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類風濕性關節炎之頸椎不完全脫位術後併發股神經及閉孔神經病變:病例報告

Combined Femoral Ncuropathy and Obturator Neuropathy in Rheumatoid Arthritis with Cervical Subluxation After Operation

摘要


類風濕性關節炎是一種慢性發炎性疾病,雖然它主要侵犯關節,但是系統性侵犯亦很常見,例如肺、皮膚、血液、心臟血管、及神經等,若侵犯到周邊神經,可以造成多種不同的臨床表徵。 本文報告一位67歲女性病人,類風濕性關節炎病史10年,在門診規則追蹤服藥,因為雙手及雙腳末端感覺麻木合併步態不穩,約兩個月之久,經神經外科醫師診斷為類風濕性關節炎伴隨第一第二頸椎不完全脫位。在接受第一第二頸椎後側脊柱融合術後,病人發現左下肢明顯較右下肢無力,左側膝伸直肌及股內收肌之肌力為2分,髖曲肌之肌力為4分,左大腿前內側有針刺感的異常感覺,四肢末端的感覺較差。肌電圖檢查呈現嚴重左側股神經病變及閉孔神經病變,及輕微週邊感覺神經病變。骨盆腔電腦斷層掃描檢查,僅顯示病患有子宮肌瘤,並未發現血腫、或其它異常。病人經過復健治療後,恢復情形良好,可以不需輔助行走15公尺,但長距離行走仍需藉助柺杖。 回顧文獻,類風濕性關節炎合併週邊神經病變雖曾被提及,但並沒有報告過手術後同時發生股神經病變及閉孔神經病變的病例。藉此一病例討論與文獻回顧,來瞭解其神經病變之原因,同時提醒避免此類病患長時間之壓迫、注意擺位,以防止發生壓迫性神經病變之後遺症。

並列摘要


Rheumatoid arthritis is a chronic inflammatory disease. Although it primarily affects joints, systemic involvement is frequent. Lung, skin, blood, cardiovascular system and nerve are often affected. Indeed, involvement of the peripheral nervous system may occur with a variety of clinical patterns. A 67-year-old woman suffered from rheumatoid arthritis for 10 years with regular medical control. Due to bilateral distal parts of hands and feet numbness, and gait disturbance for about 2 months, she was diagnosed of rheumatoid arthritis with C1-C2 subluxation by neurosurgeon. C1-C2 posterior spinal fusion was performed. But, the patient felt left lower extremity weaker than right one then. The muscle strength of left knee extension and thigh adduction was poor and hip flexion was good. Paresthesia was found over left anterior medial thigh and hypesthesia was found over distal part of four limbs. Electrodiagnosis showed severe left femoral and obturator neuropathy and mild peripheral sensory neuropathy. Pelvic CT scan showed no hematoma nor tumor. After rehabilitation, the patient could ambulate independently for 15 meters without device and with a regular cane for longer distance. Rheumatoid arthritis with peripheral neuropathy have been documented in the medical literatures, except femoral neuropathy together with obturator neuropathy. This case report aims at reminding the clinician how to prevent complication of compressive neuropathy.

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