Neurology COPY Flashcards
Secondary prevention of stroke
Anti-platelet therapy (LIFELONG)
- (1) Clopidogrel (1st line by RCP)
- (2) Aspirin AND Dipyridamole (1st line by NICE)
EXCEPTION: AF and Stroke
- Initial 14 days post-stroke –> Aspirin
- Secondary prevention –> Warfarin or DOAC (Apixaban)
Postural tremor
Most pronounced by arms are outstretched
Relieved at rest
Affects Hands and Arms
No other neurological signs (No Parkinsonism)
Diagnosis? Treatment?
Benign essential tremor
If functional impairment –> (1) Propranolol
If no functional impairment –> Observation
Fever
Headache
Progressive focal neurology
Seizures
Meningismus
CN nerve palsies
Papilloedema
Diagnosis? Ix? Tx?
Cerebral abscess
Ix: MRI Head (with Contrast) –> Ring-enhancing lesion
Tx
- Antibiotics
- AED
- +/- Dexamethasone
- +/- Surgical decompression and evacuation
Causes of cerebellar syndrome
SMART
- Stroke
- MS
- Alcohol
-
Rare
- FriedRich’s ataxia
- Trauma
PASTERIES
- Posterior fossa tumour
-
Alcohol
- B1 (Thiamine) deficiency
- B12 deficiency
- Multiple Sclerosis
- Trauma
- Rare
-
Inherited
- Friedrich’s ataxia
-
Epilepsy medication
- Phenytoin
- Stroke
Signs of cerebellar lesion
- Dysdiadochokinesia (inability w rapid alt movements) + Dysmetria (past pointing)
-
Ataxia
- Wide based gait
- Drunken gait
- Nystagmus
- Intention tremor (shaking fingers with nose-finger test)
- Slurred, staccato speech
- Hypotonia
- Rebound phenomenon
- Pronator drift
- Pendular reflexes
Sx of Lateral Medullary Syndrome
Cause?
Caused by Posterior circulation stroke
DANVAH (Ipsilateral signs - exception contralateral for loss of pain to limbs)
- Dysphagia
- Ataxia + Cerebellar signs (ipsilateral)
- Nystagmus
- Vertigo
-
Anaesthesia to Pain
- Ipsilateral for Face
- Contralateral for Limbs
- Horner’s syndrome
Friedrich’s Ataxia vs Charcot-Marie Tooth disease
Bilateral cerebellar signs (DANISH)
Pes cavus
UMN + LMN signs
Sensory loss
Kyphoscoliosis
Decreased visual acuity
Associated with HOCM and Diabetes
Diagnosis? Cause? Ix? Tx?
Friedrich’s ataxia
Autosomal recessive (GAA trinucleotide expansion in Frataxin gene)
Ix: Genetic testing
Tx:
- Conservative only
- Physiotherapists
- Orthoses
- Mobility aids
- Medical and Surgical
- Treat complications
Cerebellopontine angle syndrome - Sx
Signs
- CN 5-8 palsy
- Cerebellar signs
Causes = Acoustic neuroma
Tip: CN 5-8 (angle = 5, syndrome = 8)
Alzheimer’s disease - Sx, Ix, Tx
4A
-
Amnesia
- Short term memory loss
- Disorientiation
-
Aphasia
- Difficulty finding words
- Agnosia
- Apraxia
Ix: MMSE / MoCA
Tx
- Bio
- AChE inhibitor
- Donepazil (oral)
- Rivastigmine (transdermal)
- Memantine
- AChE inhibitor
- Psycho
- Social
Sx of
AD
LBD
VD
Pseudodementia
Delirium
Pick’s disease
Fever
Altered mental state / Confusion
Seizures
Rash
+/- Meningismus
No headache
Diagnosis? Tx?
Encephalitis
High-dose IV Aciclovir (empirical Tx for all cases)
Most common causes of meningitis
- Viral = most common
- Bacterial
- Streptococcus pneumonia (most common bacterial)
- Neisseria meningitides (2nd most common bacterial)
Triad of meningism
Headache
Neck stiffness
Photophobia
Viral vs Bacterial meningitis on CSF analysis
C/I to LP
Cushing’s triad: relative bradycardia, hypertension, irregular breathing
Papilloedema
Dilated pupil (↑ ICP –> blown pupil)
Focal neurological signs
Signs of cerebral herniation
Tx for bacterial meningitis
In community
- If non-blanching rash –> IV Benzylpenicillin
- Then, refer to A&E
In hospital
-
Antibiotics
- IV Ceftriaxone
- +/- Dexamethasone
Types of epilepsy
- Generalised
- Consulsive
- Tonic
- Clonic
- Tonic-Clonic
- Myoclonic
- Non-convulsive
- Absence
- Atonic
- Consulsive
- Focal / Partial
- Consciousness not impaired (simple)
- Consciousness impaired (complex)
- Partial with secondary Generalisation
Partial seizures - localising Sx
Tx for epilepsy
S/E of AEDs
Tuberous sclerosis - Cause, Sx
Tx of status epilepticus
Oh My Lord Phone the Anaesthetist
- Oxygen
- Buccal Midazolam (wait 10min, up to 2) = 1st line in the community
- IV Lorazepam (wait 5min, up to 2)
- IV Phenytoin
- Rapid induction anesthesia (Propofol)
Causes of CN7 palsy
LMN CN7 palsy
- Bell’s palsy (idiopathic)
- Ramsay-Hunt syndrome (HSV infection)
UMN CN7 palsy
- Stroke
- MS
Tx for Bell’s palsy
High dose oral Prednisolone (given within 72 hours)
+ Eye protection (artificial tears, tape)
If Ramsay-Hunt syndrome –> +/- Aciclovir
Large amplitude, unilateral chorea
Involuntary movement
Diagnosis? Cause? Treatment?
Hemiballismus
Lesion in contralateral basal ganglia
Tx: Dopamine antagonists
Self-resolves within months
Headache
Tight band around head
Gradual onset
Worse with stress
No N&V
Normal neurological examination
Diagnosis? Treatment?
Tension headache
Tx: Analgesia OTC
Episodes of headache
Unilateral, sharp orbital pain
Acute onset
Repeated attacks
Last 15-180min
Autonomic features (Rhinorrhoea, Partial Horner’s syndrome)
Diagnosis? Tx? Prevention?
Cluster headaches
Acute
- 100% Oxygen
- +/- Sumatriptan s.c. or nasal
Preventative
- Verapamil (CCB)
Zigzag lines or Paresthesia beforehand
Unilateral, Throbbing headache
Photophobia + Phonophobia
Nausea & Vomiting
Diagnosis? Tx?
Migraine
Acute
- Sumitriptan + Analgesia
Prevention
- β blockers (Propranolol)
- or Topiramate (AED)
Facial pain in CN V distribution
Episodic (up to 100 episodes daily)
Sudden onset, sharp pain
Trigged by touching face
No rash
Diagnosis? Cause? Tx?
Trigeminal neuralgia
Causes = Vascular compression (90%) or MS
Tx: Carbamazepine
Progressive lower limb weakness
Progressive lower limb spasticity
Pes cavus
Scissoring gait
Bilateral UMN signs
↑ tone in legs bilaterally
↓ power in legs bilaterally
↑ reflexes bilaterally
↓ sensation to pinprick to a level
Diagnosis? Tx?
Hereditary spastic paraparesis
Tx: PT/OT + Orthotics + Muscle relaxants +/- Surgery
Horner’s syndrome - Triad, Ix
Ptosis, Miosis, Anhidrosis
Ix: Topical cocaine eye drops
Normal ==> pupil dilation
Horner’s syndrome ==> no effect
Chorea
Restlessness
Motor impersistence (cannot hold tongue sticking out)
Loss of fine motor coordination
Impaired tandem walking
Slowing of saccade eye movements
Cognitive impairment
Behavioural / personality changes
Diagnosis? Ix? Tx?
Huntington’s disease
Autosomal dominant trinucleotide repeat disorder (CAG)
Genetic testing: > 36 CAG repeats
MRT: Caudate + Striatal atrophy
Symptomatic treatment only
Treat chorea ==> Tetrabenazine
Triad of normal pressure hydrocephalus
Wet (urinary incontinence)
Wobby (gait –> falls)
Wacky (dementia)
Definition of Anterior circulation stroke
2/3 = Partital
Total = 3/3
-
Higher cortical dysfunction
- L hemisphere ==> Dysphasia
- R hemisphere ==> Visual inattention or Neglect
- Hemiparesis or Sensory deficit
- Homonymous hemianopnia
Strokes
ACA
MCA
PCA
Midbrain stroke
PICA
AICA
Retinal artery
Basilar artery
I
Lacunar syndrome
Stroke in small perforating artery of MCA
1/4
- Pure sensory stroke
- Pure motor stroke
- Sensorimotor
- Ataxic hemiparesis
Tx of ischaemic stroke
- Onset < 4.5 hours
- IV Thrombolysis (Alteplase or tPA)
-
+/- Thrombectomy
- if within 6 hours of symptom onset
- or up to 24 hours if limited infarct core on CT/MRI
-
Aspirin
- Started after 24 hours
- For 14 days
- Onset > 4.5 hours
- Aspirin or Clopidogrel (for 14 days)
-
Post-stroke care
-
Stop Aspirin after 14 days ==> switch to Lifelong Clopidogrel
- Exception: AF and Stroke ==> anticoagulation (Warfarin, Apixaban)
- + Statin
-
+/- Carotid endartectomy
- If > 50% stenosis
- Modify cardiovascular risk factors
-
Stop Aspirin after 14 days ==> switch to Lifelong Clopidogrel
Tx of haemorrhagic stroke
ABCDE
URGENT CT scan ==> confirm haemorrhagic stroke
Surgical evacuation of haematoma
- +/- Coil or Clip bleeding aneurysm
- +/- Ventricular drainage
Manage ICP
Post-stroke care ==> modify cardiovascular risk factors
Tx of TIA
Onset of TIA < 7 days
- URGENT referral to TIA clinic (within 24 hours)
- If symptoms resolved –> Aspirin 300mg
Onset of TIA > 7 days
- Referral to TIA clinic (within 7 days)
Post-TIA care
- Clopidogrel (lifelong)
- Atorvastatin
- +/- Carotid endartectomy (if >50% occlusion)
- Modify cardiovascular risk factors
Extradural vs Subarachnoid vs Subdural
Cause
Onset
Symptoms
Vessel
CT changes
CT shows
Lemon-shaped haematoma
Does not cross suture line
Extradural haemorrhage
Surgical decompression and evacuation of haematoma
+/- AEDs
+/- ABx
+/- Lower ICP
CT scan shows
Hyperdense area
Located at base of skull (within basal cisterns)
Ix if -ve CT?
Subarachnoid haemorrhage
Ix:
(1) CT
(2) If -ve CT –> Lumbar puncture after > 12 hours ==> Xanthochromia (straw-coloured CSF)
Tx for subarachnoid haemorrhage
- ABCDE
- Nimodipine (CCB –> prevents cerebral artery vasospasm)
- Laxatives (prevent straining)
- Surgery
- Endovascular coiling
- Surgical clipping
CT changes in subdural haemorrhage
Concave haemorrhage
Hyperdense (in acute SDH)
Hypodense (in chronic SDH)
NOT limited by suture lines
Tx of subdural haemorrhage
If SDH < 10mm
- Conservative
- Serial imaging to monitor resorption
If SDH > 10mm or midline shift > 5mm
- Surgical
- Burr hole
- Craniotomy
- Hemicraniectomy
Acute onset
Headache
Painful ophthalmoplegia
Proptosis
Trigeminal nerve lesion (V1, V2)
—> no sensation, loss of corneal reflex
Horner’s syndrome (Ptosis)
Diagnosis?
Cavernous sinus thrombosis
CN 3-6 (not V3)
CN3, CN4, CN V1, CN V2, CN6
Tx of MND
- Riluzole (prolongs survival)
- Symptomatic treatments
- If respiratory symptoms –> BiPAP
Optic neuritis vs Papilloedema
Marcus-Gunn pupil
aka
Marcus-Gunn pupil
= Relative Afferent Pupillary Defect (RAPD)
MS presentations
Optic neuritis - painful, blurred vision, RAPD
Transverse myelitis - UMN signs, Paraesthesia below lesion, Lhermitte’s phenomenon
Cerebellar Sx - DANISH
Brainstem Sx - Ataxia, Diplopia, Bulbar pathology
Ix for MS
MRI (GAD-enhanced): demyelinating plaques = GOLD STANDARD
CSF electrophoresis: unmatched oligoclonal IgG bands
Evoked potentials: delayed conduction velocity (demyelination)
Tx of MS
Acute
- (1) IV Methylprednisolone
- (2) Plasma exchange
Once stable
- DMARDs
- Injectables (B-IFN s.c.)
- Oral (Fingolimod)
- Biologics (IV Alemtuzumab)
- Symptomatic relief
M gravis
Ix
Anti-nAChR antibody (M gravis)
Anti-VGCC antibody (Lamert-Eaton syndrome)
Tensilon test: AChE –> improves clinical features
Nerve conduction studies: repeated stimulation –> decrease in APs
Single-fibre EMG: “jitter”
Tx of Myasthenic crisis
Acute myasthenic crisis
- Measure FVC
- If low FVC –> Intubation + Ventilation
- IVIG or Plasma exchange
- +/- Prednisolone
Once stable
- (1) Anticholinesterase inhibitors (Neostimgmine)
- (2) Prednisolone
Sx of M gravis
Muscle
-
Muscle weakness worsens with repetitive use (= Fatiguabiiity)
- Affects eyes –> moves down
- Proximal muscle weakness (Arms > Legs)
Ocular
- Progressive Ptosis
- Diplopia
Bulbar
- Facial weakness –> Myasthenic snarl
- Slurred speech
- Dysphagia
MG crisis –> Acute respiratory failure
GBS
- cause
- Sx
Post-infection (Campylobacter jejuni) –> antibodies react with myelin
Sx
- Acute onset
-
Ascending motor and sensory peripheral neuropathy
-
Ascending symmetrical limb weakness
- Distal muscle weakness (Legs > Arms)
- LMN signs (flaccid paralysis, areflexia)
- LMN Facial nerve palsy
-
Ascending paraesthesia
- Impaired sensation in multiple modalities
- Type 2 respiratory failure
-
Ascending symmetrical limb weakness
- Albuminocytological dissociation
Miller-Fisher
What is it?
Triad
Ix
Subtype of GBS
- Ophthalmoplegia
- Ataxia
- Areflexia
Ix: +ve anti-ganglioside antibodies (against myelin)
Guillain-Barre syndrome
aka
GBS =
Acute inflammatory demyelinating polyneuropathy
Ix for GBS
LP ==> Albuminocytological dissociation (↑ CSF protein BUT Normal WCC) = Diagnostic
Spirometry = most important Ix
- If FVC < 1.5 L –> ITU for ventilation
Tx for GBS
(1) IVIG
(2) Plasma exchange
+ Serial spirometry
+ Serial ECGs
+ DVT prophylaxis
Avoid steroids in GBS
Cause of death in GBS
Type 2 respiratory failure (serial spirometry to measure FVC)
Tachyarrhythmia (serial ECGs)
Generalised weakness (starting in hands, feet and face)
Temporalis wasting
LMN signs (muscle wasting, areflexia)
Myotonia (contract, cannot relax)
Normal sensory examination
Diagnosis? Cause? Tx?
Myotonic dystrophy
Autosomal dominant trinucleotide repeat disorder
Physiotherapy, Mobility aids
If respiratory muscle weakness –> +/- NIPPV
Sx of Neurofibromatosis Type 1
CLANS
- Cafe au lait spots (number > 5, size > 15mm)
- Lisch nodules
- Axillary freckling
- Neurofibromas
- Sphenoid wing dysplasia
Sx of Neurofibromatosis Type 2
Bilateral acoustic neuromas
- Bilateral sensorineural deafness
- Tinnitus
- Facial nerve palsy
- Absent corneal reflex
Cerebellar signs
Complications of Neurofibromatosis
HTML
Hypertension (renal artery stenosis, phaeo)
Thoracic kyphosis
Learning difficulities
Malignant transformation (NF Type 1, neurufibroma ==> malignant PNS tumour)
Ix for Parkinson’s disease
Trial of Levodopa: improvement in symptoms
DAT scan if atypical features
Tx for Parkinson’s disease
Treat motor symptoms
- L-DOPA + DOPA decarboxylase (Sinemet = combo)
- Dopamine agonists (Apomorphin)
- MOA-B inhibitor (Selegiline, Rasagiline)
- COMT inhibitor (Entacapone)
- Anticholinergics (Procyclidine) - useful for tremor
- Deep brain stimulation
Treat non-motor features
- Postural hypotension ==> Fluids +/- Salt +/- Fludrocortisone
- Drooling ==> Anticholinergic
- Antidepressants
S/E of L DOPA
S/E of L-DOPA
Tip: DOPAMINE
- Dyskinesia
- On-Off Phenomena
- Psychosis
- ABP ↓
- Mouth dryness
- Insomnia
- Nausea and Vomiting
- Excess daytime sleepiness
Sx of Parkinson’s disease
- Resting tremor (pill-rolling, asymmetrical, improve with movement, worse with stress)
- Bradykinesia
- Rigidity (Lead pipe rigidity, Cogwheel rigidity)
- Postural instability
- Parkinsonian gait (reduced arm swing, stooped posture, shuffling gait, festination, freezing, gait ignition difficulties, falls)
- Masked facies
- Soft monotonous voice
- Micrographia
- Autonomic dysfunction ==> Postural hypotension
- Neuropsychiatric ==> Depression, Dementia
- Sleep ==> REM sleep behaviour disorder
Parkinson’s plus syndromes + Sx
Multiple System Atrophy
- Autonomic dysfunction (postural hypotension, urinary retention)
- Cerebellar Sx
- Parkinsonism
Corticobasal degeneration
- Alein limb phenomenon
- Unilateral Parkinsonism
Progressive supranuclear palsy
- Supranuclear gaze palsy (vertical gaze plasy)
- Parkinsonism
Dementia with Lewy Bodies
- Visual hallucinations
- Fluctuating cognition
- Early dementia
- Parkinsonism
Vascular PD
- Sudden onset
- Parkinsonism
Obese
Female
Headache
Visual changes
Normal neurological findings
+/- Papilloedema
Diagnosis? Ix? Tx?
Idiopathic intracranial hypertension
LP: very high opening pressure (diagnostic)
Tx:
- Conservative
- Weight loss
- Medical
- (1) IV Acetazolomide (reduce CSF production)
- (2) Topiramate
- (3) Repeat LPs
- Surgical
- +/- VP Shunt
Signs of papilloedema
Papilloedema
- Venous engorgement (1st sign)
- Loss of venous pulsation
- Blurring of optic disc margins
- “Doughnut”-shaped opacity around optic disc
Restless leg syndrome - Tx
Conservative
- Walking
- Stretching
Medical
- Dopamine agonists (Ropinirole)
Presentations of Thiamine deficiency
B1 (Thiamine) deficiency
Wernickes - ACE (= Dry Beri Beri)
- Ataxia
- Confusion
-
Eye signs
- Nystagmus
- Ophthalmoplegia (CN3 palsy, CN6 palsy)
- Peripheral sensory neuropathy
Korsakoff’s
- ACE
-
+ Amnesia (anterograde +/- retrograde)
- Cannot remember new things
- + Confabulations
- +/- Psychosis
Wet Beri Beri
- Heart failure
- Oedema
Summary of mononeuropathies
Erb’s palsy
Cause? Dx?
Traction to baby’s head/neck during delivery
Damage to C5/C6
Waiter’s tip (elbow extended and pronated, wrist flexted)
Sensory loss in C5/C6 dermatomes
Klumpke’s palsy
Clumsy Klumpke’s fell from a tree
Break fall from tree / Pulling baby’s arm
Damage to C8/T1
Complete claw hand (all intrinsic hand muscles affected)
Hyperextension of MCPJ
Flexion of DIPJ and PIPJ
Loss of sensation in C8 and T1 dermatomes
Long thoracic nerve palsy
Cause? Sx?
Breast cancer surgery (masectomy)
Lymph node sampling
Loss of innervation to serratus anterior
==> winging of scapula
Axillary nerve palsy
Cause? Sx?
Anterior shoulder dislocation
Fracture of surgical neck of Humerus
Loss of shoulder abduction (and external rotation)
Deltoid atrophy
Patch of numbess over Deltoid (Regimental patch)
Radial nerve palsy
Cause? Sx? Tx?
Humeral shaft fracture
Compression (crutches, armrest, handcuffs)
Wrist drop
Loss of sensation over dorsum of 3.5 digits
+/- Posterior Arm
+/- Posterior Forearm
Tx: Splint (reduce risk of carpal tunnel)
Median nerve supplies
Forearm muscles (majority)
Intrinsic hand muscles (some) = LOAF
Lateral 2 lumbricals
Opponens pollicis
Abductor pollicis
FPB
Ulnar nerve palsy
Cause? Sx? Tx?
Supracondylar elbow fracture
Self harm at wrist
Ulnar claw (hyper-extend MCP and flex DIP and PIP in 4th and 5th digit)
Wasting of hypothenar eminence
Froment’s sign +ve
Loss of sensation in medial 1.5 palmar and dorsal aspect of digits/palm
Tx: Splint, PT, OT, Analgesia +/- Surgical decompression or repair
explain why
Ulnar paradox = “closer to the paw, the worse the claw”
When the ulnar nerve is damaged at the elbow
==> loss of ulnar half of flexor digitorum profundus
==> reduced unopposed flexion at the IPJ
==> less marked clawing
DDx Ulnar nerve palsy and Dupuytren’s contracture
Dupuytrens = flexion of MCP, PIP + DIP
Ulnar mononeuropathy = flexion of PIP + DIP & hyper-extension of MCP
Borders of carpal tunnel
Roof = Flexor retinaculum
Floor = Carpal
Radial side = Scaphoid
Ulnar side = Pisiform
Causes of carpal tunnel syndrome
DRPARO
- Diabetes mellitus
- Rheumatoid arthritis
- Pregnancy
- Acromegaly
- Repetitive strain injury
- Obesity
Median nerve palsy - Sx
Compression (ganglion cyst, vibrating tools)
Trauma
Causes of Carpal Tunnel syndrome
Hand of Benediction (when formning a fist)
Ape Hand deformity
Thenar wasting
Loss of power of thumb abduction
Loss of sensation in median nerve distribution
Carpal tunnel syndrome
Sx
Tx
Numbness / Tingling in distribution of Median nerve
Improved by shaking
Worse in morning
Thenar wasting
Loss of thumb abduction
Conservative
- Wrist splint (70% success rate)
- PT/OT
- Modify ADLs
Medical
- Analgesia
- Corticosteroid injections
+/- Surgery
- Surgical decompression of Carpal Tunnel (cut flexor retinaculum)
Diabetic
Burning pain on anterolateral thigh
Normal motor
Diagnosis? Cause? Tx?
Lateral Cutaneous Nerve of the Thigh
Compression
Diabetes
Tx:
- Wear loose clothing
- (1) Lidocaine patches
- (1) Corticosteroids
- (2) Surgical nerve compression
Shooting, lower back pain –> leg
High stepping gait (foot drop)
↓ Power, ↓Reflexes, ↓ Sensation
Straight leg raise +ve
Diagnosis? Cause? Tx?
Sciatic nerve palsy / Sciatica / Lumbar radiculopathy
Disc herniation (90%)
Management
- Conservative
- Physiotherapy
- Medical
- Analgesia
- +/- Surgical
-
Indications
- Pain > 6 weeks
- Complications (loss of bladder/bowel function)
- Lumbar nerve decompression (Laminectomy, Discectomy)
-
Indications
Foot drop
Loss of ankle dorsiflexion and eversion
Normal reflexes
↓sensation in dorsum of foot and lateral leg
Diagnosis?
Common peroneal nerve injury
Tx: Ankle foot othosis
+/- Surgery
Common peroneal nerve injury vs L5 radiculopathy
Common peroneal nerve injury (LMN) [most common cause]
- Tip: Common peroneal nerve injury ==> ↓ ankle eversion
- Motor
- Weakness of ankle dorsiflexion + eversion
- BUT Normal ankle inversion
- Sensory
- Loss of sensation over anterolateral leg and dorsum of foot
L5 radiculopathy (LMN)
- Tip: L5 radiculopathy ==> ↓ ankle inversion
- Motor
- Weakness of ankle dorsiflexion + inversion +/- eversion
- Weakness of hip abduction
- Sensory
- Loss of sensation in 1st webspace of foot (L5)
Loss of ankle plantarflexion (inability to tiptoe)
Loss of toe flexion
Loss of sensation of Ankle and Sole of Foot
Diagnosis? Cause? Tx?
Tibial nerve palsy
Tarsal tunnel syndrome (OA, RhA, Trauma)
Tx:
- Conservative
- Orthotics / Braces
- Physiotherapy
- Medical
- NSAIDs
- Surgical
- If tarsal tunnel syndrome –> dissection of flexor retinaculum
Causes of sensory neuropathy
Diabetic neuropathy
GBS
Charcot-Marie-Tooth syndrome
Alcohol
Vitamin B12 deficiency
Vitamin B1 deficiency
Drugs (Isoniazid)
Tabes dorsalis (neurosyphilis)
1st line Tx for neuropathic pain
Pregabalin
Gabapentin
Duloxetine
Amitriptyline
Causes of UMN lesion
Causes of LMN lesion
UMN lesion
- Stroke
- MS
- Motor neurone disease (UMN + LMN)
LMN lesion
- Peripheral motor neuropathy (e.g. peroneal nerve palsy –> foot drop)
- Polio
- Guillain Barre syndrome (peripheral motor and sensory neuropathy)
- Charcot-Marie-Tooth disease
- Motor neuron disease (UMN + LMN)
UMN vs LMN signs
Examination findings
Ix
Nerve Conduction Studies + EMG
- UMN → normal nerve conduction but ↓interference pattern + firing rate
- LMN → abnormal nerve conduction | recruitment of large motor units
Charcot-Marie Tooth disease
aka
Sx
Ix
Charcot Marie Tooth disease = Hereditary motor and sensory peripheral neuropathy
Autosomal dominant
Length dependent disorder
Sensory
- Pes cavus
-
Loss of sensation ==> Distal > Proximal
- Loss of fine touch (stocking distribution)
- Loss of pain and temperature
- Loss of proprioception
- Sensory ataxia (slapping of feet due to lack of proprioception)
LMN signs ==> Distal > Proximal
-
↓ Distal muscle strength (symmetrical)
- High stepping gait (foot drop)
-
Distal muscle atrophy
- Claw hand
- Champagne bottle leg
- ↓ Reflexes
Ix: Nerve conduction studies (demyelination or axonal loss - depends on type)
Causes of mononeuritis multiplex
Causes of mononeuritis multiplex
- Vasculitis (Polyarteritis nodasa) - most common
- Rheumatoid arthritis
- SLE
- Sjogren’s syndrome
- Sarcoidosis
Ipsilateral loss of proprioception and vibration sensation
Contralateral loss of pain and temperature sensation
Ipsilateral spastic paresis below lesion (UMN)
Diagnosis?
Brown Sequard syndrome
Spinal cord hemisection
Bilateral loss of proprioception and vibration sensation
Bilateral limb ataxia
Then, Bilateral loss of fine touch (distally)
Bilateral spastic paresis (UMN + LMN)
Diagnosis?
Subacute combined degeneration of the spinal cord
Tx: Vitamin B12
Bilateral spastic paresis (UMN + LMN signs)
Bilateral loss of proprioception and vibration sensation
Bilateral limb ataxia
+ Cerebellar Sx (DANISH)
Pes cavus
Diagnosis?
Friedrich’s ataxia
Back pain (sciatic pain shooting down legs)
Saddle anaesthesia
Poor anal tone
Urinary incontinence
Leg weakness
Diagnosis? Ix? Tx?
Cauda Equina Syndrome
Ix: MRI (Spine)
Surgery –> Decompressive laminectomy
+/- High dose steroids???
Anterior cord syndrome
Posterior cord syndrome
Sx
Anterior cord syndrome
- Loss of pain and temperature (spinothalamic)
- Loss of motor function (corticospinal)
Posterior cord syndrome
- Loss of fine touch, vibration and proprioception (dorsal columns)
Acute cord compression
Sx
- Back pain
- BELOW the lesion
- Loss of fine touch and proprioception
- Loss of pain and temperature
- UMN signs
- AT THE LEVEL of the lesion
- LMN signs
- Autonomic features
- Constipation
- Incontinence
- Urinary retention
- Above T12 –> Bladder spasticity
- Below T12 –> Bladder flaccidity
Spinal cord injury
Trigger (urinary retention, constipation)
Hypertension
Without relative increase in HR
Flushing
Sweating
Diagnosis? Cause?
Autonomic dysreflxia
Only occurs if spinal cord injury ABOVE T6 level
Spinal cord injury
VERY LOW HR
VERY LOW BP
Diagnosis?
Neurogenic shock
Only spinal cord lesions ABOVE T6
Sensory disturbance in cape-like distribution (pain, temp +/- touch)
Progressive weakness in hands
Wasting of small muscles of hands
Autonomic features
Diagnosis? Tx?
Syringomyelia
Tx:
- VP shunt
- Treat underlying pathology
- e.g. If Chiari malformation –> surgical decompression at Foramen Magnum
Progressive (months)
Neck pain
Motor weakness (UMN below level, LMN at level)
Loss of sensation
Loss of digital dexterity
Hoffman reflex
Diagnosis? Ix?
Cervical spondylosis (OA of the spine –> osteophytes –> radiculopathy)
Ix: MRI (Cervical Spine)
Tx:
- (1) Analgesia
- (2) Surgical nerve decompression
Sx + Ix and Tx of spinal disc herniation
Spinal disc herniation
- Dermatomal loss
- Myotomal loss
- Lumbar region –> Sciatica
- Cauda equina –> Cauda Equina Syndrome
Ix: MRI Spine
Tx:
- Conservative –> Physiotherapy
- Medical –> Analgesia
- Surgical –> +/- Discectomy
What level does the spinal cord end
L1-L2
