Clinical neurosurgery lecture [12/01/20] Flashcards
What is neurophobia?
Perceived complexity about neuroanatomy, neurological examination, multitude of rare disease
Three types of approaches to approaching a patient? Which is the modern approach?
- Disease orientated approach [diagnose on spot from Sx, simplistic]
- Localisation approach: take each patient Sx then draw vend diagram to get Dx
- Clinical syndrome: story of Pt, only 20 or so clinical syndromes mostly anatomically based. Modern way.
Name the 20 neuro clinical syndromes [very hard]
[look at slide]
if in doubt with neuro syndrome, what should you do?
Scan!
Which junction type does myasthenic syndrome involve?
Neuromuscular junction
Which part of the nerve does a radiculopathy affect?
Nerve root
Which part of the body does vertebral pain affect?
The discs/ligaments of the spine
Part of the body does a myelopathy affect?
The spine
Which cell in spine does MND affect?
Anterior horn cell
Where does a parasellar syndrome grow in the body?
Pituitary tumour
What can cause meningeal irritation?
Pus/blood against it
Put simply, what is a stroke?
Any neurological deficit
Part of the brain does extrapyramidal Sx indicate effected?
Basal ganglia
What is somatisation?
Psychological
Next steps if patient unable to give a history
- Collateral history
- ABC resus
Next steps if patient able to give a history?
- do pain tool
- do domain tool
- pick up on ‘patient speak phrases’
Following steps after speaking to patient who is able to give history
- hypothesis-based signs from framework headings
- core examination [incl. vital signs]
Final step in basic structure of neuro-assessment
Clinical syndrome secondary to [likely] underlying disease entity
Summarise basic neuro-assessment
[look up]
Reasons why patient may not be able to give a history
Patient confused, impaired level of consciousness, can;t speak language, tracheostomy, lower CN problems, struggling to speak, dysphasia, individuals who are deaf, special needs [sign language], ventilated people
What are the 5 vital signs?
Blood pressure, body temperature, pulse rate, respiratory rate, oxygen saturation
if something wrong with vital signs, what does this indicate?
A secondary brain problem is afoot
What is a primary brain problem?
A problem of the brain
Signs of an AAA
Pulse rate up, BP down, abdominal distention
Go through the GCS pointing system
[look at slide]
Name a way of doing a quick neuro examination
GCS!
Which examination should you do in ‘anal sphincter’ scenarios?
GCS! Happen about once monthly when you qualify.
Which drive present during anal sphincter moments? Describe it.
Sympathetic drive: rush adrenaline, logic out of window
Which part most important in the GCS?
Best motor response. Apply painful stimulus. Ensure doesn’t elicit reflex.
Best place to get a motor response?
Fingers back of jaw: won’t get bruising behind ears, can do jaw thrust easily from this position, squeeze same extent when can’t see hands
Another common place to do best motor response?
Supraorbital place
Which CN distribution does mastoid area for motor response sensation test?
Trigeminal nerve
Differentiate localising, flexing, and extending in the GCS
Localising: arm comes up to push away painful stimulus
Flexing: arm up but doesn’t push away
Extending: arm goes down and stays there
Which is better to use when presenting GCS, numbers or descriptors?
Descriptors! Less confusion.
When does GCS become a good predictor of outcome for patients?
If it is done an hour after the incident. Exceptions include if on tube and ventilation done on site [as anaesthetist has put pain medication down throat]
Exceptions to pt extending meaning person is not essentially dead?
- Unless under hour car accident
- or something really simple like hydrocephalus in a young person
What happen if person is flexing?
Then patient will likely do well
What is withdrawal on the GCS and why isn’t it used now?
Squeezing finger for painful stimulus. Not used now as can cause reflex.
How common is abnormal/spastic flexion?
Rare, pt will usually come down on flexion or extension if press long and hard enough
What does lateralising signs mean?
Means a problem of one hemisphere compared to another. Don;t have to test for lateralising signs. Could be inattnetion, gaze paresis.
What are lateralizing signs
Look up
If patient has fixed dilated pupils, what could be a sign of?
Lesion 3rd nerve parasympathetic fibres
Where does the 3rd nerve supply the brain from?
I think the midbrain
Describe the course of the 3rd CN. Why does this lead to dilated pupils?
Midbrain -> Dura -> petris part of the temporal bone in middle ear, apex of it is like a guitar string.
If brain squeezes this due to e.g. blood clot, the parasympathetic fibres won’t work [outside of fibre motor, inside is sensory]. This causes pupil dilation.
How to test for dilated pupils?
Pen torch each eye. Direction pupillary reflex and look. The indirect pupillary reflex when shine another eye and look at fixed pupil. Test for direct and indirect pupillary reflex basically [think can do by swinging reflex maybe?].
Why is important to test the indirect pupillary reflex?
pt could have a blind eye.
Give example of how sympathetic vs parasympathetic NS works?
Friday evening, go to a pub at 8pm lights down pupils up. See someone pupils dilates she’s interested. Go to loo even though it’s been 10 minutes ago. Blushing, tachycardia. Feeling flustered, executive functioning not very good. Basically me on a coffee I think.
What is Horner’s syndrome and how does it relate to PS/S nervous system?
Horner’s syndrome:
- miosis, pitosis and anhedrosis
- miosis [constriction of pupil] is due to damage of the sympathetic NS of the face
Briefly describe the course of the sympathetic NS
nerve from brainstem, hitch a lift on a artery, through upper thoracic nerve roots, sympathetic chain, internal carotid artery
Which artery supplies the skin [I think around the face]?
External carotid artery
If person comes in unconscious at 3am and need more info, should call relatives etc.?
Yes, get a collateral history immediately [regardless of time]
Patient comes in unconscious, pulse 140bpm, 80% sats, 40C temp. Housekeeping for unwell patient such as this? 8am she is fine, up and having toast, what likely happened?
Housekeeping
- put her on O2
- r/o infection for temp blood cultures then start Abx, Rx paracetamol/aspirin
Likely happened
- secondary brain problem. Though had chronic subdural okay to manage and turns out main problem was pneumonia so just needed Abx
What are the 15 elements of the pain tool?
Look up slides
What are the 7 elements of the domain tool?
Look up slides
If in doubt when taking history, what should you do?
SCAN!
Which type of questions best for taking a neuro history?
Closed questions [not leading questions thought]
What can question about sleep tell you about the condition?
Severity
Important questions asked pain tool not asked SCRATES
Prceipitating factors, prgoression, disturbing sleep, ever had before, response to conservative measures, significantly interfering lifestyle
What is a myelopthy?
Look up
Which nerve does carpal tunnel effect? Which weakness does this cause and how may this present?
Median, gripping so keep dropping coffee mug [patient-speak phrases]
Strategy for patient with multiple Sx
Either take most significant tot hem and all other Sx associated/preceding
or could take pain as most prominent Sx
What is Rett syndrome?
Global neurological syndroem, random genetic inherited.
Fine until 2y, then regress after this age.
Sleep-wake distubrance, can soil self, look normal but no verbal abilities, use of hands angel prayer, struggles swalloing, needs feeding, has feeding problems, near repetitive hand movements, feeding problmes, wheelchair bound, no insight danger
Type of neurological diseases have sleep disturbances?
Global neurological deficits [like PD]
Grades for domain tool?
1 to 7 [look up], with 7 being bed bound or hoist transfer
RFs for pressure sores
Nutrition, bed bound, incontinence etc.
Red tray hospital systems
Means people need help with feeding [coordination/vision/swalloing etc. problem]
If pt can’t communicate mouth, how may communciate?
With eye and IR camera
What does personal hygiene/continence relate to?
Sphincter control [wearing pads], reducing social circle e.g. cuada equina exmaple
Interperonsal relationships: lost job 6m ago, estreanged family and friends and don;t do hobbies etc.?
possible demenita or deprression
What should exclude if person withdrawing from life?
Bullying
For sleep, best way to start Tx
Sleep hygiene, melatonin can do. Last thing want to do is sedate someone.
What is the hypothesis-based approach to neurological examination?
Core examiantion [gen app, vital signs, gait, fundscopy for pappiloedema/optic atrophy, long tract signs, vib sense] + one or two signs associated with the two or three clinical syndromes shortlisted from history
If in doubt in examination ….
SCAN
Should you routinely do dermatones?
brain dead approach check all dermatomes. Can really just ask in the history: “do you have any numbness”?
What are the vital signs?!
BP, oxygen sat, temp, pulse, , RR
Which parts of the examination are important as they won’t be told during the history?
UMN signs, back of eyes, vib sense
Knee and ankle reflex important?
Not really
Anatomical pathway of the long tracts
Parametical cell in the cortex, goes through capsule, through brainstem and then synapsing at the anterior horn cell
Other names for UMN signs
Long tract, pyramidal signs, ascending tract sign
Most common cause of myelopathy?
OA
Late sign of myelopathy, and early sign
Early sign: UMN signs
Late sign: lack of sensation
The 6 signs for UMN
Babinski, clonus, cross adductors, Hoffman’s, open and close hands, delto-pector reflex
Progression of myelopathy for most people
Insidious
two syndromes where signs before Sx in neuro. How to screen for these?
Myelopathy, peripheral neuropathy.
UMN signs and also vibration sense.
Which tuning fork vibration sense?
128Hz
Two large pieces of kit in the body nerve distributed by?
Jelly fish: avoid extreme temp, simple kit, unmyelinated, C fibres, few genes, pain
Evolutionary new: advances, myelinated, A fibres, large diameters, fast conducting
Whihc fibres effected by peripheral neuropahy?
Computer kit problems, light touch/vibration/proprioception effected
5 sentence structure to presenting a patient?
- The pt, PC
- HPC
- PMH
- Examination
- Summary and DDx
