Four limb weakness

Question 1

What produces UMN signs and what are they?

Answer 1

Lesions to the brain, brainstem and spinal cord

Bulk - normal
Tone - Increased
Power - reduced
Abnormal movement - fasciculations not seen
Reflexes - Brisk
Plantar/Babinski - Up-going
Clonus - +ve

Question 2

What produces LMN signs and what are they?

Answer 2

Lesions to the LMN, anterior horn cell nerve root or peripheral nerve

Bulk - atrophy
Tone - decreased
Power - reduced
Abnormal movement - fasciculations
Reflexes - decreased/absent
Plantar/Babinski - down-going
Clonus - -ve

Question 3

When can mixed UMN and LMN signs occur?

Answer 3

MND
B12 deficiency
taboparesis

Question 4

What is spinal shock?

Answer 4

When someone has an acute insult to the cord (vascular, trauma, haemorrhage) it can cause LMN features

Question 5

What tracts are affected in anterior cord syndrome?

Answer 5

• Lateral corticospinal tracts

* Lateral spinothalamic tracts

Question 6

What are the features of anterior cord syndrome?

Answer 6

Bilateral loss below level of lesion:
o	Motor function
o	Light touch
o	Pain
o	Temperature

Question 7

What are the features of central cord syndrome?

Answer 7

MUD-E
•	Motor > sensory
•	Upper extremity > lower extremity
•	Distal > proximal
•	Extension injury

Question 8

What tracts are affected in hemi-cord/Brown-Sequard syndrome?

Answer 8

• Lateral corticospinal
• Dorsal columns
• Lateral spinothalamic

Question 9

What are the features of hemi-cord/Brown-Sequard syndrome?

Answer 9

Ipsilateral loss below lesion
o Motor function – spastic paraparesis
o Proprioception – sensory ataxia
o Vibration

Contralateral loss below lesion – spinothalamic tract decussates
o Pain
o Temperature

Question 10

What is subacute combined degeneration of the spinal cord?

Answer 10

Vitamin B12 or E deficiency causing degeneration of the posterior and lateral columns of the cord

Question 11

What tracts are affected in subacute combined degeneration of the spinal cord?

Answer 11

• Lateral corticospinal
• Doral columns
• Spinocerebellar

Question 12

What are the features of subacute combined degeneration of the spinal cord?

Answer 12

Bilateral:
o	Motor – UMN signs 
o	Proprioception and vibration
o	Limb ataxia 
o	Absent ankle and knee jerks

Question 13

What is Friedrich’s ataxia and what symptoms does it produce?

Answer 13

Inherited condition

Same symptoms as subacute combined degeneration of the spinal cord with an intention tremor

Question 14

What is syringomyelia and what is it associated with?

Answer 14

Fluid-filled cyst forms within the spinal cord causing compression due to dilation of CSF space within spinal cord

Chiarai 1 malformation

Question 15

What does syringomyelia affect in the spinal cord?

Answer 15

• Ventral horns

* Lateral spinothalamic

Question 16

What are the features of syringomyelia?

Answer 16

• LMN signs

* Cape-like Bilateral Loss of pain and temperature

Question 17

What does neurosyphilis cause?

Answer 17

Degeneration of dorsal columns:

• Loss of proprioception and vibration

Question 18

What does compression of C5 and above cause?

Answer 18

• UMN signs
• Sensory loss in all 4 limbs
• Diaphragmic weakness
• Autonomic dysfunction - incontinence

Question 19

What does compression of C5-T1 cause?

Answer 19

• LMN signs in upper limbs
• Sensory loss below level of lesion
• UMN signs in legs
• Respiratory (intercostal) weakness
• Autonomic dysfunction – urinary incontinence

Question 20

What does compression of thoracic vertebrae cause?

Answer 20

• Spastic paraplegia
• Sensory level on trunk
• Weakness of legs
• Sacral loss of sensation
• Extensor plantar responses

Question 21

What does compression of Cauda equina/below T12/L1 above cause?

Answer 21

• LMN signs
• New onset bilateral sciatica
• New/worsening Back pain
• Saddle area anaesthesia
• Decreased anal sphincter tone
• Urinary retention

Question 22

What can cause acute transverse myelitis?

Answer 22

inflammation of the spinal cord

Inflammatory
o MS, post-infective, NMO/Devic’s
o CTD related (lupus, sjogren’s, sarcoid)

Compressive
o Discs, tumours

Infective
o	Viral (HZV, HIV)

Metabolic
o B12, copper deficiency

Question 23

What is GBS?

Answer 23

B-cells produce antibodies against a pathogen that target myelin sheath, motor nerve cell or axon

Question 24

What is the presentation of GBS?

Answer 24

• Peripheral loss of sensation or neuropathic pain
• Symmetrical ascending weakness (starting at the feet and moving upwards)
• Reduced reflexes

Question 25

What are the other features of GBS?

Answer 25

• Hx gastroenteritis
• Respiratory muscle weakness
• CN involvement
• Autonomic involvement

Question 26

What do nerve conduction studies and lumbar puncture show for GBS?

Answer 26

Nerve conduction studies:
o Slow motor nerve conduction velocity (demyelination)
o Prolonged/absent F waves
o Prolonged distal motor latency

Lumbar puncture
o Increased protein
o Normal WBC count and glucose

Question 27

How do you manage GBS?

Answer 27

• IV immunoglobulins
• Plasma exchange
• Supportive care
• VTE prophylaxis

Question 28

What is miller fisher syndrome and how does it present?

Answer 28

Variant of Guillain-Barre syndrome

Descending paralysis:
• Ophthalmoplegia
• Areflexia
• Ataxia

Question 29

What is Charcot-marie-tooth disease

Answer 29

AD peripheral neuropathy

- LMN and sensory signs

Question 30

What is MND?

Answer 30

Progressive degeneration of UMN and LMN

No sensory loss of sphincter distrubance

Question 31

What is Amyotrophic lateral sclerosis (ALS)?

Answer 31

Loss of motor neurones in motor cortex and anterior horn of the cord
o LMN signs in arms UMN signs in legs

Question 32

What is Progressive bulbar palsy?

Answer 32

Palsy of tongue, muscles of mastication and facial muscles

o Loss of brainstem motor nuclei (IX-XII)

Question 33

What is Progressive muscular atrophy?

Answer 33

Anterior horn cell lesion

o LMN signs only

Question 34

What is Primary lateral sclerosis?

Answer 34

Loss of Betz cells in motor cortex

o UMN signs only