SANS Peripheral Nerve Flashcards
Seorang pegulat SMA berusia 15 tahun mengalami dislokasi bahu kiri saat pertandingan. Setelah dilakukan relokasi, dia menjadi kesulitan mengabduksi lengannya, meskipun tidak didapatkan masalah saat diuji menggenggam jari dan sensasi raba (dalam batas normal). Hasil pemeriksaan Anda menunjukkan fungsi yang normal pada otot bisep, tricep, dan rotator eksternal pada bahu. Yang paling mungkin menyebabkan hal ini adalah perlukaan pada:
A. Nervus axilaris
B. Akar nervus C5
C. Nervus supracapsuler
D. Peregangan diffus plexus brachialis
A. Nervus axilaris
The patient has an isolated axillary nerve injury. This is a well recognized, though relatively infrequent, complication of shoulder dislocation. A diffuse plexus injury is ruled out by the evidence of motor and sensory preservation in other upper extremity muscles. The presence of shoulder external rotatory function rules out both C5 nerve root injury and suprascapular nerve injury.
Seorang wanita berusia 16 tahun dengan laserasi pada belakang paha. Hasil pemeriksaan menunjukkan berkurangnya kemampuan kaki untuk dorsifleksi dan penonjolan dengan perlukaan pada nervus peroneus. Hasil imaging menunjukkan tidak ada masalah vaskuler. langkah selanjutnya yang paling tepat adalah :
A. Pemeriksaan Elektrodiagnostik
B. Tutup luka kemudian ditelusuri dan perbaiki jika perlu dalam 3 minggu
C. Cuci dan tutup luka
D. Perbaiki nervus secara akut
D. Perbaiki nervus secara akut
In this patient with complete lack of peroneal function who suffered a clean laceration, the best treatment is to repair the nerve acutely. To wash and close the wound is incorrect because it does not address the nerve injury. Delayed exploration would be appropriate for a contaminated blunt nerve injury. Electrodiagnostic studies are not relevant for sharp nerve laceration.
Seorang pria berusia 22 tahun dengan ketidakmampuan mengangkat kaki kanan bagian depan yang timbul setelah lututnya terplintir dan punggungnya menegang saat bermain sepak bola. Dia juga mengatakan mati rasa dari betis bagian lateral hingga kaki bagian dorsal tetapi menyangkal adanya nyeri yang semakin berat dengan manuver Valsalva. Pemeriksaan pada kaki kanan didapatkan ketidakmampuan untuk melakukan dorsifleksi pergelangan kaki dan ibu jari kanan. Secara keseluruhan peregangan pergelangan kaki masih normal dan DTR dari lutut serta pergelangan kaki simetris. Tanda laseque negatif. Apakah diagnosis paling mungkin :
A. Cedera nervus peroneus komunis
B. Cedera dalam nervus peroneus
C. Cedera nervus peroneus superfisialis
D. Radikulopati L5
E. Cedera pada nervus tibialis
A. Cedera nervus peroneus komunis
The answer is common peroneal nerve injury. Loss of foot dorsiflexion and eversion after an insult to the knee would likely affect the peroneal nerve because of it’s superficial anatomical position as it passes lateral to the surgical neck of the fibula.
The common peroneal nerve derives its fibers from the L4-S2 nerve roots, and travels as one of the divisions of the sciatic nerve in the thigh. The common peroneal nerve separates from the tibial nerve at the bifurcation of the sciatic nerve in the mid- to distal third of the thigh. The common peroneal nerve then travels obliquely to the lateral popliteal fossa and travels anterolaterally to the fibular head, where it is superficial. It then travels to the anterior lower leg where it divides into the deep and superficial branches.
Injury to the common peroneal nerve results in weakness of ankle dorsiflexors (anterior tibialis and peroneus tertius) and the toe extensors which are innervated by the deep branch. In addition, there is weakness of ankle evertors (peroneus longus and brevis) which are innervated by the superficial branch. Isolated L5 radiculopathy generally spares ankle eversion.
The mechanism of injury must be considered in the management of peroneal nerve lesions. In a recent review, 141 patients who suffered peroneal nerve stretch/contusion without fracture/dislocation, with documented absence of functional recovery, underwent surgery with between 4-8 months after injury. Forty percent of the patients underwent external neurolysis because intraoperative nerve action potential (NAP) recordings indicated regeneration across the lesion; average recovery periods varied between 12 and 30 months. Sixty percent underwent graft repair due to lack of transmission of NAP’s across the lesion; recovery of proximal peroneal muscle contraction occurred with attempted eversion at 9 to 12 months whereas ankle dorsiflexion appeared at 18 to 24 months. Recovery of toe dorsiflexion by the extensor hallucis longus was variable and usually delayed.
Seorang pria berusia 25 tahun datang dengan keadaan lengan mencambuk dan mati rasa setelah mengalami kecelakaan kerja dimana letak luka dekat dengan pleksus brachialis. Setelah 6 bulan, pasien telah dapat menggerakkan bahu, siku dan pergelangan tangannya, tapi keadaan tangan tetap seperti mencambuk. Hasil pemeriksaan menunjukkan adanya ptosis dan meiosis ipsilateral pada lengan yang cidera. Hasil elektrodiagnostik menunjukkan aksi potensial nervus sensorik pada nervus ulnaris dalam batas normal. Dimanakah kemungkinan letak cedera saraf pada pasien ini :
A. Cedera post-ganglionik T1
B. Cedera pre-ganglionik C7
C. Cedera post-ganglionik C7
D. Cedera pre-ganglionik T1
E. Cedera post-ganglionik C8
D. Cedera pre-ganglionik T1
Ptosis and meiosis indicate Horner’s syndrome that is consistent with pre-ganglionic injury of T1. C7 injury is inconsistent with loss of hand function. The normal sensory nerve action potentials are inconsistent with post-ganglionic injury.The prognosis for spontaneous recovery is poor.
Seorang pria 38 tahun dengan riwayat nyeri lengan kanan hebat yang bersifat akut dan kemudian ditambah dengan kelumpuhan hebat pada deltoid dan kelumpuhan ringan pada bisep dan trisep. Setelah 6 minggu, pasien kemudian berkonsultasi dan dilakukan pemeriksaan Axial MRI imaging pada C4-5 dan C5-6 (hasil terlampir). Langkah selanjutnya yang paling tepat adalah
A. EMG/NCS
B. Injeksi steroid epidural
C. Terapi fisik rehabilitatif
D. CT mielogram
E. ACDF C4-5 dan C5-6
A. EMG/NCS
The correct answer is EMG/NCS. This patient is presenting with brachial plexitis, or Parsonage-Turner syndrome (PTS). The classic presentation of PTS is acute polyradicular pain without weakness which resolves over two weeks, only to develop into weakness affecting multiple nerve root distributions, most prominently the proximal arm and shoulder girdle. Significant supraspinatus and deltoid muscle weakness results in the complete inability to abduct the shoulder, which is a hallmark of PTS. The etiology is unknown, but preceding risk factors include recent viral illnesses, trauma, or infection. An EMG/NCS could confirm multiple motor and sensory abnormalities suggesting brachial plexus involvement and not radiculopathy, which would establish the diagnosis.
ACDF is not an appropriate next step given the likelihood of PTS. The severity of weakness in the deltoid does not correlate with the relative mild degree of stenosis seen on imaging. Epidural steroid injections have no role in the diagnosis or treatment of PTS. Physical therapy is necessary to maintain range of motion in immobile joints to prevent joint capsule contraction from non-use, but neck traction has no role in the treatment of PTS.
Pasien berusia 60 tahun menjalani reseksi facial schwannoma yang menginfiltrasi nervus fasialis dari segmen cisternal hingga segment mastoid. Karena metode yang digunakan adalah reseksi total, nervus juga ikut tereseksi bersama tumor. Jika mempertimbangkan anastomosis dari fasialis hingga hipoglossus, Kapankah waktu ideal untuk melakukan intervensi pembedahan untuk mengembalikan fungsi maksimal dari nervus fasialis?
A. Dalam 12 bulan paralisis nervus fasialis
B. Dalam 6 bulan paralisis nervus fasialis
C. Dalam 2 bulan paralisis nervus fasialis
D. Dalam 24 bulan paralisis nervus fasialis
E. Tidak ada hubungan antara durasi dari paralisis dengan pengembalian fungsi nervus fasialis
E. Tidak ada hubungan antara durasi dari paralisis dengan pengembalian fungsi nervus fasialis
There is no relationship between the duration of facial nerve paralysis and functional recovery following hypoglossal - facial nerve anastomosis (E). In comparing patients treated between 7 to 23 months as compared to those treated within 3 months, no significant difference was identified in the degree of facial nerve recovery. Patients can display up to a 2 month delay in functional recovery with delayed repair. However the final results are equivalent in early and delayed facial nerve repair. Patients older than 50 years have been found to have a slightly poorer but still acceptable result as compared to younger patients.
Pasien seorang supir truk berusia 45 tahun datang dengan nyeri pada bagian medial tangan kiri dan parestesia (dorsal dan palmar), dan kelumpuhan serta atrofi dari otot “adductor pollicis” dan “first dorsal interosseus”. Kelumpuhan otot bersifat progresif dan refrakter terhadap pengobatan konservatif. Hasil elektrodiagnostik menunjukkan adanya penjepitan dari nervus perifer tanpa ada radikulopati atau penyakit neuromuskuler intrinsik. Apakah pilihan terapi operatif untuk saraf yang terjepit :
A. Pembukaan “pronator tunnel”
B. Dekompresi dari “cubital tunnel”
C. Pembukaan “supinator tunnel”
D. Dekompresi dari ligamentum carpal tranversal
E. Pembukanaan canalis Guyon
B. Dekompresi dari “cubital tunnel”
Decompression of the cubital tunnel is helpful a this patient exhibits symptoms and signs consistent with progressive ulnar neuropathy at the elbow. In most cases, a simple decompression is sufficient unless there is evidence of nerve subluxation. Although the ulnar nerve can also be entrapped at Guyon’s canal, dorsal sensory loss suggests a more proximal entrapment. The supinator tunnel is a site of entrapment of the radial nerve. The pronator tunnel and the transverse carpal ligament are sites of entrapment of the median nerve
Seorang pria, 48 tahun dengan nyeri dan mati rasa pada bagian tengah tangan kanan, setahun setelah cidera lengannya saat menurunkan benda berat. Pemeriksaan menunjukkan adanya kelumpuhan pada otot “first dorsal interosseous”, abduktor digiti minimi dan tangan intrinsik, tapi bukan pada abductor pollicis brevis ataupun opponens pollicis. Sensasi berkurang pada jari kelingking, pertengahan medial jari manis, dan aspek ventral dari medial telapak tangan, tapi bukan aspek dorsal dari tangan. Pada regio anatomi manakah terjadi kompresi yang menunjukkan tanda dan gejala di atas :
A. Foramen C7-T1
B. Thoracic outlet
C. Cubital Tunnel
D. Canalis Guyon
E. Deltopectoral groove
D. Canalis Guyon
Weakness of the hand intrinsics and sensory disturbances that affect the ventral aspect of the medial hand is consistent with compression of the ulnar nerve at Guyon’s canal (between the hook of the hamate and the pisiform). 1,3 Ganglion cysts after trauma can cause ulnar neuropathy at Guyon’s canal.2 Ulnar neuropathy at the cubital tunnel would affect sensation on both the dorsal and ventral aspects of the hand. Compression of the elements of the brachial plexus (at the deltopectoral groove or in a case of thoracic outlet syndrome) or C8 nerve root would affect the median nerve innervated muscles (abductor pollicis brevis and opponens plicis) which are normal in this patient.
Seorang pria berusia 65 tahun datang dengan lesi pada nervus peroneus di leher Os. Fibula dengan incomplete palsy. Hasil yang didapatkan pada Frozen section intraoperatif pada lesi yang tereseksi menunjukkan tanda tumor selubung saraf perifer yang bersifat malignant. Apakah rencana paling memungkinkan untuk tindakan pembedahan :
A. Reseksi lesi dengan pemeliharaan nervus
B. Amputasi pada lesi bagian distal
C. Wide local excision with clean margins
D. Reseksi dari nervus peroneus
E. Penutupan luka
A. Reseksi lesi dengan pemeliharaan nevus
The best surgical strategy is resection of grossly visible disease with maintenance of nerve integrity. Definitive treatment should not rely upon frozen section alone. Postoperative management should involve imaging (PET, CT) to determine the stage of the lesion and multi-disciplinary planning with regard to definitive treatment. Wide local excision would likely only be considered in the absence of widely metastatic disease. Amputation is extreme and unnecessary. Nerve resection would result in unnecessary morbidity.
Pada pasien manakah dibawah ini yang memiliki hasil pemeriksaan konduksi saraf sensorik normal pada ekstremitas atas?
A. Carpal tunnel syndrome
B. Radikulopati servikal
C. Neuropati ulnar
D. Demielinisasi
E. Axonal radial neuropathy
B. Radikulopati servikal
The correct answer is cervical radiculopathy.
Cervical radiculopathies tend to be associated with normal sensory nerve conduction studies of the upper extremity, because in a radiculopathy the lesion tends to be proximal to the dorsal root ganglion, and lesions proximal to the dorsal root ganglion tend to result in normal sensory nerve conduction studies. Therefore cervical radiculopathy is the correct choice.
The other choices listed are lesions that are distal to the dorsal root ganglion, and therefore would be expected to show abnormal sensory nerve conduction studies. If, of course, a patient has a cervical radiculopathy AND a co-existing lesion distal to the dorsal root ganglion, then they would be expected to have abnormal sensory nerve conduction studies.
Seorang wanita kurus berusia 27 tahun menjalani pemasangan ventriculoperitoneal shunt di bagian kanan. Kateter berjalan melewati segitiga posterio kanan pada leher. Setelah pembedahan, pasien tidak dapat mengangkat bahu kanan. Perlukaan pada saraf manakah yang menyebabkan kelumpuhan tersebut:
A. Nervus suprascapular
B. Nervus scapular dorsalis
C. Akar nervus C5
D. Nervus Spinalis aksesorius
E. Nervus thoracalis
D. Nervus spinalis aksesorius
The spinal accessory nerve traverses superficially through the posterior triangle (bordered by the sternocleidomastoid, trapezius, and clavicle) and emerges from behind the sternocleidomastoid muscle, 2/3 of the way from the sternum to the mastoid. 1 Injury to the spinal accessory nerve can be encountered after surgery in this region, such as with catheters traversing this region or with cervical lymph node biopsy.
Eksplorasi dari lesi nervus medialis menunjukkan traumatic neuroma. Pemeriksaan penunjang intraoperatif manakah yang dapat menjadi acuan untuk melakukan eksisi dan graf repair untuk membedakan dengan neurolisis internal
A. Nerve action potentials
B. Frozen section
C. Ultrasound
D. Elektromiografi
E. MRI
A. Nerve action potentials
Measurement of intraoperative nerve action potentials (NAP) is the best method to determine whether resection or neurolysis will yield the best outcome when encountering a peripheral nerve neuroma. Neurolysis without excision and graft of lesions that conduct a NAP resulted in motor function of at least 3/5 in 94.7% of cases in one recent series.
There is no evidence to support the use of intraoperative ultrasound, frozen section, MRI, or electromyography for this decision making process. It should be noted however that in contrast to adult nerve surgery, the measurement of intraoperative NAP and CMAP recordings do not assist in decision making in the surgical treatment of infants with brachial plexus palsies.
Dalam melakukan prosedur perpindahan nervus untuk memulihkan fungsi fleksi siku, mana dari berikut dua saraf ini yang cocok :
A. Ulnar dan radial
B. Radial dan muskulokutaneus
C. Spinal aksesorius dan supraskapular
D. Ulnar dan musculokutaneus
E. Radial dan medial
D. Ulnar dan musculokutaneus
The procedure is designed to re-innervate the biceps muscle for elbow flexion. It is one of the most important of the “nerve transfer” procedures. In this procedure approximately 15% of the ulnar nerve is transferred to the musculocutaneous nerve in the arm.
Kurangya fungsi pada otot manakah yang menunjukkan adanya perlukaan pada akar saraf C5 paling proksimal?
A. Rhomboideus
B. Flexor carpi ulnaris
C. Opponens pollicis
D. Supinator
E. Biceps
A. Rhomboideus
The dorsal scapular nerve to the rhomboid muscle is one of the few nerves to emanate directly off a nerve root, in this case C5. Very proximal nerve root damage or root avulsion will therefore manifest in loss of function of this muscle (among others). A more distal injury will frequently leave the rhomboid intact.
