Neuro - Peripheral Neuropathy, Degenerative Cervical Myelopathy, Syringomyelia And Subacute Degeneration Of Spine, head injury CT criteria

Question 1

What is degenerative cervical myelopathy? Name some risk factors and symptoms

Answer 1

Risk factors: smoking, genetics and occupation (high axial loading)

Presentation: subtle symptoms

• Sx vary in severity day to day but sx will deteriorate over time
• Pain (neck, upper and lower limb)
• Loss of motor function: loss of dexterity ex can’t hold form
• Loss of sensory function (numbness)
• Loss of autonomic function (urinary and or faecal in continence)
• Hoffman sign: reflex to assess for cervical myelopathy - gently flick one finger of patient’s hand (positive results in reflex twitching of the other fingers on the same hand in response to the flick)

Question 2

Degenerative cervical myelopathy: investigations and management

Answer 2

• MRI cervical spine (gold standard): may show disc degeneration and ligament hypertrophy with accompanying cord signal change
• Patients need urgent r/w for assessment by specialised spinal services (neurosurgery or TO spinal surgery)
• Tx: early tx within 6 months of sx offers best change of recovery - decompressive surgery

Question 3

Peripheral neuropathy: name conditions which cause predominantly motor loss:

Answer 3

-Guillain-Barre syndrome
-Porphyria
-Lead poisoning
-Hereditary sensorimotor neuropathies (HSMN) - Charcot-Marie-Tooth
-Chronic inflammatory demyelinating polyneuropathy (CIDP)
diphtheria

Question 4

Peripheral neuropathy: name conditions which cause predominantly sensory loss

Answer 4

• Diabetes
• Uraemia
• Leprosy
• Alcoholism
• Vitamin B12 deficiency
• Amyloidosis

Question 5

What is subacute combined degeneration of the spinal cord?

Answer 5

• Due to vitamin B12 deficiency
• Dorsal + lateral columns affected
• Joint position and vibration sense lost first then distal paraesthesia
• Upper motor neuron signs typically develop in the legs, classically extensor plantars, brisk knee reflexes, absent ankle jerks
• If untreated stiffness and weakness persist

Question 6

What is syringomyelia? Name some causes of this condition

Answer 6

• Collection of CSF within the spinal cold

- Causes: chiari malformation, trauma, tumours, idiopathic

Question 7

Describe the presentation of someone with syringomyelia

Answer 7

• Cape-like (neck and arms) loss of sensation to temperature but presentation of dorsal column modalities.
• Due to crossing spinothalamic tracts in the anterior commisure of the spinal cord are the first tracts affected by the syrinx
• Other sx: spastic weakness (upper limbs), paraesthesia, neuropathic pain, upgoing plantars, bowel and bladder dysfunction.
• Scoliosis may appear if no tx

Question 8

What investigations and management will you perform for someone with syringomyelia?

Answer 8

• Full MRI spine (excludes tumour/tethered cord) + MRI brain to exclude Chiari malformation
• Tx: directed at treating cause of syrinx - if persistent then can put shunt in

Question 9

Head trauma: name some criteria which require a CT scan within 1h of admitting

Answer 9

• GCS < 13 on initial assessment
• GSC < 15 at 2 hours after injury on assessment in ED
• Suspected open or depressed skull fracture
• Any sign of basal skull fracture
• Post-traumatic seizure
• Focal neurological deficit
• More than one episode of vomiting since the head injury

Question 10

Head trauma: name some criteria which require a CT scan within 8h of head injury

Answer 10

Patient is anticoagulated (and does not meet criteria for 1h CT)

OR

LoC/amnesia since head injury plus any of the following risk factors:

• Age >64
• Hx of bleeding/clotting disorder
• Dangerous mechanism of injury (eg fall >1 m or 5 stairs)
• More than 30 mins retrograde amnesia of events immediately before head injury

Question 11

when should you not image a head trauma?

Answer 11

• No 1h risk factors present
• No anticoagulation
• No LoC/amnesia since injury
• No 8h risk factors present

Question 12

Name some criteria for red flag sepsis

Answer 12

• Responds only to voice or pain/unresponsive
• Acute confusional state
• Systolic BP <90 mmHg or drop >40 from normal
• HR >130
• RR > 25
• Needs O2 to keep sats >92%
• Non-blanching rash, mottled, ashen, cyanosis
• NPU in last 18h or UO < 0.5ml/kg/hour
• Lactate >= 2 mmol/l
• Recent chemotherapy