VIETNAM MEDICAL JOURNAL N°2 - APRIL - 2018
TAI LIEU THAIVl KHAO
1. Bd Y te (2013), Bao cao chung t6ng quan nganh yte n3m 2013.
2. Benh vien da khoa tinh Nam Djnh (2017), Bao cao tong ket cong tac benh vien nam 2016.
3. Ta Van Dat (2010}, ThUc trang sff dung the bao hiem y te"cua ngUOt dan tai 4 phiicSnglxa thanh pho Phu Ly, tinh Ha Nam, nam 2010, Luan van thac sT y te cong cong, Tru'dng Dai hoc Y That Binh
^. L6 Thi Minh Hue (2014), Tht/c trang cong tac
kham chiJa bSnh bao hiem y te tat Benh vi^nijla khoa tinh Thai Binh nam 2014, Luan van thac sfy te cong cong, TrUdng Dat hoe Y Du'cfc Thai Bi'nIi.
5. Quoc hoi (2014), Luat so 45/2014/QH13 ve ' ^ doi, bo sung mpt so dieu cua Luat Bao hiem ytf"
6. Ngan Do, Juhwan Oh, and Jin-Seok tee (2013), Moving toward Universal Coverages Health Insurance in Vietnam: Barriers, FaciiitatB Factors, and Lessons from Korea, Korean Lessol for Universal Health Coverage in Vietnam.
eAc DIEM HINH ANH CONG Hird-NG xir (y BENH NHAN Xa CITNG RAI RAC THE TOY SONG
T6IVI TAT
Cd sd: Benh xd cffng rai rac (XCRR) la mot benh vtem mat myelin ctia he than kmh trung Udng, xay ra ehu yeu d chat trang cija nao, ttly, hoac day than kinh tJii giac. Ton thUOng ttjy thu'dng gap trong benh XCRR nhuhg khong de de phat hien ton thu'dng tren cpng hifdng tff va phan biet vdi c^c ton diUdng tuy do cae nguyen nhan khac. Myc tieu: OUa ra mgt so dac diem ve hinh anh eong hu'dng tff (CHT}d benh nhan xd cffng rai rac c6 tonJ:hu'dng tuy song. Phu'dng phap: Nghien cffu dac diem lam sang va hmh anh hgc tren 33 benh nhan chan doan XCRR theo tieu chuan MacDonald 2010, du'dc dieu tn ngi tru tai Khoa Than kinh Benh vien Baeh Mai vi mot ddt tten trien co tan thu'dng ttJy song. Ket qua: Ton thu'dng tiJy co hay gSp hdn ton thu'dng tOy lurig. Hinh anh chup cong htJ^ng tff tuy co the binh thu'dng (15,2%) dii dmh khu ton thudng tren lam sang ro rang. Teo tuy co the gap (1/33) 6 benh nhan XCRR tai phat nhieu ddt. Da so cac ton thffdng tity trong XCRR eo chieu dai du'di hai than dot song (78,18%) va chieu rgng nho hdn nffa be ngang eot tuy (74,55%).PhLi tiiy ft gap trong ton diUdng tity cita XCRR (18,52%). SLT bat thuoc ctJa ton thu'dng tren phtm cgng hudng tff the hien ton thu'dng mdt xuat hien trung binh du'di 1 thang. Khong thay sU khac biet ve tinh trang tan tat d cac nhom benh nhan CO so iffdng va vi tri ton thu'dng tity khac nhau tren cpng hu'dng tff. ICet lu^n: Chtjp cpng hu'dng tff ttJy song CO tiem thuoe da quang tffcan thiSt de chan doan b|nh XCRR.
Tdkhdaixd cdng rai rac, ttjy song, cpng hu'dng tff SUMMARY
MRI CHARACTERISTICS I N PATIENTS WITH MULnPLE SCLEROSIS OF THE
SPINAL CORD
*Benh viin Badi Mai
**DaihgcY'HaNdi
Chju tracti nhiem chinh: Vo Hong KhSi Email: drvohongkhoiigiyahoo.com.vn Ngay nh|n bai: 3.2.2018 Ng^y phan bien khoa hoc: 30.3.2018 Ngay duyet bai: 9.4.2018
Vo Hong Kboi*, Ho Thi Dung**
Aim: multiple sclerosis (MS) is a demyelinating disease of the central nervous system which appears mainly in the white matter of tjrain, spinal coixl, or optic nerves. Spinal cord lesions are common in multiple sclerosis but it is not easy to detectand to distinguish them from other causes. Methods: To comment on magnetic resonance imaging(Hlil) characteristics of multiple sclerosis patients with spinal cord involvement. Results: Lesions incervtcal spinal cord are more common than in lumbar spinal cord, Spinal cord MRI can be normal (15.2%). Spinal cord atrophy might occur in patient who had many attacks.
Almost of spinal cord lesions were less in two vertebral bodies (78.18%)) and less in half width of the medullary canal (74.55%). Medulla edema was not common (18.52%). Enhancement on MRI showed n&v lesions with an average age of less than one month, No difference in clinical disability was found in ttie patient groups with the number and location of spinal cord lesions on the MRI. Conclusions:Magnetic resonance imaging (MFU) was very necessary to accurately diagnose multiple sclerosis.
Keywords: multiple sclerosis,sptnal cord, Magnetic resonance imaging (MRI)
I.DyBkTVANDE
Benh XCRR la mot benh viem mat myelin ciia he than kinh trung ffdng, xay ra chu yeu d ctat trang ciJa nao, tuy, hoac than kinh thj giac, gay nen nhieu trieu chiiVig than kinh tdn thffdng thanh nhieu ddt, man t i n h [ l ] .
Ton thffdng tuy thffdng gap trong lam san^
benh XCRR, dae biet d quan the ngffdi ch§u A.
Dd ta dang gay tan tat nhat cua benh do si/twi phuc thffdng khdng hoan toan va tau dai. Ton thu'dng tuy song cd the la ddt benh^dau tien, nhffng cung cd the la bieu hien cija mot ddt mdi trong tten trien cua benh. Trieu chffng lam sang cua ton thffdng tuy trong XCRR vo eiing da dang, bat ky hot chffng tdn thffdngJtuy kinh dien nao cQng cd the la bieu hien cua tdn thffdng tuy trong XCRR. Vi vay chup cong hffdng tff (CKT) tuv
TAP CHl Y HOC VIET NAM TJiP 465 - THAHG 4 - SO 2 - 2018 song khdng chi cd vai trd phat hten tdn thffdng ma
cdn giup loai trd cac can nguyen khac.
Tlieo tieu ehuan r«lcDonald 2010[2], tdn thffdng tiiy song la mpt trong bon vj trf tdn thffdng dien hinh cua XCRR tren hinh anh CHT.Tuy nhien viee phat hien tdn thu'dng tren eong hffdng tff tuy sdng kiiong d l dang, mat khae cd rat nhieu to'n thffdng d tuy song cd bleu hten lam sang va hinh anh cdng hu'dng tff tffdng tff ton thu'dng tuy trong XCRf^.
Nhien effu eija chiing tdi nham mue dich md ta dac diem lam sang va hinh anh cdng hu'dng tff d tienh nhan XCRR cd ton thu'dng tiJy song.
Dffdi day chijng tdt xtn du'a ra mdt sd dac dtem ve hinh anh cpng hffdng tff d benh nhan XCRR ed tdn thffdng tiiy song.
II. D 6 I TirpNG VA PHU'aNG PHAP NGHIEN CUU 1 . D O I tu'dng nghien cu'u: Chung toi tten hanh nghien cffu 33 benh nhan du'dc chan doan xac dinh XCf^^ theo tteu chuan l^cDonald 2010, vao Khoa Than kinh Benh bien Baeh l^al dieu tri npi trij vi mpt dpt tien trien cd ton touting tuy sdng.
2. Phu'dng phap nghien cu'u: Chung tdi tien hanh nghien effu theo phu'dng phap cat ngang md ta. Doi tffcfng nghien cffu dffdc hdi benh, tham kham lam sang va danh gia tinh trang tan tat theo thang diem Kurtzke tai hat thdi diem vao vien va ra vien, dong thdi dffdc chup cpng hffdng tff cot song bang may c^ng hffdng tff 1,5 Tesla tai vj tri theo djnh khu tdn thffdng tren iam sang.
ML KETQUA NGHIEN CO'U
1. Vj tri t»n thu'dng tuy tren cong hu'dng tiT Bing 1: Vi in ton ihUdng tdy iren cdng hudng td
Vj tri ton thu'dng
Co Lutiq ThSt luHq Binh thu'dnq
Teo tuy
So benh nhan
17 10 0 5 1
Ti l# % 51,5 30,3 0 15,2
3 - 27/33 (81,8%) benh nhan dffdc phat hien cd ^ n thffdng tren hinh anh cpng hu'dng^tff tuy.
Vi tri tdn thffdng hay gap nhat la d tuy ed chiem 51,5%, sau dd den tiiy iffng ehiem 30,3%.
- 15,2% benh nhan cd hinh anhepng hffdng tff tuy tai vj tri djnh khu tren tam sang la binh thffdng.i/33 benh nhan cd hinh anh teo toan bp tuy Iffng.
2. D $ dai ton thu'dng tiiy tren cong hu'dng tit
Bing 2: Bg dai tdn ihUdng tuy iren cdng hudng td
Kich thffde tdn I Tren hai than Dffdi hai than til ffdng dot sdng dot song So ton thffdng
Ty le % 12 21,82
43 78,18 78,18% tdn thffdng ed chieu dai dffdi hai than ddt sdng va 21,82% tdn thffdng cd chieu dai tren hai than ddt sdng.
3. Chfeu rong ton thu'dng tuy tren phim cpng hu'dng tiJ'
Bing 3: Chiiu rgng tdn thUdng tuy trin phim cdng hUdng id
Kich thffde tdn thffdnq Sdtdn thu'dng
T y l e
Du'di nffa be nqanqcdt tiiy
41 74,55
Tren nffa be nqanqcdttuy
14 25,45 - 74,55% tdn thu'dng ed chieu rong nhd hdn nffa be ngang cdt tuy va 25,45% ton thffdng cd ehieu rdng hdn nffa be ngang edt tiiy.
4.Tin hieu ton thUdng tren xung T I W Bang4: Tin hieu ion ViUdng tren samg TIW Tin hieu T l
Giam tin hieu Dong tin hieu Tanq tin hieu
Sd lu'dng ton thu'dng
41 14 0
Ty le o/o 74,55 25,45 0 100% ton thu'dng la dong hoac giam tin hieu tren xung T I W .
5. M O I lien quan giCi'a thdi diem chup vdi hinh anh cdng hu'dng tCt
Bang 5: Mdi lien quan gida thdi diem chup vdi hinh inh cdng hu'dng id Thdi gian tff khi
khdi ghat ddt tien trien den luc
chup CHT Dffdi 1 thang Tren 1 thang
Tong
So benh nhan cd tdn
thffdng ngam thudc
14
So benh nhan khdnc
cdtdn thffdng ngam thudc
12 - Tong
13 So benh nhan cd ton thffdng ngam thuoc tren CHT tuy khac biet cd y nghTa thdng ke d hai nhdm benh nhan chyp CHT trffdc va sau 1 thang tff thdt diem khdi phat ddt tten trien.
6. Tinh chat phu tuy Bing 6: Phu tuy Tinh chat phij tuy So benh nhan
Ty le %
Co 5 18,52
Khong 22 81,48 81,48% benh nhan khdng phii tuy, va 18,52% benh nhSn cd phii tiiy.
7. M6ii lien quan giu'a tinh trang tan tat vdi vj tri ton thu'dng tuy
VIETHAM MEDICAL JOURNAL H°2 • APRIL - 2018
Bing 7: Mdi liin quan gida tinh trang tin iitvdi vi tri tdn thUdng tuy
Oiem Kurtzke
tmng binh Vao vien Ra vien
Co 6,5 3 4,8
2 Lirtig
6,63 4,75
Cova limg
6,5 4,5
Binh thu'dng
6,0 4,0
Teo tuy
8 8
P 0,9 15 0,4 42 Khdng cd sff khac biet ve tinh trang tan tat d cae benh nhan cd tdn thffdng tiiy tat eac vi j:ri khac nhau tren cdng hffdng tff d ca hat thdi diem vao vien va ra vien.
8. Moi lien quan giu'a t m h trang tan tat vdi so lu'dng ton thu'dng tren phim CHT tiiy
Bing 8: Mdi liin quan gida tinh trang tin tit vd/sd IUdng tdn OiUtdig t/in phim c^ng hudng tdtiy
Diem Kurtzke I^dt ton Nhieu ton tmng binh thffdng thffdng ^
Vao vien Ravien
6,39 4,17
6,64 0,751 5,08 0,231 -Khdng cd sff khac biet ve tinh trang tan tat d hat nhdm benh nhan cd mpt tdn thffdng tuy va nhieu ton thffdng tuy d ca hai thdi diem vao vien va ra vien.
IV. BAN L U A N
XCRR tff tau da dffdc menh danh ta "ke dai bat chffdc" cua chuyen nganh Than Ktnh vi tinh da dang trong bleu hten tam sang va viec chan doan sdm va chinh xae dffdc coi nhff mot thach thiit vdi cac thay thuoc lam sang. Cd nhteu he tteu chuan chan doan da dffdc ra ddi vdi muc didi md hinh hda chan doan XCRR. Dac diem chung ciia cac tteu ehuan nay la chffng minh sff rai rac theo khdng gian va thdt gtan ciia benh.
Ngay nay nhd sff phat trien ciia cac phffdng tien chan doan hinh anhvtee chan doan trd nen de dang va sdm hdn.
Trong nghien cull ciia chung tdi, tdn thffdng d tiiy CO hay gap hdn tiiy iffng, vj tri tdn thffdng d hjy ro ehiem 51,5%, tuy tffng chiem 30,3%.
Ket qua nay cung phu hdp vdi Klawiter. E. C va cs, khi tien hanh nghien cffu tren 20 benh nhan XCRR cd tdn thffdng tiiy song cho ket qua 75%
ton thffdng tiiy cd, 15% ton thffdng tiiy Iffng va 10% tdn thffdng ca tiiy cd va tuy lffng[3]. Trong nghien cffu nay chiing tdi chffa the chup CHT tiiy toan bp tff CO den Iffng va that iffng tren ciing mdt benh nhan tai ciing mpt thdi diem, ma ehi cd tiie tien hanh chup tai mpt khu vu'c nhat djnh trong mot ddt tien trien theo dinh khu ton
thffdng tren tam sang. Vtec nay cd the dan den bd sdt cac thffdng tdn cu, tham lang hoac biei hien lam sang khdng rd rang.
Trong nghien cirtj ciia chung tdi 15,2% benh nhan cd hinh anh CHT tiiy tat vi tri djnh khu fren lam sang la binh thu'dng. Sff khac biet giiJa iam sang va hinh anh cd the dddc giai thieli mgt phan bdi vat han che. Tuy sdng la mot cau tnic cd kich thu'dc nhd, de di ddnghdn naovl \ ^ danh gta tdn thu'dng tren cpng hu'dng tuy luaiig ddi khdkhan. Hdn nffa vdi dd phan giai 1,5 Tesla ciia may cdng hffdng tff viec khdng phat hien la nhffng tdn thffdng cd kfch thffde nhd d tiiy song la dteu de hieu, hdn nifethdi diem ehup CKT d the anh hffdng den dp nhay trong phat hien ton thffdng do mot so tdn thffe(ng trong XCRR co ttie hdi phuc tff nhien hoac do dieu trj.Ngoai ra cac ky thuat cong hu'dng tff thdng thffdng co tlie khdng giat thi'ch dffdc toan bd qua trinh benti If vi nhffng hieu biet vB cd che iDenh sinh va cd die hdi phuc cua mang xd cirtig cdn nhteu hgn die.
Nhutig nam gan day, ngu£n ta da sff dung die Vj thuat CHT pho, CHT chuyen djch tff, CHT ktiuech tan, CHT ehffc nang,...de cd thehleu biet tot hdn ve dien bien cua t>enh va danh gia htSu qua dieu trj,
Cd nhieu nghien cffu ghi nhan su" teo tity nht/
mpt dien bien l a t yeu d benh nlian XCRR tai phat qua nhieu ddt[4-5]. Trong nghien cult eiia diiing tdi cd 1/33 benh nhan cd hinh anh teo toan \A tiiy Iffng. Day la benh nhan bi benh tren 10 nam, c» 13 ddt tat phat vdi nhieu ddt ton thddng tfy sdng. Nhff vay mpt benh nhan XCRR cd nliieu ddt tien trien tdn thffdng d tiiy sdng cd the dan tdi teo tuy sdng. Tuy nhien mudn chffng minli dteu nay can cd nghien euli sau hdn, ed mau Idn hdnva theo dot benh nhan lau dai.
Trong nghien ciTu ciia chung tdi, 78,18% ton thffdng tiiy cd ehieu dat dffdi hai than dot song va 74,55% ton thffdng cd chieu rdng nho titJn niia be ngang cdt tiiy. Cd khoang 21,82 - 25,45% cae tdn thffdng cd kfch thffde khong dien hinh cita tdn thffdng tiiy trong XCRI^do chiing tdi chu^ phan dmh rd rang dffdc th^ Viem tiiy-thj than kinh vdi tienh XCRR cd ton thii^ng tiiy. Theo Kira va cs nghien culi tren 1493 liinti nhan d Nhat Ban cho thay t i te cua the viem tuy thj than kinh trong XCRR la 53,'3%[6].
Trong nghien cffu ciia chung tdi, 81,48%
benh nhan khdng cd phii tuy. Ket qua nay cung ptiii hdp vdi nghien cirtj ciia Nguyin Van Tuan[7iva cac tac gia khae tren the gidl khi dio rang the viem tiiy-thj than kinh hay benh Dffljc thffdng cd phii hjy ntiteu hdn eac ton thffdng tity
108
TAP CHi Y HQC VliT NAM TAP 465 - THANG 4 - SO 2 - 2018 khae trong XCRR ndi chung.
Trong nghien cffu ciia chiing tdt sd benh nhan cd tdn thffdng ngam thudc tren cdng tiffdng tff tiiy khac biet cd y nghTa thdng ke d hai nhdm benh nhan chup cdng hffdng tff trffdc va sau 1 thang tff thdt diem khdt phat ddt tien trien.Viec ngam ttiudc ddi quang tff ciia ton thffdng tiiy phan anh tinh trang ton thffdng ciia hang rao mau-nao. Theo cd che benh sinh, siTtdn thu'dng nay xay ra trong khoang thdi gian trung binh 1 thang tff Idii bat dau ddt tien trien. Nhu' vay viec tiem thuoc dot quang tff giup xac djnh dffdc tdn thudng eu hay tdn thift^g mdi tren cdng hu'dng tff.
Ket qua nghien cffu cua chung tdi cho thay khdng cd mot lien quan ve tinh trang tan tat d cae benh nhan cd so Iffdng va vj t r i ^ n thffdng tuy ktiac nhau tren CHT. Dieu nay cd the giai thieh do thang dtem danh gta tinh trang tan tat (EDSS) d benh nhan XCRR tren 8 he thdng chirc nang gom trieu chirhg bd thap, than nao, tieu nao, ed trdn, cam giac, t r i tue,... chff khdng chi danh gia rieng cho ton thffdng tiiy sdng.
V. K i r LUAN
Xd cuTig rai rac la mdt benh cd trieu chirtig lam sang da dang, xay ra d nhieu vj tri tren he than kinh trung ffdng. Chup cdng hu'dng tff nao va tiiy sdng la phffdng tien dac lire giup ehan doan benh.
Ve dac diem hinh anh cdng hffdng tff tiiy song, tdn thffdng tuy co hay gap hdn tdn thffdng hJy Iffng. Cong hffdng tff tuy cd the binh thffdng (15,2%) du djnh khu tdn thffdng tren tam sang ro rang. Teo tiiy cd the gap (1/33) d benh nhan
XCRR tai phat qua nhteu ddt. Da so eae tdn thffdng tiiy trong XCRR cd chieu dai du'di hai than dot sdng (78,18%) va chieu rdng nhd hdn nffa be ngang cdt tiiy (74,55%). Ptiii tiiy it gap trong tdn thffdng tiiy ciia XCRR (18,52%). Sff bat thudc ciia tdn thu'dng tren phim^cdng hffdng tff the hien tdn thffdng mdi cd tudi trung binh dffdi 1 thang. Khdng tlm thay sff khac blet ve tinh trang tan tat tren tam sang d cac nhdm benh nhan cd so tffdng va vj t r i tdn thffdng tiiy khac nhau tren cpng hu'dng tff.
TAI U € U T H A M KHAO
1. Daniel D. Tru'dng, Le DuTc Hinh va N. T. Hung (2004). Than Kmh Hpc Lam Sang, Nha xuat ban y hoc. Ha Npi.
2. Polman. C. H, Reingold. S. C, Banwell. B et al (2011). Diagnosdc criteria for multiple sclerosis:
2010 revisions to the McDonald criteria. Ann Neurol, 69(2), 292-302.
3. Klawiter. E. C, Benzinger .T, Roy. A et al (2010). Spinal cord ring enhancement in multiple sclerosis. Arch Neurol, 67(11), 1395-1398.
4. Gilmore. C. P, DeLuca. G. C, Bo. L et al (2005). Spinal cord atrophy in multiple sclerosis caused by white matter volume loss. Arch Neurol, 62(12), 1859-1862.
:». Horsfleld. M. A and Filippi. M (2003). Spinal cord atrophy and disability in multiple sclerosis over four years. J Neurol Neurosurg Psychiatry, 74(8), 1014-1015.
6. Kira. J. I and Ishtzu. T (2008). Multiple sclerosis in Japan: nationwide surveys over 30 years.
Neurology Asia.
7. Nquyen Van Tuan (2011). Nghien effu mpt so dSe diem lam sang va can lam sang benh xd cuhg rai rac tai benh vien Bach Mai, Luan an Tien sT Y hpc, \flen nghien cuXi khoa hoc Y diidc lam sang 108.
HIEU QUA DIEU TRI P H A U THUAT LCSC LOI TRUaC BANG THAY THAN DOT SONG NHAN TAO
Nguyen XuSn Dien*, Nguyin Cdng To**, Khirong Van Duy*
T A M T A T ^°"9 "'^='" ^^°^ '^^^' 9'^" ^^ 1/2015 den 30/9/2017 tai l U M I M L _ _ . ^ - ^ BV Phoi Trung u'dng. Danh gia hteu qua tru'dc va sau Mtic i^u nghien cuii: Danh gta ht?u qua dieu^tri ^ g ^^^^ ^^ ^g^. ^^^ ^_^^^ y^g ^ ^ ^ ^g HH ^ j ^ ^Q^
phiu thuit LCSC loi tri/de bang thay^ than dot song ^ ^ ^ ^^ ^g jO^ g^ ^_ Ket qui: 31 benh nhan, nK=„ f.« ^ . .,K^„„ . , „ / „ ^ ^ « « nh.n nnh.^n riAif ^4 nam va 7 nff, tudi trung binh 46,5 ± 15,9. Hieu qua giu'a nhom can thiep vdi nhdm chffng gom: VAS 1 tuan sau mo: hot kho chiu (9,1%), khong thoai mai (17%), rat dau (100%), dau khiing khiep (100%), VAS ian kham cuoi eiing: hdi kho chju (10%), khong thoai'mai (39,9%). JOA 1 tuan sau md: mffc nhe 41,9%; mffe nang 50,4% va la kham eua cijng mffc nhe (72,5%), rhffe nang (74,4%). Mffe do liet ASIA: 1 tuan sau mo A (100%); B(25,l%); C(66,l%);
0(71,1%); E{33,2%): ian kham cudi cung D (50,3%);
E(9,2%): Goe gii 1 tuan sau md: mffc nhe 41,9%;
mffe nSng 50,4% va lan kham cuoi cung: mffe nhe nhan tao. Odi tddng va phUdng phip nghien cdU:
gSm 3 i benh nhan LCSC dUde ehia 2 nhdm ddi ehffnp (chi ghep xffdng t u than) va can thiep (thay than dot
*Binh viin Phoi Trung udhg
**Tn/dng Dai hpc r Hi Ngi ^ ^ Chju t r k h nhiem chinh: Nguyen Xuan Dien Email: [email protected] Ngay nhan bai: 18.2.2018 l^gay phan bien khoa hpc: 30.3.2018 Ngay duyet bai: 11.4,2018
