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Neuropathy / Myelopathy / Radiculopathy / MND Flashcards

1
Q

What is peripheral neuropathy

A

Damage to peripheral nerves (LMN)

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2
Q

If mononeuropathy i.e. single nerve affected what is this usually due to

A

Compression or trauma

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3
Q

If polyneuropathy

A

General symmetrical degeneration

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4
Q

What is a mono neuritis multiplex

A

Painful asymmetrical motor and sensory neuropathy
Isolated damage to 2+ separate nerve area
LMN
Suggest systemic inflammation

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5
Q

What causes

A

Suffest systemic inflammation

  • DM = most common
  • Vasculitis
  • Immune - RA / SLE
  • Infection - Lyme / HIV
  • Sarcoid
  • Cyroglublinaemia
WARDS PLC
Wegener
Amyloid
RA / SLE 
DM = 
Sarcoid 
Polyarteritis 
Leprosy
Cancer
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6
Q

What are the types of neuropathy

A

Nerve root disease

  • Inflammation
  • Infiltration
  • Degeneration

Individual nerve

  • Compression
  • Vasculitis
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7
Q

What are the most common causes of peripheral neuropathy

A

Alcohol
DM
B12

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8
Q

What is the ABCDE I causes of neuropathy

A 
A = alcohol 
B = B12 / botulism
C = cancer - paraprotein / CKD (uraemia) or Charcot 
D = DM / drugs
E = every vasculitis 
I = infection (HIV / HCV / Lyme's / leprosy) 
I = inflammation (GBS / demyelination / Sjogren's / SLE / sarcoid / coeliac )
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9
Q

How does alcohol affect nerve

A

Direct toxic nature
Reduced B12 absorption
Cerebellar degeneration
Usually sensory prior to motor

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10
Q

What does B12 cause

A

Subacute combined degeneration of spinal cord
Dorsal first - proprioception / vibation
Then paraestesia

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11
Q

What drugs / chemicals

A 
Amiadarone
Isonazid
Nitrofurantoin
Metronidazole
Quinolones 
Lead / mercury
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12
Q

What causes motor symptoms predominantly

A 
GBS
Lead poison
Charcot-Marie
Chronic inflammation
Diphtheria
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13
Q

What causes sensory symptoms predominantly

A 
DM
Uraemia 
Alcohol
B12 
Amyloid 
Leprosy
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14
Q

What are symptoms of neuropathy

A 
Unilateral
Myotomal wasting 
Myotomal weakness
Dermatomal sensory change 
Reflex changes
Hypotonia 
Neuropathic pain
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15
Q

If neuropathy due to axonal damage what happens e.g.DM

A 
Length dependent 
Start distal affecting long nerves e.g. fingers and toes
Glove and stocking loss 
Distal reflex loss 
Decreased amplitude on EMG
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16
Q

If neuropathy due to demyelination

A 
Symptoms occur anywhere
Diffuse loss
Non-length dependent 
Amplitude normal as axons fine
Decreased conduction velocity on EMG
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17
Q

What are acute causes of neuropathy

A

GBS
Lambort
Botulism

More reversible but most dangerous

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18
Q

What should you always screen for

A

DM
B12
Alcohol
Serum electrophoresis - not common but can mean catch cancer early

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19
Q

How do you investigate

A 
Bloods 
- FBC, U+E, LFT
- TSH
- B12 
- Glucose / HbA1c
ANCA / autoimmune screen
Infection screen 
Urinanalysis
Serum electrophoresis for paraprotein 
CXR
Genetics for Charcot 
Nerve conduction / EMG 
LP 
Nerve biopsy - NOT MOTOR
MRI
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20
Q 
LP result 
Bacterial
Viral
Inflammation
GBS
A 
Bacteria = low glucose
Viral = increased WCC
Inflammation = high Ig / WCC
GBS = high protein + normal WCC
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21
Q

How do you treat

A

Treat underlying cause
Physio
OT

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22
Q

What is Charcot-Marie Tooth Disease

A

AD

Most common inherited peripheral neuropathy

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23
Q

How does it present

A 
Predominant LMN signs
Distal weakness / atrophy 
Hyporeflexia
Hypotonia
FOOT DROP
HIGH ARCH
HAMMER TOES
Can get sensory loss
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24
Q

What is GBS

A

Immune mediated demyelination of peripheral nervous system
Molecular mimicry
Known as post-viral MS in PNS

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25
What causes
``` Usually post infectious Cambylobacter Influenza Mycoplasma pneumonia CMV / EBV ```
26
What has poor prognosis
Age | Hx diarrhoea illness
27
How does it present
``` Proximal usually affected first and LL Rapidly progressive muscle weakness - Limbs - Resp muscle - Face and eyes Muscle wasting Paraesthesia Neuropathic pain Ataxia Arreflexia Autonomic - Loss of bladder / retention (sphincter usually spared) - suggests cord compression - Tachycardia - Labile HR and BP - Arrhythmia Resp muscle weakness CN involvement ```
28
What is typical pattern
Progresses over 4 weeks then resolves | Spectrum of presentations from mild weakness to diaphragm paralysis requiring intubation
29
Who is at risk
Age 20-50 Swine flu immunisation Resp infection
30
What do you do
Always admit as can rapidly deteriorate
31
What investigation
``` Bloods - FBC, U+E, LFT - CK - ESR / CRP - Mg, Ca, phosphate Stool culture ECG to look for autonomic CXR to exclude other resp causes LP MRI if suspect spinal pathology as differential Nerve conuction + EMG = diagnostic Vital capaciy / PFT = very important ```
32
Why bloods
Exclude hypoglycaemia Exclude hypokalaemia as cause Exclude active infection If high CK suggests myositis
33
What should be shown on LP
High protein Normal WCC Inflammation without infection
34
What will nerve conduction show
Demyelination pattern
35
Why is vital capacity / PFT so important
Monitor severity IF FVC falls <20ml / kg then intubated required Phrenic nerve affected = diaphragm paralysis
36
What is general Rx
``` Analgesia - avoid opiate May need long term neuropathic pain DVT EYe car Physio O2 if resp Steroids = NO benefit unlike most inflammatory ```
37
How do you monitor
``` Lung function ECG BP Autonomic - pupils / ileus Check swallow ```
38
If severe i.e. can't walk / rapid progression what Rx
IV Ig or plasma exchange | No benefit in both
39
When is ICU indicated
``` Require intubation / ventilation Resp muscle affected Labile HR / BP Risk of aspiration pneumonia Rapidly progressive ```
40
What are complications
``` Respiration Talking Swallowing Bladder and bowel Persistent pain and fatigue Autonomic failure = arrhythmia and BP fluctuation ```
41
What if present with would give doubt to Dx
Fever | WCC
42
What is compressive myelopathy
Spinal cord injury due to compression of anterior horn cell | Occurs at level of spinal cord so get UMN symptoms at everything below
43
What causes
Trauma Tumour Disc herniation Degeneration
44
How will patient present
``` Hemi-cord lesion Bilaterally Ipsilateral propriception Contralateral pain and temp Ipsilateral UMN weakness Babinski +Ve Hypertonia and reflex Spastic below due to loss of UMN moderation ```
45
How do you investigate
Bloods X-ray CT MRI
46
How do you treat
NSAID to reduce inflammation Steroid Surgical decompression
47
What is degenerative cervical myelopathy
Degeneration of cervical vertebrae putting present on anterior spinal horn
48
How does it present
Pain in neck + UL Can affect LL Loss of fine motor = clumsy / digit dexterity / impaired gait Loss of sensation Loss of autonomic = incontinence / impotence Hoffman's
49
What is it misDx as
Carpal tunnel
50
What is Hoffmans
Flick middle finger and others twitch especially thumb | Suggestive of cervical spine issue
51
What puts you at risk
Smoking Occupation Genetics
52
How do you Dx
MRI = gold standard | - Look for disc degeneration and ligament hypertrophy
53
How do you Rx
Refer neuro or ortho for consideration of surgical decompression Early treatment aids recovery
54
What can occur
Recur at different spinal levels | Refer urgently
55
What are non-compressive causes of myelopathy
``` Demyelination Autoimmune inflammatio Infectious Metabolic Vascular Parenoplastic Drugs ```
56
Demyelination
MS | ADEM
57
Autoimmune
SLE Sarcoid Devics's Vasculitis
58
Infection
Viral - HSV / EBV / CMV / HIV Bacterial - syphillis / Lyme's / TB Fungal Schistosomiasis
59
Metabolic
B12 Folate Copper Vit A
60
Vascular
AV fistula Anterior spinal artery stenosis AVM Ischaemia
61
What artery in spinal stroke / ischaemic myelopathy
``` Anterior spinal (branch of vertebral) Posterior spinal (intercostals) Usually occurs at mid-thoracic region ```
62
What causes
``` Atheroma Thromboembolism Arterial dissection Hypotension Vasculitis Meningovascular syphillis AV malformation Occasionally haemorrhage ```
63
What are the symptoms
``` Pain in back Often radiates around IC nerve Sudden onset weakness below infarct Numb Urinary - Retention then incontinece as shock settles ```
64
What happens with spinal shock
Gives you flaccid paralysis initially then spastic
65
what are RF
``` Vascular High BP Smoking High cholesterol DM Obesity Inactivity ```
66
How do you Dx
CT / MRI
67
How do you Rx
Lower bP Anti-platelet Reverse hypovolaemia Manage vascular RF
68
What must you rule out
``` Any condition putting pressure on cord Slipped disc Tumour Inflammation Abscess Cauda equina ```
69
What is radiculopathy
Nerve root disorder that presses on LMN
70
What causes
Disc herniation Tumour Degeneration
71
What are degenerative causes
``` Age Disc prolapse Ligamentum hypertrophy OA - osteophyte Cervical spondyloiss Scoliosis ```
72
How does it present
``` Unilateral Dermatomal sensory loss Neuropathic pain in dermatome Single myotome weakness Loss of reflexes Autonomic features Sciatica if sciatic nerve compressed ```
73
How do you Dx
``` CT MRI X-ray Nerve conduction Bloods ```
74
How do you treat
NSAID Corticosteroid Surgery
75
What causes nerve pain
``` Compression of any nerve or Pain following damage to nervous system - DM - Post herpes - Trigeminal neuralgia ```
76
What is nerve pain like
Shooting Stabbing Hot In a dermatomal region
77
How do you manage
``` Exclude easily treated e.g. capsulitis Early physio to decrease inflammation and compression Neuropathic analgesia = 1st line Topical capsaicin if local Specialist pain team ```
78
What is neuropathic analgesia
``` Gabapentin Amitryptilline Pregabalin All 1st line Tramadol if exacerbation but refer to pain management team ```
79
What is 1st line in trigeminal
Carbamazepine
80
What is MND
Group of diseases which affect nerves in brain and spinal cord
81
What are the types
ALS - Most common - UMN and LMN signs Primary Lateral Sclerosis - UMN only Progressive muscular atrophy - LMN only Progressive bulbar - Palsy of tongue / muscles and swallowing - LMN - Has worst prognosis
82
What causes
Sporadic Can be familial - SOD gene that catalyses conversion of intracellular superoxide which damages nerve - Expressed highly in motor nerves
83
What are UMN and LMN signs
``` Weakness Extensor plantar Hypertonia Hyper-reflexia Stiff Wasting Fasiculation ```
84
What does MND not have
Cerebellar External ocular muscle Sensory signs
85
How will patient present What dementia
``` Weakness / tripping Spastic gait Weight loss Slurred speech Foot drop Weak grip Aspiration Dysarthria Sx of front-temporal dementia Later bulbar and respiratory ```
86
How do you Dx
``` History Dx = clinical Blood = increased CK EMG wil show muscle losing nerve supply Nerve conduction normal which excludes neuropathy MRI to rule out compression ```
87
How do you treat
``` PEG NIV - BiPAP Physio Anti-glutamate (Riluzole) as glutamate may damage nerve but small evidence Prognosis = 3-5 years from symptom onset ```
88
What is thoracic outlet syndrome
Compression of brachial plexus or subclavian at origin of thoracic outlet
89
What causes
Neck trauma in presence of anatomical variant | Cervical rib
90
How does neurogenic present
Painless muscle wasting Motor weakness Sensory - numb / tingling Autonomic - cold hands
91
How does vascular present
Painful diffuse arm swelling Distended veins Claducation
92
How do you Dx
Neuro exam Adson Exclude other pathology - cervical radiculopathy, Carpal tunnel, shoulder injury
93
What investigation
CXR and C-spine- rib, degeneration, tumour CT / MRI to rule out compression Angio for vascular
94
How do you treat
Rehab / physio | Surgical decompression
95
What would be main DDX
Cervical spondylosis - Not worse on raising arm or using - No vascular Sx
96
What is it different from subclavian steal
Steal has deceased blood flow to brain on movement of arm
97
What causes autonomic dysreflexia
Spinal cord injury above T6
98
What happens
Central mediated para response is blocked by lesion Sympathetic stimulated eg. by retention or constipation via thoracocolumbar No blockage by para
99
What does this lead too
Unbalanced physiological response Extreme hypertensoin Flushing Sweating
100
How do you Rx
Remove or control stimulus e.g. catheter | Treat any life threatening BP or bradycardia
101
What are complications
Haemorrhage stroke if untreated | Agitation
102
What is complex regional pain syndrome
Occurs following surgery or minor trauma Type 1 = no lesion Type 2 = lesion
103
What are Sx
``` Progressive / disproportionate Sx to injury Allodynia Temp + skin colour change Oedema Sweating Motor dysfunction ```
104
What criteria
Budapest diagnostic
105
How do you Rx
Physio Neuropathic Specialist pain team
106
What types of gait
Spastic - Stiff / UMN Extra-pyramidal - Shuffling - Postural instability Apraxic - Suggest normal pressure hydrocephalus - Wide based - Unsteady - Falls Ataxia = cerebellar - Wide based - Falls - No heel to toe - Worse in dark and closed eye Myopathic - Waddling - Limb girdle Psychogenic - Bizzare - No signs
107
How do you investigate
``` X-ray MRI Bloods - FBC, U+E, LFT - B12 - PSA Serum electrophoresis CXR LP EMG Muscle biopsy ```
108
What does clinical neurophysiology look at
Peripheral neuropathy Entrapment Radiculopathy Myelopathy
109
What is an EEG
Shows electrical activity in brain | Decide if epilepsy and type
110
If focal
Starts in one area so high amplitude there and doesn't spread
111
What is an EMG
Test to look at muscle and nerve supply Electrode places into muscle to measure activity Examines velocity and apmplitue of nerve
112
What is done at same time and what does that look at
Nerve conuction Measures how fast an impulse moves and strength Indicates nerve damage
113
Neuropathy
Increased amplitude and duration
114
Myopathy
Decreased amplitude and duration
115
Myasthenia Gravis
Decreased response to stimuli Fewer receptors so smaller EPSP and big variation = jitter Little variation
116
Lambort Eaton
Incremental response
117
MND
Detects muscle losing nerve supply
118
If axonal loss neuropathy
Decreased amplitude | Normal velocity on NCS
119
If demyelimation
Normal amplitude | Decreased velocity on NCS
120
If MND
Nerve conduction normal which excludes neuropathy
121
Myelopathy
Level of spinal cord | UMN
122
Radiculopathy
Nerve root | LMN in one myotome / dermatome
123
Brain
Contralateral to anatomical place in the head
124
What is in lumbar spine
Very little spinal cord as only extends to L1 then its the cauda equine
125
What do you want to know
Anatomical level of lesion Aetiology How it affects patient
126
e.g. UMN signs but none in arm
Most likely thoracic level | Worry about malignancy as degeneration unlikely
127
What is important to remember
Spinal cord ends at L1/L2 so will get LMN signs if below this
128
If cord compressed
LMN flaccid + radicular pain at level | UMN spastic + sensory loss below lesion
129
What else does it depend on
If whole cord compressed or partial e.g. if posterior would get loss of proprioception if anterior = loss of pain / temp
130
What is hereditary spastic parapersis
UMN signs FH MRI = often normal

Neuro (19 decks)

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