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Neuro > Neuropathy / Myelopathy / Radiculopathy / MND > Flashcards

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
Q

What causes

A 
Usually post infectious
Cambylobacter
Influenza
Mycoplasma pneumonia
CMV / EBV
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26
Q

What has poor prognosis

A

Age

Hx diarrhoea illness

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27
Q

How does it present

A 
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
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28
Q

What is typical pattern

A

Progresses over 4 weeks then resolves

Spectrum of presentations from mild weakness to diaphragm paralysis requiring intubation

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29
Q

Who is at risk

A

Age 20-50
Swine flu immunisation
Resp infection

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30
Q

What do you do

A

Always admit as can rapidly deteriorate

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31
Q

What investigation

A 
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
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32
Q

Why bloods

A

Exclude hypoglycaemia
Exclude hypokalaemia as cause
Exclude active infection
If high CK suggests myositis

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33
Q

What should be shown on LP

A

High protein
Normal WCC
Inflammation without infection

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34
Q

What will nerve conduction show

A

Demyelination pattern

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35
Q

Why is vital capacity / PFT so important

A

Monitor severity
IF FVC falls <20ml / kg then intubated required
Phrenic nerve affected = diaphragm paralysis

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36
Q

What is general Rx

A 
Analgesia - avoid opiate
May need long term neuropathic pain 
DVT
EYe car
Physio
O2 if resp
Steroids = NO benefit unlike most inflammatory
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37
Q

How do you monitor

A 
Lung function
ECG
BP
Autonomic - pupils / ileus
Check swallow
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38
Q

If severe i.e. can’t walk / rapid progression what Rx

A

IV Ig or plasma exchange

No benefit in both

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39
Q

When is ICU indicated

A 
Require intubation / ventilation 
Resp muscle affected
Labile HR / BP
Risk of aspiration pneumonia 
Rapidly progressive
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40
Q

What are complications

A 
Respiration
Talking
Swallowing
Bladder and bowel
Persistent pain and fatigue 
Autonomic failure = arrhythmia and BP fluctuation
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41
Q

What if present with would give doubt to Dx

A

Fever

WCC

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42
Q

What is compressive myelopathy

A

Spinal cord injury due to compression of anterior horn cell

Occurs at level of spinal cord so get UMN symptoms at everything below

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43
Q

What causes

A

Trauma
Tumour
Disc herniation
Degeneration

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44
Q

How will patient present

A 
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
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45
Q

How do you investigate

A

Bloods
X-ray
CT
MRI

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46
Q

How do you treat

A

NSAID to reduce inflammation
Steroid
Surgical decompression

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47
Q

What is degenerative cervical myelopathy

A

Degeneration of cervical vertebrae putting present on anterior spinal horn

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48
Q

How does it present

A

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

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49
Q

What is it misDx as

A

Carpal tunnel

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50
Q

What is Hoffmans

A

Flick middle finger and others twitch especially thumb

Suggestive of cervical spine issue

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51
Q

What puts you at risk

A

Smoking
Occupation
Genetics

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52
Q

How do you Dx

A

MRI = gold standard

- Look for disc degeneration and ligament hypertrophy

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53
Q

How do you Rx

A

Refer neuro or ortho for consideration of surgical decompression
Early treatment aids recovery

54
Q

What can occur

A

Recur at different spinal levels

Refer urgently

55
Q

What are non-compressive causes of myelopathy

A 
Demyelination 
Autoimmune inflammatio
Infectious 
Metabolic
Vascular
Parenoplastic 
Drugs
56
Q

Demyelination

A

MS

ADEM

57
Q

Autoimmune

A

SLE
Sarcoid
Devics’s
Vasculitis

58
Q

Infection

A

Viral - HSV / EBV / CMV / HIV
Bacterial - syphillis / Lyme’s / TB
Fungal
Schistosomiasis

59
Q

Metabolic

A

B12
Folate
Copper
Vit A

60
Q

Vascular

A

AV fistula
Anterior spinal artery stenosis
AVM
Ischaemia

61
Q

What artery in spinal stroke / ischaemic myelopathy

A 
Anterior spinal (branch of vertebral) 
Posterior spinal (intercostals) 
Usually occurs at mid-thoracic region
62
Q

What causes

A 
Atheroma 
Thromboembolism
Arterial dissection 
Hypotension
Vasculitis
Meningovascular syphillis 
AV malformation 
Occasionally haemorrhage
63
Q

What are the symptoms

A 
Pain in back 
Often radiates around IC nerve
Sudden onset weakness below infarct
Numb 
Urinary 
- Retention then incontinece as shock settles
64
Q

What happens with spinal shock

A

Gives you flaccid paralysis initially then spastic

65
Q

what are RF

A 
Vascular 
High BP
Smoking
High cholesterol 
DM
Obesity 
Inactivity
66
Q

How do you Dx

A

CT / MRI

67
Q

How do you Rx

A

Lower bP
Anti-platelet
Reverse hypovolaemia
Manage vascular RF

68
Q

What must you rule out

A 
Any condition putting pressure on cord
Slipped disc
Tumour
Inflammation
Abscess
Cauda equina
69
Q

What is radiculopathy

A

Nerve root disorder that presses on LMN

70
Q

What causes

A

Disc herniation
Tumour
Degeneration

71
Q

What are degenerative causes

A 
Age
Disc prolapse
Ligamentum hypertrophy
OA - osteophyte 
Cervical spondyloiss
Scoliosis
72
Q

How does it present

A 
Unilateral
Dermatomal sensory loss
Neuropathic pain in dermatome
Single myotome weakness
Loss of reflexes
Autonomic features 
Sciatica if sciatic nerve compressed
73
Q

How do you Dx

A 
CT
MRI
X-ray
Nerve conduction
Bloods
74
Q

How do you treat

A

NSAID
Corticosteroid
Surgery

75
Q

What causes nerve pain

A 
Compression of any nerve 
or 
Pain following damage to nervous system
- DM
- Post herpes
- Trigeminal neuralgia
76
Q

What is nerve pain like

A

Shooting
Stabbing
Hot
In a dermatomal region

77
Q

How do you manage

A 
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
Q

What is neuropathic analgesia

A 
Gabapentin
Amitryptilline
Pregabalin 
All 1st line
Tramadol if exacerbation but refer to pain management team
79
Q

What is 1st line in trigeminal

A

Carbamazepine

80
Q

What is MND

A

Group of diseases which affect nerves in brain and spinal cord

81
Q

What are the types

A

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
Q

What causes

A

Sporadic
Can be familial
- SOD gene that catalyses conversion of intracellular superoxide which damages nerve
- Expressed highly in motor nerves

83
Q

What are UMN and LMN signs

A 
Weakness
Extensor plantar
Hypertonia
Hyper-reflexia
Stiff 
Wasting
Fasiculation
84
Q

What does MND not have

A

Cerebellar
External ocular muscle
Sensory signs

85
Q

How will patient present

What dementia

A 
Weakness / tripping
Spastic gait
Weight loss
Slurred speech
Foot drop
Weak grip 
Aspiration
Dysarthria
Sx of front-temporal dementia 
Later bulbar and respiratory
86
Q

How do you Dx

A 
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
Q

How do you treat

A 
PEG
NIV - BiPAP
Physio
Anti-glutamate (Riluzole) as glutamate may damage nerve but small evidence 
Prognosis = 3-5 years from symptom onset
88
Q

What is thoracic outlet syndrome

A

Compression of brachial plexus or subclavian at origin of thoracic outlet

89
Q

What causes

A

Neck trauma in presence of anatomical variant

Cervical rib

90
Q

How does neurogenic present

A

Painless muscle wasting
Motor weakness
Sensory - numb / tingling
Autonomic - cold hands

91
Q

How does vascular present

A

Painful diffuse arm swelling
Distended veins
Claducation

92
Q

How do you Dx

A

Neuro exam
Adson
Exclude other pathology - cervical radiculopathy, Carpal tunnel, shoulder injury

93
Q

What investigation

A

CXR and C-spine- rib, degeneration, tumour
CT / MRI to rule out compression
Angio for vascular

94
Q

How do you treat

A

Rehab / physio

Surgical decompression

95
Q

What would be main DDX

A

Cervical spondylosis

  • Not worse on raising arm or using
  • No vascular Sx
96
Q

What is it different from subclavian steal

A

Steal has deceased blood flow to brain on movement of arm

97
Q

What causes autonomic dysreflexia

A

Spinal cord injury above T6

98
Q

What happens

A

Central mediated para response is blocked by lesion
Sympathetic stimulated eg. by retention or constipation via thoracocolumbar
No blockage by para

99
Q

What does this lead too

A

Unbalanced physiological response
Extreme hypertensoin
Flushing
Sweating

100
Q

How do you Rx

A

Remove or control stimulus e.g. catheter

Treat any life threatening BP or bradycardia

101
Q

What are complications

A

Haemorrhage stroke if untreated

Agitation

102
Q

What is complex regional pain syndrome

A

Occurs following surgery or minor trauma
Type 1 = no lesion
Type 2 = lesion

103
Q

What are Sx

A 
Progressive / disproportionate Sx to injury
Allodynia 
Temp + skin colour change
Oedema
Sweating
Motor dysfunction
104
Q

What criteria

A

Budapest diagnostic

105
Q

How do you Rx

A

Physio
Neuropathic
Specialist pain team

106
Q

What types of gait

A

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
Q

How do you investigate

A 
X-ray
MRI
Bloods 
- FBC, U+E, LFT
- B12
- PSA 
Serum electrophoresis 
CXR
LP
EMG
Muscle biopsy
108
Q

What does clinical neurophysiology look at

A

Peripheral neuropathy
Entrapment
Radiculopathy
Myelopathy

109
Q

What is an EEG

A

Shows electrical activity in brain

Decide if epilepsy and type

110
Q

If focal

A

Starts in one area so high amplitude there and doesn’t spread

111
Q

What is an EMG

A

Test to look at muscle and nerve supply
Electrode places into muscle to measure activity
Examines velocity and apmplitue of nerve

112
Q

What is done at same time and what does that look at

A

Nerve conuction
Measures how fast an impulse moves and strength
Indicates nerve damage

113
Q

Neuropathy

A

Increased amplitude and duration

114
Q

Myopathy

A

Decreased amplitude and duration

115
Q

Myasthenia Gravis

A

Decreased response to stimuli
Fewer receptors so smaller EPSP and big variation = jitter
Little variation

116
Q

Lambort Eaton

A

Incremental response

117
Q

MND

A

Detects muscle losing nerve supply

118
Q

If axonal loss neuropathy

A

Decreased amplitude

Normal velocity on NCS

119
Q

If demyelimation

A

Normal amplitude

Decreased velocity on NCS

120
Q

If MND

A

Nerve conduction normal which excludes neuropathy

121
Q

Myelopathy

A

Level of spinal cord

UMN

122
Q

Radiculopathy

A

Nerve root

LMN in one myotome / dermatome

123
Q

Brain

A

Contralateral to anatomical place in the head

124
Q

What is in lumbar spine

A

Very little spinal cord as only extends to L1 then its the cauda equine

125
Q

What do you want to know

A

Anatomical level of lesion
Aetiology
How it affects patient

126
Q

e.g. UMN signs but none in arm

A

Most likely thoracic level

Worry about malignancy as degeneration unlikely

127
Q

What is important to remember

A

Spinal cord ends at L1/L2 so will get LMN signs if below this

128
Q

If cord compressed

A

LMN flaccid + radicular pain at level

UMN spastic + sensory loss below lesion

129
Q

What else does it depend on

A

If whole cord compressed or partial
e.g. if posterior would get loss of proprioception
if anterior = loss of pain / temp

130
Q

What is hereditary spastic parapersis

A

UMN signs
FH
MRI = often normal

Neuro (19 decks)

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