Section 9 Flashcards
A 35-year-old male with chronic migraine, and taking multiple medications, comes to the clinic with inadequate pain relief. He states that the headaches have been affecting his quality of life. He is recommended to have the placement of an occipital nerve stimulator. He undergoes a trial placement of electrodes, connected to an external battery, and his symptoms are observed for a week. A permanent nerve stimulator is best warranted after which of the following clinical findings?
1. No change in the number of headache days
2. Improvement in quality of life
3. Less than fifty percent improvement of pain
4. Response to conventional drugs
2. Improvement in quality of life
- A trial placement of electrodes is performed under sedation first before permanent occipital nerve stimulator (ONS) implantation.
- The trial period lasts for 4-7 days. During this period, the patient is required to maintain a headache diary to note the duration and frequency of headaches.
- It is considered successful if there is more than fifty percent improvement in pain, or there is a decrease in the number of headache days or the patient reports improvement in the quality of life.
- It helps in the selection of candidates for a permanent stimulator placement.
A 47-year-old man presents with a one-year history of persistent low back pain. The patient has a past medical history of obesity. On examination, there is paraspinal muscle tenderness. Pain is elicited when the patient is instructed to extend and rotate the spine. A lumbar spine x-ray with flexion and extension shows moderate facet arthropathy in the lower lumbar levels. Which of the following is the most appropriate test to confirm this patient’s most likely diagnosis?
1. MRI of the lumbar spine
2. CT scan of the lumbar spine
3. Diagnostic medial branch block
4. Two diagnostic medial branch blocks
4. Two diagnostic medial branch blocks
- The physical exam is unreliable in diagnosing lumbosacral facet syndrome.
- The most sensitive test for diagnosing facet syndrome is the medial branch block.
- There is a high false-positive rate for medial branch blocks.
- Two blocks should be performed to confirm the diagnosis before proceeding to radiofrequency ablation.
The embryologic progenitor cell of a chordoma turns into what adult structure?
1. Dura
2. Paraspinous muscle
3. Nucleus pulposus
4. Vertebral body
3. Nucleus pulposus
- Chordomas arise from the notochord.
- The notochord gives rise to the nucleus pulposus in adults.
- The notochord is of mesodermal origin and helps signal tissues in the embryo for organization and differentiation.
- The sclerotomes form the vertebral bodies.
A 57-year old male noncompliant to medications for diabetes went to his provider due to occasional numbness on both feet for 3 months. Both tuning fork and monofilament tests showed decreased vibration, light touch, and pressure on both feet. Which of the following neuropathway regulates the transmission of pressure and vibration sensory signals?
1. Spinothalamic pathway
2. Corticospinal pathway
3. Posterior column pathway
4. Bulbar pathway
3. Posterior column pathway
- Pain and temperature sensation travels via the spinothalamic tract.
- Vibration and pressure travels via the posterior columns.
- The corticospinal tract transmits neural signals to skeletal muscle.
- Semmes-Weinstein monofilament assesses the protective ability (evaluates A-beta fibers, determining the patient’s threshold for light touch and pressure) of the foot. Tuning fork is used for vibration assessment evaluating the large-diameter fibers (A- beta fibers).
A 22-year-old football player strikes the ground with his right olecranon process. He leaves the field, and the team physician examines him. The player screams in pain when the physician begins palpating his medial epicondyle and olecranon. The cutaneous nerve fibers responsible for this pain are derived from which of the following components of the brachial plexus?
1. Lateral cord
2. Posterior cord
3. Medial cord
4. Ulnar nerve
3. Medial cord
- The skin of the medial forearm and olecranon receives cutaneous innervation from the medial antebrachial cutaneous nerve.
- The medial antebrachial cutaneous nerve is a branch of the medial cord of the brachial plexus.
- The medial cord of the brachial plexus is derived from the inferior trunk of the brachial plexus.
- The inferior trunk of the brachial plexus is derived from the ventral rami of spinal segments, C8 and T1.
A 30-year-old male patient presents with complaints of unremitting headaches, dysphagia, shoulder pain, neck pain, stiffness, and weakness. He complains that the pains keep him up at night, and he occasionally has night sweats. On physical examination, the patient appears cachectic, with a BMI of 17.9. On auscultation of the carotid arteries, no bruits are appreciated. On imaging, a mass appears to be occluding an area on the base of the skull lateral to the foramen magnum on the right side. What other clinical feature is most likely to be present in this syndrome?
1. Swaying to the left side while walking
2. Positive Romberg test
3. Deviation of uvula towards the left side
4. Weakness in turning the head to the right side
3. Deviation of uvula towards the left side
- Vernet syndrome is paralysis of cranial nerves IX, X, and XI.
- The symptoms of the disorder include hoarseness, soft plate drooping, and deviation of uvula towards the normal side. In most cases, the uvula deviates away from the affected side.
- Other features of the syndrome include loss of gag reflex, dysphagia, and paralysis of the trapezius. The weakness of the sternocleidomastoid muscle (due to spinal accessory nerve palsy) causes difficulty in turning the head to the opposite side.
- Swaying is a cerebellar sign, and a positive Romberg test is for proprioception, both of which are unlikely to be present in this case. Causes of this syndrome include tumors, trauma, infection, and vascular.
A 20-year-old man is hit in the head with a baseball bat. He is brought to the emergency department unconscious and displaying signs of decerebrate rigidity. Which of the following would most likely cause an increase in extensor posturing?
1. Damage to the lower motor neurons
2. Chemically stimulating the red nucleus
3. A decrease in neurotransmitters on the gamma motor neurons
4. Destruction of the medullary reticulospinal tract
4. Destruction of the medullary reticulospinal tract
- The vestibulospinal tract and the ponto reticulospinal tract aid in muscle extension.
- Upper motor neurons synapse onto both alpha and gamma lower motor neurons in the anterior gray horn.
- The red nucleus is part of the rubrospinal tract, and its activation leads to flexor muscle contraction.
- A decrease in neurotransmitters in the gamma motor neurons will not lead to increased extensor posturing.
A patient with a C7 spinal cord injury complains about having a pounding headache. It is noted that he has a flushed, red face. You decide to take his vitals and note that his pulse is 42 beats per minute and his blood pressure is 180/95 mmHg. What should be done immediately?
1. Have the patient lie down and ensure that his abdominal binder is tight
2. Have the patient lie down and loosen his abdominal binder
3. Keep the patient upright, dangling his legs, and give him some aspirin for his headache
4. Keep the patient upright, dangling his legs, and loosen any tight, constricting garments
4. Keep the patient upright, dangling his legs, and loosen any tight, constricting garments
- Any spinal cord injured patient with a T6 or higher lesion is at risk of autonomic dysreflexia. The higher and more complete the injury, the greater the risk. This patient has several cardinal signs of autonomic dysreflexia. His blood pressure is very high, and he is bradycardia while complaining of a severe headache. Lying him down will raise his blood pressure, potentially increasing his risk of a stroke.
- Loosening the abdominal binder is a good idea. Aspirin is not the right choice for this headache. The clinician needs to determine the cause of the autonomic dysreflexia and correct it immediately, as this is a medical emergency.
- Autonomic dysreflexia is most often due to an overfull, distended bladder such as from a blocked Foley catheter, so checking for a kinked or blocked urinary catheter is an essential early step in treatment. Asking the patient when they were last catheterized might be helpful, but in an emergency situation dealing with possible autonomic dysreflexia, a Foley catheter should be placed in all susceptible individuals if they don’t already have a urinary drainage catheter. 85% of all cases of autonomic dysreflexia occur due to bladder distension issues. Bowel distension from constipation or fecal impaction is the next most likely cause.
- If the underlying trigger cannot be determined, emergency antihypertensive pharmacological treatment should be started. Initial treatments include 1-2 inches of 2% nitroglycerine paste or nifedipine 10 mg “bite and swallow.” Sublingual nifedipine is not recommended due to inconsistent absorption. Alternative medical treatment would include sublingual captopril 25 mg or sublingual clonidine 0.2 mg. It is recommended that susceptible patients carry an emergency treatment kit containing critical personal, medical, and contact information. It should also have guidelines on treating autonomic dysreflexia and appropriate supplies, including replacement Foley catheters, anesthetic gel, gloves, a blood pressure cuff (with extra batteries if appropriate), syringes, and normal saline for irrigation. Such a kit is potentially life-saving.
A 45-year-old man presents with gradual onset deviation of the angle of the mouth to the left side for the past month. He also complains of occasional pain on the right side of the back of his head. On physical examination, the angle of the mouth grossly deviates to the left side, and he cannot close his right eye completely. An MRI brain reveals a lesion arising from the right cerebellopontine angle extending to the supratentorial compartment. He undergoes surgery through the right retrosigmoid corridor. The tentorium is incised to remove the supratentorial component of the tumor. What is the action of the muscle innervated by the nerve most likely to be injured during this procedure?
1. Closure of the right eye
2. Intorsion and depression of the right eye
3. Deviation of the uvula to the right side
4. Deviation of the tongue to the right side
2. Intorsion and depression of the right eye
- This patient has an infratentorial tumor with supratentorial extension, most likely a vestibular schwannoma or cerebellopontine angle meningioma.
- The nerve likely to be injured during a tentorial incision is the trochlear nerve.
- The trochlear nerve controls intorsion and depression of the eye by innervating the superior oblique muscle.
- The trochlear nerve arises from the midbrain below the inferior colliculus. It passes anteriorly between the posterior cerebral and superior cerebellar arteries, enters the wall of the cavernous sinus, and reaches the superior oblique muscle of the eye after exiting through the superior orbital fissure.
A 16-year-old male patient is brought to the emergency department by his friends. The friends explain that they were at the gym doing some weight training when their friend complained of a headache, but continued to exercise. Over the subsequent hour, his headache worsened, and he had two episodes of vomiting in the gym changing room. On examination, the patient is awake but very confused (E4V4M6). A CT Head is performed and reveals a hyperdense lesion, with surrounding hypodensity, in the left frontal lobe with mild mass effect. The lateral ventricles, the third ventricle, and the fourth ventricle are enlarged. The neurosurgery team is informed, and they are on their way to the emergency department to assess the patient. While doing neuro-observations, the nurse notices the patient’s right pupil is larger than the left, and it is not reactive. The neurosurgery team is beeped while they are in the stairwell, and they ask that the patient be immediately prepped for emergency surgery, and IV mannitol started. In the emergency setting, what single surgical intervention is indicated for this patient?
1. Decompressive craniectomy without evacuation of the intracerebral hemorrhage (ICH)
2. CSF diversion in the form of an external ventricular drain (EVD)
3. Posterior fossa craniectomy
4. Catheter aspiration of the ICH (minimally invasive surgery)
2. CSF diversion in the form of an external ventricular drain (EVD)
- A ‘fixed and dilated pupil’ in the context of intracranial pathology is a sign of raised ICP, and this needs management in a time- critical manner. Medical intervention includes positioning the patient head-up, hyperventilation to maintain a pCO2 between 4.5-5.5kPa, and giving an osmotic agent such as mannitol or hypertonic saline. The enlarged ventricles in this setting indicate hydrocephalus, and the emergency neurosurgical procedure to relieve this would be CSF diversion in the form of an external ventricular drain (EVD).
- In a young patient with an ICH, it is important to rule out an underlying pathology (i.e. vascular malformation) before surgery in order to assist in surgical planning.
- Posterior fossa decompression can be a life-saving treatment in infratentorial ICH; however, it is not an appropriate surgical procedure for decompression of a supratentorial lesion.
- A decompressive craniectomy may be an appropriate surgical intervention in an attempt to save a patient’s life; however, in the setting of acute hydrocephalus, CSF drainage is the priority.
A 35-year-old male patient presents to the emergency department via emergency medical service (EMS) following a motor vehicle collision that occurred on a local thoroughfare. The patient was the unrestrained driver. Vitals show temperature 37, blood pressure 148/76 mmHg, pulse rate: 140 beats per minute, respiratory rate: 26 breath per minute, saturation 97% on room air. The primary survey shows airway, circulation, and breathing intact. GCS is 14 for confusion at the time of examination. Head, eye, ear, nose, and throat exam (HEENT) exam is notable for bilateral retro auricular ecchymosis. Visual field testing shows a loss of peripheral vision bilaterally. Where is the pathologic lesion most likely located?
1. Optic nerve
2. Optic radiations
3. Optic chiasm
4. Optic tract
3. Optic chiasm
- Traumatic fracture of the frontal bone or anterior base of the skull may be due to the lesion of the optic chiasm producing bitemporal hemianopsia. In this patient, retro auricular ecchymosis, otherwise known as the battle sign, is suggestive of a basilar skull fracture.
- Bitemporal hemianopsia is a result of damage to the optic chiasm, specifically the medial nasal fibers which decussate at this location.
- The most appropriate diagnostic modality for imaging the sellar region is MRI.
- Damage to the optic radiations may produce a contralateral inferior or superior quadrantanopia, depending on whether the lesion affects the parietal or temporal areas, respectively. Lesions of the optic nerve produce monocular blindness in the affected eye. Homonymous hemianopsia, in conjunction with an afferent pupillary defect, localizes the lesion to the optic tract.
A patient develops meningitis after head trauma. The patient expires and the autopsy reveals softening of brain tissue and diffuse edema. The patient most likely had what type of necrosis?
1. Coagulation necrosis
2. Liquefactive necrosis
3. Wedge infarct
4. Fat necrosis
2. Liquefactive necrosis
- Liquefactive necrosis is transformation of solid tissue into fluid.
- Liquefactive necrosis is typical of bacterial or fungal infections.
- The necrosis is due to a release of hydrolytic enzymes.
- Liquefactive necrosis often results in abscess formation.
A 48-year-old man presents to the emergency department after eight days of continuous headaches. On the first day, he had a severe sudden headache, but he thought it was related to his migraine history. When he was born, a myelomeningocele was repaired on his first day of life but did not require a ventricular shunt. A head computed tomographic (CT) scan with and without contrast does not show evidence of blood or a tumor. No evident aneurysm is seen. A cervical puncture is performed as the lumbar area cannot be punctured because of the history of myelomeningocele. Which of the following areas of the brainstem is most at risk of penetration due to its proximity to the puncture site during the procedure in this patient?
1. Cisterna magna
2. Medulla oblongata
3. Cerebellum
4. Jugular bulb
2. Medulla oblongata
- The cervical puncture is potentially dangerous because the puncture needle directly faces the medulla oblongata. The needle should only be advanced 1-2 mm after the dura is entered.
- The cisterna magna is located between the cerebellum and medulla oblongata, and the needle should enter this space to obtain cerebrospinal fluid.
- The medulla oblongata is responsible for autonomic functions of breathing, heart rate, and blood pressure, as well as the sleep- wake cycle. If the needle enters into it, the patient may develop acute changes in heart rate and pulse.
- The jugular bulb is not at risk as it is inside the bone of the mastoid and temporo-occipital bone.
How can a patient with neurogenic claudication improve his symptoms?
1. Lying prone
2. Walking straight
3. Walking downhill
4. Riding bicycle
4. Riding bicycle
- The pain of spinal canal stenosis is relieved by methods that help to open up the inter-laminar distance and thereby open up the canal diameter.
- This helps to relieve the root as well as cord compression as well as improve their blood circulation.
- The cycling that requires stooping posture helps to open up increase the cord diameter thereby helping to relieve the symptoms of lumbar canal stenosis.
- Walking increases the pain of neurological claudication. Walking downhill requires a lumbar extension that furthers compromises the canal diameter thereby aggravating the symptomatology.
A 2-month-old boy is being evaluated for flattening of the left posterior head. He has a preferred sleeping position. His forehead is prominent on the left side. The view from above shows the shape of the head as a parallelogram. CT head shows patent sutures. What is the most appropriate management strategy for this patient?
1. Endoscopic surgery and helmet
2. Open surgery and reconstruction
3. Sleep positional change and helmet
4. Mannitol
3. Sleep positional change and helmet
- The diagnosis is positional plagiocephaly because of the parallelogram shape of the head and the patent sutures in CT.
- Only conservative treatment is needed in positional plagiocephaly.
- Change of sleeping position to either side in supine will reduce the progression of plagiocephaly.
- Helmet therapy is for molding of the head in the case of positional plagiocephaly.
Neurosurgical techniques like prefrontal leucotomy and transorbital leucotomy were erroneously used during the early periods of the 20th century to treat psychiatric disorders and in most cases causing more harm than good and leading to stigma towards surgical approaches in treating psychiatric disorders. Which of the following is not one of the rare advances that have been made that can help reduce the stigma towards neurosurgical techniques in treating psychiatric disorders?
1. The development of numerous modalities that helped in the understanding of the structure and function of the brain
2. Positive results in the use of neuromodulation surgery like deep brain stimulation in the treatment movement disorders like parkinsonian diseases
3. The possibility of using neuromodulation to modify the cognition of healthy individuals
4. The development of advanced stereotactical microsurgery techniques
3. The possibility of using neuromodulation to modify the cognition of healthy individuals
- The arrival of new diagnostic techniques and the ability to integrate information from different diagnostic modalities has made it possible for clinicians to understand the brain structure and function and help localize brain pathologies. Some of these diagnostic techniques include functional magnetic resonance imaging (fMRI), positive emission tomography (PET), neurophysiologic data from electroencephalogram (EEG), magnetoencephalography (MEG), transcranial magnetic stimulation (TMS). All these diagnostic modalities provide more in-depth knowledge of brain activities and a stronger foundation for specific targets for neuromodulation surgery as a treatment for some psychiatric disorders.
- While the stigma due to the history psychosurgery still looms, the utilization of neuromodulatory surgery to treat psychiatric disorder is backed by not only a more profound understanding of brain structure and function, but also, the development of new stereotactic microsurgical technique, and data about successful management of other neurological disorders through neuromodulation. This fountain of knowledge has led to the development of treatment options that target a particular region of the brain and with effects of these treatments that can be reversible, unlike the earlier process like prefrontal leucotomy that involves the permanent removal of parts of the brain. For example, the concept of deep brain stimulation in the treatment of psychiatric disorders can be attributed to DBS success in the treatment of movement disorder like Parkinson disease, essential tremor, and dystonia.
- In addition to the old concerns, there is a new wave concern as to what the limits of what some of these neuromodulatory surgical procedures will be. Professionals debate whether these techniques will be used only as a last resort for the treatment of refractory psychiatric symptoms, or if they will be used for other purposes like to modify the cognition of healthy individuals.
- There have been many advances made in stereotactical microsurgery and also the tools available, decreasing the complications that may arise from these procedures.
A 3-year-old male child presented with seizures. His mother claims that he stands independently but needs to hold on to something to walk; he can grasp a pencil and do random scribbles, follow 1 step commands, and knows 6 to 10 words. he is fully dependent when eating and dressing. On examination, there is spasticity on the left upper and lower extremities compared to the right. Babinski was positive bilaterally. Imaging studies show a cleft in the right cerebral hemisphere. Which of the following lines is the cleft in the brain?
1. CSF
2. Gray matter
3. Hamartomatous tissue
4. White matter
2. Gray matter
- Schizencephaly clefts are lined by gray matter of either the heterotopic, pachy- or polymicrogyric variety.
- The clefs extend from the pial surface lateral to the ependymal lateral ventricular lining medially.
- Large primitive veins may overlie the cleft.
- Porencephaly also has clefts due to trauma or vascular insult, and these clefts are thus lined by gliotic white matter, not dysplastic gray matter.
A 45-year-old female presents with progressive headaches and multiple episodes of vomiting. Fundoscopy reveals bilateral papilledema. A CT of the head demonstrates a large, hyperdense lesion in the left lateral ventricle with evidence of hydrocephalus. MRI of the brain shows a lesion with a soap-bubble appearance, and MR spectroscopy demonstrates choline and glycine peaks. Which of the following is the most likely lesion?
1. Intraventricular abscess
2. Central neurocytoma
3. Intraventricular tuberculoma
4. Glioblastoma
2. Central neurocytoma
- A hyperdense intraventricular lesion causing hydrocephalus that demonstrates a soap-bubble appearance on MRI is characteristic of a central neurocytoma.
- Choline and glycine peaks on MR spectroscopy are commonly seen in central neurocytoma and are also seen in other higher- grade intracranial tumors. The rapid turnover of cells in malignancy releases choline from the phosphatidylcholine component of the cell membrane, leading to its characteristic peak in a spectroscopy sequence.
- Patients presenting with headaches and vomiting should undergo urgent or emergent head CT to identify intracranial causes, such as obstructive hydrocephalus.
- A tuberculoma will show an increase in the lipid peak.
A 16-year-old patient is brought to an emergency department following a motor vehicle collision. He is complaining of persistent neck pain without any radiation. He has no motor or sensory deficits. CT spine revealed the presence of bilateral fractures of the C2 pars interarticularis with a displacement of 1.5 mm without any angulation. What is the most rational management strategy for the patient?
1. Hard Cervical collar
2. Soft cervical collar
3. Halo-vest orthosis
4. C1-C3 posterior fusion
1. Hard Cervical collar
- Hangman’s fracture is a fracture of the pedicles or pars interarticularis of the C2 vertebra.
- Nonunion is rare in stable hangman’s fractures, with approximately 90% healing with immobilization alone. Level III evidence shows that a hangman’s fracture may be initially managed with immobilization with a halo-vest or collar alone.
- External orthosis should be maintained for 8 to 14 weeks. This produces a reduction rate of 97% to 100% and a fusion rate of 93% to 100%.
- It is important to remember that halo-vest orthosis is not very well tolerated and has poor patient compliance, and therefore collar is recommended as first-line management.
A 65-year-old man fell from the roof of his barn. EMS is notified, and he is transported to the nearest emergency department. Upon arrival, he is noted to be comatose, with a Glasgow coma scale of 6/15. A noncontrast CT scan of the head demonstrates a depressed skull fracture in the right occiput. A right parietal-occipital subdural hematoma is also noted. After initial stabilization, he is transferred to the closest level 1 trauma center. He undergoes craniotomy for elevation of his depressed skull fracture and evacuation of the subdural hematoma. However, his neurological exam does not improve. His post-operative course is complicated by intermittent episodes of intracranial hypertension, which respond to treatment with hypertonic saline. By hospital day 7, his intracranial pressure is well-controlled, and he is no longer receiving sedation or osmotherapy. He remains intubated. Brainstem reflexes are intact. He opens his eyes to noxious stimulation, but he does not follow commands. He localizes to pain with the right upper extremity and withdraws from noxious stimulation in the left upper extremity. A brain MRI demonstrates bifrontal hemorrhagic contusions as well as scattered punctate areas with susceptibility artifact in the corpus callosum and bilateral subcortical white matter. However, none were noted in the brainstem. Median nerve somatosensory evoked potentials are present bilaterally, and EEG is notable for a breach rhythm in the right parietooccipital region with bifrontal focal slowing but no epileptiform discharges. Which of the following best describes the patient’s long-term prognosis?
1. The patient has sustained a severe traumatic brain injury, and it will likely be fatal
2. The patient has sustained a moderate traumatic brain injury; with continued supportive care and intensive rehabilitation, a full recovery is likely
3. The patient has sustained a severe traumatic brain injury; even with continued supportive care, it is unlikely that he will return to his prior level of function
4. The patient has sustained a severe traumatic brain injury, and tests results suggest there may be a cervical spine injury as well
3. The patient has sustained a severe traumatic brain injury; even with continued supportive care, it is unlikely that he will return to his prior level of function
- The patient sustained a severe traumatic brain injury resulting in bifrontal contusions, a depressed skull fracture, and a right- sided subdural hematoma. His exam did not improve notably after surgical intervention, and magnetic imaging findings were consistent with diffuse axonal injury (DAI). In patients with DAI, neurological dysfunction occurs secondary to axonal disruption. It is possible for this dysfunction to improve over time due to axonal regrowth, although recovery is slow.
- In this example, the patient has an asymmetric motor exam on hospital day 7, as well as significant cognitive dysfunction, which is apparent due to his depressed level of consciousness. Exam and EEG findings are consistent with the structural lesions seen on MRI, including bilateral frontal contusions. Pathologically, the cerebral contusions result in cellular necrosis leading to irreversible neuronal loss in the affected brain regions. Consequently, some degree of permanent disability will be likely.
- Upon initial presentation in the vignette above, the patient had a GCS of 6, consistent with a diagnosis of severe traumatic brain injury. The exam described on hospital day 7 is suggestive of a GCS of 8t. In order to appropriately classify traumatic brain injury, the GCS should be performed on admission, but after appropriate resuscitation has been performed.
- Somatosensory evoked potentials (SSEPs) can be useful for determining prognosis in survivors of traumatic brain injury. Bilateral absence of the cortical response after median nerve stimulation is associated with a universally poor outcome. However, it is important to exclude other injuries along the neuraxis in order to avoid a false-positive test. For example, lesions of the brachial plexus or the cervical spine can confound the result. In this patient, the median nerve SSEPs are present bilaterally, which is not suggestive of a cervical spine or brachial plexus lesion. Unfortunately, preserved SSEP responses do not reliably predict neurological recovery.
A 48-year-old man presents with contusions throughout the cervical, thoracic, and lumbar regions following a motor vehicle accident. His vitals are stable, and a computerized tomography (CT) scan of the head is negative for acute pathology, but on physical examination, there is a left-sided miosis associated with ptosis. A CT scan of the neck, thorax, and abdomen is ordered. At which of the following levels is he likely to have a lesion?
1. C3
2. C7
3. T3
4. L4
3. T3
- Horner syndrome is a condition in which damage to the sympathetic nervous system leads to miosis, ptosis, anhidrosis, and sometimes enophthalmos.
- The sympathetic nervous system exits the spinal cord from T1- L2/L3.
- Horner syndrome can be caused by damage to the sympathetic nervous system at various points in the sympathetic tract; it commonly results from an infarct in the lateral medulla, damage during thyroid resection, impingement by Pancoast tumor, or spinal cord injury.
- Horner syndrome is not dangerous in itself but is often a clinical indicator for one of the conditions mentioned above that may be deadly.
A 32-year-old woman with multiple sclerosis is evaluated in the clinic for sensory deficits. She is currently on glatiramer acetate and interferon therapy. She explains that she can feel, describe, and touch items in her hand but has trouble identifying the object. When asked about the object or when seeing the object, the woman is able to identify the object. Where is the most likely location of the lesion?
1. Primary somatosensory cortex
2. Secondary somatosensory cortex
3. Spinothalamic tract
4. Pacinian corpuscles
2. Secondary somatosensory cortex
- The woman’s multiple sclerosis is an autoimmune insult to the nervous system that has caused her to lose the ability to recognize sensory stimuli. A lesion to the secondary somatosensory cortex, or association cortex, can result in an inability to recognize objects that can be felt. This is called astereognosis or tactile agnosia.
- The secondary somatosensory cortex has connections to the hippocampus and amygdala, allowing us to relate the tactile sensation to prior exposure.
- In this woman, her ability to describe the item in her hand is intact, while her ability to assess the tactile stimulus is impaired. Furthermore, she is able to visually identify objects that she cannot identify using touch, indicating that her memory or attention is likely not impaired.
- Lesions in the spinothalamic tract and Pacinian corpuscles results in pain disruption. Lesions to the primary somatosensory cortex can result in an inability to recognize objects that were felt but can also affect the ability to assess features of the object itself, such as texture, shape, and size.
A 16-year-old male patient has been brought to the emergency department following a gunshot injury at the medial epicondyle of his right elbow joint. During the surgical exploration of the wound, the ulnar nerve was found to be completely scattered by the injury. During the follow-up visits, there was a sensory loss in his fourth and fifth fingers of the right hand. There was a minimal weakness of the intrinsic muscles of the hand without any claw deformity. What is the anatomical basis for these paradoxical clinical findings seen in this patient with ulnar nerve injury?
1. Martin-Gruber anastomosis
2. Marinacci syndrome
3. Riches-Cannieu communication
4. Berrettini branch
1. Martin-Gruber anastomosis
- The Martin–Gruber anastomosis is a forearm communication between the median and the ulnar nerve, with a prevalence of almost 60%.
- This communication is the commonest form of motor communication between the median and the ulnar nerve. The type 1 variant is the commonest form of this communication in which the fascicles from the anterior interosseous nerve join the median nerve.
- This communication helps to preserve the motor function of the intrinsic muscles of the hand supplied by the ulnar nerve, despite its injury. This knowledge is of paramount importance in understanding the perplexing neurological findings in such anatomical variants.
- Marinacci syndrome is the ulnar to median nerve communication in the forearm. The Berrettini branch is the superficial sensory communication between the ulnar and the median nerve in the palm of the hand.
An 8-year-old boy falls while playing soccerball. Because a readily performed radiological examination reveals a wrist fracture, the child undergoes a surgical treatment. A few days after the operation, the little patient reports neurological symptomatology featuring in numbness and tingling sensation over the lateral 3/4th of the right palm and fingers. What could be the cause of this neurological symptomatology?
1. Ulnar nerve injury
2. Median nerve injury
3. Radial nerve injury
4. Axillary nerve injury
2. Median nerve injury
- Median nerve injury could result from compartment syndrome or carpal tunnel syndrome (CTS).
- Overuse of the hands can cause CTS and rest is often advised.
- When the median nerve is compressed at the wrist, the individual will have weakness in abduction and opposition of the thumb.
- The paresthesias may occur in the lateral 3 1/2 digits including the nailbeds. Initially, the treatment of carpal tunnel syndrome is to stop the activity causing symptoms and wearing a splint.
A 45-year-old patient presents with persistent headaches, which are bitemporal, nonprogressive, and aggravated towards the end of the day. There is no aura, photophobia, or phonophobia. The patient has no red eyes or running nose during the episodes. CT head is normal, and erythrocyte sedimentation rate (ESR) is normal. What is the early recommended modality in the management of the headache in the patient?
1. Injection at the trigger points
2. Biopsy of the superficial temporal artery
3. Electrical stimulation
4. Massage of the temporalis muscle
4. Massage of the temporalis muscle
- The patient has signs and symptoms consistent with the diagnosis of tension headache.
- The presence of trigger points, which are formed following idiopathic sustained but a focal contraction of the muscle leading to ischemia, is the cause of the headache.
- Manual massage helps to improve the blood supply, thereby reducing the pain originating from the trigger points.
- The patient has normal ESR, so the likely diagnosis of superficial temporal arteritis is minimal. The redness of the eyes and running nose are associated with cluster headaches. Injections at the trigger points are undertaken in cases of refractory and persistent headaches.
A 60-year-old man is brought to the emergency department with complaints of confusion and headache for the past three days. He is a smoker and has a history of type 2 diabetes mellitus. On examination, his Glasgow coma scale score is E3V4M5, and his right pupil is bigger than his left. He undergoes a computed tomogram of the head, which shows a space-occupying lesion in his right temporal lobe, which is mildly enhancing in the periphery. There is a midline shift of 9 mm to the left. He undergoes an emergency craniotomy and decompression of the lesion. The histopathology report shows that it is a glioma showing nuclear atypia, the presence of cellular pleomorphism, and marked mitotic activity with the absence of necrosis and endovascular proliferation. Which of the following is the most likely diagnosis?
1. WHO Grade I astrocytoma
2. WHO Grade II astrocytoma
3. WHO Grade III astrocytoma
4. Gemistocytic astrocytoma
3. WHO Grade III astrocytoma
- WHO Grade III astrocytomas (also known as anaplastic astrocytomas) infiltrate the surrounding brain parenchyma diffusely and have an intrinsic tendency for malignant progression to glioblastoma. These tumors may also have regions of lower-grade tumors intermixed.
- Histological examination shows higher cellular and nuclear atypia than seen in grade II astrocytoma, but there is an absence of necrosis and microvascular proliferation seen in glioblastoma.
- Molecular profiling reveals a heterogeneous genetic mutation profile within the grade of astrocytoma. Prognosis varies widely depending on the genetic makeup between tumors of similar histological grade. Patients with unfavorable molecular patterns have a prognosis similar to grade 4 tumors (glioblastoma multiforme).
- IDH (isocitrate dehydrogenase) mutations present in grade 3 astrocytoma portend a favorable prognosis compared to IDH wild type genotypes.
A 67-year-old man presents to the clinic with a chief complaint of chronic axial low back pain. His pain is persistent, non-radiating, and described as dull and achy in nature. During the physical exam, the clinician asks the patient to bend backward while standing. As the patient did this, he reports increased pain in his low back. Which of the following is the most reliable method to diagnose the condition observed in the patient?
1. Dynamic x-ray lumbosacral spine
2. CT lumbosacral spine
3. MRI lumbosacral spine
4. Facetal block
4. Facetal block
- A positive Kemp’s test in the patient indicates facet-mediated pain. Another name for Kemp’s test is the quadrant test.
- Kemp’s test is performed in the lumbar spine by having the patient extend the spine with associated rotation. Kemp’s test will be positive if the patient’s baseline pain is reproduced while performing the maneuver.
- The diagnostic ultrasound or fluoroscopic guided facetal block is the most reliable means for diagnosing facet-mediated pain, with level I or level II evidence based on the United States Preventive Services Task Force criteria.
- The dynamic X-ray is indicated in spinal instability. Radiological imagings only provide supportive evidence in facetal joint arthropathy.
A 65-year-old female becomes suddenly unresponsive and is taken to the emergency room where workup reveals subarachnoid hemorrhage. A posterior communicating artery aneurysm is identified and treated. One day after presentation, she is alert and interactive but having severe headaches. Five days after admission, she is witnessed to have a seizure. Her workup identifies serum sodium of 122 meq/L, urine sodium of 55 meq/L, urine osmolality of 111 mosmol/kg, and hypovolemia. What is the most appropriate treatment?
1. Hypertonic fluids and careful monitoring of serum sodium
2. Fluid restriction and careful monitoring of serum sodium
3. Thiazide diuretic and careful monitoring of serum sodium
4. Foley catheterization
1. Hypertonic fluids and careful monitoring of serum sodium
- Cerebral salt wasting and syndrome of inappropriate anti- diuretic hormone (SIADH) can be confused as lab results are similar in both.
- For cerebral salt wasting a patient is hypovolemic whereas in SIADH they are euvolemic to hypervolemic.
- Treatment for cerebral salt wasting includes restoring fluid volume status and replacing lost sodium.
- For SIADH treatment includes fluid restriction.
A 40-year-old woman who recently had an epidural steroid injection two days ago presents to the clinic complaining of an occipital headache every time she tries to get to an upright position. The patient states that she started having the headache a few hours after the procedure. Her neurological exam is normal. What is the next best step in the management of this patient?
1. MRI brain w/o contrast
2. MRI lumbar spine
3. Advice increased fluid and caffeine intake
4. Perform an epidural blood patch
3. Advice increased fluid and caffeine intake
- The patient’s symptoms and timing of onset of headache are consistent with spontaneous intracranial hypotension.
- This a common complication after epidural steroid injections and can happen with an inadvertent dural puncture resulting in leakage of CSF.
- This results in low intracranial pressure causing occipital headaches. The common finding is the worsening of headaches in an upright position.
- Any further imaging is not indicated at this time since there are no changes in her neurological exam. An epidural blood patch is reserved for patients that have failed conservative therapy, including high volume fluids and caffeine. In most cases, the condition usually resolves with conservative management.
A 2-year-old boy is brought to the clinic for a well- child exam. The mother received no antenatal care, and he was delivered by a spontaneous vaginal delivery at 36 weeks gestation. He has no apparent anomalies. Examination reveals an ocular coloboma. No other physical defects are evident. Family history reveals neonatal death in a paternal cousin after they detected an intracranial malformation. Which of the following findings is most likely to be seen on a brain MRI in this patient?
1. Midline monoventricle
2. Midline and anterior cerebral arteries
3. Absent olfactory bulb
4. Fused deep grey nuclei
2. Midline and anterior cerebral arteries
- This infant with an ocular coloboma and no other anomaly is most likely a case of a middle intrahemispheric variant. An MRI would reveal bilateral frontal and parietal lobes, an absent body of the corpus callosum, and azygous anterior cerebral artery are visible in these patients.
- Holoprosencephaly (HPE) results from an incomplete midline cleavage of the forebrain (prosencephalon) and includes a wide spectrum of intracranial and craniofacial midline defects, along with a myriad of clinical manifestations, which consist of neurologic impairment and dysmorphism of the brain and face.
- Holoprosencephaly occurs rather frequently, and is observed in 1:250 conceptuses; due to a high rate of fetal demise, the birth prevalence is between 1:8000 to 1:16000 live births and is similar among different international populations. HPE is associated with pregestational maternal diabetes. Consistent maternal folic acid use appears to be protective.
- Midline monoventricle, fused deep grey nuclei, and absent olfactory bulbs are features of alobar and semi lobar variant. These are associated with facial anomalies like pronounced microcephaly cyclopia, cebocephaly, ethmocephaly.
A 54-year-old woman fell off a ladder at home and presents with neck pain. X-rays reveal a loss of cervical lordosis in the lower cervical spine, and CT confirms a C6/7 unilateral facet fracture-dislocation. Which of the following sets of physical examination findings is most likely to be seen in this patient?
1. Unilateral weakness in wrist extension, with numbness and tingling in the small finger
2. Bilateral weakness in elbow flexion (palm up), with numbness and tingling in the thumb
3. Unilateral weakness in elbow extension, with numbness and tingling in the small finger
4. Unilateral weakness in shoulder abduction, with numbness and tingling in the lateral forearm
3. Unilateral weakness in elbow extension, with numbness and tingling in the small finger
- Proper x-rays of the cervical spine must include AP, lateral, and open mouth odontoid films. Films must contain the entire cervical spine and include C7-T1. On the lateral x-ray, you must examine the 4 parallel lines of the cervical spine. Signs of cervical facet dislocation can include vertebral body subluxation compared to the vertebral body below. Unilateral facet dislocation can lead to about 25% subluxation, bilateral facet dislocation can lead to about 50% subluxation. Loss of disc height might indicate a retropulsed disc in the canal.
- Due to the pedicle nerve root mismatch of the cervical spine, the nerve root exits above the corresponding pedicle. Therefore, a C6-C7 dislocation would cause impingement on the C7 nerve root.
- Injury to the C7 nerve root can present with deficits in elbow extension and wrist flexion, as it primarily innervates the triceps and flexor carpi radialis—also, sensory deficits in fingers 2, 3, 4, and an abnormal triceps reflex.
- Typically, unilateral facet dislocations lead to unilateral symptoms. Unilateral weakness in wrist extension is associated with impingement/injury to the C6 nerve root. Unilateral weakness in shoulder abduction, with numbness and tingling in the lateral arm is associated with impingement/injury to the C5 nerve root.
A neonate is delivered and found to have a small 1.2 cm anterior skin-covered mass just above the nasal bridge at the glabella. APGAR 9/10. Eye position is normal, and respirations are adequate. Head circumference is 50% for age. The anterior fontanelle is open and easily depressible. Ultrasound confirms the sac is filled with fluid. The 10th-week fetal ultrasound did not show the mass. In which area of the head did this developmental anomaly occur?
1. Craniopharyngeal canal
2. Foramen cecum
3. Cribriform plate
4. Ethmoid bone
2. Foramen cecum
- The patient described has an anterior nasofrontal encephalocele. Anterior encephalocele development occurs from abnormal development of the foramen cecum. A diverticulum of the dura usually projects anteriorly between the developing nasal and frontal bones at the fonticulus frontalis/foramen cecum.
- Later in embryogenesis, the diverticulum regress and the bone closes; however, if it does not regress, the brain can herniate through the bone defect and form an encephalocele.
- Sincipital encephaloceles are classified as nasofrontal, nasoethmoidal, or naso-orbital. Nasofrontal encephalocele is the most common type, seen in 46.4% of the patients. It is followed by nasoethmoidal type in 39.2% of the patients. The naso-orbital and the combined type are the least common with 14.2%.
- Nasofrontal encephaloceles result from herniation through the foramen cecum and the fonticulus frontalis and project along the nasal bridge between the nasofrontal sutures into the glabella. Nasoethmoidal encephaloceles occur when there is herniation through the foramen cecum into the prenasal space and nasal cavity under the nasal bones and above the nasal septum. Naso-orbital encephaloceles occur along the medial orbit wall at the level of the frontal process of the maxilla and the ethmoid- lacrimal bone junction.
A 78-year-old female presents to the clinic with numbness and tingling in her left foot. She has a history of chronic low back pain which she aggravated after she lifted a heavy box while twisting. She also has a history of posterior knee pain from a Baker’s cyst. Which of the following muscles is crucial in distinguishing between an L5 radiculopathy and a tibial neuropathy on electromyography (EMG) in this patient?
1. Peroneus longus muscle
2. Medial gastrocnemius muscle
3. Lateral gastrocnemius muscle
4. Tibialis posterior muscle
1. Peroneus longus muscle
- On electromyography, it is key to test muscles innervated by different peripheral nerves but the same nerve root. The peroneus longus is innervated by the superficial peroneal nerve, predominantly from the L5 nerve root. Testing this muscle and comparing the results to other L5 and tibial nerve innervated muscles can help distinguish L5 radiculopathy from tibial neuropathy.
- The medial gastrocnemius muscle is innervated by the tibial nerve, by both the L5 and S1 nerve roots. However, it is generally predominantly from the S1 nerve root which makes this a common muscle to test on EMG to rule out S1 radiculopathy due to its easy accessibility.
- The lateral gastrocnemius muscle is innervated by the tibial nerve, by both the L5 and S1 nerve roots. However, it is generally predominantly from the L5 nerve root. Testing this muscle would not be very helpful in distinguishing a L5 radiculopathy from tibial neuropathy due to the overlap in its innervation.
- The tibialis posterior muscle is innervated by the tibial nerve, by both the L5 and S1 nerve roots. However, it is generally predominantly from the L5 nerve root. Testing this muscle would not be very helpful in distinguishing a L5 radiculopathy from tibial neuropathy due to the overlap in its innervation.
A 32-year-old male patient presents with complaints of intermittent episodes of headache, dysphagia, torticollis, hoarseness of voice, and pulsatile tinnitus. Clinical examination reveals paralysis of sternomastoid, loss of gag reflex, and vocal cord palsy on the right side. The CT scan of the head shows a 3x4 cm sized mass with a moth-eaten appearance in the posterior cranial fossa, and an MRI scan shows salt-and-pepper appearance in both long TR and short TR images. What is the next best step in the management of this patient?
1. Observation
2. Pre-operative embolization followed by safe surgical excision
3. Stereotactic radiosurgery
4. Fractionated stereotactic radiotherapy
2. Pre-operative embolization followed by safe surgical excision
- The diagnosis is paraganglioma (glomus jugular).
- Pre-operative embolization, followed by safe surgical excision is the treatment of choice.
- Stereotactic radiosurgery (Gamma Knife, LINAC, and CyberKnife) is a useful and safe treatment option for paragangliomas at this location, if the diameter is less than 3 cm, in order to reduce the morbidity.
- Fractionated stereotactic radiotherapy is the technology which combines the precision of stereotaxy with dose fractionation in large tumors (more than 3–4 cm in diameter) which are not suitable for radiosurgery.
A 40-year-old man is scheduled for a spinal procedure for disc herniation. He is on long-term anticoagulant therapy due to the replacement of the aortic valve ten years back. Physical examination is unremarkable. Vital signs are a pulse of 75/min, a blood pressure of 122/78 mmHg, a respiratory rate of 17/min, and a temperature of 98.6 F (37 C). Which of the following should be performed before the procedure?
1. Continue the same dose of anticoagulant therapy
2. Reduce the dose of anticoagulant therapy
3. Stopping the anticoagulant therapy
4. Increase the dose of anticoagulant therapy
3. Stopping the anticoagulant therapy
- Warfarin is an oral anticoagulant commonly used to treat and prevent blood clots. It is given in case of mechanical valve repair.
- In a high-risk procedure, it is recommended to stop warfarin five days before and start bridging therapy with low molecular weight heparin. The heparin should be stopped 24 hours before in a high-risk procedure.
- Warfarin inhibits the hepatic synthesis of coagulation factors II, VII, IX, and X, and coagulation regulatory factors protein C and protein S require the presence of vitamin K. Vitamin K is an essential cofactor for the synthesis of all of these vitamin K- dependent clotting factors.
- The use of warfarin during a high-risk procedure can lead to uncontrolled bleeding and subsequently increase morbidity and mortality.
A 20-year-old woman, G2P1, who is at 24 wks gestation, came for a regular antenatal checkup. The woman admits to drinking alcohol before she knew she was pregnant. An ultrasound was recommended for the evaluation of the fetus, which showed findings concerning clefts. Further imaging was recommended for evaluation. Which imaging modality would be the diagnostic choice of imaging in this situation?
1. Computed tomography (CT) scan
2. Magnetic Resonance Imaging (MRI)
3. X-ray
4. Repeat two-dimensional ultrasonography
2. Magnetic Resonance Imaging (MRI)
- Magnetic resonance imaging (MRI) is unique to the diagnosis of children with congenital brain abnormalities, and in utero, MR (iuMR) imaging is now used for the antenatal detection of brain abnormalities, including schizencephaly.
- Various definitions are put forward. One definition of schizencephaly is a trans-mantle column of dysplastic grey matter extending from the ependyma to the pia without a cerebrospinal fluid cleft.
- Computed tomography may also be useful, but it provides poorer images of the gray matter, which is the key factor in differentiating between schizencephaly and other fluid- associated CNS abnormalities.
- Schizencephaly may be diagnosed prenatally or postnatally by ultrasonography, but this is true for type II (open-lip) only. The diagnosis of schizencephaly may be suspected prenatally if clefts are viewed within the cerebral hemispheres by two- dimensional ultrasonography (2DUS).
A 30-year-old female presents for her yearly examination. She states that she and her husband have been trying to conceive for eight months without progress and that her menstrual cycles have become irregular. Her clinician suggests that she and her husband continue trying to conceive and that she return in 4 months for some laboratory studies if she still has not become pregnant. In between, a routine visit to the ophthalmologist shows bitemporal hemianopsia. Which of the following is the most likely cause of infertility in this patient?
1. Endometriosis
2. Failure of implantation
3. Hostile cervical mucus
4. Suppression of gonadotropins and ovulation
4. Suppression of gonadotropins and ovulation
- This patient has a pituitary prolactinoma, which is associated with amenorrhea, infertility, and galactorrhea. Prolactin inhibits the secretion of gonadotropins and suppresses ovulation. The hypothalamus has a predominant inhibitory influence on prolactin secretion via dopamine and any factor which disrupts this mechanism can cause hyperprolactinemia. It is important to consider the various causes of hyperprolactinemia as increased prolactin secretion is noted in many physiological and pathological states other than prolactinomas.
- Prolactinomas cause a wide range of symptoms either due to the mass effect of the tumor or from the hypersecretion of prolactin. Based on the size of the tumors, prolactinomas can be classified as micro prolactinomas (smaller than 10 mm), macroprolactinomas (larger than 10 mm), or giant prolactinomas (larger than 4 cm). Hyperprolactinemia is not always due to a prolactinoma, and other causes like pregnancy, medications, hypothyroidism and pituitary stalk effects due to other pituitary tumors should be considered in the differential.
- Unlike other pituitary tumors, the preferred treatment for prolactinomas is medical therapy. Oral contraceptives alone can be given if the only symptoms are amenorrhea and/or osteoporosis. Specific treatment for prolactinomas is one of the dopamine agonists such as bromocriptine. Adverse effects of bromocriptine include nausea, nasal congestion, and orthostatic hypotension. If the side effects are not well tolerated, it can be administered intravaginally.
- Ectopic endometrial tissue is seen with endometriosis. Prolactin inhibits the secretion of gonadotropins which suppresses ovulation. The ovaries are still responsive to gonadotropins.
A 3900-gram (85th percentile) newborn male is delivered at 39 weeks gestation to a 30-year-old G3P3 woman. The patient was born via normal vaginal delivery but required vacuum- assisted delivery. At 6 hours of age, the nurse reports a swollen deformity of the baby’s scalp. Upon physical examination, the baby is hemodynamically stable and well-appearing. Scalp examination reveals a soft palpable swelling over the left temporoparietal area, slight discoloration, and it does not cross the suture lines. The patient’s physical examination is otherwise unremarkable. His head circumference is noted to be 36 cm (90th percentile). Which of the following is the next best step in the management of this patient?
1. Incision and drainage
2. CT head
3. Reassurance
4. Ultrasound head
3. Reassurance
- Due to the circumstances of delivery and clinical features (location of the hematoma that does not extend suture lines), the most likely cause of this patient’s condition is a cephalohematoma.
- Whenever a clinician diagnoses a cephalohematoma, reassurance with counseling of the parents is necessary.
- Cephalohematomas require observation and most cases resolve in several weeks without any intervention.
- There is no need to drain a cephalohematoma. The patient’s condition is not consistent with intracranial hemorrhage, as cephalohematomas occur beneath the periosteum. Thus, further imaging is not necessary. If there is a concern for intracranial injury, computed tomography of the brain (if the patient has clinical signs or symptoms of increased intracranial pressure) or magnetic resonance imaging (to avoid ionizing radiation if the patient is stable) is recommended not only to characterize the area but to determine if there is any underlying skull deformity as well (i.e., fracture).
A 78-year-old male with a past medical history of atrial fibrillation on anticoagulation, insulin-dependent diabetes, and spinal stenosis of the cervical spine at C5-C6 presents to the office with chronic, worsening right arm pain, numbness, tingling, and weakness. Symptoms have been occurring for years but have gotten progressively worse over the last few weeks. He now has difficulty gripping objects with his right hand. Conservative management has failed previously, including physical therapy and oxycodone for pain relief. The symptoms have made it difficult to perform his activities of daily living. His physical exam is significant for a strength of 3 out of 5 on the right in arm’s flexion, the sensation is reduced along the C5 dermatome on the right, and C5 deep tendon reflexes is 1/4. Which of the following is an absolute contraindication of the non-surgical management of this patient?
1. Failure of medical management and physical therapy
2. Progressively worsening neurological symptoms
3. History of symptomatic spinal stenosis of the cervical spine
4. Chronic pain affecting his activity of daily living
2. Progressively worsening neurological symptoms
- Cervical epidural corticosteroid injections would be the next step in management for cervical radiculitis with failed conservative management. However, it is contraindicated in severe, progressive neuropathy, suggestive of a need for surgical correction.
- The corticosteroid epidural injection is preferred over surgery in patients with progressive pain without worsening neurological findings. Before the procedure, the provider should monitor for progression of symptoms, including associated worsening weakness or sensory changes.
- In cases of worsening or severe symptoms, a neurosurgeon should be consulted for surgical decompression of the spinal cord rather than a minimally invasive epidural injection.
- Absolute contraindications for cervical spine epidural injections include worsening and progressing neurological deterioration, but not his history of chronic stenosis of the cervical spine. This alone would not be a contraindication. If his pain were stable, this would be an indication of a cervical spine epidural.
A patient presents with weakness and cranial nerve deficits. Imaging studies done shows a small unilateral lesion on the basal portion of the ventrocaudal pons. Which of the following structures are expected to be involved in this syndrome?
1. Ipsilateral oculomotor and trochlear nerve, contralateral corticospinal tract
2. Ipsilateral trochlear nerve and abducens nerve, contralateral corticospinal tract
3. Ipsilateral oculomotor nerve and abducens nerve, contralateral corticospinal tract
4. Ipsilateral abducens nerve and facial nerve, contralateral corticospinal tract
4. Ipsilateral abducens nerve and facial nerve, contralateral corticospinal tract
- This patient has Millard-Gubler syndrome (MGS), also known as facial abducens hemiplegia syndrome or the ventral pontine syndrome.
- MGS is characterized by a unilateral lesion of the basal portion of the ventrocaudal pons involving fascicles of abducens (VI) and the facial (VII) cranial nerve, and the pyramidal tract fibers.
- This syndrome involves the fibers of cranial nerves VI (abducens), VII (facial) on the ipsilateral side, and corticospinal tract fibers contralaterally. Symptoms include ipsilateral lateral rectus palsy leading to diplopia that is accentuated when the patient looks towards the side of the lesion, internal strabismus (i.e., Esotropia) and loss of power to rotate the affected eye outward due to the involvement of CN VI, ipsilateral peripheral facial nerve paresis leads to flaccid paralysis of the muscles of the facial expression and loss of the corneal reflex due to cranial nerve VII involvement, and contralateral hemiplegia of the extremities (sparing the face) due to pyramidal tract involvement.
- Neurological imaging, i.e., computed tomography (CT) and magnetic resonance imaging (MRI) help identify the lesion. However, MRI of the brain is more sensitive and specific than CT scan to determine the infarcts at an early stage of onset, especially in the setting of small pontine lesions.
