Neuro- findings Flashcards
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
