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Neuro > Peripheral Nerve Disorders I - Exam 4 > Flashcards

Peripheral Nerve Disorders I - Exam 4 Flashcards

1
Q

_____ carries information away from the cell body. _____ carries information to the cell body

A

axon= away from cell body

dendrite: to the cell body

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2
Q

__________ a fatty layer of tissue that insulates the axon to allow for faster neurotransmission. ________ a chemical synapse formed by the motor neuron and a muscle fiber

A

Myelin sheath

Neuromuscular junction

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3
Q

_____ is the blood supply of nerve fibers?

A

vasa nervorum

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4
Q

______ nerves carry sensory signals toward the CNS for review. ____ nerves carry motor signals from the CNS to the target

A

Afferent

Efferent

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5
Q

What are the 3 types of peripheral nerves?

A

large myelinated
small myelinated
small unmyelinated

type of fiber depends on the type of sensation

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6
Q

Draw the breakdown of the peripheral nervous system.

A
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7
Q

What kind of neuropathy affects the cell body? What type?

A

neuronopathy or ganglionopathy

usually only motor or sensory RARELY mixed

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8
Q

What kind of neuropathy affects the axon? What type of dz? Where does it occur first? What type of nerve fiber? What are the associated sensations?

A

axonopathy

metabolic

distally first

small nerve fibers

think pain/burning

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9
Q

What kind of neuropathy affect the myelin? What does it result in? What type of nerve fiber? What are the associated sensations?

A

myelinopathy

slower nerve conduction

large nerve fiber

buzzing and tingling

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10
Q

What kind of neuropathy affects the vascular supply? Where do they tend to occur?

A

neurovascular disorders: Inflammation (vasculitis) or ischemic

Usually distal ⅔ of limb

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11
Q

neuropathies that affect the neuromuscular junction are called ______. What is the problem?

A

NMJ disorders

dysfunction of chemical synapse

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12
Q

______ is when only one nerve is affected. What is the usual underlying cause? How will the s/s present?

A

Mononeuropathy

Injury/compression to specific nerve

Sensory/motor dysfunction distal
to affected area

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13
Q

What is Mononeuritis Multiplex (Multiple Mononeuropathy)? What are they associated with?

A

Damage to 2+ specific nerves
in unrelated areas

commonly associated with systemic diseases: think DM, RA, SLE, vasculitis

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14
Q

______ is when multiple nerves are affected and present in a patchy multifocal disease process. Are they usually symmetric? proximal or distal? Give an example

A

polyneuropathy

symmetric: can be sensory, motor or both

distally

diabetic peripheral neuropathy

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15
Q

What is this pattern called? What disease it is associated with?

A

stocking-glove distribution

diabetic peripheral neuropathy

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16
Q

_______ damage or irritation to one or more spinal nerve roots with a _____ distribution pattern

A

radiculopathy

dermatomal distribution

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17
Q

______ is damage or irritation to nerve plexus. What are the 2 MC? What is it usually due to? Give an example

A

plexopathy

brachial and lumbosacral plexus

Usually due to trauma or radiotherapy

Erb palsy

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18
Q

What is Erb’s palsy? What is a common underlying cause?

A

damage to the cervical plexus especially C5-6 due to traumatic childbirth when the should gets stuck behind the mother’s pelvis

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19
Q

How will metabolic causes usually present in peripheral neuropathy?

A

metabolic will present distally first

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20
Q

Define acute, subacute and chronic in peripheral neuropathy

A

Acute (days to 4 weeks)

Subacute (4 to 8 weeks)

Chronic (>8 weeks)

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21
Q

What is a telling sign that the underlying cause of peripheral neuropathy might be hereditary?

A

the pt will not notice lack of sensory symptoms despite having sensory signs because they have always been like that and do not know what “normal” feels like

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22
Q

When doing a PE, what is an easy way to tell if the problem is bone or muscle?

A

active vs passive ROM

if the provider and the pt cannot successfully complete full ROM think the problem is bone

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23
Q

_______ assess function of motor and sensory nerves and helps determine the extent/location of neuropathy. What does it measure?

A

Nerve Conduction Studies (NCS)

Measures how fast an electrical impulse moves through a nerve (BOTH kinds of nerves)

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24
Q

_____ assess electrical activity in skeletal muscles. What should you order when working a pt up for peripheral nerve disorders?

A

Electromyography (EMG)

combo NCS and EMG

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25
Q

What are the CI to a NCS (nerve conduction test)? When should you consult cardio?

A

external pacemaker wires - risk of electrical injury to the heart

Consult cardiology if pt has implantable cardioverter-defibrillator (ICD) or internal pacemakers. NCS are generally safe to use within 6 inches of pacemakers or ICDs

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26
Q

What are the interfering factors in a NCS? Give a brief summary of each

A

Age - nerve conduction velocities (NCV’s) are slower in infants and children

Sex - NCV slower in men than women

Temperature - decreased NCVs in colder temperatures

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27
Q

What will axonal degeneration show up like on NCS? demyelination?

A

Axonal degeneration - reduced amplitude

Demyelination - slow internodal conduction and reduced conduction velocity

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28
Q

What is the procedure of a NCS?

A
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29
Q

What is the procedure for EMG? What is an interfering factor?

A

deep brain stimulator can create electrical artifact

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30
Q

What are the 12 cranial nerves with functions. Which ones are sensory vs motor?

A

Some Say Marry Money But My Brother Says Big Brains Matter Most

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31
Q

What is the difference between parosmia and cacosmia?

A

parosmia: Parosmia is a distorted sense of smell. Things that used to smell pleasant now smell foul to people with parosmia

cacosmia: With cacosmia, the smell is often described as similar to feces, or a burning, rotten, or chemical odor.

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32
Q

What are some causes that would present as a olfactory nerve disorder? What is the associated timeline?

A

trauma, compression, systemic diseases, URI

May see improvement in 1st 4-6 weeks after acute injury but some patients never regain function

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33
Q

What will a disorder of the optic nerve present like? What is the tx?

A

Partial or complete monocular blindness

visual field deficits, blurring, scotomata, monocular diplopia, pupillary defect
+/- pain

surgical decompression or high dose steroids, depending on the cause

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34
Q

ptosis; lateral, slightly depressed eye, EOM restricted except laterally
+/- pupillary involvement
Loss of depth perception, reading and visual scanning problems

What CN?

A

Oculomotor Nerve (CN III)

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35
Q

Upward deviation of eye with failure of depression on adduction
Vertical diplopia worst on looking down
Loss of depth perception, reading and scanning problems

What CN?

A

Trochlear Nerve (CN IV)

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36
Q

pain, corneal drying, numbness, impaired mastication

What CN? What do you need to test?

A

Trigeminal Nerve (CN V)

need to test if it is affecting all branches of the nerve or just one

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37
Q

What is the nerve pattern distribution of the trigeminal nerve?

A
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38
Q

Affected eye turned medially - inability to abduct
Horizontal diplopia; increases with gaze to affected side
Loss of depth perception, reading and scanning problems

What CN?

A

abducens nerve CN VI

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39
Q

What is Bell’s palsy? What CN? What are some s/s?

A

complete or partial paralysis of face, progresses from weakness→paralysis over 48 hours

facial nerve, CN VII

Pts may report facial drooping, poor eyelid closure
Hyperacusis, pain in/behind ear, and/or impaired sense of taste

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40
Q

What are the viral association of Bell’s palsy? What are some additional causes?

A

suspected viral (HSV, VZV)

inflammatory, AI, ischemic, trauma

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41
Q

What time of the year is Bell’s palsy seen more? What is a common pt?

A

MC in colder months

MC in 20-40 y/o pts, pregnant or DM pts

42
Q

How do you dx Bell’s palsy? What else do you need to consider?

A

clinical dx through facial nerve testing

consider EMG/NCS is complete ongoing paralysis or CT/MRI is concerned about tumor or additional nerve involvement

43
Q

What is the tx for Bell’s palsy? What is the associated timeline?

A

high dose Prednisone 60-80 mg PO QD x 7 d, followed by 5 d taper)

valacyclovir 1000 mg PO TID x 7 d especially if no forehead movement, cannot close eye and/or vesicular lesions

eye protection: eyepatch and artificial tears to protect eye from drying out

Within 5 days

44
Q

When do you need to get imaging in Bell’s palsy?

A

Imaging (MRI, CT) if s/s >8 wks or progress after 3 wks

refer to ENT/Neuro/ophthalmology if needed or s/s do not improve

45
Q

Positional vertigo, hearing loss, tinnitus, deafness

What CN?
What testing?

A

Vestibulocochlear Nerve (CN VIII)

Weber, Rinne, audiologic, brainstem auditory evoked response

46
Q

dysarthria, dysphagia, loss of bitter/sour taste, impaired gag reflex, impaired pharyngeal sensation, voice change

What CN?
What is the associated testing?

A

Glossopharyngeal Nerve (CN IX)

Gag reflex, voice quality and tones, uvula and soft palate rise, pharyngeal sensation testing, attempt swallowing water

47
Q

Weakness and atrophy of trapezius and sternocleidomastoid

What CN?
What will it present like?

A

Accessory Nerve (CN XI)

drooping or depression of affected shoulder with weak abduction
no sensory loss; pain often present
may see winged scapula

48
Q

** What is the MC cause of accessory nerve damage? Name additional causes

A

medical procedures

trauma, brainstem lesions, tumors, systemic disease

49
Q

dysarthria, swallowing difficulties
Tongue wasting and fasciculation
Tongue deviation

What CN?
What is the associated testing?

A

Hypoglossal Nerve (CN XII)

Protrusion and active ROM of tongue; lingual speech

50
Q

What is carpal tunnel syndrome? Give specific anatomical features. MC in males or females?

A

compression of median nerve between transverse carpal ligament (flexor retinaculum), carpal bones, and other structures in the carpal tunnel

MC in females

51
Q

In carpal tunnel, what does direct compression lead to?

A

damages nerve fibers which leads to impaired axonal transport

compression of the vessels leads to ischemia

52
Q

What are risk factors for CTS? What pharm drug in particular?

A

Obesity
Pregnancy
Hypothyroidism
DM
Arthritis (OA, RA)
hx of median mononeuropathy

Aromatase inhibitors (anastrozole)

53
Q

What nerve distribution will you see in a pt with CTS?

A

median nerve distribution

palmar surfaces of the thumb, index, and middle fingers, and the radial half of the ring finger

54
Q

What are some aggravating factors for CTS? Alleviating factors?

A

aggravating:
Sleep (Night)
Sustained hand or arm positions (driving)
Repetitive movements of the hand or wrist
typing, writing, wait staff/tray carrying

alleviating:
Changing hand posture (not as effective in late dz)
Shaking/wringing of the hands

55
Q

What are 3 late findings associated with CTS? What is the initial PE reveal?

A

Atrophy of the thenar eminence (see picture)

(+) sensory changes along median nerve but not thenar eminence

(+) weak thumb abduction and opposition

basic exam is often benign

56
Q

What are the 4 provocative maneuvers that you should perform when working a pt up for CTS? Give a brief description of each. Give the associated timeframe for each

A
57
Q

What is important to note about 3 of the 4 CTS PE manuevers? Which one is different? Which CTS test provides instant feedback?

A

Phalen/“Prayer” sign
carpal compression test
hand elevation test** this one is at least for 60 seconds!!!

all require the pt to hold the position for 30-60 seconds

Tinel sign is instant shock like pain with wrist percussion

58
Q

Which CTS maneuver has the best sensitivity and specificity of all PE tests? How long do you need to hold it for?

A

Hand elevation test

at least 60 seconds!!

59
Q

____ is first line testing for CTS? What will mild/moderate/severe CTS show?

A

NCS/EMG

Mild CTS - sensory conduction delay only
Moderate CTS - sensory and motor delays
Severe CTS - evidence of axon loss (low amplitude of action potential)

60
Q

When would you want to order imaging with CTS?

A

US or MRI
Indicated if suspected structural abnormality of the wrist

61
Q

What is the goal of tx for CTS? What are the non-surgical tx options?

A

relief of pressure on median nerve

Modify activities and avoidance of precipitating activities

NEUTRAL (volar) position wrist splints

62
Q

What are the 2 invasive tx options for CTS? When should you refer out for CTS? What about if a pt is pregnant?

A

steroid injection
or
surgical decompression

-Symptoms last >3 mo despite conservative treatment
-thenar muscle weakness or atrophy
-severe symptoms that limit ADLs

Recommended to delay surgery till after pregnancy is completed

63
Q

What is tarsal tunnel syndrome? Give specific anatomical landmarks. What ligament?

A

Posterior tibial nerve supplies plantar flexors of foot and toes. Passes through tarsal tunnel behind and below medial malleolus

Nerve compression in ankle region as nerve passes under transverse tarsal ligament (flexor retinaculum)

64
Q

What is the MC pt with tarsal tunnel syndrome? What is the MC cause?

A

think athletes

fracture or dislocation

65
Q

What is the pattern of paresthesia/pain associated with tarsal tunnel syndrome?

A

Paresthesias (itching, burning, numbness, and tingling) and pain involving the sole of the foot, the distal foot, the toes, and occasionally the heel

66
Q

What makes TTS s/s worse? What PE test should you do?

A

night, walking/prolonged standing, dorsiflexion, eversion

+/- Tinel’s sign over nerve posterior to the medial malleolus and pt will have weakened toe flexion

67
Q

What will severe TTS present like?

A

Atrophy of intrinsic foot musculature

68
Q

What will the foot xray/MRI of a pt with TTS look like? ______ may help to confirm dx. What will it show?

A

typically will be NORMAL

NCS

Typically must compare to unaffected foot
(+) - prolonged tibial motor latencies and slowed conduction velocities

69
Q

What is the tx for TTS?

A

trial conservative therapy if no trauma hx

NSAIDs, shoe modification, orthotics

Steroid injection may provide relief

Surgical decompression if severe or refractory but is less effective than in CTS

70
Q

What is ulnar nerve palsy? Give the anatomical landmarks

A

ulnar nerve passes through the condylar groove between the medial epicondyle and the olecranon at the elbow “cubital tunnel” and at wrist pases through Guyon’s canal

71
Q

_____ is the MC focal neuropathy. _____ is the 2nd MC

A

1: carpal tunnel 2: ulnar nerve palsy

72
Q

What are the risk factors for ulnar nerve palsy? ** What is the highlighted one from lecture?

A

occupation (leaning on elbows/prolonged elbow flexion),
cycling, baseball, karate

73
Q

What is the nerve paresthesia pattern associated with ulnar nerve palsy?

A

paresthesias (numbness and
tingling in 4th and 5th digits, elbow pain, night awakening

74
Q

Are motor symptoms more or less common in ulnar nerve palsy?

A

motor symptoms overall are LESS common

aka LESS likely to have trouble gripping or dropping items

75
Q

What is claw hand deformity? What is it associated with?

A

mild weakness in the ring and picky finger, ulnar nerve palsy

76
Q

What is froment’s sign? What nerve disorder is it associated with? How are the s/s reproduced?

A

Froment sign - thumb adductor weakness
Flexion of thumb at IP joint when attempting to oppose thumb

ulnar nerve palsy

flexion + compression

77
Q

What testing should you order if you suspect ulnar nerve palsy? How do you dx?

A

NCS: to determine if s/s are coming from elbow or wrist

EMG: for muscle weakness

MRI or US: to demonstrate compression

confirm with electrodiagnostic testing or imaging when suspected on the basis of clinical s/s

78
Q

What is the tx for mild/moderate ulnar nerve palsy? How is that defined?

A

Avoid leaning on the elbows, prolonged elbow flexion
Brace or wrap elbow with towel at night to limit flexion
Padded gloves for protection with occupational or recreational activities
NSAIDs/steroids - not as much evidence to support

mild-moderate - sensory loss, weakness WITHOUT wasting

79
Q

When do you consider sx in ulnar nerve palsy? What do you do if the compression is in the cubital tunnel? condylar groove? at wrist?

A

moderate to severe ulnar neuropathy at elbow >6 mo refractory to conservative tx or moderate -severe progressive s/s

If in cubital tunnel - release procedure
If in condylar groove - nerve transposition
At wrist - decompression

80
Q

What is the etiology behind radial nerve palsy? Where is it likely to compress?

A

winds around the proximal humerus in the spiral groove and proceeds down the lateral arm and enters the forearm, dividing into the posterior interosseous nerve and superficial nerve

Predisposed to compression where adjacent to the humerus (spiral groove)

81
Q

What are the risk factors for radial nerve palsy?

A

crutches
inebriation (“Saturday night palsy”)
improper positioning (limited mobility pts)
frequent tight straps or tight gloves on wrists
trauma

82
Q

Where are the 3 places the nerve is getting compressed in radial nerve palsy?

A

axilla

spiral groove

posterior interosseus

83
Q

What will radial nerve palsy at the axilla present like?

A

weakness/paralysis of all the muscles supplied by the nerve, including triceps

Sensory - hand (radial distribution), possibly posterior forearm

84
Q

What will radial nerve palsy with compression at the spiral groove present like? what are the 2 specific signs?

A

Same as axilla but spared triceps - weakness of wrist extensors (“wrist drop”), finger extensors, brachioradialis

cannot make “thumbs up” sign: weakness in thumb abduction

85
Q

What will compression of the radial nerve present like at the posterior interosseus?

A

purely motor; supplies
extensors of the wrist and fingers

may be able to extend wrist
but not finger

Pain and/or weakness with extension of wrist and fingers

86
Q

How do you dx radial nerve palsy?

A

clinically, can confirm with NCS/EMG. consider imaging if hx of trauma

87
Q

What is the tx for acute/one time radial nerve palsy? What is the tx for severe injury/trauma?

A

ock-up wrist and finger splints, avoiding further compression
physical therapy to avoid flexion contracture

Surgical decompression

88
Q

When should you refer a pt for radial nerve palsy?

A

Not improved in 2–3 wks, NCS/EMG to confirm and determine severity
Lack of improvement warrants further imaging or surgery

89
Q

What is the trigeminal neuralgia? Specifically _______.

A

Usually due to compression of the trigeminal nerve root that causes demyelination of large myelinated fibers and the fibers becomes hyperexcitable and electrically coupled with smaller unmyelinated or poorly myelinated pain fibers in close proximity

Aberrant arteriovenous loop - 80-90%

90
Q

What are the risk factors for trigeminal neuralgia? Who is the MC pt?

A

increasing age
female gender
MS
vascular disease

middle-aged and older women

91
Q

What are the primary symptoms of trigeminal neuralgia? What branches are the MC?

A

paroxysmal, stereotyped attacks of usually intense, sharp, superficial or stabbing pain in distribution of 1+ trigeminal branches

(V2, V3 MC)

92
Q

What are the facial muscle spasms called that are associated with Trigeminal neuralgia?

A

tic douloureux

93
Q

If V1 is involved, what are the associated s/s?

A

may see increased lacrimation, conjunctival injection, rhinorrhea

94
Q

What does the distribution look like from the from for V1,V2, V3 TN? What will the PE look like?

A

PE will be normal, light touch of “trigger zones” may reproduce symptoms

95
Q

What are some clinical features that would make you think it is secondary TN?

A
96
Q

______ may help differentiate classic TN from secondary TN. Is it always neccessary?

A

MRI/CT w and w/o contrast

recommendation for imaging varies

97
Q

How does cluster HA differ from TN?

A

cluster HA has V1 distribution and the pain lasts longer than TN

TN: attacks are shorter in duration but frequent

98
Q

What is first line tx for TN? Need to asses for _____ in pts of Asian ancestry. Why?

A

Carbamazepine (Tegretol) for 1 month and then try and taper as tolerated

HLA-B*15:02 allele

risk of SJS/TEN

99
Q

What is the major possible SE of carbamazepine/oxcarbazepine? Which one is worse?

A

agranulocytosis

carbazepine carries higher risk of bone marrow problems

100
Q

What are second line tx options for TN?

A

Second-line:

Antiepileptics - lamotrigine (Lamictal), gabapentin, phenytoin (Dilantin), pregabalin (Lyrica)

Muscle relaxants - baclofen, tizanidine (Zanaflex), botulinum toxin injection

101
Q

What are the surgical tx options for TN? Give a brief description of each

A
102
Q
A

Neuro (13 decks)

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