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（A）發生於四肢者較易有嚴重程度之傷害而發生於軀幹者較不會有嚴重程度之傷害
（C）因為肌肉壞死，釋出大量肌蛋白(myoglobin)而較容易發生急性腎衰竭
（D）傷及肢體者在進行擴創術時經常可發現即使淺層肌肉無恙在骨頭旁較深層之肌肉卻可能已產生壞死

神經

微血管壁滲透性（capillary permeability）上升

血中白蛋白偏低

25%

燒傷後血清中之濃度會增加

大量清水沖洗眼球

36%；8640 mL 乳酸鹽林格氏液（lactated Ringer’s solution）

(B)減少清創手術的次數
(C)減緩高代謝率（hypermetabolism）
(D)降低死亡率

肌球蛋白尿症（myoglobulinuria）

所有小面積燙傷皆可以自來水降溫

建立輸液管道

--Head injury( GCS, Brain CT, ICP and CPP)
--Brain tumor (Menigioma, astrocytoma, acoustic neuroma)
-- Pediatric neurosurgery (Hydrocephalus)
--Spinal disease( spinal stenosis, spondylolisthesis, metastasis, infection)
--Spinal cord injury( complete and incomplete)
--Peripheral nerve injury( CTS, ulnar nerve entrapment)

取最佳反應

睜眼反應（E）： 4分 病患能自行張開眼睛
3分 聽到別人說話而張開眼睛
2分 因為檢查者施以疼痛刺激而張開眼睛
1分 完全沒有睜眼反應
語言反應（V）： 5分 對時、地、人等定向問題可以正確回答
4分 雖可回答問題，但答案錯誤
3分 答非所問，但仍有語言結構
2分 能發出聲音，但無法了解其意思
1分 完全無法發出聲音
運動反應（M）： 6分 可以遵從指示作動作
5分 疼痛刺激時，手腳可向刺激處移動
4分 疼痛刺激時，肢體可回縮
3分 疼痛刺激時，肢體呈屈曲反射
2分 疼痛刺激時，肢體呈伸張反射
1分 身體完全無運動反應

4

瞳孔對光反射(pupillary light reflex)：
此反射是腦幹上段中腦的功能(II進III出)
眼角膜反射(corneal reflex)：
此反射是腦幹中段橋腦的功能(V進VII出)

前庭--動眼反射：
橋腦下端與位於橋腦和中腦之內側縱束
所構成(VIII進III,VI出)
作嘔反射(gag reflex)：
此反射是腦幹下段延髓的功能(IX進
IX,X,XII出)

有較長之聯絡徑路，必須有相當健全之
腦幹功能才能表現出來。當病人的頭由
正前位置突然被轉至一側時，此轉動之
動作刺激前庭系統之耳石或頸部之自體
感覺或二者都參與反射，經由內側縱束
之作用使兩眼仍處於正前方之位置，在
轉動瞬間不隨著頭部之偏向而一起偏向。

9至12分

急性腦膜下出血

50-90%
60% in aged; 90-100% in coagulopathy
Four hour rule
30% mortality if operation within 4 hrs; 90% mortality if surgery delayed > 4hrs
Functional survival (GCS>4) 65% if surgery within 4 hrs

(A) 在橫切面影像呈半月狀
(B) 在冠切面影像，可呈紡錘狀
(D) 其對大腦造成的腫塊效應，通常比硬腦膜外血腫的腫塊效應大

8/15

Symptoms
頭痛 噁心 嘔吐 視乳突水腫..
(Headache, N/V, papillary edema)
Signs
瞳孔放大無光反射 (pupillary dilatation, no light reflex)
去大腦或者去皮質姿勢 (decorticate or decerebrate
posture deterioration of neurologic exam)

心跳下降 血壓上升 呼吸不規則(HR↓, BP↑, irregular
RP)

頭部抬高(HOB 30o)
過度換氣(HPV , PaCO2 30 mmHg)
鎮定(Sedation)
利尿劑使用(Mannitol, Glyceral and Furosemide)
類固醇(Steroids)：不建議使用在頭部外傷，但是對於腦腫瘤者可使用
巴比妥鹽昏迷(Barbiturate coma)
低溫療法(Hypothermia)
腦室外引流(CSF drainage)
顱骨切除減壓 (Craniectomy)

MABP減ICP

(A) 降低體溫，避免發燒
(B) 維持高換氣量，降低血中CO2分壓至35 mmHg
(C) 使用Mannitol或Glycerol靜注

源自於神經上皮組織 (Tumors of neuroepithelial tissue)
源自於腦膜組織(Tumors of meningothial cells)
源自於週邊神經 (Tumors of peripheral nerves)
源自於淋巴組織或者血液 (Lymphomas and hemopoietic neoplasms)
生殖細胞腫瘤 (Germ cell tumors)
蝶鞍部腫瘤 (Tumors of the sellar region)
轉移性腫瘤 (Metastatic tumors)

一般處置(General care)
預防抽筋(Prevent seizure) : 抗癲癇藥物使用(Anticonvulsion drug)
預防腦水腫(Prevent brain edema) : Mannitol, Glyceral or furosemide
Steroid
降低顱內高壓(IICP control)

(B)起自蜘蛛膜帽細胞（arachnoid cap cells）
(C)男女性發生率相同
(D)良性腦膜瘤，不侵犯腦部

Second most common primary brain tumor
Slow growing, extra-axial, usually benign, arise from arachnoid (not dura)
Most commonly located along falx, convexity, or sphenoid ridge; may be multiple in 8% of cases
Hyperostosis
Calcification: psammoma bodies
Female: male: 1.8:1
Simpson grading system for surgery

Current MRI (>0.5 tesla) will show most meningiomas on T2WI (unless it is nearly totally calcified)
Give information regarding patency of dural venous sinuses (90%)
“Dural tail” is a common finding

(A)最常見的腦瘤是神經膠質瘤（glioma）
(B)星狀細胞瘤第四級（Astrocytoma, grade 4）
(C)病理切片可見細胞有絲分裂、內皮細胞增生、壞死（mitotic figure、endothelial proliferation、necrosis）

Grade Median survival
I 8-10 yrs
II 7-8 yrs
III 2-3 yrs
IV <1 yr

前庭神經

Misnomer: vestibular schwannoma as the preferred term from superior division of the vestibular nerve.
3 most common symptoms
Insidious and progressive hearing loss
High pitched tinnitus
Dysequilibrium
Antoni A (narrow elongated bipolar cells) & Antoni B fibers (losse reticulated)

Parinauds syndrome
Convergence, accommodation and “setting sun sign” (upgaze palsy + lid retraction)
Stereotactic procedure
May be used to ascertain diagnosis or to treat symptomatic pineal region cysts
Radiation treatment
Germinomas are very sensitive to radiation (and chemotherapy).

顱咽瘤 (craniopharyngioma)

From anterior superior margin of the pituitary
Solid and cystic components
Cholesterol crystals
Do not undergo malignant degeneration
Calcification
Plain x-ray: 85% in childhood; 40% in adults
Microscopy: 50%

Adults
Lung ca (44%)
breast (10%)
kidney (7%),
GI (6%)
melanoma (3%),
undetermined (10%)
Peds
Neuroblastoma, rhabdomyosarcoma, Wilm’s tumor

中風(Stroke, Hemorrhagic stroke)
動脈瘤 (Aneurysm, Subarachnoid hemorrhage)
動靜脈畸形 (Arteriovenous malformation)
頸動脈靜脈竇廔管 (Carotic-cavenous fistula)
Moyamoya disease

Putamen : 50%
Thalamus : 15%
Pons : 10-15%
Cerebellum : 10%
Cerebral white matter 10-20%

視丘（thalamus）

小腦

Lesions in cerebellar hemisphere
Ataxia of the extremities
Dysmetria
Intention tremor
Lesions in cerebellar vermis
Wide based gait
Truncal ataxia
Titubation

Putamen : 50%
Thalamus : 15%
Pons : 10-15%
Cerebellum : 10%
Cerebral white matter 10-20%

腰椎狹窄症 (lumbar spinal stenosis)

Hypertrophy of facets and ligmentum flavum
Most common at L4-5 and then at L3-4
Neurogenic claudication
Gradually progressive back and leg pain
Relieved at rest regardless of position
Responds to decompressive surgery

腰椎彎曲（Flexion）

Neurogenic claudication
Exaggerated waist flexion, possibly reduces lumbar lordosis, thereby reducing inward buckling of ligamentum flavum and also distracting facet joints

脊椎滑脫是由於一塊脊椎骨相對其下脊椎骨滑動的狀況

Anterior subluxation of one vertebral body on another, usually L5 on S1.
Grade I,II,III & IV: <25%, 25-50%, 50-75% & 75%-complete of subluxation
Spondylolysis: isthmic spondylolisthesis
Defect in the pars interarticularis
Defect in the neck of the “Scotty dog” on oblique LS-spine x-ray

80%~90%

Type Characteristics Stability
I Through tip, rare stable
II Through base of neck, most common Unstable
IIA Type II + large bone chips at fracture site Unstable
III Through body of C2 Stable

屈曲－牽開性骨折（flexion-distraction fracture）

(A)神經痛
(B)運動乏力（motor weakness）
(D)痙攣（spasticity）

Extradural: 55%
metastases
Intradural extramedullary: 40%
Meningioma
Neurofibromas
Intramedullary: 5%
Astrocytoma
Ependymoma

攝護腺癌

Most cause osteolyic
Lymphoma
Lung
Breast
Prostate
May be osteoblastic
In men: prostate Ca
In women: breast Ca

腰椎骨脫位（Spondylolithesis）

Complete transection – loss of all sensibility and voluntary movement below the lesion
Tetraplegia, paraplegia

Anterior cord syndrome
Posterior cord syndrome
Central cord syndrome
Brown-Séquard syndrome

Hyperflexion
Ant. Two thirds of the cord injury (ant. Spinal artery supply)
Paraplegia (bilateral)
Dissociated sensory loss : loss of pain & temperature with preserved posterior column function
The poorest prognosis

Direct penetrating contusion impaction, spondylosis with hyperextension
Preserve pain, temperature, and motor
Loss of joint position, vibratory, two point discrimination, and deep pressure; but light-touch preserved
Good prognosis

Acute hyperextension with pre-existing spinal stenosis
Weakness of upper limbs, lesser lower limbs
Acute sphincter dysfunction
Varying degree of sensory disturbance
Most frequent

2 分

Spinal cord hemisection (penetrating, epidural compression)
Contralateral finding : loss of pain & temperature
Ipsilateral Motor paralysis, proprioception loss

First goal is to protect the spine
Spinal shock
High dose methylprednisolone
Acute spinal cord injury within 8 hrs of trauma, loading dose 30mg/kg and maintenance dose of 5.4mg/kg/hr for 23 hrs
Major goal of the surgical procedures is to achieve adequate neural decompression and stabilization

中央脊髓症候群（central cord syndrome）
過度伸張損傷（hyper extension injury）
如果症狀未持續惡化，則可以先用下列何種藥物治療？
(A)大劑量methylprednisolone

胸廓痙攣（Spasticity）

(A)肛門周圍有感覺（Perianal sensation）
(B)肛門可自主收縮（Voluntary anal contraction）
(C)大拇趾可屈曲（Great toe flexion）

Any residual motor or sensory function more than 3 segments below the level of the injury
Sacral sparing
Sensation around anus
Voluntary rectal sphincter contraction
Voluntary toe flexion

IV drug abuse
DM
Hemodialysis
Immunosuppression: AIDS, chronic steroids use, ethanol abuse
Infectious endocarditis
Following spine surgery or invasive procedure
Elderly patients

Carpal tunnel syndrome ( median n. )
Tardy ulnar palsy
Nerve injuries, entrapments
Peripheral nerves tumors
Facial nerve palsy
Hemifacial spasm ( AICA vs. CNVII )
Trigeminal neuralgia ( SCA vs CNV )
Brachial plexus injury ( C4 ~ T1 )
Thoracic outlet syndrome ( subcl a, v, bra plexus )

正中神經（Median nerve

(A)患者夜眠時常因手掌麻痛醒來，甩動手部可以減緩症狀
(C)手腕極度屈曲或伸展可以誘發症狀
(D)嚴重者會有拇指外展短肌之無力

(A)最常見的位置在手肘
(B)在手肘處的尺神經壓迫必須和內側肱上髁炎（medial epicondylitis）區分
(D)尺神經在手肘部位受壓迫的幾種開刀方式中，並沒有那一種方式較好

Options
Simple nerve decompression
Nerve decompression and transposition
Medial epicondylectomy
Result not as good as with CTS, possibly due in part to the fact that patients tend to present much later (good 60%, fair 25%, poor 15%);

尺神經

Wasting of the first dorsal interosseous
Wartenberg’s sign: abducted little finger due to 3rd palmar interosseous weakness
Froment’s prehensile thumb sign: Adductor pollicis weakness
Claw deformity of the hand: 4th & 5th fingers hyperextended at the MCP joints and flexed at the interphalyngeal joints