Neurology Potpourri - 2- GK Flashcards
T/F: Carpal tunnel is MC in women.
TRUE
What are the risk factors of carpal tunnel?
Obesity
Pregnancy
What disease involves the following structures:
- flexor retinaculum (transverse carpal ligament)
- carpal bones
- 9 flexor tendons
- Median nerve
Carpal Tunnel Syndrome
What sensory and motor deficits would a patient with Carpal Tunnel Syndrome present with?
Motor:
- ABductor pollicis brevis
- Flexor pollicis brevis (SF head)
- Opponens pollicis
- 1st & 2nd lumbricals
What disease does this describe?
Median nerve compression –> inflammation –> ischemia –> nerve damage
CTS (carpal tunnel syndrome)
What disease?
Extrinsic:
Compression is work related (typing on a keyboard)
Recreation related (cycling)
Positional (sleeping)
Intrinsic:
small anatomical space
fluid retention during pregnancy
tendon inflammation due to overuse or connective tissue disorder
CTS
Clinical presentation of what disease?
- aching radiating to the thenar area
- pain + numbness
- dropping objects, cannot open jars or twist off lids
- pain worsened by repetitive motion/ remaining stationary
CTS
Clinical Px of what dz?
- sx worse @ night
- pt awakens at night with pain or numbness & needs to “shake out” involved hand/wrist (flick sign)
CTS
What dz is this?
Physical Exam:
- Inspect for thenar atrophy
- thumb opposition against resistance
- sensation over median nerve (Phalens & Tinnels)
CTS
What is the Dx & Tx of CTS
Clinical Dx
+/- nerve conduction testing
Treatment:
1. NSAIDS
2. PT
3. Wrist Splint @ night
+/- ergonomic modifications
How do you treat CTS if initial treatments didnt work?
Ortho surgery consultation
steroid injection
carpal tunnel release
Describe anatomy of ulnar nerve
passes through condylar groove b/w medial epicondyle & olecrenan
Clinical Px for which disease?
- Paresthesias, tingling, numbness in medial hand, 1/2 of 4th finger, entire 5th finger.
- pain @ elbow/forearm
- Dec. sensation in ulnar distribution
- Tinel’s sign @ elbow.
Ulnar neuropathy (cubital tunnel syndrome)
Tx for ulnar neuropathy
- elbow pads
- surgical tx performed IF:
1. no improvement after 6-12 wks conservative tx
2. progressive palsy or paralysis
3. muscle wasting, clawing
Clinical Px of what?
- wrist drop
- cannot extend finger or abduct thumb
- sensory loss in dorsal web b/w thumb and index finger
- normal tricepts & brachioradialis strength
- triceps reflex intact
- spontaneously recovers in 6-8 weeks
Radial neuropathy
Tx of radial neuropathy
cock-up wrist & finger splints
PT
Clinical Px of what?
- paresthesias, numbness, occasionally pain in lateral thigh
- Sx increased with standing/walking
- sx relieved by sitting
- knee reflexes intact
Lateral cutaneous femoral neuropathy
“Meralgia paresthetica”
What is another name of lateral cutaneous femoral neuropathy?
meralgia paresthetica
T/F: meralgia paresthetica (lateral cutaneous femoral neuropathy) resolves spontaneously over wks-mos but CANNOT have permanent numbness
False: you CAN have permanent numbness
Tx of lateral cutaneous femoral neuropathy (meralgia paresthetica)
weight loss
avoid tight belts
analgesics (lidocaine patch)
NSAIDS
neuropathic pain meds
What is another name of Lateral cutaneous femoral neuropathy?
skinny jeans syndrome
Causes of skinny jean syndrome (lateral cutaneous femoral neuropathy OR meralgia paresthetica)
obesity
belts w/stuff hanging off
skinny jeans & heels
Clinical Px for what dz?
- Foot drop
- sensory loss
- onset upon wakening
- NO pain
Peroneal neuropathy
Which dz must you differentiate from L5 radiculopathy?
Peroneal neuropathy
What dz is this?
acute idiopathic facial nerve (CN VII) mononeuropathy
Lower motor neuron “lesion”
weakness –> paralysis
caused by HSV
Bell Palsy
What are risk factors of Bell Palsy?
DM
pregnancy in 3rd trimester
Clinical px of what dz?
- sudden onset, peaks by 3 days
- forehead unfurrows
- facial creases & nasolabial fold disappear
- corner of the mouth droops
- sagging of the lower eyelid
- tearing from the eye
- loss of corneal reflex
Bell Palsy
What is the main difference between Bell Palsy vs. Stroke?
Stroke spares the forehead
Bell Palsy does not
Bell’s palsy is a _______ lesion.
Stroke is a _______ lesion.
Peripheral
Central
How do you dx Bell Palsy (main dx)?
Dx based on history & physical exam
What other diagnostic tests (+/-) can you do for Bell Palsy?
electrodiagnostic testing for complete paralysis
High resolution CT/ Gadolinium enhanced MRI : slow progression beyond 3wks, no improvement after 4 mos or when hx/physical exam suggest an alternate diagnosis
Serologic testing: Borrelia Burgdorferi
Audiometry: if hx/PE suggest an alternate diagnosis
What is 1st line of treatment of Bell Palsy?
Prednisone: start within 3 days of sx onset
When would you use Valacyclovir in Bell Palsy?
reserved for pts with severe nerve palsy or HZV presentation
Additional therapeutic interventions for Bell Palsy
Eye protection
Acupuncture
PT
What is CRPS (complex regional pain syndrome) AKA “reflex sympathetic dystrophy”?
rare disorder of extremities characterized by autonomic & vasomotor instability
What dz?
- Burning pain
- autonomic dysfunction
- vasomotor instability
Preceded by surgery or trauma
Complex Regional Pain Syndrome (CRPS)
OR
“reflex sympathetic dystrophy”
inflammation, neurogenic inflammation, maladaptive changes in pain perception @ CNS
What dz?
CRPS
Clinical Px for what dz?
- Most commonly involves findings localized to the hand (not a single peripheral nerve)
- burning/aching, allodynia that is aggravated by changes in environment or emotional stress
- color & temp changes
- physical changes in skin & nails
- Limited ROM
CRPS (complex regional pain syndrome)
“reflex sympathetic dystrophy”
Clinical Px for what dz?
- cutaneous vasomotor changes (vasodilation & vasoconstriction)
- red, mottled ashen color
- inc or dec temp
- dry or hyperhidrotic skin (excessive sweating)
- edema
-
Motor abnormalities
- Psychological distress
CRPS
“Reflex sympathetic dystrophy”
Affected limb px within weeks of injury:
- swollen, red, burning
- diaphoresis
- sx near site of injury
What stage of CRPS Type 1?
Acute Stage
Affected limb sx within mos of injury:
- skin cool & diaphoretic
- sudek’s atrophy of bone on x-ray
- pain occurs throughout entire limb
What stage of CRPS Type 1?
dystrophic stage
affected limb sx yrs after injury:
- skin pale & shiny
- atrophy of muscle & bone
- pain constant w/tx
What stage of CRPS Type 1 is this?
Atrophic Stage
Dx of CRPS?
No specific test**
starts after limb trauma 4-6 wks
not explained by initial trauma
affects distal limb, goes beyond region involved in trauma
“pain out of proportion”
what dz?
CRPS
What is the budapest consensus criteria for clinical dx of CRPS?
_Continuing pain, disproportional to inciting event. **_
1 or more sx/sign in 3 of the following 4 categories:
sensory (hyperesthesia, allodynia)
vasomotor (temp, asymmetry, skin color changes)
sudomotor/edema
motor/trophic (dec. ROM, weakness, tremor, dystonia, changes of hair/skin/nails)
What dx tools would you utilize for CRPS to determine whether there are bone changes/demineralization present?
Bone scan: diffuse increased uptake in affected extremity (early phase)
X-ray: generalixed osteopenia (later stages)
Tx for mild cases of CRPS?
NSAIDS
Tx for severe cases w/edema of CRPS?
Prednisone
Neuropathic medications for CRPS?
tricyclic antidepressants: nortriptyline
anticonvulsatnts: gabapentin + pregabalin
SNRI’s: duloxetine, venlafaxine
what meds would you use for bone changes (demineralization) present in CRPS?
biphosphonates, calcitonin
What dz would you use the following as last line meds?
Topical lidocaine
tramadol, opioids
CRPS
You can use neuromodulation as a tx for CRPS
T/F?
True:
implanted spinal cord stimulators
transcutaneous nerve stimulation (TENS)
brisk rubbing of affected part (counter irritation) & acupuncture
You can use PT/OT for CRPS.
T/F?
True
How can you attempt to prevent CRPS?
early mobilization after injury or surgery
What disorder?
Neurodevelopmental d/o manifested by motor & phonic tics
M>F
Accompanied by OCD & ADHD.
affects kids aged 6-17 (adolescents)
Tourette Syndrome
T/F: Fam hx of Tourette syndrome or OC is common
True
What is the onset age of tics typically?
2-15 yrs w/ avg age of onset 6 yrs.
Give examples of
Simple & Complex motor tics
Simple: blinking, facial grimacing, shoulder shrugging, head jerking
Complex: bizarre gait, kicking, jumping, body gyrations, scrathcing and seductive gestures
What is echopraxia and what disorder is this part of?
mimicking gestures
TS
What is copropraxia and what disorder is this part of?
obscene gestures
TS
Give examples of simple vocal/phonic tics
sniffing, coughing, throat clearing, grunting
Define coprolalia
obscene words
define echolalia
repitition of words
Define palilalia
repeating a phrase/word with inc rapidity
Do tics often improve when focused on other tasks in Tourette’s Syndrome?
Yes, they do
T/F: tics worsen with stress, anxiety or excitement
TRUE
What are the clinical manifestations of Tourette?
motor/vocal/phonic tics
ritualistic behavior–> repeating behavior
PE normal except for presence of tics
Dx of Tourettes Syndrome
Brain MRI: order only when abnormality detected on neurological exam.
EEG: IF need to evaluate seizure activity
Diagnostic criteria for Tourette Syndrome
multiple motor + one or more phonic tics must be present (do not need to be concurrent)
tics must occur multiple times a day, nearly everyday
OR
intermittently throughout a period of more than one year
Onset before 18 y/old
tics must be witnessed
Tx of Tourette Syndrome
Tx psychiatric disorder 1st if present
CIBT (comprehensive behavioral intervention)
1st line Mod-severe tics TX
clonidine/guanfacine
Which tx of TS is favored by specialists?
antidopaminergic (tetrabenazine)
Tx for severe tics unresponsive to other meds
Haloperidol (antipsychotic)
Tx for focal motor tics
Botox
