Neuro composite deck Flashcards
Eye Exam
Observe- Dx facies Cornea- arcus + other Sclera- jaundice, pallor, injection Ptosis Exophthalmos- behind and above patient Eyelids- xanthelasma Lid Lag Orbits - palpate tenderness Auscultate eyes with bell for bruit, hold rbeath Neuro exam - acuity - fields -pupils- shape, symmetry, direct, consensual, RAPD, accomodation - eye movements - Fatiguability - Corneal reflex Fundi - cornea, lens, humour, colour of disc, state of cup, retina Dependent on findings- cranial nerves+/- long tract signs
Higher centres exam
Ax
= Language
= Level of education
= Consciousness,
= Orientation
= Attention
Temporal= Memory
3 x objects, immediate and late recall
Occipital= Eyes
Look at my nose, which side is wriggling
Parietal= neglect, gnosis, praxis
neglect- sensory
gnosis- coin, key
praxis- 3 hand movements (thumbs up, ok, rock on)
Frontal
Palmar-mental
Grasping
Pout
Fist/edge/palm
Obsrv- Dx facies, obvious CN or limb neuro lesions assess level of consciousness Ask -handedness -level of education Orientation- T/P/P Speech- - name objects - repeat words - comprehension (Verbal, written) - writing Parietal Lobes - sensory inattention - visual inattention - agraphaesthesia (number on palm) -asterognosis (object on pam) - Constructional apraxia- clockface - Dressing apraxia (shirt inside out, ask them to put on- non dominant) Temporal Lobe- - short term memory (3 items) (Cat, orange, pen) - Long term (twin towers) Frontal lobe - reflexes- grasp, pout, palmar-mental - proverb interpretation (rolling stone gathers no moss) - gait apraxia Proceed - fundi, - isual fields - carotid bruits - BP
Speech exam
Obsrv0 Dx facies, asyemmtry Ask - language, hearing, handedness Cough Orientation- T/P/P Description/fluency= boston cookie theft Comprehension 1- poke out your tongue 2- touch left hand to right ear 3- Touch your nose, then your chin, then your forehead Tricky- point to the ceiling after you point to the floor Written- close your eyes Repetition “say what i say” hippopotomus, british constitution no ifs ands or buts the orchestra played and the audience clapped Pa(lips), Ta(tongue), Ka(palate) PATAKA (motor speech) Naming- thumb, ring finger, knuckles Fatiguability- 1 to 20 PROCEED Language= Dysphasia - read a phrase, write a phrase Articulation= dysarthria as per findings - cerebellar exam- drift/overcorrection, finger nose, dysdiado, nystagmus, ataxia - lower cranial nerves with jaw jerk - Movement disorder- gait, tone, bradykinesia, gaze palsy - UMN/LMN- tone, reflexes, jaw jerk, CN9-12 (GVAH)
Shoulder girdle Exam
Dx facies- esp masseter and temporalis Palpate muscle bulk When Ax movement- look for winging Shrug shoulder Push against wall Pull shoulder blades together hands on hips Abduct arms against resistance <15deg and >15 deg Adduct arms External rotate upper arm Internal rotate upper arm Sensation
Myotonic Dystrophy
Observe Facial features= frontal balding, bilateral ptosis, dull triangular facies, temporalis + masseter + sternomastoid atrophy Cataracts +/- glasses Neck - sternocleidomastoid atrophy -weak neck flexion, preserved extension Upper limbs- OFTEN STEM -grip myotonia -percussion myotonia- tap over thenar eminence= contraction then slow relaxation of abductor pollicis brevis -wasting and weakness- more over forearm muscles -sensory changes may occur- peripheral neuropathy- usually mild -fingers- evidence finger pricks from diabetes Chest -gynaecomastia -cardiovascular system- cardiomyopathy +/- pacemaker Proceed -testicular atrophy -Lower limbs if time -Urinalysis for glycosuria -Mental status- common to have mental retardation -EMG
Gait Exam
Obs- deformity, aids, obvious lesions (i.e. prev strokes), shoes, fasciculations, abnormal movements GAIT -Normal gait -Heel- toe- cerebellar -Toes- S1 -Heels- L4/5 Squat- proximal myopathy Rombergs -Eyes open= cerebellar disease -Eyes closed= proprioception(posterior columns) Proceed -Examine lower limbs
Cerebellar Exam
Gait -Will stagger towards affected side, unless bilateral or vermis Legs -Tone -Coordination -Reflexes- pendular knee jerks Arms -Extend arms arm drift, static tremor (due to hypotonia of agonist muscles) -Pronator drift -Tone- Hypotonia in unilateral cerebellar disease -Coordination Finger nose- intention tremor, past pointing Rapid alternating movements- dysdiadochokinesis= inability to perform smoothly Face -Eyes- nystagmus- Jerky, horizontal. Increases when looking towards lesion -Speech- jerky, explosive, loud with irregular separation of syllables- Hippopotamus, Constitution, West register street Trunk -Truncal ataxia- fold arms, sit up Proceed -Assess for causes oCranial nerves Cerebellopontine angle tumour- 5th, 7th, 8th CN affected oLateral medullary syndrome -Fundi- papilloedema -Peripheral evidence of malignant disease
Parkinsons exam
Observe - Lack of facial expression= mask like facies - Paucity of movement Gait - Ask to walk, turn quickly, stop and restart - Assess- Difficulty starting, shuffling, freezing, festination - If safe can assess for propulsion or retropulson, if not don’t! Arms -Resting tremor pill rolling- unilateral, or asymmetric if bilateral Finger nose testing- resting tremor diminishes, action tremor may appear -Wrist tone- cog wheel or lead pipe Reinforce by asking patient to turn head from side to side -Assess for involuntary movements dyskinesia associated with dopamine treatment -Rapid alternating movements -Pincer movements- gets smaller -Rolling hands- gets smaller Face -Observe- Tremor, absence of blinking, dribbling saliva, lack of expression -Glabellar tap- continues to blink after tapping sevral times from behind (note: must be out of site) -Speech- monotonous, soft, poorly articulated, faint -Ocular movements- supranuclear palsies Other -Write- micrographia -Frontal reflexes -Higher centres- dementia -Postural BP for hypotension Presentation -Degree of disability -Main problem being rigidity or tremor -Presence of autonomic dysfunction or gaze palsy
Cranial Nerve Exam
Expose, position, wash hands Obs- scars, neurofibromata, facial asymmetry, ptosis, skew, Dx facies Smell Eyes= 6 (3, 4, 6) - Acuity - Fields + blind spot - Colour vision - Fundoscopy (4)- retina, vessels, optic nerve, macula - Pupils (4)- shape/size, direct, consensual, RAPD, accommodation - Eye movements (3)- screen, cross, saccades Face sensation (5) - sensation x 3- (pain only= pontine, light touch only= medullary/upper cervical) - Corneal reflex - Muscles mastication - Jaw jerk Face movement (7) = 4 (2 eyes, 2 mouth) Ears (8) - screen, webers, rinne= 256 Throat (9 + 10) - uvula +/- gag - hoarseness, cough Shoulders (11) - SCM, Trap Tongue (12)
Upper Limb Neuro Exam
Expose, position, wash hands Obs- facies, obvs stroke, abno movements, cafe au lait Neck- scars Arms/shoulder girdle- wasting, fascic, tremor Screen + pronator drift- arms out, palms extended, eyes closed Palpate- muscle bulk, thickened nerve (ulnar elbow, median and radial wrist) Tone Reflexes x 3 + hoffman (flick ext, flexion thumb= positive) Power -Shoulder ab(5/6) ad(6-8) -Elbow flex (5/6) Ext (7/8) -Wrist flex (6/7) Ext (7/8) - FInger flex (7/8) Ext (7/8) abduction (8/1) (ulnar- finger ab/adduction, median thumb abduction) Coordination- finger nose, rapid alternating Sensation Pain, Temp, Vibration (128), Proprioception C4= shoulder C5= upper arm lateral C6= thumb C7= middle C8= pinky T1= upper arm medial ulnar=pinky median= middle finger radial= base of thumb
Lower Limb Neuro
Expose, position, wash hands Obs- facies, obvs stroke, abno movements, cafe au lait, IDC, pes cavus. Aids Gait- normal, heel toe (cerebellar), toe (S1), heel (L4/5), squat to stand, Rhomberg Palpate muscle bulk, nerves Tone + clonus if increased Reflexes Power Hip- flex, ext, abd, add Knee- flex, ext Ankle- flex, ext, inv, ev Toe flex Hip Flex L2- tie your shoe Knee Ext L3- Kick your knee Dorsiflex L4- heel to floor Toe ext- L5- Toe to sky Knee flex S1- kick your bum Coordination- heel shin, toe finger, tap feet Sens- pin prick, temperature, vibration, proprioception Groin L1, Lateral thigh L2, Medial Thigh L3, Medial Leg L4, Lateral Leg L5, Pinky toe S1
Causes nystagmus
HORIZONTAL
- Vestibular lesion. Fast phase away from the side of the lesion
- Cerebellar lesion- unilateral Dx= fast phase to lesion. Drift to midline with fast phase in direction of gaze= Gaze evoked. A/W Dysarthria, limb ataxia, hyper/hypometric saccades
- INO- nystagmus in abducting eye, with failure of adduction on affected side. If young- MS, if older- brain stem infarct
VERTICAL Brain Stem Lesion Toxic
Causes pupillary constriction
Horner’s syndrome,
Argyll Robertson pupil,
Pontine lesion (often bilateral and reactive to light),
narcosis, pilocarpine drops, old age
AR pupil- no react to light, react to accomodation. cause= syphilis, diabetes, alcohol
Causes pupillary dilatation
third nerve lesion, Adies pupil, Iridectomy/lens impant/iritis, post trauma, deep coma, cerebral death, congenital, mydriatics
Visual field defect location
Central scotoma= retina optic nerve= monocular vision Bitemporal hemianopia= optic chiasm homonymous hemianopia (away from lesion)= optic tract/radiations
Causes ptosis with normal pupils
Senile, Myotonic dystrophy Fascioscapulohumeral dystrophy Ocular myopathy- e.g. mitochondrial myopathy Thyrotoxic myopathy Myasethnia gravus Botulism, snake bite Congenital Fatigue
Causes ptosis with contrsicted pupil
Horners syndrome Tabes dorsalis
Causes ptosis with dilated pupil
third nerve lesion
Features third nerve palsy
Ptosis Divergent strabismus (eye ‘down and out’)- limited adduction and elevation Dilated pupil (unreactive)
Causes third nerve palsy
Central -Vascular (e..g brain stem infarct) -Tumour -Demyelination (rare) -Trauma -Idiopathic Peripheral -Compressive lesions- aneurysm, tumour - Infarction- diabetes mellitus, arteritis (pupil usually spared - Trauma -Cavernous sinus lesions
Features sixth nerve palsy
Failure of lateral movement. +/- convergent strabismus (in) Diplopia- worst by looking to affected side
Causes sixth nerve palsy
Bilateral- head trauma, wernickes encephalopathy, raised ICP, mononeuritis multiplex Unilateral -Central- vascular, tumour, wernicke’s encephalopathy, MS (rare) -Peripheral- diabetes, other vascular lesions, trauma, idiopathic, raised ICP
Causes fifth (trigeminal) nerve palsy
-central (pons, medulla, upper cervical cord)- vascular, tumour, syringobulbia, multiple sclerosis -posterior fossa- aneurysm, tumour (acoustic neuroma), chronic meningitis -Trigeminal ganglion (petrous temporal bone)- meningioma, # -Cavernous sinus (a/w 3rd, 4th and 6th nerve palsies)- aneurysm, thrombosis, tumour -Other- sjogrens syndrome, SLE, toxins, idiopathic Hints -all 3 divisions- ganglion or sensory root. -one division postganglionic lesion -loss pain preserved soft touch-brain stem or upper cervical cord lesion -soft touch lost, pain preserved- pontine nucleus lesion
Causes seventh (facial nerve) palsy
Upper motor neurone lesion (supranuclear)- vascular, tumour FOREHEAD SPARED Lower motor neurone lesion- FOREHEAD INVOLVED - Pontine- often a/w 5th and 6th nerve palsy= Vascular, tumour, syringobulbia, multiple sclerosis -Posterior fossa- Acoustic neuroma, meningioma - Petrous temporal bone- Bells palsy, ramsay hunt syndrome, otitis media, fracture - Parotid- Tumour, sarcoid Bilateral Guillain Barre syndrome Bilateral parotid disease (e.g. sarcoidosis) Mononeuritis multiplex (rare) (myopathy and NMJ defects can cause bilateral facial weakness)
Causes 9th (glossopharyngeal) and 10th (vagus) nerve pasly
Central -Vascular (E.g. lateral medullary infarction due to vertebral or posterior inferior cerebellar artery disease), tumour, syringobulbia, motor neurone disease (vagus only) Peripheral- posterior fossa -Aneurysm, tumour, chronic meningitis, Guillain Barre syndrome (vagus only)
Causes 12th (hypoglossal) nerve palsy
Upper motor neurone lesion- vascular, motor neurone disease, tumour, multiple sclerosis NOTE: bilateral UMN lesion of 9th, 10th, 12th nerves= pseudobulbar palsy Lower motor neurone lesion- unilateral -Central- vascular (thrombosis of vertebral artery), motor neurone disease, syringobulbia -Peripheral (posterior fossa)- aneurysm, tumour, chronic meningitis, trauma, Arnold-chiari malformation, fracture/tumour of base of skull Lower motor neurone lesion- bilateral -Motor neurone disease, Arnold chiari malformation, Guillain barre syndrome, polio
Causes multiple cranial nerve palsies
Think cancer first Nasopharyngeal carcinoma Chronic meningitis (e.g. carcinoma, tuberculosis, sarcoidosis) Guillain Barre syndrome (spares CN 1, 2, 8) including miller fischer variant (ataxia, areflexia, and ophthalmoplegia) Brain stem lesions- usually vascular disease causing crossed sensory or motor paralysis (e.g. CN signs on one side, contralateral long tract signs). Gliomas in brain stem can cause similar signs Arnold chiari malformation Trauma Lesion of base of skull (e.g. pagets disease, large meningioma, metastasis) Rarely mononeuritis multiplex (e.g. DM)
Causes horners (ptosis, miosis, anhidrosis)
- Carcinoma of ling apex- likely squamous cell - Neck- thyroid malignancy, trauma - Carotid arterial lesion (carotid aneurysm or dissection, pericarotid tumour, cluster headache - Brain stem lesions- vascular disease (especially lateral medullary syndrome), syringobulbia, tumour - Retro-orbital lesions - Syringomyelia
5 broad causes dysarthria
- Upper motor neurone (pseudobulbar) - Lower motor neurone (bulbar) - Cerebellar - Movement- PD, HD - Muscle Cerebellar- slurred/scanning (irregular, staccato) Pseudobulbar palsy- slow, hesitant, hollow sounding w harsh, strained voice Bulbar- nasal speech with imprecise articulation Motor neurone can be mixed
Expressive aphasia- description, location
- Slow and non fluent - Broca’s- frontal gyrus
Receptive aphasia- - description, location
- Fluent but content poor - Wernicke’s- temporal gyrus
Summary of cranial nerve pathology locations
Brain stem
3-4=mid brain, 5-8= pons, 9-12=medulla
Stroke, tumour, demyelination
Subarachnoid sinus
Meningitis
Peripheries
Tumour etc
Eye movements
LR6 SO4
All other 3
Hereditary motor and sensory neuropathy (Charcot Marie Tooth)
Pes Cavus- short, high arched feet with hammer toes Distal muscle atrophy (not above elbows or middle 1/3 thighs) Absent reflexes Minimal sensory loss Thickened nerves
Brachial plexus lesions
Complete- LMN whole arm, including sensory loss. +/- Horners syndrome Upper trunk- loss shoulder and elbow, sensory over lateral arm and thumb Lower trunk- claw hand, intrinsic muscle paralysis, sensory loss ulnar hand/forearm, horners syndrome
Radial Nerve Palsy C5-8
- Wrist drop- Weak wrist extension, finger extension. Finger abduction appears weak because hard to spread fingers when flexed.
- Elbow extension loss if above spiral groove, preserved if below. Supination- in spiral groove
- Sensory loss over anatomical snuff box
Median Nerve Palsy C6-T1
- Weakness of wrist flexors and pronators
- Weak thumb abduction, flexion, opposition
- Wasting thenar eminence
- Hand of benediction- when trying to make a fist- unable to flex at MCP or extend at IP of index and middle fingerà so first 3 digits remain in extension
- Sensory loss over palm- thumb and 2.5, and dorsal- finger tips of same
Positive tinnels, phalens–> carpal tunnel syndrome
Ulnar Nerve Palsy- C8-T1
Observation
Evidence of scar indicating surgery or trauma over ulnar nerve at (?elbow ?wrist).
Resting flexion deformity of the 4th and 5th finger (ulnar claw)
Wasting of the intrinsic muscles of the hand and hypothenar eminence
Tone and reflexes were normal.
Power was reduced in
finger abduction and adduction,
thumb adduction - positive Froments sign.
Weak flexion of 4th 5th fingers
Loss of sensation of the dorsal and palmar surfaces of the fifth and medial aspect of fourth digits.
Sciatic nerve palsy L4/5 S1/2
Weak knee flexion Loss all muscles below knee- Flaccid foot drop intact knee jerk, absent ankle jerk and plantar response sensory loss posterior thigh and all below knee
Femoral nerve palsy L2-4
Weak knee extension slight hip foexion weakness preserved adductor loss knee jerk sensory loss inner thigh and leg
Common peroneal nerve palsy
foot drop, loss of eversion ONLY Sensory loss over dorsum foot,
Foot drop differentials
Inversion normal peroneal nerve palsy, absent with L5 radiculopathy. Sciatic- flaccid foto drop If ankle jerk absent- S1 lesion, normal- common peroneal nerve, increased= UMN lesion or MND
Paraplegia in extension only
intracranial lesion likely
Paraplegia in flexion and extension–> lesion location
spinal cord lesion likely e.g. Cord compression (UMN weakness below, LMN weakness at level. sensory level) Transverse myelitis Anterior spinal artery occlusion (dorsal column spared)
Paraplegia with arm involvement
Cervical spondylosis Syringomyelia MND MS
Peripheral neuropathy with paraplegia
B12 deficiency Freidreichs ataxia Cancer Hereditary spastic paraplegia Syphilis
Cord compression signs- Cervical
If upper- UMN signs upper and lower limbs. Paralysis of diaphragm if above C4 If C5-C8 - LMN rhomboids, delts, biceps, brachioradialis -UMN rest upper and lower limbs - absent biceps - If C8- LMN weakness and wasting intrinsic muscles hand, UMN lower limbs
Subacute combined degeneration of cord (B12 deficency)- features
Symmetric posterior column (vib, prop) loss Symmetric UMN signs in LL BUT with absent ankle jerks
Extensor plantar response, absent ankle jerk causes
o Subacute combined degeneration of cord- B12 deficiency o Conus medullaris lesion o Combination IMN lesioj with cauda equina compression or peripheral neuropathy o Syphilis o Friedreich’s ataxia o Diabetes mellitus o Adrenoleukodystrophy or metachromatic leukodystrophy
BRown Sequard syndrome= hemisection spinal cord
MOTOR= UMN below level on same side. LMN at level same side SENSORY= Pain and temp CONTRALATERAL, Vib Prop SAME SIDE. Light touch normal
Spinothalamic- pain and temperature- loss only
o Syringomyelia- cape distribution o Brown Sequard syndrome- contralateral leg o Anterior spinal artery thrombosis o Lateral medullary syndrome- contralateral to other signs o Peripheral neuropathy- DM, amyloid, fabrys
Dorsal column- vibration and proprioception- loss only
o Subacute combined degeneration o Brown Sequard syndrome (ipsilateral leg) o Spinocerebellar degeneration (Friedreich’s ataxia) o Multiple sclerosis o Tabes dorsalis o Sensory neuropathy or ganglionopathy- e.g. carcinoma o Peripheral neuropathy from diabetes mellitus or hypothyroidism
Syringomyelia (Cetral cavity in spinal cord)
o Loss of pain and temperature over neck, shoulders and arms- cape distribution o Amyotrophy- weakness, atrophy, areflexia of arms o Upper motor neurone signs in lower limbs
Causes proximal muscle weakness
Myopathic Neuromuscular junction disorder- e.g. myasthenia gravis Neurogenic o Kugelberg-Welander disease- proximal muscle wasting and fasciculations due to anterior horn cell damage- autosomal recessive o Motor neurone disease o Polyradiculopathy
Causes myopathy
Hereditary muscular dystrophy Congenital myopathies ACQUIRED Polymyositis or dermatomyositis Alcohol Carcinoma Endocrine- Periodic paralysis Osteomalacia Drugs Sarcoidosis Inclusion body myositis- proximal leg and distal arm weakness –> Finger flexors, quads Endocrine causes- e.g. hypothyroidism, hyperthyroidism, cushings syndrome, acromegaly, hypopituitarism Drug causes- fibrates, chloroquine, steroids
Causes proximal myopathy and peripheral neuropathy
o Paraneoplastic syndrome o Alcohol o Connective tissue disease
Duchennes Muscular Dystrophy (+Beckers)
pseudohypertrophy calf males early proximal weakness Dialted cardiomyopathy Severe progressive kyphoscoliosis HIGH CK Tendon reflexes in proportion to weakness
Limb Girdle Musuclar dystrophy
- Shoulder or pelvic girdle affected - Onset third decade - Face and heart spared
Fascioscapulohumeral Muscular dystrophy
- Facial and pectoral girdle weakness w hypertrophy of deltoids
Myotonic Dystrophy
Observe Facial features= frontal balding, bilateral ptosis, dull triangular facies, temporalis + masseter + sternomastoid atrophy Cataracts +/- glasses Neck - sternocleidomastoid atrophy -weak neck flexion, preserved extension Upper limbs- OFTEN STEM -grip myotonia -percussion myotonia- tap over thenar eminence= contraction then slow relaxation of abductor pollicis brevis -wasting and weakness- more over forearm muscles -sensory changes may occur- peripheral neuropathy- usually mild -fingers- evidence finger pricks from diabetes Chest -gynaecomastia -cardiovascular system- cardiomyopathy +/- pacemaker Proceed -testicular atrophy -Lower limbs if time -Urinalysis for glycosuria -Mental status- common to have mental retardation -EMG
Causes peripheral neuropathy
DAM IT BICH Drugs/toxins/Alcohol Amyloid Metabolic- diabetes, uraemia, thyroid Immune- GBS Tumour B vitamins- B12, B1 deficiency, B6 excess Idiopathic CT disease, vasculitis Hereditary
Nerve conduction findings- demyelinating
Demyelinating- slowed velocity, increased distal altency, normal amplitude
Nerve conduction findings- axonal
Low amplitude, normal velocity
Peripheral neuropathy- Motor Symmetrical
Guillain Barre- ascending Spinal muscular atrophy- global Hereditary motor neuropathy (distal)
Peripheral neuropathy- Motor Asymmetrical + distal
Multifocal acquired motor axonopathy Multifocal motor neuropathy with conduction block
Peripheral neuropathy- Sensory Spinothalamic- pain + temp
Fabrys Diabetes Amyloid Hereditary sensory
Peripheral neuropathy Sensory Proprioception, vibration
B12 deficiency
Peripheral neuropathy Sensory All modalities
Chronic immune sensory polyradiculoppathy Vit E deficiency Ganglionopathy
Peripheral neuropathy Mixed sensorimotor Symmetrical
Charcot marie tooth (distal)
Peripheral neuropathy Mixed sensorimotor Asymmetrical
Hereditary neuropathy with pressure palsies Multifocal acquired demyelinating sensory and motor neuropathy (MADSAM)- distal and proximal Mononeuritis multiplex (named nerves)
Causes fasciculations
o Benign idiopathic fasciculations o Motor neurone disease o Motor root compression o Malignant neuropathy o Spinal muscular atrophy/bulbospinal muscular atrophy o Any motor neuropathy
Causes thickened nerves
o Hereditary motor and sensory neuropathy o Acromegaly o Chronic inflammatory demyelinating polyradiculoneuropathy o Amyloidosis o Leprosy o Others- sarcoidosis, neurofibromatosis
Causes mononeuritis multiplex
CHRONIC Multiple compressive neuropathies, especially with joint deforming arthritis Sarcoidosis Acromegaly Leprosy Lyme disease Carcinoma Idiopathic ACUTE Diabetes mellitus Polyarteritis nodosa or CT Dx- SLE, RA
Wasting small muscles hand
Nerve lesions Median and ulnar nerves Brachial plexus Peripheral motor neuropathy Anterior horn cell disease Motor neurone disease Polio Spinal muscular atrophies Myopathy Myotonic dystrophy- forearms more affected than hands Distal myopathy Spinal cord lesions Syringomyelia Cervical spondylosis with compression of C8 segment Other- e.g. tumour Trophic disorders Arthropathies (disuse) Ischemia, including vasculitis Shoulder-hand syndrome
Extrapyramidal Gait- e.g. parkinsons
- Hesitation in starting
- Shuffling
- Freezing
- Festination (hurrying forwards to attempt to catch up with centre of gravity)
- Propulsion (pull towards you, unable to stop) + Retropulsion (pull backwards, unable to stop)
Cerebellar gait
- Drunken, wide based or reeling on narrow base, patient staggers to affected side
Apraxic gait
- Prefrontal lobe
- Feet appear glued to floor when erect but move more easily when patient supine.
Posterior column gait
- Clumsy, slapping down of feet on broad base
Proximal vs distal weakness pattern gait
- Distal weakness
- High stepping gait
- Proximal weakness
- Waddling gait
Causes cerebellar disease
- Unilateral
- Space occupying lesion (tumour, abscess, granuloma)
- Ischaemia- vertebrobasilar disease
- Paraneoplastic syndrome
- Multiple sclerosis
- Trauma
- Bilateral
- Drugs (E.g. phenytoin)
- Friedreichs ataxia
- Hypothyroidism
- Paraneoplastic syndrome
- Multiple sclerosis
- Trauma
- Arnold Chiari malformation
- Alcohol
- Large space occupying lesion, cerebrovascular disease, rare metabolic diseases
- Midline
- Paraneoplastic syndrome
- Midline tumour
- Rostral Vermis Lesion (lower limbs only affected)
- Alcohol (most common cause of cerebellar lesion)
Friedreichs ataixia
- Often young with
- Cerebellar signs- bilateral, including nystagmus
- Posterior column loss in limbs
- Upper motor neurone signs in limbs (although ankle reflexes are absent)
- Peripheral neuropathy
- Optic atrophy
- Pes cavus, cocking of the toes, kyphoscoliosis
- Cardiomyopathy (ECG abnormalities)
- Diabetes mellitus
Causes pes cavus
- Freidreichs ataxia or other spinocerebellar degenerations
- Hereditary motor and sensory neuropathy (CMT)
- Neuropathies in childhood
- Idiopathic
Causes spastic and ataxic parapesis
- In adolescenceà spinocerebellar degeneration (E.g. Friedreichs ataxia)
- In young adultsà MS, Syphilitic meningiomyelitis, spinocerebellar ataxia, arnold-chiari malformation or other lesions at craniospinal junction
- In later lifeà Multiple sclerosis, syringomyelia, infarction (in upper pons or internal capsule bilaterally- ataxic hemiparesis), lesion at the craniospinal junction (e.g. meningioma), spinocerebellar ataxia
Causes parkinsonism
- Idiopathic= parkinsons disease
- Drugs- phenothiazines, methyldopa
- Postencephalitis
- Others
- Toxins, wilsons, steele-richardson syndrome, multisystem atrophy, syphilis, tumou
Causes chorea
- Huntingtons disease- autosomal dominant
- Sydenhams chorea- rheumatic fever
- Senility
- Wilsons disease
- Drugs- phenothiazines, OCP, phenytoin, L dopa
- Vasculitis or CT Dx- e.g. SLE
- Thyrotoxicosis- rare
- Polycythaemia or other hyperviscosity causes- rare
- Viral encephalitis- rare
Chorea
- Extrapyramidal choreifom movement disorder
- Choreiform movements non repetitive, abrupt, involuntary, more distal, jerky movements
- Patient often attempts to disguise by completing involuntary movement with voluntary one
- Caused by lesion in corpus striatum
- Hemiballismus- unliateral, rotary movements of proximal joints, caused by subthalamic nucleus lesion on opposite side
- Athetosis- slow, sinuous distal writhing at rest- outer segment of putamen
Assess
- Shake hand – variability of sustained grip = milkmaid grip
- Hold hands out- choreic posture- finger and thumb hyperextension and wrist flexion due to hypotonia
- Signs vasculitis
- Face
- Eyes- exophthalmous, kayser-fleischer rings, conjunctival injection (ataxia-telangectasia)
- Poke out tongue- serpentine tongue
- Rash- SLE
- If young- examine CV system for rheumatic fever
- Test for pendular knee jerks and examine higher centres for huntingtons disease
Grading power
0= none 1= flicker 2= no gravity 3= gravity 4= resistance 5= normal
UMN findings
pyramidal weakness (upper limb extensor, lower limb flexor) increased tone (spastic) clonus hyperreflexia, upgoing plantar no wasting/fasciculations
LMN findings
weakness wasting fasciculations (esp ant horn cell) decreased/absent reflexes Decreased tone (flaccid)
Spastic parapesis
Increased tone in both limbs
Hyper reflexia
Ankle clonus
Weakness bialteral lower limbs
Wasting
Causes spastic parapesis
Trauma, Tumour, OA
MS, transverse myelitis
MND
Friedreichs ataxia
Hereditary spastic parapesis
Subacute combined degeration of cord
Syringomyelia
HIV, syphilis
Large fiber neuropathy is
dorsal column= proprioception and vibration
small fibre neuropathy is
spinothalamic- pain and temperature
cervical myelopathy
- Upper limb-?scar over neck. Older patient. Fasciculations, weakness and wasting of biceps, brachioradialis, deltoids. Absent or inverted biceps and supinator jerks (triceps contraction, finger flexion) +/- positive hoffmans. Weak elbow flexion, forearm supination, shoulder abduction. Numbness in C5-7 distriution- lateral arm, forearm and hand (thumb to fourth finger)
- Lower limb findings- spastic parapesis with impaired dorsal column- wide based, scissor gait with impaired rombergs. Hypertonia, hyperreflexia, extensor plantar response. Impaired proprioception and vibration sense but preserved pain and temperature.
Differential diagnosis for spastic parapesis with impaired dorsal column
- Cervical myelopathy- LMN upper limbs, inversion of reflexes, hyperreflexia lower linbs
- Freidreichs ataxia- absent ankle jerks and extensor plantar response. Pes cavus, kyphoscoliosis, cerebellar signs
- Multiple sclerosis- cerebellar signs, optic atrophy
- Taboparesis- absent ankle jerks and extensor plantars
- Subacute combined degeneration of the cord- absent ankle jerks and extensor plantars, peripheral neuropathy in stocking distribution, anaemia, jaundice, glossitis, splenomegaly
Causes distal wasting and weakness
Hereditary motor sensory neuropathy (charcot marie tooth), distal spinal muscular atrophy, inclusion body myositis, other distal myopathy
Ulnar Nerve Palsy- C8-T1
Observation
Evidence of scar indicating surgery or trauma over ulnar nerve at (?elbow ?wrist).
Resting flexion deformity of the 4th and 5th finger (ulnar claw)
Wasting of the intrinsic muscles of the hand and hypothenar eminence
Tone and reflexes were normal.
Power was reduced in
finger abduction and adduction,
thumb adduction - positive Froments sign.
Weak flexion of 4th 5th fingers
Loss of sensation of the dorsal and palmar surfaces of the fifth and medial aspect of fourth digits.
Median Nerve Palsy C6-T1
- Weakness of wrist flexors and pronators
- Weak thumb abduction, flexion, opposition
- Wasting thenar eminence
- Hand of benediction- when trying to make a fist- unable to flex at MCP or extend at IP of index and middle fingerà so first 3 digits remain in extension
- Sensory loss over palm- thumb and 2.5, and dorsal- finger tips of same
Positive tinnels, phalens–> carpal tunnel syndrome
Radial Nerve Palsy C5-8
- Wrist drop- Weak wrist extension, finger extension. Finger abduction appears weak because hard to spread fingers when flexed.
- Elbow extension loss if above spiral groove, preserved if below. Supination- in spiral groove
- Sensory loss over anatomical snuff box
Hereditary motor and sensory neuropathy (Charcot Marie Tooth)
Pes Cavus- short, high arched feet with hammer toes Distal muscle atrophy (not above elbows or middle 1/3 thighs) Absent reflexes Minimal sensory loss Thickened nerves
Brachial plexus lesions
Complete- LMN whole arm, including sensory loss. +/- Horners syndrome Upper trunk- loss shoulder and elbow, sensory over lateral arm and thumb Lower trunk- claw hand, intrinsic muscle paralysis, sensory loss ulnar hand/forearm, horners syndrome
Hereditary motor and sensory neuropathy (Charcot Marie Tooth)
Pes Cavus- short, high arched feet with hammer toes Distal muscle atrophy (not above elbows or middle 1/3 thighs) Absent reflexes Minimal sensory loss Thickened nerves
Hereditary motor and sensory neuropathy (Charcot Marie Tooth)
Pes Cavus- short, high arched feet with hammer toes Distal muscle atrophy (not above elbows or middle 1/3 thighs) Absent reflexes Minimal sensory loss Thickened nerves
Causes distal wasting and weakness
Hereditary motor sensory neuropathy (charcot marie tooth), distal spinal muscular atrophy, inclusion body myositis, other distal myopathy
Differential diagnosis for spastic parapesis with impaired dorsal column
- Cervical myelopathy- LMN upper limbs, inversion of reflexes, hyperreflexia lower linbs
- Freidreichs ataxia- absent ankle jerks and extensor plantar response. Pes cavus, kyphoscoliosis, cerebellar signs
- Multiple sclerosis- cerebellar signs, optic atrophy
- Taboparesis- absent ankle jerks and extensor plantars
- Subacute combined degeneration of the cord- absent ankle jerks and extensor plantars, peripheral neuropathy in stocking distribution, anaemia, jaundice, glossitis, splenomegaly
cervical myelopathy
- Upper limb-?scar over neck. Older patient. Fasciculations, weakness and wasting of biceps, brachioradialis, deltoids. Absent or inverted biceps and supinator jerks (triceps contraction, finger flexion) +/- positive hoffmans. Weak elbow flexion, forearm supination, shoulder abduction. Numbness in C5-7 distriution- lateral arm, forearm and hand (thumb to fourth finger)
- Lower limb findings- spastic parapesis with impaired dorsal column- wide based, scissor gait with impaired rombergs. Hypertonia, hyperreflexia, extensor plantar response. Impaired proprioception and vibration sense but preserved pain and temperature.
small fibre neuropathy is
spinothalamic- pain and temperature
Large fiber neuropathy is
dorsal column= proprioception and vibration
Causes spastic parapesis
Trauma, Tumour, OA
MS, transverse myelitis
MND
Friedreichs ataxia
Hereditary spastic parapesis
Subacute combined degeration of cord
Syringomyelia
HIV, syphilis
Spastic parapesis
Increased tone in both limbs
Hyper reflexia
Ankle clonus
Weakness bialteral lower limbs
Wasting
LMN findings
weakness wasting fasciculations (esp ant horn cell) decreased/absent reflexes Decreased tone (flaccid)
UMN findings
pyramidal weakness (upper limb extensor, lower limb flexor) increased tone (spastic) clonus hyperreflexia, upgoing plantar no wasting/fasciculations
Grading power
0= none 1= flicker 2= no gravity 3= gravity 4= resistance 5= normal
Chorea
- Extrapyramidal choreifom movement disorder
- Choreiform movements non repetitive, abrupt, involuntary, more distal, jerky movements
- Patient often attempts to disguise by completing involuntary movement with voluntary one
- Caused by lesion in corpus striatum
- Hemiballismus- unliateral, rotary movements of proximal joints, caused by subthalamic nucleus lesion on opposite side
- Athetosis- slow, sinuous distal writhing at rest- outer segment of putamen
Assess
- Shake hand – variability of sustained grip = milkmaid grip
- Hold hands out- choreic posture- finger and thumb hyperextension and wrist flexion due to hypotonia
- Signs vasculitis
- Face
- Eyes- exophthalmous, kayser-fleischer rings, conjunctival injection (ataxia-telangectasia)
- Poke out tongue- serpentine tongue
- Rash- SLE
- If young- examine CV system for rheumatic fever
- Test for pendular knee jerks and examine higher centres for huntingtons disease
Causes chorea
- Huntingtons disease- autosomal dominant
- Sydenhams chorea- rheumatic fever
- Senility
- Wilsons disease
- Drugs- phenothiazines, OCP, phenytoin, L dopa
- Vasculitis or CT Dx- e.g. SLE
- Thyrotoxicosis- rare
- Polycythaemia or other hyperviscosity causes- rare
- Viral encephalitis- rare
Causes parkinsonism
- Idiopathic= parkinsons disease
- Drugs- phenothiazines, methyldopa
- Postencephalitis
- Others
- Toxins, wilsons, steele-richardson syndrome, multisystem atrophy, syphilis, tumou
Causes spastic and ataxic parapesis
- In adolescenceà spinocerebellar degeneration (E.g. Friedreichs ataxia)
- In young adultsà MS, Syphilitic meningiomyelitis, spinocerebellar ataxia, arnold-chiari malformation or other lesions at craniospinal junction
- In later lifeà Multiple sclerosis, syringomyelia, infarction (in upper pons or internal capsule bilaterally- ataxic hemiparesis), lesion at the craniospinal junction (e.g. meningioma), spinocerebellar ataxia
Causes pes cavus
- Freidreichs ataxia or other spinocerebellar degenerations
- Hereditary motor and sensory neuropathy (CMT)
- Neuropathies in childhood
- Idiopathic
Friedreichs ataixia
- Often young with
- Cerebellar signs- bilateral, including nystagmus
- Posterior column loss in limbs
- Upper motor neurone signs in limbs (although ankle reflexes are absent)
- Peripheral neuropathy
- Optic atrophy
- Pes cavus, cocking of the toes, kyphoscoliosis
- Cardiomyopathy (ECG abnormalities)
- Diabetes mellitus
Causes cerebellar disease
- Unilateral
- Space occupying lesion (tumour, abscess, granuloma)
- Ischaemia- vertebrobasilar disease
- Paraneoplastic syndrome
- Multiple sclerosis
- Trauma
- Bilateral
- Drugs (E.g. phenytoin)
- Friedreichs ataxia
- Hypothyroidism
- Paraneoplastic syndrome
- Multiple sclerosis
- Trauma
- Arnold Chiari malformation
- Alcohol
- Large space occupying lesion, cerebrovascular disease, rare metabolic diseases
- Midline
- Paraneoplastic syndrome
- Midline tumour
- Rostral Vermis Lesion (lower limbs only affected)
- Alcohol (most common cause of cerebellar lesion)
Proximal vs distal weakness pattern gait
- Distal weakness
- High stepping gait
- Proximal weakness
- Waddling gait
Posterior column gait
- Clumsy, slapping down of feet on broad base
Apraxic gait
- Prefrontal lobe
- Feet appear glued to floor when erect but move more easily when patient supine.
Cerebellar gait
- Drunken, wide based or reeling on narrow base, patient staggers to affected side
Extrapyramidal Gait- e.g. parkinsons
- Hesitation in starting
- Shuffling
- Freezing
- Festination (hurrying forwards to attempt to catch up with centre of gravity)
- Propulsion (pull towards you, unable to stop) + Retropulsion (pull backwards, unable to stop)
Wasting small muscles hand
Nerve lesions Median and ulnar nerves Brachial plexus Peripheral motor neuropathy Anterior horn cell disease Motor neurone disease Polio Spinal muscular atrophies Myopathy Myotonic dystrophy- forearms more affected than hands Distal myopathy Spinal cord lesions Syringomyelia Cervical spondylosis with compression of C8 segment Other- e.g. tumour Trophic disorders Arthropathies (disuse) Ischemia, including vasculitis Shoulder-hand syndrome
Causes mononeuritis multiplex
CHRONIC Multiple compressive neuropathies, especially with joint deforming arthritis Sarcoidosis Acromegaly Leprosy Lyme disease Carcinoma Idiopathic ACUTE Diabetes mellitus Polyarteritis nodosa or CT Dx- SLE, RA
Causes thickened nerves
o Hereditary motor and sensory neuropathy o Acromegaly o Chronic inflammatory demyelinating polyradiculoneuropathy o Amyloidosis o Leprosy o Others- sarcoidosis, neurofibromatosis
Causes fasciculations
o Benign idiopathic fasciculations o Motor neurone disease o Motor root compression o Malignant neuropathy o Spinal muscular atrophy/bulbospinal muscular atrophy o Any motor neuropathy
Peripheral neuropathy Mixed sensorimotor Asymmetrical
Hereditary neuropathy with pressure palsies Multifocal acquired demyelinating sensory and motor neuropathy (MADSAM)- distal and proximal Mononeuritis multiplex (named nerves)
Peripheral neuropathy Mixed sensorimotor Symmetrical
Charcot marie tooth (distal)
Peripheral neuropathy Sensory All modalities
Chronic immune sensory polyradiculoppathy Vit E deficiency Ganglionopathy
Peripheral neuropathy Sensory Proprioception, vibration
B12 deficiency
Peripheral neuropathy- Sensory Spinothalamic- pain + temp
Fabrys Diabetes Amyloid Hereditary sensory
Peripheral neuropathy- Motor Asymmetrical + distal
Multifocal acquired motor axonopathy Multifocal motor neuropathy with conduction block
Peripheral neuropathy- Motor Symmetrical
Guillain Barre- ascending Spinal muscular atrophy- global Hereditary motor neuropathy (distal)
Nerve conduction findings- axonal
Low amplitude, normal velocity
Nerve conduction findings- demyelinating
Demyelinating- slowed velocity, increased distal altency, normal amplitude
Causes peripheral neuropathy
DAM IT BICH Drugs/toxins/Alcohol Amyloid Metabolic- diabetes, uraemia, thyroid Immune- GBS Tumour B vitamins- B12, B1 deficiency, B6 excess Idiopathic CT disease, vasculitis Hereditary
Myotonic Dystrophy
Observe Facial features= frontal balding, bilateral ptosis, dull triangular facies, temporalis + masseter + sternomastoid atrophy Cataracts +/- glasses Neck - sternocleidomastoid atrophy -weak neck flexion, preserved extension Upper limbs- OFTEN STEM -grip myotonia -percussion myotonia- tap over thenar eminence= contraction then slow relaxation of abductor pollicis brevis -wasting and weakness- more over forearm muscles -sensory changes may occur- peripheral neuropathy- usually mild -fingers- evidence finger pricks from diabetes Chest -gynaecomastia -cardiovascular system- cardiomyopathy +/- pacemaker Proceed -testicular atrophy -Lower limbs if time -Urinalysis for glycosuria -Mental status- common to have mental retardation -EMG
Fascioscapulohumeral Muscular dystrophy
- Facial and pectoral girdle weakness w hypertrophy of deltoids
Limb Girdle Musuclar dystrophy
- Shoulder or pelvic girdle affected - Onset third decade - Face and heart spared
Duchennes Muscular Dystrophy (+Beckers)
pseudohypertrophy calf males early proximal weakness Dialted cardiomyopathy Severe progressive kyphoscoliosis HIGH CK Tendon reflexes in proportion to weakness
Causes proximal myopathy and peripheral neuropathy
o Paraneoplastic syndrome o Alcohol o Connective tissue disease
Causes myopathy
Hereditary muscular dystrophy Congenital myopathies ACQUIRED Polymyositis or dermatomyositis Alcohol Carcinoma Endocrine- Periodic paralysis Osteomalacia Drugs Sarcoidosis Inclusion body myositis- proximal leg and distal arm weakness –> Finger flexors, quads Endocrine causes- e.g. hypothyroidism, hyperthyroidism, cushings syndrome, acromegaly, hypopituitarism Drug causes- fibrates, chloroquine, steroids
Causes proximal muscle weakness
Myopathic Neuromuscular junction disorder- e.g. myasthenia gravis Neurogenic o Kugelberg-Welander disease- proximal muscle wasting and fasciculations due to anterior horn cell damage- autosomal recessive o Motor neurone disease o Polyradiculopathy
Syringomyelia (Cetral cavity in spinal cord)
o Loss of pain and temperature over neck, shoulders and arms- cape distribution o Amyotrophy- weakness, atrophy, areflexia of arms o Upper motor neurone signs in lower limbs
Dorsal column- vibration and proprioception- loss only
o Subacute combined degeneration o Brown Sequard syndrome (ipsilateral leg) o Spinocerebellar degeneration (Friedreich’s ataxia) o Multiple sclerosis o Tabes dorsalis o Sensory neuropathy or ganglionopathy- e.g. carcinoma o Peripheral neuropathy from diabetes mellitus or hypothyroidism
Spinothalamic- pain and temperature- loss only
o Syringomyelia- cape distribution o Brown Sequard syndrome- contralateral leg o Anterior spinal artery thrombosis o Lateral medullary syndrome- contralateral to other signs o Peripheral neuropathy- DM, amyloid, fabrys
BRown Sequard syndrome= hemisection spinal cord
MOTOR= UMN below level on same side. LMN at level same side SENSORY= Pain and temp CONTRALATERAL, Vib Prop SAME SIDE. Light touch normal
Extensor plantar response, absent ankle jerk causes
o Subacute combined degeneration of cord- B12 deficiency o Conus medullaris lesion o Combination IMN lesioj with cauda equina compression or peripheral neuropathy o Syphilis o Friedreich’s ataxia o Diabetes mellitus o Adrenoleukodystrophy or metachromatic leukodystrophy
Subacute combined degeneration of cord (B12 deficency)- features
Symmetric posterior column (vib, prop) loss Symmetric UMN signs in LL BUT with absent ankle jerks
Cord compression signs- Cervical
If upper- UMN signs upper and lower limbs. Paralysis of diaphragm if above C4 If C5-C8 - LMN rhomboids, delts, biceps, brachioradialis -UMN rest upper and lower limbs - absent biceps - If C8- LMN weakness and wasting intrinsic muscles hand, UMN lower limbs
Peripheral neuropathy with paraplegia
B12 deficiency Freidreichs ataxia Cancer Hereditary spastic paraplegia Syphilis
Paraplegia with arm involvement
Cervical spondylosis Syringomyelia MND MS
Paraplegia in flexion and extension–> lesion location
spinal cord lesion likely e.g. Cord compression (UMN weakness below, LMN weakness at level. sensory level) Transverse myelitis Anterior spinal artery occlusion (dorsal column spared)
Paraplegia in extension only
intracranial lesion likely
Foot drop differentials
Inversion normal peroneal nerve palsy, absent with L5 radiculopathy. Sciatic- flaccid foto drop If ankle jerk absent- S1 lesion, normal- common peroneal nerve, increased= UMN lesion or MND
Common peroneal nerve palsy
foot drop, loss of eversion ONLY Sensory loss over dorsum foot,
Femoral nerve palsy L2-4
Weak knee extension slight hip foexion weakness preserved adductor loss knee jerk sensory loss inner thigh and leg
Sciatic nerve palsy L4/5 S1/2
Weak knee flexion Loss all muscles below knee- Flaccid foot drop intact knee jerk, absent ankle jerk and plantar response sensory loss posterior thigh and all below knee
Ulnar Nerve Palsy- C8-T1
Observation
Evidence of scar indicating surgery or trauma over ulnar nerve at (?elbow ?wrist).
Resting flexion deformity of the 4th and 5th finger (ulnar claw)
Wasting of the intrinsic muscles of the hand and hypothenar eminence
Tone and reflexes were normal.
Power was reduced in
finger abduction and adduction,
thumb adduction - positive Froments sign.
Weak flexion of 4th 5th fingers
Loss of sensation of the dorsal and palmar surfaces of the fifth and medial aspect of fourth digits.
Median Nerve Palsy C6-T1
- Weakness of wrist flexors and pronators
- Weak thumb abduction, flexion, opposition
- Wasting thenar eminence
- Hand of benediction- when trying to make a fist- unable to flex at MCP or extend at IP of index and middle fingerà so first 3 digits remain in extension
- Sensory loss over palm- thumb and 2.5, and dorsal- finger tips of same
Positive tinnels, phalens–> carpal tunnel syndrome
Radial Nerve Palsy C5-8
- Wrist drop- Weak wrist extension, finger extension. Finger abduction appears weak because hard to spread fingers when flexed.
- Elbow extension loss if above spiral groove, preserved if below. Supination- in spiral groove
- Sensory loss over anatomical snuff box
Brachial plexus lesions
Complete- LMN whole arm, including sensory loss. +/- Horners syndrome Upper trunk- loss shoulder and elbow, sensory over lateral arm and thumb Lower trunk- claw hand, intrinsic muscle paralysis, sensory loss ulnar hand/forearm, horners syndrome
Hereditary motor and sensory neuropathy (Charcot Marie Tooth)
Pes Cavus- short, high arched feet with hammer toes Distal muscle atrophy (not above elbows or middle 1/3 thighs) Absent reflexes Minimal sensory loss Thickened nerves
Hereditary motor and sensory neuropathy (Charcot Marie Tooth)
Pes Cavus- short, high arched feet with hammer toes Distal muscle atrophy (not above elbows or middle 1/3 thighs) Absent reflexes Minimal sensory loss Thickened nerves
