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N935 Advanced Pathophysiology > neuromuscular diseases > Flashcards

neuromuscular diseases Flashcards

1
Q

What are neuromuscular diseases?

A

disorders that adversely affect muscle function either primarily or via nerve or neuromuscular junction abnormalities

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2
Q

upper motor neurons are

A

completely contained within the CNS

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3
Q

where do upper motor neuron pathways being and end?

A

begin: cerebral cortex
end: ventral horn of the spinal cord

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4
Q

primary roles of upper motor neurons

A

directing, influencing, and modifying reflex arcs, lower level control centers and motor neurons and some sensory

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5
Q

upper motor neurons form

A

synapses with interneurons which then form synapses with lower motor neurons before projecting to the periphery

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6
Q

the corticospinal tract supplies the

A

voluntary muscles of the trunk and extremities

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7
Q

where does the corticospinal tract originate?

A

precentral gyrus

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8
Q

75-90% of the corticospinal tract decussates in the ___ and forms the ____

A

medulla; lateral corticospinal tract

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9
Q

10-25% of the corticospinal tract makes up the ____

A

ventral corticospinal tract and travel to the spinal cord

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10
Q

the corticobulbar tract supplies the

A

voluntary muscles of the head and follow the corticospinal tract until they reach the brainstem

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11
Q

where does the corticobulbar tract originate

A

in the precentral gyrus next to the lateral fissure of Sylvius

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12
Q

the corticobulbar tract innervates cranial motor nuclei _____ bilaterally except

A

III, IV, VI, IX, X, XI; except facial and hypoglossal

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13
Q

the corticobulbar tract is involved in

A

precise motor movements

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14
Q

lower motor neurons are located in

A

the brain stem or in the spinal cord

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15
Q

the lower motor neurons are responsible for

A

direct influence on muscles

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16
Q

lower motor neurons send axons out through nerves in the ____ to synapse on and control ____

A

peripheral nervous system; skeletal muscle cells

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17
Q

the lower motor neurons that pass through the spinal nerves primarily control

A

muscles of the limbs and the trunk

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18
Q

lower motor neurons that pass through cranial nerves primarily control

A

the skeletal muscles of the head and the neck

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19
Q

What happens when an action potential arrives and initiates synaptic transmission at the neuromuscular junction

A

Na+ channels open depolarizing the axon terminal causing VG Ca++ channels to open allowing Ca++ to enter the cell and vesicles to fuse and release ACh into the synaptic cleft, the ACh will bind to receptors on the postsynaptic membrane opening nAChR channels and depolarize the membrane

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20
Q

ACh in the synaptic cleft is broken down by

A

acetylcholinesterase

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21
Q

upper motor lesion characteristics

A 
muscle groups are affected
mild weakness
minimal disuse muscle atrophy
no fasciculations
increased muscle stretch reflex
hypertonia
spasticity
pathological reflexes (+ babinski)
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22
Q

lower motor lesion characteristics

A 
individual muscles may be affected
mild weakness
marked muscle atrophy
fasciculations
decreased muscle stretch reflex
hypotonia
flaccidity
(-) babinski sign
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23
Q

Types of lower motor neuron BULBAR diseases

A

bulbar palsies, amyotrophic lateral sclerosis (ALS- this is mixed upper and lower)

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24
Q

types of lower motor neuron Anterior Horn Cell diseases

A

poliomyelitis, motor system disease, polyneuritis, amyotrophic lateral sclerosis

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25
Q

types of lower motor neuron primary muscle diseases

A

muscular dystrophies, myasthenia gravis, polymyositis

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26
Q

causes of upper motor neuron motor cortex diseases

A

cerebral palsy, neoplasms, trauma, inflammations, ALS

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27
Q

causes of upper motor neuron internal capsule diseases

A

vascular lesions (CVA, thrombosis, embolism, hemorrhage, aneurysm), neoplasm, trauma inflammations

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28
Q

causes of upper motor neuron brainstem diseases

A

demyelinating diseases (MS), vascular lesions, neoplasms, trauma, inflammations, degenerative disease (Parkinson’s), ALS

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29
Q

causes of upper motor neuron spinal cord diseases

A

demyelinating diseases, neoplasms, trauma, inflammations, ALS

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30
Q

which upper motor neuron diseases are we focusing on for exam purposes

A

cerebral palsy, MS, CVA, Parkinson’s, Huntington’s

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31
Q

Cerebral Palsy is a ____ disorder

A

non-progressive

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32
Q

cerebral palsy is caused by

A

injury or abnormal development in the immature brain, before, during, or after birth up to 1 year of age

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33
Q

cerebral palsy is from damage to or defect of

A

the corticospinal pathway

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34
Q

Signs and symptoms of cerebral palsy

A

muscle weakness, loss of fine motor control, impaired speech, drooling, exaggerated deep tendon reflexes, spasticity, rigidity of extremities, scoliosis, contractures, joint dislocation

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35
Q

Associated problems with cerebral palsy

A

vision and hearing impairment, swallowing problems, seizures, intellectual disability, reflux disease, abnormal touch/pain perception, osteopenia

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36
Q

in patients with cerebral palsy symptoms

A

don’t worsen but become more apparent

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37
Q

cerebral palsy treatment

A

no cure
Botulinum toxin - prevent release of ACh decreasing spasticity
PT/OT
Surgery - ortho, dental, general, ophthalmology, ENT
(dorsal rhizotomy, antireflux operation, intrathecal baclofen pump)

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38
Q

What does a dorsal rhizotomy treat

A

treats muscle spasticity, cuts the nerve at the root

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39
Q

anesthetic considerations for cerebral palsy

A

hold preop sedatives and cautious with opioids, difficult vascular access, difficult airway, decrease MAC need, slow emergence, cautious administration of NDMR

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40
Q

cerebral palsy patients are prone to ____ perioperatively

A

bleeding, hypothermia, intravascular depletion

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41
Q

what is the main concern (organ system) for cerebral palsy patients?

A

respiratory

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42
Q

Multiple sclerosis is an ____ disease characterized by ___

A

autoimmune disease characterized by combo of demyelination, inflammation, and axonal damage of the CNS

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43
Q

which kind of nerves are not affected with MS?

A

peripheral nerves are not affected

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44
Q

Signs and symptoms of MS

A

parathesia, muscle fatigue and weakness, painful muscle spasm, visual problems (optic neuritis, diplopia), autonomic instability, bulbar muscle dysfunction, cognitive dysfunction

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45
Q

treatment of MS is directed at and includes

A

decrease spasticity, tremors, bladder spasticity

  • diazepam, dantrolene, baclofen
  • glucocorticoids and immunosuppressants
  • CD20 monoclonal antibody, interferon B1a or glatiramer acetate
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46
Q

situations that exacerbate the symptoms of MS

A

stress, increased body temperature, infection, hyponatremia

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47
Q

anesthetic considerations of MS

A 
avoid succinylcholine, scopolamine, and atropine
use NDMR cautiously
don't have surgery during flare
avoid spinal block
aspiration risk
increase risk of DVT
stress dose steroids
exaggerated hypotensive effects
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48
Q

CVA is characterized by

A

sudden neurologic deficits resulting from ischemia or hemorrhage

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49
Q

CVA of the anterior cerebral artery causes

A

contralateral leg weakness

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50
Q

CVA of the middle cerebral artery causes

A

contralateral hemiparesis and hemisensory deficit (face and arms), aphasia, contralateral visual field defect

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51
Q

CVA of the posterior cerebral artery causes

A

contralateral visual field defect and hemiparesis

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52
Q

CVA of the penetrating arteries causes

A

contralateral hemiparesis, contralateral hemisensory deficits

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53
Q

CVA of the basilar artery causes

A

oculomotor deficits and/or ataxia, crossed sensory and motor deficits

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54
Q

CVA of the vertebral artery causes

A

lower cranial nerve deficits and/or ataxia with crossed sensory deficits

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55
Q

CVA is the ___ leading cause of death

A

4th

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56
Q

Signs and symptoms of CVA

A

HA, confusion, aphasia, decreased cough/swallow reflex, hemiparesis or hemiplagia, incontinence, seizures, hyperthermia, emotional lability, horner’s syndrome, vomiting, perceptual defects, HTN, apraxia

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57
Q

TIA signs and symptoms

A

HA, confusion, vertigo, dysarthria, transient hemiparesis, temporary vision changes, syncope

58
Q

What is the first thing that ERs typically do when stroke is suspected

A

CT scan to determine if ischemic or hemorrhagic

59
Q

treatment of CVA

A

ASA, TPA (IV or direct infusion), surgery (crani, cerebellar resection)

60
Q

anesthetic considerations for CVAs

A

aspiration risk, DVT risk, BS maintenance, BP maintenance

61
Q

What do we want to avoid in CVA patients

A

hyperglycemia, dehydration, hyperthermia, infection

62
Q

What would be a good anesthetic option for CVA patients

A

regional with MAC

63
Q

Parkinson’s disease is a ___ disorder

A

neurodegenerative disorder of unknown cause

64
Q

Parkinson’s disease has a characteristic loss of

A

dopaminergic fibers in the basal ganglia, regional dopamine is also depleted

65
Q

depletion of dopamine results in

A

diminished inhibition of neurons controlling the extrapyramidal motor system and unopposed stimulation by Acetylcholine

66
Q

signs and symptoms of Parkinson’s disease

A

skeletal muscle tremor (pill rolling) at rest, rigidity, atkinesia, diaphragmatic spasms, dementia, depression, facial immobility (infrequent blinking, paucity of emotional expressions), shuffled gait

67
Q

triad of Parkinson’s disease

A

tremors
akinesia
rigidity

68
Q

treatment for Parkinson’s disease

A

levodopa, carbidopa, amantadine, selegiline, rasagiline, surgery (DBS - deep brain stimulation)

69
Q

What do we worry about with Selegiline therapy

A

risk of serotonin syndrome

70
Q

Which volatile anesthetic can exacerbate Parkinson’s disease

A

isoflurane

71
Q

Carbidopa is a

A

peripheral dopa decarboxylase inhibitor

72
Q

Amantadine is an ___ and can cause ___

A

antiviral; prolonged QT

73
Q

If a patient is taking Rasagiline what do we need to check/monitor?

A

blood sugars

74
Q

anesthetic considerations for parkinson’s disease

A

continue levodopa therapy, will see HoTN and cardiac dysrhythmias at induction, use Sevoflurane, avoid benzos, use direct acting agents such as phenylephrine, risk of periop HTN, aspiration, laryngospasm

75
Q

What is less effective is someone is on anticholinergics in Parkinson’s

A

NDMR

76
Q

Huntington’s disease is a ___ characterized by ___

A

degenerative disease of the CNS characterized by marked atrophy of the caudate nucleus, putamen, and globus pallidus

77
Q

signs and symptoms of Huntington’s disease

A

progressive dementia, chorea, tremors, rigidity/contractures, depression, aggressive outburt, mood swings, difficulty with speech and swallowing, weight loss

78
Q

treatment of Huntington’s disease

A

treat choreiform movements, Haldol, antidepressants, PT/OT/speech therapy

79
Q

anesthetic considerations for Huntington’s disease

A

aspiration risk, prolong response to succinylcholine, sensitive to NDMR, consider avoiding reglan and anticholinergics, use glycopyrrolate > atropine

80
Q

lower motor neuron diseases we are going to focus on for the purposes of the exam

A

MG, MD, Lambert-Eaton, myotonic dystrophy, mitochondrial disorder, Guillain Barre, spinal muscular atrophy

81
Q

myasthenia gravis is

A

autoimmune destruction or inactivation of postsynaptic acetylcholine receptors at the neuromuscular junction leading to reduce numbers of receptors and degradation of their function

82
Q

signs and symptoms of myasthenia gravis

A

diplopia, ptosis, fluctuating fatigue and weakness that improves after rest, muscle weakness of mouth and throat, dyspnea with exertion, proximal muscle weakness

83
Q

treatment of myasthenia gravis

A

cholinesterase inhibitor, plasmapheresis, corticosteroids, immunosuppressants, immunoglobins, thymectomy

84
Q

situations that exacerbate myasthenia gravis

A

pregnancy, infection, electrolyte imbalance, surgical and psychological stress, aminoglycoside antibiotics

85
Q

pregnancy and myasthenia gravis

A

increased weakness in 3rd trimester

baby may show S/S of MG requiring intubation when they are born

86
Q

anesthetic considerations for myasthenia gravis

A

aspiration risk, sensitive to NDMR, sensitive to respiratory depressants, regional preferred (amides not esters), resistant to succinylcholine

87
Q

lambert-eaton is a

A

presynaptic defect of the neuromuscular transmission in which antibodies to voltage gated calcium channels on the nerve terminal markedly reduce the quantal release of acetylcholine at the motor end plate

88
Q

signs and symptoms of lambert-eaton

A

proximal muscles are mostly affected, weakness generally worse in the morning and improves thru the day, respiratory and diaphragm muscles become weak, autonomic nervous system dysfunction (orthostatic HoTN, slowed gastric motility, urinary retention), dry mouth, impotence, small cell carcinoma

89
Q

treatment for lambert-eaton

A

3,4-DAP, guanidine hydrochloride, corticosteroids, immunosuppressants, plasmapheresis

90
Q

anesthetic considerations for lambert- eaton

A

sensitive to succinylcholine and NDMR, inadequate reversal with anticholinesterase, high risk of postop respiratory failure

91
Q

60% of patients with lambert- eaton have

A

small cell carcinoma

92
Q

duchenne muscular dystrophy is a ___ disorder that results from __

A

X linked recessive disorder that results from production of abnormal protein dystrophin

93
Q

duchenne muscular dystrophy affects ___>___ and presents between ____ years of age

A

males > females, 3-5 years of age and don’t live past 30 years old usually

94
Q

signs and symptoms of duchenne MD

A

symmetric proximal muscle weakness “gower sign”, fatty infiltration causes enlargement of muscles (calves), kyphoscoliosis, respiratory muscle weakness, degeneration of cardiac muscles, impaired GI hypomotility, imparied airway reflex, impaired cardiac conduction, cognitive impairment, pulmonary hypertension

95
Q

becker muscular dystrophy is a ____ disorder

A

X linked recessive disorder (just less common)

96
Q

signs and symptoms of becker muscular dystrophy

A

presents later in life (adolescence), progress slower, intellectual disability less common, proximal muscle weakness, prominent calf pseudohypertrophy, degeneration of cardiac muscles

97
Q

what do patients with becker muscular dystrophy die from?

A

respiratory complications

98
Q

diagnosis of muscular dystrophy

A

genetic testing, CK levels (usually 10x higher), muscle biopsy (rare)

99
Q

treatment for muscular dystrophy

A

surgery (for scoliosis, release contractures, ex lap for ileus), PT, steroids, biphosphates, mystatin inhibitors, gene modification, protease inhibitors, stem cell infusions

100
Q

why are steroids a good treatment in muscular dystrophy

A

delay progression of disease by 2-3 years

101
Q

anesthetic considerations for muscular dystrophy

A

risk of MH like syndrome (rhabdomyolysis, hyperkalemia), avoid succinylcholine and volatiles, avoid opioid and benzos preop, intraop position complications d/t kyphoscoliosis, sensitive to NDMR, local and regional preferable, aspiration risk, look at echo, ecg, PFTs

102
Q

myotonic dystrophy is a ___ disease

A

hereditary degenerative disease of the skeletal muscle that results in the dysfunctional calcium sequestration by the SR
sodium and chloride channel dysfunction

103
Q

signs and symptoms of myotonic dystrophy

A

weakness, inability to relax hand grip (myotonia), cardiomyopathy, conduction defects (1st degree), dysphagia, slowed gastric emptying, endocrine dysfunction, central sleep apnea, ptosis

104
Q

triad in males with myotonic dystrophy

A

frontal balding, cataracts, testicular atrophy

105
Q

treatment for myotonic dystrophy

A

procainamide, phenytoin, mexiletine, baclofen, dantrolene, carbamazepine, cardiac pacemaker

106
Q

anesthetic considerations for myotonic dystrophy

A

avoid succ, aspiration risk, volatile anesthetics may produce exaggerated myocardial depression, neostigmine and physostigmine can aggravate myotonia, sensitive to respiratory depressants, maintain normothermia and avoid shivering, have PFTs, ecg, and transthoracic pacing available

107
Q

mitochondrial disorders are a group of disorders of __

A

skeletal muscle energy metabolism

108
Q

mitochondria produce the energy required by skeletal muscle cells through

A

oxidation-reduction reactions of the electron transfer chain and oxidative phosphorylation (generating ADP)

109
Q

signs and symptoms of mitochondrial disorders

A

abnormal fatigability with sustained exercise
skeletal muscle pain and progressive weakness
hearing loss, impaired vision
balance and coordination problems
seizures
learning deficits

110
Q

treatment for mitochondrial disorders

A

treat symptoms, administer metabolites and cofactors, sodium bicarbonate/dichloroacetate, ketogenic diet

111
Q

anesthetic considerations for mitochondrial disorders

A

prone to acidosis and dehydration, lactate level, avoid propofol for continuous infusion, avoid succinylcholine and LR, maintain normothermia, use caution with NDMR and local anesthetics, avoid prolonged tourniquets, avoid bupivacaine

112
Q

Guillain Barre is an

A

immunologic assault on myelin in the peripheral nerves particularly lower motor neurons, the action potential cannot be conducted so the motor endplate doesn’t receive the incoming signal

113
Q

guillain barre typically persists for ___ and ends ___

A

2 weeks; with full recovery in 4 weeks with some permanent paralysis remaining

114
Q

signs and symptoms of guillain barre include

A

flaccid paralysis that begins in the distal extremities and ascends bilaterally, intercostal muscle weakness, facial and pharyngeal weakness, sensory deficits, autonomic dysfunction, paresthesia, vital sign changes

115
Q

treatment for guillain barre

A

plasmapheresis, IVIG if plasmapheresis CI

116
Q

what is not useful in treatment of guillain barre

A

steroids

117
Q

when is plasmapheresis contraindicated?

A

in hemodynamically unstable patients or if they are bleeding

118
Q

anesthetic considerations for guillain barre

A

avoid succinylcholine, sensitive to NDMR, increased risk of DVT, risk of aspiration, exaggerated response to indirect sympathomimetics, high incidence of SIADH (monitor Na+), controversy of combined GA and regional, controversy with epidural, slow position changes, avoid respiratory depressants, risk of postop mechanical ventilation

119
Q

spinal muscular atrophy are due to

A

deletions or mutations in the survival motor neuron gene on chromosome 5q13

120
Q

the SMN gene product is involved in the formation of

A

RNA complexes and their trafficking out of the nucleus

121
Q

loss of SMN function promotes

A

apoptosis of lower motor neurons and affect the anterior horn of the spinal cord

122
Q

SMA I is also known as

A

infantile spinal muscular atrophy

123
Q

SMA I is an autosomal recessive disorder that manifests

A

usually within the first 3 months of life

124
Q

infants with SMA I have difficulty

A

swallowing, sucking, and breathing

125
Q

SMA I is ____ progressive leading to ___

A

rapidly; death from respiratory complications usually by age 3

126
Q

SMA II begins

A

latter half of the first year of life

127
Q

SMA II has ___ progression vs SMA I

A

slower

128
Q

SMA III develops at what age

A

after age 2

129
Q

SMA III develops weakness of ____

A

proximal limb muscles with relative sparing of bulbar muscles

130
Q

treatment of SMA

A

spinraza, zolgensma, evrysdi, PT, surgery, antibiotics

131
Q

anesthetic considerations for SMA

A

pulmonary consultation, difficult intubation, avoid succ, varying sensitivity to NDMR, regional is controversial, cautious with opioids, postop mechanical ventilation likely

132
Q

what is an example of a mixed motor neuron disease

A

amyotrophic lateral sclerosis (ALS)

133
Q

ALS is a

A

rapidly progressive degeneration of motor neurons in the corticospinal tract (primary descending upper motor neurons) and the lower motor neurons in the anterior horn gray matter of the spinal cord

134
Q

what replaces the affected motor neurons in ALS?

A

astrocytic gliosis

135
Q

signs and symptoms of ALS

A

spasticity, hyperreflexia, loss of coordination, muscle weakness, fasciculations, atrophy in hands, orthostatic HoTN, resting tachycardia, sensation remains intact

136
Q

what typically remains intact in ALS?

A

bladder and bowel function

137
Q

treatment for ALS

A

riluzole (NMDA receptor antagonist), edaravone, spasmolytics, analgesics

138
Q

what is the only drug that reduces mortality in ALS

A

riluzole

139
Q

anesthetic considerations for ALS

A

avoid succ, increase sensitivity to NDMR, aspiration risk, consider postop mechanical ventilation, increase sensitivity to respiratory depressants, autonomic dysfunction with hemodynamic instability risk, avoid spinal anesthesia

140
Q

What heart rhythm can ALS patients go into after induction?

A

PEA

141
Q

A patient with myasthenia gravis will be sensitive to ____ and resistant to ____

A

rocuronium; succinylcholine

142
Q

characteristics of lower motor neuron lesion

A

fasciculations, flaccidity

N935 Advanced Pathophysiology (15 decks)

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