Revisin Flashcards
1
Q
what are 2 possible side effects of a statin
A
muscle pain and weakness
2
Q
what do you worry about with night pain
A
cancer
3
Q
what are spinal red flags
A
back pain (worse at night, new pain in old patient)
bilateral sciatica, urinary incontinence
impotence
saddle anaesthesia
4
Q
what is cauda equina syndrome
A
Compression/ irritation of lumbosacral nerve roots below conus medullaris
5
Q
what are the common causes of cauda equina syndrome
A
herniated disc, spinal stenosis, vertebral fracture, tumour
6
Q
what are the clinical features of cauda equina syndrome
A
usually acute (<24hrs), rarely subacute or chronic. Motor signs - LMN signs → weakness in multiple root distribution, reduced tendon reflexes Sensory signs - low back pain radiating to legs aggravated by sitting, relieved by lying down. Saddle anaesthesia (S2-5) Autonomic signs - urinary retention/ overflow incontinence, loss of anal tone (faecal incontinence).
7
Q
treatment for cauda equina
A
PR
MRI of lumbar spine
decompression within 48 hrs
8
Q
what reflexes are usually absent in cauda equina
A
ankle
9
Q
where does the conus medullaris end
A
L1/2
10
Q
what is degenerative cervical myelopathy
A
spinal cord dysfunction from compression in the neck.1 Patients report neurological symptoms such as pain and numbness in limbs, poor coordination, imbalance, and bladder problems. Owing to its mobility, the vertebral column of the neck is particularly prone to degenerative changes such as disc herniation, ligament hypertrophy or ossification, and osteophyte formation
11
Q
what are the common symptoms of degernative cervical myelopathy
A
Neck pain/stiffness
Unilateral or bilateral limb/body pain
Upper limb weakness, numbness, or loss of dexterity
Lower limb stiffness, weakness, or sensory loss
Paraesthesia (tingling or pins and needles sensations)
Autonomic symptoms such as bowel or bladder incontinence, erectile dysfunction, or difficulty passing urine
Imbalance/unsteadiness
Falls
12
Q
what are the motor signs of degenerative cervical myelopathy
A
o Pyramidal weakness (Upper limb; extensors more than flexors. Lower limb: flexors more than extensors)
o Limb hyperreflexia
o Spasticity (eg, clasp knife sign)
o Clonus, especially Achilles tendon
o Hoffman’s sign (thumb adduction/flexion +/− finger flexion after forced flexion and sudden release of a finger, distally)
o Babinski’s sign (upgoing plantar)
o Segmental weakness (corresponding to the level of compression)
13
Q
what are the features of an upper motor neurone lesion
A
paralyses affects movement rather than muscles slight muscle wasting spasticity hyperreflexia hypertonia normal power
14
Q
what are the features of a lower motor neurone lesion
A
flaccid paralysis (of muscle or muscle group) severe atrophy hypotonia absent reflexes may have fasciculation and fibrillation
15
Q
what is the most likely benign tumour of the brain
A
meningioma
16
Q
what is foster kennedy syndrome
A
when a slow growing frontal lobe tumour compresses optic nerve causing it to atrophy
17
Q
what level in spinal cord do sensory afferent from bladder enter
A
S2-4
18
Q
what is danish
A
how to examine to cerebellum
- dyskensia
- ataxia
- nystagmus
- intention tremor
- staccato speech
- hypotonia
19
Q
what tract will an upper motor neurone be in
A
pyramidal tracts
20
Q
is parkinsons an UMN lesion
A
no as not within the pyramidal tract
21
Q
are tremors pyramidal or extrapyramidal
A
extra pyramidal (involuntary movements)
22
Q
where are LMNs
A
anywhere below L1/2 or out with the CNS
23
Q
what is a tremor
A
involuntary movement in which there is rhythmicity, is a regular movement
24
Q
what movements tend to develop in extrapyramidal disorders
A
involuntary- tremors
25
what are the types of tremors
resting- when sitting and relaxed
postural- holding arms in certain postitions
intention- when trying to complete an action
26
where must a lesion be if it affects the leg and arm
cervical spin or above
27
weakness is a symptoms of a lesion affecting which tract
pyramidal
28
why is there not weakness in parkinsons
as extrapyramidal
29
what are the hallmarks of parkinsons
SLOWNESS (bradykinesia- only symptoms seen in everyone)
tremor
tone (stiffness and rigidity)
30
what are the other symptoms of parkinsons
```
can 'freeze' and struggle to initiate and stop movements
shuffling gate
stooped posture
changes in mood
handwriting gets smaller (micrographia)
balance problems
depression and anxiety
sleeping problems
loose paralysis in dreams so cant act out what they are dreaming
REM sleep disorder
loose sense of smell and taste (before motor symptoms)
memory changes
voice gets quieter
constipation
bladder problems
```
31
where is the lesion in parkinsons
substantia nigra in the basal ganglia (produces dopamine)
32
why is cerebrovascular pmhx important in parkinsons
as type of vascular parkinsons
33
what diseases are related to parkinsons
cerebrovascular disease, psychiatric problems (anti dopamine drugs)
34
what drugs are related to parkinsons
antihistamines, anti emetics (block dopamine), some anti psychotics
35
what are the risk factor for parkinsons
family Hx
risk factors for cardiovascular disease- alcohol, diet etc
NOT SMOKING - smoking protects you from parkinsons
36
what occupations have increased risk of parkinsons
agriculture, manganese minors, general exposure to chemicals
37
what is the commonest form of parkinsons
idiopathic
38
what type of movement do you loose in parkinsons
spontaneous
- facial
- adjusting position
- rolling over in bed
39
are cranial nerves affected in parkinsons
no
40
how is tone affected in parkinsons
increased (not in same way as UMN lesion)
= rigidity (high tone but velocity independant)
also get cog wheel rigidity
41
what type of tone changes in UMN lesion
velocity dependent
spactity
hypertonic
42
what type of tone changes in LMN lesion
hypotonia
| flaccidity
43
does parkinsons affect one or both sides
affects both sides of the brain but to different degrees so usually have one side affected in early stages then becomes more symmetrical
44
how is power affected in parkinsons
isnt as extrapyramidal
45
are reflexes affected in parkinsons
no as reflexes are pyramidal
46
is coordination affected in parkinsons
no as cerebellum fine
47
what do yuo get a resting tremor in
parkinsons
48
what do you get a postural tremor in
drugs, dystolic tremor, anxiety
49
what do you get an intention tremor in
cerebellar disease
50
what is a holmes tremor
a resting, postural and intentional tremor all at the same time
51
what is bradykinesia
slowness with decrement and degradation of repetitive movements (“fatigue”)
52
what are is affected in a central nervous system lesion
hemiplegia/ paraplegia/ whole limb
53
what type of weakness in a central nervous system lesion
heaviness
54
what are the additional features of a central nervous system lesion
spasms/ jerks
| cognitive/ sphincter involvement
55
can you get sensory symptoms in a central nervous system lesion
yes
56
what area will be affected in a peripheral nervous system lesion
may be peripheral or localised areas
| can be whole limb if affects plexus
57
what type of weakness in a peripheral nervous system lesion
positional/ with sleep
| ascending
58
what additional features can exists in a peripheral nervous system lesion
```
cramp
twitching (fasciculations)
loss of grip
tripping up
unsteady with eyes closed
```
59
can you get sensory symptoms in a peripheral nervous system lesion
yes
| pain may be prominent
60
where might be affected in NMJ lesion
ocular/ bulbar/ proximal limb
61
what is the weakness like in a NMJ lesion
fatiguable - worse after use
| diurnal variations- worse towards end of day
62
what additional features can be seen in a NMJ lesion
bulbar- swallowing, speaking, loss of chewing/ talking
ocular- diplopia, ptosis, prolonged gaze hard
resp- orthopnoea
63
can you get sensory symption in a NMJ lesion
no
64
where might be affected in muscular lesion
proximal
| symmetrical
65
what is the weakness like in a muscle lesion
may be aching
may be insidious
proximal weakness
symmetrical
66
what additional features can you get in a muscle lesion
myalgia
cramping
hard to get up from low chairs/ hang out washing
67
can you get sensory symptoms in a muscle lesion
no
68
what might be seen on inspection in a CNS lesion
abnormal limb posture
69
what might be seen on inspection in a PNS lesion
wasting/ fasciculations
| pes cavus
70
what might be seen on inspection in a NMJ lesion
ptosis
| ophthalmoplegia
71
what might be seen on inspection in a muscle lesion
proximal wasting
72
what happens to tone in a CNS lesion
increased
| spacticity/ clonus
73
what happens to tone in a PNS lesion
decreased
74
what happens to tone in a NMJ lesion
normal or decreased
75
what happens to tone in a muscle lesion
normal or decreased
76
what is the pattern of weakness like in peripheral neuropathy
distal weakness
77
what is a pyramidal pattern of weakness
arm: extensors weaker than flexors
leg: flexors weaker than extensors
if brain affected= contralaterla
if cord affected= ipsilateral side
78
what are reflexes like in a CNS lesion
increased
79
what are reflexes like in a PNS lesion
decreased
80
what are reflexes like in a NMJ lesion
normal or decreased
81
what are reflexes like in a muscle lesion
normal or decreased
82
what are reflexes like in a CNS lesion
extensor
83
what are reflexes like in a PNS lesion
flexor/ mute
84
what are reflexes like in a NMJ lesion
flexor
85
what are reflexes like in a muscle lesion
flexor
86
what distribution of sensory symptoms in a CNS lesion
brain- hemi sensory (one side for body, other side for face (trigeminal nerve))
cord- at sensory level
87
what distribution of sensory symptoms the PNS lesion: sensory neuropathy
glove and stocking
88
what distribution of sensory symptoms the PNS lesion: root/ plexus/ mononeuropathy lesion
depends on dermatome/ nerve
89
what does velocity dependant increased tone mean
involves pyramidal tract
90
where will see the effects of a lesion in the internal capsule
leg, arm, face and trunk
91
what is the general pattern of an inflammatory lesion in the brain
relapsing and remitting
92
what are the types of NMJ pathology and how can you differentiate them
lambert eaton= diminshed/ adbscence deep tendon reflex, autonomic features (is a pre synaptic problem)
myaestenia gravis - has ocular problems (post synaptic problem)
93
how do you demonstrate NMJ pathologies
```
bulbar- counting out loud
ocular- fixed horizontal gaze
ptosis- fixed upward gaze
limb- repetitive movements
(fatiguing weakness)
```
94
what results from an L4/5 L5 impingement
weak toe dorsiflexion
95
what results from an L5/S1 S1 impingement
weak knee flexion
| decreased knee jerk
96
what happens in a lesion on the brachial plexus
extensive arm weakness
97
what happens in a lesion on the lumbosacral plexus
extensive leg weakness
98
what results from a median nerve neuropathy
weak thumb abduction
99
what results from a ulnar nerve neuropathy
weak finger abduction
100
what are 2 features and common causes of peripheral neuropathy
is distal and sensory more than weakness
if acute- guillane barre syndrome
if chronic- diabetes/ alcohol
101
what test do you always do in epilepsy
ECG!!!!!
102
what does rigidity occur in
extrapyramidal conditions affecting the basal ganglia (e.g. parkinsons)
103
is rigidity associated with weakness
no
| but can have slow developing muscle contractions (bradykinesia)
104
is there usually a change in tendon reflexes in rigidity
no
105
what is spasticity dependent on
(velocity)
| input to the spinal cord produced by the passive movement of the limb
106
which muscles is spasticity predominantly found in
flexor muscles and forearm pronators inarm
extensor muscles in the legs
(think opposite to pyramidal weakness)
107
what is the clasp knife phenomonenum
where spasticity builds up soon after the start of the passive movement, then melts away
108
how is spasticity most easily elicited in the arm and leg
rapid extension of the elbow or supination of
the forearm
in the leg by rapid flexion of the knee
109
will a slow movement meet resistance in spasticity
no
110
what are the features of rigidity that distinguish it from spasticity
not velocity dependent
present equally in flexors and extensors
present throughout the range of movement
can have cog wheel or led pipe quality
111
how is rigidity best elicited
relatively slow passive movements
In the arm by flexion-extension of the wrist and elbow, and by supination-pronation of
the elbow.
In the lower limb flexion-extension of the knee and ankle are tested
112
what is the MRC power scale
0= No contraction
1= Flicker of contraction without movement
2= Slight movement with gravity eliminated*
3= Movement against gravity only
4= Movement against resistance
(can expand grade 4 to: 4+, 4 and 4-)
5= Normal power
113
why do tendon reflexes change
Reflexes are very sensitive to pathology affecting the afferent side of the reflex arc. If
conduction is blocked in only a few muscle spindle primary afferents, then the
compound action potential elicited in all the motorneurones will be smaller, and the
reflex will be less brisk or absent.
Reflexes are also sensitive to “upper motorneurone lesions” affecting the descending
motor pathways in the cerebral hemispheres, brainstem and spinal cord. The
excitability of the alpha motorneurones increases and the reflexes become brisker.
114
when is clonus abnormal
when it is sustained
115
what is reinforcement when testing a reflex
e.g.to link the fingers of each
| hand and attempt to pull them apart to test lower limb reflexes
116
what is clonus
the rhythmic contraction of a muscle group elicited by a rapid passive stretch of it
117
what is the triceps surae
pair of muscles located at the calf - the two-headed
| gastrocnemius and the soleus- ankle extensors- common to get clonus here
118
what is clonus a sign of
UMN lesions
| always associated with brisk ankle jerks
119
when are reflexes abnormal
when they are absent (with reinforcement).
when they are asymmetrical (right v left).
when there is a marked discrepancy between different reflexes (eg between those
in the arms and those in the legs).
when there is sustained clonus.
120
what is a positive babinski response
big toe extends and the other toes fan- sign of UMN lesion
121
what is a spastic gait
due to UMN lesion
| affected limbs appear very stiff
122
what causes a parkinonian gait
basal ganglia pathology
123
what causes a truncal ataxia (widebase, unsteady)
cerebellar disease
hydrocephalus
proprioceptive loss (neuropathy/ myelopathy)
124
what causes a high stepping gate
```
biltaeral= peripheral neuropathy
unilateral= peroneal nerve or L4 root lesion
```
125
what causes a waddling gait
proximal leg weakness
126
what are the types of tremor
Rest: Present when the subject is relaxed, and decreasing on
maintaining a posture or during movement
Postural/Action: Present on maintaining a posture and during movement, but
disappearing at rest.
Intention: Present towards the end of a movement to a target, causing
overshoot (dysmetria).
127
what are the causes for resting tremor
parkinsons
128
what are the causes for postural/ action tremor
Physiological
Essential tremor, drugs
Anxiety, Thyrotoxicosis
129
what are the causes for intention tremor
cerebellar disease
130
what happens to rapid supination/ pronation movements in parkinsons
In extrapyramidal diseases (Parkinsonian syndromes) there is a reduction in
the amplitude and speed of supination/pronation movements.
131
what happens to rapid supination/ pronation movements in cerebellar disease
irregularity of the movements as well as slowing
| and reduction in amplitude.
132
how do different pathologies affect fine finger movement
impaired in upper motor neurone lesions affecting the hand,
particularly with cortical lesions when the hand may be clumsy with little
weakness.
Fine finger movements are also impaired in extrapyramidal
diseases and cervical myelopathy.
133
what type of taste do the CN VII an IX nerves carry
sourness
sweetness
bitterness
saltiness
134
what vision loss in optic neuritis
central scrotoma
135
what causes red vision to be lost
optic nerve dysfunction
136
where is a defect if vision loss is homonymous
behind the chiasm
137
what is a hippus
oscillation in pupillary size
138
what is the pupil like in horners syndrome
miotic (constricted)
| will also have lack of upward gaze
139
what is bells phenomenon
the upward deviation of the eyes on closure
140
what causes diplopia when only one eye is open
refractive error or cerebellar problem
141
what causes vertical upbeat nystagmus
most commonly seen as a side-effect of anticonvulsants but it may also occur in cerebellar and pontomedullary abnormalities and in Wernicke's encephalopathy
142
what causes down beat vertical nysatgmus (fast downward phase)
abnormality at the craniocervical junction
cerebellar degeneration and drug intoxication
Wernicke's encephalopathy, demyelination, brain stem encephalitis, tumours at the foramen magnum and hydrocephalus.
143
is there diplopia in long standing strabismus
no
144
what does the medial longitudinal fasciculus connect
CN III, IV and VI
145
in the trigeminal nerve, what are the central connection for touch and pain/ temperature afferents
touch = main sensory nucleus
| pain/ temp= spinal nucleus
146
where does UMN facial weakness tend to spare
the upper half of the face
147
what nerve supplies taste to the anterior 2/3rds of the tongue
CN VII (facial)
148
what does a corrective saccade in the head thrust test mean
a peripheral cause of vestobular problems
149
does the spinal accessory nerve originate from cord or brain stem
both hehe
150
what s a bulbar palsy
(bulbar= medulla)
| caused by diseases affecting the lower cranial nerves e.g. a LMN lesion, NMJ or muscle problem
151
what causes a pseudobulbar palsy
when a UMN lesion affects the lower cranial nerves (a disease of the corticobulbar tracts)
152
what can a bulbar palsy with a LMN lesion cause
-impaired voluntary palatal movement
impaired palatal movement on eliciting the gag reflex or loss of the gag reflex
wasting and fasciculation of the tongue
slurring dysarthria and dysphagia
153
what does a pseudobulbar palsy cause
```
a brisk jaw jerk
a brisk gag reflex
a spastic tongue (with difficulty protruding the tongue and impaired rapid tongue
movements)
a spastic dysarthria and dysphagia
```
154
how do you test each occular muscle and nerve (movements)
III -superior rectus (looks laterally and upwards), inferior rectus (looks laterally and
downwards), medial rectus (looks medially), inferior oblique (looks medially and
upwards)
IV -superior oblique (looks medially and downwards)
VI - lateral rectus (looks laterally)
155
what are the different types of articulation
Palatal articulation – “KA”,
Guttural articulation – “GO”,
Labial articulation – “PA”
156
what level does should abduction test
C5
157
what level does elbow flexion and wrist extension test
C6
158
what level does elbow extension and wrist flexion test
C7
159
what level does thumb extension test
C8
160
what level does finger abduction test
T1
161
what level does hip flexion test
L1,2
162
what level does knee extension test
L3
163
what level does ankle dorsiflexion test
L4
164
what level does great toe extension
L5
165
what level does ankle plantar flexion test
S1
166
what is a glioblastoma
a high grade (grade 4) astrocytoma
167
what is coning
where the brainstem and cerebellum get pushed through the foramen magnum (tonsillar herniation
168
what is cushings triad
reduced respiratory, high BP and bradycardia
happens in coning
169
what can cause too much CSF to be produced
choroid plexus malignancies
170
who gets medulloblastomas
children
171
what is seen pathologically in an acute infarct
oedema
discolouration (grey/ brown)
loss of normal architecture
172
what happens to old strokes
gliosis, liqudification by macrophages
173
what o watershed infarctions look like
wedge shape infarct on the peripheries of the brain
174
what does global hypoxia look like pathologically
mottling
| loss of differentiation between grey and white matter
175
what are the RF for a subarachnoid haemorrhage
ADPKD
HPTx
obesity
smoking
176
what increases and decreases in atrophy
```
increase sulcus (depression- think in a sulc)
decreased gyrus (bumps- think gyrating, bump and grind)
```
177
what does MS look like pathologically
dark grey spots mainly affecting white matter, periventricular
178
what is the lateral horn of the spinal cord
a triangular projection between the dorsal and ventral horns
it is present only in the thoracic and upper lumbar segment of the spinal cord
contains autonomic neurones (sympathetic system T1-L2)
179
what is the path of the dorsal column medial leminiscus pathway
primary sensory fibres travel via the posterior root ganglion
up spinal cord
synapse with 2ndary order in medulla (nucleus cuneatus if above T6, nucleus gracilis if below T6)
fibres decussate to the contralateral medial leminiscus and travel upwards to synapse in the thalamus
relayed to the ipsilateral somatosensory cortex
180
what is the path of the spinothalamic tract
The primary sensory axons enters the spinal cord, via the posterior root ganglion, then travel upwards for one or two segments at the periphery of the spinal cord through the tract of Lissauer to synapse in the dorsal horn.
They then cross to the contralateral side of the spinal cord to ascend to synapse in the thalamus.
Sensory signal are then relayed from the thalamus to the ipsilateral somatosensory cortex.
181
what is the function of the spinocerebellar pathways
provides unconscious proprioceptive information to the cerebellum, in order to coordinate posture and the movement of the lower limb and upper limb musculature.
182
what are the three spinocerebellar pathways and their functions
Dorsal/posterior spinocerebellar: carries unconscious proprioceptive information (from muscle spindles mainly) from the lower limbs, synapses in the dorsal nucleus of Clarke.
Cuneocerebellar: carries unconscious proprioceptive information from the upper limbs.
Ventral/anterior spinocerebellar: carries unconscious proprioceptive information (golgi tendon organs mainly) from the lower limbs then decussate twice to reach the ipsilateral cerebellum.
183
do the spinocerebellar tracts travel to the contra or ipsilateral cerebellum
ipsilateral
184
what is the role of the corticospinal tract
voluntary movements
185
where do the anterior corticospinal tracts decussate
the anterior white commissure
186
what does the anterior corticospinal tract mainly supply
proximal and axial muscles
