Nuero II Flashcards
Lumbar and sacral roots fan out like a horses tail around_______ and this is called the ________
L1-L2
“cauda equina”
Where are most lumbar punctures performed at?
L4/5
The PNS consists of _________ and ________. They project to the heart, visceral organs, skin, limbs.
cranial nerves peripheral nerves.
The PNS controls the ____________ which regulates 2 things:
somatic nervous system
1. muscle movement
2. responds to sensations of pain/touch
The ____________ connects to organs and generations autonomic responses. This consists of what?
autonomic nervous system
- sympathetic NS
-activates organs and their functions during times of stress and arousal - parasympathetic NS
-conserves energy during rest/relxation
What are the 3 motor pathways?
- corticospinal (pyramidal tract)
- basal ganglia system
- cerebellar system
Corticospinal (pyramidal tract)
-Upper and lower motor neurons
-Mediate voluntary movement
-Stimulate selected muscular actions by inhibiting others
-Damage to this system causes weakness
Basal Ganglia System
-Maintains muscle tone to control body movements
-Gross movements: walking
-Damage cause movement issues (disturbances in posture and gait)
Cerebellar System
Coordinates motor activity
Equilibrium
Posture
Damage: impairs coordination
What are sensory pathways?
Reflex activity
Conscious sensation
Body positioning
Blood pressure regulation
Heart rate regulation
Respiration
What are dermatomes?
Band of skin innervated by sensory root of spinal nerve
Can help localize a lesion to a specific spinal cord segment
What are the 3 facial branches?
V1 opthalmic
V2 maxillary
V3 mandibular
CNI
Olfactory: smell
CNII
Optic: vision
CNIII
Oculomotor: pupillary constriction, opening eye, EOM
CNIV
Trochlear: downward internal eye rotation
CNV
Trigeminal: motor—temporal/masseter/lateral pterygoid muscle movement (chewing), sensory—facial
CNVI
Abducens: lateral eye deviation
CNVII
Facial: motor—facial movements, sensory—salty/sweet/sour/bitter tastes
CNVIII
Acoustic aka vestibulocochlear: hearing and balance
CNIX
Glossopharyngeal: motor—pharynx, sensory—posterior ear drum, canal, posterior pharynx, tastes
CNX
Vagus: motor—palate, pharynx, larynx, sensory—pharynx, larynx
CNXI
Accessory: motor—SCM/upper trapezius
CNXII
Hypoglossal: motor–tongue
Exam for CN1: Olfactory
Loss of smell occurs in: sinus conditions, head trauma, smoking, aging, use of cocaine, Parkinson’s Disease, COVID
TEST:
Test nasal patency
Exam for CNII Optic
Visual acuity (Snellen, Rosenbaum)
Visual fields by confrontation
Fundoscopic exam
Paying special attention to the optic disc
Exam for CN III, CN IV CN VI (oculomotor, trochlear, abducens
-inspect pupils
-EOM
-looking for diplopia
-looking for nystagmus > vestibular and cerebellar disease
pupillary reactions (direct/consensual)
-if ptosis and opthalmoplegia also present, consider intracranial anyreusm if pt is awake
-if comatose, transtentorial herniation
-accomodation/convergence, lid lag/ near response
Exam for CN V trigeminal
-Palpate masseter and temporal muscles
-Close eyes> check light sensation with cotton
-Close eyes> check sharp/dull
-Corneal reflex test> touch cornea with cotton (pt should blink)
While doing the exam for CN VII (facial) the flattening of the nasolabial fold/drooping of lower lid suggests ________
weakness
_______ injury to the facial nerve affects the upper and lower face: _________
peripheral, bells palsy
________ injury/lesion of the facial nerve affects just the_______ face.
central, lower
Exam for CN VIII Vestibulocochlear
-auditory acuity
-weber, rinne (is hearing loss sensorineural- damage to CNVIII (hearing loss from aging)
Exam for CN IX: Glossopharyngeal
-Symmetrical movement of soft palate and uvula with phonation
-Gag reflex
Exam for CN X Vagus
Hoarseness of voice, Observe for difficulty swallowing
Exam for CN XI: Spinal accessory
-Inspect muscle groups for atrophy/fasciculation
-inspect muscle strength of SCM
Exam for CN XII: Hypoglossal
-Inspect tongue at rest for atrophy, fasciculation
-Move tongue from side to side
-Tongue muscle strength
Involuntary Movements
Tremors
Tics
Brief, repetitive, coordinated movements
Tourettes, phenothiazine reaction
Athetosis
Slow twisting movements, hands/feet, face. Spastic, cerebral palsy
Dystonia
Like athetosis but involving larger parts of body: trunk
Oral-Facial Dyskinesias
Arrhythmic, repetitive, bizarre motions of face/mouth/jaw
Phenothiazine reactions not corrected
Chorea
Brief, rapid, jerking movements. Huntingtons Disease
Atrophy
loss of muscle bulk
Aging, diabetic neuropathy
Hypertrophy
increase in bulk with normal or increasing strength
Pseudohypertrophy
increase in bulk with diminished strength
Duchenne muscular dystrophy
Muscle Tone
When a normal muscle with an intact nerve supply is relaxed voluntarily it maintains slight residual tension
What is Hypotonia/Flaccid and what type of disorder is associated with it ?
marked floppiness
Peripheral motor system disorder
Spasticity indicates a ________ tract disorders. Explain what it is?
Central corticospinal tract disorder
increased tone that intensifies at end range movements, increases with rapid movements
Rigidity
increased resistance through all ROM
What are the 6 abnormalities of muscle strength?
Paresis: impaired strength
Plegia: absent strength
Hemiparesis: weakness on ½ of body
Hemiplegia: paralysis on ½ of body
Paraplegia: paralysis of legs
Quadriplegia: paralysis if all 4 limbs
Muscle strength scale
5- active movement against full resistance without evident fatigue normal muscle strength
4- active movement against gravity and some resistance
3- active movement against gravity
2- active movement of the body part with gravity eliminated
1- a barely detectable flicker or trace contraction
0- no muscular contraction detected
Spinal cord syndrome
Loss of pain and temperature, but intact touch and vibration
Define light touch and the different indications
Touch skin lightly with fine wisp of cotton, ask pt to respond whenever touch is felt
Anesthesia: Absence of touch sensation
Hypesthesia: Decreased sensitivity
Hyperesthesia: Increased sensitivity
For the vibration part of the sensory exam, you want to use a _________ hz fork and place it on the patients _______ joints of finger/toe
128 Hz, IP joints
________is the FIRST SENSE to be lost in peripheral neuropathy. It is also lost in posterior column disease such as_________ and _______
vibration, tertiary syphilis, vit B12 def
Define the three types of abnormalities related to feeling pain
Analgesia: absence of pain
Hypalgesia: decreased sensitivity to pain
Hyperalgesia: increased sensitivity to pain
Proprioception/Position Sense is lost in _______, _______, _______, and _________
in tertiary syphilis, MS, B12 deficiency, diabetic neuropathy
Point localization
touch patient and ask them to point where you touched them
Extinction
touch each arm individually, then simultaneously. Ask where patient feels each stimulus
Stereognosis
identify object placed in hand (key, pen, etc) within 5 seconds
Graphesthesia
write a number in patients hand, ask them to identify
Two point discrimination
using paperclip, touch pad of index finger and move the two points closer together (secondary, confirmation test)
In __________ one movement CANNOT be followed quickly but its opposite. movements are ____, _______ and ______
cerebellar disease
slow, irregular, culmsy
Point-to-point movement UE and LE
UE: have patient touch your finger then their nose
LE: run heel down the shin
Rapid alternating movements (RAM)
Pat thighs alternating with dorsal and palmar aspects of hands
Tap feet against your hands
What occurs during a + Romberg (position sense) test? In ataxia, from ____________ disease, __________ compensates for sensory loss
balance is lost with eyes closed
Swaying is normal: proprioceptive correction
dorsal column disease, vision
Pronator Drift
Eyes closed
Arms fully extended with palms up (occurs when one forearm and palm turn inward and down – both sensitive and specific for a corticospinal tract lesion)
Briskly tap arms downward
A gait that lacks coordination is called
ataxia
Reflex
involuntary stereotypical response that may involve 1 sensory and 1 motor neuron across a single synapse
For a reflex to occur, all components of the reflex arc must be intact:
Sensory nerve fibers
Spinal cord synapse
Motor nerve fibers
Neuromuscular junction
Muscle fibers
Biceps__________ Strike your thumb overlying pts bicep tendon
(C5, C6)
Triceps _______Strike directly behind and above elbow
(C6, C7)
Brachioradialis _________ Strike directly 1-2 inches above radial aspect of wrist
(C5, C6)
Patellar/Quadriceps________Strike directly on patellar tendon w knee flexed
(L2, L3, L4)
Achilles/Ankle______Strike directly on Achilles tendon, watch for plantar flexion
(S1)
A slowed down Achilles/ankle reaction is seen in ___________
HYPOthyroidism
If reflexes seen hyperactive, test for _________
clonus
Sustained clonus indicates ___________ disease. 1-3 bears can be a normal finding
CNS disease
Ankle/wrist clonus> rapidly dorsi/plantar flex foot, hold in dorsiflexion and feel for _____________ muscle rhythmic oscillations (“tapping”)
continued
Clonus must be present to document a grade ________ reflex
4
Hyperactive Reflexes/Hyperreflexia indicates CNS lesions of __________ corticospinal tract. May have associated ___________ motor neuron findings such as?
descedning
upper
Weakness, spasticity, +babinski sign
Absent Reflexes/Hyporeflexia
indicates lesions of ________, __________, and ____________. May have associated __________ motor neuron findings such as?
spinal nerve roots, spinal nerves, peripheral nerves
lower
Weakness, atrophy, fasciculations
DTRs in hypothyroidism displays a ____________________ of reflex. It is best detected in __________ reflex
slowed relaxation phase of reflex
Achilles reflex
DTR Grading
4+ very brisk, hyperactive, with clonus
3+ brisker than average, slightly hyperreflexic
2+ average, expected response, normal
1+ somewhat diminished, low normal
0 no response, absent
DTRs: plantar response _______ on bottom of foot slide bottom of reflex hammer laterally to medially
L5-S1
What is a positive test for DTR plantar response
great toe extends (+Babinski)
What is a negative test for DTR plantar response?
great toe plantar flex (negative = good)
A positive test for plantar DTR can indicate a spinal lesion. What area does this affect? When is this usually seen?
affects corticopsinal tracts
seen in post-ictal states, drug/ETOH use
For the plantar response DTR, a positive test in adults is ________ in babies
normal
Abnormal cutaneous reflexes _________. This may be absent in both _________ and _______ disorders
T8-12
Run handle of reflex hammer from each corner of abdomen towards umbilicus
Umbilicus will pull towards hammer
central, peripheral
Loss of anal reflex indicates problems with what?
S2, S3, S4 CAUDA EQUINA
Nuchal Rigidity + test
neck stiffness
Caused by inflammation in subarachnoid space
Found in subarachnoid hemorrhage, meningitis
Brudzinski’s Sign + test
BL active hip/knee flexion
Kernig’s Sign + test
pain with extension of knee
Pain from stretched nerves when leg is extended
With the straight leg raise, pain radiating to leg is a _______ straight leg test. Tightness or discomfort in the buttocks/hamstrings is ______ positive test
positive, not
When doing a straight leg raise, what does pain in the ipsilateral leg indicate?
positive straight leg test for lumbosacral radiculopathy
When doing the straight leg raise, when pain is present in the contralateral healthy leg what does this indicate?
positive crossed straight-leg raise sign
In the glasgow coma scale, a score between _____ and ______ is good
13-15
In the glasgow coma scale, patients who are between ______ and ______ are comatose
3-8
In comatose patients, light reaction remains_______ in a _________coma
intact, metabolism
What are metabolic reasons associated with a comatose patient
uremia, hyperglycemia, etoh/drugs, anoxia(not getting enough oxygen), meningitis, encephalitis, hyper/hypothermia
What are structural reasons associated with a comatose patient?
hemorrhage, cerebral infarct, tumor, abscess
In a comatose patient,_________ lesions from stroke/abscess/tumor may lead to asymmetrical pupils and _______ of light reaction
structural
loss
-small/pinpoint
-midposition fixed
-large
-one large
What do b/l small pupils suggest?
- damage to the sympathetic pathways in the hypothalamus
- metabolic encephalopathy
- diffuse failure of cerebral function that has many causes, including drugs
-light reactions are normal
What do pinpoint pupils suggest?
- hemorrhage in pons
- effect of morphine, heroin, other narcotics
-light rxn may be seen with magnifying glass
What do midposition fixed pupils indicate?
structural damage in the midbrain
-fixed to light
What do b/l fixed and dilated pupils suggest?
- anorexia
- some meds
What do b/l reactive pupils suggest?
- cocaine, LSD, etc
What does a pupil that is fixed and dilated suggest?
- warns of herniation in the temporal lobe causing compression in the oculomotor nerve and midbrain
A single large pupil is commonly seen in _______ patients with infarction of CN _________
diabetIc, 3
When checking for ocular movement in a comatose patient with an INTACT brainstem, their eyes will move ….
towards the opposite direction e.g. head to the right..eyes to the left
When doing the neuro exam on comatose patients and assessing posture, you may need to apply painful stimuli. What will the normal-avoidant pt, sterotypic pt and flaccid pt do?
normal avoidant- pt pushes stimulus away
Sterotypic- stimuli evokes abnormal postural response of trunk/extremities
Flaccid- no response
When doing the neuro exam on comatose patients, Decorticate Rigidity is an (abnormal _________ response)
flexor
When doing the neuro exam on comatose patients, Decerebrate Rigidity is an (abnormal______________response)
extensor
Decorticate
Destructive lesion of the corticospinal tracts within or very near to the cerebral hemispheres
Decerebrate
Caused by a lesion in the diencephalon, midbrain, or pons. May arise from severe metabolic disorders (hypoxia, hypoglycemia)
