Motor Systems Flashcards
Decerebration resembles…
Supratentorial lesions; central/transtentorial herniation
What is decerebrate rigidity (extensor posturing)?
Unopposed hyperactivity in extensor muscles in all limbs. Lesion caudal to red nucleus.
A noxious stimulus administered to a decerebrate patient may ______ the rigidity, or _______ when it is not apparent.
Exacerbate; evoke decerebrate posturing
What is the diencephalic stage of central/transtentorial herniation?
Before herniation through the tentorial notch
What are symptoms of the diencephalic stage of central herniation?
- decreased level of consciousness
- lethargy
- small but poorly reactive pupils
- eye movement disorders
- withdrawal reflex to noxious stimuli is intact
- reflexes are hyperactive
- bilateral Babinski response
- may become decorticate (ipsilateral, then contralateral)
After complete central herniation…
Patient becomes decerebrate, rapid decline, pupils dilated and fixed, comatose, no eye movement, Cheyne-Stokes respiration, tachypnea, maybe death
Why are flexor muscles inactive in the decerebrate condition?
Loss of descending corticospinal and rubrospinal input to flexor motor neurons
Why are extensor muscles unaffected by loss of cortical fibers?
Activated by descending reticulospinal and vestibulospinal inputs
Decerebrate rigidity is also known as _______. Why?
Gamma rigidity. Descending reticulospinal influence on extensor motor neurons is focused primarily on gamma rather than on alpha extensor motor neurons.
What is decerebellate rigidity?
Enhanced activity of vestibulospinal system; extensor hypertonus enhanced compared with that seen with decerebration alone.
(lesion of anterior lobe of cerebellum - cut off inhibitory Purkinje cells)
Why is decerebellate extensor rigidity referred to as alpha rigidity?
Increased excitatory activity in vestibulospinal system produces enhanced direct input to alpha motor neurons.
What is decorticate posturing/rigidity?
- flexion of the upper extremities (intact rubrospinal fibers) at the elbow
- extensor hypertonus in the lower extremities (intact reticu- lospinal fibers)
- altered state of consciousness and respiration
- oculomotor deficits
- range of motor responses from weakness to motionlessness
Lesions of the hemisphere (tumor/hemorrhage) frequently lead to…
Decorticate rigidity (removal of cortical influence on brainstem motor nuclei)
What does it mean if a patient passes from decorticate to decerebrate posturing?
The lesion is spreading downwards and they are in danger. It is now affecting more caudal brainstem and the patient may eventual lose respiration.
What are nerve conduction studies?
Divide distance between stimulating and recording electrodes by the time of travel for action potential; amplitude of the response indicates the number of axons that fired, and shape of the response graph depicts synchrony.
Diseased nerve will not have a sharp wave appearance due to demyelination.
What is a compound muscle action potential (CMAP)?
Recording electrode placed over muscle innervated by the stimulated nerve to test: motor axon, neuromuscular junction, muscle fibers
What is electromyography?
Recording electrode placed in the muscle and recording made of the depolarization of the muscle fibers following voluntary contraction under three conditions:
1) muscle at rest
2) patient exerting minimal effort,
3) patient exerting maximal effort
What is fibrillation?
Myofibers that become denervated have a membrane that is less stable and can fire spontaneously producing fibrillations; these are NOT VISIBLE
What is fasciculation?
Spontaneous firing of a motor unit which ARE VISIBLE, cased by unregulated activity of a motor neuron; can be benign or pathological
Reinnervation causes a switch in the characteristics of the myofiber to __________.
the new characteristics of the motor neuron which innervated it. Often seen in ALS.
What is myasthenia gravis (MG)?
Disease of neuromuscular junction where antibodies bind to nicotinic acetylcholine receptors –> lysis of postsynaptic receptors
What are symptoms of myasthenia gravis?
- weakness waxing/waning
- ocular muscles most often affected first (65%)
- 85% cases have limb musculature weakness
What is ocular myasthenia?
What is myasthenic crisis?
Confined to ocular muscles.
Weakness involving the respiratory muscles.
How do you treat myasthenia gravis?
Acetylcholinesterase inhibitors
What is the stretch reflex?
Monosynaptic excitatory connection of Type Ia spindle with alpha motor neuron innervating afferent origin
What is reciprocal inhibition?
Type Ia fiber –> Ia interneuron –> Inhibit motor neuron of ANTAGONIST muscle
What is the crossed extensor reflex?
Muscle afferents –> interneuron –> CONTRALATERAL side & propriospinal neurons (example: help stand when lifting the other foot)
What are long loop reflexes?
Muscle sensory information via ascending pathways to thalamic relay –> cortex –> alter gain on spinal reflexes via descending supraspinal pathways
What is poliomyelitis?
Viral disease causing damage to somatic motor neurons in the spinal cord or brainstem; leads to weakness/paralysis
Lesion to decussating corticospinal fibers:
Upper extremity decussates more ______ and lower extremity decussates more ______.
rostrally; caudally
Important for localization of lesion.
What is superior alternating hemiplegia (Weber Syndrome)?
Hemorrhage in paramedian branches of P1
(1) contralateral hemiparesis (spasticity)
(2) lesion of ipsilateral CNIII - deviation of ipsilalteral eye down and out; direct and consensual light reflex/accommodation LOST ipsilaterally
What is middle alternating hemiplegia (Foville Syndrome)?
Occlusion of paramedian branches of basilar a.
1) alternating hemiplegia
(2) ipsilateral CN VI sign
(if ischemia is bad enough can cause loss of DC-ML sense
What is inferior alternating hemiplegia (Dejerine Syndrome)?
Occulsion of anterior spinal a.
(1) contralateral hemiparesis of extremities
(2) ipsilateral deviation of tongue on protrusion (CN XII)
(and contralateral fine touch/vibration from DC-ML)
What is multiple sclerosis (MS)?
Chronic, degenerative inflammatory disorder, associated with autoimmune disease
- demyelination/degeneration in SC, brainstem, optic nerve weakness, numbness, pain, vision loss
Early symptoms: blurred vision, blind spots, muscle weakness
Typically progresses steadily or can cause acute attacks followed by remission; NORMAL lifespan
What is amyotropic lateral sclerosis (ALS)?
Loss of anterior horn motor neurons (lower motor neuron syndrome), potential for loss of cranial motor nuclei and Betz cells.
Typically middle age, extremity weakness, bulbar signs/symptoms, NO SENSORY PROBLEMS (typically), dysphagia, 2-6 yr course post-diagnosis… fatal :(
In ALS:
Astrocytosis is caused by…
Loss of lower motor neurons.
In ALS:
Gliosis is caused by…
Lateral column degradation (loss of upper motor neurons); “sclerosis” of lateral columns
What is spinal shock?
Periods of time following a spinal cord injury, typically a complete spinal cord transection, where there is hyporeflexia/areflexia below the level of the lesion as well as hypotonia.
Reflexes then return over a period of months but are hyperreflexic in nature due to upregulation of postsynaptic neurotransmitter receptors.
What is central cord syndrome (CCS)?
Incomplete spinal cord injury, often cervical/upper thoracic from neck hyperextension.
3 big symptoms:
- lead to weakness of arms and variable sensory loss = inverse paraplegia (arms/hands affected and legs are not)
- urinary retention
- patchy loss of ALS sensation below lesion
What are causes of central cord syndrome?
Trauma, hemorrhage, ischemia, necrosis of central cord
What are lateral corticospinal fibers not affected in CCS?
Lesion is too peripheral
What is anterior cord syndrome?
Ischemia to the anterior spinal artery perfused SC region –> loss of motor function below lesion, loss of sensation via ALS but DC not affected
What is posterior cord syndrome?
Rare incomplete lesion due to ischemia in posterior spinal artery –> damage to DC causing loss of associated sensation below the level of the lesion
What is tabes dorsalis?
Tertiary syphilis in which the DC neurons are demyelinating; more common in males.
Symptoms:
- weakness,
- hyporeflexia
- ataxic gait
- progressive degeneration of joints
- sensory ataxia (lack of proprioceptive input)
- episodes of intense pain and disturbed sensation
- personality changes
- dementia
- deafness
- visual impairment
- impaired light response
What is Romberg’s test?
Try to maintain balance when eyes are closed. Can help diagnose tabes dorsalis.
Lesion to cervical enlargement:
Damage only to lateral funiculus
ipsilateral upper and lower extremity upper motor neuron signs