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Pod Med III > 1) Introduction to Lower Neurology > Flashcards

1) Introduction to Lower Neurology Flashcards

1
Q

Each axon is surrounded by

A
  • Endoneurium
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2
Q

Axons bundled into

A
  • Fascicles
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3
Q

Fascicles are held together by

A
  • Perineurium
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4
Q

Bundles of perineurium encased nerved form

A
  • Nerve proper

- Held together by the epineurium on the outside

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5
Q

Each nerve fascicle/fasciculus is a bundle of

A
  • Funiculi
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6
Q

Prolongation of nerve cytoplasm

A
  • Axonlemma
  • Axoplasm
  • Axoplasmic flow
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7
Q

Axonlemma

A
  • Very thin outer layer
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8
Q

Axoplasm

A
  • Viscous material contained within axonlemma
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9
Q

Axoplasmic flow

A
  • Transmit substances ante- and retrograde direction
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10
Q

Cellular process responsible for movement of mitochondria, lipids, synaptic vesicles, proteins, and other organelles toand from a neuron’s cell body

A
  • Axonal transport

- Axoplasmic transport/flow

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11
Q

Myelin is produced by

A
  • Schwann cells

- Interrupted by nodes of ranvier

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12
Q

Axon potential carried via

A
  • Saltatory conduction

- Rate of conduction is proportionate to nerve diameter

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13
Q

Dorsal nerve roots carry

A
  • Sensory neural signals to the central nervous system (CNS) from the peripheral nervous system (PNS)
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14
Q

Dorsal root ganglion (DRG)

A
  • Association with neuropathic pain
  • Emerge from the dorsal root of the spinal nerves, carrying sensory messages from various receptors
  • Pain and temperature towards the central nervous system for a response
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15
Q

Afferent neurons

A
  • Sensory nerves
  • Carry signals to the brain and spinal cord assensory data
  • Neuron’s response: send an impulse through the central nervous system
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16
Q

Efferent neurons

A
  • Motor nerves

- Carry neural impulses away from CNS toward muscles to cause movement

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17
Q

A fibers (2-22 microns)

A
  • Myelinated afferent and efferents
  • Alpha
  • Beta
  • Gamma
  • Delta
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18
Q

A alpha fibers

A
  • Largest

- Motor, proprioception, and reflexes

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19
Q

A beta fibers

A
  • Muscles
  • Touch
  • Proprioception
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20
Q

A gamma fibers

A
  • Muscle tone
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21
Q

A delta fibers

A
  • Pain and temperature
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22
Q

B fibers

A
  • Preganglionic autonomic nerves
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23
Q

C fibers (0.5-1 micron)

A
  • Poorly or unmyelinated nerves
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24
Q

Nerve fibers are classified according to

A
  • Diameter
  • Degree of myelination
  • Speed of conduction
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25
Q

Group A fibers

A
  • Large diameter
  • Myelinated
  • Somatic sensory and motor fibers
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26
Q

Group B fibers

A
  • Intermediate diameter

- Lightly myelinated `ANS fibers

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27
Q

Group C fibers

A
  • Smallest diameter

- Unmyelinated ANS fibers

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28
Q

Loose connective tissue layer about an axon

A
  • Endoneurium
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29
Q

Endoneurium inner layer

A
  • Outside and around Schwann cells
  • Myelinating cell of the PNS
  • Dips at nodes of Ranvier
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30
Q

Endoneurium outer layer

A
  • Does not “dip”

- Blood-nerve barrier

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31
Q

Perineurium

A
  • Binds together fascicles of endoneural sheaths
  • Layers proportionate to number of fascicles within
  • Contain “tight junctions”
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32
Q

Perineurium tight junctions

A
  • Possess unique diffusion properties

- Create barrier against infectious agents

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33
Q

Epineurium ancases perineurium covered fascicles and contains

A
  • Collagen and elastin fibers
  • Mast cells and fibroblasts
  • Lymph vessels
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34
Q

Class I neuropraxia (Seddon’s)

A
  • Transient loss of conductivity
  • Motor fibers very susceptible
  • Recovery within days to weeks
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35
Q

Class II axonotmesis (Seddon’s)

A
  • Axons damaged but the neural tube is intact
  • Wallerian degeneration occurs
  • Regeneration: 1 – 2 mm/day
  • Presence of Tinel’s sign
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36
Q

Class III neurotmesis (Seddon’s)

A
  • Structural framework divided, torn or destroyed
  • Wallerian degeneration occurs
  • Regeneration may be impossible
  • May develop into a bulbous or a stump neuroma
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37
Q

Tinel’s Sign

A
  • Feet at edge of table
  • Tap PT nerve
  • Positive = radiating pain/tingling
  • Indicates tarsal tunnel syndrome
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38
Q

First degree nerve injury (Sunderland’s)

A
  • Transient conduction deficit
  • Perhaps mild demyelination
  • May have an “irritable” phase
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39
Q

First degree nerve injury (Sunderland’s) may occur secondary to

A
  • Compression
  • Tourniquets
  • Tight shoe gear
  • Blunt trauma
  • Nondisplaced fractures
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40
Q

Second degree nerve injury (Sunderland’s)

A
  • Seddon’s “axonotmesis”
  • Axon severed within intact endoneurium
  • Undergoes Wallerian degeneration
  • Regeneration occurs
  • Positive Tinel’s sign
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41
Q

Third degree nerve injury (Sunderland’s)

A
  • Involves axon and fascicles
  • Some degree of endoneural scarring
  • May require up to 6 months to determine extent of injury
  • Regeneration occurs but unpredictable
  • Residual deficit should be expected in sensation or motor
  • To prevent fibrosis motor innervation must be restored
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42
Q

Fourth degree nerve injury (Sunderland’s)

A
  • “Neuroma in Continuity”
  • Neuroma that results from failure of the regenerating nerve growth cone to reach peripheral targets
  • Axon, endoneurium and perineurium are disrupted
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43
Q

Fourth degree nerve injury (Sunderland’s) occurs within an intact nerve in response to

A
  • Internally damaged fascicles, resulting in a distal portion of the nerve that no longer functions properly
  • No possible regeneration!!!!
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44
Q

Fifth degree nerve injury (Sunderland’s)

A
  • Complete transection of nerve

- May develop “stump” neuroma

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45
Q

Fifth degree nerve injury (Sunderland’s) common etiologies

A
  • Laceration

- Rupture from stretch

46
Q

Sixth degree nerve injury

A
  • Introduced by Susan Mackinnon in 1988

- A combination of nerve injuries within one singular nerve

47
Q

Detection of motor nerve injury

A
  • Flaccid paralysis → atrophy
  • Acetylcholine receptors begin to regenerate causing fibrillations
  • Unique to lower motor neuron lesion!!
  • Detect with EMG
48
Q

Detection of autonomic nerve injury

A
  • Anhidrosis (inability to sweat)
49
Q

Microscopic detection of nerve injury

A
  • Presence of Wallerian degeneration
50
Q

One major characteristic to identify lower motor neuron lesion

A
  • Flaccid paralysis

- Paralysis accompanied by loss of muscle tone

51
Q

Identifying an upper motor neuron lesion

A
  • Spastic paralysis

- Paralysis accompanied by severe hypertonia

52
Q

Recognition of nerve recovery

A
  • Motor function return in most proximal muscle
  • Sensory function return (deep sensation, proprioception)
  • Distal progression of Tinel’s sign (lack of progress suggests surgical intervention required)
53
Q

Nerve recovery is better if…

A
  • Injury occurs at younger age
  • Wound is clean and uncontaminated
  • No crush or traction element
  • Primary repair occurs within hours
  • Delayed repair within 5 to 7 days
  • The injury is more distal
  • A predominantly sensory or motor nerve (not mixed)
54
Q

Two types of nerve repair

A
  • Primary

- Delayed

55
Q

Epineurial nerve repair (primary)

A
  • End-to-end
  • Sutured without tension
  • Use of “traction” suture
  • Blood vessels may act as anatomical landmarks
  • Monofilament nylon (7-0 to 11-0) epifascicular sutures
56
Q

Repair of nerve deficit can use

A
  • Nerve graft
  • GEM neurotube
  • Silicone tubing
57
Q

Nerve graft

A
  • Sural nerve donor

- End to end anastomosis

58
Q

GEM neurotube

A
  • Absorbable woven polyglycolic acid mesh
59
Q

Silicone tubing

A
  • Type I collagen
  • Neurocrescin )increases numbers of fibers)
  • MDP-77 (aids in terminal and collateral sprouting and nerve maturation)
60
Q

Descending spinal tracts (motor)

A
  • Lateral corticospinal

- Ventral corticospinal

61
Q

Ascending spinal tracts (sensory)

A
  • Dorsal columns
  • Lateral spinothalamic
  • Ventral spinothalamic
62
Q

Lateral corticospinal tract

A
  • Main voluntary motor

- Upper extremity motor pathways are more medial (central)

63
Q

Ventral corticospinal tract

A
  • Voluntary motor
64
Q

Dorsal columns

A
  • Deep touch
  • Lower extremity input in most medial location
  • Sensory Modalities
  • Light Touch
  • Vibratory Sense
  • Proprioception(Conscious Position Sense)
65
Q

Lateral spinothalamic tract

A
  • Pain

- Temperature

66
Q

Ventral spinthalamic tract

A
  • Light touch
67
Q

Dorsal columns are made up of

A
  • Fasciculus gracilis

- Fasciculus cuneatus

68
Q

Dorsal columns pathway

A
  • Ascend on the same side to brain stem

- Fibers decussate at the brainstem continuing to the thalamus

69
Q

Dorsal column testing

A
  • Vibratory sense w/ tuning fork
  • Position sense
  • Conscious proprioception w/ Romberg test
70
Q

Romberg test

A
  • Measures balance
71
Q

Lateral spinothalamic tract pathway

A
  • Enter and ascend one or two vertebral levels
  • Decussate within the cord
  • Travel to thalamus and continue to cerebral cortex
72
Q

Lateral spinothalamic tract sensory examination

A
  • Sharp/dull
  • Pain Perception
  • Temperature
  • Most sensitive indicator of small fiber neuropathy
  • Affects A-delta and autonomic C (unmyelinated) fibers
73
Q

Spinocerebellar tract sensory modalities

A
  • Unconscious proprioception

- Stereognosis

74
Q

Spinocerebellar tract pathway

A
  • Proprioceptive fibers ascend completely ipsilateral

- Enters cerebellum via superior and inferior peduncles

75
Q

Corticospinal tract

A
  • Primary efferent motor pathway
  • voluntary motor control
  • UMN lesion
  • Pyramidal tract disease
76
Q

Corticospinal tract pathway

A
  • Exits the cerebral cortex
  • Travels through the medullary pyramids and decussate – 80% of fibers – lateral tract
  • Travel to anterior motor horn cells
77
Q

Pyramidal tract lesions will present very similarly to upper motor lesions with symptoms such as

A
  • Hyperreflexia
  • Weakness
  • Spasticity
  • (+) Babinski sign
78
Q

The corticospinal tract, AKA, the pyramidal tract

A
  • Major neuronal pathway providing voluntary motor function

- Connects the cortex to the spinal cord (enable movement of the distal extremities)

79
Q

Systemic illnesses affecting neurological function

A
  • Hypothyroidism
  • Diabetes
  • Hereditary disorders
80
Q

Skin associations with neuro dysfunction

A
  • Trophic changes
  • Nails
  • Birthmarks
  • Hypopigmentation
81
Q

Facial features of neuro dysfunction

A
  • Head size
  • Genetic abnormalities
  • “Myopathic” face (facial appearance characteristic of myopathic conditions)
  • Ptosis
82
Q

Myopathic face

A
  • Face appears expressionless with sunken cheeks, bilateral ptosis, and inability to elevate the corners of the mouth, due to muscle weakness
83
Q

Extremity findings with neuro dysfunction

A
  • Muscle wasting
  • Spastic paralysis
  • Flaccid paralysis
  • Pseudohypertrophy
  • Cavus foot
  • Intrinsic minus foot
  • Gait abnormalities (steppage, scissor, Neri’s sign)
84
Q

Anesthesia

A
  • Complete loss of sensation
85
Q

Analgesia

A
  • Loss of pain sensation
86
Q

Heightened perception

A
  • Hyperesthesia
  • Hyperalgesia
  • Hyperpathia
87
Q

Decreased perception

A
  • Hypesthesia

- Hypoalgesia

88
Q

Hyperpathia

A
  • Painful syndrome characterized by an abnormally painful reaction to a stimulus, as well as an increased threshold
89
Q

Hyperalgesia

A
  • Augmented pain response
  • Increased pain response to a painful stimulus
  • Pain threshold may be lowered
90
Q

Distal polyneuropathy

A
  • Stocking glove distribution
  • Compare distal to proximal sensation
  • Loss is more profound distally
91
Q

Examples where you may see distal polyneuropathy

A
  • Diabetes
  • Metabolic Neuropathies
  • Infectious Neuropathies
92
Q

Dermatomal loss may benefit in identifying

A
  • Radicular injury
  • Spinal stenosis
  • Disc herniation
  • Tissue mass
93
Q

Peripheral nerve course

A
  • Testing along a specific nerve

- Deficits are common with compression neuropathies and trauma

94
Q

Dorsal column nerve testing

A
  • Light touch (cotton wisp)
  • Vibratory (most sensitive, C-128 tuning fork, biothesiometer)
  • Biothesiometer < 25 suggests infection risk
95
Q

Lateral spinothalamic tract pain sensory testing

A
  • Done over dermatomal distribution

- Quantitate “sharp” versus “dull” – not pressure

96
Q

Lateral spinothalamic tract temperature sensory testing

A
  • Ability to sense cold

- Be aware of presence of any vasospastic disorder

97
Q

Protective threshold used to determine

A
  • Foot’s ability to protect itself

- Semmes-Weinstein monofilament (5.07 10 gram)

98
Q

Diabetic sensory neuropathy testing

A
  • Pressure specified sensory device – PSSD

- Most accurate way of testing the lower extremity forsensorydeficits

99
Q

Positive Babinski (corticospinal lesion) associated with

A
  • UMN lesion
  • Paraventricular leukomalacia from brain injury
  • Muscle spasticity and increased stretch reflex
100
Q

Babinski sign

A
  • Present until 6 months to two years
  • Evaluates pyramidal tract disease (aka corticospinal tract dx)
  • Dorsiflexion of the hallux with plantarflexion and fanning of the lesser digits
  • Distinguish from plantar withdrawal response
101
Q

“Babinski-like” reflexes

A
  • Chaddock’s sign
  • Oppenheim’s test
  • Gordon’s sign
  • Rosolimo’s sign
102
Q

Chaddock’s sign

A
  • Stroke the lateral aspect of the foot

- Proximal to distal behind the lateral malleolus

103
Q

Oppenheim’s test

A
  • Using the thumb and finger as a caliper squeeze the tibial crest
104
Q

Gordon’s sign

A
  • Squeeze the posterior calf

- Positive with dorsiflexion of hallux

105
Q

Rosolimo’s sign

A
  • Percuss the distal digital pulps

- Positive with plantarflexion of the lesser digits

106
Q

5 components of the nervous system evaluated with deep tendon reflex

A
  • Intact sensory afferent
  • Functional synapse at the spinal cord level
  • Intact motor nerve
  • Functional neuromuscular junction
  • Competent muscle
107
Q

Deep tendon reflex grading

A
  • 4+ = Brisk – associated with clonus
  • 3+ = Brisker than normal – hyperreflexic
  • 2+ = Average
  • 1+ = Low normal – hypo-reflexic
  • 0 = Absent
108
Q

Jendrassik maneuver

A
  • “Recruitment”
  • Patient pulls hands prior to you doing reflex
  • Eliminates their conscious resistance
109
Q

Deep tendon reflexes and their root levels

A
  • Patellar – L2-L4
  • Achilles (ankle) – S1-S2
  • Biceps – C5-C6
  • Triceps – C7-C8
  • Clonus
110
Q

Cerebellar examination

A
  • Dictates smooth coordination of voluntary movements
  • Helps maintain posture, balance and unconscious proprioception
  • Contributes to vestibular function
  • Heel-Knee test
111
Q

Stork leg deformity

A
  • In patients with Charcot-Marie-Tooth disease (CMT),distal muscle wastingmay be noted in the legs
  • Resulting in the characteristic stork leg or inverted champagne bottle appearance

Pod Med III (8 decks)

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