Neurology COPY Flashcards
1
Q
Secondary prevention of stroke
A
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)
2
Q
Postural tremor
Most pronounced by arms are outstretched
Relieved at rest
Affects Hands and Arms
No other neurological signs (No Parkinsonism)
Diagnosis? Treatment?
A
Benign essential tremor
If functional impairment –> (1) Propranolol
If no functional impairment –> Observation
3
Q
Fever
Headache
Progressive focal neurology
Seizures
Meningismus
CN nerve palsies
Papilloedema
Diagnosis? Ix? Tx?
A
Cerebral abscess
Ix: MRI Head (with Contrast) –> Ring-enhancing lesion
Tx
- Antibiotics
- AED
- +/- Dexamethasone
- +/- Surgical decompression and evacuation
4
Q
Causes of cerebellar syndrome
A
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
5
Q
Signs of cerebellar lesion
A
- 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
6
Q
Sx of Lateral Medullary Syndrome
Cause?
A
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
7
Q
Friedrich’s Ataxia vs Charcot-Marie Tooth disease
A
8
Q
Bilateral cerebellar signs (DANISH)
Pes cavus
UMN + LMN signs
Sensory loss
Kyphoscoliosis
Decreased visual acuity
Associated with HOCM and Diabetes
Diagnosis? Cause? Ix? Tx?
A
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
9
Q
Cerebellopontine angle syndrome - Sx
A
Signs
- CN 5-8 palsy
- Cerebellar signs
Causes = Acoustic neuroma
Tip: CN 5-8 (angle = 5, syndrome = 8)
10
Q
Alzheimer’s disease - Sx, Ix, Tx
A
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
11
Q
Sx of
AD
LBD
VD
Pseudodementia
Delirium
Pick’s disease
A
12
Q
Fever
Altered mental state / Confusion
Seizures
Rash
+/- Meningismus
No headache
Diagnosis? Tx?
A
Encephalitis
High-dose IV Aciclovir (empirical Tx for all cases)
13
Q
Most common causes of meningitis
A
- Viral = most common
- Bacterial
- Streptococcus pneumonia (most common bacterial)
- Neisseria meningitides (2nd most common bacterial)
14
Q
Triad of meningism
A
Headache
Neck stiffness
Photophobia
15
Q
Viral vs Bacterial meningitis on CSF analysis
A
16
Q
C/I to LP
A
Cushing’s triad: relative bradycardia, hypertension, irregular breathing
Papilloedema
Dilated pupil (↑ ICP –> blown pupil)
Focal neurological signs
Signs of cerebral herniation
17
Q
Tx for bacterial meningitis
A
In community
- If non-blanching rash –> IV Benzylpenicillin
- Then, refer to A&E
In hospital
-
Antibiotics
- IV Ceftriaxone
- +/- Dexamethasone
18
Q
Types of epilepsy
A
- 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
19
Q
Partial seizures - localising Sx
A
20
Q
Tx for epilepsy
A
21
Q
S/E of AEDs
A
22
Q
Tuberous sclerosis - Cause, Sx
A
23
Q
Tx of status epilepticus
A
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)
24
Q
Causes of CN7 palsy
A
LMN CN7 palsy
- Bell’s palsy (idiopathic)
- Ramsay-Hunt syndrome (HSV infection)
UMN CN7 palsy
- Stroke
- MS
25
Tx for Bell's palsy
**High dose oral Prednisolone** (given within 72 hours)
**+ Eye protection** (artificial tears, tape)
If Ramsay-Hunt syndrome --\> +/- Aciclovir
26
**Large amplitude, unilateral chorea**
**Involuntary movement**
Diagnosis? Cause? Treatment?
**Hemiballismus**
Lesion in contralateral basal ganglia
Tx: Dopamine antagonists
Self-resolves within months
27
**Headache**
**Tight band around head**
**Gradual onset**
**Worse with stress**
**No N&V**
**Normal neurological examination**
Diagnosis? Treatment?
**Tension headache**
Tx: Analgesia OTC
28
**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)
29
**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)
30
**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
## Footnote
Causes = Vascular compression (90%) or MS
Tx: Carbamazepine
31
**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
32
Horner's syndrome - Triad, Ix
**Ptosis, Miosis, Anhidrosis**
Ix: **Topical cocaine eye drops**
Normal ==\> pupil dilation
Horner's syndrome ==\> no effect
33
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**
34
Triad of normal pressure hydrocephalus
Wet (urinary incontinence)
Wobby (gait --\> falls)
Wacky (dementia)
35
Definition of Anterior circulation stroke
2/3 = Partital
Total = 3/3
* **H**igher cortical dysfunction
* L hemisphere ==\> Dysphasia
* R hemisphere ==\> Visual inattention or Neglect
* **H**emiparesis or Sensory deficit
* **H**omonymous hemianopnia
36
**Strokes**
ACA
MCA
PCA
Midbrain stroke
PICA
AICA
Retinal artery
Basilar artery
I
37
Lacunar syndrome
Stroke in small perforating artery of MCA
1/4
* Pure sensory stroke
* Pure motor stroke
* Sensorimotor
* Ataxic hemiparesis
38
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
39
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
40
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
41
**Extradural vs Subarachnoid vs Subdural**
Cause
Onset
Symptoms
Vessel
CT changes
42
CT shows
**Lemon-shaped haematoma**
**Does not cross suture line**
**Extradural haemorrhage**
## Footnote
**Surgical decompression and evacuation of haematoma**
+/- AEDs
+/- ABx
+/- Lower ICP
43
CT scan shows
**Hyperdense area**
**Located at base of skull** (within basal cisterns)
Ix if -ve CT?
Subarachnoid haemorrhage
## Footnote
Ix:
(1) **CT**
(2) If -ve CT --\> **Lumbar puncture** after \> 12 hours ==\> **Xanthochromia** (straw-coloured CSF)
44
Tx for subarachnoid haemorrhage
* ABCDE
* **Nimodipine** (CCB --\> prevents cerebral artery vasospasm)
* **Laxatives** (prevent straining)
* Surgery
* **Endovascular coiling**
* **Surgical clipping**
45
CT changes in subdural haemorrhage
**Concave haemorrhage**
Hyperdense (in acute SDH)
Hypodense (in chronic SDH)
**NOT limited by suture lines**
46
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**
47
**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
48
Tx of MND
* **Riluzole** (prolongs survival)
* Symptomatic treatments
* If respiratory symptoms --\> **BiPAP**
49
Optic neuritis vs Papilloedema
50
Marcus-Gunn pupil
aka
**Marcus-Gunn pupil**
= **Relative Afferent Pupillary Defect** (RAPD)
51
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
52
Ix for MS
**MRI (GAD-enhanced)**: demyelinating plaques = GOLD STANDARD
*_CSF electrophoresis_*: **unmatched oligoclonal IgG bands**
*_Evoked potentials_*: **delayed conduction velocity** (demyelination)
53
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
54
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"
55
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
56
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**
57
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**
* **Albuminocytological dissociation**
58
Miller-Fisher
What is it?
Triad
Ix
Subtype of GBS
* Ophthalmoplegia
* Ataxia
* Areflexia
Ix: **+ve anti-ganglioside antibodies (**against myelin)
59
Guillain-Barre syndrome
aka
**GBS** =
## Footnote
**Acute inflammatory demyelinating polyneuropathy**
60
Ix for GBS
LP ==\> **Albuminocytological dissociation** (**↑ CSF protein BUT Normal WCC**) = Diagnostic
**Spirometry** = most important Ix
* If FVC \< 1.5 L --\> ITU for ventilation
61
Tx for GBS
(1) **IVIG**
(2) **Plasma exchange**
**+ Serial spirometry**
**+ Serial ECGs**
**+ DVT prophylaxis**
Avoid steroids in GBS
62
Cause of death in GBS
**Type 2 respiratory failure** (serial spirometry to measure FVC)
**Tachyarrhythmia** (serial ECGs)
63
**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
64
Sx of Neurofibromatosis Type 1
CLANS
* **Cafe au lait spots** (number \> 5, size \> 15mm)
* **Lisch nodules**
* **Axillary freckling**
* **Neurofibromas**
* **Sphenoid wing dysplasia**
65
Sx of Neurofibromatosis Type 2
**Bilateral acoustic neuromas**
* **Bilateral sensorineural deafness**
* **Tinnitus**
* Facial nerve palsy
* Absent corneal reflex
Cerebellar signs
66
Complications of Neurofibromatosis
HTML
**Hypertension** (renal artery stenosis, phaeo)
**Thoracic kyphosis**
**Learning difficulities**
**Malignant transformation** (NF Type 1, neurufibroma ==\> malignant PNS tumour)
67
Ix for Parkinson's disease
**Trial of Levodopa**: improvement in symptoms
DAT scan if atypical features
68
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
69
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
70
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
71
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
72
**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
73
Signs of papilloedema
Papilloedema
* **Venous engorgement** (1st sign)
* **Loss of venous pulsation**
* **Blurring of optic disc margins**
* "Doughnut"-shaped opacity around optic disc
74
Restless leg syndrome - Tx
Conservative
* Walking
* Stretching
Medical
* Dopamine agonists (Ropinirole)
75
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
76
Summary of mononeuropathies
77
**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
78
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**
79
**Long thoracic nerve palsy**
Cause? Sx?
Breast cancer surgery (masectomy)
Lymph node sampling
Loss of innervation to serratus anterior
==\> **winging of scapula**
80
**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)
81
**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)
82
Median nerve supplies
**Forearm muscles** (majority)
**Intrinsic hand muscles** (some) = **LOAF**
Lateral 2 lumbricals
Opponens pollicis
Abductor pollicis
FPB
83
**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
84
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
85
DDx Ulnar nerve palsy and Dupuytren's contracture
Dupuytrens = flexion of MCP, PIP + DIP
Ulnar mononeuropathy = flexion of PIP + DIP & hyper-extension of MCP
86
Borders of carpal tunnel
Roof = Flexor retinaculum
Floor = Carpal
Radial side = Scaphoid
Ulnar side = Pisiform
87
Causes of carpal tunnel syndrome
DRPARO
* Diabetes mellitus
* Rheumatoid arthritis
* Pregnancy
* Acromegaly
* Repetitive strain injury
* Obesity
88
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**
89
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)
90
**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
91
**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)
92
**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
93
Common peroneal nerve injury vs L5 radiculopathy
**Common peroneal nerve injury** (LMN) [most common cause]
* Tip: Common p**_e_**ron**_e_**al nerve injury ==\> ↓ ankle **_e_**version
* 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 rad**_i_**culopathy ==\> ↓ ankle **_i_**nversion
* Motor
* Weakness of ankle dorsiflexion + inversion +/- eversion
* Weakness of hip abduction
* Sensory
* Loss of sensation in 1st webspace of foot (L5)
94
**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
95
Causes of sensory neuropathy
**Diabetic neuropathy**
**GBS**
**Charcot-Marie-Tooth syndrome**
**Alcohol**
**Vitamin B12 deficiency**
**Vitamin B1 deficiency**
**Drugs** (Isoniazid)
**Tabes dorsalis** (neurosyphilis)
96
1st line Tx for neuropathic pain
Pregabalin
Gabapentin
Duloxetine
Amitriptyline
97
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)
98
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
99
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)
100
Causes of mononeuritis multiplex
Causes of mononeuritis multiplex
* **Vasculitis** (Polyarteritis nodasa) - most common
* **Rheumatoid arthritis**
* **SLE**
* **Sjogren's syndrome**
* **Sarcoidosis**
101
**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
102
**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
103
**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
104
**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**???
105
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)
106
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
107
**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**
108
**Spinal cord injury**
**VERY LOW HR**
**VERY LOW BP**
Diagnosis?
**Neurogenic shock**
Only **spinal cord lesions ABOVE T6**
109
**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
110
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
111
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_* --\> Physiot**h**erapy
* *_Medical_* --\> **Analgesia**
* *_Surgical_* --\> **+/- Discectomy**
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What level does the spinal cord end
L1-L2
