
nn trn nh l hnh ti.
- Ty xng (xng xp), t chc m cho cng tn hiu cao nn c hnh
sng, c bit l m cho hnh sng trng.
- nh T2W: cho bit s khc bit v hm lng nc trong t chc c
th. S khc bit v hm lng nc cng ln th trn T2W cho cng tn
hiu cao, c hnh sng. Nhng nu hm lng nc khc nhau khng ng k
th cng tn hiu khc bit cng khng ng k, nn vic chn on tn
thng nhiu khi cng gp kh khn.
- Trn nh T2W, t chc cho cng tn hiu cao v c hnh sng trng
l DNT; nhn nhy a m ngi tr; m m.
- Trn nh T2W, t chc cho cng tn hiu thp v c hnh ti l
khng kh.
3. Hnh nh bnh l trn CHT.
3.1. U no:
+ Cc u no lnh tnh hay c tnh u nhn r trn nh CHT. Hu ht cc
u no trn nh CLVT v trn nh CHT cho kt qu nh nhau.
+ Vng ph quanh u trn nh T2W biu hin tng cng tn hiu so vi
xung quanh nn c hnh sng trng v nhn r hn so vi nh CLVT.
+ Trn nh CHT c th pht hin c nhng u c t trng thp hn so vi
m no m trn nh CLVT khng pht hin c.
3.2. Trn dch no (hydrocephalus):
Cng hng t c th ghi c nh theo cc bnh din khc nhau nh theo
mt ct dc (sagittal); theo mt ct ngang qua trn (coronal; frontal) v theo
trc ca no (axial); nn ton b h thng no tht bn, no tht III, cng Sylvius
v h thng no tht IV... nhn r hn nhiu so vi CLVT.
3.3. Hnh nh u ty sng:
Nhng u ty c cao st vi no, trn nh CLVT khng cho bit mt cch r
rt ranh gii ca u do nhng hnh gi ca xng (artifacts) v cu trc xung
quanh i vi u c ng t trng so vi ty. Trn nh CHT th ngc li, chng
cho bit r cu trc bn trong ca u (rn hay lng), kch thc, v tr ca u v
lin quan ca u vi t chc xung quanh.
+ U mng ty (meningioma):
Trn nh T1W u c gii hn tng i r, u c ng cng tn hiu so vi
ty sng. Trn nh T2W u mng ty c cng tn hiu thp nn nhn r u
trn nn ca DNT c cng tn hiu cao.
+ U r thn kinh (neurinoma):
Trn nh T1W u c ng cng hoc hi tng nh cng tn hiu so
vi ty. Cu trc bn trong ca u l tng i thun nht v u c ranh gii r.
Trn nh T2W, u c c trng l tng nh cng tn hiu, i khi tng nh
DNT nu trong u cha dch nhiu hn l t chc u c.
+ U ni ty (u trong cht ty):
U ni ty thng pht sinh t t bo thn kinh m. V phng din t
chc hc c 2 loi hay gp nht l u t bo hnh sao (astrocytoma) v u t
bo ng ni ty (ependymoma).
Cc u khc t gp hn nh u nguyn bo xp; u nguyn bo mch mu
(heamangioblastoma); u t bo Schwann trong ty...
c im u ni ty l u thng ko di 4 - 5 on ty v mt trong u
khng u, l phn chc ca u v phn nang cha dch, do vy:
- Trn nh T1W: u c ng cng tn hiu hoc gim cng tn
hiu so vi ty lnh. Trn nh T1W kh phn bit c phn c v phn
nang ca u. Vng c u ty dy ln, tng th tch, ng knh ty ln hn. ty
c c khi ng knh ty ti 20 - 22 mm (ty c c ng knh trung bnh 7 -
8 mm).
- Trn nh T2W: phn c cng nh phn nang ca u cho cng tn
hiu cao hoc tng nh cng tn hiu so vi DNT. i khi phn nang ca
u cho cng tn hiu thp v ngi ta cho rng l do chy mu trong u.
Ngay c trn nh T1W cng nh trn nh T2W nhiu khi rt kh xc nh
ranh gii ch thc ca u vi t chc xung quanh, khi ngi ta phi tim
thuc cn quang t gadolinium (GADO - Gd). Gadolinium l cht cn t
(paramagnetism) rt c, nn c gn vi cht diethylene triamine pentaacetic
acid (Gd-DTPA), to nn cht khng c, dng lm cht cn quang t lm
r hn vng nh khm xt.
3.4. Thot v a m:
Trn nh T1W a m gian t sng, ty sng v phn xp ca thn t
sng c cng cng tn hiu thp nh nhau.
Trn nh T2W: ngi tr nhn nhy (nucleus pulposus) v lp trong ca
vng si (annulus fibrosus) cha nhiu nc nn c cng tn hiu cao v trn
nh cho hnh sng trng. Nhng ngi gi, c bit ngi b thoi ha a
m th nhn nhy thoi ho, mt nc nn cho cng tn hiu thp, trn
nh cho hnh ti.
Trn nh T1W v T2W, v xng ca thn t sng v b phn dy chng
ca ct sng khng nhn r trn nh CHT. Trn CHT cho thy r hnh thot v
a m Schmorl, tc l nhn nhy a m chui vo phn xp ca thn
t sng m trn nh CLVT v chp ty cn quang khng nhn thy c.
4. Ch nh v chng ch nh chp cng hng t.
4.1. Ch nh:
Chp CHT c ch nh trong chn on bnh l no, ct sng v ty
sng; bnh l xng khp; lng ngc; trong chn thng ct sng-ty sng cho
thy y cc tn thng xng ct sng v ty.
Trong cp cu chn thng s no th chp CHT l khng cn thit v thi
gian to nh CHT mt 45 - 50 pht s nh hng n thi gian cp cu cho ngi
bnh.
4.2. Chng ch nh chp CHT:
+ Cn d vt kim kh trong c th.
+ Cn cc phng tin kt xng bng kim loi trong c th nh cc clp
cm mu trong no; cc np vt kim loi trong kt xng chi th v ct
sng; my to nhp tim; rng gi; chm xng i bng kim loi...
+ Bnh nhn qu s hi, tm thn kch ng, hn m phi th my..
Chng 2

Chn thng h thn kinh

CHn thng s no

Bi Quang Tuyn

1. i cng.
1.1. Phn loi:
Chn thng s no (CTSN) l cp cu ngoi khoa thng gp hng ngy;
nguyn nhn ch yu l do tai nn giao thng, lao ng v tai nn trong sinh
hot.
Petit J.L. (1774) chia chn thng s no lm 3 th: chn ng no, ng
gip no v mu t ni s (MTNS).
Nhiu nh nghin cu Hnh thi hc lm sng v Phu thut thn kinh
c gng a ra bng phn loi CTSN mt cch chi tit hn, y hn v c
tnh khoa hc hn nhng trn c bn vn da theo phn loi kinh in ni trn.
1.2. C ch bnh sinh chn thng s no:
C nhiu yu t lin quan ti c ch bnh sinh ca CTSN nh yu t c
hc, yu t ng lc hc ca dch no ty (DNT), yu t huyt qun, yu t
thn kinh th dch v yu t xung ng thn kinh.
+ Trc ht phi c mt lc chn thng vo u mnh mi c th gy
tn thng xng s v no. Do vy tc nhn c hc c coi l yu t c bn,
l yu t khi ng cho cc qu trnh bnh l no xy ra.
+ Trn c s tn thng no tin pht (gip no hoc mu t) xy ra ngay sau
chn thng s dn ti tn thng no th pht l do hu qu ca ri lon vn
mch, ri lon thn kinh th dch... dn ti ph no v lm cho p lc ni s
(ALNS) tng cao. Hu qu tng ALNS dn ti tt kt no. Tn thng no tin
pht v th pht lm cho tnh trng bnh ngy mt trm trng hn.
+ Ngi ta quan tm ti 2 c ch chn thng: u ng yn v u
chuyn ng.
- u ng yn: trong trng hp b nh bng vt cng vo u (b nm
, p gy...), tn thng xng s v no (gip no hoc mu t...) thng
ngay di ch b nh v tn thng thng khng phc tp lm. Ngoi tr
trng hp b nh vo vng chm gy BN c th t vong ngay sau khi b
thng.
- u chuyn ng: trong trng hp b ng do tai nn giao thng hoc ng
t trn cao xung... tn thng xng s v no thng nng v phc tp.
 Khi ng, u chuyn ng tng tc (accleration), khi u chm xung
ng b chn ng li v gim tc t ngt (dceleration) nn hp s thay
i v bin dng tc th dn ti v xng s.
Khi tng tc v gim tc t ngt lm cho no trong hp s trt trn cc g
xng ng thi xoay, xon vn, ging x gy tn thng no nng n v
phc tp nh gip no ln, gip thn no, t rch cc mch mu...
Trong chn thng m u chuyn ng hay gp tn thng i bn
(contre coup), v d: chn thng vng nh u bn tri, ngay di ch chn
thng c th gip no nhng vng nh bn phi c th c mu t.
2. c im tn thng xng s.
V xng s thng km theo gip no, mu t ni s.... Thc t c nhiu
trng hp tn thng no nng nhng xng s khng c tn thng.
2.1. V xng vm s:
Thng gp v rn (cn gi l nt s) v v ln xng vm s.
+ V rn xng vm s: hay gp tr em mc d lc chn thng khng
mnh v nhiu trng hp v rn xng s nhng khng c triu chng thn
kinh no.
Trc mt trng hp chn thng c v rn xng s, mc d khng c triu
chng thn kinh no, bnh nhn hon ton tnh to nhng vn phi theo di
st din bin ca tri gic v cc du hiu thn kinh khu tr pht hin sm
mu t ni s.
+ V ln xng vm s:
Xng vm s c th ln xung nh qu bng b lm (thng gp tr nh
di 1 tui) hoc mnh xng v ln su vo trong c th gy rch mng no
v t chc no...
2.2. V xng nn s:
Nn s c cu trc khng u, ch th xng c, ch th xng xp;
nn s c nhiu l cho mch mu v dy thn kinh i qua, do vy nn s
yu hn rt nhiu so vi vm s. V nn s hay gp v thng km theo gip
no.
+ V nn s trc:
- Chy mu ln dch no ty (DNT) ra mi.
- Du hiu knh dm biu hin 2 hc mt qung tm do mu chy
vo t chc lng lo sau nhn cu.
- C bit c trng hp mu t sau nhn cu gy li mt, au nhc trong
hc mt, th lc gim... cn pht hin sm v phu thut kp thi.
- C th gp tn thng dy thn kinh (TK) th gic trong ng th do v
xng gy nn, biu hin: th lc gim dn, teo dy TK th gic dn ti mt
hon ton th lc. Cn pht hin sm v phu thut m rng l th gic gii
phng chn p dy TK.
+ V nn s gia:
 - Chy mu v DNT ra tai.
- Bm tm pha sau v trn vnh tai.
- Lit dy TK VII ngoi vi.
+ V nn s sau (h s sau):
- Chn thng vng chm gy, thng l chn thng nng v rt nng.
- Ri lon nghim trng chc phn h hp v tim mch. Mc nng c
th ngng th ngay sau khi b chn thng.
- C th thy cn dui cng t chi.
- Mc nh hn, bnh nhn au u d di, u t th bt buc, c
cng khng quay c sang bn.
- Chp s qui c c th thy ng v xng lan xung l chm.
3. Triu chng lm sng.
3.1. Chn ng no (commotio cerebri):
Chn ng no (CN) c xem l th nh ca CTSN. V hnh thi hc
th CN khng c tn thng thc th cht no m ch c biu hin ri lon
hot ng chc nng ca no. Do no b rung ng mnh trong lc chn thng,
sng DNT p vo thnh no tht gy nn ri lon chc nng thn kinh ca h
li - v no v di v, biu hin nh sau:
+ Ri lon tri gic (RLTG): xy ra ngay sau chn thng vo u vi biu
hin t trng thi chong vng cho n mt thc ngn trong vi chc giy
n vi pht.
+ Qun ngc chiu: khi tnh li, bnh nhn qun cc s vic xy ra trc,
trong v sau khi b tai nn. Ty theo mc chn thng, qun ngc chiu c
th ko di mt vi gi, mt vi ngy thm ch hng tun sau chn thng.
+ Ri lon thn kinh thc vt (TKTV): biu hin au u, bun nn v
nn. Nn nhiu khi thay i t th nh cho bnh nhn ngi dy, hoc
chuyn bnh nhn t cng sang ging. Sc mt ti nht, v m hi, mch
nhanh...
Nhng triu chng au u, chng mt, bun nn, hi hp nh trng
ngc, ng hay m sng, git mnh, mt c lc ti nht, nhc 2 hc mt... thng
xut hin v ko di vi ngy ti mt vi tun.
+ Du hiu thn kinh khu tr (TKKT) khng c.
+ Sau 12 - 24 gi, nu chc ng sng tht lng thy mu sc DNT bnh
thng, p lc DNT bnh thng hoc hi tng nh.
3.2. Gip no (contusio cerebri):
V phng din gii phu th gip no l vng no b tn thng bm gip
nhng mng mm (pia) b mt no cn nguyn vn. Vng no gip c th
nng ngay b mt ca no (gip cht xm ca v no) nhng cng c th gip
su xung cht trng ca no v thm ch gip su ti thn no.
 3.2.1. Ri lon tri gic (RLTG):
Bnh nhn m ngay sau chn thng vo u. S phc hi tri gic ph
thuc vo mc ca gip no.
+ Nu gip no mc nh v va (gip nng v no): bnh nhn bt
tnh 5 - 10 pht ri tnh li, c th tip xc c nhng chm. Bnh nhn
kch thch, dy da, bun nn v nn. Tri gic tt dn ln sau vi ngy n 1 -
2 tun iu tr.
+ Nu gip no mc nng (gip su ti cht trng ca no): RLTG
biu hin qua cc giai on sau: bnh nhn m ngay sau chn thng ko di
10 - 20 pht sau tnh li trong trng thi dy da. Sau vi gi, do ph no tng ln,
tri gic bnh nhn c xu hng xu i. Nu iu tr tch cc th mt s
trng hp qua c giai on nguy kch, tri gic tt dn ln v hi phc sau 3 - 4
tun iu tr. Mt s khc nng hn, hn m su ko di v t vong. Nu
gip thn no, hn m su ngay t u sau chn thng v ko di cho ti khi
t vong.
3.2.2. Ri lon thn kinh thc vt (TKTV):
Biu hin ri lon h hp, tim mch v thn nhit:
+ Mc gip no nh: ri lon TKTV khng nng lm. Mch nhanh va
phi (95 - 100 ln/pht), huyt p ng mch (HAM) tng nh do ph no;
bnh nhn t th vi tn s 25 - 30 ln/pht, c th cha c n tc h hp ngoi
vi.
+ Mc gip no nng: biu hin ri lon TKTV nghim trng, th chm,
v ngng th; mch chm 60 - 50 ln/pht ngay sau chn thng, HAM tng
cao do nh hng thn no; nhit 390C - 40 0C, v m hi, rung c, c nhng
cn dui cng mt no, p lc ni s (ALNS) tng cao do ph no v sau no
mt b, mch nhanh, nh, yu, HAM tt thp, tin lng cc k nng.
3.2.3. Du hiu thn kinh khu tr:
+ Gin ng t cng bn vi gip no.
+ Bi yu 1/2 ngi i bn vi gip no.
+ Du hiu Babinski (+) mt bn.
+ Tn thng dy thn kinh VII trung ng; tn thng dy thn kinh s
III v VI vi biu hin lc ngoi hoc lc trong.
+ Cn co git ng kinh cc b (cn Bravais-Jackson) biu hin co git
1/2 ngi hoc ch co git c mt mt bn.
Mt s du hiu TKKT khc ch pht hin c khi bnh nhn hi
phc sc khe, tnh to tip xc c nh ri lon ngn ng, ri lon th lc,
thnh lc v ri lon ngi.
Trong thc t c nhng trng hp chn thng s no m, no nt chy ra
ngoi nhng khng pht hin du hiu TKKT nh ni trn. Trng hp gip no
nn s, gip no vng m nhn t chc nng, khi khm kh pht hin du
hiu TKKT. Tri la c nhng trng hp lit rt ng u 1/2 ngi nhng trn
phim chp CLVT khng thy hnh nh gip no hoc mu t ni s.
3.2.4. Tng p lc ni s (ALNS):
T chc no b bm gip dn n ri lon tnh thm ca thnh mch, ri
lon vn chuyn nc trong v ngoi t bo lm cho t bo no b nc v
ph no. Ph no l tnh trng tch t nc qu nhiu c trong v ngoi t bo
no. Ph no dn ti tng ALNS vi biu hin au u, bun nn v nn, ph
a th, c cng, kch thch tm thn vn ng. Nu ph no mc nh,
ALNS s gim dn v tnh trng chung ca bnh nhn s tt dn ln. Nu
ALNS tng cao v ko di s gy nhiu bin chng nh tt kt no e do t
vong.
3.3. Mu t ni s trn lu:
Cn c vo lu tiu no ngi ta chia ra: mu t trn lu (tc l mu t khu
tr bn cu i no) v mu t di lu (tc l mu t h s sau).
Mu t trn lu gm mu t ngoi mng cng, di mng cng, trong no v
mu t trong no tht.
3.3.1. Mu t ngoi mng cng (NMC):
Mu t NMC l bc mu t nm gia xng s v mng no cng. Ngun chy
mu hay gp l t rch ng mch mng no gia; rch tnh mch mng no
cng hoc xoang tnh mch dc trn v t tnh mch xoang xng (do v
xng).
Triu chng lm sng mu t NMC: 1 2 3 4
+ Ri lon tri gic:
Ri lon tri gic i vi mu t NMC l khong tnh (lucid interval).
Khong tnh c biu hin nh sau: bnh nhn b m ngay sau chn thng
vo u (do ng hoc b nh), sau mt vi pht bnh nhn tnh li hon
ton, tip xc tt, i li sinh hot bnh thng; nhng mt vi gi sau th tri gic
bnh nhn xu dn, tip xc rt chm, i a khng t ch v m li. Thi
gian tnh gia 2 ln m: M-Tnh-M c gi l khong tnh.
Khong tnh di hay ngn l ty thuc vo ngun chy mu. Nu t rch
ng mch mng no gia, khi mu t hnh thnh nhanh v gy p no th
khong tnh thng ngn ch mt vi gi, thm ch khong tnh rt ngn
ch 40-50 pht. Khong tnh cng ngn tin lng cng nng v cha kp m
t vong. Nu chy mu t xng s, khi mu t hnh thnh chm c khi mt
vi ngy sau mi gy p no v m li.
Theo di mt trng hp CTSN nu thy tri gic ngy mt xu i, im s
Glasgow gim dn th cn phi ngh n kh nng do MTNS.
+ Du hiu TKKT:
- Gin ng t cng bn vi mu t. Gin ng t c c trng l gin t t.
 - Bi lit 1/2 ngi i bn vi mu t c xu hng ngy mt tng dn. Du
hiu Babinski c th (+).
- Tn thng dy thn kinh VII trung ng.
+ Thay i mch v huyt p:
ngha c trng trong MTNS ni chung v mu t NMC ni ring l mch
c xu hng ngy mt chm dn t 80 - 90 ln/pht xung cn 60 hoc 50
ln/pht. HAM li c xu hng ngy mt tng cao dn. Nu khi mu t ngy
mt tng ln m khng c ly b, ALNS ngy mt tng cao s gy tt kt no;
khi no mt b th mch s nhanh nh, yu v HAM tt dn, tin lng cc k
nng.
3.3.2. Mu t di mng cng cp tnh (DMC):
Mu t DMC l bc mu t nm gia mng no cng v b mt ca no.
Ngun chy mu thng t tnh mch cun no. Ngi ta chia mu t DMC ra lm
3 th: cp tnh (trong 3 ngy u sau khi b chn thng), bn cp tnh (t
ngy th 4 n ngy th 14) v mn tnh (t ngy th 15 tr i).
Mu t DMC cp tnh gp nhiu hn mu t NMC. Theo Lichterman L.B.
trong s 176 trng hp MTNS th mu t NMC gp 21,6%, mu t DMC l
43,2%, gp 2 ln mu t NMC. So vi cc trng hp CTSN th mu t DMC
gp 0,4 - 2% (Irger, 1972). Th tch khi mu t t 80 - 150 ml. Triu chng
mu t DMC biu hin nh sau:
+ Ri lon tri gic:
Phn ln mu t DMC thng km theo gip no, do vy RLTG ph thuc
vo mc gip no.
- Khong tnh in hnh gp t hn so vi mu t NMC, ch gp
trong trng hp mu t DMC n thun, tc l khng km theo gip no hoc
gip no mc nh.
- Khong tnh khng in hnh gp trong trng hp mu t km theo
gip no, biu hin: bnh nhn m ngay sau chn thng (Glasgow: 3 - 4
im), sau tnh li, tip xc c nhng kh khn, kch thch vt v
(Glasgow: 7 - 8 im). Vi gi sau tri gic bnh nhn xu dn i v m li.
- Trng hp mu t DMC km theo c gip no ln, gip thn no: bnh
nhn m su ngay t sau khi b chn thng (khng c khong tnh) ko di
cho ti khi t vong hoc nu sng s li di chng nng n.
+ Du hiu TKKT: tng t nh mu t NMC, gin ng t ngy mt tng
dn cng bn vi mu t; bi yu 1/2 ngi i bn vi mu t ngy mt tng
ln.
+ Triu chng no chung: au u d di, nn, kch thch tm thn, v
m hi, sc mt ti nht...
+ Ri lon TKTV: th nhanh nng 35 - 40 ln/pht; ri lon h hp ngoi vi,
th kh kh do n tc ng h hp trn; mch chm dn v huyt p tng cao
dn.
 3.3.3. Mu t DMC mn tnh:
L khi mu t nm DMC c pht hin ngy th 15 tr i c gi l
mu t DMC mn tnh. Trong thi gian ny khi mu t khng cn ng chc
na m dch ha bin thnh mu en long hon ton.
Cn nguyn mu t DMC mn tnh thng do chn thng, nhng mt s
trng hp khng xc nh c c b chn thng hay khng v v th ngi ta
ngh ti kh nng do tai bin mch mu no. Lm sng mu t DMC mn tnh
biu hin nh sau:
+ Chn thng s no thng nh, c khi bnh nhn khng ti khm hoc
n khm vi chn on l chn ng no, khng nm vin.
+ Sau 3 tun hoc lu hn, bnh nhn xut hin au u tng ln, bun
nn v nn. C biu hin thay i tm thn nh trm cm, ln, hay qun; c
th thy bi nh 1/2 ngi; BN hay nh ri vt hoc c cn ng kinh...
+ Chn on lm sng mu t DMC mn tnh thng kh v ch c
chn on sau khi chp ct lp vi tnh hoc chp ng mch no.
3.3.4. Mu t trong no:
Bohne (1889) l ngi m t u tin mu t trong no, sau ny n cc
cng trnh ca Courville v Blomguist (1940), Samiy (1962), Ixacov (1965).
Trn nh ct lp vi tnh nhn thy th tch khi mu t dao ng t 5 - 100
ml; do vy chn on lm sng mu t trong no c nhiu kh khn v nhiu
trng hp khng c chn on xc nh. Chp ct lp vi tnh (CLVT) cho
bit chc chn v tr, kch thc mu t.
Tuy nhin nhng triu chng lm sng sau y c th gip ngi ta ngh
ti mu t trong no:
+ Khong tnh: khong tnh i vi mu t trong no t gp hn v c
c im khc vi mu t NMC v DMC l khong tnh xy ra t ngt nh
kiu t qu (apoplexia), tc l bnh nhn ang tnh to, t dng tri gic xu
i rt nhanh v hn m. Nhng trng hp din bin tri gic nh ni trn cn
ngh ti mu t trong no.
+ Tri gic khng tt ln mc d c iu tr tch cc th cn ngh ti
mu t trong no.
+ Lit rt ng u 1/2 ngi i bn vi mu t, kh nng mu t
bao trong.
+ au u dai dng pha c mu t vi biu hin thay i tm thn,
trm cm, ngi tip xc.
+ ph a th v nhn i; nn v bun nn.
3.3.5. Mu t trong no tht:
Ngi ta chia ra 2 loi: mu t trong no tht tin pht v mu t trong no tht
th pht. Mu t trong no tht tin pht l do tn thng m ri mng mch
gy nn mu t 1 hoc 2 no tht bn. Mu t trong no tht th pht l bc
mu t nm trong cht no st thnh no tht bn v chc thng thnh no tht
to nn mu t c trong cht no v trong no tht bn
Tin lng mu t trong no tht (tin pht hoc th pht) l rt nng, t l
t vong cao, c nguy c gy tc ng dn dch no ty v gy trn dch no.
Chp CLVT cho chn on chc chn mu t trong no tht. Tuy nhin mt
s nhng triu chng sau y cn ngh ti mu t trong no tht:
+ M su ngay t u sau chn thng.
+ Lc u gim trng lc c nhng sau tng trng lc c t chi, biu
hin cn co cng, rung c.
+ Ri lon TKTV: nhit c th tng cao 39oC - 40oC; mch chm 70 - 60
ln/pht; HAM tng cao c th trn 200 mmHg.
+ Tng ALNS, kch thch vt v, nn nhiu.
+ Sc mt ti nht, c lc ng , v m hi.
3.4. Mu t di lu:
L bc mu t nm h s sau, c th gp mu t NMC, DMC v mu t
trong bn cu tiu no.
Mu t h s sau gp t hn rt nhiu so vi mu t trn lu. Theo s liu
ca Fisher (1958) trong s 135.000 trng hp CTSN ch c 14 trng hp mu t
h s sau (chim 0,01%). So vi MTNS ni chung th mu t h s sau chim
khong 2,3%.
H s sau cha hnh no, cu no v tiu no nn rt cht chi v th khi
mu t nh ch 15 - 30 ml cng e do t vong.
Mt s du hiu sau y cn ngh ti mu t h s sau:
+ C chn thng trc tip vo vng chm-gy.
+ au u d di vng chm, nn, ph a th, c cng khng dm quay
u sang bn v au.
+ Gim trng lc hoc co cng t chi; rung git nhn cu t pht, run tay,
chng mt, bun nn v nn.
+ Ri lon h hp v tim mch: th nhanh nng; mch nhanh nh, huyt p
thp.
+ Chp phim s c ng v xng lan xung l chm.
Chn on chc chn mu t h s sau l nh chp CLVT.
4. Cc bin chng ca chn thng s no.
4.1. Ph no:
Gip no l nguyn nhn chnh dn ti ph no. Gip no cng ln, ph no
cng nng. Ph no s dn ti tng ALNS, biu hin au u, bun nn v
nn; ph a th; kch thch tm thn; mch chm, huyt p tng cao; th
nhanh nng; ri lon h hp v tim mch trm trng. Tng ALNS rm r s dn
ti nguy c tt kt no: y thy thi dng vo khe Bichat; y thy nhng tiu
no vo l chm v gy ri lon h hp v tim mch nghim trng do chn p
hnh ty.
 4.2. Chy mu di nhn (CMDN):
Trong chn thng, CMDN thng do gip no, nhng cng hay gp do tng
tnh thm thnh mch, hng cu xuyn thm vo DNT, biu hin:
+ au u, bun nn v nn.
+ Kch thch tm thn, dy da, ku la, vng dy chy khi ging; s nh sng,
mt lun nhm, nhc trong hc mt.
+ Cng gy (+++), Kernig (+) xut hin sau 24 gi.
+ Du hiu TKKT khng c hoc khng pht hin c.
+ Chc ng sng tht lng (OSTL) thy DNT mu mu hoc pht hng.
iu tr: bt ng, an thn; thuc chng co mch (nimotop); chng ph no...
nn chc OSTL 2 - 3 ln/tun cho ti khi DNT trong vt nh bnh thng.
4.3. Xp no:
Xp no ch yu do mt DNT trong cc trng hp v nn s. Xp no cn
c th do ri lon qu trnh sn sinh DNT, chng c sinh ra t l do c ch
m ri mng mch.
Triu chng lm sng: ging nh tng ALNS, au u bun nn v nn;
kch thch tm thn, dy da; soi y mt khng c ph a th v chc
OSTL p lc DNT thp hn bnh thng.
iu tr: bt ng; khng truyn dch chng ph no v khng dng thuc
li niu thm thu. Nn nm u thp, thuc an thn, thuc gim au, truyn
dch ng trng nh glucose 5%, ringer lactat...
4.4. T nc di mng cng:
L tnh trng ng DNT nm gia mng no cng v mng nhn. T nc
DMC cng gy p no nh mu t DMC, nhng khng c triu chng c
trng nn chn on lm sng thng kh khn. Chp CLVT cho thy khoang
di nhn vng t nc gin rng, biu hin: khong cch gia b mt ca no
vi mt trong xng s gin rng ra, l vng thun nht c t trng ging nh
t trng ca DNT (4 - 14 HU).
iu tr: phu thut m thng khoang t nc vi khoang di nhn ca no.
4.5. Trn dch no (hydrocephalus):
Trn dch no cp tnh do chn thng thng do mu t hoc gip no
gy chn p v lm tc cng Sylvius. Biu hin lm sng: tng ALNS, au
u d di, bun nn v nn; ph a th 2 bn; mch chm v huyt p tng
cao. Chp CLVT thy 2 no tht bn gin to.
iu tr: iu tr ni khoa khng khi phi can thip phu thut dn DNT
t no tht bn xung bng.
4.6. Trn kh no:
L do v xoang trn hoc v nn s. Kh t cc xoang (xoang trn, xoang
chm...) hoc kh t ngoi vo trong no qua ng v xng s gy p no v
c nguy c gy vim mng no. Lm sng khng c triu chng c trng, bnh
nhn ch au u, bun nn v nn, cng gy, kch thch tm thn, vt v,
dy da...
Chp s qui c c bit l chp CLVT s thy kh ri rc trong khoang
di nhn hoc t trong no tht nh mt bc kh ln gy p no.
iu tr: bt ng; nm u cao, cho thuc an thn, khng sinh. Nu chy
DNT do v nn s th cn nht gc (mche) ngn chn v khng cho kh
tip tc vo trong no.
4.7. R dch no ty:
Chy DNT ko di qua ng v xng nn s c nguy c gy vim
mng no, p xe no. Lm sng: biu hin au u, st cao, cng gy, nn v
bun nn; ri lon tm thn, chy DNT ra mi hoc tai.
iu tr: bt ng nm u cao; khng sinh. Nu iu tr bo tn khng
kt qu th cn phi can thip phu thut khu bt ng r.
4.8. R ng mch cnh trong vi xoang hang:
V nn s trc lm gy xng cnh bm nh gy rch ng mch cnh trong
(MCT) nm trong xoang hang. Mu t MCT qua l rch chy vo xoang tnh
mch hang gy r ng mch cnh trong-xoang hang (MCT-XH). L rch c
th 1 - 2 mm. Triu chng lm sng nh sau:
+ C ting ng theo mch p nh ting ci xay la trong u.
Ting thng xut hin sau chn thng mt vi ngy v ting thi ngy
mt to dn lm cho bnh nhn ht sc kh chu.
+ Mt li: ting xut hin mt vi ngy th bnh nhn thy mt bn
mt ngy mt li to ra, th lc gim. L r cng ln, li mt xut hin cng
nhanh.
+ Ting thi lin tc v rung miu: khi khm t tay v ng nghe ln nhn
cu s thy rung miu v nghe thy ting thi lin tc lan ra xng thi dng.
Nu mnh ngn tay ln ng mch cnh gc th ting thi lin tc v rung
miu s mt v mt li s nh li.
Chp ng mch no s xc nh c l r.
iu tr: phu thut lm tc l r (phng php Brooke) hoc tht buc
ng mch cnh trong.
5. Chn on cn lm sng.
5.1. Chp s qui c:
Chp 2 phim thng v nghing tm ng v xng. Nu c ng v rn
xng thi dng th rt c kh nng tn thng ng mch mng no gia; bnh
nhn cn phi c theo di tin trin ca tri gic pht hin sm mu t ni
s.
5.2. Chp ng mch no:
Trc khi c my chp CLVT ra i th chp ng mch no (MN) cho bit
v tr mu t. Trn phim thng v nghing, cn c vo s thay i v dch
chuyn ng mch no trc v no gia ngi ta c th xc nh c v tr
mu t (hnh 1).

Hnh 1: Hnh nh mu t trn phim chp MN.

1. Hnh nh MN bnh thng; 2. Hnh nh MN trong mu t
NMC hoc DMC; 3. Hnh nh MN khi c mu t trong no.

5.3. Chp ct lp vi tnh:

Chp CLVT l phng php chn on hin i, cho bit y cc tn
thng xng s v no, ng thi gip cc nh lm sng la chn phng
php iu tr v tin lng bnh.
+ Mu t NMC: trn nh CLVT c c trng l hnh thu knh 2 mt li
(biconvex) vi t trng cao (trn 70 - 80 HU), y ng gia sang bn v p
lm thay i hnh dng no tht.
+ Mu t DMC cp tnh: trn nh CLVT mu t DMC c c trng l
hnh lim vi t trng trn 75 HU. Mu t DMC thng km theo gip no nn
ngay di mu t l vng gim t trng (do ph no) so vi m no lnh, biu
hin trn nh CLVT l hnh ti.
+ Mu t DMC mn tnh: l mu t dch ho c mt thun
nht (homogens) v gim t trng hoc ng t trng so vi m no lnh. Hnh
nh gin tip ca mu t DMC mn tnh trn nh CLVT l y ng gia v
lm thay i hnh dng no tht bn.
+ Hnh nh gip no: trn nh CLVT gip no chnh l vng gim t
trng so vi m no lnh ng thi c chon ch do ph no nn y ng gia
sang bn, lm thay i hnh dng no tht (no tht b thu nh hoc b mt
khng nhn thy).
Nu gip no km chy mu th trn nh CLVT s thy nhng nh tng
t trng, l nhng mu t to nh khc nhau trn nn ca vng no ph v
gim t trng.
6. iu tr.
6.1. iu tr bo tn:
Ch nh: chn ng no; gip no; chy mu di nhn.
iu tr m bo nhng nguyn tc sau:
+ Bt ng 5 - 7 ngy hoc lu hn. Khi no bnh nhn au u,
ht chng mt v bun nn th cho ngi v tp i li.
+ Gii quyt ri lon h hp: th oxy; ht m ri nu c biu hin n tc,
th kh kh. Nn m kh qun sm trong trng hp gip no nng.
+ An thn: cho thuc an thn khi bnh nhn dy da, la ht, kch thch
tm thn: seduxen 10 mg 1 ng/tim bp tht hoc cho ng min gm cc
thuc sau: promedon 0,02 (1 ng) + amynazin 0,025 (1 ng) + pipolphen 0,05 (1
ng). Trn ln, tim tnh mch 2ml mi khi bnh nhn dy da. Cn ch ch
cho an thn khi xc nh chc chn khng c MTNS.
+ Chng ph no:
- Chn ng no, chy mu di nhn v gip no mc nh:
Magn sulfat 25% 5 - 10 ml/tim bp tht su (khng nn tim tnh mch);
atropin 1/2 mg 1ng/tim di da hoc bp tht; lasix 20 mg 1ng/tim bp
tht.
- Gip no nng:
Mannitol 15% 150ml/truyn tnh mch nhanh; lasix 20 mg 2 - 3 ng/tim
bp; truyn dextran, nhng cht thay th mu.... Khng nn truyn glucose 20 -
30% v d gy toan ha no.
Cc thuc h thn nhit khi bnh nhn st cao; cc thuc lm bn vng
thnh mch, chng co tht mch mu v phc hi chc phn thn kinh
(nimotop; cerebrolysin; lucidrin; duxil; nootropyl..). Nui dng bnh nhn qua
ng thng d dy khi bnh nhn hn m ko di; chng toan mu (bicacbonat
natri); cc khng sinh chng bi nhim...
6.2. Phu thut:
Ch nh: v ln xng s; chn thng s no m v mu t ni s.
6.2.1. V ln xng s:
Ln xng s nu khng c m nng xng ln hoc khng c ly b
s li di chng v sau nh au u, ng kinh, ri lon tm thn...
 K thut nng xng ln: t 1 l khoan xng cnh b xng ln, sau
dng by xng lun di mnh xng ln v by xng ln ln.
tr cn b v tr em th ngi ta c th nng xng ln v v tr c
tng i d dng. Nhng ngi ln nhiu khi rt kh, ngi ta phi gm xung
quanh b xng ln ri dng by nng xng ln. Trong trng hp kh khn
phi nhc b cc mnh xng ln.
6.2.2. Chn thng s no m:
L chn thng gy rch da u, v xng s, rch mng no cng v gy
tn thng cht no; DNT v no nt c th chy ra ngoi.
Chn thng s no m cn c phu thut cng sm cng tt trnh
nguy c nhim trng no mng no...
K thut: ct lc tit kim phn mm da u b gip nt, ly b cc d
vt bao gm cc mnh xng ln, tc, d vt khc nh t ... M mng cng
theo chiu mng cng b rch. Bm ra no nt chy ra ngoi. Dng ngn
tay kim tra nu cn d vt th ly b, sau khu kn mng no cng.
Nu vt thng bn, bnh nhn n mun v sau khi ly ht d vt nhng
no ph cng th khng c khu kn mng cng.
6.2.3. Phu thut ly b mu t ni s:
* K thut m xng: c 2 phng php m xng vo ly b mu t:
+ M np hp s (volet): ch nh khi tnh trng bnh nhn cn tt, cho php
c th ko di thi gian m. Sau khi ly ht mu t, np hp s s c y li
(hnh 2).

Hnh 2: K thut m np hp s.
Nu no ph cng, khng nn y li np xng; mnh xng s c du
di da bng, khong 6 - 8 thng sau s m li v ly mnh xng ny che
y li khuyt s.
+ M xng s bng mt l khoan ri gm b xng s:
- Ch nh: khi BN trong tnh trng nng cn cp cu nhanh, khng cho
php ko di cuc m.
- K thut: khoan mt l xng ri sau gm rng ra xung quanh sao cho
ng knh ch m xng rng (d = 4 - 5 cm) ly b mu t v cm
mu. Sau 6 - 8 thng, khi tnh trng sc khe ca BN cho php th tin hnh
m che y li khuyt s bng xng mo chu t thn hoc bng
chnh bn ngoi xng s.
* K thut ly mu t:
+ Mu t NMC: dng tha (curet) gt nh nhng lp mu t ri ht b. Tm
ngun chy mu t in cm mu. Sau khi ly ht mu t nn khu treo
mng no cng vo ct mc xng s hoc cn Galia trnh b t mu li.
+ Mu t DMC: m mng no cng hnh ch thp; dng bng nc bm
y mu t ra ngoi hoc dng ng ht v ht b mu t. t in cm mu.
Nu sau khi ly ht mu t m no khng ph c th khu kn mng cng;
nu no ph cng th khng nn khu kn mng no cng m h.
+ Mu t trong no: m mng cng ch thp, dng kim Troca chc thm d
mu t. Khi xc nh v tr mu t ri, rt kim Troca mu en s theo kim
chy ra. Sau rch v no ri vn no sang 2 bn ht b mu t. t in
cm mu. t dn lu mu t; khu mng cng.
iu tr sau m: cn m bo nhng nguyn tc gii quyt thng kh tt;
chng ph no tch cc; an thn; khng sinh; cc thuc phc hi chc nng thn
kinh ging nh iu tr khng m.

Vt thng s no do ho kh

Nguyn Th L
1. i cng v phn loi.
1.1. i cng:
Trong chin tranh, vt thng s no (VTSN) l loi vt thng hay gp. Theo
tng kt ca Qun i X-Vit (Lin-x c) trong cuc Chin tranh Th gii ln
th II th VTSN chim 5 - 7%. Vit Nam trong thi k Khng chin chng
Php th VTSN chim 10 - 13%; Khng chin chng M 10 - 15% v Chin tranh
bin gii Ty-Nam (1978 - 1979) l 7 - 10%.
1.2. Phn loi:
1.2.1. Theo tc nhn:
Trc y VTSN do n thng chim 35 - 40%, cn li do mnh n. Trong
cc cuc chin tranh hin i gn y, VTSN do n thng ch chim 10 - 15%,
cn li l do mnh n (mnh mn, mnh pho, mnh n B40) c bit do v kh
bom bi gy nn.
1.2.2. Theo v tr gii phu ca s v no:
Hay gp vt thng vng trn, vng nh v thi dng. Vt thng vng
chm v h s sau t gp hn nhng l vt thng nng v c t l t vong cao.
 1.2.3. Theo ng ng vt thng:
Ngi ta chia 2 loi: vt thng khng thu no v vt thng thu no.
+ Vt thng khng thu no: l vt thng ch gy tn thng da u v
xng s; t l khong 40 - 45% (hnh 1).

Hnh 1: Hnh nh vt thng s no.

1. Vt thng thu no tip tuyn. 3. Vt thng cht bn knh.
2. Vt thng xuyn thu no. 4. Vt thng bt i gc.

+ Vt thng thu no: l vt thng gy tn thng da u, xng s, mng

no cng v t chc no. Ngi ta chia vt thng thu no ra 4 loi:
- Vt thng cht thu no: l vt thng ch c mt l vo, mnh n nm
trong hp s. Vt thng cht thu no cn c chia thnh:
. Vt thng cht thu no n gin: mnh n khng su qu 4 cm so vi v no.
. Vt thng cht thu no na ng knh: mnh n nm chnh gia hai
bn cu i no, hay gy tn thng no tht bn.
. Vt thng cht thu no ng knh: mnh n xuyn qua c hai bn cu
i no
. Vt thng cht thu no dy cung: ng n gy tn thng mt s thy no.
. Vt thng cht theo dc bn cu i no: ng n xuyn t thy trn n
thy chm hoc ngc li.
- Vt thng xuyn thu no: l vt thng c l vo v l ra. L vo thng
nh, ngay di l vo l mnh xng v, d vt kim kh. L ra thng rng hn,
ming vt thng thng c no nt, dch no ty chy ra, mnh xng s bn ra
ngoi hoc dnh vi ct mc xng s nm ngay ming l ra.
- Vt thng thu no tip tuyn: ng i ca mnh n tip tuyn vi b
mt ca no.
- Vt thng bt i gc: mnh n c th bt i gc khi chm phi xng
s hoc bt i gc trong t chc no (hay gp do mnh bom bi) gy tn thng
no phc tp.
2. Khm xt v chn on VTSN.
2.1. Khm hp s:
Trc khi khm, thng binh cn c co sch tc.
+ Xc nh v tr v kch thc cc vt thng.
+ Xc nh mc tn thng xng s v no; xem c dch no ty v cht
no nt chy ra khng.
Nguyn tc khi khm VTSN l khng c dng dng c thm khm a su
vo trong t chc no v c th gy tn thng t chc no lnh, gy chy mu v
a d vt vo su hn trong ng vt thng.
2.2. Khm xt tm thn kinh:
2.2.1. Tri gic:
Gi hi, kch thch au xem p ng ca bnh nhn, qua nh gi mc
ri lon tri gic theo thang im Glasgow. Nu im Glasgow: 3 - 4 im l
hn m rt nng (tng ng vi hn m IV); 5 - 8 im l hn m nng (hn
m III); 9 - 11 im l hn m va (hn m II) v 12 - 13 im hn m
nng ( I).
Ngoi ra cn khm cc phn x nut, phn x gic mc, phn x ng t
tin lng i vi ngi bnh.
2.2.2. Khm cc chc phn thn kinh:
+ Khm vn ng:
Quan st khi bnh nhn dy da, so snh hai bn xem b lit vn ng bn
no. Trng hp lit khng r th cn lm mt s nghim php Barre tay,
Mingazzini, Reimist.
+ Khm cm gic au: dng kim chm vo da i xng hai bn t mt
xung ngc, bng v chi th. Hi ngi bnh (nu tnh) hoc quan st xem phn
ng ca ngi bnh khi b kch thch au (nu hn m) nh gi mc ri
lon cm gic.
+ Phn x gn xng: khm v so snh phn x gn xng hai bn; khm
phn x bnh l b thp (du hiu Babinski); phn x t ng ty.
+ Khm tn thng dy thn kinh s no: trong giai on cp tnh ch cn
khm mt s dy thn kinh s no nh dy thn kinh VII, dy III.
Khm dy thn kinh s III: c gin ng t khng, c ph a th khng.
Gin ng t thng cng bn vi bn cu no tn thng.
 Khm dy thn kinh VII: quan st np nhn trn, np mi-m v nhn trung.
Khm phn x gic mc. Khi thng binh hn m th xc nh tn thng dy
VII bng du hiu Marie-Foix.
2.3. Chp X quang s:
Tt c cc thng binh b vt thng thu no hoc khng thu no u phi
c chp phim s qui c xc nh xem c tn thng xng s khng? xc
nh v tr, kch thc mnh xng s hoc mnh kim kh. Xc nh xem l vt
thng thu no hay khng thu no.
2.4. Chp ct lp vi tnh:
Trong iu kin cho php nn chp ct lp vi tnh (CLVT) xc nh y
hn cc tn thng xng s v no, gip cho cc nh phu thut thn kinh la
chn phng php iu tr thch hp v tin lng bnh.
3. Tin trin ca vt thng s no.
Smirnov chia 5 giai on tin trin ca VTSN:
3.1. Giai on I: (giai on cp tnh):
Trong vng 3 ngy u sau b thng, ngi bnh c cc biu hin sau:
+ Ri lon h hp v tim mch: huyt p gim v mch tng nhanh do mt
mu. Th nhanh, nng. Cn ch gii quyt ri lon h hp do n tc ng h
hp trn. Nng huyt p bng truyn mu, dung dch keo.
Giai on ny cn theo di pht hin chn p no do mu t ni s.
+ Do vt thng khng c x tr, p lc ni s tng cao (ALNS), nn dch
no ty (DNT), no nt chy ra ngoi. Nu vt thng gy khuyt hng ln
xng s c th gy thot no ln.
3.2. Giai on II (giai on bin chng sm):
Ko di t ngy th 4 n ht thng u sau khi b thng. Trong thi gian
ny thng binh thot khi hn m v biu hin r cc tn thng khu tr. Ph
no gim dn nhng bin chng nhim khun rm r hn v l nguyn nhn gy
t vong. Bin chng hay gp nht trong giai on ny l nhim trng vt thng,
vim mng no, p xe no sm, thot no, no hoi t chy mu.
3.3. Giai on III (giai on trung gian):
Giai on ny ko di t thng th 2 n thng th 6 sau b thng. Cc bin
chng sm qua khi, hnh thnh so no-mng no, biu hin lm sng c th
gp nh: ri lon tm thn, nhng thiu ht thn kinh nh lit 1/2 ngi, ri lon
ngn ng, mt li, c th biu hin ng kinh sm.
3.4. Giai on IV (giai on bin chng mun):
T thng th 6 v ko di cho n 2 - 3 nm sau; giai on ny thng binh
hi phc sc khe. Bin chng c th gp nh: ct ty vim xng s, r
DNT, ng kinh. ng kinh thng bt u sau 6 thng b thng (gp 60%).
Biu hin cn ng kinh cng rt khc nhau nh cn ng kinh ton th, cc b,
cn ri lon tm thn tng ng, cn ng kinh ni tng.
 3.5. Giai on V (giai on di chng):
Giai on ny ko di t nm th 3 tr i, di chng hay gp nh: ng kinh,
sa st tr tu, ri lon tm thn, au u ko di, p xe no mun, ct ty vim
xng s.
4. Cp cu v iu tr.
4.1. Cp cu khn cp:
Gii quyt khn cp nhng ri lon h hp nh lm thng ng th do n
tc ng h hp trn, th oxy, cn thit phi m kh qun sm, h hp nhn to
nh th my; nng huyt p ng mch nh: truyn mu, dung dch keo, b sung
khi lng tun hon.
Cm mu ngay nu chy mu da u nhiu. Phu thut cng sm cng tt khi
c ch nh nh c mu t ni s, tn thng xoang tnh mch.
4.2. Chng nhim khun:
Khng sinh mnh ngay t u. X tr ct lc vt thng cng sm cng tt,
ly ht d vt. Thi gian tt nht l m trong vng 6 gi u sau khi b thng.
4.3. Bo v chc phn thn kinh:
Penfield cho rng phu thut ly ht t chc no gip nt, ly ht d vt, gii
phng chn p no, ti to li mng cng v hn ch ti mc thp nht cc tn
thng t chc no lnh v cc bin chng nhim khun l to iu kin phc hi
chc phn thn kinh, hn ch c cc di chng v sau ny.
4.4. X tr k u vt thng s no:
Khi x tr k u VTSN phi m bo c nhng nguyn tc sau:
+ Ly ht d vt (mnh xng cht, mnh n, tc, t ct), nhng khng c
tnh ly mnh n qu su trong no.
+ Hn ch ti mc thp nht tn thng t chc no lnh, khng cho
nhim khun lan rng hn.
+ Sau khi cm mu k, ng kn mng no cng khi c nhng iu kin sau:
thng binh c m sm, vt thng tng i sch, ly b c trit d vt,
c iu kin theo di st bnh nhn, c kinh nghim iu tr v khng sinh mnh.
4.4.1. Nguyn tc v k thut x tr k u
vt thng s no:
+ Rch da: m rng theo chiu rch ca da do vt thng gy nn. Khng
rch da ct ngang qua ng mch v thn kinh ca da u. Ct lc da tit kim v
da u khng c kh nng ko gin khi ng kn vt thng.
+ M xng s: gm rng xng cho ti phn mng cng lnh; ng knh
khuyt xng t 3 - 4 cm; cm mu xoang xng bng sp ong.
+ M mng no cng: ct theo chiu rch ca mng cng rng ly cc
d vt. C th m mng no cng hnh ch thp. Ct lc mng no cng tht tit
kim v sau khi x tr vt thng phi khu kn mng cng.
+ Ly d vt: bm ra vt thng bng thanh huyt mn 9%0 cho no nt chy
ra ngoi. Vn nh nhng ming ng vt thng v gp b cc mnh xng, d vt,
mnh n. Dng ng ht ht b t chc no nt, hoi t, mu cc. Cm mu bng
t in. Ch khng c c tnh ly cc d vt qu su trong no v c th
gy chy mu do tn thng mch mu ln, a t chc bn vo su, gy tn
thng t chc no lnh.
+ X tr xoang tnh mch tn thng:
Nu xoang tnh mch dc trn b rch, c th cm mu bng c (ly c thi
dng hoc c t u i). Nu xoang rch theo chiu dc c th khu xoang
bng cc mi ch ri. Trong trng hp rch khuyt rng xoang tnh mch, 1/3
trc ca xoang tnh mch dc trn th c th tht buc xoang (khng c tht
buc xoang tnh mch dc trn t 1/3 gia v pha sau v s gy t vong).
+ Ti to li mng no cng:
Mng cng cn c khu kn sau khi ly ht d vt v t chc no hy
hoi. Nu mng cng khuyt rng th cn phi ng kn bng cn c thi dng
hoc cn c i. Trong nhng iu kin sau cho php khu kn mng cng: m
sm trong vng 24 - 36 gi u, tt nht l trong 6 - 12 gi u sau khi b thng;
c iu kin chm sc vt thng sau m nh khng sinh mnh, liu cao,
c iu kin theo di bnh nhn.
Khng nn khu kn mng no cng nu vt thng x tr mun sau 2 - 3
ngy tr i, vt thng bn, no gip nt nhiu.
+ t dn lu, khu da bng cc mi ch tha.
4.4.2. Nguyn tc iu tr VTSN theo tuyn:
+ Tuyn qun y i i:
a thng binh ra khi trn a. Bng b cm mu. Tim thuc tr lc, tr
tim ri nhanh chng a thng binh v tuyn sau.
+ Tuyn qun y tiu on:
B sung bng b vt thng. Truyn dch chng chong, gii quyt ri lon
h hp nh chng n tc ng h hp trn. Tim khng sinh.
Ch : khng c p hoc bi bt k thuc g ln vt thng s no nh bt
hoc dung dch khng sinh c penixilin, streptomycin hoc cc thuc khng sinh khc.
u tin vn chuyn cc thng binh nng v tuyn sau cng sm cng tt.
+ Tuyn qun y trung on: b sung v kim tra li bng b vt thng ca
tuyn trc. M kh qun nu c ri lon h hp nng. Chng chong, truyn
dch, khng sinh, chng un vn, khu cm mu tm thi vt thng da u. Ch
gi li thng binh nh, chuyn thng binh nng v tuyn sau, c th vt tuyn
chuyn thng v bnh vin qun khu.
+ Tuyn qun y s on v i iu tr:
Khm xt v phn loi thng binh. Phu thut khn cp cc trng hp mu
t ni s; m kh qun v gii quyt tt thng kh (th my, ht m ri).
+ Tuyn bnh vin khu vc:
Tt c cc thng binh s no u c chp phim s no, co sch tc,
khm xt k cng khng b st cc thng tn. Phu thut ly b cc d vt
trong iu kin cho php (c t phu thut thn kinh tng cng). Chuyn tuyn
chuyn khoa cc thng binh s no nng.
5. iu tr sn sc sau phu thut VTSN.
m bo nhng nguyn tc sau:
+ Bt ng tuyt i 2 - 3 tun sau phu thut.
+ Khng sinh liu cao c ph tc dng rng, kt hp khng sinh dit vi khun
Gr(+) v Gr(-). Khng sinh qua c hng ro mu-no tt nht hin nay l
nhm cephalosporin th h III nh claforan, rocephin, axepim; kt hp vi khng
sinh thuc nhm aminoglicoside nh: gentamycin hoc amiklin.
+ Chng ph no tch cc: cc dung dch chng ph no nh mannitol, dung
dch cao phn t nh dextran. Cc thuc li niu thm thu nh lasix (furosemid).
Hin nay ngi ta khuyn khng nn dng glucose u trng v gy toan ha
no lm cho ph no tng ln, tri gic hi phc chm hn.
+ Thuc an thn: bnh nhn kch thch vt v, dy da nhiu th cho an thn
bnh nhn nm yn. Thng dng seduxen tim hoc phenobarbital. C th
dng liu ng min bao gm: amynazin + pipolphen + promedol.
+ Nu hn m ko di phi nui dng bnh nhn bng ng thng d dy.
Thuc h thn nhit nu st cao. Sn sc chng lot, xoa bp, vn ng chng teo
c cng khp, chng vim phi.

Chn thng kn ct sng v ty sng

Bi Quang Tuyn
ng nh Nam
1. i cng.
Chn thng ct sng c tn thng ty (CTCS-TS) l chn thng nng c
t l t vong cao v li nhiu di chng nng n. Nguyn nhn ch yu l
do tai nn giao thng, tai nn trong lao ng, tai nn trong th thao v tai nn trong
sinh hot.
1.1. C ch chn thng:
+ C ch trc tip:
Do vt cng p trc tip vo ct sng (b nh hoc b ng nga p
lng vo vt cng).
+ C ch gin tip:
- p theo trc ct sng t trn xung: gp trong st l t xung vai trong
khi ngi o ging hoc o cng s; ng ln u xung trc trong tai nn
th thao.
 - p theo trc t di ln: ng t trn cao p mng hoc nn gt xung trc.
- Xoay xon vn, gp n qu mc ct sng hay gp trong tai nn giao
thng, ngi trong t phanh gp.
1.2. V tr t sng tn thng:
C 2 v tr hay gp tn thng l t sng c CV-CVI v DXII-LI. y l 2
im yu, l ni tip gip gia t sng di ng (cc t sng c v cc t
sng tht lng) v on t sng t di ng (cc t sng ngc).
Trong chn thng thng hay gp tn thng 1 t sng nhng cng c khi
gp tn thng 2 hoc 3 t sng k lin nhau. Rt t khi gp tn thng 2
t sng cc v tr xa nhau.
1.3. Phn loi:
1.3.1. Cn c vo tn thng ct sng v ty
sng:
+ Tn thng ct sng khng c tn thng ty:
Tn thng xng c th gp nh gy xp thn t (khng di lch hoc
di lch nh); gy gai sau, gy gai ngang. Tn thng dy chng ct sng nh
gin dy chng, t rch dy chng lin gai sau v dy chng lin cung sau.
+ Tn thng ct sng c tn thng ty:
Tn thng ct sng c th gp nh: gy xp t sng (khng c di lch
hoc t sng di lch cc mc khc nhau). Tn thng ty c th gip
ty chy mu trong ty; khi t sng di lch ln c th gy t rch gii phu
ty.
+ Tn thng ty nhng khng tn thng ct sng:
Do ty b rung lc mnh trong thi im chn thng, do c ch xon
vn, gp n qu mc ca ct sng, ty c th tn thng nng m trn phim
khng xc nh c ct sng c tn thng hay khng.
Mc nh nht l chn ng ty. Chn ng ty xy ra ngay sau khi b
chn thng vi biu hin lm sng l lit mm (lit ngoi vi) hon ton t
ch tn thng tr xung, mt cc loi cm gic au, mt phn x gn xng;
nhng sau 3 - 4 tun cc chc phn ca ty s c hi phc hon ton.
1.3.2. Cn c vo vng ca ct sng:
Nicole (1958) v mt s tc gi khc chia ra 2 loi: gy vng v gy khng vng:
+ Gy vng: l trng hp gy ct sng nhng khng c sai khp ct sng. Do
khng sai khp nn t sng khng di lch ra sau.
+ Gy khng vng: l gy ct sng km sai khp. Do cc mu chn khp b
gy, dy chng ct sng b t, khp ct sng b chch v t sng di lch ra
sau gy chn p ty.
 Gy khng vng gy tn thng ty v ct sng nng n. Gy khng vng
c ch nh phu thut cng sm cng tt, thi gian m tt nht to
iu kin cho ty hi phc l trc 8 gi sau khi ct sng v ty b tn thng.
2. Triu chng.
2.1. Tn thng ct sng khng c tn thng ty:
+ au l triu chng gp tt c cc BN. au khu tr t sng tn thng
v phn mm xung quanh.
+ Hn ch vn ng ct sng: trng hp nh nh gin dy chng, biu
hin: au nhiu khi tr mnh, ngi v i li au tng ln. Ct sng cng ,
au khng dm ci. Trng hp nng hn nh gy xp t sng th ngi bnh
khng th ngi, khng dm tr mnh v au. au ko di vi tun.
+ Bin dng ct sng: c th thy t sng tn thng bin dng, g nh ra
sau. Quanh im g b n, bm tm, n au. Nu tn thng ct sng c s
thy ct sng c nh ngn li, vo sang bn v hn ch quay u.
2.2. Tn thng ct sng c tn thng ty:
2.2.1. Triu chng ton thn:
+ Ri lon tri gic (RLTG):
Bt tnh ngay sau chn thng gp trong chn thng CS-TS c, t gp
trong chn thng CS-TS ngc thp hoc tht lng.
+ H hp:
Ri lon h hp (RLHH) gp ch yu trong chn thng CS-TS c, c
bit l ty c cao. Nguyn nhn l do tn thng trung khu ca dy thn kinh
honh ty c C4, do ph ty ngc dng ln trn kch thch trung khu h hp
ca hnh ty, biu hin: kh th, th nhanh, i khi th chm. C trng hp
BN hon ton tnh to nhng khng t th m phi th h tr bng my c khi
ko di hng thng, vi thng thm ch c trng hp hng nm.
+ Tim mch:
Tn thng ty c cao mc nng c th ngng tim ngay sau chn
thng; mc nh hn thy mch chm 50 - 60 ln/pht v huyt p ng
mch c khi gim thp 90/50 mmHg (do sc ty). Trong 1 - 2 ngy u sau
chn thng nhit c th c khi ch o c 340C - 350C l do ri lon
trung khu vn mch v trung khu iu ho thn nhit.
2.2.2. Triu chng thn kinh:
+ Giai on sc tu (3 - 4 tun u sau chn thng hoc lu hn):
D tn thng bt c on ty no u biu hin lm sng l lit mm,
mt hon ton vn ng, mt cc loi cm gic v phn x t ch tn thng tr
xung; ri lon c tht vi biu hin b tiu v b i tin.
+ Giai on sau sc ty:
 Ht giai on sc ty (ngoi 4 tun sau chn thng hoc lu hn) cc
phn x bnh l ty mi r ln, khi ngi ta mi phn bit c r rng lit
trung ng (TW) hay lit ngoi vi.
Biu hin lit TW l: lit cng, tng phn x gn xng, xut hin phn x
bnh l b thp nh Babinski (+), phn x t ng ty vi biu hin rung git
bn chn.
Biu hin lit ngoi vi l: lit mm, mt phn x gn xng, khng c phn
x t ng ty, khng c phn x bnh l b thp, du hiu Banbinski (-), chi teo
nh.
2.2.3. Triu chng nh khu tn thng ty:
+ Tn thng CS-TS c cao (t t sng c CI -CIV):
- Giai on sc ty: lit mm (lit ngoi vi) t chi. Ri lon nghim trng
chc phn sng nh nhp tim chm, th kh khn c khi ngng th. C th xut
hin triu chng ca hnh ty nh: nc, ni kh, nut kh, ng t khng u,
khng hi t c nhn cu (du hiu nhn cu bi).
- Giai on sau sc ty: lit cng (lit TW) t chi, tng phn x gn xng,
tng trng lc c, xut hin phn x t ng ty v phn x bnh l b thp vi
du hiu Babinski (+).
+ Tn thng CS-TS c thp ( CV-DI):
- Giai on sc ty: lit mm, lit ngoi vi t chi, mt phn x gn xng
v khng c phn x bnh l b thp, du hiu Babinski (-). C th gp hi
chng Brown-Sequard do tn thng na ty vi biu hin: pha bn ty tn
thng lit na ngi kiu TW nhng cn cm gic au, na ngi i bn
khng lit nhng li mt cm gic au .
- Giai on sau sc ty: lit ngoi vi 2 tay v lit TW 2 chn vi biu hin
tng phn x gn xng, phn x bnh l b thp (+) v xut hin phn x t
ng ty (rung git bn chn +).
+ Tn thng CS -TS ngc cao ( DII-DIX ):
- Giai on sc ty: lit ngoi vi 2 chn, mt phn x gn xng, mt cc
loi cm gic t ch tn thng tr xung.
Khm v xc nh vng mt cm gic au c th gip ngi ta xc nh
c on ty v t sng tn thng. V d: mt cm gic au t lin sn IV
tr xung l tn thng on ty D5 (tng ng vi t sng DIII). Mt cm gic
au t b sn tr xung l tn thng on ty D7-D8 ( tng ng vi t sng
DV-DVI). Mt cm gic au t ngang rn l tn thng on ty D9-D10 (tng
ng vi t sng DVII-DVIII).
- Giai on sau sc ty: lit TW 2 chn, tng phn x gn xng, phn x
bnh l b thp v t ng ty (+).
+ Tn thng CS-TS ngc thp (DX-DXI):
- Giai on sc ty: lit ngoi vi 2 chn, mt cm gic au t np bn tr
xung tng ng vi on ty D12-L1. Hay gp hi chng phc mc gi vi biu
hin au v chng bng l do lit rut c nng d nhm vi tn thng c
quan trong bng. Cn khm xt cn thn khng b st cc thng tn
trong bng.
- Giai on sau sc ty: lit ngoi vi 2 chn, mt phn x gn xng, khng
c phn x bnh l b thp, 2 chn teo nh v lot sm vng cng-ct.
+ Tn thng CS-TS tht lng (t DXII-SI):
Ty sng n b trn t sng LII th ht v tht li thnh dy cng (filum
terminale). ng sng tht lng cha cc r thn kinh gi l chm ui nga.
Khi tn thng cc r thn kinh s gy hi chng ui nga.
- Giai on sc ty: lit mm 2 chn, mt cm gac t np bn tr xung,
teo c nhanh v lot cng-ct sm.
- Giai on sau sc ty: biu hin hi chng ui nga in hnh nh lit
ngoi vi 2 chn, c bit lit nng l 2 cng chn v 2 bn chn. BN cn
nhc nhch co dui c 2 i. Mt cm gic vng yn xe tc l mt cm gic
au xung quanh hu mn v b phn sinh dc. Mt cm gic au t gi tr
xung. Mt phn x gn xng. Ri lon dinh dng biu hin 2 chn teo nh,
lot sm, lu bn v ngn chn bin dng, co qup, da kh, mng chn
gin d gy. Ri lon c quan y chu nh mt cm gic mt tiu v nc tiu
khng gi c, i dm.
3. Chn on cn lm sng.
3.1. Chp ct sng qui c:
Chp CS thng v nghing xc nh cc hnh thi tn thng ct sng.
Trn phim nghing nh gi gy vng hay khng vng; gy xp t sng n
thun hay gy v thn t c mnh ri. Nu gy khng vng th c th xc
nh di lch ca t sng, c th:
+ I: t sng di lch ra sau so vi t sng trn l 1/4 thn t (khong
di 25%).
+ II : di lch 1/2 thn t (t 26% - 50%).
+ III: di lch 2/3 thn t (t 51% - 75%).
+ IV: di lch mt thn t sng (t 76% - 100%), thm ch c trng
hp di lch trn mt thn t sng.
3.2. Chp ty cn quang:
Nu nghi ng c chn p ty th nn tin hnh chp ty cn quang
kim tra xem ty c b chn p khng. Thuc chp ty thng dng trong lm
sng hin nay l omnipaque v iopamiron.
3.3. Chp cng hng t (CHT):
L phng php chn on hin i cho bit y cc tn thng ca
ty nh gip nt ty hay t gii phu ty. Cho bit cc hnh thi tn thng ct
sng v p ty do cc cn nguyn khc nhau nh ph ty, do mu t, chn p
do xng, do a m; trn c s gip cc nh lm sng la chn cc bin
php iu tr thch hp.
4. iu tr.
Vn lun lun t ra l iu tr bo tn (khng m) hay m c
th em li kt qu tt nht cho ngi bnh. Trn thc t th 2 phng php
ny lun h tr cho nhau v s la chn tng phng php iu tr cn ty thuc
vo v tr cc t sng tn thng.
4.1. Tn thng ct sng c CI v CII:
ng sng ca CI v CII kh rng nn c nhiu trng hp gy mm rng ca
CII nhng khng gy lit . Nhng CI v CII li rt gn vi hnh ty nn khi c
tn thng ty l rt nng. Nu khng c tn thng ty th iu tr ch
yu bng b bt u c (bt Minerve) t th u n v bt 6 tun.
Phu thut: nu gy di lch t sng CII c lit ty hay khng lit ty
ngi ta cng khuyn nn phu thut ng cng xng chm vi cc gai sau ca
CII, CIII v CIV (phng php Brook). Nu gy mm rng ca CII ngi ta tin
hnh phu thut xuyn inh vo mm rng ri b bt trong 5 - 6 tun.
4.2. Tn thng t sng c t CIII n CVII:
+ Phng php Crutchfield (hnh 1):
- Ch nh: trong trng hp gy vng khng c di lch cc t sng hoc
di lch khng nhiu.
- Chng ch nh: trong cc trng hp BN tui cao khng th nm lu,
tnh trng BN qu nng v trn phim c gy v cung sau.
- K thut: c th tin hnh ngay ti ging
bnh hoc phng m v tin hnh di gy t
ti ch. BN nm nga, tc c co sch, st trng
2 bn xng nh. Gy t ti ch bng lidocaine
2%. Sau khi gy t, rch da 2 bn nh u mi
bn di 2 - 3 cm. t khoan xng s, khoan cho
ht bn ngoi xng x. t mc xng vo 2 l
khoan v c nh chc bng vt vo khung
Crutchfield. Cho ko lin tc ct sng vi trng lng
tng dn t 3 kg ti 5 hoc 6 kg. t 1 gi ct nh
ngay di t sng tn thng mc ch y
t sng di lch tr v v tr ban u. Sau 7
ngy cho chp phim nghing kim tra xem t
sng ht xp v ht di lch cha. Khi t sng
ht di lch v ht xp th cho b bt u c
(bt Minerve) v bt trong vng 6 tun.
Nhc im ca phng php l BN phi nm
lu, c khi phi ti 3 - 4 tun, nn rt hay b lot
vng chm v cng-ct, d vim phi do nm lu v sau khi b bt t sng c
th di lch li. Do vy hin nay ngi ta ch trng m cng sm cng tt.
+ Phu thut:
 Nhm mc ch gii phng chn p ty v sau khi nn chnh t sng tr
v v tr thng trc, tin hnh lm vng ct sng bng xng t thn hoc
np vt kim loi. Phu thut c th bng ng vo pha trc hoc pha sau
ct sng:
- ng vo pha sau: c th ct cung sau (hoc khng ct cung sau) ca
t sng tn thng, nn chnh cho t sng ht di lch v v v tr. Sau
c nh cc gai sau cn li bng xng mc t thn hoc bng np vt kim
loi.
- ng vo pha trc: bc l thn cc t sng; sau khi y t sng v
v tr cho ht di lch ri c nh ct sng bng np vt kim loi hoc bng
xng mo chu c bt vt kim loi.
4.3. Tn thng cc t sng ngc:
V cc t sng ngc c cc cung sn c nh chc nn gy t sng ngc
thng t c di lch ln.
4.3.1. Gy t sng nhng khng c tn
thng ty:
+ Phng php Magnus:
Cho BN nm trn ging c vn cng, khng cn ko nn g, ch dng cc
thuc gim au v BN nm trong vng 3 - 4 tun. C th nghing tri hoc
nghing phi v khi au cho tp ngi, xoa bp chng teo c th pht v 4 - 5
tun cho BN tp i li. Mc ch ca phng php ny l phc hi li sc
c v dy chng ct sng to iu kin gi vng ct sng khng b di
lch th pht v sau.
+ Ko gin ct sng trn ging dc:
- Ch nh: cc trng hp xp t sng n thun khng c di lch v
khng c tn thng ty. Phng php ny c tc dng phc hi li sc c v
dy chng, ng thi ko gin t sng b xp tr v v tr ban u.
- K thut: t BN nm trn ging c vn cng, vn ging t th dc
30 - 400 (u cao). Lun 2 dy vi qua 2 vai ca BN v buc c nh vo
0

thnh ging. Ngay di t sng gy t mt gi ct nh vi mc ch y

t sng tr v v tr c; cho thuc gim au v chng co cng c. Ko nh
th 3 - 4 tun v khi ht au cho BN ngi dy v tp i li.
+ Phng php Bohler:
- Ch nh: i vi gy t sng ngc thp nh DX, DXI, DXII v LI, c
hoc khng c tn thng ty.
- K thut: cho BN nm sp. Gy t thn t sng tn thng bng
lidocaine 2%. Buc cht 2 chn v mng BN vo cng, 2 tay BN ta vo bn
cao hn cng 30 cm. Lun ai vi qua vai (hoc ngi tr th nng 2 vai BN ln
cao) ko na ngi trn t th n qu mc trong khong thi gian 15 - 20 pht.
Ngi tr th th 2 n mnh vo t sng tn thng y t sng v v
tr c. Khi thy t sng ht di lch, v v tr c v thng trc th tin
hnh b bt ngc-bng v bt 3 - 4 tun. Sau b bt 4 - 5 ngy nu BN
au th cho tp ngi v dn dn cho tp ng (hnh 2).

Hnh 2: Nn chnh mt th theo phng php

Bohler.

4.3.2. Gy ct sng c lit ty:

Nu gy t sng c di lch gy lit ty, ngi ta ch trng phu thut
cng sm cng tt, tt nht trong vng 8 gi u sau khi ty b tn thng.
Mc ch ca phu thut l gii phng chn p ty v c nh ct sng. Sau
khi ct cung sau (hoc khng ct cung sau) s c nh ct sng bng khung
Harchile.
4.4. Tn thng ct sng tht lng:
4.4.1. Trng hp khng c tn thng ty:
Cc phng php iu tr nh trnh by trn, c th bo tn bng phng
php Magnus, phng php Bohler.
4.4.2. Trng hp c tn thng ty:
+ Ch nh: gy ct sng khng vng, t sng di lch ra sau.
+ K thut: c 2 k thut lm vng ct sng bng ng vo pha trc bn
ct sng v bng ng vo pha sau ct sng:
- Phu thut bng ng vo pha trc-bn ct sng: sau khi nn chnh
cho t sng ht di lch v khi t sng v v tr c th tin hnh lm
vng ct sng bng np vt kim loi (trng hp gy t sng DXII-LI ng cng
ct sng bng ng vo pha trc thn t sng l kh khn v c c honh
bm vo).
- Phu thut bng ng vo pha sau: nn chnh cho t sng ht di
lch (c th ct hoc khng ct cung sau), sau lm vng ct sng bng
xng mc t thn hoc bng bng np vt kim loi xuyn qua cung sng vo
thn t sng. Khoa Phu thut thn kinh Bnh vin 103 thng p dng c
nh ct sng bng xng mc t thn (hnh 3).

Hnh 3: C nh ct sng bng xng mc

t thn.
(phng php Henle).
a,b: Nhn thng v nhn nghing.
c: Xng mc ch i t 2 bn.

Ngoi cc phng php iu tr bo tn v phu thut ni trn, trong tn

thng ty ngi ta cn cn c bit ch ti vn iu tr ton thn nh
sn sc chng lot, chng vim phi do nm lu, iu tr ri lon tiu tin nh
gii quyt b tiu, vim bng quang v vim ng tit niu ni chung; xoa
bp tp vn ng chng teo c cng khp; cc thuc nhm phc hi chc
phn ty, thuc tng dn truyn thn kinh.
Vt thng ct sng-ty sng

Bi Quang Tuyn
ng nh Nam

1. i cng.
1.1. S lc lch s:
Hyppocrates (460 - 370 trc Cng Nguyn) m t phng php ko gin
iu tr di lch t sng do chn thng.
Paul of Aegina (265 - 690) l ngi u tin m t ct cung sau gii
phng chn p ty. Sau Ambrose Pare (1564 - 1598) l ngi gii thiu kh
chi tit v phu thut ct cung sau.
 Pirogop N.I. (1847) l ngi u tin phu thut ly b u n ct sng
c do vt thng ha kh. Thi k ny cc nh ngoi khoa rt lo ngi khi m
vo ct sng v ty sng v chy mu ln v vim ty. Do vy trong thi
k chin tranh Nga-Php (1870 - 1871) trong s 167 thng binh b vt thng
CS-TS ch c 10 trng hp c phu thut.
Vic p dng phng php v khun trong ngoi khoa (1892) v s ra i
khng sinh vo nm 1929 a li nhiu thnh cng trong phu thut vo ct
sng v ty sng.
1.2. Nguyn nhn:
VTCS-TS ch yu gp trong thi chin do mnh ph (bom, mn, mnh
pho) v n thng. Trong thi bnh ch yu do nh nhau b m bng vt
sc nhn.
T l VTCS-TS do ho kh rt khc nhau v ty thuc vo tng thi k v
tng trn nh. Trong Chin tranh Th gii ln th nht (1914 - 1918) VTCS-
TS l 0,53%. Trong cuc chin tranh V Quc v i Lin-X (1941 - 1945)
VTCS-TS l 0,3 - 1,5%.
VTCS-TS l vt thng nng, c t l t vong cao. Nhng trng hp sng
st li di chng v tn ph nng n.
1.3. Phn loi:
Cn c vo ng ng vt thng ngi ta chia ra vt thng thu ty v
vt thng khng thu ty.
1.3.1. Vt thng thu ty:
L vt thng gy tn thng ng sng, mng ty v ty. Vt thng thu
ty c chia ra 3 loi.
+ Vt thng xuyn (nhm I theo Coxinski) (xem hnh 1):
L vt thng xuyn qua ng sng v xuyn qua ty. Ty thng b tn
thng nng, c th t rch gii phu ty. Nu mnh kim kh nh c th
gy tn thng ty khng nng.
+ Vt thng cht (nhm II theo Coxinski):
L vt thng m u n (hoc mnh kim kh) xuyn vo ng sng v
nm li trong ng sng. Tn thng ty c th hon ton hoc khng hon
ton.
 Hnh 1: ng ng VTCS-TS do ho kh (theo
Coxinski N.X.).

+ Vt thng tip tuyn (nhm III theo Coxinski):

ng i ca ng vt thng tip tuyn vi ng sng v ty. Thnh ng
sng v mng ty b ph hy, trong ng sng c th c cc mnh xng. Ty
tn thng c th hon ton hoc khng hon ton.
1.3.2. Vt thng khng thu ty (nhm IV theo
Coxinski):
L vt thng khng ph hy thnh ng sng, khng gy tn thng ty v
mng ty nhng c th gy tn thng thn t sng, gai ngang hoc gai sau,
ng thi ty c th tn thng hon ton hoc khng hon ton .
1.3.3. Vt thng cnh ct sng (nhm V theo Coxinski):
L vt thng i bn ngoi ct sng, khng gy tn thng ct sng. Tuy
vy ty c th tn thng hon ton (do hot nng ca mnh n qu ln), c
th tn thng mt phn hoc tn thng ty mc nh sau chc phn
ty c hi phc.
2. Tin trin lm sng ca vt thng CS-TS.
2.1. Thi k cp tnh (trong 2-3 ngy u sau khi b thng):
Burdenco gi thi k ny l thi k hn lon v ngoi biu hin sc chn
thng, sc mt mu cn km theo tn thng kt hp cc c quan khc nh ngc,
bng, chn tay, hm mt... lm cho tnh trng BN trm trng hn.
X tr ngoi khoa k u tt nht vo nhng gi u hoc trong 3 ngy
u sau khi b thng.
2.2. Thi k sm (2 - 3 tun u sau khi b thng):
Tin trin ti ch ca vt thng c th din ra nh sau: vt thng lin
so nu do mnh nh; nhng nu vt thng ph hy phn mm rng c th
lm m ng ng vt thng.
Din bin ton thn biu hin nh lot cng-ct, vim bng quang, vim
phi do nm lu.
 2.3. Thi k trung gian (ko di ti 2 - 3 thng):
Vt thng lc ny lin so. Biu hin ch yu ca thi k ny l cc
bin chng ton thn nh lot, suy mn, vim ng tit niu, nhim khun
huyt, vim mng nhn ty hc ct ty vim xng ct sng...
2.4. Thi k mun:
Bt u t thng th 3 - 4 sau khi b thng v ko di 2 - 3 nm sau. Giai
on ny nu ty tn thng nh bt u hi phc. Nu ty tn thng
nng th cha c hoc khng c biu hin hi phc. Xut hin cc di chng
nh co qup chi th, si tit niu, thn nc v suy thn.
3. Triu chng vt thng CS-TS.
3.1. Triu chng ton thn:
+ Ri lon tri gic (RLTG):
RLTG gp ch yu trong vt thng CS-TS c cao, chim trn 50%; c
thp khong 25%, ngc cao 12%. VTCS-TS tht lng t khi gp RLTG.
RLTG biu hin t trng thi chong vng cho n mt thc ngn trong
khong thi gian vi pht n vi gi. RLTG vi biu hin hn m ngay sau b
thng c th do chn ng no km theo, do c ch bo v ca v no.
+ Ri lon h hp (RLHH):
Vt thng CS - TS c cao (CI-CIV) thng biu hin RLHH nng c th
ngng th ngay sau khi b thng. Trng hp nh hn, biu hin th chm,
kh th. Do cc c h hp b lit nn thng binh khng th ho v tng cc cht
m ri ra ngoi, v th hay gy n tc ng h hp trn lm cho tnh trng
chung ca BN ngy cng trm trng hn.
Cc VTCS -TS ngc thp v tht lng biu hin RLHH nh hn.
+ Thay i mch v huyt p ng mch (HAM):
c im VTCS-TS c l mch chm c khi ch 40 - 50 ln/pht. HAM
gim thp di 90/50 mmHg mc d khng c mt mu do vt thng v khng
c chy mu do tn thng kt hp cc c quan khc. i khi HAM gim thp
ko di hng tun mc d truyn dch v mu nhng HAM khng thay i
(do sc ty gy nn). VTCS -TS ngc v tht lng th s thay i v mch v
huyt p c khi khng ng k thm ch trong gii hn bnh thng.
+ Thay i nhit :
VTCS -TS c cao trong nhng gi u, nhng ngy u sau b thng
nhit c th gim ch cn 340C - 350C, rt hn hu tng ln ti 380C - 390C.
Nhng ngy sau nhit c th tng cao l do ph ty, do nhim trng vt
thng hoc do vim phi, do lot, do vim ng tit niu...
3.2. Triu chng thn kinh:
+ Giai on sc ty: sc ty xy ra ngay sau khi ty b tn thng v ko
di 3 - 4 tun thm ch lu hn. Tn thng ty cng nng th sc ty cng
ko di. Biu hin sc ty l lit mm, mt tt c cc loi cm gic v phn
x t ch tn thng tr xung, ri lon c tht biu hin b tiu, ri lon dinh
dng biu hin lot, ph chi th...
+ Giai on sau sc ty (sau 4 - 5 tun hoc lu hn): cc phn x bnh l
ca ty biu hin r hn v lc ny mi phn bit c lit trung ng (TW)
hay lit ngoi vi:
- Lit TW: biu hin lit cng, tng phn x gn xng, phn x bnh l
b thp vi du hiu Babinski (+), t ng ty r, rung git bn chn (clonus
+).
- Lit ngoi vi: biu hin lit mm, mt phn x gn xng, khng c
phn x bnh l b thp, Babinski (-), khng c t ng ty, chi th teo nhanh.
4. Triu chng nh khu VTCS -TS.
4.1. Vt thng CS-TS c cao (CI-CIV):
L vt thng nng, thng binh c th t vong ngay sau khi b thng.
Nhng trng hp sng st thng rt nng vi cc biu hin sau.
+ Giai on sc ty:
- Mt thc (hn m) ngay sau b thng.
- Lit t chi kiu TW; nhng trong giai on sc ty nn biu hin lit
mm t chi, mt phn x gn xng v cha xut hin phn x bnh l b
thp.
- RLHH biu hin th kh khn. C trng hp khng c kh nng t th,
phi th bng my c khi ko di hng thng, vi thng thm ch c trng hp
hng nm.
- Mch c th chm 50 ln/pht, HAM gim thp 90/50 mmHg ko di
(do sc ty).
- Ri lon thn nhit biu hin nhit c th gim thp c khi 340C -
350C trong nhng ngy u.
+ Giai on sau sc ty: lit TW t chi vi biu hin: lit cng t chi, tng
phn x gn xng v xut hin phn x bnh l b thp (+)...
4.2. Vt thng CS -TS c thp (CV-DI):
+ Giai on sc ty:
- Mt thc ngay sau khi b thng gp 25 - 30% cc trng hp.
- ang trong giai on sc ty nn biu hin lit mm t chi.
- RLHH v tim mch nng, trng hp nng t vong sau vi ngy hoc
mt vi tun.
- C th c hi chng Claude-Bernard-Horner do tn thng thn kinh giao
cm c: biu hin 1/2 mt pha ty tn thng ng , hp khe mi, ng t
co nh v nhn cu nh tht li v sau.
 - Nu tn thng 1/2 ty th c biu hin hi chng Brown-Sequard: pha
ty tn thng lit 1/2 ngi kiu TW, nhng cn cm gic au; pha na ngi
i bn khng lit nhng mt cm gic au.
+ Giai on sau sc ty: lit ngoi vi 2 tay v lit TW 2 chn.
4.3. Vt thng CS-TS ngc cao (DII-DX):
+ Giai on sc ty:
- Lit mm hon ton 2 chn (do sc ty).
- Mt hon ton cm gic au, xc gic tinh t v cm gic su t ch tn
thng tr xung.
Khi khm cm gic au cho php ta xc nh on ty tn thng v t
suy ra t sng tn thng, v d: nu mt cm gic au t lin sn IV tr
xung l do tn thng on ty D5 (tng ng vi t sng DIII). Mt cm gic
au t ngang b sn tr xung l tn thng on ty D7-D8 (tng ng t
sng DV-DVI). Mt cm gic au t ngang np bn tr xung l tn thng
on ty D12-L1 (tng ng t sng DX-DXI).
+ Giai on sau sc ty: lit TW 2 chn vi biu hin: lit cng2 chn,
tng phn x gn xng xut hin phn x bnh l b thp (+)...
4.4. Vt thng CS -TS ngc thp v tht lng (DXI-LV):
+ Giai on sc ty:
- Lit mm 2 chn.
- Hay gp hi chng phc mc gi do lit rut c nng (bng trng cng v
au, khng trung tin) d nhm vi tn thng c quan trong bng. Cn
khm xt k trnh b st tn thng.
- Nu tn thng ct sng LII-LV v cc r thn kinh biu hin hi chng
ui nga vi triu chng lm sng l lit hon ton 2 bn chn (cn gp v
dui c i v cng chn), ri lon cm gic vng yn xe tc l mt cm
gic au vng hu mn v sinh dc, ri lon c trn biu hin khng gi c
nc tiu.
+ Giai on sau sc ty: biu hin lit ngoi vi 2 chn (lit mm), mt
cm gic au t np bn tr xung, mt phn x gn xng, 2 chn teo nhanh.
5. Cc bin chng ca VTCS -TS.
5.1. Bin chng sm:
L bin chng xut hin thi k cp tnh v thi k sm, tc l ngay sau
b thng v ko di 1 - 2 tun u sau khi b thng, vi biu hin:
+ Sc chn thng: do au n kt hp vi tn thng cc c quan khc.
+ Sc mt mu:
Do tn thng ng mch i theo r thn kinh, do tn thng phn mm
rng hoc do chy mu c quan khc (ngc, bng hoc chn tay...). Sc chn
thng v sc mt mu l nguyn nhn chnh gy t vong ngay nhng gi
u hoc nhng ngy u sau b thng.
+ Sc ty:
Sc ty xy ra ngay sau khi ty b tn thng vi biu hin mt ton b cc
chc phn ca ty t ch tn thng tr xung nh lit ngoi vi, mt tt c cc
loi cm gic v phn x, ri lon thn kinh thc vt nh mch c th chm,
HAM gim thp, nhit c th gim trong tn thng ct sng ty c cao.
Sc ty ko di 3 - 4 tun v thm ch lu hn. Tn thng ty cng nng
th sc ty cng ko di.
+ Nhim khun vt thng:
Nu vt thng khng c ct lc k u, vt thng bn s biu hin
lm m vt thng, st cao, mt mi; xt nghim mu thy bch cu tng
cao...
+ Vim phi: hay gp trong tn thng ty c. Vim phi ch yu do n
tc ng h hp trn vi biu hin st cao, rt run, au tc ngc v ho...
+ Vim ng tit niu: biu hin vim bng quang nh nc tiu c, st,
rt run, au tc vng h thn v au rt vng bng quang; xt nghim mu:
bch cu tng cao, cng thc bch cu chuyn tri...
+ Lot vng cng-ct: tn thng ty cng nng lot cng sm v lot
rng, su. Thng hay lot vng b t nn lu ngy nh vng cng-ct, xng
b vai, mt c ngoi...
+ Nhim khun huyt: nhim khun huyt hay gp trong VTCS-TS tht
lng-cng. Vi khun t vt lot, t bng quang vim, hoc t m vt thng s
vo mu v gy nhim khun huyt (biu hin: st cao, rt run, mch nhanh,
HAM thp, tnh trng nhim trng nhim c, mt mi, xt nghim mu:
BC tng cao; cy mu c th bt c vi khun gy bnh). Nu khng c
iu tr tt c th t vong.
+ Suy mn suy kit: l hu qu ca mt dch, mt mu qua vt thng,
vt lot; do st cao ko di, nui dng km, n ung t, do tn thng ty
gy ri lon s hp thu ca rut... (biu hin: c th gy yu, st cn, da nhn
nheo do mt nc, c th ph do thiu dng, xt nghim mu: proteine mu v
hng cu gim thp...).
4.2. Bin chng mun:
L cc bin chng xut hin sau 1 - 2 thng b thng tr i. Trong thi gian
ny cc bin chng sm c th cn ko di dai dng vi thng sau, do vy c
th gp:
+ Vim ng tit niu (vim bng quang, vim niu o, vim tinh hon
v c th vim b thn..).
+ Lot cc im t, c bit lot cng-ct.
+ Si tit niu (si bng quang, si b thn...).
 + Nhim khun huyt.
+ Suy mn, suy kit.
+ Ct ty vim xng ct sng.
+ au ti ch v lan xuyn do vim dnh cc r thn kinh, vim mng nhn
ty.
+ Co qup chi th do au n ko di; teo c, cng khp v bin dng chi
th...
6. iu tr VTCS-TS.
6.1. iu tr ngoi khoa:
Cn tin hnh ct lc ngoi khoa k u sm (tt nht trong vng nhng
gi u hoc trong 3 ngy u sau khi b thng). Ly b trit cc d
vt trong iu kin cho php.
Nu vt thng do mnh nh, ming vt thng c th lin sau mt vi
ngy b thng th nn chuyn BN v tuyn sau gii quyt chuyn khoa.
+ Ch nh v chng ch nh ct cung sau t sng:
- Ch nh: trong trng hp vt thng thu ty; chn p ty mt cch t
t sau khi b thng; chy dch no ty (DNT) ko di; trong trng hp au r
thn kinh cp tnh sau b thng; gy v cung sau chn p ty...
- Chng ch nh: thng binh ang b sc nng; nhng trng hp c cc
vt thng ngc hoc bng km theo; trng hp vt thng cnh ct sng m
trn phim chp ct sng qui c khng thy tn thng ct sng v khi chc ng
sng tht lng (OSTL) khng thy c chn p ty; trong iu kin trang thit
b v phng tin khng tin hnh phu thut.
+ K thut ct cung sau:
- Ct lc ming vt thng tit kim, ct b t chc c gip nt.
- Cm mu bng nht gc. Ch khi nht gc v y c sang bn phi lm
nh nhng trnh gy tn thng ty do cc mnh xng v. M rng vt
thng bng banh t ng.
- Ct dy chng lin gai v dy chng lin cung sau ca t sng tn
thng. Ly b cc xng v gy p ty, ly b cc d vt kim kh, bm
ra vt thng v ly ht cc d vt. Nu mng cng rch th sau khi bm ra
sch mi c php khu kn mng cng bng cc mi ch tha (nu vt
thng bn, m mun th khng nn ng kn mng cng).
- Kim tra cm mu, t dn lu v ng vt m (khu c, cn c, di
da v khu da).
6.2. iu tr ton thn:
+ Khng sinh ton thn liu cao c ph tc dng rng.
+ Sn sc chng lot: nm trn ging m mm c vn cng di. Tr
mnh 1 gi/ln, xoa bp tp vn ng chi lit.
 + Gii quyt b tiu: t ng thng tiu qua niu o bng sonde Foley c
16-18. C 5 - 7 ngy thay ng thng tiu mt ln. Nc tiu c dn ra bnh
kn v trng.
+ Khi bng quang (BQ) b vim c biu hin nc tiu c, nng rt vng
BQ, st cao rt run th cho ra BQ ngy 2 ln. Mi ln ra 2 lt nc mui sinh
l 9%0 c pha khng sinh streptomycine. Ra cho n khi no ht st, nc tiu
trong...
Sn sc tit niu l cng vic rt phc tp, kh khn v lu di (bt u
t khi b thng cho n ht qung i cn li ca ngi bnh).
+ Nui dng tt bng truyn dch, truyn m v truyn mu liu nh mi
tun 250 ml. n ung cc cht giu m v sinh t...
+ Chng to bn bng cch n nhiu rau, hoa qu, ung nhiu nc.
Khi to bn cn tht tho, ung cc thuc nhun trng.
Tn thng dy thn kinh ngoi vi

Bi Quang Tuyn

1. i cng.
1.1. Nguyn nhn:
+ Tn thng m: do vt thng ho kh, tai nn trong lao ng v trong sinh
hot.
+ Tn thng kn: gp trong tai nn giao thng, th thao, luyn tp qun
s: dy thn kinh (TK) b bm gip, ko cng qu mc.
+ Do bnh l: u dy TK; vim dy TK; do nhim c; p mn tnh
trong hi chng sn c VII; hi chng ng c tay.
+ Do thy thuc gy nn: do tim truyn; garo ko di; tai bin trong phu
thut; do chiu tia x ko di.
1.2. Phn loi tn thng dy thn kinh ngoi vi
(TKNV):
Da theo phn loi ca SEDDON:
+ Mt dn truyn thn kinh (neurapraxia): dy TK ch mt chc nng dn
truyn ch khng c tn thng thc th cc si TK. Nhn b ngoi dy TK
cn nguyn vn. Kh nng hi phc hon ton chc nng dy TK s din ra sau
vi gi, vi ngy hoc vi tun.
Ch c th chn on l neurapraxia sau khi dy TK hi phc hon
ton chc nng. Neurapraxia cn c gi l chn ng dy thn kinh.
+ t si trc thn kinh (axonotmesis): nhn b ngoi dy TK cn nguyn
vn nhng trong dy c mt s si TK b t hoc bm gip nng. S
hi phc chc nng dy TK l c kh nng nhng phi ch thi gian v s hi
phc l khng hon ton. axonotmesis chnh l gip dy thn kinh.
 + t dy thn kinh (neurotmesis): l tn thng t hon ton hoc
khng hon ton dy TK. Kh nng t hi phc chc nng dy TK l khng
th c m phi can thip bng phu thut mi c hy vng hi phc chc nng
ca dy TK.
1.3. i cng v s thoi ho v ti to:
Khi dy TK b t ri hon ton, 2 u dy s xy ra ng thi 2 qu
trnh thoi ho v ti to.
+ u ngoi vi:
- Qu trnh thoi ho (dgenration): cc si thn kinh u ngoi vi b t
khng cn lin h c vi u trung tm s b thoi ho nng n cho ti tn cc
nhnh TK phn b cho c v da. Qu trnh thoi ho ny gi l thoi ho Waller
(Vale).
Qu trnh thoi ho din ra nh sau: mng myeline ca si TK b ph hy v
tiu i nn khng cn kh nng dn truyn thn kinh. S thoi ho mng
myeline bt u gi th 24 - 48 sau khi dy TK b tn thng v khong 3 -
4 tun sau qu trnh thoi ho ny s kt thc.
- Qu trnh ti to: khi qu trnh thoi ho ang din ra th ng thi u
ngoi vi cng din ra qu trnh ti to. Qu trnh ti to din ra ngy th 3 sau
khi dy TK b tn thng (xy ra mun hn qu trnh thoi ho 2 ngy). Cc t
bo Schwann c sn sinh nhiu hn v chng sp xp li cc si trc thn
kinh, to thnh ng ni m thn kinh ch n si trc thn kinh t u
trung tm pht trin xung.
S pht trin ca t bo Schwann t cao tun th 3 v tun th 4.
Nu cc si trc u trung tm pht trin xung nhng khng chui c vo
ng ni m thn kinh, th ng ni m TK ny s b co dm li v on ngoi vi
s dn dn teo i.
+ u trung tm:
- Qu trnh thoi ho: mt s si TK u trung tm b thoi ho ging nh
cc si TK u ngoi vi, gi l thoi ho ngc chiu. Trong trng hp tn
thng m ri thn kinh cnh tay mc nng, s thoi ho ngc chiu c
th pht trin ti tn cc t bo TK ty sng.
- Qu trnh ti to: tuyt i a s cc si TK u trung tm s pht trin
xung tip ni vi u ngoi vi. Trong iu kin thun li, cc si TK
u trung tm s chui c vo ng ni m TK u ngoi vi v s din ra
qu trnh ti to li si TK v chc nng dy TK dn dn c hi phc.
Ngi ta nhn thy rng: tc pht trin ca cc si TK u trung tm
mi ngy c 1 - 2 mm.
Trong iu kin khng thun li (do mu cc, c gip nt, t chc lin kt
pht trin xen vo gia 2 u dy TK b t), cc si TK u trung tm
pht trin xung nhng khng chui c vo ng ni m TK, chng pht trin
theo cc hng khc nhau, cun trn li v to nn u x thn kinh.
2. Triu chng lm sng v cn lm sng.
2.1. Ri lon vn ng (RLV):
+ Nu tn thng hon ton dy TK, biu hin RLV l lit cc c m
dy TK chi phi. Do c i khng khng b lit s co v lm cho bin
dng bn tay hoc bn chn, v d: bn tay r c c do lit dy TK quay;
bn tay vut tr do tn thng dy TK tr.
+ Nu tn thng khng hon ton dy TK th chc nng vn ng ca
dy TK ch mt mt phn.
2.2. Ri lon cm gic (RLCG):
Biu hin mt hon ton hoc khng hon ton cm gic au m dy
TK chi phi. Thng vng cm gic au bao gi cng hp hn vng phn chia
cm gic v phng din gii phu.
Trong trng hp tn thng khng hon ton dy TK s c hin tng kch
thch gy au tng hn vng dy TK chi phi; cm gic kin b (d cm)
hoc cm gic bng but.
2.3. Ri lon dinh dng v thn kinh thc vt
(TKTV):
+ Ri lon dinh dng: teo c m dy TK chi phi. Mun hn c th lot
da, tha xng, mng tay, mng chn mt bng, kh gin d gy.
+ Ri lon bi tit m hi vng dy TK chi phi. Lng bn tay hoc bn
chn lc no cng t hoc kh rp khng c m hi.
+ Ri lon vn mch: da lnh, gi tay ln cao th trng bt, thng tay
xung th tm ti.
2.4. Chn on cn lm sng:
Chn on in thn kinh: nu kch thch in t ngy th 2 sau tn
thng hon ton dy TK tr i s thy s co c gim dn theo thi gian v
mt hn khng cn s co c ngy th 12 - 15, ngha l khng cn hin tng
dn truyn in, c khng co, thoi ho in hon ton.
3. Tn thng m ri thn kinh cnh tay.
3.1. Nhc li gii phu:
m ri TK cnh tay c to nn bi 5 ngnh trc ca cc r TK c C5, C6,
C7, C8 v D1 (hnh 1).
 Hnh 1: m ri thn kinh cnh tay.
1. Thn nht trn; 9. Dy TK m;
2. Thn nht gia; 10. Dy TK b cng tay trong;
3. Thn nht di; 11. Dy TK gia;
4. Thn nh sau; 12. Dy TK quay; 13. Dy TK tr;
5. Thn nh trc trn; 14. Dy TK b cnh tay trong;
6. Thn nh trc trong; 15. Dy TK ngc di;
7. ng mch cnh tay; 16. Nhnh dy TK di n;
8. Dy TK c b; 17. Dy TK ngc lng.
Cc r ny to thnh 3 thn nht, ri sau to nn 3 thn nh v t cc
thn nh cho ra cc dy TK chi trn, c th nh sau:
3.1.1. Thn nht:
9------- 10------
+ Thn nht trn: do r C5, C6 to nn. 11------ 12 --------
+ Thn nht gia: do r C7, C8 v D1 to nn.
+ Thn nht di: do r C8 v D1 to nn.
3.1.2. Thn nh:
+ Thn nh ngoi (thn nh trc trn): do ngnh trc ca thn nht gia
to nn. Thn nh ngoi cho ra cc dy:
- Dy TK c b (C5, C6, C7).
- R ngoi dy TK gia (C5, C6, C7, C8 v D1).
+ Thn nh di (thn nh trc trong): do ngnh trc ca thn nht di tr
thnh thn nh di, cho ra cc dy:
- Dy TK tr (C7, C8, D1).
- R trong dy TK gia (C5, C6, C7, C8, D1).
- Dy TK b cnh tay trong.
- Dy TK b cng tay trong.
+ Thn nh sau: do cc ngnh sau ca 3 thn nht to nn, cho ra cc dy:
- Dy TK m (C5, C6).
- Dy TK quay (C5, C6, C7, C8, D1).
- Dy TK di vai di.
- Dy TK di vai trn.
 - Dy TK ngc lng.
3.2. Triu chng lm sng:
3.2.1. Tn thng hon ton m ri TK cnh
tay:
+ Mt vn ng hon ton chi trn.
+ Mt ton b cc loi cm gic v phn x gn xng ca chi trn.
+ C th gp hi chng Claude-Bernard-Horner: co hp ng t; hp khe
mi; nhn cu tht li v sau.
3.2.2. Tn thng thn nht trn (hi chng Duchen -
Erb):
+ Lit c Delta do tn thng dy TK m: khng gi c cnh tay ln cao.
+ Lit c nh u do tn thng dy TK c b: khng gp c cng tay
vo cnh tay.
+ Biu hin lit v teo c gc chi; chc nng ca bn tay v ngn tay do
dy TK quay, tr, gia chi phi vn cn nguyn vn.
+ Gim cm gic au b ngoi ca vai, cnh tay, cng tay v nn t bn
mt.
3.2.3. Tn thng thn nht gia:
Do r C7 to nn, khi tn thng biu hin ch yu l lit dy TK quay.
+ Lit cc c dui: khng dui c c tay v t 1 cc ngn.
+ C nga di v c nga ngn khng lit. Cn phn x gn c tam u.
+ Mt cm gic au mt sau cng tay v mu tay.
3.2.4. Tn thng thn nht di (hi chng aran-Duchen hay Dejerin-
Klumpke):
Tn thng thn nht di l tn thng r C8, D1; biu hin ch yu l
lit dy TK tr.
+ Dng v khp cc ngn khng lm c.
+ Teo cc c lin ct; c gp ngn tay; teo c tr trc; teo cc c m t nn
ng tc gp bn tay v khp bn tay b mt.
3.2.5. Tn thng thn nh ngoi (thn nh trc trn):
+ Lit c nh u v c cnh tay trc: khng gp c cng tay vo cnh
tay do tn thng dy TK c b.
+ Lit c sp trn, c gan tay ln v c gp ngn ci: khng gp c ngn
ci v sp bn tay kh khn.
3.2.6. Tn thng thn nh di (thn nh trc trong):
+ Biu hin tn thng mt phn dy TK gia.
+ Tn thng mt phn dy TK tr.
+ Mt cm gic mt trong cnh tay v cng tay.
 3.2.7. Tn thng thn nh sau:
+ Biu hin tn thng dy TK quay: khng dui c c tay v t 1 cc
ngn tay; mt phn x c tam u.
+ Lit dy TK m: khng gi c cnh tay ln cao.
+ Ri lon cm gic au vng c Delta, mt sau ngoi mu tay, cng tay v
cnh tay.
4. Tn thng cc dy thn kinh chi trn.
4.1. Tn thng dy TK m (nervus axillaris):
Dy TK m do r C5, C6 to nn, tch ra t thn nh sau. Hay gp tn
thng dy TK m trong trng hp sai khp vai; gy xng b vai hoc xng
n; gy chm xng cnh tay; chn thng ng gip vng b vai. Lm sng:
+ Lit v teo c Delta.
+ Mt cm gic au vng c Delta.
4.2. Tn thng dy TK quay (N. radialis):
4.2.1. Gii phu:
Dy TK quay do r C7 to nn, tch ra t thn nh sau. cnh tay, dy
chy trong rnh xon xng cnh tay, vng t sau ra trc vo rnh c nh
u ngoi. Ti y phn ra 2 nhnh vn ng v cm gic. Nhnh vn ng
cho cc c tam u cnh tay; c quay cnh tay cn gi l c nga di (tc dng
nga bn tay nhng ch yu l gp cng tay vo cnh tay); c quay nht v c
quay nh tc dng dui c tay; c dui t 1 ngn tay; c nga ngn; c dui
di ngn ci; c dng di ngn ci; c tr sau (c dui c tay tr).
4.2.2. Chc nng sinh l:
Dy TK quay chi phi cc ng tc dui cng tay; dui c tay; dui t 1
cc ngn tay v dng ngn ci.
4.2.3. Nguyn nhn tn thng:
Hay gp trong gy thn xng cnh tay; gy chm xng quay; gy xng
kiu Monteggia (gy xng tr km sai khp tr quay). Do thy thuc gy nn
nh tim, garo ko di; do phu thut kt xng cnh tay; do vim; do gi u
tay trong lc ng.
4.2.4. Triu chng lm sng:
+ Tn thng dy TK quay hm nch:
- Bn tay r c c in hnh (hnh 2).
- Khng dui c c
tay v t 1 cc ngn tay.
- Khng dng c ngn ci.
- Khi t 2 lng bn tay p st
vo nhau ri lm ng tc tch nga 2
bn tay th bn tay b lit TK quay

Hnh 2: Hnh nh tn thng TK quay v

du hiu tch nga bn tay.
s khng n thng ln c m gp li v tri trn lng bn tay lnh (do tn
thng c nga ngn).
- Mt phn x c tam u cnh tay v phn x trm quay.
- Ri lon cm gic mt sau cnh tay, cng tay v r nht l khe lin t
bn 1 v 2 trc h lo.
- Ri lon dinh dng biu hin ph mu bn tay.
+ Tn thng dy TK quay 1/3 di xng cnh tay: l v tr hay gp tn
thng vi biu hin lm sng nh cc
triu chng tn thng hm nch nhng
c tam u khng b lit nn dui c
cng tay v cn phn x gn c tam
u.
+ Tn thng dy TK quay 1/3 trn
cng tay: y l ch phn ra 2 nhnh
vn ng v cm gic, khi tn thng
biu hin lm sng:
- Dui c tay cn nhng yu. Hnh 3: S
- Khng dui c t 1 cc ngn. phn b
- Ri lon cm gic mu tay v pha thn kinh da
lng ngn tay ci (hnh 3). bn tay.
4.3. Tn thng dy TK gia (n. medialis):
4.3.1. Gii phu:
Dy TK gia c to nn bi r C5, C6, C7, C8 v D1. Dy tch ra t thn
nh trn v thn nh di. Phn nhnh vn ng cho cc c gan tay ln v gan
tay b c tc dng gp c tay; c sp trn v c sp vung tc dng gp bn
tay; c gp chung nng v c gp chung su; c giun 1 v 2; c gp ngn ci;
c i chiu ngn ci.
Chi phi cm gic lng bn tay, ngn I, ngn II, ngn III v na ngoi ngn
IV. Pha mu tay t t cui cng cc ngn II, III, IV.
4.3.2. Chc nng sinh l:
Dy TK gia l dy ca bn tay c chc nng cm nm, gp bn tay vo
cng tay, sp bn tay, gp t 2 cc ngn, gp t 3 ngn tr v ngn gia,
gp t 1 ngn ci v lm ng tc i chiu.
4.3.3. Nguyn nhn tn thng:
Do vt thng bi vt sc nhn; do gy u di xng cnh tay hoc
u trn xng quay; do thy thuc gy nn nh garo ko di; tai bin trong
phu thut nn sai khp khuu; do tim thuc c canxi ra ngoi tnh mch
np khuu; do chn p mn tnh ng c tay (hi chng ng c tay).
 4.3.4. Triu chng lm sng:
+ Bn tay mt kh nng cm nm: bnh nhn khng lm c ng tc
nm vo thn v chai ri nhc ln cao (hnh 4).
+ Khng lm c ng tc i
chiu ngn ci vi cc ngn do lit c
gp ngn ci.
+ Khng gp c ngn tr v ngn
gia: bo bnh nhn nm bn tay th
ngn tr v ngn gia lun dui thng
trong khi ngn IV v V vn gp
bnh thng.
+ Teo c m ci, bn tay gy
guc v ngn ci lun p st vo ngn
tr to nn t th c o ca bn tay
gi l bn tay kh.
+ Ri lon cm gic vng dy TK
chi phi: mt hoc tng cm gic au
lng bn tay v cc ngn. Nu tn
thng khng hon ton dy TK gia
Hnh 4: hay gp hi chng bng but.
+ Ri lon dinh dng v thc vt: teo c m ci; lng bn tay nhm nhp
m hi; ri lon vn mch, bn tay tm ti khi thng tay v trng bt khi gi tay
ln cao; teo da nn u ngn tay thon nh, mng tay m c d gy.
4.4. Tn thng dy TK tr (n. ulnaris):
4.4.1. Gii phu:
Dy TK tr c to nn bi r C7, C8 v D1; tch ra t thn nh di v
phn nhnh vn ng cho cc c tr trc, 2 b trong c gp chung su; cc c
m t; c lin ct; c giun 4 v 5; c khp ngn ci v b trong c nga ngn
ngn ci. Phn nhnh cm gic cho ton b ngn t v na ngn nhn.
4.4.2. Chc nng sinh l:
Lm nhim v gp c tay; khp nh bn tay; dng v khp cc ngn; dui
t gia v t cui cc ngn IV v V; gp t 1 ngn IV v V.
4.4.3. Nguyn nhn tn thng:
Chn thng gy u di xng cnh tay; gy u trn xng tr; sai khp
khuu; gy kiu Monteggia; t li khp khuu hoc gar ko di.
4.4.4. Triu chng lm sng:
+ Bn tay c du hiu vut tr, biu hin t 1 ngn IV v ngn V dui,
trong khi t 2 v 3 li gp (hnh 5).
 + Khng lm c ng tc dng v
khp cc ngn do lit c lin ct.
+ Khng lm c ng tc khp
ngn ci (do lit c khp ngn ci): cho
bnh nhn kp t giy vo khe gia
ngn I v II 2 tay ri bo bnh nhn
ko cng t giy, bn tn thng s khng
gi c t giy.
+ Teo c m t; teo cc c lin ct v
teo c khp ngn ci. Mt cm gic au
r nht l ngn t.
5. Tn thng cc dy thn kinh chi
di. Hnh 5:
m ri thn kinh cng c to nn bi Hnh
cc r tht lng L4, L5 v cc r S1, S2, S3. m ri nm mt trc xng cng
v cho ra cc dy: dy TK hng to; dy TK mng trn; dy TK mng di (cn
gi l dy TK hng b) v dy TK da i sau. Cc dy TK u chui qua l
m hng ln ra ngoi.
5.1. Tn thng dy thn kinh hng to:
5.1.1. Gii phu:
Dy TK hng to (n. ischidiacus) l dy TK ln nht v di nht trong c
th, c to nn t m ri cng. Dy TK hng to sau khi chui qua l m hng
ln ra ngoi nm di c thp v nm gia c mng ln pha sau v cc c sinh
i, c vung i, c bt pha trc. Dy TK nm gia khe ngi v mu
chuyn ln (khi vim dy TK hng to, nu n vo vng ny rt au gi l
im Valleix), ri dy TK chy dc chnh gia mt sau i n hm khoeo
th chia ra 2 nhnh cng l: dy TK hng khoeo ngoi (cn gi l dy thn
kinh mc chung) v dy TK hng khoeo trong (cn gi l dy TK chy).
Thc ra, dy TK hng to nm trong chu hng b c s tch bit r
rt cc b ca dy TK hng khoeo trong v hng khoeo ngoi ri.
Dy TK hng to chia ra nhnh bn chi phi vn ng c bn gn, bn mc
v c nh u i.
5.1.2. Chc nng sinh l:
Chi phi ton b vn ng ca bn chn; gp bn chn v pha mu v
v pha gan chn; xoay bn chn ra ngoi v vo trong; gp cng chn vo
i.
5.1.3. Nguyn nhn tn thng:
Do vt thng ho kh, vt sc nhn; chn thng gy xng chu, gy sai
khp hng; tai bin trong phu thut vo khp hng, khi tim mng.
 5.1.4. Lm sng:
+ Tn thng hon ton dy TK hng to np mng s c nhng biu hin
sau:
- Lit hon ton vn ng bn chn v cc ngn chn
- Mt phn x gt; mt cm gic au ton b cng chn v bn chn.
- ng tc gp cng chn vo i cn nhng yu (l nh c thng trong,
c may v c khoeo trong).
- Tn thng khng hon ton dy TK hng to: lit khng hon ton bn
chn v hay gp hi chng bng but.
5.2. Tn thng dy thn kinh hng khoeo ngoi:
5.2.1. Gii phu:
Dy TK hng khoeo ngoi (n. peronaeus) (cn gi l dy TK mc chung)
phn ra 2 nhnh :TK mc nng v TK mc su.
+ Thn kinh mc nng (dy TK c b): chi phi vn ng c mc di, c
mc ngn c tc dng gp bn chn v pha mu v xoay bn chn ra ngoi
v cho nhnh cm gic.
+ Thn kinh mc su (dy TK chy trc): chi phi vn ng c chy trc,
c dui di ngn ci, c dui chung cc ngn.
5.2.2. Chc nng sinh l:
Dy TK hng khoeo ngoi c tc dng gp bn chn v pha mu, xoay
bn chn ra ngoi v ng bng gt chn.
5.2.3. Nguyn nhn tn thng:
Do vt thng ho kh, vt sc nhn m phi; gy v sai khp gi; gy
chm xng mc; tai bin do b bt, phu thut ng cng khp gi.
5.2.4. Lm sng:
+ Khng gp c bn chn v pha mu chn.
+ Khng xoay c bn chn ra ngoi; khng dui c cc ngn chn.
+ Khi i bn chn thng xung; khi i li ngi bnh phi nhc cao bn
chn cc ngn chn khng vp phi ch t g gh.
+ Teo c khu trc cng chn; gim hoc mt cm gic au mt ngoi
cng chn v bn chn.
5.3. Tn thng dy TK chy (n. tibialis):
5.3.1. Gii phu:
Dy TK chy cn gi l dy TK hng khoeo trong, chi phi vn ng c
tam u cng chn; c gp di ngn ci; c chy sau; c khoeo v c gan
chn gy.
 5.3.2. Chc nng sinh l:
Gp bn chn v pha gan; ng bng mi chn (king gt); xoay bn
chn vo trong v gp ngn chn.
5.3.3. Nguyn nhn tn thng:
Gy u di xng chy c mnh ri km sai khp gi; tai bin trong kt
xng chy, can thip vo khp gi.
5.3.4. Lm sng:
+ Khng gp c bn chn v pha gan.
+ Khng ng c bng mi chn (khng king c gt chn).
+ Khng xoay c bn chn vo trong.
+ Teo c khu cng chn sau; mt phn x gt; khi i thng t gt chn
xung trc, gi l bn chn gt (pes calcaneus).
+ Gim hoc mt cm gic vng gan bn chn v cc ngn chn; mt sau
cng chn v mu t cui cc ngn chn.
+ Ri lon dinh dng v vn mch gan chn: bn chn lnh, nhm nhp
m hi, lot, gan bn chn trng bt, c lc tm ti...
6. Bin chng giao cm trong tn thng dy thn kinh ngoi vi.
6.1. Hi chng au bng (causalgie):
Causalgie xut pht t ch Hylp: causis ngha l bng v algos ngha l
au. Causalgie l th lm sng c bit, l bin chng giao cm thng
gp trong tn thng khng hon ton dy TKNV.
Hi chng au bng (cn gi l au chy, bng but) c Oemixen m t
u tin vo nm 1864. Bnh sinh ca hi chng causalgie cho ti nay vn cha
c r rng. Ngi ta cho rng bnh c lin quan ti tn thng cc si thn kinh
giao cm trong dy TK. Do vy m causalgie hay gp trong tn thng
khng hon ton dy TK c nhiu si thn kinh giao cm nh dy TK gia,
TK tr, dy TK hng to; dy TK chy v tn thng cc r C7, C8, D1.
Triu chng lm sng in hnh ca hi chng bng but nh sau:
+ au bng: au bng xut hin trc ht vng cm gic m dy TK
chi phi (hay gp lng bn tay, lng bn chn, u cc ngn tay...). Ngi
bnh c cm gic nh p thanh st nng vo da. Hay gp 2 th xung huyt
v th thiu mu.
- Th xung huyt: au theo nhp p ca mch mu; vng da xung huyt
, ra m hi.
- Th thiu mu: cm gic au bng, da kh; ri lon vn mch biu hin
da bt trng hoc tm ti, lnh v khng c m hi.
+ au thng xuyn, lin tc v xen k c nhng cn au bng pht d di.
 Tin trin ca au nhn thy nh sau: lc u ch au nh v khu tr
vng cm gic ca dy TK; au tng khi s trc tip vo vng au. Sau mt thi
gian au tng ln ti mc m mi kch thch bn ngoi vo gic quan ca ngi
bnh cng gy au d di: V d nh ting ko l guc dp ca ngi i bn
cnh; ting gi rt qua khe ca hoc ting st sot khi lt cc trang sch ca
ngi ngi bn cng gy bng pht cn au cho ngi bnh. Thm ch c bnh
nhn ku tht ln v au khi nhn thy thy thuc g ba phn x gi cho ngi
bnh ngi bn.
+ Cm xc vui bun, tc gin, lo s ca ngi bnh cng gy cm gic au
tng.
+ Triu chng khn m: v au v cm gic da kh nn ngi bnh bc
tay bng khn t hoc nhng bn chn vo chu nc au. Lu ngy
dn ti vim lot da, ri lon dinh dng, cc mng mt bng, khum hnh vm
d gy. Tha xng, thoi ho xng bn v ngn (hi chng Sudeck).
+ Trng thi tm thn kinh thay i, hay cu gin; nt mt lun cau c;
ngi tip xc vi mi ngi...
6.2. Hi chng au gi (phantoma):
Hi chng au gi hay cn gi l chi ma ch xut hin cc trng hp
ct ct chi th v au ch yu khu tr mm ct. Ngi bnh c cm gic nh
vn cn chi th v lun lun phn nn l au but n tn ngn tay hoc
ngn chn m thc t chi b ct ct.
Cn nguyn ca hi chng ny vn cha c r rng. Ngi ta cho rng do
mm ct c qu t c che ph do gy ri lon cung cp mu mm ct.
d phng hi chng au gi, khi ct ct chi th phi ct dy TK ng nguyn
tc v m bo c che ph mm ct.
iu tr bnh nhn c hi chng chi ma l tm l liu php kt hp thuc
phng b gim au. Nu khng khi phi phu thut sa li mm ct.
7. iu tr tn thng dy thn kinh ngoi vi.
7.1. Phu thut:
Cc vt thng (do ho kh, do vt sc nhn...) c ch nh phu thut
vo cc thi im sau:
7.1.1. Phu thut k u:
Tin hnh ngay sau khi dy TK b tn thng hoc 2 - 3 ngy sau, c
th:
+ Nu dy TK b t ri, vt thng sch, 2 u dy khng gip nt c
th x tr ct lc 2 u t v khu ni tn-tn 2 u dy vi nhau.
+ Nu 2 u dy b t nhng gip nt nhiu, sau khi ct lc m 2 u
dy gin cch ln th t 2 u dy nh hng vi nhau sau ny phu
thut tm 2 u dy d dng hn.
 7.1.2. Phu thut k hai:
Bao gm: phu thut k hai sm vo thi im 3 - 4 tun u sau khi
dy TK b tn thng v phu thut k hai mun trong thi gian 3 - 4 thng
u sau khi dy TK b tn thng.
Phu thut k hai mun bao gm: g dnh dy TK; khu ni dy thn
kinh v ghp dy thn kinh.
+ G dnh dy thn kinh (neurolyse):
Gm 2 k thut: g dnh ngoi dy v g dnh trong dy thn kinh:
- G dnh ngoi dy: l g dnh dy TK ra khi khi x so; ra khi ch
xng can gy p. Sau khi dy TK c g dnh v ct b t chc x
so, ngi ta t dy TK vo v tr mi v trnh dnh li ngi ta dng
cn i bc quanh dy TK.
- G dnh trong dy (cn gi l g
dnh trong bao): l m bao dy TK v
g dnh cc b TK b tn thng
trong dy (hnh 6). Sau khi cc b TK
c g dnh, ngi ta ct b ch tn
thng ri ni tn-tn cc b li vi nhau.
Nu sau khi ct m 2 u gin cch ln
> 1,5 cm khng c kh nng ko st 2
u li vi nhau c th phi bc
cu ni 2 u cc b li vi nhau bng
k thut ghp dy TK.
Hnh 6:
+ Khu ni G dnh cc b thn kinh trong dy.
tn-tn 2 u 1. Cc b thn kinh g dnh.
2. Ct v ghp cc b thn kinh.
dy thn kinh:
Nu dy TK b t to thnh u x thn kinh 2 u t. Sau khi ct b u
m gin cch 2 u khng ln (< 0,5 cm) v khi ko 2 u li vi nhau khng
lm cng dy, th c th tin hnh t cc mi khu vo bao ngoi ca dy
TK ni tn-tn 2 u dy TK vi nhau (hnh 7).
Sau khi khu ni phi c nh
chi th t th chng dy TK t 10-
14 ngy, sau cho tp vn ng
nh nhng kt hp vi vt l tr
liu.
Nhc im ca k thut ny l
nhn bn ngoi dy thn kinh sau
khi khu ni rt p, nhng bn

Hnh 7: Khu
trong cc b TK khng cng hng c th chng ln nhau. Do vy s phc hi
chc nng ca dy TK d b tht bi.
+ Ghp dy thn kinh t thn:
Khi mt on dy TK > 1,5 cm m mi bin php lm chng dy TK li
nhng khng kt qu, khng a st 2 u dy li vi nhau c, ngi ta phi
tin hnh bc cu ni 2 u t li vi nhau bng on dy TK t thn,
gi l ghp dy thn kinh t thn (hnh 8).
K thut Millesi: sa 2 u dy
TK b t, ct b u x 2 u cho ti
tn b lnh; cm mu trong dy
TK bng t in lng cc.
Ly dy TK chun b ghp:
thng ly dy TK b cng chn (n.
suralis); tin hnh ghp ni cc b
TK li vi nhau di knh vi phu,
bng ch 10/0 v b dng c chuyn
khoa.
7.2. iu tr tn thng
kn dy thn kinh ngoi
Hnh 8: vi:
Ghp dy Tn thng kn cc dy TK hoc
thn kinh (k m ri TK cnh tay, trc ht phi
c iu tr bo tnthut
mt cch tch cc kt hp vi nhiu bin php nh vt l
tr liu; xoa bp tp vn ng, chm cu; thuc chng so ho v tiu vim;
cc thuc lm tng kh nng dn truyn thn kinh.... Nu sau 1-2 thng iu
tr m khng thy c kt qu th cn nghin cu in thn kinh xem c th
phu thut c khng.
Phu thut trong tn thng kn dy TK cng nh tn thng m ri TK
cnh tay l rt kh, trc ht l khng xc nh c mt cch chc chn v
tr tn thng v mc tn thng. Trong nhiu trng hp tn thng m
ri TK cnh tay, cc si thn kinh b thoi ho c th ti tn ty sng, nn phu
thut cng kh mang li kt qu.
Nu s thy vng dy TK tn thng c mt khi x so, s thy u gy
xng chn p thn kinh hoc xut hin hi chng bng but, au tng ln th
cn tin hnh phu thut sm.
Chng 3
Bnh l h thn kinh
U no

Nguyn Th L
1. i cng.
U no (Brain tumor) l nhng u pht trin t trong hp s, xm ln v chn p
t chc no mt cch t t. U no ng hng th su i vi tt c cc u trong c
th.
1.1. Phn loi:
Theo t chc Y t th gii (WHO) u no c chia thnh 9 nhm.
+ U t bo biu m thn kinh.
- U t bo hnh sao (astrocytic tumor).
- U t bo thn kinh m t nhnh (oligodendroglial tumor).
- U mng ng ni tu (ependymomal tumor) .
- U hn hp t bo thn kinh m (mixed tumor).
- U mng mch (choroid plexus tumor).
- U khng r ngun gc.
- U hn hp t bo thn kinh v thn kinh m (neural and mixed neural
glial tumor).
- U tuyn tng (pineal tumor).
+ U nguyn pht t cc dy thn kinh s no.
+ U mng no (tumor meninges).
+ U mu (heamangioma).
+ U t bo mm (gern cell tumor).
+ U nang (cyst).
+ U thy trc tuyn yn (tumor of the anterior pituitary).
+ U xm ln t vm s hoc t nn s vo t chc no.
+ U di cn (metastatic tumor).
1.2. Nguyn nhn ca u no:
Cho ti nay nguyn nhn ca u no vn cha c bit mt cch r rng, song
cc nh khoa hc bit c mt s yu t nh hng ti bnh l u h thn
kinh trung ng. 15% bnh nhn u h thn kinh trung ng c tin s gia
nh mc bnh ung th. Trong 10 nm qua nhng thnh tu nghin cu gen
phn t cho thy s thay i cu trc gen t bo. Gi thuyt ny cho
rng giai on u do sai lch tn hiu tng hp Protein ca gen dn ti s
tng sn v lon sn ca t bo. Mt gi thuyt khc cho rng gen tng hp
Protein ca t bo u b kch thch.
Cc yu t mi trng nh hng ti bnh l ny. Cui nm 1970 n u
nm 1986, cng trnh nghin cu ca cc nh khoa hc Bc M v Thy in
thy rng t l cng nhn ngnh cng nghip ha du v cng nghip cao
su b mc bnh u no cao hn cc ngnh khc. iu ny thy r ng vt
thc nghim c dng cc cht hydrocarbon v vinylchlorid to u. Cc ni
tit t oestrogen, progesteron v androgen hoc mt s cht kch thch nh
thuc l c lin quan ti s pht trin ca u.
2. Hnh nh lm sng v cn lm sng u no.
2.1. Hnh nh lm sng.
+ au u.
au u l triu chng thng gp. Giai on sm au u gp 35% s
bnh nhn u no. Giai on mun au u gp 70%. Phn ln bnh nhn
au u tng cn, m , khng rm r nn kh phn bit vi au u do
cao huyt p. au u thng xy ra cng bn vi u. U h s sau thng chn p
vo dy thn kinh IX, X v cc dy thn kinh c gy au vng chm v vng
c. au u tng khi thay i t th, ho hoc ht hi. au u thng km
theo chng mt, bun nn v nn.
+ Ph gai th.
Ph gai th l du hiu ca tng p lc trong s. T l ph gai th bnh
nhn u no n mun gp 50 - 70%. Ngy nay nh chn on sm u no bng
k thut hin i nn t l ph gai th thp hn nhiu.
+ Cn co git ng kinh.
Mt phn ba s bnh nhn u no c biu hin cn co git ng kinh. Gn
mt na s biu hin cn co git cc b, s cn li l co git ng kinh
ton th. U no vng trn c cn co git cao hn c sau n vng nh, vng
thi dng v vng chm. U no vng thalamus v h sau t c biu hin cn co git
ng kinh. U no vng Rolando thng biu hin ng kinh l triu chng
u tin ca bnh.
+ Thay i trng thi tm thn.
Thay i trng thi tm thn gp 15 - 20% bnh nhn u no. Biu hin nh
gim tr nh, gim kh nng tp trung, thay i nhn cch, hoc trm cm, th
lnh m vi xung quanh.
+ Cc du hiu thn kinh khu tr.
Cc du hiu v triu chng thn kinh khu tr sau y c gi tr chn
on nh khu ca u.
+ U vng v: u vng trn biu hin ri lon nhn cch, mt kh nng kim
ch, d b kch thch. C th biu hin trm cm, th lnh m vi xung
quanh, i khi biu hin trng thi sng khoi bnh l. C th thy lit na
ngi, co git, ri lon ngn ng, xut hin cc phn x nm (grasping), phn x
vi (snont).
U mng no vng hnh khu c th mt ngi. U thu thi dng thng gy
cn co git, ri lon tr nh, ri lon ngn ng. U thu nh biu hin o
khu, cm gic lo s hoc sng khoi bnh l, ri lon nhn cch. U thu nh
bn tri gy ri lon ngn ng, mun hn gy lit bn i din, gim th trng
cng bn, mt phi hp ng tc v cn ng kinh cm gic. U thu chm c th
gy bn manh cng bn, ri lon mu sc.
+ U thn no.
U vng thalamus gy mt cm gic v lit na ngi i bn; mt kh nng
nhn thc vt, mt th lc v ri lon ngn ng. U vng ny c th gy tc
ng dn dch no tu dn ti trn dch no, tng p lc ni s biu hin au
u, nn v bun nn, ph a th...
+ U tuyn tng v no tht ba.
U tuyn tng gy chn p ng dn dch no tu dn ti trn dch no.
Khi u ln chn p gian no gy tn thng dy thn kinh s III v IV, ri lon
ni tit biu hin tr em l dy th sm.
+ U tiu no.
au u v tht iu l triu chng hay gp nht tr em c u tiu no. au
u vng chm km bun nn v nn; cng gy, rung git nhn cu; gim trng
lc c; tn thng dy thn kinh s no v tn thng b thp.
+ Cc du hiu tn thng dy thn kinh s no.
U vng nn s hay gy tn thng dy thn kinh hnh khu nh mt ngi,
ri lon th lc do u chn vo dy thn kinh th gic. U vng xoang hang hoc
thn no gy tn thng dy thn kinh s VI. U gc cu tiu no gy tn
thng dy thn kinh thnh gic nh ic hoc tn thng dy thn kinh VII
ngoi vi. U thn no hoc h s sau gy tn thng dy thn kinh IX, X, XI
v XII.
2.2. Chn on cn lm sng.
2.2.1. Chp X Quang qui c:
Chp 2 phim thng v nghing c th thy biu hin bnh l nh sau:
hnh nh ng vi hay gp trong u t bo hnh sao (chim 20%); u t bo
thn kinh m t nhnh (chim 50%); u s hu (chim 70%); u mng no
gp 10%.
Tng p lc ni s ko di thy hnh nh gin rng h yn v mn vt mm
yn; du hiu n im ch; gin rng l ng tai trong trn phim chp t th
Schuller v Stenvert.
2.2.2. Chp ct lp vi tnh (CLVT):
Chp CLVT c s dng rng ri chn on cc bnh nh u no; p xe
no; mu t ni s do chn thng hoc do tai bin mch mu no.... Trn nh
CLVT cho bit chc chn v tr v kch thc ca u, ngoi ra cn cho bit
phn no tnh cht t chc hc ca u no v s lin quan ca u vi t chc xung
quanh.
i vi u no c t trng thp hoc ng t trng vi m no lnh, ngi ta
tim cht cn quang nhn u c r hn.
2.2.3. Chp cng hng t (MRI: magnetic resonance imaging):
 Cng hng t (CHT) l k thut to nh khng dng tia x chn on
cc bnh l chon ch trong hp s. Khi c th ngi c t trong mt t
trng mnh, cc nguyn t trong c th c nh hng theo t trng ca my.
Sau khi pht sng v tt sng Radio, h thng my tnh s chuyn cc tn
hiu thnh hnh nh c gi tr cao chn on bnh. Chp cng hng t
c ch nh i vi bnh l h thn kinh trung ng (no v tu sng); h
xng khp; bng v lng ngc.
Chp CHT c u vit hn chp CLVT l c kh nng cho bit cc u c t
trng thp m trn CLVT khng pht hin c. Cho bit chc chn mi lin
quan ca u vi t chc xung quanh. Chp CHT c bit c gi tr trong chn
on u thn no; u h s sau; u vng tuyn yn...
2.2.4. Chp ng mch no (Angiography):
Trc khi c my chp CLVT ra i, vic chn on u no ch yu nh chp
ng mch no (MN). Thng qua hnh nh chn y MN ngi ta c th xc
nh c v tr ca u no. Chp MN cn cho bit tun hon mch mu quanh
u, cho bit bnh l mch mu no. T khi c chp CLVT v chp CHT th chp
MN khng cn vai tr quan trng nh trc y.
2.2.5. in no (Electroencephalography - EEG):
Trn in no, vng c u thng biu hin sng c in th thp, sng
chm hoc c nhng sng nhn. Tuy nhin hnh nh in no ch pht hin
1/3 bnh nhn u no. U v no hoc gn v no thng biu hin thay i
trn in no r hn. U thn no v u h s sau nhiu trng hp in no vn
bnh thng.
2.2.6. Xt nghim dch no tu:
Xt nghim dch no tu (DNT) chn on phn bit gia u no v
vim no mng no do vi khun. Trong u no biu hin phn ly albumin v t
bo (albumin tng cao nhng t bo bnh thng). Ngc li, vim mng no do vi
khun th albumin tng cao v ng thi bch cu cng tng cao, thm ch c
th thy c t bo m. Chc ng sng tht lng (OSTL) c th xy ra nguy c
tt kt no v gy ri lon nghim trng chc phn sng, c th t vong. Do
vy, chng ch nh chc OSTL trong trng hp tng p lc ni s v u h s
sau...
3. iu tr.
3.1. Phu thut:
Hu ht cc u no c ch inh phu thut. Tu thuc vo v tr, kch
thc ca u, ngi ta c th tin hnh ly ton b u, ly mt phn u v phu
thut t dn lu no tht hoc ch phu thut gii p nhm ko di s sng
cho ngi bnh.
U mch mu (cc d dng mch mu no) hoc cc u thn no... phu thut
ly u nhiu khi rt kh khn, ngi ta c th p dng k thut lm tc ha mch
mu no, phu thut nh v lp th (stereotacsic).
 3.2. iu tr tia x:
i vi u c tnh hoc u cha bit ho, sau khi ly u ngi ta iu tr kt
hp tia x ngn chn s ti pht ca u.
3.3. iu tr bng ho cht:
U no c tnh khng th phu thut hoc phu thut ly khng ht t
chc u, nn dng ho cht iu tr kt hp nh cyclophosphamide,
mythramycine hoc methotrexat...

Hi chng tng p lc ni s

Bi Quang Tuyn
1. i cng.
1.1.Cc thnh phn cha trong hp s:
C 3 thnh phn chnh cha trong hp s: no, dch no ty v mu trong
lng mch.
1.1.1. T chc no:
No l thnh phn chnh, chim 80 - 90% th tch ca hp s. ngi ln,
no c trng lng t 1300 - 1500 gram, tng ng vi 1300 - 1500 ml. No l
thnh phn rt t thay i la tui t 20 - 50. Trn 50 tui, th tch no c
th thay i cht t do teo lp v no.
Th tch no tng ln trong cc trng hp nh u no, p xe no, mu t trong
t chc no... s dn ti tng p lc ni s.
1.1.2. Dch no ty:
Th tch dch no ty (DNT) chim 5 - 10 % th tch hp s. Dch no
ty c sinh ra 2 ni: no tht bn v no tht bn (NT4). DNT sinh ra ch
yu no tht bn, chim trn 80%. DNT sinh ra t no tht bn qua l Monro
vo no tht ba (NT3). T NT3, DNT qua cng Sylvius xung ho vi
DNT ca NT4. T NT4, DNT qua l Luska 2 bn ra khoang di nhn ca
no v qua l Magendie xung khoang di nhn ca ty.
Mi mt gi DNT c sinh ra t 18 - 20 ml v trong 24 gi DNT sinh ra t
430 - 480 ml.
Dch no ty c hp thu nh cc ht Pacchioni, cc ht ny nm dc theo
cc xoang tnh mch v khoang di nhn.
Bnh thng s sn sinh v hp thu DNT l cn bng nhau, do m s
lng DNT ngi ln t thay i v lun hng nh t 130 - 170 ml, trong
mt na DNT khoang di nhn ca ty.
 V l do no m s tp trung qu nhiu DNT cc no tht bn v
khoang di nhn l biu hin ca trn dch no (hydrocephalus) v gy tng
p lc ni s (ALNS). Qu trnh bnh l l do nhng kh nng sau:
+ Ri lon lu thng DNT: thng tc cng Sylvius do vim, do u. DNT sinh
ra no tht bn khng c dn ra khoang di nhn ca no v khoang di
nhn ca ty, DNT b li, lm cho cc no tht bn v NT3 gin to gy trn
dch no kn, hay cn gi l trn dch no do tc.
+ Ri lon qu trnh sn sinh v hp thu DNT:
C 2 kh nng xy ra: DNT sinh ra nhiu nhng qu trnh hp thu khng
tng ln v kh nng th 2 l DNT sinh ra bnh thng nhng s hp thu DNT li
km do khoang di nhn v l do no b cht hp mt on di. Tnh
trng trn dn ti d tha DNT c no tht bn v khoang di nhn, ngi ta gi
l trn dch no thng thng.
1.1.3. Mu:
Th tch mu trong lng mch khong 150 - 170 ml chim 5 - 10% th
tch hp s. Nhng trng hp bnh l nh vim tc xoang tnh mch; chn p
ng-tnh mch no gy cn tr dng mu v tim (nh mu t ni s do cc cn
nguyn khc nhau; hoc do u no...), s dn ti tng ALNS.
1.2. p lc ni s:
Bnh thng ALNS ca ngi ln t th nm ngang l 10 - 15 mmHg ( t
th ngi l 15 - 20 mmHg). Nu ALNS trn 20 mmHg l tng ALNS. Trong
chn thng s no ALNS c th ln ti 40 - 50 mmHg hoc cao hn.
C 3 thnh phn chnh cha trong hp s l no, DNT v mu trong lng
mch. Theo thuyt MONRO-KELLIE cho rng: khi th tch mt trong 3 thnh
phn ni trn m tng ln th 2 thnh phn cn li s pht trin theo chiu hng
ngc li duy tr ALNS trong gii hn bnh thng. V d: c khi u pht
trin trong t chc no, th tch no s tng ln, khi cc no tht s thu nh
li, s lng DNT s t i; cc mch mu b p li v y mu v tim nhanh
hn cn bng ALNS.
Khi s b tr ni trn ti mt chng mc no khng cn p ng c na
s dn ti tng ALNS.
tr nh, cc khp s cha lin, khi ALNS tng cao, cc khp s s gin rng
ra do vy m th tch u to ra v to nn u nc. Nhng ngi ln, cc
khp s dnh lin, khng cn kh nng gin c na s dn ti tng ALNS.
Do vy, thc cht ca vn tng ALNS l s mt cn bng gia hp s
khng cn kh nng gin n vi cc thnh phn bn trong hp s c khuynh hng
ngy mt tng ln v th tch.
2. Nguyn nhn tng p lc ni s.
+ U no:
 U no s gy tng ALNS. Mc tng ALNS cn ty thuc vo kch thc,
v tr khi u; ph thuc vo tnh cht t chc hc ca u (u t bo hnh sao, u
nguyn bo ty hay gy ph quanh u).
U cng Sylvius, u h s sau gy tng ALNS rm r hn l u khu tr vng
trn hoc vng chm.
+ Do vim: vim no do virus; vim mng no do lao; vim mng no m...
+ Do p xe no.
+ Do tai bin mch mu no: nghn mch no, tc mch no (do bnh l v
tim, do kh, do m sau m ln xng i...); chy mu di nhn, mu t trong
no t pht...
+ Do trn dch no bm sinh hoc mc phi.
+ Do chn thng.
Tng ALNS do chn thng thng do gip no, do mu t, do trn kh no
v t nc di mng cng.
+ Do k sinh trng: gp trong trng hp nang sn no gy tc cng Sylvius.
+ Do cc cn nguyn khc: ph no do nhim c; ph no sau cc cn ng
kinh lin tc cng gy tng ALNS.
3. Triu chng tng p lc ni s.
3.1. au u:
Khi ALNS tng cao s p vo cc dy thn kinh s no nh dy thn
kinh V, dy IX v dy X; p vo mch mu v mng no l nhng b phn
c phn b thn kinh cm gic au. Khi cc b phn ny b p do tng
ALNS, do vim hoc do co tht mch mu s gy au u.
au u trong tng ALNS thng l au u ton th, au m nhng
c lc au tng tng cn d di lm cho ngi bnh phi ku la, rn r. au u
c tnh cht cn, gia cc cn au bnh nhn c th d chu hn.
Cn c vo cng au, tnh cht v v tr au c th chn on c
cn nguyn, v d: au u trong u no c c trng l au d di u nh
mun v lm i, cm gic au nh i m cht. au u hay xut hin
vo bui sng sm, khi cng thng sinh l.
3.2. Nn:
c im nn trong tng ALNS l nn vt, nn thc nn tho m khng c
cm gic bun nn. Nn khi thay i t th nh tr mnh hoc ngi dy...
Nn trong u no c c im l hay nn vo bui sng sm, nn vt nn
khng lin quan ti ba n v thng nn khi au u tng.
 3.3. ph a th:
ph a th l triu chng khch quan. Khi ALNS tng cao p vo dy
thn kinh th gic lm cn tr dng mu tnh mch t vng mc tr v, dn ti
ph a th.
Trong u no, ph a th cn ph thuc vo v tr, kch thc ca u, mc
tng ALNS v soi y mt vo giai on sm hay mun. U h s sau gy tc
ng dn DNT (tc cng Sylvius) hay gy ph a th hn l u bn cu
i no.
3.4. Mch v huyt p ng mch:
Do ALNS tng cao gy kch thch vo trung khu vn mch hnh no lm
cho mch chm v huyt p ng mch (HAM) tng cao. HAM tng cao l
phn ng t iu chnh ca c th sao cho thng c ALNS ang tng cao
a mu ti no (phn ng Cushing).
Nu ALNS vn tip tc tng cao, phn ng t iu chnh khng cn p
ng, no mt b, khi mch s nhanh nh, yu v HAM s tt thp, tin lng
rt nng.
3.5. Ri lon tm thn (RLTT):
Trng thi kch thch tm thn vn ng, ku la, vt v do au. Nu
ALNS vn tng cao, trng thi kch thch s c thay bng trng thi nm im,
th , n v au, mt nh hng, tri gic xu dn v i vo hn m.
3.6. Tn thng dy thn kinh s no (TKSN):
Dy thn kinh tn thng thng l 2 bn, hay gp l tn thng dy II
(teo gai th), dy III v dy VI vi biu hin gin ng t u 2 bn (c khi
ng t mo m khng u), mt lc. Nu tn thng dy TKSN mt bn cn
ngh ti u no.
4. Chn on cn lm sng.
4.1. Chp s qui c:
Nu tng ALNS lu ngy, trn phim s thy nhng thay i sau:
+ Khp s b gin rng (hay gp tr em).
+ Du hiu n ngn tay (digitate impession), hay gp tr nh v tng
ALNS lu ngy.
+ Thay i h yn: h yn dong rng, mn vt hoc mt cc mm yn
trc v sau; nn h yn mng v mt cht vi.
4.2. Chp ct lp vi tnh (CLVT):
Chp CLVT l phng php chn on hin i gip xc nh chnh xc
nguyn nhn gy tng ALNS nh u no, p xe no, mu t ni s do cc nguyn
nhn khc nhau...
 4.3. Chp cng hng t (MRI):
Chp MRI cho nhng trng hp m chp CLVT khng xc nh c
nguyn nhn tng ALNS.
5. Bin chng ca tng ALNS.
5.1. Mt th lc:
Do ph a th lu ngy dn ti teo gai th thn kinh v mt hon ton
th lc 2 mt, hay gp trong trn dch no bm sinh.
5.2. Thiu mu no:
ALNS tng cao s chn p ng mch no lm cho p lc ti mu no
(ALTMN) gim, no thiu oxy, ph no tng ln. p lc ti mu no (cerebral
perfusion pressure) l hiu s gia huyt p ng mch (HAM) v ALNS:
ALTMN = HAM - ALNS

Bnh thng ALTMN l 90-100 mmHg mi m bo c lu lng mu qua

no l 54 ml/pht. Khi ALNS tng cao th HAM cng tng cao nh phn ng t
iu chnh ca c th (phn ng Cushing) m bo cho cung lng mu ti
no. Nhng nu ALNS tng cao m HAM li gim thp th ALTMN khng
m bo cung cp mu cho no, no thiu oxy, ph no tng ln, no mt b, tin
lng xu.
5.3. Tt kt no:
+ L bin chng rt nng e do t vong. Nu ALNS tng cao mt bn
bn cu i no (nh u no, mu t...) s y thy thi dng vo khe Bichat (khe
Bichat c to bi b t do ca lu tiu no v cung no), p vo cung no v
thn no, biu hin: gin ng t cng bn, lit 1/2 ngi i bn, ri lon
nghim trng chc phn h hp v tim mch (th nhanh nng 35 - 40 ln/pht,
mch nhanh nh yu, huyt p tt...).
+ y hnh nhn tiu no vo l chm: ALNS tng cao 2 bn cu s
p no theo trc v y hnh nhn tiu no vo l chm gy chn p hnh
ty, biu hin: ri lon nghim trng chc phn h hp v tim mch, ngng th,
mch nhanh nh, yu v ri rc e do ngng tim (hnh 1).
 Hnh 1:
Hnh nh mu t di mng cng v du
hiu
tng ALNS gy tt kt no.
1. Thot v di lim i no (cingulate herniation).
2. Thot v lu tiu no (tentorial herniation),
thy thi dng b y vo khe Bichat.
3. Thot v trung tm (central herniation).
4. Thot v thy giun (tonsillar herniation)
vo l chm ln.
5. Khi mu t di mng cng.
6. Lim i no.
7. Lu tiu no;
8. L chm

6. iu tr.
6.1. iu tr ni khoa:
C nhiu nguyn nhn tng ALNS khng phi phu thut m i hi iu
tr ni khoa nh ph no do chn thng, do chy mu di nhn trong tai bin
mch mu no; nghn mch no, tc mch no, vim mng no. iu tr ni khoa
m bo nhng nguyn tc sau:
+ Chng ph no: mannitol 15% (1 gram cho 1 kg trng lng c th); glycerin
50% 50 - 80 ml/ung. Truyn dextran 10%; li niu thm thu furosemid.
Khng dng glucose 30 - 50% v gy toan ha no.
+ Thuc an thn: seduxen hoc ng min (dolosan + lagactin +
phenergan).
+ Gim au: prodafalgan; aspegc tim hoc efferalgan ung.
 + Chng co tht mch mu trong chy mu di nhn do chn thng hoc
tai bin mch mu no v cc thuc phc hi thn kinh nh nimotop; cerebrolysin;
nootropyl...
+ Khng sinh mnh trong cc trng hp vim mng no, vim no.
+ Chng n tc ng h hp, th oxy...
+ Chc ng sng tht lng rt bt DNT trong chy mu di nhn. C th
chc tun 2 - 3 ln cho ti khi no DNT trong vt khng cn hng cu. Ch
trc khi chc ng sng tht lng (OSTL) nn kim tra y mt, nu c ph
a th th khng nn chc OSTL trnh tt kt no.
6.2. Phu thut:
Tng ALNS c th din ra t t ko di vi thng, thm ch nhiu nm.
Nhng trong nhiu trng hp tng ALNS cp tnh, gy ri lon nghim trng
chc phn sng. Do vy trong thc t c nhiu trng hp cn phi can thip
phu thut cp cu mi c th cu sng c ngi bnh.
6.1.1. Phu thut cp cu trong nhng trng
hp sau:
+ Tng ALNS cp tnh do mu t t pht (tai bin mch mu no), mu t
sau chn thng.... Phu thut ly b mu t.
+ U no (u h s sau, u thn no, u no ln...) gy ri lon nghim trng chc
phn sng, e do t vong. Mc ch m cp cu l dn lu tm thi DNT ra
ngoi cu sng bnh nhn; sau 5 - 7 ngy khi tnh trng bnh nhn kh
hn s m ly b u.
6.1.2. Phu thut gii quyt cn nguyn:
+ Ly b u no, ly b mu t ni s do chn thng hoc do tai bin mch
mu no.
+ Dn lu DNT t no tht bn vo bng hoc vo tm nh phi ca tim
cho nhng trng hp trn dch no; u thn no khng c kh nng phu thut
ly b u. Phu thut ny ch c tnh cht ko di s sng cho ngi bnh,
iu tr triu chng ch khng gii quyt c cn nguyn.

Chy mu trong no t pht

(Spontaneous Intracerebral Haemorrhage)
Bi Quang Tuyn
1. i cng.
T vong do tai bin mch mu no ng hng th ba sau bnh tim mch v
ung th. Chy mu trong no chim khong14,8 - 40% cc trng hp tai bin
mch mu no v c t l t vong dao ng 28 - 61% (Lebedev, 1980).
Chy mu trong no t pht hay cn gi l mu t trong no (spontaneous
intracerebal haematoma) c xem nh l chy mu t pht do v phnh mch
(spontaneous aneurysmal haemorrhage). Chy mu t pht c th xy ra tr s
sinh, tr em v ngi ln vi cc biu hin lm sng khc nhau ty thuc vo v
tr v s lan rng ca vng chy mu.
1.1. C ch chy mu:
C 2 c ch chy mu no:
1.1.1. V ti phng ng mch vi th:
Charcot v Bouchard (1868) ln u tin m t cc vi phnh mch (microaneurysms)
ng mch th vn (striate). ng mch th vn l mch mu c thnh mng v
d chy mu nn thng c gi l ng mch chy mu (ng mch Charcot).
1.1.2. C ch xuyn mch ca Rouchoux:
Rouchoux (1884) cho rng: vng chy mu no l vng trc xut hin
nhi mu no, thnh mch ti vng nhi mu b hoi t. Khi tun hon bn c
ti lp, mu c a n ch nhi mu, nhng do thnh mch mu ny b
hoi t nn thnh mch v, chy mu v to thnh mu t.
1.2. Nguyn nhn:
1.2.1. tr em:
+ tr s sinh: do non thiu thng; do thiu vitamin K.
+ tr em c th do bnh a chy mu (haemophilia); chy mu th pht do
d dng ng-tnh mch no; hoc chy mu do u no.
1.2.2. ngi ln:
+ Do huyt p cao v va x ng mch.
+ Do v phnh mch mu no; d dng ng-tnh mch no (arteriovenous
malformation - AVM); do u no; nhi mu no; bnh ri lon ng mu; bnh
thoi ho mch mu no dng tinh bt (cerebral amyloid angiopathy).
1.3. V tr chy mu:
+ Chy mu cc thy no: hay gp chy mu thy thi dng v thy chm;
thy nh v thy trn t gp.
+ Chy mu no tht.
+ Chy mu bao trong: chy mu bo vn (putamen); chy mu i th.
+ Chy mu thn no.
+ Chy mu bn cu tiu no.
+ Chy mu c th mt hoc nhiu .
Chy mu do cao huyt p v va x ng mch hay gp v tr bao
trong; thn no v bn cu tiu no. Loi chy mu ny hay gp ngi c tui t
50 - 60.
Chy mu do v cc vi phnh mch v d dng ng-tnh mch no (AVM)
v nguyn nhn khng r rng thng xy ra ngi tr (k c tr em), khu tr
thng no tht, cc thy no v c th c nhiu mu t.
2. Lm sng.
2.1. Triu chng chung:
2.1.1. Giai on khi pht:
Cch khi pht ca bnh cng rt khc nhau, n ty thuc vo ngun chy mu.
+ Khi pht t ngt kiu st nh: bnh din ra khng h c triu
chng bo trc. Ngi bnh ang khe mnh bng t dng au u d di, c
cn co cng v i vo hn m ngay; ri lon nghim trng chc phn sng v
nhiu trng hp t vong khi cha kp a ti bnh vin. Loi ny thng do v
phnh mch ln, v vo no tht, thn no.
+ Khi pht t t: mt s trng hp c du hiu bo trc nh au u v
nn. C mt s trng hp khc din bin ca bnh nh sau: ngi nh thy
bnh nhn thay i tnh nt, hay qun, hay nh ri vt cm trn tay
hoc biu hin tm thn nh ri lon nhn cch, trm cm t ni, bi nh 1/2
ngi. Tnh trng trn c khi ko di mt vi ngy ngi nh mi pht hin c
v cho i vin v khi chp CLVT pht hin thy mu t trong no. Nhng
trng hp nh th ny tin lng thng thun li, c th iu tr ni khoa
khng cn m.
2.1.2. Giai on ton pht:
Bnh nhn biu hin hn m hoc bn hn m; th su ngy to.
Biu hin tng p lc ni s nh bun nn v nn. C n ra sau hoc u
nm nghing v mt bn. Soi y mt c biu hin ph a th.
Ri lon thn kinh thc vt: mt ng ; mch chm v ny cng. Huyt
p ng mch tng cao. V m hi, nhit c th tng cao; th ngy, tng tit
m ri, ri lon h hp kiu Cheyne Stockes.
Du hiu thn kinh khu tr r nh lit 1/2 ngi; ng t mt bn gin; du
hiu Babinski (+); tn thng dy thn kinh s no nh lit dy thn kinh VII
trung ng.
2.2. Triu chng nh khu:
2.2.1. Chy mu bao trong:
Chy mu bao trong chim 50% cc trng hp mu t trong no t pht, biu
hin lit rt ng u 1/2 ngi i bn vi mu t. Lit dy thn kinh VII
trung ng; bnh nhn (BN) quay u v mt v pha c mu t. Nu
chy mu bn cu tri c biu hin ri lon ngn ng, mt li.
Nu chy mu ln, hn m su v c biu hin ri lon thn kinh thc vt
(TKTV): mt , v m hi. Ri lon h hp (RLHH) th su nhp th khng
u, kh kh do tng tit m ri, mc nng c th ngng th; mch chm
v huyt p tng cao.
Ph no tng cao dn thng sau mt vi gi b chy mu; nn, cng gy,
ph a th.
Tri gic xu dn v hn m. ng t lc u gin mt bn dn dn gin 2
bn, mt phn x nh sng l tin lng xu.
 2.2.2. Chy mu thn no:
Din bin lm sng rt nng. Bnh nhn hn m su. Nu chy mu hnh
no, mu t chn p ch bt cho ca b thp nn biu hin lit hon ton t chi.
ng t c khi co nh c 2 bn. Ri lon nghim trng chc phn h hp v tim
mch. Ri lon TKTV biu hin v m hi, rung c, co cng mt no. Huyt p
tng cao vt. T l t vong rt cao, nhng trng hp sng st li di chng
thn kinh nng n.
2.2.3. Chy mu bn cu tiu no:
V h s sau cht chi nn s lng mu t nhiu khi khng ln nhng cng
gy tng p lc ni s rm r, biu hin nn nhiu, huyt p tng cao, ri lon
nghim trng chc phn h hp v tim mch. Hn m, bi lit 1/2 ngi.
Biu hin du hiu nhn cu bi, mt lc th a sang phi, lc th a
sang tri. Lit dy thn kinh s VI cng bn.
Nu chp CLVT thy no tht gin to v c mu t bn cu tiu no.
2.2.4. Chy mu cc thy no:
Chy mu hay gp thy thi dng v thy nh nhiu hn l thy trn v
thy chm. Nguyn nhn hay gp do v cc phnh mch hoc d dng ng tnh
mch no (AVM). Song nhiu trng hp khng xc nh c nguyn nhn v
thc t khi m khng tm thy ch chy mu. c im lm sng:
+ au u xut hin t ngt.
+ thc biu hin u m, bn hn m. Nu chy mu ln c th hn m su.
+ Triu chng thn kinh khu tr biu hin bi lit nh 1/2 ngi (c th lit
nng tay hoc lit nng chn, nhng ni chung lit tay bao gi cng nng hn lit
chn). Gin ng t cng bn vi mu t. Ri lon ngn ng nu chy mu bn
cu i no bn tri. Chy mu no vng trn hoc chm nhiu trng hp khng
c triu chng thn kinh khu tr hoc triu chng thn kinh khu tr khng r rng.
+ Ri lon thn kinh thc vt biu hin RLHH v tim mch, ri lon thn
nhit, v m hi, rung c.
+ Ph no tin trin gy tng p lc ni s, au u, bun nn v nn;
ph a th.
2.2.5. Chy mu no tht:
L th rt nng v chn on quyt nh nh chp CLVT. Biu hin
lm sng c nhng c trng sau:
+ Khi pht t ngt, rm r, hn m su ngay.
+ Ri lon nghim trng chc phn h hp v tim mch.
+ Ri lon TKTV: mt , v m hi; rung c v c nhng cn co cng mt
no; tng ALNS, nn nhiu.
+ Du hiu thn kinh khu tr thng kh pht hin nu chy mu c 2 no
tht bn.
3. Chn on.
3.1. Chn on phn bit:
Thng chn on phn bit chy mu trong no vi nhi mu no. Trc
y vic chn on phn bit 2 loi bnh ny l rt kh khn. Ngy nay nh
CLVT vic chn on khng kh khn. Trn nh CLVT, vng mu t c t trng
cao (hyperdense) trn 70 - 75 n v Hounsfield (HU), biu hin khi chon
ch, y ng gia. Cn vng nhi mu no c t trng thp (hypodense) hn
so vi m no lnh (bnh thng t trng m no lnh l 34 - 38 HU). Vng nhi
mu no thng khu tr tng i nng so vi v no.
3.2. Chn on nguyn nhn:
3.2.1. Chy mu do cao huyt p:
Thng gp bnh nhn tui trung bnh > 45 - 50, trong tin s c cao
huyt p ko di hoc huyt p thng tng cao nhng dao ng, khng n
nh: huyt p c lc tng cao, c lc nh bnh thng.
Ngi ta t vn l huyt p cao n mc no th gy chy mu ni
s, iu ny cha c xc nh. C tc gi cho rng: huyt p t 160/90 hoc
170/100 mmHg l c nguy c chy mu no. Nhng thc t c bnh nhn huyt
p cao hn th nhiu nhng khng gy chy mu no.
C nhiu bnh nhn chy mu no nhng trong tin s khng bit c cao
huyt p hay khng (v khng c kim tra). Huyt p cao thi im chy
mu cn phn bit xem c phi huyt p cao do phn ng ca TKTV hay do
bnh cao huyt p.
Trong thc t cho thy nhng bnh nhn c cao huyt p l c nguy c
cao chy mu ni s do vy cn c bin php phng trc.
3.2.2. Chy mu th pht do v cc phnh mch
hoc rch v d dng ng- tnh mch no
(AVM).
V lm sng thng xy ra ngi tr, khe mnh. Bnh khi pht t ngt,
rm r, hn m su ngay, triu chng nh khu r v ri lon nghim trng
chc phn sng.
Chn on cn nguyn da vo chp mch cng hng t (MRA) hoc chp
ng mch no.
4. Chn on cn lm sng.
4.1. Chp CLVT:
Cho bit chc chn v tr, kch thc mu t, nhng khng cho bit cn
nguyn chy mu do v cc phnh mch, rch v cc AVM hoc chy mu do u
no.
 4.2. Chp mch cng hng t (MR Angiography):
Cho bit ton b h thng ng mch cnh trong v h ng mch t
sng- thn nn v c th pht hin c cn nguyn chy mu. Tuy nhin
phng php ny cng khng pht hin c nhng vi phnh mch hoc nhng
d dng ng-tnh mch qu nh.
4.3. Chp ng mch no (MN):
Hin nay vi k thut chp ng mch no s ho xo nn cho bit c th
ng mch, th tnh mch v mao mch, t ngi ta c th bit c cc vi
phnh mch v d dng ng-tnh mch rt nh (vi AVM).
Trong thc t khi tnh trng bnh nhn qu nng khng cho php chp
MN, do vy nhiu trng hp cng khng pht hin c nguyn nhn chy
mu no.
Theo Lebedev (1990): trong s 1124 bnh nhn chy mu di nhn cp
tnh khng phi do chn thng c chp ng mch no pht hin thy
45,9% do rch v phnh mch no. Theo cc tc gi khc nhau th rch phnh
mch no to thnh mu t ni s l 17,8 - 40%.
4.4. Chc ng sng tht lng (OSTL):
Trong tt c cc trng hp chy mu di nhn ngi ta khuyn nn chc
OSTL kim tra dch no ty (DNT) trc khi tin hnh chp MN. Nu
DNT mu l chy mu nng, chy mu no tht, tin lng rt nng. Nu
DNT pht hng chng t chy mu khng nng, tin lng tng i thun li.
Nu DNT trong nh bnh thng m ALNS tng cao cn ngh ti kh nng mu
t trong cht no, cn khm xt lm sng v cho chp CLVT kim tra.
5. Tin lng.
Tin lng chy mu no ni chung ty thuc vo cc yu t sau:
5.1. Theo din bin lm sng:
Din bin lm sng rm r, t qu kiu st nh th tin lng rt
nng. Din bin lm sng mt cch t t, no c kh nng b tr tt hn, tin
lng thun li.
Theo Hunt W. v Hess R. (1968) chia 5 mc din bin lm sng
tin lng i vi chy mu no:
+ Mc I: au u nh, tnh to, khng c triu chng thn kinh khu
tr.
+ Mc II: au u nhiu, tnh to nhng kch thch tm thn vn
ng, khng c triu chng thn kinh khu tr.
+ Mc III: thc l m (bn hn m), c triu chng thn kinh khu tr
(bi 1/2 ngi; gin ng t, tn thng dy thn kinh s no). T vong 30 - 40%.
+ Mc IV: hn m su; triu chng thn kinh khu tr r. C th c
nhng cn co cng mt no; ri lon nghim trng chc phn h hp v tim
mch. T vong 50 - 80%.
 + Mc V: hn m rt su; co cng mt no; ngng th phi h hp nhn
to. T vong c th 100%.
5.2. V tr mu t:
Tin lng tt i vi mu t vng trn, vng chm. Tin lng xu, cho t l
t vong cao i vi mu t thn no, mu t no tht v mu t tiu no.
5.3. Kch thc mu t:
Nu cng v tr th kch thc khi mu t cng ln v y ng gia
cng nhiu th tin lng cng nng; mu t nh y ng gia khng
ng k th tin lng tt hn.
5.4. Bnh l kt hp khc:
Bnh nhn c bnh l kt hp khc nh i ng, suy thn, suy gan, suy
tim, bnh phi mn tnh hoc lao phi ang tin trin th tin lng xu.
Tui cao tin lng xu hn so vi tui tr.
6. iu tr.
6.1. iu tr ni khoa:
+ Ch nh: khi mu t trn nh CLVT nh, tri gic bnh nhn hon
ton tnh to hoc hn m nng.
Nhng trong qu trnh iu tr, nu theo di thy tri gic bnh nhn c xu
hng xu i, im Glasgow tt xung, triu chng thn kinh khu tr r hn,
c biu hin ri lon h hp v tim mch nng ln cn phi xem xt v c ch
nh m kp thi.
+ iu tr ni khoa m bo nhng nguyn tc sau:
- m bo thng kh tt (th oxy, ht m ri lm thng ng th, cn
thit c th m kh qun sm).
- m bo huyt p ng mch trong gii hn bnh thng. Nu huyt p
cao th phi cho thuc h huyt p.
- Chng ph no tch cc bng nhiu bin php nh: truyn mannitol (1
gr/kg trng lng c th); li niu thm thu nh lasix; liu php corticoide
(synacthne).
- Thuc chng co mch no v hi phc chc phn no nh nimotop;
cerebrolysine; nootropyl.
- Nui dng bnh nhn bng truyn m, cho n qua ng thng d dy nu
hn m ko di.
- Khng sinh chng bi nhim.
6.2. Phu thut:
+ Ch nh:
- Tri gic xu dn, chn p no do mu t ngy mt tng ln.
- Mu t ln, iu tr ni khoa khng tt ln.
 - Mu t ln c nguy c chn y gy tt kt no.
- Ch nh cn nhc i vi cc mu t cc thy no m tri gic khng
xu i, chn p no khng tng ln. Nu mu t vng trn th nn m trnh
di chng tm thn sau ny.
- Mu t tiu no th cn phi phu thut sm.
Vn l phu thut khi no? Mt s tc gi khuyn nn phu thut
nhng gi u sau khi b chy mu no. Nhng giai on ny thng ri lon
nghim trng chc phn h hp v tim mch (giai on bo tp thc vt), t l t
vong cao. Do vy nhiu tc gi khuyn nn phu thut khng sm hn 5 - 6
ngy sau khi chy mu no, thm ch c th phu thut sau 2 - 3 tun. Theo
mt s tc gi cho rng nu m khi BN hn m cho t l t vong trn 60%.
+ Chng ch nh:
- Tnh trng bnh nhn qu nng giai on V theo Hunt v Hess, tc l
hn m su, ri lon nghim trng chc phn sng.
- Mu t nh thn no vi ri lon nghim trng chc phn sng.
- Bnh nhn tui qu cao, th trng chung yu.
- Bnh nhn c km theo mt s bnh khc nh i ng giai on bin
chng nng, lao phi ang tin trin, x gan, suy tim, huyt p cao c tnh.
+ K thut:
Thng khoan v gm rng xng s (kch thc khong 2 - 3 cm l
rng). M mng cng. Xc nh v tr mu t bng chc kim Troca, sau
rch v no mt l nh v vn no vo mu t v ht b mu t. Tm
ngun chy mu cm mu bng t in.
7. Bin chng v kt qu sau phu thut.
7.1. Bin chng:
+ Ph no.
+ chy mu li do cm mu cha tt hoc sau khi m v huyt p cao vt
v gy chy mu li. Do vy khi m v nn duy tr huyt p mc bnh
thng v phi kim sot c huyt p. Bnh vin 103 gp trng hp
sau m c 6 ngy, bnh nhn hon ton tnh to, tip xc tt nhng bng
nhin huyt p cao t ngt gy trn kh ph mc v ph phi cp, bnh
nhn hn m li v t vong.
Chy mu c th t mp da khu khng tt v gy mu t.
+ Nhim trng vt m.
+ Vim mng no, vim no; p xe no.
+ R dch no ty qua vt m.
7.2. Kt qu sau m:
Ph thuc vo mt s yu t sau y:
 + Phu thut giai on V ca Hunt v Hess, theo Lebedev (1990): t vong
c th 100%. giai on IV t vong 50 - 80%. Phu thut tng i thun li
l giai on II v III.
+ Nguyn nhn chy mu:
- Chy mu do rch phnh mch c t l t vong cao. Theo Lebedev: t vong
l 28 - 61% trong cc trng hp phu thut mu t do rch phnh mch no. Rch
phnh mch no bao gi cng km theo co tht mch no, cho nn nhiu tc gi
khuyn nn m tht sm trong 3 ngy u hoc tht mun sau 10 - 14 ngy
th trnh c bin chng co mch no. Co mch no thng xut hin sau 3
ngy chy mu no v co mch ko di ti 1 tun.
- Chy mu do huyt p cao cng cho t l t vong cao. Tuy nhin phi
kim sot c huyt p trong v sau m.
Ngoi ra kt qu ph thuc rt nhiu vo kinh nghim iu tr hi sc
tch cc sau m.
p xe no
(brain abscess)

Bi Quang Tuyn

1. i cng.
1.1. S lc lch s:
Morand (1768) l ngi u tin phu thut thnh cng p xe no. Petit J.L.
(1774) phu thut dn lu m ra ngoi cho mt trng hp p xe no do
chn thng.
Sir William McEwen (1893) Glasgow bo co 19 trng hp p xe no
c phu thut trong 18 trng hp hi phc sc kho.
Ni chung t l t vong do p xe no theo thng k ca nhiu tc gi cn rt
cao. Theo Papchin trong chin tranh V quc v i (1941-1945): p xe no do
vt thng ho kh t vong trn 53%. Theo Bhatia R. (1989): trong s 1276
trng hp p xe no 3 trung tm Phu thut thn kinh ln ca n- t vong l
17,2%. Theo thng k ca bnh vin Ch Ry (1986): t vong do p xe no l 40%.
p xe tiu no c t l t vong cao nht. Theo irger (1971): t vong do p xe
tiu no t 62 - 85%.
1.2. Nguyn nhn:
C 3 nguyn nhn chnh sau y:
+ p xe no do chn thng (do vt thng ho kh v do chn thng s
no m thi bnh).
+ p xe no do nhim khun t c quan ln cn: nh vim xng chm
(mastoiditis), do vim tai gia, vim xoang trn xoang sng (rhinogenous).
 + p xe no do vi khun theo ng mu (haematogenous infection): hay
gp trong cc bnh nh gin ph qun (bronchoectasia), p xe phi hoc vim
m mng phi; vim mng trong tim do vi khun, bnh tim bm sinh; cc
vim m t xa nh p xe gan, vim ty xng (osteomyelit), vim b thn, mn
nht. Tuy nhin nhiu trng hp p xe no khng tm thy nhim khun tin
pht.
c im p xe no theo ng mu l p xe thng su trong t chc
no, c th mt hoc nhiu cc v tr khc nhau.
Vi khun gy bnh thng l vi khun i kh nh trc khun ng rut, t
cu vng, lin cu khng gy tan huyt, hoc cc vi khun k kh v c th
do nm. Tuy nhin khng phi cy m bt c trng hp p xe no cng bt c
vi khun.
1.3. V tr p xe:
p xe no c th bn cu i no hoc tiu no. Ngi ta chia ra p xe
ngoi mng cng, di mng cng v trong no.
1.3.1. p xe ngoi mng cng (NMC):
p xe NMC l m nm gia xng s v mng no cng. Nguyn nhn
thng do vim xng chm, vim tai gia, vim xoang trn, ct ty vim xng s
do vi khun i theo ng mu gy nn; hoc vim b khuyt xng s sau
phu thut m s, sau chn thng v rn xng s (nt s).
1.3.2. p xe di mng cng (DMC):
p xe DMC hay cn gi l lm m DMC (empyoma) l bc m nm gia
mng no cng v b mt ca no c khu tr li bng mt bao x. Cn nguyn
thng do vim xng chm, vim tai gia, do ng mu v trong chn thng
do v nn s trc hoc v nn s gia.
1.3.3. p xe no:
L m nm trong t chc no, cn nguyn thng gp do vt thng ho
kh; p xe ng mu. p xe theo ng mu c c im l m nm su
trong t chc no, c th mt nhng cng c th nhiu p xe.
p xe trong nhu m no l p xe hay gp nht nn trong c ch bnh sinh
di y ch cp n p xe trong no.
1.4. C ch bnh sinh p xe no:
p xe ng mu bao gi cng din ra qua 3 giai on:
+ Giai on vim no cc b:
Khi vi khun hoc t bo m theo ng mu ti t chc no s to nn mt
vim no cc b (c th 1 hoc nhiu ri rc nm k lin nhau hoc xa
nhau). Biu hin no vim l phn ng ph n lan rng ra xung quanh. Nu
chp ct lp vi tnh (CLVT) giai on ny ch thy mt vng ph, gim t
trng so vi m no lnh, d nhm vi nhi mu no.
+ Giai on ha m trong t chc no:
Trung tm vim l t chc no hoi t. T chc no hoi t cng vi xc
bch cu to nn m. m c xu hng ngy mt lan rng ra xung quanh.
+ Giai on to bao p xe:
Do phn ng t v ca c th (hoc do dng khng sinh sm), cc t bo
thn kinh m tng sinh xung quanh vim, cc mch mu tn to n
nhiu hn v bch cu c huy ng n bao vy khng cho m lan
rng ra xung quanh, chng to nn mt vnh ai chc chnh l bao x ca
bc p xe. Bao x ny s dy ln v m c khu tr li.
Nu chp CLVT khng tim thuc cn quang th cng c th nhn thy bao x
ny. Nu tim thuc cn quang th bao x cng nhn r hn v phn bit r vi t
chc xung quanh. Bn trong bao x l m, c t trng gim so vi m no lnh.
Ngi ta cho rng: s hnh thnh bao x din ra trong vng 3 - 4 tun, nhng
nu iu tr khng sinh mnh v sm ngay t u th p xe s tiu i, li
l t chc x so v cc giai on ca p xe no khng cn din ra trnh t nh
ni trn.
2. Triu chng lm sng.
Biu hin cc hi chng v cc triu chng sau:
3.1. Hi chng nhim trng nhim c:
Bnh nhn (BN) st cao 380C - 390C hoc 40 0C; mt mi, chn n. Xt
nghim thy bch cu mu ngoi vi tng cao, cng thc bch cu chuyn tri,
tc mu lng tng.
3.2. Hi chng tng p lc ni s (ALNS ):
Biu hin au u, nn v bun nn. Soi y mt c ph a th. C
biu hin phn ng mng no nh c cng, s nh sng nn mt lc no cng
nhm, t th BN nm nghing v co gp ngi vo bng.
Biu hin tng ALNS c bit rm r nu p xe tiu no, au u d
di, nn nhiu, i lo o nh ngi say ru, hai chn dang rng, nghim php
Romberg (+), sai tm, qu hng nu lm nghim php ngn tay tr mi; rung
git nhn cu (nystagmus), tht iu (ataxia).
3.3. Du hiu thn kinh khu tr (TKKT):
C th thy bi 1/2 ngi i bn; tn thng dy thn kinh s no nh dy
VII TW, dy thn kinh III, dy II. Cn co git ng kinh cc b; ri lon ngn
ng vn ng (aphasia) nh mt li, hoc ni kh.
3.4. Triu chng tm thn kinh:
Lc u biu hin trng thi kch thch, vt v, dy da, ku la v au.
Nhng dn dn tri gic BN xu hn, nm im, mt nh hng, l ln, bn hn
m v hn m nu nh khng c iu tr kp thi s t vong.
 3.5. Triu chng ti ch:
Nu p xe NMC hoc DMC th khi n hoc g ln vng xng vim BN s
rt au. Nu trn BN c m s no do vt thng c li khuyt
xng s th s thy khuyt xng cng phng, khng p, n au, nng v
ty , thm ch c th thy x r m trn ng so m c.
3. Tin trin ca p xe no.
iu tr khng sinh sm, khng sinh mnh c ph tc dng rng th cc triu
chng ca p xe s mt i, p xe s nh li, dn dn teo i, li vng so x
ho. Tin trin xu nu p xe khng c iu tr tch cc, c th s dn n
nhng kh nng sau y:
3.1. Vim mng no m:
Do m xuyn thm qua bao p xe ra khoang di nhn ca no v lan rng
gy nn vim mng no m. Hay gp trong cc p xe nm st vi v no hoc
thnh no tht bn, p xe di mng no cng.
3.2. V p xe:
Nhng p xe ln nm st thnh no tht bn hoc st v no, do tng p
trong bc p xe c th gy v, m s lan trn ra khoang di nhn, din bin
lm sng rt nng, ri lon h hp v tim mch nghim trng; tin lng c th t
vong.
3.3. Tt kt no:
Nhng bc p xe ln c v bao dy chc s bnh trng trong hp s nh mt
khi u gy tng ALNS rm r, chn y no v gy tt kt no (y thy thi
dng vo khe Bichat hoc y thy nhng ca tiu no vo l chm gy chn p
vo hnh ty). c bit ch ti p xe tiu no v h s sau rt cht chi nn mc
d p xe nh nhng gy ri lon nghim trng chc phn h hp v tim mch.
4. Chn on cn lm sng.
4.1. Xt nghim mu:
Bch cu mu ngoi vi tng cao c th trn 10.000, tng BC a nhn, cng
thc BC chuyn tri, tc mu lng tng cao.
4.2. Dch no ty (DNT):
Nu ALNS tng cao hoc nghi ng p xe tiu no th khng c chc ng
sng tht lng (OSTL) v c th nguy him gy tt kt no e do t vong.
Tuy nhin nu cn phi chc OSTL ly DNT xc nh chn on th
ngi ta c th chc OSTL vi 3 iu kin ch sau: BN nm u thp
150 so vi mt ging; dng kim chc loi nh c kch thc nng khong 0,3 -
0,5 mm v khng rt ht thng kim; khi rt thng kim sao cho DNT khng chy
ra thnh tia m chy tng git mt. Ly 5 ml xt nghim.
Kt qu s thy ALNS tng cao, DNT c th hi c, tng protein, tng bch
cu trn vi trm t bo/mm 3, c th thy t bo m, glucose gim thp.
 4.3. Chp s qui c:
Chp 2 phim thng v nghing hoc chp t th Schuller ( kim tra cc
xoang), c th thy hnh nh vim xoang; i vi vt thng do ho kh c th
thy mnh kim kh hoc mnh xng trong nhu m no; hnh nh gin tip do
tng ALNS nh gin ng khp, mn mm yn, du hiu n im ch hay
gp tr nh.
4.4. Chp ng mch no (MN):
Trc khi c chp ct lp vi tnh, chp MN l phng php chn on cn
lm sng c gi tr chn on p xe no. Thng qua hnh nh chn y ng
mch v vng tng sinh mch mu tn to ngi ta c th xc nh c v tr ca
p xe.
4.5. Chp ct lp vi tnh (CLVT):
L phng php chn on hin i cho bit chc chn v tr, kch thc
p xe, s lng mt hoc nhiu ; p xe n thun hay p xe phc tp vi
nhiu ngn to nh khc nhau.
Trn phim khng tim thuc cn quang, du hiu c trng p xe no l du
hiu vng trn. Vng trn chnh l bao p xe, c t trng cao hn m no
lnh nn nhn r hn. Bn trong vng trn l m gim t trng. Nu tim thuc
cn quang s thy bao p xe ngm thuc mnh v nhn r ranh gii ca bc p xe
vi t chc xung quanh.
Hnh nh gin tip ca p xe l ph quanh bc p xe, y ng gia sang
bn v lm thay i hnh dng no tht (xo mt no tht hoc lm mo m
cc no tht bn). Nu p xe gy tc cng Sylvius s thy no tht bn gin to.
5. Chn on phn bit.
5.1. Vim mng no m:
Biu hin hi chng nhim trng nhim c rm r, au u, st cao
mt mi. Hi chng tng ALNS: nn, ph a th. Hi chng mng no (+);
DNT c nh nc vo go, tng protein, tng BC a nhn, glucose gim. Du
hiu thn kinh khu tr khng c hoc khng r rng.
5.2. Vim tc tnh mch trong no:
Do t bo m di chuyn trong mu ti tnh mch trong s hoc t bo m
qua tnh mch trong xng s (xoang xng) i vo gy tc cc tnh mch
trong no hoc gy vim tc cc xoang tnh mch dc trn hay xoang ngang...
biu hin: hi chng nhim trng nhim c nng, st rt cao v rt run. Cc
tnh mch da u v tnh mch mt ni gin to, ph kt mc mt v c th
thy mt li nh; lit cc dy thn kinh s no nh dy III, dy IV v dy
VI. Tin lng rt nng.
5.3. U no:
C biu hin hi chng tng ALNS; hi chng thn kinh khu tr. C th st
nh nhng phn ln BN khng st; xt nghim mu BC khng tng, tc mu
lng khng tng. DNT trong, tng protein, BC bnh thng (phn ly albumin v
t bo). Chn on quyt nh nh CLVT.
6. iu tr.
6.1. iu tr ni khoa:
Ch nh i vi p xe nh v su (mt hoc nhiu ); p xe no
v gy vim mng no m lan trn; tnh trng BN qu yu khng cho php phu
thut.
Nguyn tc chung l khng sinh mnh, ph tc dng rng, phi hp nhiu
khng sinh c tc dng vi vi khun Gram (-) v Gram (+). Khng sinh thng
c dng l nhm cephalosporin th h 3 hoc 4 kt hp vi nhm quinonone
c th nh sau:
Nhm cephalosporin: ceftriaxone (th h 3 hay dng trong lm sng l
rocephine); cefedim (th h 4 hay dng trong lm sng hin nay l axepim). Kt
hp vi nhm quinonone nh peflox (thuc hay dng trong lm sng l peflacin
0,4 2 - 3 ng pha trong 200 ml glucose 5% truyn nh git tnh mch. C th
truyn metronidazone kt hp.
Ngoi khng sinh ra cn phi iu tr chng ph no, nui dng v sn sc BN
chng vim phi do nm lu, chng lot; cho thuc an thn, gim au v h st.
6.2. Phu thut:
C 3 phng php: chc ht; dn lu v ly ton b bc p xe no.
6.2.1. chc ht p xe no:
L phng php thng dng nht hin nay. u im ca phng php ny l
khng gy tn thng nhiu t chc no lnh. Ch nh khi p xe ln su
trong t chc no, p xe nhiu ngn, khi tnh trng bnh nhn qu nng.
Nhc im ca phng php ny l khng ly trit nn d ti pht.
+ K thut: sau khi khoan mt l xng rng 2 - 3 cm. M mng no cng.
Dng kim di 10 - 15 cm (kim chc OSTL) c ng knh nng 1 mm. Tt nht
l chc p xe di s hng dn ca mn hnh. Nu khng c cn phi xc nh
to chc cho chnh xc vo p xe.
Cn che ph tt khi rt thng kim m khng lan trn ra t chc no lnh.
Sau khi ht ht m c th bm ra bng dung dch khng sinh (gentamycine). Sau
khi bm ra xong rt kim v ng vt m bng cc mi ch tha.
Sau 3 - 5 ngy kim ta li bng CLVT, nu cn p xe th c th chc ht
qua da ln 2 hoc ln 3 (theo ti liu nc ngoi c th chc ht 4 - 5 ln). Khng
sinh ton thn cng cc bin php iu tr nh ni trn.
6.2.2. Dn lu p xe:
+ Ch nh: trong cc trng hp p xe NMC, DMC v p xe ln su
hoc nng so vi v no.
+ K thut: m xng rng (ng knh l m xng khong 3 - 4 cm).
M mng cng vo p xe. Ht ht m, ra sch bng dung dch NaCl 9%0 c
pha khng sinh. t ng dn lu t p xe ra ngoi vo bnh kn v trng. Hng
ngy tin hnh bm ra p xe mt ln. Gi ng dn lu 7 - 10 ngy. Chp
CLVT l phng php tt nht kim tra p xe. Trc y cha c CLVT
ngi ta p dng phng php Baculep (Nga): sau khi bm ra sch p xe a
vo khoang p xe 30 - 40 ml khng kh hoc cht cn quang tan trong nc ri
tin hnh chp phim kim tra xem p xe thu nh li cha rt b hn dn
lu.
6.2.3. Ly b ton b bc p xe:
+ L phng php trit nhng c nhiu kh khn. Nhc im l gy
tn thng nhiu t chc no lnh, c th gy thng v bc p xe.
+ Ch nh: trong trng hp bc p xe c bao x chc nm khng su so
vi t chc no, thng ch nh trong cc trng hp p xe no do vt thng
ho kh. Trong bc p xe c th bao gm cc mnh kim kh hoc mnh xng
v cc d vt khc.

U ty
Nguyn Hng Minh
1. i cng.
1.1. T l:
U ty l mt bnh him gp, chim t l 2,06% so vi cc khi u trong c
th ni chung v chim t l 15% cc u thuc h thng thn kinh trung ng.
U ty t hn u no 4 - 6 ln ngi ln; tr em u ty rt him gp.
C nhiu phng php cn lm sng gip cho xc nh bnh l u ty nh
chp ct sng thng, chp ty cn quang (myelography), chp ct lp vi tnh
(CT.scanner), chp cng hng t (MRI), trong chp ty cn quang vn ng
vai tr quan trng. Tuy nhin khng th ph nhn tnh u vit tuyt i trong
chn on u ty ca cng hng t, n cho bit mt cch chnh xc v tr,
kch thc, hnh dng khi u, cng nh s xm ln p ca u vi ty-r thn
kinh trong ng sng v cc thnh phn lin quan khc.
 1.2. Phn loi u ty:
1.2.1. Theo nh khu:
y l phn loi thng p dng trong lm sng, gip cho chn on v
iu tr phu thut.
+ U vng ct sng c chim t l thp (< 25%), hay gp u ni ty.
+ U vng ct sng ngc chim t 1 cao nht (> 65%).
+ U vng ct sng tht lng-cng chim khong 15 - 25%, hay gp l u r
thn kinh.
1.2.2. Theo t chc hc:
y l phn loi c tnh khoa hc, thng c tin hnh sau phu thut,
phc v cho cng tc nghin cu, iu tr v tin lng bnh.
+ Theo kinh in, cc tc gi chia 2 nhm:
- U nguyn pht (u mng ng ni ty, u nguyn bo thn kinh m, u nguyn
bo ty, u mch mu...).
- U di cn do ung th t c quan khc n ty.
+ Ngy nay cc tc gi u thng nht phn loi da trn ngun gc t chc
hc u:
- Meningioma (u mng ty - chim t 1 khong 15 - 25%).
- Neurinoma (u r thn kinh - bao gm c Schwannoma v neurofibroma
chim t l cao nht t 30 - 50%).
Cn li cc u sau y chim t 1 thp:
- Ependymoma (u mng ng ni ty).
- Astrocytoma (u t bo hnh sao).
- Dermoid cyst (u nang b).
- Lipoma (u m).
- Lymphoma (u hch bch huyt).
- Haemangioma (u mu).
- U sn.
- U di cn.
- U hn hp khc.
1.2.3. Theo gii phu:
+ U ni ty (intramedulle tumor): him gp (khong 5 - 10%), thng l u
mng ng ni ty (ependymoma), u nang, u nguyn bo xp, hoc u m
(lipoma).
+ U ngoi ty (extramedulle tumor) hay gp, ngi ta chia nh sau:
- U ngoi ty- di mng cng (intradural- extramedulle tumor): l nhng u
hay gp (khong 65 - 75%), thng l u mng ty (meningioma) v u r thn
kinh (neurinoma).... y l nhng u lnh tnh, ranh gii r, mt chc, phu
thut c th ly c ton b u, t gy tn thng ty-r thn kinh. C tc gi
nghin cu thy: u pht trin t dy chng rng dnh vo mng ty, hay gp u loi
ny on ty D4-D8, him thy on ty D12 tr xung do dy chng rng
khng cn bm ti on ny.
- U ngoi ty - ngoi mng cng (extradural-extramedulle tumor): thng l
nhng u di cn, u mu hoc u xng... chim t l thp khong l5 - 25%.
- U hn hp: l loi u pht trin c trong v ngoi mng cng, u c dng
hnh ng h ct hoc u c dng hai ti... U dng ng h ct l th u c
bit mt phn u nm trong ng sng, mt phn u chui qua l ghp ra ngoi ng
sng. Nu on ngc th u c th nm trong trung tht, nu on tht lng
th u c th nm trong bng hoc chu khung; u loi ny c th to bng qu
chanh, qu cam hoc thm ch to hn. Phu thut ly trit loi u ny rt
kh khn. pht hin loi u ny ch c chp cng hng t 1 mang li kt
qu tt nht. Trc y hay b st khi m u loi ny.
3. Triu chng lm sng.
3.1. Giai on au r:
+ au do u ty c c trng l au theo r thn kinh, thi gian thng au
lu, n c th l triu chng duy nht ca bnh. Nhiu trng hp au c th
ko di nhiu nm, bnh thng au ko di trn 6 thng. V th c khi chn
on nhm vi mt s bnh khc (nh u vng ty c giai on u hay nhm
vi thot v a m c; hoc u vng ct sng ngc d chn on nhm l
vim r thn kinh lin sn; u vng ct sng tht lng d nhm vi cc bnh
vim dy thn kinh hng to, thoi ha ct sng, vim khp cng-chu...).
+ c im khi bnh bng cc du hiu ban u thng thng nh au
ct sng hoc d cm hoc ri lon vn ng chi th mt cch t nhin, t t
v au c xu hng ngy mt tng ln.
+ au c th do u pht trin v p t mt bn ty, hoc c hai bn chng
t u nm pha sau. Nhng u pht trin pha trc hoc mt trc bn ty, u pht
trin t cc r ui nga, c th khng c au m ngay t u xut hin cc
triu chng ri lon vn ng ca mt vi nhm c hoc ca c chi th m
khng c biu hin au r, hoc nu c ch thong qua.
Gn 50% u ty pht trin trc tip t cc r ty, t ty, hoc t cc thnh
phn ty v mng ty nn a n kch thch r sm gy au ct sng lng
vi cc mc khc nhau; tnh cht au su, au tht trong c bp, c
bit l c cnh sng, au tng dn theo thi gian. Tnh cht au y khc
hn mt s bnh l khc, khi dng thuc th triu chng au gim.
U r thn kinh so vi u mng ty thng gy au sm hn v u pht trin
trc tip t cc r v di ng hn. au r c th l triu chng lm sng duy
nht trong cc u nang ty.
+ Chn on u ty trong giai on au r rt kh khn (khong 15 - 20%).
 3.2. Giai on p ty:
+ Ty theo mc p ty v v tr u m biu hin lm sng di cc hnh
thc khc nhau, c th thy lit mt vi nhm c, hoc lit hai chn nu nh u
on ty ngc v tht lng, lit t chi trong nhng u ty c.
Trong trng hp u chn p mt na ty bn (bn tri hoc bn phi) s biu
hin hi chng Brown-Sequard vi cc triu chng sau: pha c u biu hin
lit tay v chn kiu trung ng nhng cn cm gic au, trong khi pha
na ngi i bn (bn khng c u) khng lit nhng mt cm gic au. Hi
chng Brown-Sequard hay gp u chn p ty c hoc ty ngc cao.
S hnh thnh bi lit hon ton ph thuc vo mc p ty do u
gy nn v ty thuc vo thiu mu trong ty. Ri lon vn ng c th mt
bn hoc hai bn, iu c quan st thy trong cc u nm gia mt trc
hoc mt sau ty, hoc cc u trong ty.
+ Ri lon cm gic c ngha c bit nh nhng d cm (30%), t b
theo r thn kinh (60 - 90%); tuy nhin n cn ph thuc ngun gc u. Trong cc
u ngoi ty thng nhng ri lon cm gic nng xut hin mun hn, trc ht
l cm gic au, sau l cm gic nhit, v cui cng l cm gic xc gic.
Trong nhng trng hp phn ly cm gic (ri lon vn ng, mt cm gic
nhit v au) cc tc gi gp 20% cc trng hp u ngoi ty, theo kinh in
cho thy phn ly cm gic him gp cc u trong ty.
+ Ri lon c tht (sphinter) c th thy trong tt c cc u, khng ph thuc
vo on ty, chng dng nh l c sm hn, rm r hn cc u trong ty so vi
cc u ngoi ty. Biu hin lm sng l b tiu, hoc i r khng gi c nc tiu.
+ Ri lon sinh dc c th quan st thy ch yu khi u chn p phn ui
nga hoc on c.
+ Ri lon phn x dng lng (pilomotorius) v ri lon bi tit m hi.
+ Ri lon dinh dng c th gp lot bn chn trong cc u vng tht lng,
teo c gp cc u trong v ngoi ty; g cc gai sau hoc c cnh sng lun gy
au ngang mc u ty.
+ U ty vng c cao c th c nhng triu chng ri lon tiu no (do ph
ty hoc ri lon lu thng dch no ty trn ch p). Hu qu l lit cc
dy s nh tn thng dy V, teo c c-n-chm v c thang, c th gp ri
lon nhnh qut ngc ca dy X, dy IX v dy XII. C th quan st thy ri
lon tim mch (mch chm) do kch thch dy X ( hnh no), rt him gp
mch nhanh trong tn thng dy X. Ri lon h hp pht sinh l do vn ng
u mt cch ng k lm tng s p ty. C th biu hin tng thn
nhit (41 oC - 42 oC), him gp gim nhit . Thn nhit tng ln do tn
thng trung tm iu ho thn nhit ca hnh no. Nhng u vng ny c th
thy s xm nhp ti h s sau, a n hi chng tng p lc ni s (au
u, nn, ph gai th, lit cc dy s trong u s ty).
 Nu p ng mch t sng hoc cc nhnh ca n c th to nn s ri
lon cung cp mu cc khu vc tng ng gy nn cc triu chng v no.
+ Cc u nm phn ngc trn (C7-D2) trong giai on u ca bnh biu
hin au t pht mt bn hoc hai bn. Trong a s trng hp ngun gc ca
au ch c pht hin khi xut hin ri lon vn ng, lit chi hoc lit c
tht v s pht trin nhanh l c trng ca u vng ny.
+ U nm on ngc thp (D7-D12) gy au r khu vc lin sn hoc
c th c hi chng bng-ngc (10%) hoc mt s bnh l lng ngc khc.
Nhng u on tht lng lun bt u bng au r mt bn v sau l au
r hai bn. Cc u ny gy au tht lng hoc au hai chi, triu chng au
tin trin t vi thng ti hng nm l triu chng duy nht.
Cc u vng ui nga thng c triu chng ngho nn, chng c th pht
trin mt thi gian di vi triu chng au t pht hoc au khi th.
4. Chn on u ty.
Vic chn on pht hin bnh u ty cn phn bit vi cc bnh khc
vng bng-ngc v mt vi bnh pht sinh t t sng, vi tt c cc tn thng
trong ng sng lin quan n r hoc ty. Vic chn on u ty giai on
sm (giai on au r) cn nhiu kh khn; theo Arseni ch c khong 20% u
ty c chn on giai on r. Theo Fried (1988) chn on giai on sm
khong 25%; Osborn A.G (1994) nhn thy trong nhng nm gn y nh c my
ct 1p vi tnh (CT.Scanner) v chp cng hng t (MRI) th t l u ty c
chn on sm t khong 50%.
Giai on au r cn chn on phn bit vi nhng bnh au thn kinh
chm, hi chng c-vai, nhng bnh bng-ngc (vim mng phi, au tht
ngc, bnh d dy-t trng, bnh gan mt), nhng bnh vng tht lng-cng
(bnh l gai i, hi chng tht lng hng, bnh l chu hng...). Tuy nhin
khng c qun rng u ty c th kt hp vi cc bnh l ni trn.
Mun chn on bnh u ty, ngoi cc triu chng lm sng ni trn cn
cn phi da vo cc xt nghim chuyn khoa:
4.1. Chp ct sng khng chun b:
Chp ct sng qui c (hay cn gi l chp ct sng thng) l rt cn thit
v nht thit phi c trong chn on phn bit au r thn kinh do cc nguyn
nhn khc nhau nh: h ct sng, chn thng ct sng, ung th di cn vo ct
sng hoc vim khp, cng ho tht lng V, gai i...
Trong bnh u ty th s thay i X quang xng l him gp v xut
hin mun (50%). Nhng thay i v xng ch r rng khi u t n mt
kch thc ln p ln xng. Kt qu ca s p lu di ca u l
ng sng gin rng v lon dng chn khp, bn sng v thn t sng; biu
hin bng du hiu tng gin cch cung sng (du hiu ELBERG-DYKA) trn
phim thng. S gin rng cung sng ch c ngha khi n rng t 2 - 4mm so
vi cung sng trn v di n. S tng gin cch cung sng c th t mt ti vi
thn t sng.
4.2. Chc ng sng tht lng:
Chc ng sng tht lng vi mc ch kim tra s lu thng dch no ty
trong khoang di nhn v xt nghim kim tra cc thnh phn ca dch no
ty.
S lu thng ca dch no ty c nh gi bng cc
nghim php.
Queckenstedt-Stockey. Theo cc tc gi c ti 90% trng hp ri lon lu
thng dch no ty.
Thnh phn dch no ty thng cng thay i theo s ri lon lu thng.
Bin i u tin phi k n l thnh phn albumin, n thng tng t vi
trm miligram ti vi gram thm ch hng chc gram/lit. Trong trng hp
albumin tng cao c th thy du hiu Froin, trong khi thnh phn t bo
li gn nh bnh thng, ngi ta gi y l hin tng phn ly albumin-t bo.
Thi gian gn y nh c knh hin vi in t (cng vi s pht trin ca
ngnh siu cu trc t bo), cc tc gi chn on c ngun gc ca u ty
thng qua nghin cu thnh phn dch no ty.
4.3. Chp ty cn quang:
Chp ty cn quang ln u tin c Dandy W.E tin hnh nm l919 bng
loi cn quang m tnh (khng kh hoc oxy). n nm 1921, Sicar F. chp
ty cn quang bng lipiodol thnh cng m u cho vic dng cc cht cn
quang dng tnh kim tra khoang di nhn. Cht cn quang lipiodol
mang nhiu nhc im nh: vim dnh mng nhn, tn ti lu di trong
khoang di nhn. Sau ny nh cng ngh pht trin, sn xut ra cc cht
cn quang tan trong nc metrizamide (amipaque, omnipaque, iopamiron) vo
nm 1969 do Amen ngi H Lan tm ra. T nm 1975 ti nay cht cn quang
tan trong nc thc s thay th cc cht cn quang tan trong du trong vic
kim tra khoang di nhn m khng c tai bin g.
Khi tin hnh k thut ngi ta bm vo khoang di nhn t 10 - 15ml
cht cn quang ri thay i dc ca bn ty theo yu cu trong chn on.
Hnh nh X quang sau chp ty c th thy cc hnh nh sau:
+ Vim dnh khoang di nhn: thuc cn quang ng thnh git loang l
hnh da bo.
+ U ty: tc nghn ct thuc cn quang hnh chn chn hoc hnh cng
cua.
Ngoi ra c th tin hnh chp ty bng chp ct lp vi tinh (CT.scanner)
hoc chp cng hng t (MRI).
5. iu tr v tin lng.
+ Ch nh phu thut tuyt i cho tt c cc bnh nhn c xc
nh c u ty.
+ Ch nh tng i vi nhng trng hp u ty c cao qu ln v bnh
nhn n giai on mun, nhng bnh nhn gi yu, nhng bnh nhn c
lao phi tin trin, nhng bnh l c tnh ct sng r rng, di cn trn lan.
+ Ch nh m cp cu trong nhng trng hp u b tt kt hoc chy
mu trong u gy lit chi, gy b tiu mt cch t ngt.
+ iu tr ngoi khoa c kt qu ty thuc nhiu yu t trong vic chn
on sm l v cng quan trng. Cc tc gi trong v ngoi nc u cho rng:
phu thut vo giai on au r em li nhiu kt qu tt.
Mc ch phu thut l ly b ton b u v hn ch n mc thp nht
lm tn thng ty v r. Cc trng hp u mng ty v u r thn kinh c kh
nng phu thut ly b trn vn u. Mt s u c tnh hoc tin trin c tnh
th ly b ton b u l cc k kh khn.
Thi gian phc hi vn ng t nht l t 3 thng tr ln. Cc tc gi thy
rng: nu bnh nhn b lit khng hon ton th thi gian c du hiu phc
hi phi t 2 thng tr ln.
Ti pht ca u ty khong t 3 - 4% ty theo tnh cht ca u v qu trnh
phu thut c ly b c ht t chc hay khng.
iu tr phc hi sau m ng vai tr v cng quan trng, n gip bnh nhn
mau chng tr li cuc sng i thng, ng thi trnh c cc bin chng nh
lot im t, vim phi, vim bng quang, vim thn, teo c cng khp...

Lao ct sng

Bi Ngc Tin
1. i cng.
Lao ct sng l mt bnh nhim khun xng khp v a m c
hiu do trc khun lao (Bacille de Kock-BK) gy ra khu tr ct sng. Lao ct
sng c Percival Pott m t u tin (1779 - 1783) bao gm 4 triu chng c
in l: mc xng (carie asseuse), bu sng lng (gibbosite), p xe v lit.
Nm 1880, Kock tm ra trc khun lao. Nm 1910, Albee l ngi u tin tin
hnh phu thut lao ct sng c ghp xng c nh pha sau.
Lao ct sng l bnh th pht, ch xut hin khi c th b lao tin pht
(thng l lao phi), i khi sau mt bnh lao th pht nh lao tit niu-sinh
dc. ng truyn t lao tin pht sang lao ct sng l ng mu.
Lao ct sng c th xy ra bt k t sng no. Trn mt t sng n c
th xm nhp vo thn t sng hay cung sau, nhng tuyt i a s l
thn t sng pha trc v a m.
Lao ct sng chim t l cao nht trong lao xng khp: 36.4% (Kocnhep),
40% (Gnard Marchand). Ti Php lao ct sng ngi ln chim 60,73% v
tr em l 39,26%.
2. Tin trin ca bnh lao ct sng.
2.1. Giai on xm nhp (giai on khi pht):
lao thng xut hin thn t sng ( gn b trc hay b sau) to thnh
nhng hang lao nh; trong hang cha y m lao, xung quanh l mt vng tha
xng. Trong giai on ny thng a m cha b tn thng; tuy nhin
mt s lao ct sng c khi u bng s hp a m n thun m
khng thy tn thng trn phim thng hoc phim chp ct lp vi tnh.
2.2. Giai on hy hoi (giai on ton pht):
Thn t sng b ph hy nhiu, do thn t sng phi chu mt lc c
hc l trng lng c th nn dn dn thn t sng b sp trn mt phm vi
rng hay hp (c th mt, hai hoc ba thn t sng).
vng ct sng tht lng tn thng c th lm cho cc t sng chng ln
nhau theo hnh chm v to ra g ct sng, c khi cn lm cho ct sng b vo
(scoliose). a m cng b ph hy mt phn hoc ton b.
2.3. Giai on phc hi (giai on n nh):
Trong giai on ny tnh trng ph hy xng ngng li v thn xng c
th dn dn b vi ha nu tn thng nh, ch c th thy du vt duy
nht cn li l mt khe khp b hp.
Nu tn thng nng n s hnh thnh mt khi xng chc gia hai thn
t sng k cn b hy hoi hon ton lm cho t chc xng xp ca hai
thn t sng p st vo nhau.
 Tuy nhng tn thng ny giai on hi phc nhng thc ra khng c s
chc chn l bnh khi hon ton. Bnh c th ti pht sau mt thi gian
nm im c khi 3 - 4 nm, thm ch hng chc nm.
3. Triu chng lm sng.
3.1. Triu chng ton thn:
C hi chng nhim c lao cc mc khc nhau: mt mi, chn n, st
cn, st nh v chiu, ra m hi trm...
3.2. Triu chng ti ch:
3.2.1. au ct sng:
au t pht, lc u au m , ri tng dn ln, au su, au nhiu v
m. au d di khi kch thch vo gai sau t sng tn thng, au tng ln
khi tay ln u, ln vai; c th biu hin nh au thn kinh lin sn, au
d dy, au rut tha, au bng quang hay c khi au xung vng bn...
Tnh trng au khin bnh nhn (BN) khng ci c, mun nht mt vt
g di t th phi ngi xung.
3.2.2. Co cng c cnh sng lng:
Do au nn tnh trng co cng hai khi c lng (nh dy thng) l triu
chng dy cng (Kocnhep).
3.2.3. T th bnh nhn:
Lun lun ch gi yn tnh ct sng. Trong trng hp lao ct sng c, BN
dng tay t di cm, mt tay m sau gy gi ly u, i tng bc ngn,
u hi nga. Nu l lao ct sng lng th thn ngi gp nh, nu l lao ct
sng tht lng th thn ngi n ra sau.
Trong trng hp c bc m lnh vng c tht lng chu th BN i lt hai
bn chn, khp hng v khp gi gp, thn ngi ng v pha trc.
3.2.4. Bc m lnh:
Khi m pht trin ra nng th nhn v s thy r sng n (khng nng
), c du hiu ba ng, chc ht ra m long.
Nu bc m su th phi lm xt nghim X quang v cc th thut khc
mi c th pht hin c.
3.2.5. G ct sng:
G l do xp thn t sng pha trc lm cho ct sng gy gc. Do vy g
trong lao ct sng l g nhn khc vi g trong bnh ci xng, bnh g thiu
nin (Scheuermann) l g trn.
Nu b tn thng nhiu t sng gn nhau v xp ln th g nhn rt
r v thng thy cc t sng lng. cc t sng tht lng th kh thy g
v bn thn cc t sng lng thng l n, do phi thm khm k mi pht
hin c.
 3.3. Triu chng thn kinh:
3.3.1. au theo kiu vim r thn kinh:
Nh vim dy thn kinh lin sn, dy thn kinh hng to... nguyn nhn l
do cc r thn kinh b kch thch v phn ng vim hoc v l ghp b hp
li do tn thng lao vo.
3.3.2. Bi hoc lit:
p xe lnh c th lan vo ng sng gy chn p trc tip ty sng hoc
lm cho mng ty, thm ch c ty sng b vim lao. Theo Hodgson th c hai
nguyn nhn gy lit trong lao ct sng:
+ Nguyn nhn ngoi lai: cc mnh xng cht, p xe lnh, trt khp vng t
sng b lao chn p ty sng.
+ Nguyn nhn ni ti: vim mng ty v vim ty sng.
Lit ty sng c khi l tm thi sau hi phc, cng c khi l vnh vin.
Nhng BN lao ct sng b lit nu khng c chm sc c bit s c
nhiu bin chng nh nhim khun ng tit niu, lot im t, suy mn.
Thi k cha c my chp X quang, Pott a ra ba triu chng l g, p xe lnh
v lit (tam chng Pott) chn on lao ct sng.
4. Triu chng cn lm sng.
4.1. Xt nghim mu:
Bch cu n nhn tng, tc mu lng tng cao...
4.2. Xt nghim dch no ty (DNT):
C tc nghn lu thng DNT nu c chn p ty do p xe, mnh xng
cht, mnh a m...
Albumin v t bo trong DNT bnh thng nu khng c thm nhim
lao vo trong ty gy chn p ty.
4.3. Phn ng Mantoux:
Nu phn ng Mantoux m tnh th c th loi tr lao, nhng nu
Mantoux dng tnh th vn khng c gi tr quyt nh.
4.4. Gy nhim lao cho chut th nghim:
Bng cch ly m lao tim qua ng phc mc v c kt qu sau 5 - 6
tun, y l xt nghim c gi tr chn on tt nhng phi ch lu.
4.5. Xt nghim gii phu bnh l:
C gi tr chn on quyt nh nhng khng phi trng hp no cng
lm c, thng phi m vo lao mi c th ly c bnh phm lm sinh
thit.
4.6. Triu chng X quang.
+ Triu chng trn xng:
- Thn t sng c hnh nh ph hy xng.
 - Hp khe a m.
- Thn t sng xp pha trc c hnh chm.
+ Triu chng ca bc p xe:
- C b r rt, thng l hnh thoi hai bn thn t sng.
- C hnh nt ng vi.
- Hnh dy chng dc trc tch khi thn t sng v bc p xe y c
tht lng - chu phnh ra ngoi.
T khi c my chp ct lp vi tnh (CT.scanner) gip cho vic chn on
lao ct sng sm v chnh xc hn, c bit l nhng lao nh. Hin nay
chn on lao ct sng bng cng hng t (MRI) l phng php chn on
hin i nht, cho php xc nh y cc tn thng v ct sng, ty
sng v nhng phn lin quan khc.
5. Chn on phn bit.
C nhiu bnh ct sng d nhm vi lao ct sng.
5.1. Bnh vim t sng a m khng c hiu:
Bnh ny kh ph bin thiu nin, ngc li vi lao ct sng l mt bnh
mn tnh, khi u m thm. Bnh vim ct sng a m khng c
hiu l mt nhim khun cp tnh, khi u t ngt, rm r (st cao, ton
thn suy sp nhanh chng, bch cu tng cao...).
5.2. Bnh dt t sng (vertebra plana):
L mt bnh ct sng khc ca tr em, mt th hoi t v khun (khng phi
do nhim khun) c cc du hiu au ct sng v vn ng hn ch, tin
trin mn tnh d nhm vi lao ct sng nhng li c hnh nh X quang in
hnh: t sng b dt dn nhng xng c, cn quang mnh hn cc t
sng khc (tri ngc vi hnh nh long xng v mt xng ca lao xng), b
thn t sng vn u n, khe a m hon ton bnh thng.
5.3. Bnh g thiu nin (bnh Scheuermann):
Thng gp tr em lc tui dy th.
5.4. Cc bnh l khc ca ct sng:
Vim t sng chn thng, hi chng Clippel-Feil, bnh trt t sng...
6. iu tr.
Mc ch iu tr lao ct sng l: cha khi nhim khun lao; lm
ngng ph hy xng do trc khun lao gy nn, to iu kin phc hi xng
t c chu lc bnh thng ct sng c th hot ng c.
Kt hp nhiu bin php iu tr: dng thuc khng lao, tng cng sc chng
ca c th, bt ng tt, phu thut...
6.1. S dng cc thuc khng lao c hiu:
+ Nhiu trng hp lao ct sng c th khi hon ton bng thuc c
hiu. Dng thuc khng lao l iu kin bt buc thc hin an ton phu
thut, nht l cc phu thut trc tip vo lao ly b cc m cht v m
x m trc kia b cm v d lm cho lao lan rng.
+ Nn dng thuc sm khi lao cn nh, cha hnh thnh m x bao quanh,
dng thuc 6 - 12 tun l (Anderson L.D).
+ Nu giai on ton pht mi dng thuc th phi ko di 12 thng, thm
ch cn lu hn.
Tuy nhin sau tng t iu tr 6 - 8 tun, phi kim tra kt qu lm
sng, nu cha n nh phi tip tc dng thuc, ch n khi ht hon ton
cc biu hin bnh l ti vng lao, ton trng tr li bnh thng, chp X quang
ht cc du hiu long xng, cc hang lao y n tr li, xng dnh chc
vo nhau, cc xt nghim mu (c bit tc mu lng) tr v bnh thng
mi thi dng thuc.
+ trnh trc khun lao nhn thuc, trong iu tr cn kt hp hai hoc
nhiu thuc khng lao. Phc c nhiu tc gi p dng l:
- Rifamycin 300 mg: ngi ln 8-12 mg/kg/ngy. Tr em trn 10 tui 10 - 20
mg/kg/ngy.
- Ethambutol (100 mg, 400 mg): liu lng 15 - 25 mg/kg/ngy.
- Rimifon (INH) 0,1 liu lng 5 - 6 mg/kg/ngy.
6.2. iu tr phu thut:
+ Ch nh: nhiu tc gi trong v ngoi nc thng nht ch nh m
lao ct sng trong cc trng hp sau:
- C bin chng bi hoc lit hai chn do chn p ty.
- au, bin dng ct sng.
- Chn p r thn kinh.
- p xe c y chu hoc p xe cnh ct sng thy r trn phim X quang.
+ Ty tng trng hp m c th p dng cc k thut m gii phng
chn p ty, r thn kinh, ly b trit t chc lao. Lm vng ct sng
bng cc phng php khc nhau.
Thot v a m ct sng c

V Hng Lin

1. t vn .
1.1. Tm quan trng v dch t bnh:
Thot v a m ct sng l mt bnh l kh ph bin, trong thot
v a m ct sng c ng hng th hai sau thot v a m ct sng
tht lng. Bnh hay gp la tui lao ng nn nh hng nhiu n nn
kinh t x hi.
Theo Kokubun (Nht Bn) th thy c 1,54 bnh nhn/100 nghn dn b
bnh thot v a m (TV) c cn can thip phu thut.
1.2. c im gii phu ct sng c lin quan n
bnh:
+ Khp mm mc t sng (khp Luschka):
Mt trn cc thn t sng t CIII - CVII c hai mm mc hay mu bn
nguyt m ly gc di ca hai bn thn t pha trn hnh thnh khp mm
mc t sng. Cc khp ny c vai tr gi khng cho a m lch sang hai
bn.
+ S ti mu ca ty c ch yu l do ng mch t sng c chy trong l
ngang t CVI tr ln (cp mu mt phn qua ng mch r) cn ch yu l
ngun ng mch ty sng trc (1 ng mch) v hai ng mch ty sng sau (2
ng mch ny u bt ngun t t ty sng hai bn on trong s).
+ ng mch ty sng trc cp mu cho 2/3 trc ty, ng mch ty sng sau
cp mu cho 1/3 ty cn li. Khi TV ty trung tm s gy chn p vo ng
mch ty sng trc gy thiu mu cc b vng ty tng ng to ln hi chng
chn p ty trn lm sng.
+ Thn kinh thc vt lin quan: t cc hch giao cm c trn, gia, di v
ngc trn (hch sao) c cc nhnh thn kinh giao cm i vo cc dy thn
kinh c t C1 - C4 (hch giao cm cao), C 5 - C6 (hch giao cm gia), C 7 - D2
(hch giao cm di). T cc hch ny li c nhnh i ti tim, cc ng mch v
cc c quan ni tng khc. Do vy khi TV c, ngoi triu chng ty, r
cn c nhng triu chng ca thn kinh thc vt.
+ Dy chng dc trc ph kn mt trc cc thn t sng v a m
rt dy v khe, TV c t xy ra pha trc. Dy chng dc sau tha,
mng, y l im yu, ni d xy ra TV sau bn.
2. Phn loi TV c.
C mt s phn loi chung:
+ Phn loi theo lin quan a m thot v vi ty sng v r thn kinh:
theo Rothman P.H v Marval J.P 1975 c 3 loi:
- TV trung tm ch yu chn p ty sng gy hi chng bnh l ty l
chnh.
- TV cnh trung tm: chn p c ty v r thn kinh gy hi chng
bnh l ty kt hp bnh l r thn kinh.
- TV cnh bn: cn gi l TV l ghp, gy chn p r thn kinh l ch
yu.
+ Phn loi theo bnh sinh - bnh cn:
Yumashev G.S; Furman M.E (1916); Yamano Y. (1985); Rothman R.H (1975)
chia ra:
- TV cng (hard disc herniation): TV hay m xng hoc a m
ct ho p vo ty r. Bnh l loi ny mang tnh cht mn tnh, TV c
thoi ho i km xy ra ch yu ngi nhiu tui.
- TV mm (soft disc herniation): khng hoc c t thoi ho i km,
thng do TV cp tnh sau chn thng gy nn (th ln, ng, vt nng ri,
tai nn giao thng...).
+ Phn loi a m thot v lin quan vi dy chng dc sau:
Wagner O.H. (1995) chia ra:
- TV nm di dy chng dc sau.
- TV xuyn rch qua dy chng dc sau.
Woad II G.W. (1992); Arcenia v Cimonescu (1973) chia 4 loi:
- Loi 1: phng a m (normal bulge): nhn nhy cn nguyn vn
nhng nm lch v tr vng x rn nt phng ln.
- Loi 2: li a m (protrution): a m x rch vng x nm di
dy chng dc sau gi l tin thot v.
- Loi 3: thot v thc s (extrusion): nhn a m chui mt phn qua
dy chng dc sau.
- Loi 4: TV mnh ri (sequestration): mnh a m ri khi a
m hoc l nm trc, sau dy chng dc sau di chuyn i ni khc (ln trn,
xung di ng sng; c trng hp tng nhm nh u ty (pseudo tumor), c bit
xuyn thng mng cng vo r - ty gy bnh l nng n. Tc gi Arcenia
gi nhng trng hp l "a m lang thang"- Micration (a m di
chuyn).
3. Bnh sinh v nguyn nhn c ch TV c.
3.1. Bnh sinh:
+ Yu t dch t: Theo Gore v Kelsey th TV c c t l
5,5/100.000 dn (t l mi mc). Nam b nhiu hn n; tui trung bnh
khong 40. V tr hay gp l a m C V - CVI > CIVC V > CVIC VII >
CIIICIV > CVIIDI > CIICIII.
Theo Kelsey J.L. cc ngh nghip thi quen lin quan bnh l: th ln,
khun vc, ht thuc, cc ng tc ci gp qu mc, li xe, bm nn c khng
ng k thut, cc ngh s piano, nh trng, xic nho ln... c t l mc
bnh cao hn.
+ Bnh sinh: a m c coi nh mt loi khp ct sng c bit, c 3
chc nng chnh:
- Gn kt hai thn t sng gi cho ct sng v ty sng n nh.
- Hp thu lc sang chn v chu ti ct sng. Hn ch ti a tc ng rung
sc lm chn ng no v ty sng.
+ Tham gia vo chc nng vn ng ct sng. lm c chc nng
a m c cu trc nh mt bn khp trong dch khp chnh l nhn
nhy (c gelatin) lng snh c, 2 mt khp chnh l 2 mm sn trong
(hyalin). Cc vng si x v dy chng xung quanh nh l bao khp. Do vy
a m cng chu s chi phi ca quy lut thoi ha khp nh mi khp khc
trong c th.
Khi a m cha b thoi ha (di tui trng thnh) cc thnh phn
nhn nhy, bao x, mm sn... cn tt, khi c lc nn ln ct sng c th nhn
nhy chu lc u tin bt xung, cc vng si phnh ra. Lc nn chia u ra
nhiu hng vo vng si v tc ng ln cc tm sn trong. Lc nn xung
thn t sng di gim i nhiu. Khi ti tui trng thnh (18 - 20 tui) cng
l lc a m bt u thoi ho, biu hin l: nhn nhy kh kit dn,
vng si rn nt dn. Qu trnh pht tn dch th ra khi a m nhiu ln
m qu trnh ti hp thu dch th qua cc l nh li ti mm sn t dn do b
bt tc dn. a m dn thoi ho cng vi s thoi ho khc cc thnh
phn ct sng v c th.
TV l hu qu ca mt qu trnh thoi ha sinh l (hoc thoi ha bnh
l).
Nhn nhy thoi ha u tin: mt kh nng hp thu lc, thoi ha rch
vng si cc mc khc nhau.
Nu s cng phng nhn nhy cn duy tr mc no m cc vng si v
dy chng t rch nhiu th ch cn mt lc nh cng nhn nhy
thot ra qua l rch , mch mu s bao quanh nhn nhy i su vo ch t
rch hnh thnh so a m.
 Mt trn ca t sng pha di b lc tc ng mnh hn v b x ho dn
cc th ct sng, cc khp mm mc cng thoi ho. Cc khp ph i, nhiu gai
xng hnh thnh, hp l ghp chn p vo c r thn kinh v mch mu t
sng.
n lc dy chng dc sau cng b y ra sau tch khi mt t sng ko
rch mng xng to phn ng sinh xng mp thn t sng, vi ho dy
chng.
Dy chng vng cng b thoi ha, ko gin lm cho mt kh nng n
hi, ph i dy chng vng, t gy hi chng hp ng sng ct sng
c.
3.2. Nguyn nhn c ch TV c:
C 2 c ch gy ra TV c l: thoi ho v chn thng. Trong
thoi ho l nguyn nhn chim a s.
Thoi ha ct sng a m (CS) tin trin theo la tui c cc yu
t vi chn thng thc y, mt lc chn thng tc ng ln mt c a thoi
ha ct sng s l c hi gy TV.
Ngoi ra c kin nu thm l: ri lon chuyn ho, d dng ct sng c,
bnh l t min dch. Nhng yu t coi nh l yu t tin thoi ho cng
d gy TV c trong mt s hon cnh lc tc ng vo ct sng c.
4. Lm sng.
TV ct sng c xy ra nh l mt bin chng ca qu trnh thoi ho a
m ct sng c; n nm trong bnh cnh chung ca hi chng hp ng sng
c nn lm sng rt a dng v phong ph (ty theo v tr thot v, th thot
v, mc v giai on bnh, tnh phn ng ca tng c th). Tuy vy cng
c nhng bnh cnh chung nht. Cc tc gi chia 3 loi.
4.1. Hi chng chn p r n thun:
* Nguyn nhn: do TV vo l ghp (hoc cnh trung tm chn p vo l
ghp) kt hp vi m xng, gai xng do thoi ha ct sng hnh thnh dn
dn lm hp l ghp, t gy kch thch, p, cng ko r thn kinh
c ko theo vim, ph n thn kinh, thiu mu r thn kinh.
* Triu chng:
+ au kiu r thn kinh: y l mt triu chng sm nht, hay gp nht
gy ch bnh nhn. Ngi bnh thng phn nn thy au gy c lan
xung vng vai, ngc, au dn xung cnh tay, cng tay v cc ngn tay.
- au lin quan ti vn ng ci, n nghing, c th lm bnh nhn vo c
(torticolis).
- au tng khi ho hoc ht hi.
- C th thy au u hay au mt nhng t gp hn.
- Khi pht au c th cp tnh sau chn thng u, c. C th t t sau
mt m ng dy hoc mt ln i xe ng xa v.
 - Tnh cht au: hoc m hoc au su trong c xng, nhc nhi
kh chu nh dao m hoc nh bng rt mt vng no chi trn, au u
th gc chi km theo t b cc ngn tay.
- Tin trin: au thng khng lin tc, ban u au gy c sau au
tng t lan xung chi trn. Ngh ngi c th , iu tr c th n nh lu
di.
Khm c th thy mt s du hiu:
. 2 bn hay, ngn tay n, t ph mp mp (hi chng Steinbrocker): gp
khong 2% cc trng hp.
. Du hiu Spurling: khi n tay nh u trong khi bnh nhn nghing
u v bn au gy au tng ln th l du hiu dng tnh. L do au
tng v nh vy lm hp l ghp v lm tng p lc ni a m nn chn p
thn kinh tng ln.
. Du hiu bm chung: n gai sau hoc cnh sng c, bnh nhn au t
c xung vai i xung cnh tay, cng tay, bn tay. l du hiu dng tnh.
. Du hiu Lhermitle: khi ci bnh nhn au t gy c lan xung cnh
tay, cng tay.
. Test ko gin ct sng c: cho bnh nhn nm hay ngi, ko cm, gy,
u bnh nhn dc trc ct sng mt lc = 10 kg nu bnh nhn thy d
chu (triu chng r gim) th test dng tnh.
. Test dang vai: bnh nhn ngi a tay ln u nu bnh nhn thy d
chu (triu chng r thn kinh gim) th l test dng tnh.
Hai test trn mc ch: gim p lc ni ty v gim cng ko dy thn
kinh, do vy bnh nhn gim au.
+ Ri lon cm gic:
c im ri lon cm gic thng i cng triu chng au tp trung chi
trn. Vng ri lon cm gic cho php nh gi mt phn nh khu r thn kinh
b p. V d:
- Ri lon cm gic au ngn ci: r C6 b tn thng.
- Ri lon cm gic au ngn gia: r C7 b tn thng.
- Ri lon cm gic au ngn t: r C8 b tn thng.
+ Ri lon vn ng: tng t nh vy c th cn c chc nng chi phi vn
ng ca cc r m suy lun lm sng:
- Yu dang vai: r thn kinh C5 chi phi.
- Yu gp khuu: r thn kinh C6 chi phi.
- Yu dui khuu: r thn kinh C7 chi phi.
- Yu gp v dng khp ngn tay: r thn kinh C8 chi phi.
Thng ch yu ng tc ch t khi b lit hon ton v y l bnh l
mn tnh.
 + Ri lon phn x:
- Mt hoc gim phn x c nh u: r C5 tn thng.
- Gim phn x chm quay: C6 tn thng.
- Gim phn x c tam u: C7 tn thng.
Tm li: ty theo r tn thng m c triu chng r khc nhau v vn
ng, cm gic, phn x. Tuy vy do s an xen chi phi ca cc r thn kinh
vi nhau, mt khc c th thot v c kt hp vi hi chng bnh l thoi ha
hp ng sng c hoc l TV c a tng, thot v cch tng cho nn khng
c triu chng thn kinh no c c nhy v c hiu cao cho nh gi
mc a m b thot v. Do vy cn MRI chn on chnh xc.
4.2. Hi chng chn p ty n thun:
* Nguyn nhn: do TV ty trung tm v cnh trung tm ln gy p
trc tip vo sng trc ty sng, ng mch t sng trc (chi phi 2/3 ty trc).
* C ch bnh sinh: kt hp vi m xng, gai xng gy hp ng sng
sn (bnh thng ng knh trc sau ty sng c 12 mm, nhng c gai
xng nn ng knh tr ln hp dn 12 mm) nn khi c thm thot v th
cng gy thiu mu ty tng ln, c th gy nn ph ty ngang mc thot v.
Nu chn p mn tnh c th gy thoi ha mt phn si trc myelin.
* Lm sng hi chng ty c:
Bnh thng xy ra t t la tui trung nin hoc khi pht t ngt sau
chn thng. Bnh c tng t tin trin sau thoi lui do iu tr thuc, ngh
ngi, ko gin. C th gp cc triu chng sau:
+ Ri lon vn ng: l triu chng hay gp nht, chi trn bnh nhn
thy t b, cm nm yu, s kho lo gim i. Chi di bnh nhn i li kh
khn, chng mi mt bn hay c hai bn chn. i thng dng chn, c khi phi
chng gy khi i, i lc co git chn lm bnh nhn c th ng.
C th triu chng chi trn xut hin trc hoc xut hin sau hay c khi
gp trn mt bnh nhn c lit ngoi vi mt chi trn, lit trung ng hai chi di
(nu thot v CV tr xung).
Nhng nu thot v CIII - CIV, CIV - CV th lit c t chi trung ng. Do vy
m ri lon phn x chi trn c th l tng hay gim phn x, trong khi phn
x chi di thng tng trong thot v c.
+ Ri lon c trn: thng kh i, kh a.
Nhiu tc gi Hauser S.L 1988, Clark C.R 1991, Hoff J.T 1997, 5 loi du
hiu tn thng u th.
+ Hi chng ty c trc: tn thng ch yu b v gai v t bo sng trc
sau chn thng ci qu mc: a m, gai xng chn vo ng mch ty
trc v phn trc. Bnh nhn thng lit hon ton v mt cm gic nng,
lnh, au di mc tn thng.
 + Hi chng ty trung tm: tn thng c cht trng v cht xm trung
tm.
- Mt cm gic nng: nng, lnh, au 2 tay.
- Cn cm gic su v cm gic rung t chi.
+ Hi chng Brown - Sequard:
- Mt bn pha tn thng do thot v vo: lit kiu trung ng, mt
cm gic su v cm gic rung.
- Bn kia mt cm gic nng: nng, lnh, au, cn cm gic su v cm gic
rung.
+ Hi chng ty ct ngang: lit hon ton t chi.
+ Hi chng ty c sau: thin v tn thng sng sau nn c chn thng
nga qu mc (hyper extension), mt cm gic su, vn ng, dng i long
chong, 2 chn dang rng, cn cc cm gic khc.
+ Hi chng r ty phi hp: bao gm 2 triu chng trn. y l hi chng
ph bin nht. Tuy vy nhng triu chng ty vn tri hn triu chng r
(Clark 1991). Ri lon vn ng + phn x r hn ri lon cm gic; thng gim
cm gic hn l mt cm gic hon ton.
4.3. Hi chng ri lon thn kinh thc vt:
* Nguyn nhn v c ch bnh sinh:
+ Khi thot v p vo cc mng ty, mch mu cc thn kinh c cc
nhnh giao cm i ln kch thch ngc li hch giao cm v cc nhnh ti cc
tng khc (mt, tim v cc c quan ni tng khc).
+ M xng, gai xng p vo ng mch t sng.
+ Bn thn a m c cng vi ct sng c c chc nng vn ng
c v iu tit nh hng khng gian v iu khin t th; nn khi TV
thng gy mt iu khin trong hot ng c, nh hng chc nng thc vt
c thng qua phn x iu chnh ng tc: mt, u, thn mnh.
* Lm sng:
+ Chng mt, mt thng bng.
+ tai, m mt tng cn.
+ Mt tng lc, h huyt p v v m hi.
+ Cn au ngc do cn nguyn ct sng c: hay gp trong thot v CVI -
CVII.
5. Cc phng php chn on TV ct sng c.
Cc triu chng lm sng nh va nu trn gip cho ngi ta nh hng ti
bnh l vng ct sng c. Cc phng php chn on cn lm sng ng vai
tr ch yu chn on xc nh bnh v cc phng php t n gin
n hin i nh sau:
5.1. Chp X quang thng quy:
y l thm khm cn lm sng u tin vi chp thng, nghing, chch
phi, chch tri v t th Fank chp CI, CII h ming to. l cc kiu chp
phim thng thng ct sng c.
+ u im:
- n gin, gi thnh r...
- Cho bit trc ct sng, cong sinh l ct sng ra sao ? hnh dng thn
t, khe khp, mm mc, gai xng, khe lin t, l tip hp (phim chch 3/4 hai
bn).
+ Nhc im:
- y ch l nhng thng tin ban u v xng ct sng c khng nh
gi y cc thay i v ty, a m c v phn mm cnh sng.
- Hay b cn hnh bi khp hm pha trn, xng vai pha di.
5.2. Chp ty cn quang:
Sicard (1922) chp ty cn quang bng lipiodol chn on bnh l ty.
Nhng nhc im l d gy vim dnh mng nhn ty v tn ti rt lu
trong ty sng. Nm 1957, ngi ta tm ra amipaque (metrizamid) sau tm ra
omnipaque (iohexol) l loi tt nht hin nay (tan trong nc hp thu nhanh
trong vng 4 - 6 gi, khng b ion ha, t c li c cn quang cao) nn vic
chp ty cn quang an ton hn nhiu.
+ K thut: chc kim ngang CI - CII t th nm sp hoc nga ti a,
bm 5 - 10 ml omipaque hm lng 300 hoc 350 (khng dng loi 370). K
thut ny do Henz v Goldmen xut ln u tin (nm 1972).
+ u im: xc nh c s p t xng, a m, r thn kinh, u,
vim dnh ca ct sng c.
+ Nhc im:
- y l th thut gy sang chn.
- K thut chc kh.
- Thuc cn quang d tt n u cng c mt t l d nh gy phn ng
ph.
- Hnh nh cho l hnh nh gin tip.
5.3. Chp a m:
u tin l Lindblom (1948) chp a m vng tht lng, sau Smith
l ngi chp a m ct sng c.
+ K thut: a 2 ml thuc cn quang bm trc tip vo a m.
+ u im:
 - nh gi c trc tip hnh dng cu trc bn trong a m, do
bit c tn thng c th ca a m, cc th bnh a m.
- L th thut bt buc iu tr theo phng php ho tiu nhn.
+ Nhc im:
- Th thut gy au n, kh lm.
- C kh nng b nhim khun th pht.
Ngy nay t lm, nht l t khi c MRI.
5.4. Chp ct lp vi tnh:
K thut:
Khng dng thuc cn quang: ct lp ngang mng 1mm v chp kiu xon
c.
+ u im: phng php ny c th gip ngi ta nhn thy cc hnh nh
khc ca TV: trung tm, lch bn vo l tip hp. l hnh nh gim t
trng a m thot v 80 n v HU so vi xng v tr a m
bnh l. C th thy thm hnh nh m xng, thoi ho mm mc.
+ Nhc im: hay b nhiu, cn hnh vng vai - gy nn kh lm bnh
nhn bo, vai rng, c ngn; thun li nht l chp a m c CV - CVI -
CVII.
5.5. Chp CLVT c dng thuc cn quang (hoc l a thuc ng ng
sng hoc l ng tnh mch):
a s l chp CLVT sau bm thuc cn quang vo ng sng.
+ u im:
- Cho thy r hn s y ca a m vo ty v r thn kinh.
- D ti to hnh nh dc ton b ty (tt nhin phn gii khng cao).
- C th chn on hp ng sng c hoc tc ngn lu thng dch no ty,
pht hin bt thng xa ng gia.
Theo Greenberg (1997) gi tr chn on chnh xc phng php CLVT +
c bm thuc cn quang cc bnh ct sng c l 98 %.
Phng php ny ch ng khi khng th chp MRI hoc khi cn bit k
hn v xng.
+ Nhc im:
- y cng l phng php chn on c can thip.
- Hnh nh b nhiu t CVI - DI v mc xng b vai bnh nhn.
5.6. Chp cng hng t (MRI - magnetic resonance imaging):
+ u im:
- An ton, th thut khng xm hi.
- Khng gy nhim x cho bnh nhn v thy thuc.
 - Cho hnh nh khng gian 3 chiu vi nhiu lp ct nhiu bnh din khc
nhau.
- tng phn cao ca cc t chc phn mm.
- nh gi kh ton din: ty sng, dch no ty, dy chng vng, mch mu,
t chc m, xng sng v a m.
Tm li: MRI l phng php tin tin nht hin nay chn on cc bnh l
ct sng ty sng. c bit chn on TV ct sng c, nht l lin quan ch
nh iu tr ni khoa, ngoi khoa.
+ Hnh nh TV trn phim cng hng t:
- a m l mt t chc c ranh gii r rt.
Mu en trn hnh nh T1W l t chc gim tn hiu.
Mu trng trn hnh nh T2W l t chc tng tn hiu.
- Khi TV ng tn hiu vi m a m y nh ra sau vo ng
ty khng ngm thuc i quang t.
- Cc hnh nh Sagittal (ct dc trc sau) cho bit y k v xng ct
sng, cong t sng c, v tr TV, s tng TV. Mc p a
m thot v vo ty, s ph ty th no ?
- Hnh nh ct ngang (axial) cho thy r TV l loi TV trung tm,
cnh trung tm, thot v l ghp thm ch cho bit c rch dy chng dc sau
do a m p hay khng.
Vi 2 hnh nh ct dc v mt hnh nh ct ngang c bn ngi ta o
c cc kch thc ca ng sng v ty sng. Ngi ta nh gi tnh
trng c hp ng sng c khng ? y l mt loi hi chng bnh l kh
ph bin ngi cao tui.
Theo nhiu tc gi, cc bnh nhn c ng knh ng sng trc sau 12
mm t CIV - CVII coi nh hp ng sng. ng knh rng bnh thng ca CIV -
CVII l 13 - 14 mm, CI 21 mm, CII 20 mm, CIII 17 mm. Ngi ta cn thy
nu ng knh ty sng hp 10 mm th biu hin lm sng TV c
r rng hn khi ng knh ty sng > 13 mm.
+ Nhc im MRI:
- t tin (nhiu ngi dn khng th lm c).
- B nhiu t (artifact) khi trong c th bnh nhn c mnh kim kh
hoc t my to nhp.
- C mt s bnh nhn qu s hi (tr em, ph n...) khng lm c.
Trong mt s trng hp c TV ct sng c trn phim MRI nhng khng c
biu hin lm sng. Do vy lun lun khm xt lm sng tht k trc khi
quyt nh phng php iu tr no ? Nht l ch nh phu thut ?
6. Chn on phn bit.
Hi chng c-vai-cnh tay v bi yu hai chi di c th c do nhiu nguyn
nhn khc nhau nn cn phi phn bit trong chn on mi c phng php
iu tr hp l. Ngi ta chia ra 2 ngun gc bnh l:
+ Ngun gc t ct sng-ty sng lnh tnh hoc c tnh:
- U ty: u mng ty (meningioma), u r thn kinh (neurinoma,
schwannoma), u mng ng ni ty ependymoma, u t bo thn kinh m ca
ty (glioma, astrocytoma), u m (lipoma); cc nang nc ty do vim dnh, do
mu t c tiu i, do thoi ho sau chn thng (kistique).
- U xng sn (osteochondroma), u xng (osteoma), u c tnh (osteosarcoma),
cc m xng (osteophis), gai xng chn p vo ng sng gy hp ng sng
c. Cc loi u vng ny c th l di cn ung th phi, ung th tin lit tuyn,
ung th tuyn gip, ph n c th l ung th t cung, ung th tuyn v...
- 2 loi bnh l cng c nhc n nhiu l:
. X cng ct sng bn teo c vi triu chng ch yu l teo c, rung git
c, khng ri lon cm gic, c tn thng km theo, tn thng thn kinh XII,
IX, X, phn x bnh l thp tng r c t chi (hay gp tui 40 - 60).
. Bnh x cng ri rc: hay gp tui t 20 - 40, tin trin tng t,
nng dn hay ri lon v mt hoc tiu no.
- Vim a khp dng thp khng c hiu hay gp nht l vim tiu mm
nha gy sai khp trc-i, t gy chn p ty sng ngang CI, CII, bnh
nhn b bi yu t chi, co cng chn tay, lit c vng d gy thiu nng
ng mch sng-nn (mt thng bng, chng mt, tai, rung git nhn cu).
Bnh l ny cn lm phu thut Brook and Jenkin ng cng chm c sau.
- Vim xng khp do vi khun: bnh nhn c hi chng nhim khun ton
thn au, n sng to gy c, hi chng r-ty xut hin nu c vim lan
to p ng sng hoc trt t sng, xp t sng do vim gy nn.
Trong y c t l 3 - 5 % vim xng a m do lao t sng. Trong 6
nm gn y Bnh vin 103 gp 2 trng hp lao ct sng c. Phu thut
kt hp iu tr ton thn bng thuc chng lao t kt qu tt.
- Chn thng ct sng c c.
- Bnh rng ty.
- Bnh vi ho ph i dy chng dc sau hay dy chng vng.
+ Ngun gc bn ngoi ct sng c gy au thn kinh m ri c:
- Hi chng ph o khoc do u nh phi (pancast).
- Hi chng vim quanh khp vai.
- Bnh l m ri (plexus) v r thn kinh.
- Bnh tm cn v cc bnh khc ni tng au theo kiu xut chiu ti c
c th au theo ng thn kinh giao cm; do nn cn khm xt cn thn, k
lng.
7. iu tr bnh TV c.
7.1. iu tr ni khoa:
Sau khi khm xt chn on TV c ngi ta iu tr theo nguyn tc
iu tr ni trc, iu tr ngoi sau.
+ iu tr c h thng, bao gm nhiu bin php:
- Ung thuc chng vim gim au.
- Tim thuc chng vim gim au.
- Xoa bp, bm nn, vt l tr liu: b nn, in xung, in phn.
- Chm cu.
- Bt ng ct sng giai on cp bng np Minerve hay bng khung Halo,
Coloar.
- Ko gin ct sng nu c ch nh.
+ iu tr c bn: ty th bnh, ngi bnh m c liu tr liu khc
nhau v vi phng php iu tr thch hp ring. Trnh bin chng v gy
tn thng thm cho bnh nhn ch v khng hiu bit gii phu sinh l,
bnh l, bnh cn, bnh sinh. iu tr theo kiu m mm, tim chch thuc
vo ct sng, ty sng khng ng nguyn tc ch nh.
nh k ti khm xt: c hng dn cho ngi bnh bit cch v sinh lao
ng, ngh ngi hp l, phng nga ti pht v tai bin. Nu thy bnh l c
xu hng tng dn hoc khng thuyn gim hoc ti pht nhanh th cn chn
on xc nh li v chuyn phng php iu tr hp l hn.
7.2. iu tr ngoi khoa:
Sau iu tr ni khoa h thng v c bn m khng c kt qu.
+ iu tr ngoi khoa nhm 3 mc ch:
- Gii phng chn p ty, r thn kinh do a m chn p hoc l x
si, dy chng vng tng sinh p.
- Phc hi gii phu ct sng c.
- C nh vng ct sng trnh di lch tn thng th pht sau khi ly a
m c.
+ Ch nh:
- TV trung tm, cnh trung tm, TV l ghp gy bi yu t chi,
chn p au n dai dng, khng khc phc c bng thuc v cc phng
php iu tr ni khoa khc.
- Chp MRI xc nh r v tr, th bnh v mc bnh TV.
+ K thut:
- Trc y thng lm phu thut i ng sau:
To hnh cung sau ct sng sau gii phng chn p; m rng l ghp; to
hnh cung sau m rng.
 - Vo nhng nm 50 th k XX n nay, phu thut ch yu i ng trc
bn vi cc phng php ca cc tc gi: Cloward, Robinson, Bailey, Badgley,
Simmon.
7.3. Cc phng php khng m hoc phu thut gy thng tn ti thiu
(minimaly invasive neurosurgery):
* Phng php ho tiu nhn (phng php n mn bng men chemonucleolyse):
Lyman (nm 1963) l ngi u tin xut v p dng phng php ny.
C giai on p dng ph bin M v Php (nhng nm 1980 - 1990).
+ Nguyn l: men s phn hy protein, polysacharide thnh nc, nc s c
o thi ra ngoi qua nc tiu lm a m kh x cng li, p lc ni a
m gim, chn p r ty thn kinh.
+ Nguyn liu tiu nhn: chymopapain hoc aprotimin (trasylon). y l
nhng cht men tiu m rt mnh.
+ Ch nh: TV cn bao x tng i tt.
Khng p dng phng php ny khi TV v rch bao x, TV mnh ri
(sequestration) TV ln p ty sng, TV t do (micration), TV xuyn
mng cng, xuyn r, thoi ho ct sng-a m, a m giu mch mu
nui: cht men d hp th qua mch mu gy sc phn v.
Hn ch dng phng php ny vi vng gii phu quan trng.
+ u im:
- Hiu qu nhanh.
- Thi gian nm vin ngn.
- V cm n gin: t ti ch, khng cn gy m.
Tt nhin l cn phi chp a m trc.
+ Bin chng:
Vim t sng, chy mu di nhn, sc phn v nu a m giu mch
mu.
* Phng php ly a m qua da bng ni soi:
+ y l phng php mi cn c dng c tinh xo chuyn dng: mn hunh
quang tng sng, dng c m ni soi, l cc dng c:
Vi phu tch: rougeur, bipolar, gouse, carry-sion n soi ni vi mt video.
+ u im: an ton, thun li, gy t tn thng nht cho xng sn ct
sng.
+ Nhc im: ch ly mnh a m ln chn p nhiu nht.
Khng m cho cc th c bit nh: a m mnh ri di chuyn
(micration), a m xuyn mng cng.
* Dng Laser YAG gim p a m:
 + Phng php do Choy v Ascher (1980) xut v p dng da trn nguyn
l nng lng ca laser nd YAG c tc dng lm quang ng v bc bay hi t
chc cp thi.
+ K thut: dng kim chc sng tht lng s 18 chc vo nhn nhy a
m, lun si quang dn c laser nd YAG di gy t ti ch v theo di qua
mn hunh quang khi ng v tr tin hnh t. Khi nhn nhy a
m b co li. p lc bn trong a m gim i t ngt gy co ton b
a m nn s hn ch p ty, thn kinh.
+ Ch nh v chng ch nh nh 2 phng php trn.
+ u im: rt n gin, hiu qu tc th. Bnh nhn c th iu tr
ngoi tr, c th lm nhc li. Tuy nhin khng phi th TV no cng
p dng phng php ny c.
Vit Nam hin ti gi thnh ca iu tr theo phng php ny cn t.

thot v a m vng tht lng

V Hng Lin
1.i cng.
1.1. nh ngha:
Thot v a m (TV) l s l s dch chuyn hoc bnh trng ca
a gian t sng ra khi v tr bnh thng ban u (c th ra pha trc,
pha sau, pha 2 bn hoc xm ln vo thn t sng...) gy nn nhng
triu chng lm sng ca ct sng v triu chng thn kinh (au n) khin
cho bnh nhn (BN) kh chu phi quan tm hoc phi cha tr bng cc bin
php khc nhau nh ni - ngoi thn kinh, ng y, l liu...
y l th bnh c bit ca bnh l thoi ho a m nm trong
bnh cnh chung ca chng h sn khp a m (osteochondrose).
1.2. Dch t:
80% BN c hi chng tht lng- hng lin quan ti bnh l a m.
Theo Greenberg (M - 1997) c 1% dn s b TV, trong c 10 - 20%
phi can thip phu thut.
TV hay gp nht la tui lao ng, t l nam gp i n.
TV c th gp mi a m ca ct sng nhng nhiu nht l a
m vng tht lng (chim 90 - 95%), sau n a m vng c (5 - 7%),
cn li rt t gp cc ni khc ca ct sng.
TV vng tht lng nhiu nht 2 khe gian t LIV-LV v LV-SI (trong
LIV-LV nhiu hn LV-SI). TV th lch bn chim a s, TV bn tri chim
nhiu hn bn phi
 1.3. Lch s nghin cu bnh:
1.3.1. Nc ngoi:
+ Bnh c t lu nhng ch c nghin cu v cng b vo cui th k 19.
+ Domenio Cotugno (1770) l ngi u tin m t bnh thn kinh to.
+ Virchow v Von Luska (1858) m t c tnh a m v ni ti vai
tr gy bnh ca a dm.
+ Schmorl (1929) nu ln hin tng a m thot vo cc thn t sng,
a ra khi nim herniation of disk v c dng t n nay.
1.3.2. Trong nc:
+ Nguyn Thng Xun v Trn Quang V (1958) ln u tin thng bo
m TV cho 20 bnh nhn; sau Hong Tin Bo cng phu thut loi
bnh ny.
+ L Xun Trung (1965) thng bo v bm kh chp ty.
+ 1966 Trn Quang Vip thng bo hnh nh chp X quang TV vng
tht lng - cng.
+ Trn Mnh Ch, Phan Chc Lm, V Hng Lin (1978 1980) thng bo
m 47 ca TV tht lng - cng ti Bnh vin 103.
+ L Vn Tin v cng s (1981) thng bo m 12 trng hp TV ti Bnh
vin 108. T ti nay c nhiu tc gi khc nh V Quang Bch, Nguyn
Xun Thn, H Hu Lng, Bi Quang Tuyn, Nguyn Th L, Hong c
Kit, V Vn Nho, Phm Ho Bnh v nhiu tc gi khc c nhng cng
trnh v vn ny.
+ Lun vn tin s u tin trong nc ca V Hng Lin (1992) chnh thc
nghin cu v iu tr ngoi khoa 306 BN TV c cng b. n nay c 4 lun
vn tin s, khong 10 lun vn thc s v chuyn khoa II cng b v vn
TV.
2. Cu to gii phu a m (anatomic), sinh ho nhn m
(Biochemistry), chc nng sinh c hc (biomechanical function).
2.1. Cu to gii phu a m:
a m nm gia 2 mt ca t sng trn v di, vi chc nng nh l
mt tm m gim sc v c chia lm 3 phn:
2.1.1. a sn (sn a m):
Nm ngoi cng a m, nm st v bc lt 2 mt t sng trn v di,
cu to nh sn khp ni khc nhng mng hn. l lp sn trng kiu pha l
(hyalin cartilage). Trn mt a sn c rt nhiu l nh li ti, ni cung cp
dch th dinh dng cho a m v cng l ni khuch tn dch th t
a m ra ngoi. Bnh thng qu trnh ny iu ho nu lao ng v
ngh ngi ph hp, song nu tng qu trnh khuch tn dch th nh lao ng lin
tc (khun vc, li xe ng di nhiu ngy hoc ngi lu...) s lm cho nhn
nhy kh kit dn. cng l qu trnh thoi ho xy ra t t ca a m ni
chung v nhn nhy ni ring.
a sn va l ni truyn lc vo nhn nhy (hydrodyamic boll bearing) v
cng l ni chu lc phn hi ca nhn nhy. Do vy thng thy lm mt
thn ct sng ngi gi, ng vin a m trn di hai thn t thng l
mt ng cong lm vo thn t sng, l s thoi ho sn khp a m
kh in hnh.
2.1.2. Bao x a m (annulus fibrosus):
y l mt h thng di x chy t sn a m n nhn nhy a
m, n c tc dng to dng nhn m. Bao x a m chy t nhn
nhy ra trc v ra 2 bn ct sng, chui su vo cc dy chng dc trc v mp
thn t sng 2 bn hn l chui vo dy chng dc sau (bn thn dy chng
dc sau mng dn t trn c xung ct sng tht lng), do thot v a
m hay xy ra pha sau hn l pha trc v 2 bn, nguyn nhn l do bao
x nhn nhy pha sau yu.
2.1.3. Nhn nhy a m (nucleus pulposus):
Nhn nhy nm trung tm a m, rt linh ng trong cc ng tc
ct sng (ci, n, xon vn...). Cu to ca nhn nhy a m gm nhng
si nhy (fibrogelatinous) kiu nhng si keo (semigelatinous). Nh c nhng si
keo ny nn s di ng ca nhn nhy d dng v tun theo nh lut cht
lng, l s linh ng, co gin ty thuc vo lc truyn ti v s vng chc ca
bao x a m.
Nhn nhy c nhim v hp thu lc theo chc nng thy lc ng hc.
Nu qu trnh pht tn dch th ko di, thng th hn qu trnh hp thu
dch th th thnh phn nhn nhy gm si x v gelatin s thay i (gelatin
gim i cn fibro tng ln), nhn nhy kh kit dn, kh nng hp thu lc km
i, chc nng gim sc mt dn hiu lc; mt khp ct sng cng dn dn b
tn thng thoi ho theo, a m thot v chn p thn kinh cng vi nhng
bnh l khp ct sng (spondylo arthrose). l nguyn nhn gy nn au ct
sng tht lng v au r thn kinh sau ny.
2.2. Dy chng dc chung (common longitudinal ligament):
Bao ly thn t sng v bao ly a m 2 mt trc v sau.
2.2.1. Dy chng dc trc (Lig. longitudinal anterios):
Dy chng dc trc dy, ph mt trc a m v thn t sng nn
hn ch a m thot ra pha trc, nhng do s di chuyn a m cng
tc ng ti b mp ca dy chng vi ct sng, nn c hin tng ngm mui
vi to thnh cc m xng (osteophytes) 2 bn v pha trc ct sng, cng
cao tui hnh nh m xng cng in hnh.
2.2.2. Dy chng dc sau (lig. longitudinal posterios):
y l mt dy chng mng, tha dn t trn xung di nn kh nng gia c
cho a m km. l l do TV hay xy ra pha sau.
2.3. Chc nng sinh c hc ca a m:
2.3.1. Kh nng chu lc ca a m:
+ a m ct sng tht lng ca ngi chu mt ti trng rt ln v thng
xuyn t khi bt u tp i, l trng lng na ngi dn xung cng vi
trng lng vt mang vc, phn lc dn nn khi i li, chy nhy.
+ p lc ni a m tng ln khi na trn c th chuyn dch ra xa
ng gia (ci, nghing, n, xoay). C tc gi th nghim v o c p lc
ni a m vng tht lng cc trng thi v thu c kt qu nh sau:
- Nm nga p lc ni a m l 1 ln.
- Nm nghing, gp nh ct sng th p lc ni a m l 2 ln tng ln.
- ng thng th p lc ni a m l 4 ln tng ln.
- ng ci khng ti th p lc ni a m l 6 ln tng ln.
- Ci xoay nh th p lc ni a m l 8 ln tng ln.
- Ngi gh khng ta th p lc ni a m l l 6 ln tng ln.
- Ngi c ta th p lc ni a m l 3 ln tng ln.
- Ho ht hi th p lc ni a m l 2 ln tng ln.
- Ngi xm b vt nng th p lc ni a m tng 11 ln.
2.3.2. Kh nng chu lc ca cc thnh phn
a m c thy nh sau:
+ a sn: chu c nhng lc nn v nhng lc mnh do chn thng,
cho nn nhiu BN c chn thng ct sng, thn t sng b xp trc nhng
a sn khng b tn thng.
+ Bao x: khng chu nh hng nhiu lc thng ng nhng b nh
hng rt r nt lc ngang xn ct hay lc tip tuyn, lc xon vn. Ngi
ta thy t sng ngc xoay quanh trc gia thn t sng, trong khi t
sng tht lng xoay quanh trc sau thn t sng (theo phn loi 3 trc ca
Dennis), iu gy nn lc nn thng d chuyn thnh lc xoay, lc tip
tuyn v d lm tn thng bao x pha sau v dy chng dc sau hn nn
nhn nhy a m d b thot ra pha sau.
+ Nhn nhy: chu lc kh tt, ngi ta tnh vi lc nn 450 - 600 Kg th
mt t sng b tc ng nhiu cn nhn nhy v a m t b tn
thng. Nhng nu th tch nhn nhy gim t 1,5 - 2,5 ml th kh nng
thch ng lc km i nhiu. Chnh v vy lao ng hp l, th dc gia gi,
ngh ngi gii tr sau nhng ngy lao ng l nhng bin php tt lm cho
qu trnh ti hp thu a m c iu ho, chnh l to cho a m c
sc bn do dai, m nhn chc nng gim sc rt tt.
3. M phi ng lc hc (Dynamic histology), bnh hc v c ch
bnh sinh TV (Pathology).
3.1. M phi ng lc hc:
+ T tun th 24 ca bo thai, a m hnh thnh a sn v nhn
nhy. Sau khi sinh ra a m tip tc hon thin hnh thnh bao x a
m. Ti 10 tui a m hnh thnh y 3 thnh phn (a sn, bao
x, nhn nhy a m).
+ tui trng thnh (18 - 20 tui), a m c nui bng cc mch
mu xuyn qua cc tm sn m, qua cc l nh li ti. Nh vy a m hon
chnh v chu lc tt nht tui 10 - 18, nhng cng t tui ny tr i th
a m bt u i dn vo thoi ho, biu hin cc l nh ny dn dn
bt tc tui khong 30, chnh v vy nn t l TV tui di 20 rt him
bi v a m cn nguyn vn. Trong 25 nm qua ti khoa PTTK - Bnh
vin 103 phu thut trn 4.000 BN TV nhng s lng tui di 20 gp rt
t (khong 50 BN, chim 1%).
3.2. C ch bnh sinh ca TV:
3.2.1. Ngh nghip chn thng v ti trng:
C t 30 - 50% cc trng hp TV c yu t chn thng v ch 1/3 s BN
TV tht lng lm ngh lao ng chn tay nng nhc. Trong thc t lm
sng c nhiu trng hp chn thng ct sng nng m khng c TV nhng
c ti hn na s BN b TV hnh thnh t t, khng c yu t chn thng.
Nhng yu t bt li do ngh nghip trn y thc s tr thnh "vi chn
thng" (micro trauma) v nhng tc ng trng ti qu mc khng cn i
thc y nhanh qu trnh thoi ho a m.
3.2.2. Thoi ho a m (discose):
Thoi ho sinh l din ra cc a m tht lng rt sm. Ngi ta cho
rng: bt u t khi 5 tui v qu trnh thoi ho tng dn theo tui, din
bin t t sut c i, c nhng giai on khng c biu hin lm sng.
S thoi ho theo la tui l nguyn nhn c bn trong a m. Nu c
nhng lc xn ct t ngt ca chn thng (shear force) hoc lc xon vn
(torsion strain) th nhn a m d thot v ra sau.
Do nhiu yu t bn trong v bn ngoi tc ng nn thoi ho c th tin
trin nhanh hn v tr thnh nhng yu t bnh l. C ngi cho rng: TV
l mt s t bin, mt giai on ca qu trnh thoi ho bnh l a m.
Khi a m cn nguyn vn th chu lc tt, khi a m thoi ho n
mt giai on nht nh th TV mi c iu kin xut hin. Khi
ch cn mt lc chn thng nh hoc mt tc ng ca mt trng ti nh
khng cn i cng c th gy nn TV.
 3.2.3. Nhng yu t c bn gy TV:
+ Nhng iu kin lm chuyn dch t chc a m gy nn li hoc
TV l:
- p lc trng ti cao.
- p lc cng phng ca t chc a m cao.
- S lng lo tng phn vi s tan r ca t chc a m.
- Lc y v lc xn ct t ngt cc vn ng ct sng qu mc.
tui cao, mc d sc khng ca cc vng si ngy cng km i do
b rch t, thoi ho, nhng t xy ra TV l v gim st p lc cng phng
nhn nhy. Nhn nhy b kh cn thoi ho nn kh nng dch chuyn linh
ng ca t chc a m hu nh khng cn na. Mt khc cc ng tc
ngi gi thng chm, cn trng, va chm t, cc lc y xn ct t, v vy
hay thy TV ngi trung nin, t thy ngi qu gi. Trong 25 nm qua,
trong s trn 5.000 BN TV phu thut th ch c di 50 BN TV (< 1%)
phi m c tui trn 70, BN cao tui nht l 79 tui.
C ch bnh sinh ca TV c th ni khi qut rng: thoi ho a m
l nguyn nhn c bn bn trong, tc ng c hc l nguyn nhn khi pht bn
ngoi v s phi hp ca 2 yu t l ngun gc pht sinh TV. Khi TV
xy ra, qu trnh bnh l s din bin theo quy lut sau:
+ TV ra sau lc u gy xung t a-r (dick-rood conflict) do a
m chim ch, xung t ny c 3 mc :
- Kch thch thn kinh nu thot v mi v thot v nh.
- p thn kinh nu thot v lu, TV ln (compress).
- t dn truyn thn kinh, mt 3 chc nng (vn ng, cm gic, dinh
dng).
+ Qu trnh xung t a-r thn kinh ko theo qu trnh xung t a-
mch mu (disk-vascular conflict), gy gin tnh mch ng sng v cc xung t
khc.
+ Xung t a-dy chng vng (disk-ligament platum conflict) lm tng
sinh dy chng vng, tiu t chc m ngoi ng sng, v sau chnh nhng
thnh phn ngoi a li xung t vi nhau.
+ Xung t r-mch mu-dy chng vng-m xng: y l nhng thnh
phn ngoi a xung t ln nhau gy vim dnh t chc xung quanh. Cui
cng c th khng ch mt r thn kinh lin quan a m ban u m l ton
b b si thn kinh trong bao cng (b thn kinh ui nga) b tn thng, BN d
b tn ph nu khng ct t sm c cc xung t trn. l vng xon bnh
l ca TV.
4. Lm sng bnh l TV vng tht lng.
Gm 2 hi chng chnh l hi chng ct sng v hi chng r.
4.1. Hi chng ct sng:
4.1.1. Triu chng c nng:
+ BN au ct sng vi tnh cht au m (dull pain), lan to hay au cp
(a cute pain) sau mt gng sc nh gnh nng, bc ht... c khi ch l mt c
ng rt bnh thng nh xoay nh ngi, ko mt vt g s lm BN au
ngay. C khi au n mc BN phi b vic, ngi xung hay nm li.
+ au tng ln khi ho ht hi, khi c ng (l do l tng p lc ni ty nh
trn trnh by).
+ au c th khu tr, c th lan tht lng xung di (i, bu, cng chn,
bn chn...).
4.1.2. Triu chng thc th:
+ Co cng c cnh sng.
+ Vo ct sng t t n nhiu.
+ BN khng th lm nghim php ngn tay chm mt t trong t th ci
thng gi (du hiu Schober + 10/10, 11/10, 12/10...).
+ Lm ng tc khc nh nghing phi, nghing tri, n nga u au,
thng BN rt kh thc hin cc ng tc trn.
4.2. Hi chng r thn kinh:
4.2.1. Triu chng c nng:
+ au dc thn kinh hng to vi tnh cht au m , au rt bng hoc
au but, nhc nhi bp chn, bn chn. C BN v au qu mc
(hyperalgie) nn khc, bi quan, chn nn, thm ch mun cht, khng th c
thuc no cha n. BN c nhng t th chng au c bit nh ch c th
ng hoc ch c th ngi, phi qu xung khi n cm hoc ch c th nm
nghing co, khng th nm thng c...
+ D cm bp chn, tng sinh mn.
+ C BN b t b, kh i, kh a nu TV th trung tm p mnh
vo ui nga hoc vim dnh ko di do TV qu lu. Hoc TV
th gi u chn p ui nga nh mt khi u, nht l TV tht lng cao DXII-
LI, LI-LII.
4.2.2. Triu chng thc th:
+ Ri lon vn ng cc c thn kinh hng to chi phi t mc nh n
bi yu, lit nhm c, i li kh khn, phi ngh cch hi khi i xa.
+ Ri lon phn x gn xng, a s l gim phn x gn xng (phn x gn
c t u, phn x gn gt), c bit c trng hp tng phn x gn xng bn
bnh l. C th do thn kinh b kch thch do vim dnh hoc dng nhiu thuc
tng dn truyn (strycnin, nivalin...).
 + Ri lon cm gic: vng do thn kinh chi phi thng l gim cm gic so
vi bn lnh (thng khm cm gic nng).
+ Ri lon dinh dng: teo c, nho c bp chn, c i so vi bn lnh.
Nhn c th thy da chn bn bnh tm ti hn bn lnh, s vo lnh hn bn
lnh.
+ Cc nghim php: cng dy thn kinh (Lasgue) v n thn kinh
(Walleix) dy thn kinh hng to c biu hin dng tnh r.
+ Du hiu bm chung dng tnh: n khe khp hoc cnh sng c a
m bnh l thy au dc xung di theo ng thn kinh hng to.
+ o in thn kinh c so vi bn lnh thy biu hin bnh l r.
4.3. Phn loi cc th bnh TV chnh trn lm
sng:
y l c s chnh ch nh phu thut.
4.3.1. TV th thng thng:
y l th bnh hay gp nht, biu hin bng au mt bn, hi chng
tht lng thng thy trc, hi chng r thy sau. Sau mt t lao ng di
ngy, BN thy au mi ct sng tht lng, phi nm ngh v dng thuc hoc
vo vin iu tr (ng y, Ty y...). Sau n nh, BN li tip tc lm
vic, mt thi gian sau (ngn hoc di) bnh ti pht nh c v c xu hng
nng dn, lan dn xung theo r thn kinh hng to mt bn, BN li c iu
tr v n nh hon ton nu ch nh iu tr ng kt hp vi lao ng
hp l. Mt s t khc, bnh lp i lp li nhiu ln v nng dn ln, s ny
cn c chn on v iu tr theo hng Ngoi khoa kt hp vi Ni khoa mi
n nh.
4.3.2. TV th khc thng (uncommon):
* TV th lun phin (from side to side):
BN b au lc u hng xung chn bn ny, sau hng xung chn bn
kia, ri dn dn au c 2 bn hng v 2 chn, mt bn au nng cn mt bn
au nh hoc c hai bn au nng.
* TV c hi chng ui nga:
+ TV th gi u (hay gp nht): sau khi thot ra khi bao si, a m
p nh 1 khi u, trn lm sng c hi chng ui nga hay thiu, X quang
thy nghn tc hon ton ct thuc, dch no ty c albumin tng, phn ly albumin
t bo.
+ TV xuyn mng cng (chim 1-2%): v c im lm sng ging
TV th gi u.
C ch bnh sinh ca TV xuyn mng cng c nhiu ngi cho
rng: do a m b li p vo mng cng lu ngy, s p mn tnh l
yu t chnh gy thiu mu ti ch v gy lon dng ni mng cng b
p. Tnh n hi ca mng cng b mt. Qu trnh lm vim khu tr, lm
cho mng cng mng v dnh c nh tng i chc vi thnh ng sng. n
mt lc no y xut hin yu t thun li (c ng mnh, t ngt...), a
m lm thng v xuyn mng cng. Mnh a m nm gn trong mng
cng hoc cn c th mt phn nm ngoi mng cng, dnh vi phn a
m thot, gy dnh v x ho. Theo y vn th TV xuyn mng cng hay
gp nht v tr LIV-LV (42%).
+ TV th au qu mc: theo Mark S.G v V Hng Lin vn gi TV
au qu mc l bt thng (uncommon), BN au d di khng chu ni mc d
c dng liu cc thuc gim au v thuc ng nhng ch au thong
qua, BN chn nn, bi quan hay ny sinh ngh tiu cc. Loi ny c ch nh m
bn cp cu. Trong loi ny thng gp cc loi sau:
- TV th gi u + TV th xuyn mng cng ( trnh by trn).
- TV lch bn qu mc:
Theo Mark S.G th TV lch bn qu mc gm TV l ghp (foraminal
lumbar disk herniation) v TV ngoi l ghp (extraforaminal lumbar disk
herniation). Cc th ny c mt c im khc vi TV ct sng tht lng
thng thng.
- TV xuyn r: th ny rt him gp (1-4% theo Greenberg, 1997).
c im lm sng, cn lm sng gn ging vi TV bn qu mc. M ra
thy TV xuyn qua r thn kinh. Trong 25 nm qua, Khoa PTTK - Bnh
vin 103 ch gp 1 BN n b TV xuyn r thn kinh.
5. Cc phng php chn on cn lm sng chnh.
V chn on cn lm sng c cc phng php chnh sau:
5.1. Chp phim ct sng tht lng thng (spondylography):
Nu chp phim ct sng thng bng phim ln c th ly ht c bng, h
tit niu, ton b khung chu v 2 khp hng. Ly chiu di t DXII n ht
cng, ct... (trc khi chp cn c tht tho k th cng tt), nhm trnh s
lm, st (v c BN b au lng do si thn, si niu qun m lm sng
khng in hnh ca cn au qun thn, hoc c BN b gai i nhng
khng r nt), nht l nh gi mt t sng, chn tip khp l nhng nh
gi rt quan trng, nu phim khng sng t, c bng hi nhiu bng th kh
c v d lm ln.
Phim thng c chp 2 t th thng v nghing, c th chp chch 3/4
thy mt khp, khe khp, khi cn thit c th chp t th chc nng (ang
gp hay ang n).
Nu c TV th trn phim thng thy tam chng Barra hoc thiu
(vo ct sng, hp khe a m, mt ng cong sinh l).
Chp X quang thng ct sng tht lng c th chn on phn bit vi cc
bnh khc: vim khp ct sng-cng chu (arthritis), tin trt t sng
(prespondylolisthesis), trt t sng (spondylolisthesis), vim xng (osteotis),
bnh Paget, bnh d sn si (fibrous dyplasia), gy xp xng do u nguyn pht,
lao ct sng (pott's disease), cng ho tht lng, tht lng ho cng, gai i
(spina bifida)...
 5.2. Chp bao r thn kinh (sacco-radiculography):
+ y l phng php cn lm sng ph bin nht gip cho chn on
chnh xc ti 85 - 90% bnh l TV tht lng-cng.
Ngy nay ngi ta thng dng omnipaque (metrizamide) tan trong nc, c 3
iode khng phn ly, l thuc an ton c th va chp bao r li va chp ty
(myelography) khi cn thit (dc ngi v u BN xung chp).
+ Trn phim bao r c th thy:
- Hnh ct r thn kinh trong TV bn.
- Hnh lm y ct thuc t 1/4 n 2/4 v 3/4 bao cng.
- Hnh ng h ct (TV trung tm hoc cnh trung tm).
- Hnh li a m hoc thy hnh tc thuc hon ton. Cng c th thy hnh
vim dnh mng nhn ty, hnh rng v hp ng sng.
Lu : c t 5-10% trng hp b mu thun gia triu chng lm sng v
hnh nh X quang bao r (v d: trn lm sng c biu hin au r thn kinh hng
to rt r nhng hnh bao r bnh thng hoc ngc li lm sng BN ngho nn
cng cc nghim php Lassque v Valleix khng in hnh nhng X quang bao
r thy c cc tn thng: hnh ct r, li a m, khi cn phi c MRI hoc
C.T.scanner khng nh chn on).
5.3. Chp CT.scanner (computer tomography scanner):
Phng php ny ch chp theo trc ngang (axial). Nu my CT.scaner tt,
khng li k thut (artifact), BN khng bo ph, thng chp CT.scaner c th
chn on c 80 - 95%. Tuy nhin c th c TV m khng tim cn quang
th khng th nhn thy c.
+ u im chp CT.scanner:
- Cho thy hnh nh m mm.
- Chi tit xng rt r.
- Khng nguy him cho BN ngoi tr.
- Thy c TV pha ngoi xa (far lateral disk of herniation).
- Nhanh v r tin hn MRI.
+ Nhc im:
- Khng nh gi c mt phng ng dc.
- Ch nh gi c mt lp ct.
- t tin hn chp bao r.
- nhy cm thp hn MRI v CT.scaner c cn quang.
5.4. Chp cng hng t (magnetic resonance imaging - MRI):
y l phng php hin i nht chp c theo khng gian 3 chiu, chn
on chnh xc nht ang c p dng thay th cho CT.scaner, khng nguy
him cho ngi bnh v l cu cnh cho phng php chp bao r khi tht bi, c
th chn on bnh l v cc thng tin ngoi a m vng bng, vng xng
ct v cc bnh l khc. Chp MRI i khi rt cn thit cho lm sng, v d: c
BN TV in hnh nhng BN c m u nang bung trng c hoc u x t
cung, khi chp thy u x t cung to di cn vo ng sng gy triu chng chn p
r. Vy au thn kinh hng to ny l au triu chng ca di bo ung th vo a
m v ct sng nh trnh mt cuc m khng cn thit cho BN.
Nhn chung nu chp MRI cho ct sng tht lng chn on TV th l
l tng nht, tuy vy cng c nhiu kh khn ring ca phng php ny:
- BN phi nm lu lp trnh thi gian ko di.
- Gi thnh cn cao so vi mc sng ca i b phn nhn dn chng ta.
- Kh xc nh chn on khi ct sng lch vo (scoliosis).
5.5. Nhng phng php cn lm sng khc:
- Chp cn quang ngoi bao cng.
- Chp gai sng.
- Chp a m.
- in thn kinh c...
Nhng phng php ny ngy nay t s dng.
6. Chn on phn bit au thn kinh do TV vi cc bnh l khc.
6.1. au thn kinh hng to c ngun gc t xng:
+ U di cn t cc c quan khc: u v, phi, tuyn gip, thn, tuyn tin lit.
Chp X quang c th thy thn xng b nham nh, chn cung b ph hy, chn
tip khp mt cn i 2 bn, hnh nh tn thng xng thy r khi lm x hnh
(scintigraphy).
+ U nguyn pht lnh tnh: osteoma, vertebral angioma...
+ U c tnh: osteosarcoma, bnh Paget.
+ Bnh nhim khun: staphycocus, lao.
+ Hp ng sng bm sinh hay do trt t sng.
6.2. au thn kinh hng to ngun gc t trong ng
sng:
+ U trong ng sng: neurinoma, ependymoma, hemangioblastoma, meningioma...
+ Vim mng cng, mng nhn: epiduritis, arachnoiditis, do nhim khun, do
tim chch nhiu thuc chng vim gim au vo khoang ngoi mng cng.
+ D tt bt thng ca ti cng: ti cng qu ln tr thnh nang ln, dy thn
kinh trong b xon-vn cn tr lu thng dn truyn thn kinh.
6.3. au thn kinh hng to ngun gc t xng
cng-chu:
+ Vim nhim khun khp cng-chu (infectious sacro-illiitis).
+ Vim khp do trt (spondylolisthetis pelvis rheumatism).
6.4. au thn kinh hng to t bn thn thn kinh
hng to:
+ Chn thng: v xng chu gy cng ko ng gip r thn kinh, t mu
ng i dy thn kinh hng to gy chn p thn kinh, chn thng i cng
chn-gy xng sang chn thn kinh hng to.
+ Chn p bi u trc trng, bung trng, di cn thm nhim chn p thn kinh.
+ Vim thn kinh hng to do d ng, ng c, thi tit...
7. Phng php iu tr TV.
7.1. iu tr ni khoa:
Phi quan nim rng iu tr ni khoa TV bao gi cng l phng php
iu tr c bn u tin. C ti 80 - 90% iu tr ni khoa TV c kt qu v
iu tr ni khoa cn c cng c tip tc sau khi iu tr ngoi khoa.
Nguyn tc iu tr ni khoa:
+ iu tr c h thng: bao gm nhiu bin php b tr ln nhau, kt hp ng
y v ty y nh ngh ngi, ko gin ct sng, th dc liu php, tm hi, tm bn,
bi nc, xoa bp, chm cu, vt l tr liu (dng nhit, in phn thuc...). Dng
thuc cc loi chng vim gim au loi steroit hoc non-steroit (tim, ung),
phong b cnh sng, ngoi bao cng khi c ch nh, c k thut an ton.
+ iu tr phi c bn: phi cn c tui bnh, th bnh, c a BN, trang thit
b v trnh kh nng bc s m ra phng php no ph hp nht, t hiu
qu cao nht. Trong qu trnh iu tr phi hn ch ti a nhng bin chng do
phng php iu tr gy ra cho ngi bnh. Chng cc hin tng iu tr sai
nguyn tc nh nn chnh ba bi gy tai bin, tai nn cho BN. Chng lm dng
thuc tn dc phong b, chch thuc ba bi gy p xe c mng, p xe ngoi
bao cng, chy mu d dy v ng tiu ho, khng quan tm ti li ch ca
ngi bnh. Chng hin tng iu tr ni khoa ko di, khng tham kho cc
ng nghip cc chuyn ngnh thn kinh nh ni, ngoi, cn lm sng thn
kinh, tm gii php iu tr ph hp nht cho BN, nht l BN kh, iu tr ni
khoa km hiu qu.
7.2. iu tr ngoi khoa:
7.2.1. Nguyn tc:
+ Phi ch nh cht ch, khng c m p, m non, phi c iu tr ni
khoa h thng, c bn trc nhng khng c kt qu v trc khi phu thut phi
chn on tht r rng v lm sng v cn lm sng.
+ Chn cc k thut ngoi khoa phi ph hp th bnh v tui bnh, cc bin
chng ca bnh c k thut cho ph hp, iu kin thc t trnh ti a bin
chng do phu thut gy nn.
+ Lun phi iu tr cng c cho BN trc, trong v sau phu thut bng
thuc ni khoa.
+ Hng dn v sinh phng bnh, v sinh lao ng sau phu thut trnh tai
bin, tai nn cho BN.
7.2.2. Ch nh phu thut:
+ Nhm phu thut cp tnh:
- TV cp tnh gy lit c nguyn nhn do a m vo ng mch r
ty, cn gii phng kp thi.
- TV gy hi chng ui nga, lit nho 2 chi di, ri lon cm gic tng
sinh mn, ri lon c trn.
 + Nhm phu thut sm:
- TV th au qu mc.
- TV khm c lit c v d BN lit c gp dui c chn, i li kh
khn, c du hiu cch hi.
+ Nhm phu thut TV thng thng (c chun b): BN iu tr ni
khoa c h thng v c bn t 1 - 2 thng, khi pht bnh t 1 nm tr ra, nh
hng ti cht lng cuc sng, BN c nguyn vng m.
7.2.3. Cc phng php iu tr ngoi khoa
chnh:
+ Cc phng php kinh in:
- Phng php phu thut chnh hnh (orthopedia).
- Phu thut gii phng chn p thn kinh (decompression).
- Phng php kt hp c chnh hnh v gii phng thn kinh.
ng m: c th i ng trc v vo pha sau phc mc ly a m.
C th i ng sau ly b a m gii phng thn kinh. C th ghp xng
t thn hoc mt cht liu khc sau khi ly a m.
+ Nhng phng php mi (mt s trung tm trong nc v trn th gii
v ang lm):
- Ly a m qua da t ng s dng nucleotomic (automatec percutaneous
lumbar discectomy).
- Ly a m qua ni soi (percutaneous endoscopic discectomy).
- Dng laser gii p a m (laser disk decompressing) c hoc khng c ni
soi dn ng.
- Phng php ho tiu nhn (chemonucleolysis): cn nh rng phng php
ny c ch nh, k thut cht ch. N ch c p dng cho cc TV m gii
hn vng x cn nguyn vn, khng th p dng cho mi loi TV v rt nguy
him v tn km.
Tm li: khi chn phng php iu tr cho BN phi khm xt k lng, phi
c lng tm ca ngi thy thuc. Chng 2 khuynh hng:
- cao phng php iu tr ni khoa qu ng.
- Tuyt i ho kt qu iu tr ngoi khoa.
Lun bit dn d, hng dn BN bit cch lao ng, sinh hot, luyn tp
phng bnh TV khi BN n vi thy thuc ln u do au lng hoc sau phu
thut TV.
8. Phng bnh TV.
- y l mt vn quan trng t c cp lu nay, n i hi trnh dn
tr cao, iu kin v sinh lao ng tt, sinh hot vt cht v tinh thn phong ph
y , mi trng x hi thun li. Ni mt cch khc, va i hi yu t khch
quan, va i hi thc t gic thng trc ca mi thnh vin trong x hi ngay t
lc cn nh (tui mu gio, hc sinh, sinh vin) cho n khi v gi, nhm mc ch:
 - Gim tc thoi ho sinh l a m ct sng n sm, lm thoi ho
chm li.
- Trnh nhng thoi ho bnh l a m, nng sc kho ton thn bng n
ung, v sinh lao ng.
- Hn ch ti a nhng c hi gy nn TV.
- Khi b TV, hn ch ti a nhng bin chng do n gy nn bng cch
cha tr sm, ng phng php, ng nguyn tc, phu thut ng ch nh, kp
thi vi k thut trang thit b tt nht.
+ Nguyn tc chung ca phng bnh l:
- V sinh lao ng sinh hot gi cho p lc ni a m iu ho.
- Gi ct sng lun thng khi lao ng v sinh hot.
- Khi phi khing nng, b vc, nng by, phi rt thn trng, san s lc nn
ct sng v lm vic phi t t, trnh t ngt, c phn chia cng on, t t n
nhiu, t thp n cao.
- Xen k gia lao ng v ngh ngi hp l.

gai i t sng

V Vn Ho

1. i cng.
1.1. Khi nim:
S khng khp kn ng gia ca ct sng t thi k phi thai gy khuyt
hng mt thm ch 2 - 3 t sng c gi l gai i t sng hay tt nt t
sng (spina bifida).
1.2. Phi thai hc:
Mc d gai i t sng c m t t thi Hyppocrate (460 - TCN) v
cc thy thuc Rp (Trung C), nhng mi ti nm 1983 vi s ra i hc
thuyt hp nht ca Pang D v cng s mi gii thch y v c ch hnh
thnh ca tt c cc dng d tt k h ca ct sng-ty sng. Vo cui thng th 2
ca qu trnh pht trin phi trong mi t sng xut hin cc im ct ho. Mi
t sng c pht trin t 3 cp im ct ho chnh. im ct ho trung tm
pht trin thnh thn t sng, cc im ct ho bn pht trin ra sau to nn bn
sng. Vo nm u sau khi sinh hai im ct ho ny dnh li vi nhau. Khi cc
im ct ho khng gn lin s li cc khe h t sng to thnh cc dng d
tt khc nhau ca t sng.
 1 2 3

4 5 6

Hnh 1: Cc im ct ho ca t sng
ang pht trin.
1. Gai i do khng ct ho hai im sau. 4. Gai i do khng ct ho hai im trc
2. H eo. 5 - 6. Khuyt thn t sng.
3. Na t sng.

Gai i t sng c th gp bt k v tr no trn ct sng nhng theo James

C.M v Lassman L.P (1972); Eckstein H.B v Macnab W (1966): gai i t
sng ch yu xy ra vng tht lng-cng (TL-C) i khi t sng c v rt
him khi gp cc t sng ngc.
1.3. Phn loi gai i t sng:
Ty theo ngun gc phi thai hay v tr ca gai i t sng c cc cch phn
loi khc nhau; song cho n ngy nay, cch phn loi theo v tr ca Bucy P.C
(1939) vn c nhiu tc gi ng dng:
+ Gai i t sng pha trc (spina bifida anterior).
+ Gai i t sng pha sau (spina bifida posterior):
- Gai i t sng kn (spina bifida occulta).
- Gai i t sng dng nang (spina bifida cystica):
. Thot v mng ty (meningocele).
. Thot v mng ty - ty (meningomyelocele).
. Thot v ty (myelocele).
. Thot v ng ni ty - ty (syringomyelocele):
Gai i t sng (GS) rt him khi xy ra pha trc (thn t sng),
ch yu xy ra pha sau (cung sau, gai sau). Theo Gabriel S.R (1980): trong s
1390 trng hp GS ch c 6 bnh nhn b GS pha trc cn li l GS
pha sau.
2. Gai i t sng kn.
Gai i t sng kn l mt dng ca GS pha sau c th gp 20 - 30%
dn s (theo Reilgel H.D, 1968). GS kn c c im l gai sau, thm ch
cung sau ca mt hoc vi ba t sng ng khng trn vn nhng cc thnh
phn ca ty sng khng b thot v ra ngoi.
 2.1. Triu chng:
Hu ht GS kn khng c biu hin g, nhiu khi ch c pht hin mt
cch tnh c trn cc film chp X quang c lin quan ti vng tht lng-cng
hoc khi m xc.
i khi GS kn gy au vng tht lng-cng v cc thiu khuyt v thn
kinh c c im: au vng tht lng-cng l triu chng u tin ca bnh, au
thng tng ln khi vn ng, ngh ngi c . n vo t sng b gai i bnh
nhn thng rt au.
Mt s t trng hp cn c biu hin au cc r ca dy thn kinh tht lng-
cng ko di, km theo c cc ri lon v cm gic, dinh dng v phn x.
Thm ch c nhng ri lon c quan y chu.
mt s bnh nhn vng da tng ng vi t sng b gai i c mt vi bin
i nh: lm da, m nvi, ng r hoc u nang dng biu b... Theo Ingraham
F.D (1961): y l nhng du hiu c ngha ch im cho GS kn pha di.
Tuy nhin, nhng biu hin ny khng phi c tt c cc bnh nhn. Theo
Gabriel S.R (1980): ch c 35% s bnh nhn c nhng thay i trn da.
Chp film X quang qui c cho chn on xc nh GS kn trn c s
khuyt gai sau, cung sau c cc hnh nh: dy xng b khuyt, tn ti im
ct ho mu gai, gai i pht trin to ln li vo ng sng hay ph i gai sau ca
LV p xung vng h xng cung sau ca SI.
 Hnh 2: GS kn bnh
l.
1. Lm da. 5. Mng cng.
2. T chc x. 6. Mng nhn.
3. Chn khp. 7. L lin t.
4. Dy thn kinh sng.

Chp bao r thn kinh c th thy hnh nh vim dnh co ko bao cng hoc
chn p bao cng t pha sau.
Chp MRI c th pht hin thm nhng d tt kt hp vi GS kn: thot v
mng ty vo xng cng, vim dy dy cng, u m dy cng...
2.2. iu tr:
a s bnh nhn GS kn ch cn iu tr bo tn bng cc bin php kt hp:
+ Ngh ngi.
+ Thuc: gim au chng vim, sinh t nhm B liu cao, gin c, an thn.
+ Vt l tr liu kt hp.
t iu tr ko di 3 - 4 tun; nu khng c th thay thuc khc.
Khi iu tr ni khoa khng c kt qu, hoc c nhng thiu khuyt v
thn kinh th can thip bng phu thut.
Phng php m c bn l ct gai i, phn cung sau cn li ca t sng c
gai i, ly b ton b t chc x tng sinh vng xng khuyt, gii phng chn
p bao cng v r thn kinh. Khoa PTTK-Bnh vin 103, trong thi gian t thng
12-1991 n thng 7-1998 m ct gai i cho 96 bnh nhn kt qu l 95,51%
hoc ht au vng tht lng-cng v cc thiu khuyt v thn kinh hi phc
kh tt.
3. Gai i t sng dng nang.
GS dng nang cn gi l GS m hoc GS km thot v (spina bifida
cystica hay spina bifida apecta). Theo Reil gel H.D (1982): Bc M c t l
GS dng nang (GSN) khong 0,1 - 0,2% trong s cc tr s sinh.
GSN cng l mt dng ca GS pha sau trong s khuyt cung sau
rng lm cho ng sng thng vi phn mm bn ngoi ng sng, qua mng
cng ty d dng phnh ra to thnh ti thot v. Ty theo ni dung cha trong ti
thot v m ngi ta chia ra cc dng nh sau:
+ Thot v mng ty: ti thot v cha y dch no ty, c bao bi mng
cng ln mng mm nhng khng cha cc m thn kinh.
+ Thot v mng ty-ty: ti thot v cha mng cng, dch no ty v mt
phn ty hoc ui nga.
+ Thot v ty: ty sng lp y ti thot v.
+ Thot v ng ni ty - ty: ti thot v cha ty sng v ng ty trung tm.

1 2 3

4 5

Hnh 3: Cc dng GS pha sau.

1. Thot v mng ty. 4. Thot v ty.
2. Thot v mng ty ty. 5. Gai i t sng kn.
3. Thot v ng ni ty ty.

3.1. Triu chng:

+ Ngay t khi mi sinh, tr b GS dng nang c biu hin bng mt
khi u nm chnh gia ct sng c mt mm, c che ph bi mt lp da
nhn nheo, c th thy cc hnh thi ti thot v nh sau:
- Lp da tng i dy, rt t khi v gy r dch no ty.
- Lp da mng, cng bng, d rch gy r dch no ty.
- Lp da v lp m di da rt dy to thnh mt u m (lipoma) bao quanh ti
thot v.
+ Ti thot v thng ln ln theo la tui, c trng hp (nht l trong thot v
mng ty) t c biu hin v ri lon vn ng, cm gic, phn x v c quan y
chu. Nhng trng hp ti thot v c cha cc m thn kinh thng c ri lon
nng v chc nng ca ty v r thn kinh vi cc biu hin:
- au r thn kinh sm, ko di
- Lit mt phn hoc hon ton hai chn vi cc ri lon v cm gic v c
quan y chu: i khng t ch.
S c mt ca cc r thn kinh hoc ty sng c th c pht hin kh sm
khi soi n pin qua ti thot v.
Chp film X quang qui c cho php xc nh v tr, mc khuyt cung sau.
Chp MRI xc nh chnh xc cc thnh phn cha trong ti thot v.
+ Mt s trng hp GS dng nang kt hp vi trn dch no ty.
Morgagni G.B (1769) l ngi u tin m t v d tt bm sinh ny. Theo Klein
M.R (1968): tt nt t sng bm sinh kt hp vi trn dch no ty l 37%. Tuy
nhin, Lapras C (1968) thy t l ny c khi tng ln ti 75 - 85%. y l mt d
tt bm sinh c th gy nn t l t vong cao cho tr s sinh v li nhiu di
chng nng n cho nhng a tr cn sng st.
Trong trng hp GSN xy ra t sng c cao v h s sau kt hp vi
trn dch no c gi l hi chng Arnold - Chiari.
Hi chng Arnold - Chiari c c im l hnh ty v hai hnh nhn ca tiu
no tt xung ng sng c ca CI v CII gy chn p cng Sylvius v l Magendie
lm cho dch no ty khng thng ra khoang di nhn c, dn n trn dch no.
+ Hi chng Arnold - Chiari c chia lm 4 typ:
- Typ 1: cc hnh nhn tiu no tt xung l chm v xung ng sng c, c
th thy cc biu hin nh sau:
. Cc hi chng ca thn no v dy thn kinh s thp: chng mt hoc mt
thc t ngt, nht l khi chuyn ng u hoc ht hi (bt tnh khi ht hi).
. Cc hi chng tiu no r nht khi quay u v rung git nhn cu dc.
. Trn dch no.
. Cc hi chng ca ng dn truyn b thp.
. Ri lon cm gic nht l cm gic cm th bn thn.
. Cc triu chng ca rng ty (syringomyelie) nht l au v lon dng c
chi di.
. Gim kh nng sinh dc - lit dng.
- Typ 2: cc hnh nhn ca tiu no, phn di ca thy nhng v no tht IV
tt xng l chm v vo ng sng c.
Hu ht cc trng hp ny thng kt hp vi trn dch no.
- Typ 3: biu hin bng GS ti t sng c, mt phn tiu no thot v, to
thnh mt mt nang. Nang thot v ny chnh l thot v mng no-no trong
phn no thot v l tiu no.
- Typ 4: ch c s gim sn ca tiu no khng c s tt xng ca tiu no.
Chp film X quang qui c pht hin thy nhng thay i dng bong bng x
phng ln xng vm s. l do xng s b hng (Lkenschdel). CT.Scan
cho thy xng s hnh kim t thp, trn dch no v hp h s sau.
 MRI l chn on quan trng cho thy c s dch chuyn xung di ca tiu
no vo l chm, d dng ca hnh nhn tiu no v cc tn thng khc.
3.2. Phu thut:
Phu thut GS km thot v c tin hnh t rt sm. Forestus J (1610) l
ngi u tin m tht ti thot v v hin nay phu thut ny tng i ph bin.
Tuy vy, vic la chn thi im phu thut cn c nhng kin khc nhau.
Theo Sharrad W.J, Zachary R.B; Lober J v cng s (1962) v nhiu tc gi khc
thy rng: nn m sm trong vng 48 gi u sau khi sinh s mang li kt qu
kh quan hn. Tuy nhin, Matson D.D (1969) li cho rng: nhng a tr vi tnh
trng bnh nng, lit hon ton hai chi di, g vo ct sng, trn dch no ln th
rt d b t vong, v th cn theo di k. Nu chng c kh nng sng st th nn
phu thut tui t 2 - 6.
Phng php m c bn l rch da quanh ti thot v, bc tch c ti khi t
chc xung quanh. M ti thot v kim tra ni dung bn trong: tch ty v r thn
kinh dnh vo thnh ti. Sau ct ti thot v v khu phn mm che ph ch
xng khuyt. Nu mng cng ty khuyt rng c th v bng cn c.
Phu thut sao cho khng ti pht ti thot v v ht cc ri lon v r v ty.
Sau m phi lun theo di vng u ca tr pht hin cc triu chng ca trn
dch no mun.
i vi hi chng Arnold - Chiari, sau khi tht ti thot v mng ty t khi
mi sinh, cn t sonde dn lu trong nhng trng hp c trn dch no. Vic
gii phng chn p chm - c v ct cung sau t sng c ch thc hin trong
trng hp c cc biu hin p vo thn no.
 Chng 4
Khm cp cu
chn thng h thn kinh
Khm v x tr cp cu
chn thng s no

Bi Quang Tuyn

Chn thng s no (CTSN ) l cp cu ngoi khoa thng gp hng ngy.

Trc mt trng hp CTSN, ngi thy thuc cn phi bnh tnh, khm xt t
m, khn trng, khng b st cc tn thng s no v cc tn thng kt hp
khc. Trnh t cc bc nh sau:
+ Hi bnh.
+ Khm.
+ X tr cp cu v theo di.
1. Hi bnh.
1.1. Kim tra tnh trng chung ca bnh nhn:
Vic trc tin phi quan st khi ngi bnh c a n cp cu xem c
biu hin ri lon h hp, ri lon tim mch khng ? nu c phi x tr cp cu
trc khi hi bnh v khm xt mt cch y .
+ Tnh trng h hp:
Nu thy sc mt bnh nhn (BN) tm ti, th kh khn do n tc ng
h hp trn hoc nhp th ri rc, c nguy c ngng th th cn phi nhanh
chng cho bnh nhn th oxy, ht m ri hoc cht nn gy bt tc ng
th, thm ch phi t ng ni kh qun thng kh nhn to.
+ Chy mu:
Nhiu trng hp t rch ng mch da u gy chy mt mu nhiu,
tuyn trc bng b khng ng ch hoc bng b tut trn ng vn chuyn;
khi n bnh vin mu vn chy t bng, thnh git, sc mt bnh nhn
tm ti, nht nht, mch nhanh nh, huyt p ng mch (HAM) gim thp th
cn phi nhanh chng m bng ct tc kim tra, cm mu tm thi bng km
cm mu, sau khu vt thng cm mu.
Nu mu chy nhiu ra l mi hoc l tai, thng do v nn s trc hoc
nn s gia, cn nht gc (mche) cm mu.
+ Tnh trng tim mch:
Bnh nhn n trong tnh trng mch nhanh nh yu, kh bt; HAM rt
thp hoc khng o c. Nu khng phi do mt mu, khng chy mu trong
bng hoc ngc, thng l CTSN nng. Cn phi hi sc tt m bo
HAM ti a trn 90 mmHg.
 1.2. Hi bnh:
Hi bnh nhn (nu BN tnh) hoc ngi nh (nu bnh nhn hn m) v
nguyn nhn chn thng v tnh trng thc ca bnh nhn sau khi b chn
thng.
1.2.1. Nguyn nhn:
Do b nh hay b ng (tai nn giao thng hoc ng t trn cao xung).
+ Nu b nh vo u bng vt cng: tn thng da u, xng s v
no thng ngay di ch lc chn thng tc ng v tn thng thng khng
nng v khng phc tp.
+ Nu b ng: tn thng xng s v no thng nng v phc tp do c
ch tng tc v gim tc t ngt ca s v no trong thi im chn thng.
Gip no v mu t c th ngay di ch lc chn thng hoc i bn vi
lc chn thng (c ch i lc - contre coup).
- Cn ch din bin trc khi b ng: nu ngi bnh ang i b hoc
ang i xe p t dng thy kh chu, dng xe, chong vng v ng khuu
xung ri hn m th cn ngh n kh nng ri lon tun hon no xy ra trc
ri bnh nhn mi ng ra. Nhng trng hp nh th hay gp ngi cao tui,
ngi c tin s huyt p cao, c biu hin bnh l mch mu no t trc.
- Cn ch ti lc chn thng: i vi ngi gi i khi lc chn thng
vo u rt nh, ngi bnh hon ton tnh to nhng vi ting sau au u
v nn, thc xu dn v hn m. Khm khng thy du hiu thn kinh khu
tr no nhng ri lon chc phn h hp v tim mch ngy cng nng ln v
mt s trng hp t vong. Gii phu thi th ch thy chy mu vi th ri rc
trong cht no; trng hp nh trn l c bit, do vy cn c bit ch i vi
chn thng s no ngi gi.
1.2.2. Din bin ca thc:
Hi xem tnh trng thc ca bnh nhn sau chn thng din bin nh
th no, c hn m hay khng ? c khong tnh hay khng ? Ngi ta thng
gp ri lon thc nh sau:
+ Bnh nhn m ngay sau chn thng mt vi pht (2 - 5 pht) ri tnh li
v khi c hi, bnh nhn khng nh c s vic xy ra trc, trong v sau tai
nn. l triu chng qun ngc chiu do chn ng no gy nn v chng
t CTSN mc nh; bnh nhn cn c theo di cht ch v tri gic. Nu
sau vi gi, thc bnh nhn xu dn v hn m li th khi phi ngh ti
kh nng do mu t ni s (MTNS).
+ Nu bnh nhn hn m su ngay sau chn thng, ng t hai bn gin
to, c cn dui cng t chi, chng t tn thng nng, tn thng thn no,
gip no ln, tin lng rt nng.
+ Bnh nhn c khong tnh khng ?
- Theo ngi nh bnh nhn k li: sau khi ng hoc b nh, bnh nhn
hn m ngay (hoc ch chong vng, khng m), sau mt vi pht tnh li, t i
v nh; khi c hi bnh nhn k li y s vic xy ra nh th no.
Nhng mt vi gi sau bnh nhn ku au u, i nm, bun nn v nn, gi
hi tr li khng thnh ting, ch , i dm, gia nh vi vng a n
bnh vin. Khi ti bnh vin bnh nhn hn m su.
Tnh trng M - tnh - m nh ni trn c gi l khong tnh kinh
in, l triu chng c trng trong MTNS v hay gp trong mu t ngoi
mng cng.
2. Khm xt.
2.1. Khm thc:
Khm xc nh c ri lon thc (RLYT) khng v t xc nh
hn m. Khm 3 loi thc: thc cao cp, thc t ng v thc bn nng.
2.1.1. Cch khm:
+ thc cao cp (cn gi l thc hiu bit): l kh nng nh hng ca
ngi bnh v chnh bn thn mnh v kh nng hiu thc hin mnh
lnh ca ngi thy thuc.
Cch khm: hi tn, tui, ch ca ngi bnh. Bo bnh nhn lm theo
lnh nh gi tay, co chn, nhm mt v nhn nh kt qu:
- Tt: tr li v thc hin mnh lnh nhanh v chnh xc.
- Ri lon: phi hi to i khi va hi va lay ngi hoc kch thch au
bnh nhn mi tr li v thc hin mnh lnh rt chm v khng chnh xc.
- Mt: bnh nhn ch khng thnh cu hoc nm im khng p ng.
+ thc t ng (conscience automatique): l khi v no b c ch, chc nng
di v vn cn p ng vi kch thch au.
Cch khm: kch thch au bng chm kim hoc cu vo ngc, cnh tay
ca bnh nhn, kt qu:
- Tt: bnh nhn a tay gt ng ch au, nhanh v chnh xc.
- Ri lon: a tay qu qung tm ch au, chm v gt khng ng ch
au.
- Mt: ch ca mnh hoc nm im khng p ng.
+ thc bn nng (intictive):
Cch khm: cho BN ung tha nc v nhn nh kt qu.
- Tt: khi a tha chm vo ming, bnh nhn a mi ra n tha nc
v h ming ra (gi l th mi), khi nc vo, bnh nhn s ngm ming
li (gi l th ming) v nut (gi l th hng).
- Ri lon: khng a mi n tha nc, nc vo ming bnh nhn
ngm rt lu ri mi nut.
- Mt: bnh nhn khng nut nhng do nc chy xung hng gy sc, ho
bn nc ra ngoi.
Khi phn x nut b ri lon ngha l tn thng ti hnh ty, tin lng
nng.
 Khm phn x nut khi bnh nhn hn m su thng nguy him v khng
cn thit. Thay vo , ngi ta khm thc bn nng bng khm phn x gic
mc v khm phn x ng t vi nh sng.
. Khm phn x gic mc: dng mt vi si bng sch vut cho nh li, qut
nh si bng ln gic mc mt ca bnh nhn. Kt qu: tt: bnh nhn chp
mt nhanh; ri lon: phn x chp mt chm; mt: khng cn phn x chp mt.
. Khm phn x ng t vi nh sng: bnh thng khi chiu nh sng vo
ng t, ng t s co li, khi tt nh sng ng t s gin to hn. Kt qu
khm: tt: ng t co v gin rt nhanh khi chiu n; ri lon: co-gin km v
chm; mt: ng t gin to hoc co nh nhng khng cn phn x vi nh sng.
Khi mt phn x gic mc, mt phn x ng t vi nh sng th tin lng
nng do tn thng n hnh no.
2.1.2. xc nh hn m:
Hn m l tnh trng ri lon su sc hot ng ca v no v trung khu di
v, c bit l ri lon cc chc phn sng (h hp v tim mch). Ngi ta chia
4 hn m (xem bng).

IV
I II III
hn (hn m nng) (hn m va) (hn m su) (hn m vt
m gii hn)
coma sopor coma confirme coma carus
coma
dpasse

Ri lon Gi hi: p Gi hi: ch Gi hi: khng p Mt

thc ng chm, c khng thnh ting, ng, nm im. (khng p
cao cp lc ng, c rn hoc nm im. ng)
lc sai.

Ri lon Cu au: gt Cu au: tay a Cu au: ch xon

thc t ng ch, nhanh. ln chm chp v vn ngi; c th Mt
ng. gt khng ng thy nhng cn (khng p
ch. dui cng t chi. ng).

Ri lon Cn phn x
Ri lon phn x Mt phn x nut, Mt.
thc nut, phn x
nut, phn x ng phn x gic mc (khng p
bn ng t v
t v phn x gic v phn x ng ng).
nng. phn x gic
mc. t.
mc.
Ri lon Mch nhanh. Mch nhanh nh Mch nhanh nh Th my.
chc Nhp th 25-30 trn 100 l/p yu, lon nhp. Th HAM duy
phn ln/pht. Th 30-35 ln/pht. 40-50 ln/pht. tr bng
sng. HAM tng va HAM tt thuc.
phi thp.

2.2. Khm thn kinh.

Tm du hiu thn kinh khu tr (TKKT) xem tn thng bn cu no bn
no. Khi khm bao gi cng so snh 2 bn vi nhau.
2.2.1. Khm vn ng:
+ Nu bnh nhn tnh: bo bnh nhn lm cc ng tc Bar tay,
nghim php Raimist; Mingazzini... nu tay bn no lit s khng lm c.
+ Nu bnh nhn hn m:
- Quan st khi bnh nhn dy da hoc khi b kch thch au; na ngi
bn no lit th tay chn bn s c ng km hn hoc khng c ng,
trong khi na ngi bn i din tay chn co v dy kho.
- Khm: cm 2 tay BN gi ln cao ri b 2 tay BN ri xung. Tay bn
no lit s ri nhanh hn (ch tay ri xung khng p vo mt
bnh nhn), tay bn khng lit t t h xung.
+ Nhn nh kt qu:
- Lit na ngi thng i bn vi bn cu no tn thng, v d: lit na
ngi bn tri c ngha l bn cu no bn phi b tn thng. i khi gp lit
1/2 ngi cng bn vi bn cu no b tn thng (c ch contre coup).
- Lit 1/2 ngi c ngha chn on MTNS l lit c xu hng ngy mt
tng dn.
- Nu BN c biu hin dui cng t chi hoc gp cng 2 tay th chng t
tn thng no nng.
2.2.2. Khm phn x:
Phn x gn xng gim hoc mt na ngi bn lit. Mc d t bo
thp v b thp tn thng nhng t khi thy tng phn x gn xng thi k
cp tnh ca chn thng.
Phn x bnh l b thp khng c, du hiu Babinski (-) hoc khng r.
Nu du hiu Babinski (+) mt bn th c gi tr chn on nh khu. Nu
Babinski (+) 2 bn chng t v no b kch thch lan to.
2.2.3. Khm cm gic au:
Dng kim hoc bu vo ngc hoc mt trong cnh tay BN xem phn
ng vi kch thch au bn no r hn, thng gim cm gic au na ngi
b lit.
 2.2.4. Khm ng t:
Trong CTSN s thay i v kch thc v phn x ng t vi nh sng c
ngha chn on v tin lng.
+ Nhc qua gii phu:
- C co ng t do thn kinh ph giao cm chi phi; nhn ca thn kinh
ph giao cm nm trung no, cc si ph giao cm i trong dy thn kinh s III
(dy vn nhn chung), ti hch mt v cho cc si vo c mi (dy mi ngn) tc
dng lm co ng t.
- C gin ng t do dy thn kinh giao cm chi phi v iu khin, cc
si giao cm xut pht t m ri thn kinh giao cm c.
Bnh thng hai h thn kinh giao cm v ph giao cm lun lun cn
bng nhau, hot ng mt cch nhp nhng, do vy m ng t lc co lc gin
iu tit gip cho nhn xa v nhn gn.
Bnh thng ng t hai bn u nhau v c kch thc t 2 - 4 mm. Ngi
ta khm phn x ng t bng cch chiu nh sng n vo mt. Phn x ng
t bnh thng: khi chiu n th ng t co li v khi tt n hoc gim
cng nh sng th ng t gin ra.
+ ngha chn on v tin lng: trong CTSN thng gp gin ng t,
t gp co nh ng t. Gin ng t trong CTSN c gii thch l do tn
thng nhn dy thn kinh s III v r ca n thot ra trung no. Do tng
ALNS (hu qu ca ph no, mu t) thy thi dng b y vo khe lu tiu
no (khe Bichat) v chn vo dy TK s III.
- Thng gin ng t cng bn vi bn cu no b tn thng. Tuy nhin trong
CTSN cng gp mt s trng hp gin ng t i bn vi bn cu no tn thng.
- Gin ng t c ngha chn on MTNS l gin ng t mt bn ngy
mt tng dn. Nu gin ng t mt bn ngay t u sau chn thng l hu
qu ca gip no.
- Gin ng t ti a c hai bn ngay gi u sau chn thng l tn
thng thn no tin pht, tin lng rt nng v t vong trn 90%.
- Trong CTSN, nu ng t co nh hai bn v mt phn x vi nh sng th
tin lng cng rt nng.
- Gin ng t mt bn va phi v cn phn x vi nh sng, c ngha l no
cn kh nng thch ng, cn b. Nu c mu t nhng phu thut kp thi th
tin lng s thun li; nu phu thut mun, khi ng t hai bn gin to ti a,
khng cn phn x vi nh sng th tin lng cc k nng.
2.2.5. Dy thn kinh s no:
Khm cp cu CTSN ch cn khm dy thn kinh s VII v s III. Cc i
dy thn kinh s no (TKSN) khc ngi ta ch c th khm v xc nh tn
thng khi BN tnh to, tip xc c v cng phi hp khm vi thy thuc.
+ Dy thn kinh VII (dy mt: nervus facialis):
 Nhc qua gii phu: dy TK mt l dy hn hp gm dy vn ng v
dy trung gian VII Wrisberg (gm cc si cm gic v thc vt). Thc t trong
khm CTSN, ngi ta ch khm dy VII vn ng. Nhn ca dy VII vn
ng nm cu no, dy thot ra rnh hnh-cu. Cc si vn ng ca dy
VII chia ra 2 nhnh: nhnh trn vn ng c my v c vng mi lm cho mt
nhm kn, khi nhnh ny b tn thng th mt bn nhm khng kht gi
l du hiu Charles-Bell (+). Nhnh di vn ng c vng mi, c ci; khi
nhnh ny tn thng mm s b ko lch sang bn lnh.
+ Khm vn ng dy VII: nu BN tnh: bo BN nhm mt kim
tra nhnh trn v hut so, nhn rng kim tra nhnh di. Nu BN hn m
su (hn m III) ta quan st xem c b lch nhn trung hoc c du hiu
cnh bum khng ? Do c vng mi mt bn b lit, c vng mi bn lnh
kho hn s ko nhn trung v ming b ko lch sang bn lnh (du hiu
nhn trung). Nu BN m su, khi th ra, kh ra c ng mi v mm lm cho
m bn lit phng ln khi th ra v lm khi ht vo (gi l du hiu cnh
bum). Lch nhn trung v du hiu cnh bum l tn thng nhnh di. Nu
BN hn m va (hn m II) th ngi ta c th khm bng cch dng 2 ngn
tay n mnh vo gc hm hai bn ca BN, bnh nhn s nhn mt li v khi
quan st thy ming BN b ko
lch v mt bn (du hiu Marie -
Foix).
+ Nhn nh kt qu: tn thng
dy thn kinh s VII ch c ngha
chn on nh khu (hnh 1).
- Lit dy thn kinh VII trung
ng (lit mt TW) biu hin lm
sng l tn thng nhnh di ca dy
VII, ming b ko lch v bn lnh.
nh khu: tn thng bn cu i no
i bn, c th l tn thng t v
no ti nhn ca dy VII cu no
(b v - nhn). Thng lit mt cng
bn vi lit na ngi, ngha l i
bn vi bn cu no b tn thng
(hu qu c th do gip no hoc
chn p do mu t).
- Lit dy VII ngoi vi (lit mt
ngoi vi) biu hin lm sng l tn
thng c 2 nhnh trn v nhnh di
(hnh 2). Tn thng nhnh trn biu Hnh 1:
hin mt nhm khng kn l do c nh khu
tn thng
vng mi b lit (du hiu Charles-Bell +). Tn thng nhnh di biu hin
ming b ko lch v bn lnh.
nh khu: tn thng dy VII ngoi vi l tn thng t ch dy va thot ra
khi rnh hnh-cu (on trong s) v on dy TK i trong xng . Do vy
v nn s gia hay b tn thng dy thn kinh VII i trong xng vi biu
hin lit mt ngoi vi cng bn.
+ Dy thn kinh III (dy vn nhn chung: nervus
occulomotorius):
Nhc qua gii phu: nhn dy III nm trung no,
dy thot ra cung i no, mt trc trung no. Dy
chy t tng s sau ra tng s gia ri chy vo thnh
ngoi xoang tnh mch hang. Khi ti khe bm th phn
ra 2 nhnh: nhnh trn vn ng c thng trn, c ko
m trn. Nhnh di vn ng c thng di, c cho
b v c thng trong. Nhnh di tch mt nhnh chy
vo hch mt v t hch mt c si ph giao cm chy
vo c mi (dy mi ngn) tc dng lm co ng t.
Trong CTSN thng gp du hiu gin ng t mt
bn do tn thng nhnh thn kinh ph giao cm. Gin ng t va c ngha
chn on va c ngha tin lng (xem khm ng t).
3. Khm thn kinh thc vt.
3.1. H hp:
Ri lon h hp (RLHH) c chia ra: RLHH trung ng v RLHH ngoi vi.
+ RLHH trung ng: do trung khu h hp hnh ty b kch thch bi
chn thng nh sng dch no ty, do ph no, gip no, chn p no do mu t;
nu tn thng thn no tin pht th BN c th ngng th ngay sau chn
thng.
Biu hin lm sng l th nhanh nng c th ti 30 - 35 hoc 40 ln/pht.
Cng th nhanh tin lng cng nng.
+ RLHH ngoi vi: do BN hn m, phn x ho v nut gim, cc cht tit ca
ng h hp trn, cht nn, mu chy t ming v mi xung khng c ho
tng ra ngoi s gy bt tc ng h hp trn mt cch t t. Biu hin th
kh kh, th kh khn v gng sc, c du hiu rt lm h thng n.
Do ng h hp trn b bt tc nn thng kh km, oxy vo phi gim,
oxy mu gim v tng kh cacbonic. Kh CO2 tng cao gy gin mch no, nc
thot khi lng mch vo gian bo gy ph no. Ph no tng lm cho BN hn m
ngy cng su hn. No thiu oxy, chuyn ho tr ln ym kh dn ti tnh
trng toan ho no, t bo thn kinh b nhim c, b hy hoi lm cho no tn
thng cng trm trng hn v hn m cng su hn.
 Do vy, vic trc ht l phi ct b c mt trong cc mt xch quan
trng ca vng lun qun bnh l ni trn, ngha l phi gii quyt thng kh
tt ngay t u, ht m ri v m kh qun sm, th oxy v chng ph no
tch cc.
3.2. Mch:
Mch chm trong CTSN c gii thch l do dy thn kinh X b kch
thch bi tng ALNS gy nn. Mch chm trong CTSN va c ngha chn
on v tin lng
+ Mch chm di 60 - 50 ln/pht xut hin ngay gi u sau chn thng
l do tn thng thn no tin pht, tin lng cc k nng.
+ Mch chm c ngha chn on MTNS l mch chm gim dn t 90,
80 xung cn 60 - 50 ln/pht; l hu qu ca khi mu t hnh thnh v
chn p no t t.
Nu mch chm do mu t m khng c phu thut kp thi th mch
chm s chuyn thnh mch nhanh nh, yu, no mt b, tin lng cc k nng.
3.3. Huyt p ng mch (HAM):
HAM tng cao trong CTSN c gii thch l do tng ALNS s y phn
trn ca thn no vo khe lu tiu no lm cho HAM tng cao.
Mt s tc gi khc cho rng: HAM tng cao l phn ng ca hnh ty
(hiu ng Cushing) sao cho p lc ng mch thng c ALNS a mu ti
no.
V phng din sinh l hc ngi ta thy: trung khu iu ho huyt p v
mch nm hnh ty, l mt ton nhn (cn gi l ct nhn) chy di nm
dc hnh ty. Khi kch thch vo na ct nhn pha trn s lm cho HAM
tng cao v mch chm li; khi kch thch na ct nhn pha di s lm cho
HAM gim thp v mch nhanh nh.
Trong CTSN, khi na ct nhn trn b kch thch bi ph no hoc do
MTNS. s lm cho HAM tng cao v mch chm. Giai on ny cc nh lm
sng cho rng no cn kh nng thch ng v b tr tt. Nu chn p no vn
tip tc tng cao s p na ct nhn di lm cho HAM gim thp v mch
nhanh nh yu, lon nhp. Giai on ny no mt kh nng thch ng, mt b,
tin lng cc k nng.
Trong CTSN, tng HAM va c ngha chn on v tin lng: nu
huyt p tng cao ngay gi u sau chn thng th thng do tn thng
thn no tin pht v tin lng nng. ngha chn on MTNS l HAM
tng cao t t.
Nu phu thut MTNS giai on HAM tng cao, no cn b, cn thch
ng tt th tin lng thun li hn l khi HAM gim thp, no mt b.
 3.4. Nhit :
Nhit tng cao ch c ngha tin lng, ni ln tn thng no nng,
ri lon trung khu iu ha thn nhit vng di i. Nhit c khi ti 40 -
410C km theo v m hi, rung c, tin lng nng.
4. Khm tn thng da u v xng s.
Cn khm di nh n v nhiu trng hp phi ct b tc b dnh mu
tm ch tn thng. C th thy nhng tn thng sau:
4.1. Bc mu t di da u:
Ngay ch b chn thng ngi ta s thy mt khi cng mm, n au v c
biu hin dch di tay, l bc mu t di da u.
X tr: sau mt vi gi c th chc ht b khi mu t; sau khi ht xong cn
phi bng p cht. Trng hp BN n mun, mu di da u ng chc,
ht khng c th phi co sch tc, gy t v rch da ly ht mu cc.
i vi tr em, nhiu trng hp mu t di da u hnh thnh rt nhanh
gy bc tch ct mc xng s v ton b da u cng bng. Nhng trng hp
cn phi chc ht sm hoc trch rch nhiu l tho b mu cc. C
trng hp n mun nn da u b hoi t.
4.2. Chn thng s no m:
l vt thng gy rch da u, v xng s v rch mng no cng; dch
no ty v thm ch c c no nt chy ra ngoi.
Nguy c ca CTSN m l nhim trng no-mng no. Do vy CTSN m cn
c phu thut cng sm cng tt.
X tr: ct tc v co sch, c th khu hoc bng p cm mu tm
thi, sau tin hnh m cp cu, ly ht d vt, xng v, t chc no nt v
khu kn mng no cng trong iu kin cho php.
4.3. V nn s trc:
Mu ln DNT chy ra mi, mu long khng ng; du hiu eo knh
dm mt bn hoc hai bn mt.
X tr: nu mu chy nhiu th phi nht gc (mche) vo ngch mi sau
cm mu; nm u cao; khng sinh.
4.4. V nn s gia:
Mu ln DNT chy ra l tai, bm tm quanh tai, lit dy VII ngoi vi.
X tr: nu chy mu nhiu th cn phi nht gc (mche) l tai; nm u
cao v cho dng khng sinh.
Ngoi ra cn phi khm ton thn pht hin xem c tn thng ngc
bng, ct sng v chi th khng.
5. Khm cn lm sng
5.1. Chp s qui c:
Bnh nhn cn c chp s qui c xc nh tn thng xng s.
Nu BN ang trong tnh trng nng, ri lon nghim trng chc phn sng th
khng nht thit phi a BN i chp phim s ngay m phi hi sc cp cu.
Chp 2 phim thng v nghing, khng c chp nn s (t th Hirtz v
nguy him cho ngi bnh).
5.2. Chp ng mch no:
Khi nghi ng c MTNS th nn tin hnh chp ng mch no (chp ng
mch cnh trong). Trong chn thng ch cn chp phim t th thng cng
c kh nng pht hin mu t.
5.3. Chp ct lp vi tnh (CLVT):
Chp CLVT l phng php chn on hin i, cho bit y cc tn
thng xng s v no. Cho bit v tr, kch thc mu t, cho bit hnh
nh gip no, ph no, chy mu di nhn... Hnh nh CLVT cn gip cc thy
thuc quyt nh ng hng iu tr phu thut hay bo tn khng m.
3. X tr cp cu v theo di.
Sau khi khm cp cu CTSN cn i ti kt lun l BN c cn phi m cp
cu khng ? nu khng, BN cn c iu tr ni khoa v tip tc theo di
pht hin mu t ni s c th xut hin mun.
3.1. Phu thut cp cu:
3.1.1. Mu t ni s:
nu trn nh CLVT thy khi mu t ln th cn phi tin hnh m cp
cu. c th khoan mt l ri sau gm rng xng s hoc m np hp s.
Sau khi ly ht mu t np hp s c th c y tr li. Nu khng c
CLVT hoc chp MN, khi nghi ng mu t ni s th c th khoan thm d
mu t. V tr khoan thm d thng chnh gia v pha trn xng g m
(zygoma) 2 - 3 cm. V tr ny tng ng vi ng mch mng no gia. Nu
mu t NMC, sau khi khoan ht xng s nhn thy mu t mu thm en;
nhng nu mu t DMC th s thy mng no cng mu xanh thm; nu khng
thy mu t NMC hoc DMC v khi nghi ng mu t trong no th c th chc
thm d bng kim Troca vo t chc no ni nghi ng c mu t.
Nu khoan thm d v tr trn m khng thy mu t th cn khoan thm
d v tr th 2 l vng trn, hoc vng nh.
Khi thy mu t th phi bm ra v ht b mu t, tm ngun chy mu v
t in cm mu.
3.1.2. Chn thng s no m:
Tin hnh phu thut cng sm cng tt, ct b t chc phn mm gip
nt, ly b xng gy ri v d vt, bm ra cht no nt chy ra ngoi. Sau
khi ly ht d vt v no nt, tin hnh khu kn mng no cng nu c ch
nh.
 3.1.3. V ln xng s:
V ln xng s c ch nh phu thut nhc b xng ln trnh nhng
di chng sau ny nh ng kinh, ri lon tm thn, p xe no...
tr nh c th nng xng ln tng i d dng, nhng ngi ln th
nhiu khi nng xng ln rt kh khn, khi phi khoan mt l bn cnh b
xng ln ri gm xung quanh v nhc b xng ln. Ch xng ln gn
xoang tnh mch dc trn, xoang tnh mch chm ngang, hi lu Herophin... khi
nhc mnh xng ln c th lm tn thng xoang tnh mch, gy chy mu
d di.
3.2. Theo di thc:
Nhng trng hp khng m cn c theo di tri gic mt cch cht ch, c
30 - 60 pht/ln pht hin trng hp mu t xut hin mun.
Hin nay ngi ta theo di tri gic theo bng chia im Glasgow (nm 1973,
Teasdan v Jennet Glasgow a ra bng theo di tri gic c cho im gi
l bng Glasgow: Glasgow Coma Scale). Bng Glasgow da vo 3 p ng l
mt-li-vn ng, c th nh sau:

p ng im
Mt (E: eyes):
- M mt t nhin 4
- Gi: m. 3
- Cu: m. 2
- Khng m. 1

Tr li (V: verbal):
- Nhanh, chnh xc. 5
- Chm, khng chnh xc. 4
- Tr li ln xn. 3
- Khng thnh ting (ch , rn...). 2
- Nm im khng tr li. 1

Vn ng (M: motor):
- Lm theo lnh. 6
- Bu au: gt tay ng ch. 5
- Bu au: gt tay khng ng ch. 4
- Gp cng hai tay. 3
- Dui cng t chi. 2
- Nm im khng p ng. 1

Cch tnh im nh sau: cng E + V + M; im thp nht 3 - 4 im,

im cao nht 15 im.
 Glasgow 3 - 4 im (tng ng vi hn m IV); Glasgow 5 - 8 im
(hn m III); Glasgow 9 - 11 (hn m II) v Glasgow 12 - 14 (hn m
I)
Trong qu trnh theo di nu tri gic bnh nhn mi ngy mt xu i,
im Glasgow gim dn th cn phi tm nguyn nhn, c th do mu t ni
s hoc do ph no ngy mt tng dn. Trong iu kin cho php nn tin
hnh chp CLVT xc nh nguyn nhn
3.3. iu tr chn thng s no nng:
Chn thng s no nng l nhng trng hp chn thng c im s
Glasgow t 3 n 8 im. Nhng nguyn tc chung iu tr CTSN nng m
khng phi m (hoc sau m) nh sau:
+ m bo thng kh tt: khi BN c biu hin tm ti hoc c nguy c
ngng th (apnea), kim tra phn p oxy di 60 mmHg c coi l thiu oxy
no (hypoxia). Cch gii quyt cho th oxy, c th m kh qun sm, ht m
ri gii quyt n tc ng h hp trn.
+ m bo huyt p ng mch: nu huyt p tm thu( huyt p ti a)
di 90 mmHg s gy thiu mu no, no thiu oxy v ph no tng ln. Cn
truyn mu, hoc dch thay th mu, thuc nng huyt p, khng HAM
gim thp ko di.
+ Theo di p lc ni s (ICP monitoring):
Trong iu kin cho php nn t thit b theo di ALNS cho BN b
CTSN nng. Thit b c t vo no tht bn (c th t catheter vo
cht no hoc di mng cng vo khoang di nhn) theo di ALNS v khi
cn thit c th rt bt DNT lm gim ALNS v ci thin kh nng ti
mu no.
Trong qu trnh theo di, nu ALNS tng trn 20 - 25 mmHg th phi tin
hnh iu tr tch cc lm gim ALNS (dung dch chng ph no, li niu
thm thu...).
+ S dng mannitol trong CTSN nng:
Khi ALNS tng cao, c nguy c gy tt kt no th nn dng mannitol
truyn tnh mch tng t, c 4 - 5 gi truyn mt ln, liu lng 1gram/1 kg
trng lng c th, truyn nhanh vi tc 120 git/pht.
+ Dng bacbituriate:
Ngi ta chng minh: dng bacbiturate liu cao c kh nng lm gim
ALNS v chng thiu mu no, lm gim t l t vong.
+ Nui dng BN hn m ko di:
Nui dng qua ng thng d dy; iu chnh nc v in gii, chng toan
ho mu...
+ Khng sinh:
 phng bi nhim, vim phi do nm lu, phng vim mng
no... cn dng khng sinh c ph tc dng rng. Sn sc chng lot, chng vim
bng quang...
Cc phng php chn on
Bnh l ct sng-ty sng

V Hng Lin

1. t vn .
+ Bnh l ct sng ty sng (CS - TS) bao gm nhiu loi: bnh ni khoa
v ngoi khoa. Ring bnh l ngoi khoa ph bin nht gm: thot v a
m, chn thng ct sng (trong c vt thng ct sng-ty sng), lao ct
sng - ty sng, u ty km theo cc bnh t ph bin nh: cc bnh l bm sinh
(n gai, hp ng sng, rng ng sng, qu pht gai ngang...) hoc cc bnh khc
nh Scheuermann (ri lon cu trc xng tui tr), bnh sm nu (ochronose),
vim ct sng dnh khp (Bechterew).
Mi loi bnh trn c triu chng, biu hin lm sng v phng php
chn on cn lm sng khc nhau. Tuy vy tn thng ct sng-ty sng do
nguyn nhn g cng c nhng triu chng chung v din bin theo quy lut
chung nht. Ngy nay nh hiu bit su v gii phu hc i cng, gii
phu hc nh khu, sinh l hc ty sng, nron dn truyn thn kinh v nhng
trang thit b hin i m vic chn on cng chi tit thu o hn. Tn
thng ct sng-ty sng trc ht phi ni n tn thng khoanh on ty v
tn thng mt n v vn ng ca ct sng (moto - segment) t n chi
phi ti bng lm sng c th.
+ Trong bi ny ch yu ni v cc bnh l ph bin nht l thot v
a m (TV), chn thng CS - TS, u ty...) vi cc phng php chung
nht.
C hai phng php chnh: phng php lm sng bao gm vic khm xt
pht hin triu chng v phng php cn lm sng l nhng phng php
thm d t n gin n phc tp. Hai phng php trn b tr cho nhau nhm
chn on chnh xc nht t ra c phng php iu tr tt nht.
2. Phng php lm sng.
2.1. Hi bnh v cc triu chng ch quan:
2.1.1. Hi chng au:
y l mt hi chng chung nht cho mi loi tn thng CS - TS, n chim
mt v tr quan trng ni bt trong bng lm sng. i su vo hi chng ny
cng rt phong ph, c th tp trung vo my triu chng chnh nh sau:
+ Khi pht au:
- au mt cch t ngt gp trong chn thng CS - TS 100%.
- Trong TV gp 40 - 50% khi pht t ngt.
 - Khi pht t t thng gp trong cc bnh l khc.
+ S lin quan ca au:
- Thi tit: cc bnh l mn tnh thng c lin quan rt r (nh: au thn
kinh hng to do TV, vim ct sng dnh khp...).
- Lin quan ti lao ng, ngh nghip: lao ng nng hay dn ti TV.
T th lao ng hay gy chn thng CS - TS l t th b nn p theo trc.
Cc bnh l v u ty th khng lin quan r ti lao ng.
- Nhim khun: lao ct sng (lao th pht) thng c hi chng nhim c
vi khun lao r.
+ Tnh cht lan xuyn ca au v ri lon cm gic:
- au ti ch: m , nng rt, tc but lan xuyn chm thng gp trong lao
ct sng hoc trong chn thng ct sng n thun, bnh u ty giai on sm,
bnh l a m giai on 1, 2, 3a (theo Arcenia).
- au lan xuyn theo di r thn kinh, lin sn, chn. Nh nm chc triu
chng ny trn lm sng nn ngi ta c th s b hng ti chn on nh khu
bnh l.
C 3 kiu ri lon cm gic theo khoanh ty nh sau:
. Tn thng r su cm gic: au theo r thn kinh, hoc au thon tht
theo nhp p ca mch mu hoc au but, au nh ai.
. Tn thng sng sau: c th khng c au, ri lon cm gic mang tnh phn
ly: mt cm gic au v nhit, cn cm gic xc gic v cm gic c khp (lin quan
ti b Goll - Burdach).
. Tn thng mp sm trc: mt cm gic au v nhit i xng hai bn
c th tng ng vi khoanh ty tn thng nh: chy mu ni ty (hemato -
siringomyelya) hoc u mng ng ni ty Ependymoma.
Quan h gia khoanh ty sng v cc khu cm gic ngoi da nh sau:

Khoanh TS Vng cm gic da Khoanh TS Vng cm gic da

C1 - C3 Gy v c D9 - D10 Ngang rn
Ngang dy chng bn
C4 Vai D12 - L1
(np hng)
Na quay ca bn tay,
C5 - C7 L1 - L5 Mt trc chi di
cng, cnh tay
Na tr bn tay, cng tay,
C5 - D2 S1 - S3 Mt sau ca chi di
cnh tay
Mt trong mng, y
ng v b sn cui
D5 - D7 S4 - S5 chu hu mn, c
cng
quan sinh dc

+ Tin trin au:

 - Chn thng ct sng n thun gy gin, rch dy chng, ln ct sng
nh th s c biu hin au cp tnh nu c bt ng v thuc gim au
tin trin tt: au gim dn v ht au.
- Chn thng ct sng c xp v di lch r th s c din bin: au - khi
- au mn tnh khi thay i thi tit.
- TV: au tht lng m mn c th khi hoc khng, sau au n
r thn kinh hng to do xung t a - r, vim dnh r thn kinh (au hai
pha).
- U ty: au ti ch m mn c xu hng ngy cng au tng km theo cc
triu chng khc: lit 1/2 ngi - h lit. Cng c khi u r thn kinh li au
c hoc da vng r thn kinh chi phi trc, sau dn dn mi thy au
lng ri tip tc bi yu chi di.
2.1.2. Cc triu chng ch quan khc:
+ D cm: l cm gic ch quan ca ngi bnh khng phi do kch thch
t bn ngoi vo. Biu hin d cm c th l: t t, bun bun, nng rt, kin
b, kim chm... in hnh l hi chng bng but (causangie - causis l bng,
algos l au). C khi bng rt khu tr cng dy thn kinh chi phi, cng c khi
vt ra ngoi dy thn kinh chi phi mang tnh cht "bt tt tay, bt tt
chn". Ngun gc au bng ny c gii thch l do t qung hay tn
thng khng hon ton ng dn truyn thn kinh kt hp kch thch
bng ng thn kinh giao cm. Theo M.I Axtratxaturop: au chy cn bn l do
kch thch qu mc i th.
Cc bnh l c th gp hin tng bng but l:
- U r thn kinh (neuvrinoma).
- TV lu ngy c vim dnh thn kinh, hoc TV l ghp (him).
- Di chng chn thng ct sng - ty sng: gy vim dnh r v mng
ty...
i khi v tr ca d cm ban u gi cho ngi ta v tr r thn kinh
hoc khoanh ty b tn thng, v d: d cm xut hin vng ngn 1 bn
chn, mu chn v mt ngoi cng chn tng ng vi r L5. Nu d cm
ngn 5 b ngoi mu chn v mt sau ngoi cng chn tng ng vi r S1.
+ Bi yu chn, tay mt bn, hai bn t ngt hoc t t ty theo r thn
kinh v khoanh ty bng vi mc bnh l v tnh cht bnh l quyt
nh.
+ nh hng ca bnh l ti lao ng, sinh hot ca ngi bnh. Lu nhng
ri lon v bi tit phn v nc tiu nh: b hoc sn... nhng triu chng
ny s gip cho tin lng bnh l.
2.1.3. Tin s:
+ Bnh mang tnh cht gia nh: Scheuermann, Bechterew.
 + Ngh nghip lin quan ti bnh l: nhng lao ng nng nh: bc vc, li
xe lin quan n chn thng hoc vi chn thng l tin thun li ca
thoi ho ct sng v trong nhng hon cnh nht nh c th gy nn TV.
+ Cc bnh l khc kt hp (u ty nguyn pht hay l di cn ca nguyn
pht khc, lao ct sng v lao th pht...).
+ c im tm l nhn cch bnh nhn.
2.2. Khm khch quan:
C nhiu vn trong khm khch quan nhng y ch tp trung vo cc hi chng chnh:
2.2.1. Hi chng ct sng:
+ Khm xt trc ct sng xem ng cong sinh l cn hay mt, c b g
lch, vo v n qu mc hay khng, hoc c hnh bc thang trc ct sng
tht lng:
- Mt cong sinh l: c nh trong bnh Bachterew, co cng c cnh
sng hay gp trong bnh l a m.
- n qu mc: tng n trong trt thn t sng, khi s c th thy ch lm
ca mm gai. n qu mc cn c th gp do phn x b tr ca bnh ct sng
on ngc gy ra nh lao ct sng ngc, chn thng gy ct sng lng, bnh
Scheuermann...
- G (c hai loi g): g nhn thng gp trong bnh l gy tn thng cc
b hoc hai thn t sng nh gy xp thn t sng do chn thng ct sng
ty sng. G trn hay gp trong lao t sng c km theo p xe lnh, ung th ct
sng, hoc gp ngi gi h a m lu nm c th km theo nhiu hch
sn kiu Schmorl. ngi tr, g trn tht lng c th thy trong mt s bnh
thiu nng c hoc th tht lng ca bnh Scheuermann.
- Vo ct sng: TV t giai on 3B tr i thng thy c vo ct sng r.
y l mt t th chng au thng km theo co cng c cnh sng 1 bn hoc
2 bn. Ty theo t th v tr a m v s xung t a r nh th no
m au vo cng bn hay khc bn.
+ Xc nh im au, vng au trn ct sng v cnh sng:
- Dng ngn tay n vo gai sau hoc khe lin gai sau.
- Dng ngn tay n vo cnh sng cch ng gia 2 - 3 cm l ni xut
chiu r thn kinh c mt s triu chng v nghim php sau:
. Triu chng mm gai: au khi g vo mm gai c u (bng ba phn x
hoc phn mm bn tay) c th bnh nhn au tng ln hoc c khi xut
hin d cm c bit (cm gic lung in).
. Du hiu chung bm: khi n vo cnh sng ni xut chiu ca r thn kinh
(hoc n vo khe lin t) th bnh nhn thy au lan truyn hoc git mnh xung
dc theo dy thn kinh gi l du hiu chung bm (+)
+ Cc nghim php khm tm hot ng ca ct sng:
- Nghim php khong cch ngn tay nn nh: bnh thng t 0 - 5 cm
thanh nin Vit Nam (ch s theo Ng Thanh Hi v L Gia Vinh).
 - Nghim php v ch s Schober: bnh thng ngi Vit Nam l: 14,5 -
15cm/10.
- Nga ct sng: bnh thng l 25 - 300 (ly mc l ng ni 2 gai chu
trc trn).
- Nghing phi, nghing tri ct sng: bnh thng 25 - 300 (mc l mm gai S1).
2.2.2. Hi chng r - ty:
y l hi chng tn thng ty sng, r thn kinh vi cc mc khc nhau;
t trn xung di c cc hi chng sau:
+ Hi chng on ty c trn (C1 - C4):
- Lit hoc kch thch dy thn kinh honh gy kh th, nc (singulitis)
hoc gy nut kh (deglution).
- Lit cng t chi, mt tt c cc cm gic tng ng (b i hoc i dm
cch hi). Lu : c th gp cc hin tng sau y: ng t khng u
(anisocoria), nhp tim khng u hoc chm (bradycardi), rung git nhn cu
(nystagmus).
+ Hi chng ca on ty c di (C5 - D1):
Nu tn thng C5 - C6 c hi chng Erb, nu tn thng t C7 - D1 c hi
chng Degerin - Klinke:
- Lit ngoi vi hai chi trn, lit trung ng hai chi di.
- Ri lon tiu tin kiu trung ng.
- C th au r thn kinh lan xung chi trn.
- Hay gp hi chng: Claude - Bernard - Horner: sng bn C8 - D1 c nhm
t bo trung tm mi-gai (centrum ciliospinale) t y c cc si giao cm ti
hch giao cm c, dy thn kinh giao cm, m ri giao cm quanh ng mch
qua hch mi (ganglion ciliare) ri ti mi mt chi phi cho 3 c trn t ng:
. C gin ng t (dilatator) (pupillae).
. C gin khe mi (tarsalis superior).
. C orbitalis: lm nh nhn cu ra mt t.
Do vy khi tn thng hay kch thch vo trung tm mi-gai s c hi
chng ngc li: hp khe mi, co ng t, mt hi trng xung.
+ Hi chng on ty ngc D3 - D12:
- Lit cng hai chi di.
- B i kiu trung ng.
- au r thn kinh kiu nh ai (corset).
+ Hi chng phnh tht lng t L1 - S2:
- Lit ngoi vi hai chi di.
- Mt cm gic chi di v y chu.
- Ri lon tiu tin hn hp thin v ri lon tiu tin kiu trung ng.
+ Hi chng nn cng (conus medulleris) t S3 - S5:
- Khng r lit.
- Mt cm gic au vng y chu.
 - Ri lon tiu tin ngoi vi: i dm thc s.
+ Hi chng ui nga (caude equin):
- Triu chng ging nh tn thng phnh tht lng v nn cng: lit ngoi
vi hai chi di, ri lon tiu tin, b i hoc i dm thc s.
- C ch ri lon tit niu:
Mc khoanh ty S3,4,5 trong cht xm (c tc gi cho t S2) c trung tm ca
bi tit nc tiu (centrum vesico spinale (v i tin) C. ano - spilane). Bnh
thng hot ng ca ngi ln c s iu ho trn v no qua dn truyn ct bn
ty sng cnh cc b thp; khi tn thng mt bn v no vn chi phi c, do
khng c ri lon i tiu tin. Khi tn thng c hai bn (gip ty do chn
thng, u ty p...) th s xut hin cc kiu b i:
. B i kiu trung ng: i dm cch hi (Incontinentio Tntemittens).
. Mt s iu ho ch ng t trn v no xung.
. Hnh thnh mt kiu thot nc tiu phn x do hot ng t ng ca
trung tm trn. tr em di 1 tui hay gp trng hp ny: khi bng quang
y nc tiu kch thch ni c tht v h c bc bng quang gi l c thi
niu (detrusor urinae) th nc tiu c tng ra t ng ngoi mun; cho ti
ln sau bng quang li y dn v li c tng ra. S nc tiu cn li do
khng tng ra ht l nc tiu tn d c nguy c gy vim bng quang, vim
b thn, thn, si tit niu. Nu mc nh th bnh nhn b mt i
khng nhn c, nu mc nng th b i hon ton (retentio urinae)
c bit thy trong chn thng ct sng-ty sng ngy u, tun u
sau chuyn dn sang b i cch hi.
. B i kiu ngoi vi: i dm thc s (incontinentio vera) khi tn thng
ng vo trung tm tiu tin tr xung.
Do c tht v c bng quang u b yu lit, nc tiu chy vo bng
quang n u thot ra tng git n , trng lc bng quang mt gy nn
hi chng bng quang nh, gy phin phc cho bnh nhn trong cuc sng v
sinh hot.
Lu : c khi tn thng trung ng vn c i dm thc s hoc tn
thng ngoi vi vn c tc niu nh thng (ishuria paradoxa).
+ Mt s nghim php tm tn thng r thn kinh:
- Du hiu chung bm ( nu phn trn).
- Tm im au xut chiu: du hiu Valleix.
- Du hiu Lasegue (thng, cho) lu : test Lasegue phn bit vi au
c, au khp.
- Nghim php Neri: gp u bnh nhn thy au dy thn kinh hng
to.
- Nghim php Valsava: th mnh ra trong khi ngm ming gy tng p lc
tnh mch trong ng sng a n tng p lc dch no ty kch thch vo r
thn kinh gy au.
- Du hiu Dejerine: ho ht hi thy au.
 - Du hiu Wasserman: gp u gi dui mnh i: kim tra au dy
thn kinh i.
Tng hp nhng ri lon ty tht lng - cng.

R tn Ri lon
Ri lon cm gic Ri lon vn ng
thng phn x
L1 - L2 Vng bn v mt trong i - C tht lng - chu Phn x bn-bu
- C may

L3 - L4 Mt trc i v mt trc - C t u i Phn x gi

trong cng chn - C khp
L5 Mt ngoi i, trc ngoi Cc c trc ngoi cng
cng chn, mu chn v chn
ngn ci

S1 Mt sau ngoi i, sau Cc c khu sau cng chn: Phn x gt, phn
ngoi cng chn, b ngoi gp gan chn, gp ngn 1, x da gan chn
bn chn ngn 5 gp cc ngn

S2 Sau trong i, cng chn, Cc c nh bn chn Phn x da gan

gan chn (1 phn); vng (dng khp, gp ngn), c chn, phn x
yn nga (y chu) tht hu mn v bng quang hu mn

3. Cc phng php cn lm sng.

3.1. o thi tr (Chronasimetria):
+ Thng thy thi tr ko di nhng nhm c nht nh trong bnh l
TV. Bnh thng thi tr c ny (c do dy thn kinh L5 - S1 chi phi) l:
1,5 mm/giy n 3 mm/giy; khi b TV thi tr ko di ti 4,5 - 5
mm/giy.
Ngi ta hay o thi tr c dui di ngn ci, c dui chung cc ngn, c chy
trc (L5). Hoc o c tam u cng chn, c nh u i (S1) hoc cc c
khc.
Nhn chung au tng, thi tr ko di. Kt qu nh khu kh.
+ Nhc im:
- Nhiu r thn kinh chi phi mt c do vy chn on mang tnh tng
i.
- Khng cho chn on chuyn bit v mt loi bnh thn kinh no.
3.2. Ghi in c (Electromyographia):
Nhm pht hin s gim, thp, hay bin i cht lng hot tnh in
sinh hc ca cc c do cc r thn kinh chi phi.
Cc tc gi: Maguth, Shea, Woods, Smith... l nhng ngi s dng in cc
kim nh gi in th mt phn b thn kinh tng c.
Trn lm sng in c s dng cc l loi in cc b mt.
 Theo Brothman M.K ghi in c nhiu khi chn on tn thng r thn
kinh chnh xc hn chn on lm sng. Phi ghi hai bn hai trng thi (c
co, c ngh) v cng ghi cc c nh o thi tr.
Triu chng l s mt cn xng v hot ng in hai c hai bn.
3.3. Xt nghim dch no ty:
+ ngha ln trong chn on u ty c hin tng phn ly albumin - t
bo. Thng thy 0,6 - 10g albumin/lt trong 80 % cc trng hp u ty.
+ TV t gi tr.
+ Trong chn thng ct sng ty sng ngi ta c th thy cc hin tng sau:
- Chn ng ty th p lc hi tng, t bo bnh thng, lu thng dch no
ty tt.
- Mu : trong chn thng ct sng-ty sng mi, hoc u mu (hemangiome).
- Mu vng, vng chanh: lao ct sng.
- Mu trng c: vim no, vim r ty.
- p lc dch no ty thp di mc p, c th thy hng cu nu
chn thng mi, lu thng tc nghn hoc bn tc (nghim php Queckenstedt
- Stookey).
- Gip ty th dch no ty c hng cu, lu thng c th bn tc do ph
ty.
- Trong lao ct sng: dch no ty c th trong sut hoc c mu vng
chanh, t bo c nhiu limph. Nu lao giai on 3 (chn p gy h lit) c
th thy lu thng dch no ty b tc nghn.
3.4. Cc phng php chn on bng X quang:
+ X quang thng thng (quy c): y l mt quy nh bt buc chp vi
2 t th: chp thng, chp nghing, nhng trung hp cn thit cn chp chch
(3/4F hay 3/4T) nh gi l ghp.
- Phim thng:
. Thy vo c, di lch sang ngang: ch vo, ch di lch l trung tm bnh
l.
. Hp khe khp: dnh khe khp, m khe khp, khe khp nham nh.
. C th thy ch xp c hnh chn nhn (nu xp ct sng ngc).
. Chn tip khp: u n, cn i hai bn.
+ Chp bao r (saccoradiculographia): chn on TV vng ct sng tht
lng v ni ty, cc bnh l khc vng tht lng.
+ Chp ty cn quang (myelographia): chn on bnh l ty, ct sng nh
u ty, hp ng sng t c tr xung.
Ring ct sng c, k thut chp l chc ngang CI CII (nh bi TV c).
+ Chp CT.Scanner ct sng (ty theo on).
3.5 Chp MRI (magneto resonance imaging):
y l phng php tin tin nht, u vit nht chn on bnh l ct
sng ty-sng (xem bi TV c).
iu tr ri lon tiu tin
trong chn thng ct sng-ty sng

Bi Quang Tuyn

1. c im sinh l tiu tin.

C 2 trung khu iu khin tiu tin:
+ V no (hi mc) iu khin i tiu theo mun.
+ Ty cng (S2, S3, S4) iu khin tiu tin phn x.
1.1. Tiu tin theo mun:
Bnh thng khi bng quang y nc tiu, cc th cm th n hi
(stretch receptors) trong thnh bng ( BQ) truyn xung ng v ty cng (S2,
S3, S4) v t xung ng truyn tip ln v no (hi mc) gy nn cm gic
mt i tiu. T v no, xung ng truyn theo b thp i xung iu khin
m c tht c bng quang v i tiu theo mun c thc hin.
1.2. Tiu tin phn x:
Khi ty sng tn thng, con ng lin h v no-ty sng(b thp) b mt
nn bnh nhn khng cn cm gic mt tiu v khng th iu khin ng
tc i tiu theo mun. Ht giai on sc ty, c ri bng quang hi phc, khi
BQ y nc tiu th xung ng truyn n ty cng S2, S3, S4 v ri xung
ng li c truyn tr li bng quang, kch thch BQ gy co bp c ri
ng thi m c tht c BQ v nc tiu c tng ra ngoi.
Mc d khng cn cm gic mt tiu nhng bnh nhn thng c nhng
du hiu bo trc khi BQ y nc tiu. Cc cm gic c th thy nh ni
da g; nng bng mt; cm gic tc bng di; v tng nc tiu ra
ngoi bnh nhn phi kch thch nh g ln bng quang; p cht 2 i; gi
mt trong i hoc gi xng ct gy kch thch phn x co bp c ri v
c tht c BQ c m ra.
2. Cc biu hin ri lon tiu tin.
Cc biu hin ri lon tiu tin (RLTT) trong chn thng thng gp nh
sau: b i; b i nghch thng; tiu tin ngoi mun nh k; khng gi
c nc tiu nh k; khng gi c nc tiu thc s.
2.1. B i (urinary retention):
B i xy ra ngay sau chn thng ty v ko di 2 - 3 thng hoc lu
hn.
Ngi ta cho rng: khi ty tn thng th c ri BQ b lit, trong khi c
tht trong c BQ li co chc, tnh trng dn ti b tiu.
 Ht giai on sc ty (2 - 3 thng sau hoc lu hn) c ri BQ bt u
hi phc, ri lon tiu tin s c biu hin khc nhau, c th nh sau:
2.2. B i nghch thng (ischuria paradoxa):
B i nghch thng l th c bit ca b i, thng xut hin 2 - 3
thng sau chn thng ty v thng gp tn thng ty cao, trn phnh tht
lng.
Biu hin: khi BQ y nc tiu ti mc ti a, p lc trong BQ tng cao s
thng c c tht trong ca BQ ang co tht chc v nc tiu c tng ra
ngoi tng t mt.
B i nghch thng chnh l c ch t bo v cn thit gim bt s
cng BQ qu mc.
Sau mi ln i tiu khng c nhiu, nn lng nc tiu d cn li trong
BQ c th trn 150 ml. Lng nc tiu d cn nhiu s gy nn vim BQ. Do
vy khi c b i nghch thng th cn phi c thng tiu kp thi
phng vim BQ.
2.3. Tiu tin ngoi mun nh k:
Tiu tin ngoi mun nh k cn gi l i dm cch hi (incontinentio
intermittens) vi biu hin l khi BQ y, nc tiu s c tng ra ngoi mt
cch t ng ngoi mun v bnh nhn hon ton khng cn cm gic mt
tiu. Ln i sau cng vy, BQ y l nc tiu c tng ra mt cc t ng
ging nh hin tng i dm tr em di 1 tui, thn kinh cha pht trin
hon thin, ngi u i , BQ y nc tiu l tng ra ngay.
i dm cch hi hay gp trong tn thng ty cao, trn phnh tht lng tr
ln v thng xut hin vo thng th 2 - 3 sau chn thng.
Tuy bnh nhn khng cn cm gic mt tiu nhng c nhng du hiu bo
trc khi BQ y nc tiu v bnh nhn phi kch thch g ln BQ gy
phn x i tiu.
2.4. Khng gi c nc tiu nh k:
Khng gi c nc tiu nh k hay cn gi l mt i mnh lnh
thng gp trong tn thng ty khng hon ton, mt phn ng dn truyn
ty vn cn, b thp khng tn thng hon ton.
Mt i mnh lnh thng xut hin thng th 2 - 3 sau chn thng,
biu hin: bnh nhn cn cm gic mt i nhng l mt i mnh lnh,
khn cp ti mc va c cm gic mt i l phi i ngay, khng th nn
nhn. V th i khi bnh nhn cha kp th i ra qun.
2.5. Khng gi c nc tiu thc s:
Khng gi c nc tiu thc s hay cn gi l i dm thc s (incontinentio
vera) hay gp trong tn thng ty thp, ty phnh tht lng v ui nga,
xut hin 2 - 3 thng sau chn thng ty.
Thng tn thng vng nn ty, trung tm tiu tin S2, S3, S4. Do c tht
trong c BQ v c ri u b lit nn nc tiu t niu qun vo BQ bao nhiu
th chy ra ngoi ngay lp tc, c BQ lun lun m nn nc tiu khng gi li
c BQ.
nhng bnh nhn ny khng c nc tiu d v ngi bnh lun phi
eo ti ng nc tiu bn mnh.
Tm li:
+ B tiu xy ra ngay sau chn thng ty v ui nga. B tiu ko di
2 - 3 thng hoc lu hn.
+ Tiu tin ngoi mun nh k (hay cn gi l i dm cch hi)
thng gp trong cc tn thng ty cao trn phnh tht lng. Bnh nhn
khng cn cm gic mt tiu nhng c nhng du hiu bo trc v ngi bnh
thc hin c ng tc tiu tin phn x nh g, kch thch ln bng quang.
+ Khng gi c nc tiu thc s (i dm thc s) thng xy ra khi tn
thng phnh tht lng, nn ty cng v ui nga.
3. Cc bin php gii quyt b tiu.
Khi b tiu, bng quang cng qu mc (c th cha ti 2 - 3 lt), nu
khng c thng tiu s c nguy c v BQ, hoi t thnh BQ v tro ngc nc
tiu ln thn...
Do vy vic gii quyt b tiu bnh nhn lit ty trc ht phi dc
sch nc tiu ra khi BQ. C nhiu phng php khc nhau v mi mt phng
php c ch nh ring, c nhng u im v nhc im ring.
3.1. Thng tiu nh k:
+ Dng c: ng thng tiu (sonde) bng st hoc bng cao su (nelaton).
Hin nay hay dng ng thng Foley c 16 - 18, ng ny c u im t kch
thch nim mc niu o, u ng thng c qu bng nh (balon) gi c nh
cho ng thng khi tut.
+ K thut: tin hnh t ng thng tiu qua niu o (ch phi m
bo tuyt i v trng) sau tho b ht nc tiu ri rt b ng thng.
Khong 5 - 6 gi sau, khi BQ y li tin hnh t li thng tiu ri tho
b ng thng.
Nu tin hnh t thng tiu nh k nh ni trn th trung bnh mt
ngy phi t thng tiu t 5 - 6 ln. Do vy phng php ny c nhc im
l d gy nhim trng v gy tn thng niu o do t i t li nhiu
ln; mt nhiu thi gian v khng th tin hnh sut thi gian b tiu 2 - 3
thng. Do phng php ny ch c tnh cht tm thi, thc hin vi ngy
u sau phi chuyn phng php khc cho thch hp hn.
3.2. t thng tiu lu di:
+ K thut: tin hnh t thng tiu bng sonde Foley v lu ng thng
bng quang 5 - 7 ngy. Sau 5 - 7 ngy rt b v t li ng thng mi. Khng
nn ng thng qu lu, cn vi s bm vo u ng thng, khi rt b ng
thng d gy chy mu niu o, d gy nhim trng BQ...
+ Ch :
 - ng thng tiu lun c kp li, c 4 - 5 gi th m kp cho nc tiu
chy ra ht. Khng c ng thng tiu m lin tc v s lm cho bng
quang co hp th tch v mt kh nng tiu tin phn x.
- Khi no thy nc tiu r ra ming so, chn ng thng, chng t c
ri BQ hi phc vn ng, tiu tin phn x xut hin, khi ta c th
rt b hn ng thng tiu.
+ Ch nh: ch nh rng ri cho tt c cc trng hp tn thng ty.
+ Chng ch nh: r gc niu o; t niu o do chn thng; vim
tinh hon; bng b phn sinh dc.
+ Bin chng: l phng php c nhiu ngi a chung nhng cng c
nhiu bin chng nh vim niu o m; vim qui u (balanitis); p xe v r
gc niu o; vim tinh hon (orchitis).
3.3. Dn lu bng quang trn xng mu (vesicotomy):
Hohrand (1912) l ngi u tin tin hnh m dn lu BQ trn xng mu.
Trong cuc chin tranh th gii ln th nht v th hai, phng php ny c
ng h v p dng rng ri. Tuy nhin cng c nhiu kin phn i phng
php ny bi nhng l do sau: khng ngn nga c nhim khun tit niu;
cn tr s phc hi phn x co bp ca BQ; gy hoi t thnh BQ do r thm
nc tiu vo c ca thnh BQ; lm hp dung tch v bin dng bng quang.
+ Do vy dn lu BQ trn xng mu c ch nh nh sau:
- p dng trong chin tranh, tin cho vic chm sc v vn chuyn thng
bnh binh.
- Khi c chn thng gy t niu o; bng b phn sinh dc ngoi;
trong cc trng hp m ly si BQ v tuyn tin lit.
3.4. Chc r bng quang trn xng mu:
+ Ch p dng trong iu kin ngi bnh qu xa bnh vin (nh hi
o, rng ni xa xi), trong lc chin u c lit m khng c bt c phng
tin no dn lu nc tiu trong khi BQ cng qu mc e do v bng
quang.
y ch l bin php tnh th, c tnh cht cp cu, sau phi tm cc
gii php khc.
+ K thut: dng kim tim di 5 - 6 cm, chc kim chnh ng trng gia
cch trn xng mu 2 cm. Sau khi tho ht nc tiu th rt kim. Mt ngy c
th chc 3 - 4 ln v c th tin hnh 2 - 3 ngy, sau tm cch chuyn
bnh nhn v bnh vin c chuyn khoa.
4. Tp luyn bng quang
ngi bnh thng, BQ lun lun c lp y v dc ht nc tiu theo
mun mt cch nhp nhng. Khi ty tn thng, cm gic mt tiu b mt, c
ri BQ b lit, c tht trong c BQ co chc dn ti nc tiu b . Do vy
ngi ta ch ng tp luyn BQ nhm nhng mc ch sau:
+ Nhanh chng phc hi c ri b lit.
 + Phc hi kh nng tiu tin phn x.
+ m bo cho BQ khng b teo nh.
+ Lm gim lng nc tiu d cn li t nht sau mi ln i tiu.
+ Ngn nga vim BQ.
Thng tin hnh tp luyn BQ t tun th 2 - 3 sau chn thng. Khng
nn tp sm v ang giai on sc ty. thi k ny mt s trng hp bt
u xut hin tiu tin ngoi mun nh k vi lng nc tiu d trn 200
ml (s lng nc tiu d cho php ngi lit ty l 100 - 120 ml).
C 2 phng php luyn tp BQ: bng tay v theo phng php Munro.
4.1. Tp luyn bng quang bng tay:
+ Dng c: bm tim 100 ml; ng thng tiu Foley c 16 - 18; bnh c dung
tch 2 lt ng nc ra BQ.
+ Dung dch: thng dng nc mui sinh l 9%0. Trng hp BQ b vim c
th dng dung dch c tnh cht st khun nh furacilin, xanh methylen,
berberin, rivanol...
+ K thut: t ng thng tiu BQ qua niu o, c nh ng thng tiu.
Dng bm tim 100 ml bm nc mui 9%0 vo BQ. Ch ngy u ch nn
bm vo BQ 100 ml mi ln. Nhng ngy sau c th tng ln 150 ml - 250 ml.
Tin hnh u n ngy 2 ln (sng v chiu) trong thi gian t 7 - 10
ngy. Cch luyn tp ni trn lm cho BQ lun cng y v xp li mt cch
nhp nhng, to iu kin hi phc sm kh nng tiu tin phn x.
Ch : khng nn bm vi p lc ln v khng nn a vo BQ qu nhiu
nc mui 9%0 v d gy chy mu nim mc BQ, gy thng thnh BQ v tro
ngc nc tiu.
4.2. Tp luyn bng quang theo phng php Munro:
Nm 1939, Munro v Hahn trnh by phng php tp luyn v ra BQ
theo h thng ln - xung, sau ny c p dng rng ri v gi l phng php
Munro.
+ Dng c: bnh ng nc mui 9%o (2 - 3 lt) (Khoa PTTK Bnh vin
103 thng dng l dch truyn 500 ml, mi ln luyn tp khong 4 l). Mt b
dy truyn c ng m git v c kho iu chnh git (kho K1); chc 3
v ng thng tiu Foley; dy dn nc tiu ra bnh cha c kho (kho K2);
bnh cha 2-3 lt (bnh kn m bo v trng).
+ Cch tin hnh: treo bnh ng dung dch ra BQ ln cc truyn cch
mt ging 80 - 100 cm. t thng tiu qua niu o; lp chc 3 vi ng thng
Foley, 2 u chc 3 cn li ni vi dy dn dch vo BQ v dn nc tiu ra
bnh cha.
- Bc 1: ng kho K2. M kho K1 cho dch t t chy vo BQ (ch
khng dch chy thnh tia v d gy kch thch nim mc BQ, chy mu
BQ v thm ch c th gy thng BQ). Ln u a vo 80 - 100 ml th
dng li.
- Bc 2: ng kho K1
khng cho nc chy vo BQ na,
ng thi m kho K2 nc
trong BQ chy ra bnh cha. Ch
: khi m kho K2 ng thi nng
dy dn nc ra bnh cha ln cao
chng 15 cm so vi xng mu, mc
ch c ri BQ co bp mnh
hn to iu kin cho c ri
nhanh chng hi phc.
Tin hnh ln lt theo cc
bc ni trn mi ngy 2 ln sng
v chiu, mi ln 2 - 3 lt. S
lng nc a vo BQ cng tng
dn t 100 ml ln 150 - 250 ml.
+ Ch : khi nc vo BQ c
th thy 2 hin tng sau:
- Khi c ri b lit cha c
biu hin hi phc: BQ c th
gin v cha c 500 - 700 ml,
thm ch cn nhiu hn. Do vy
khng nn a vo BQ qu nhiu
s c nguy c gy hoi t thnh
BQ, gy tro ngc nc tiu ln
niu qun v thn (xem s
S ra BQ theo phng php Munro:
ra BQ theo phng php Munro).
1. Bnh ng dung dch ra BQ; 2. Kho K1;
3. ng m git; 4. Dy dn dch vo BQ; - C ri BQ hi phc: khi nc
5. Chc ba; 6. Sonde Foley; 7. Bng quang; a vo BQ c khong 100 ml
8. Dy dn nc tiu ra bnh cha; 9. Xng mu; m thy hin tng nc khng
10. Bnh cha; 11. Kho K2.
tip tc chy vo BQ na m
ngc li, nc b y ngc tr li t trong BQ ra, iu chng t c ri BQ
hi phc, BQ co bp phn x. Khi phi ng kho K1 v m kho K2
nc trong BQ chy ra bnh cha. Tp luyn nh trn cho n khi no nc
vo BQ 200 - 250 ml hoc nhiu hn l c.
5. D phng v iu tr vim bng quang bnh nhn lit ty.
C nhiu bin chng tit niu bnh nhn lit ty nh: b tiu; vim
BQ; vim niu o; vim tinh hon; r gc niu o; si tit niu (si BQ, si
thn); vim b thn - thn, thn nc, m... v cui cng l biu hin thn
mt chc nng dn ti suy thn v t vong
Do vy vic sn sc tit niu bnh nhn lit ty l cng vic cc k
phc tp, lu di, c bt u t ngay sau khi ty b tn thng cho n ht
qung i cn li ca ngi bnh.
D phng tt v iu tr kp thi khi BQ b vim l iu kin tt nht
gim nh cc bin chng v tit niu.
5.1. D phng vim bng quang:
+ Thng tiu phi m bo ng qui cch v tuyt i v trng.
+ Sn sc tt ng thng tiu, c 5 - 7 ngy rt b ng thng tiu v t li
ng thng tiu mi. Khi no thy nc tiu chy ra chn ng thng th rt b
hn ng thng tiu.
+ Ung nhiu nc.
+ Ung li tiu ng y (kim tin tho, ru ng, bng m ...).
+ Lm toan ho nc tiu nh ung nhiu nc cam, chanh, vitamin C (nc
tiu bnh nhn lit ty thng kim nn d b vim).
+ Khi tho b nc tiu nn p tay ln vng BQ y ht nc tiu ra
ngoi, khng nc tiu d cn li nhiu trong BQ, d gy vim BQ.
5.2. iu tr vim bng quang:
+ Biu hin vim BQ l: nc tiu c; cm gic au rt vng BQ; st cao
v dao ng, lc rt, lc nng, ra m hi; xt nghim nc tiu c nhiu bch
cu; xt nghim mu thy s lng BC tng cao; bnh nhn mt mi, chn n...
+ Khi BQ b vim cn ra BQ v iu tr ton thn:
- Ra BQ: phng php ra BQ bng tay hoc theo phng php Munro nh
trnh by phn luyn tp BQ ni trn, nhng ch : nu ra bng nc
mui sinh l 9%0, khi gn kt thc ra BQ th nn cho 1 gram streptomycin vo
dung dch ra ln cui cng.
Dung dch ra BQ c th l nc mui sinh l 9%0; rivanol 1%; berberin
1%0; furacilin 5%0 hoc xanh methylen 1%...
Ra cho ti khi nc tiu trong, bnh nhn ht st.
- iu tr ton thn: truyn m; dch thay th mu; n ung bi dng c
th; thuc h st; chng lot, chng suy mn suy kit... khng sinh ton thn
nh tim hoc ung peflacin; negram; nitrofurantoin; ung nhiu nc; sn sc tt
ng thng tiu...
Thuc s dng trong phu thut thn kinh

Bi Quang Tuyn
1. Khng sinh.
Hng ro mu-no l tr ngi ln khng sinh ti c vim nhim
su trong no, c bit trong cc trng hp vim mng no, vim mng no
m, p xe no.
Do vy vic iu tr cc bnh vim nhim no phi m bo nhng
nguyn tc sau y:
+ Khng sinh c th qua c hng ro mu-no (nhm cephalosporin).
+ Khng sinh c ph tc dng rng nhng c tnh thp.
+ a khng sinh bng nhiu ng: tnh mch, bp tht v dch no ty.
1.1. Penicilin:
1.1.1. Nhm beta - lactam:
Fleming S.A.(1881-1955) chit xut thnh cng penicilin t nm vo
nm 1929 (nhn gii thng Nobel 1945) m ra thi k mi trong Y hc. Song
penicilin khi cn rt c nn cha c p dng trong lm sng. Mi ti nm
1944 ngi ta mi chit xut c penicilin tinh khit, khng c v chnh
thc a vo s dng rng ri trong lm sng
+ Tc dng:
Tc dng vi vi khun Gram (+) (nh t cu, lin cu, ph cu), vi vi khun
Gram (-) (nh lu cu, mng no cu), vi trc khun un vn, trc khun than,
bch hu, hoi th sinh hi v xon khun Leptospira, giang mai.
+ Ch nh: cc bnh vim xoang, thp khp cp, giang mai, lu, hoi th
sinh hi, un vn v vim mng trong tim.
i vi vim mng no, vim mng no m (bin chng ca vt thng s
no), trc y ngi ta phi dng liu cao t 5 - 10 triu n v/ngy/tim bp
hoc tim tnh mch, ng thi a khng sinh vo dch no ty (DNT). Nhng
hin nay nh cng ngh pht trin, c khng sinh ph rng c th thm
c qua hng ro mu-no nn vic dng penecilin iu tr cc bnh vim
nhim no cn c p dng rt t trong lm sng.
+ Cc loi penicilin v ch phm:
- Loi ph hp: penicilin G; penicilin V v penicilin chm.
- Loi dit c vi khun tit beta-lactamaza c tc dng trn t cu nhn
vi penicilin nh penicilin M; oxacillin (bristopen); cloracillin.
- Loi ph rng: ampicillin; amoxylin.
- Loi dit c trc khun m xanh: ticarcillin; carbenicillin.
+ Tai bin:
 - Sc phn v: bnh nhn c th t vong ngay sau tim. Mc nh mn
nga, nn chng mt kh chu. Do vy cn phi th phn ng trc khi tim.
- Khng c p penicilin ln t chc no v gy co git ng kinh c
th cht ngi.
- Dng liu cao ko di c th gy au u, hng phn thn kinh do
ng amoniac no.
1.1.2. Nhm cephalosporin:
+ Tc dng: l khng sinh ph rng tc dng trn Gr (+) v Gr (-), t gy
c hn penicilin.
+ Ch nh: nhim khun huyt (do t cu hoc trc khun Gr (-) nh
proteus, trc khun coli); vim phi, vim ph khoa, bnh lu; vim mng trong
tim; vim tai-mi-hng. c bit thuc qua c hng ro mu no do dng
rt tt trong cc bnh nhim khun no mng no.
Sau y l cc dn xut v thuc c s dng trong lm sng:

Cephalosporin Dn cht Thuc s dng trong lm sng

Cephalexin Ceporex; keflex; cephalexin; sporidex; servispor.
Cephalosporin Cefalotin Intralotine
(th h I)
Cefazolin Intrazoline; kefzol; lyzolin.
Cefapirin Cephaloject.
Cephalosporin Cefuroxime Zinnat; Zinacef.
(th h II)
Cefamandole Mandol
Cefotaxime Claforan; cefotaxime; petcef; lyforan; cefatral;
Kalfoxim; cefacron; larcefoksym; tirotax; ceforin;
Ceftazidime Fortum; kefadim; ceftum; ceftidin;
Ceftriaxone Rocephine; oframax; cyfoxone; lyfaxone; trizol;
Pacefin; rofine;
Cephalosporin
(th h III) Cefoperazone Cefobis; medocef; cefoperazone

Cephalosorin Cefepime Axepim.

(th h IV)

Nhm cephalosporin khng c tai bin g c bit, tuy nhin m bo

an ton, nn th phn ng trc khi tim.
1.2. Khng sinh loi aminoglicosid:
Gm cc thuc: streptomycin; gentamycin; kanamycin; neomycin; amikacin;
amiklin; likacin; nitilmicin; netromycin; tobramycin; nebcin.
 Tt c cc khng sinh ny u c nhng im chung ging nhau v cu
trc ha hc v tnh cht sinh hc vi biu hin:
+ L khng sinh ph rng tc dng ch yu trn vi khun Gr (-). i vi vi
khun Gr (+) tc dng yu hn penicilin.
+ Khng hp thu bng ng ung.
+ c vi tai, thn. Khng dng cho ph n c thai; ngi suy gan, suy thn.
1.2.1. Streptomycin:
Do Waksman S.A. (1888-1973) chit xut t nm (1944) v nhn gii
thng Nobel nm 1952.
+ Ch nh: iu tr cc bnh v lao (lao phi; lao mng bng; lao tinh
hon) v mt s bnh khc nh nhim khun huyt; vim mng trong tim do
lin cu; dch hch.
+ Chng ch nh: khng dng cho ngi c phn ng vi streptomycin;
khng dng cho ph n c thai, ngi suy gan, suy thn.
+ Tai bin:
- Sc phn v: c th t vong, do vy cn phi th phn ng trc tim.
- Mc nh: mn nga; hi hp nh trng ngc, au tht ngc; nng
hn tn thng dy thn kinh s VIII biu hin nh tai, ic, ri lon tin
nh, chng mt.
+ Liu dng: ch dng duy nht 1 gr/ngy/tim bp tht. Khng c p
streptomycin ln vt thng s no v vt bng. C th dng ra bng
quang khi b vim; ra mng phi; mng khp.
1.2.2. Cc thuc kanamycin; gentamycin;
amikacin; amiklin:
+ Ch nh: tc dng ch yu vi Gr (-), do vy c s dng trong cc
trng hp vim bng quang, thn, nhim khun huyt, vim phi vim ph
qun; vim mng bng; vim ng mt; kt hp cng penicillin iu tr vim
mng trong tim do lin cu trng.
+ Chng ch nh: khi c phn ng vi cc thuc trn; khi c biu hin vim
dy thn kinh s VIII.
1.3. Khng sinh thuc nhm macrolid:
+ Gm cc thuc sau: erythromycin; oleandomycin; spiramycin (rovamycin);
azithomycin (zitromax); roxythromycin (rulid, roxodrin); lincomycin (1962);
clidamycin (1970).
+ Tc dng ca nhm macrolid ni chung l km hm s pht trin ca vi
khun v dit vi khun Gr (+), c ch nh trong cc bnh v tai, mi,
hng (rovamycin); vim bng quang sinh dc; tuyn tin lit; vim xng.
 Ngi ta xp lincomycin vo nhm macrolid v c ph tc dng v c ch tc
dng rt ging cc thuc nhm macrolid mc d lincomycin c cu trc khc hn
khng ging cu trc macrolid. Lincomycin phn phi mnh vo cc m k c
xng v dch sinh hc (vo dch no ty th rt km). Do tc dng trn Gr (+)
c bit vi t cu; lin cu; ph cu khi chng c da, xng. Dng lincomycin
liu cao v ko di c th gy vim rut gi c gi mc v a chy; c th gy
nhim nm candida, biu hin bun nn v nn. Khng dng cho ngi suy gan,
suy thn.
1.4. Khng sinh thuc nhm tetracyclin:
+ Gm cc thuc sau: clotetracyclin (aureomycin, biomycin); oxytetracyclin
(tetran, teramycin); tetracyclin, doxyclin.
+ Tc dng: tc dng trn Gr (+) v Gr (-); tc dng trn trc khun Gr (+)
ym kh v i kh.
+ Ch nh: trong cc bnh brucella; leptospira; ricketsia; vim ph qun.
+ c tnh: gy ri lon tiu ho, bun nn v nn. Gy thoi ho m gan
khi dng clotetracyclin. Khng dng cho ph n c thai hoc tr em di 7 tui
v thuc ngm vo men rng lm nh hng n s pht trin ca rng. Khng
dng cho ngi suy gan, suy thn. Thuc c th gy chng mt, mt thng
bng, tai.
1.5. Khng sinh thuc nhm quinolon:
Ch cp n loi quinolon mi cn c gi l th h th 2 hoc
nhm fluoroquinolon gm cc dn cht v cc thuc sau:

Thuc ang s dng Dng bo ch

Dn cht trong lm sng Vin (v) ng () hoc l
Ciprobay 500mg L truyn t/m.
Ciprofloxacin Cifran Dung dch nh mt
Ciloxan
400 mg 400mg ()
Peflacine 400mg (l)/100ml
400 mg 400mg ()/tim t/m
Pefloxacin Peflox L 100ml (400 mg)
truyn t/m
Oflocet 200 mg 200 mg/40ml
Ofloxacin Ofloxacin; 400 mg
Ofus 200 mg
Zanocin Dung dch nh mt
Nalidixic acid Negram fort 500 mg
 Norfloxacin Norbactin
Urobacid
Gatifloxacin Terquin 400 mg
Avelox 400 mg

+ Tc dng: tc dng ch yu trn Gr (-) c bit vi trc khun ng

rut.
+ Ch nh: trong cc bnh nhim khun tit niu; nhim khun huyt;
vim mng trong tim; bnh lu; nhim khun h hp.
+ Chng ch nh: khng dng cho ph n c thai, cho con b v cho tr em
di 15 tui; khng dng cho bnh nhn suy gan, suy thn; bnh nhn c biu
hin ng kinh.
+ Tc dng ph: c th thy bun nn v nn, ni mn nga.
1.6. Khng sinh thuc nhm imidazol:
Dn cht metronidazol hay c dng trong lm sng, gm cc thuc sau:
flagyl (vin ung); klion (vin) v dung dch metronidazol truyn tnh mch.
+ Tc dng: tc dng vi vi khun k kh Gr (-) v Gr (+). Thuc hp thu
nhanh qua ng tiu ha v t nng cao trong mu nh khi tim tnh mch.
Thuc c phn phi vo tt c cc m trong c th, t nng cao trong
dch no ty.
+ Ch nh: nhim khun ng rut; p xe no; vim mng no m; vim
phi; p xe phi; vim ph khoa, xng khp v m mm; vim mng trong tim.
Trong trng hp p xe no hoc vim mng no, nn kt hp vi nhm
cephalosporin v quinolon.
+ Tc dng ph: bun nn v nn; chn n; vim li, vim ming; ta li v
i lng. C th vim nhiu dy thn kinh chi. Khng dng cho bnh nhn
ng kinh. Thuc o thi qua nc tiu c mu xm.
1.7. a khng sinh vo dch no ty (DNT):
V hng ro mu-no l cn tr ln khng cho thuc vo c DNT bng
ng tim bp hoc tnh mch, do vy hn ch kt qu iu tr i vi
vim mng no hoc p xe no.
V th ngoi ng tim bp v tnh mch, ngi ta cn a khng sinh
vo DNT iu tr nhng bnh vim nhim nng no, mng no.
Theo ti liu Nga (1966) ngi ta a khng sinh vo DNT vi cc thuc
v liu lng nh sau:
+ Benzylpenixilin : tr em < 4 tui l 5000 n v.
tr 4 - 14 tui l 5000 - 8000 n v.
Ngi ln 10.000 n v.
+ Gentamycin: Tr em : 1 mg; ngi ln: 5-10 mg.
+ Streptomycin: < 1 tui : 8 - 10 mg; < 2 tui: 10 - 25 mg.
4 - 14 tui: 25 - 50 mg; ngi ln: 50 - 75 mg.
 Khoa Phu thut thn kinh - Bnh vin 103 s dng gentamycin v
streptomycin a vo DNT iu tr vim mng no m cho hn 100 trng hp
cho kt qu tt m khng c bin chng g c bit (khng gp trng hp no
ng kinh, ic, tai, lit 2 chi di nh mt s ti liu nc ngoi).
Hin nay, mc d khng sinh tt c th vo c DNT bng ng tim nhng
ngi ta vn kt hp a khng sinh vo DNT iu tr vim mng no nng.
2. Thuc an thn, chng co git, ng kinh.
Ng l hin tng sinh l bnh thng ca ngi v ng vt. Gic ng rt
cn thit bo v v phc hi chc phn t bo thn kinh sau nhng gi
lm vic cng thng v mt mi.
S iu ha gic ng thuc v vng di i (hypothalamus) v th li
nm thn no. Th li ko di t hnh no n trung no (diencephale), gm
2 phn: phn trc (phn i ln) c tc dng hot ho v phn sau (phn i
xung) c tc dng c ch v no.
Gic ng c thc hin khi th li b c ch, khng thu nhn kch thch
bn ngoi cng nh bn trong c th.
Do vy, mt ng c th do:
+ S c ch th li khng .
+ Hoc do s kch thch (hng phn) qu mc (hyperexcitabilite) chng
hn nh ung cph, ht thuc l, au rng hoc suy nhc thn kinh, suy nhc
c th, lo lng, s st, bc tc.
Thuc an thn (c bit l thuc ng) c tc dng ln th li bng cch c
ch v km hm nhng kch thch t bn ngoi i qua th li ln v no v
to nn gic ng ging nh gic ng sinh l.
2.1. Dn cht benzodiazepine:
+ Thuc hay dng trong lm sng: diazepam (seduxen; valium); tranxen;
noctran v stilnox (zolpidem).
+ Tc dng: an thn, gy ng, chng co git v gin c.
+ Ch nh:
- Khi bn chn lo lng, mt ng: ung 1 vin vo bui ti trc khi i ng.
- Co git ng kinh hoc co git ty sau chp ty cn quang hoc bnh l
ty: tim tnh mch hoc tim bp 1 ng seduxen hoc valium loi 10mg.
- Bnh nhn dy da ku la sau chn thng s no, sau m s no. Khi chc
chn khng c mu t ni s th c th dng liu ng min gm cc thuc sau:
promedon + amynazin + pipolphen. Trn ln 3 thuc trn, c th tim bp, tim
tnh mch hoc cho nh git tnh mch.
2.2. Barbiturat:
+ Thuc dng trong lm sng: phenobarbital (ng tim); gardenal (vin v
ng tim); veronal; luminal (vin).
 + Tc dng: l thuc gy ng v chng ng kinh c hiu qu. Thuc hp
thu nhanh v phn phi hu ht cc c quan nhng tp trung ch yu no,
gan v thn.
+ Ch nh: chng ng kinh (gardenal 0,1 1 vin/ngy; ung 7 - 10
ngy).
+ Nguyn tc dng thuc chng ng kinh l: tng liu mt cch t t v
khi t hiu qu ct cn th duy tr t 5 - 10 ngy; sau ung gim liu ri
ngng ung thuc. Khng c ngng ung thuc t ngt, c th xut hin
cn ng kinh lin tc.
Cp cu ng kinh nn tim gardenal 0,1 1 ng (bp tht hoc tnh
mch).
Hi ngh Quc t v chn thng s no t chc ti CHLB c (1981) v ti
Anh (1982) u cho rng: barbiturat c tc dng bo v no khi b thiu mu
v c tc dng lm gim p lc ni s. Do vy ngi ta khuyn nn dng barbiturat
trong CTSN nng. Einsenberg H.M. (1988) dng barbiturat liu cao cho
bnh nhn CTSN nng v kim tra p lc ni s (ALNS) nhn thy: ALNS
gim nhiu so vi nhm khng dng barbiturat l 2:1 v bin chng tim mch t
hn nhiu so vi nhm khng dng barbiturat l 4:1.
+ Ngoi cc thuc chng ng kinh kinh in ni trn, hin nay cn c
nhiu thuc chng ng kinh khc nh:
- Deparkin: vin nn 200 mg. Ch nh cho ng kinh ton th v ng
kinh cc b; st cao co git.
- Tegretol
- Trileptal
3. Thuc li niu.
Thuc li niu c tc dng o thi nc, cc cht c v c hoc hu c ra
khi c th bng ng niu. Do vy thuc c dng trong lm sng thi
c, cha mt s bnh ph thng (nh ph tim, ph do thn, ph do x gan v ph
no do chn thng v bnh l).
Tt c cc thuc li niu v mt s dung dch c tc dng li niu u c
im chung l: tc ng ln ng thn, lm thay i thnh phn ion (Na+, K+,
bicarbonat - HCO3-, v Cl-) ca nc tiu trong lng ng thn, lm gim ti hp
thu Na+ v ti hp thu nc, trn c s o thi nc v natri ra ngoi.
3.1. C ch tc dng:
C 2 c ch tc dng chnh sau y:
+ C ch lm tng p lc thm thu (ALTT) ca dch cu thn:
Mt s thuc v dch c trng lng phn t thp khi lc qua cu thn
khng b ti hp thu tr la, do vy lm tng ALTT dch lc ng thn. Nh
ALTT nn nc c gi li nhiu trong ng thn, lm cho ion Na+ trong nc
tiu ca ng thn long dn, Na+ khng c ti hp thu tr li, nh m lng
nc tiu bi tit ra ngoi nhiu ko theo c ion Na+ v Cl-.
Cc dch truyn nh mannitol, glucose; NaCl; ure; magn sulfat tc dng
theo c ch ny v c gi l li niu thm thu.
+ C ch lm gim ti hp thu Na+ ng thn:
Bnh thng 98 - 99% ion Na+ (khong 2500 mEq) c ti hp thu tr li
mu ng ln gn, quai Henle v ng ln xa, ng thi ko theo nc tr li mu.
Thuc furosemide (lasix); hypothiazit l cc thuc lm c ch s ti hp thu
Na+, K+ , Cl- nh vy lm tng o thi cc ion ni trn v tng bi niu.
Hypothiazit tng thi tr kali nn khi dng thuc li niu ny nn ung thm
vin kali.
3.2. Cc dung dch v thuc li niu dng trong
lm sng:
3.2.1. Glucose u trng (10%; 20%; 30%):
+ Tc dng chung: li niu, gii c, tng khi lng mu lu hnh do lm
tng huyt p ng mch.
Trc y ngi ta dng glucose u trng loi 30% chng ph no sau
chn thng, nhng hin nay ngi ta khng dng glucose u trng chng
ph no sau chn thng hoc sau phu thut no v glucose s lm tng thoi
ho ym kh no, gy ng nhiu axid pyruvic, axid lactic, gy toan ho
no lm cho tn thng t bo no nng hn v tri gic hi phc chm hn
3.2.2. Mannitol:
Mannitol l mt hexa-alcol ca ng mannoza c cng thc ho hc
CH2OH(CHOH)4 CH2OH c Wise B. v Charter N.(1961) a vo s dng
trong lm sng.
Mannitol l ch phm lm mt nc c hiu qu nht c s dng
chng ph no. Khi vo c th, mannitol khng gy c, phn b nhanh trong
t chc gian bo; hp thu ng thn rt t (khong 10%) v bi tit nhanh
qua thn.
+ Tc dng:
- Ko nc t gian bo ra lng mch do lm tng khi lng tun hon.
- Tng ALTT ng thn do tng bi niu.
- Lm gim ALNS 40 - 70% so vi ALNS ban u v ko di 2 - 4 gi.
Cc nghin cu ca Vasin N. Ya.(1984); ca Nath F. v Galbraith S. (1986)
cho thy: mannitol lm gim nht ca mu do vy tng cng dng mu ti
no, tng kh nng len li ca hng cu mang oxy ti t bo no; ng thi
mannitol lm tng t trng ca m no, gim s cha nc trong t bo do vy
tc dng chng ph no.
 + Ch nh: dng trong ph no do CTSN nng; sau khi m ly u no, p
xe no; dng trong suy thn cp, v niu do cn nguyn trc thn.
+ Liu dng: 0,5 gr - 1gr/kg trng lng c th. Truyn tc nhanh 120
git/pht. Sau 4 gi c th dng li.
3.2.3. Furosemide (lasix):
+ Tc dng: tc dng lm gim ti hp thu Na+ v Cl- ng thn, nh vy
tng bi niu.
Lasix c tc dng chng ph no trc ht l lm tng thm thu huyt tng,
ko nc t t chc no ra lng mch v tng bi niu.
Nghin cu ca Vasin N.Ya. (1984) cho thy: lasix c tc dng tt vi ph no
khi nng Na+ trong mu tng v khi ALNS tng cao > 30 - 40 mmHg; tc
dng km khi ALNS thp < 10 - 15 mmHg.
+ Ch nh: suy thn; ph do thn, x gan; ph do chn thng s no, sau m
no.
4. Thuc khng vim, gim au, h st.
C 2 loi thuc khng vim gim au:
- Loi khng c steroid (non - steroid).
- Loi c steroid.
4.1. C ch gy vim v gy au:
Prostaglandin l cht ch yu gy nn vim, gy au v gy thoi ho khp
ni chung v thoi ho khp ct sng ni ring. S hnh thnh prostaglandin c
th tm tt nh sau:
Cc cht ngoi lai nh: vi khun, c t, ho hc, khi vo c th s kch
thch gy ri lon mng t bo lm cho cht phospholipid mng t bo
(c bit l mng t bo bch cu) s sinh ra acid arachidonic. Di tc dng
ca cc men cyclooxygenase chng chuyn acid arachidonic thnh cht
prostaglandin (PG). S xut hin PG s gy au, vim, st v gy ngng tp
tiu cu trong lng mch.
Cc thuc nhm khng vim non-steroid khi vo c th s c ch men
cyclooxygenase lm cho men ny khng hot ng, nh vy m acid
arachidonic khng chuyn ho thnh PG. Cn thuc khng vim loi c steroid
s c ch men phospholipase A2, khng cho men ny hot ng (xem s di
y v s hnh thnh prostaglandin).

Phospholipides
(ca mng t bo)

Thuc
Men Phospholipase A2 steroide
(+)

c ch (-)
Acide arachidonic

Men
Cyclooxydase (+)
 Do vy cc thuc khng vim non-steroid u c chung tc dng l gim
au, chng vim, h st, chng thoi ho khp v chng ng vn tiu cu trong
lng mch.
Qu trnh thoi ho khp ni chung v thoi ho khp ct sng ni ring dn ti
3 hin tng sau:
+ Lm h hng mt sn ca khp.
+ Vim xung quanh khp v bao hot dch.
+ Pht trin cc gai xng (osteophytes).

c ch (-)
Cc thuc khng vim non-steroid gip cho cc khp khng b xung huyt,

Prostagladin Leucotriens
(cht gy au, vim, (gy hen suyn do co
Nhm
st, ngng kt tiu tht c ph qun; kch
Non-steroide cu trong lng mch) thch nhu ng rut)

bo ton c mt sn khng b ph hy, khng b thoi ho.

4.2. Cc thuc khng vim non-steroid:

+ Tc dng ph:
Cc thuc khng vim non-steroid ang c s dng hin nay u l cc
axit yu, hp thu nhanh qua ng tiu ho, c phn hy gan v thi tr qua
thn. Tc dng ph c th gp nh sau:
- Gy vim lot d dy, t trng v rut.
Nim mc d dy sn xut ra prostaglandin, c bit l prostaglandin E2 c
tc dng bo v nim mc d dy v nim mc ng tiu ha. Cc thuc non-
steroid c tc dng c ch men cyclooxygenase nn khng to thnh
prostaglandin, v th to iu kin cho HCl v pepsin ca dch v gy tn
thng nim mc d dy.
- Dng ko di nh hng n thn kinh trung ng nh hoa mt, nhc
u, ng g, mt ng, trm cm, kch thch, o gic, thay i tm thn.
- Mn nga, bun nn v nn.
- Hi hp nh trng ngc.
+ Ch nh:
- Vim khp mn tnh nh: vim a khp dng thp; vim ct sng dnh khp.
- Bnh vim khp cp tnh.
- Thoi ho khp gy au v bin dng khp gy tn ph.
- Vim quanh khp vai (vim ngoi khp).
 - Bnh gut.
- au ct sng c, ngc v tht lng do thoi ha.
- au thn kinh ta (thn kinh hng to) do thoi ho ct sng.
- Gim au sau chn thng, sau m, bong gn, bm gip phn mm do chn
thng.
- Gim au trong bnh rng.
+ Chng ch nh:
- Tin s d ng vi cc thuc ni trn.
- Tin s c biu hin vim lot d dy-t trng.
- Suy gan, suy thn
+ Nguyn tc khi s dng thuc l: ung trong hoc ngay sau ba n trnh
kch thch nim mc d dy. Ung nhiu nc khi ung thuc; ung thuc bo v
nim mc d dy nh maalox, cimetidin.
+ Sau y l cc dn cht v cc thuc ang c s dng trong lm sng:

Dn cht Tn thuc v hm lng Liu dng/ngy

Axit salycilic Aspirin; aspirin pH8 (vin 0,5). 2 vin.
aspgic (l 0,5 v 1 gr) 1 - 2 l/tnh mch
Hin nay khng dng
Pyrazolon Phenylbutazol; antipyrin; v gy gim bch
cu; suy tu; i
Pyramidon. mu
Indol Indomethacin; indocid; 2 - 4 vin.
indocin (vin 25 mg).

Felden 20 mg (ng); 1 - 2 ng/tim bp.

piroxicam; hotemin
Piroxicam felxicam; neotica; 2 - 4 vin.
Oxicam piricam
(vin 20 mg)
Tenoxicam Tilcotil 20 mg (l) v 1 l/tim bp.
vin. 2 vin.
Ibuprofen Advil (vin 200, 300, 2 - 3 vin.
400 mg)
Apranax (vin 275 v
550 mg);
Naproxen Apo-naproxen (vin 250, 2 - 4 vin.
350, 375, 500 mg)
 Propionic Profenid (l 0,1gr) 1 l/tim bp.
Vin 50, 25 mg 2 vin.
Ketoprofen Apo-ketoprofen (l 0,1gr)
Novo-keto-ec (vin)
Voltaren 75 mg () - vin 50 mg 1 - 2 /tim bp.
Diclofenac Diclofenac 75 mg () - vin 50mg
Dicloberl 50mg (v) 2 - 3 vin.
Apo-diclo; Clofon; Clovanc (v)
Axit Tiaprofenic Tiafen 300mg (vin) 2 vin/ngy.
Surgam 500 mg(vin)
Meloxicam Mobic: vin 7,5 mg v 15 mg. 7,5 mg 2 vin
15 mg 1vin/ngy
4.3. Khng vim steroid:
Corticosteroid l hocmon v thng thn c dng trong lm sng l:
+ Prednisolon.
+ Depersolon.
+ Metyl-prednisolon (solu-medrol 40 mg v 125 mg/tim bp hoc tnh
mch; depo-medrol 40mg).
+ Dexamethazon 5mg (vin v ng);
+ A.C.T.H. (hydrocortison 125 mg/l; synacthn 1ml/ng).
4.3.1. Tc dng ca corticoid:
+ To glucose t peptid do lm tng glucose mu v gim tit insulin. Do
bnh nhn i ng khng nn dng corticoid.
+ Tng ti hp thu Na+ v nc ng thn gy tng huyt p v ph.
+ Tng tit HCl v pepsin, lm gim sn xut cht nhy, gim tng hp
prostaglandin E1 v E2 l nhng cht c tc dng bo v nim mc d dy, v
vy dng corticoid c th gy vim lot d dy-t trng.
+ Lm chm lin so vt thng do c ch s pht trin t bo ht.
+ C tc dng chng vim, chng d ng v c ch min dch.
- Tc dng chng vim v chng d ng: corticoid ngn chn (hay cn gi l
c ch) men phospholipase khng cho chng hot ng. V men ny hot ng
s kch thch phospholipides ca mng t bo, gii phng ra cc histamin;
serotonin, cc leucotriens v prostaglandin (xem s trn).
- Tc dng c ch min dch: tc ng lm gim t bo lympho, gim kh
nng tp trung t bo lympho, bch cu n nhn v a nhn v tr vim; c ch
phn ng khng nguyn v khng th nh c tc dng gi c mnh ghp.
 4.3.2. Ch nh:
+ Suy thng thn cp v mn (bnh Addison).
+ Cc bnh thp khp, Luput ban h thng; bnh x cng ct bn lan
ta; bnh d ng; bnh thn h nhim m.
+ Dng sau ghp c quan chng loi b mnh ghp.
+ Vim thnh mch d ng.
+ Dng trong tn thng ty do chn thng; vim mng nhn ty, (synacthn
dng chng ph no do u no hoc tai bin mch mu no cho kt qu tt).
+ Ung th giai on cui.
4.3.3. Chng ch nh:
Trong trng hp vim lot d dy-t trng; suy gan, suy thn. Khng dng
cho ph n c thai v ang cho con b; nhim nm ton thn, qu mn vi
thuc.

ti liu tham kho

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