Neurology

Question 1

Increased lower limb tone
Pyramidal weakness
Hyperreflexia
Upgoing plantars
Spastic scissoring gait
+/- sensory level
+/- dorsal column los

Answer 1

Spastic paraparesis

Question 2

Causes of bilateral spastic paraparesis

Answer 2

Inflammatory
–Transverse Myelitis
–Sarcoid

Vascular
–Spinal infarct

Mass lesion
–Spinal tumour
–myeloma

Paraneoplastic

Trauma/compression
–Trauma
–Cord compression
–Disc prolapse

Demyelination
—MS

Horn Cell
–MND

Congenital
–Cerebral Palsy
–Herediatary Spastic Paraparesis
–Freidrech’s

Question 3

What extra features to consider if spastic paraparaesis?

Answer 3

?Sensory level
–cord compression
–cord infarction
–transverse myelitis

?Dorsal column
–Demyelination (Multiple sclerosis)
–Friedreich’s ataxia
–Subacute combined degeneration of the cord
–Cervical myelopathy

?Spinothalamic loss
–Syringomyelia
–Anterior spinal artery infarction

Question 4

Ix for spastic paraparesis

Answer 4

MRI brain and spine (demyelination, trauma, cord compression)

Visual evoked potentials (if suspect demyelination)

Lumbar puncture (if suspect demyelination)

Bloods: FBC, U+E, LFT, bone profile, CRP, HIV, syphilis, HTLV-1, serum ACE, ESR, ANA, ANCA, antiphospholipid antibodies, immunoglobulins, AQP4 antibodies (NMO), paraneoplastic screen and serum electrophoresis, B12 (SACD of the cord)

Nerve conduction studies and EMG

Question 5

What separates sensory from cerebellar ataxia

Answer 5

Cerebellar - nystagmus and dysarthria
Rhombergs may help (though if positive does not exclude a cerebellar syndrome)

Sensory - impaired sensation (esp dorsal column - joint position and vibration)