subs shelf study Flashcards
phimosis
tight uncircumcised foreskin can’t be pulled over head of penis
can’t advance urinary catheter, what to do…
try coude (firm slightly curved tip, keep curve up)
try larger catheter (larger firmer easier to advance, don’t go smaller)
absolute contraindication to urinary catheter
urethral injury - eg usually in setting of pelvic fracture
-so trauma pt w blood at meatus gross hematuria perineal hematoma high-riding prostate -get good geinital and rectal exam and retrograde urethrography to check for urethral injury before cath
relative contraindications to urinary catheterization
urethral stricture
recent urethral or bladder surg
combative or uncooperative pt
no urine flash after cath insertion, what to do
press on bladder
flush w saline
(cath tip may be obstructed by lubricating jelly)
normal urinary cath size
16-18 french (can do 14 or lower for women or w narrow urethra or hx of stricture or scarring)
22-24 (larger) for pts w gross hematuria to avoid clots obstructing cath lumen
double lumen urinary catheters what are lumens for
- baloon inflation
- urine
triple lumen urinary catheters what are lumens for
- baloon inflation
- urine
- saline irrigation
what are urinary catheters made out of
latex
silicone
silver-coated
what is a foley catheter
double lumen
straight tip
baloon at end for inflation and position maintanence
tf
urinary catheter placement is a sterile procedure
t
what to do if urinary catheter accidentally inserted into vagina
discard it, get a new one
what injected to fill foley balloon
water
not saline - can crystallize and cause valve malfuinction
not air - can float in bladder and kink catheter
most common compx of urinary catheterization
trauma infection (so avoid as much as possible and remove asap)
layers of scrotum - and abdominal wall derivative
skin
dartos fascia and muscle - subq tissue
ext spermatic fascia - ext oblique
cremaster muscle, fascia - int oblique
internal spermatic fascia - transversalis fascia
parieteal tunica vaginalis (around teste and epididymis) - peritoneum
visceral tunica vaginalis (around teste only) - peritoneum
tunica albuginea… part of teste…?
how does hsp cause testicular pain
henoch-schonlein purpura
-vasculitis of scrotal wall
tf
scrotal exploration is a procedure of low morbidity
t
so a small but real negative exploration rate is acceptable
bell clapper deformity
what is it
predisposes to what
most pts, tunica vaginalis attaches to posterior surface of testi allowing very little mobility within scrotom
-bell-clapper is high attachment of tunica vaginalis in 12% male pts allowing transverse lie of testi and free rotation on spermatic cord within tunica vaginalis for INTRAVAGINAL testicular torsion
most common cause of testis loss in us
torsion
laterality preference of testicular torsion
left
descends first
varicocele more common (testi vein to L renal v) heavier, easier to torse
how much twist required to compromise flow thru testicular artery
720 degress
per experimental evidence
but in real life ^360 can cause
tf
testicular torsion can occur at rest
t
eg in sleep
but also common trauma, physical activity
how does LATE testicular torsion resemble epididymoorchitis
after 12-24 hrs
entire hemiscrotum a confluent mass wo identifiable landmarks
elevated wbc can be seen (LATE)
dx testicular torsion
if high degree of suspicion – scrotal exploration wo imaging (low morbidity)
if questionable – scrotal us for absence of flow
salvage rates of testicular torsion
100% w/in 6 hrs
20% after 12 hrs (will have atrophy)
0% after 24 hrs (consider orchiectomy for pain relief)
procedure for testicular torsion
open, detorse, wrap in warm moist gauze… if pinks up, perform 3-point orchiopexy on affected testi and contralateral
chances of passing a urinary stone by size
1mm - 90% chance 2mm - 80% chance ... 8mm - 20% chance 9mm - 10% chance
tf
bph can cause hematuria
t
define hematuria
^3 RBC’s per HPF on two of three specimens
in what % of hematuria can a cause be identified
and what to do if workup inconclusive
80% cause can be identified
w persistent hematuria after negative eval - repeat eval at 48-72 mos as 3% of this group will be dxd w urologic malignancy
evidence for screening asymptomatic pts for asymptomatic hematuria
none
1-20% of pop will have asymptomatic hematuria…
how does potassium citrate treat kidney stones
alkalinizes urine
eg to tx uric acid stones (sodium urate..)
most common non-cutaneous malignancy in men and 2nd most common cause of cancer death
prostate cancer (lung = 1st cause of cancer death in men)
prostate cancer race preference
AA high risk
white intermediate
asian low risk
what is biologic function of psa
prostate specific antigen
serine protease that liequefies seminal coagulum
elevated in ejaculation, bph, infection, instrumentation, Not diagnostic dre
tf
psa elevated in all men w prostate cancer
f
not all
so dre still important
how to interpret psa
-age-adjusted - naturally increases w age and prostate enlargement
-psa density (total psa/prostate volume)
suspicious if ^.15
-psa velocity (3 different measurements as psa naturally fluctuates)
abnormal is .35 ng/ml/y for psa v4
.75 for psa ^4
-free/total psa ratio
^25% is low likelihood of cancer
best for psa ^4
finsasteride commercial moa uses se's
propecia, proscar 5-a-reductase inhibitor (prevents T conversion to DHT) male pattern hair loss bph female hirsutism (off-label) -low libido, erectile dysfunction...
gleason score
modified gleason grade group
for prostate carcinoma biopsy
1-5 based solely on architectural features (growth pattern and differentiation)
1 = normal prostate tissue
5 = undifferentiated
add two most prevalent differentiation patterns (primary pattern is most prevalent, secondary pattern is second most prevalent) in the sample for composite score of 2-10 (6-10 is dxd cancer, higher score is higher likelihood of non-organ-confined disease)
group 1 = gleason v6 group 2 = gleason 3+4 (HR 2) group 3 = gleason 4+3 (HR 5) group 4 = gleason (HR 8) group 5 = gleason 9-10 (HR 12) HR = hazard ratio for mortality
location of most prostate cancer
most common type
multifocal in peripheral zone (85%)
adenocarcinoma most common
-also mucinous adenocarcinoma, small cell neuroendocrine ca, squamous cell, rhabdomyosarcoma, leiomyosarcoma
how does prostate ca spread
local ext, lymphatics, vascular
local to bladder and urethra
mets to lymph nodes and bone
treatment options for prostate cancer
- active surveillance for low risk low volume local (v2 bx postiive, gleason 6 or less, psa 10, age^750
- radical prostatectomy - best chance for long term cure for local dz, but high risk…for young men v70, healthy long life expectancy, high volume gleason 6+
- radiation - good outcomes but not as effective as surgery, reserve for older pts ^70 or multiple comorbidities making surgery difficult
- cryosurgery, high intensity focused ultrasoind
- hormonal therapy for mets / advanced dz
95% of bladder tumors
transitional cell carcinoma / urothelial cell carcinoma
urachus
fibrous remnant of allontois - drains fetal urinary bladder into umbilical cord
bladder cancers
which to expect
how to treat
-transitional cell / urothelial carcinoma 95% bladder tumors can be lower or upper tract .................... .................... ................... .................
A 56 year old female complains of severe headache and a stiff neck with an abrupt onset. She states that she has no history of headache in the past and is nauseated, and on further questioning has photophobia. The etiology of the headache is likely to be:
subarachnoid hemorrhage
A subfrontal meningioma is likely to interfere with which cranial nerve function?
olfactory
The corneal reflex tests which cranial nerve(s)?
Afferent reflex: trigeminal nerve (V), Efferent reflex: facial nerve (VII)
An aneurysm of the internal carotid artery at the junction of the posterior communicating artery may lead to dysfunction of which nerve?
Oculomotor nerve (III)
With central facial weakness, the entire side of the face is weak. True or false?
just the lower… ipsilateral? quadrant
rinne vs weber fork placement
rinne - mastoid process
weber - middle of head
The Rinne’s test helps differentiate which types of hearing loss?
Conductive vs. sensorineural
can’t hear vibration… sensorineural? can’t hear air… conductive?
Which cranial nerves are affected with an acoustic neuroma?
VIII, V, VII
Weakness of the left accessory nerve will result in weakness of head turning to which side?
Right
Pronator drift with testing of outstretched supinated arms is indicative of pathology in which location of the motor system?
Corticospinal system
A cerebral lesion would produce the following deficit in sensory function in the contralateral extremity:
two-point discrimination
fine touch, vibration, proprioception?
dorsal columns medial lemniscus pathway?
A positive Romberg test, performed standing with eyes closed, indicates a lesion in the
proprioceptive system (not cerebellum…)
cerebral perfusion pressure =
CPP = MAP - ICP
MAP = (sbp+2dbp)/3
how does hyperventilation affect icp
decreases it
via cerebral vasoconstriction
(opposite of lungs)
critical score in gcs
8 or less is severe head injury (3-15 possible)
laterality of pupillary dilation and hemiplegia with uncal herniation
Ipsilateral pupillary dilation.
Contralateral or ipsilateral hemiplegia
primary survey and resusciatation of pt w head trauma
abc's (and d) airway patentency breathing control circulatory and hemorrhage control disability (pupils and GCS.. prob check for spine inj too...)
tf
high dose corticosteroids can be used to treat inc ICP from trauma
f can mild sedate evd osmotic diuretics etc... not steroids...
tf
alcohol intoxication is an indication for hospital obs of a pt w concussion
t
also abnormal ct
decreased level of consciousness…
tf
cerebral contusions frequent with subdural hematoma
f
subdural from rupture of bridging veins usually… not necessarily blunt head trauma…
tf
burr hole drainage is surgical treatment of choice for subdural hematoma
f
craniotomy and surgical evacuation… to clotted for burr hole drainage
size of cavity produced by bullet related to
kinetic energy (massxvelocity) and shape of bullet
highest risk type of skull fracture requiring surgical treatment most
open, depressed skull fracture
-operative irrigation, debridement, removal of depressed fragments, later procedures to correct cosmetic deformity
(open NON-depressed skull fxs can be inspected, cleaned, scalp sutured w acceptably low rate of infection…)
how does csf shunt predispose to chronic subdural hematoma
dec icp by draining csf
brain shrinks, bridging veins easier to tear
juvenile pilocytic astrocytoma cured by surg? malignant? cystic? histology?
cured by surg often
considered benign
often cystic
-histologically loose and dense areas of stellate astrocytes as well as rosenthal fibers
oligodendrogliomas present w seizures? have calcifications? respond to chemo? more common than astocytomas? more common after age 65?
often present w seizures often have calcifications do respond to chemo less common than astrocytomas more common in young adulthood
glioblastomas kids or adults? cure w surg alone? average survival? histopath? mets?
adults not curable w surg alone survival v5years -histopath inc cellularity, nuclear pelomorphism, mitoses, endothelial proliferation, necrosis kills before mets
ependymomas
- where are subependymal giant cell astrocytomas found in pts w tuberous sclerosis?
- where do ependymomas often arise from?
- spread pattern?
- better prognosis if conus or filum terminale vs 4th ventricle?
- typically in foramen of monro in pts w tuberous sclerosis
- floor of 4th ventricle
- spread along csf pathways
- better w conus or filum terminale (e.g. myxopapillary ependymoma)
vestibular schwannoma
- aka
- presentation and progression
- when is stereotactic radiosurgery effective
- bilateral suggests…
- aka acoustic neuroma
- usually present w tinnitus and sensori-neural hearing loss (VIII)… facial numbness (V) at 2.5 cm… coordination and facial (VII) weakness at 3cm
- stereotactiv radiosurgery for v2.5cm
- bilateral… think neurofibromatosis type II
meningiomas arise from…
arachnoid cap cells in cranium and spine
most common location for meningioma
parasagittal
conexity
tuberculum sella
sphenoid ridge
meningioma assoc w…
neurofibromatosis type II
and 22q arm abnorm
tf
resection of meningioma is often curative
t
meningioma on imaging
hyperostosis of underlying bone,
homogenous enhancement w contrast,
enhancing dural tail
tf
pituitary adenomas always secrete hormones
f
classified as hormone secreting or NON hormone secreting
etiology of cerebral abscess
hematogenous spread,
penetrating trauma,
surgery,
local spread from the paranasal sinuses, mastoid air cells or emissary veins
are brain abscesses commonly aerobic or anaerbobic?
either
1/3 have multiple organisms
treat brain abscess
stereotactic aspiration
6 wks abx
can consider resection if fails after 3rd aspiration
most common organism in brain abscess in aids
toxoplasmosis
toxoplasma brain abscess (eg in aids) can be confused with…
cns lymphoma
most common location of spontaneous intracerebral hemorrhage from htn
basal ganglia
what other vascular malformation s venous angioma commonly associated with
cavernous angioma (irregularly formed vessels without intervening brain parenchyma)
define eloquent cortex
if removed it will result in fnd
linguistics, sensation, motor, vision, etc
tf
surgery for avm is risky if had previous hemorrhage
f
consider size, venous drainage, eloquence of adjacent brain…
goal of treatment for avm is to…
prevent hemorrhage
they can cause seizures, but those can be prevented other ways…?
scintillating scotoma aka
visual migraine
most common migraine prodrome
most comon physical finding in pts w clinically significant corotoid artery atherosclerosis
bruit
common but NOT always, absence does not rule out diagnosis…
TIAs cause
FNDs (transiently)
when to consider carotid endarterectomy
when symptomatic w ^70% stenosis (if procedure m and m is v7%)
asymptomatic w ^60% stenosis if perioperative compx v3%
how many c-spine trauma pts show/develop signs of neurologic injury
how many show another major associated injury
how many c-spine fx will have multiple
5-10% neuro inj
60% a major assoc inj
15% multiple if one fx
tf
ct better for bone viewing than mri
t
when should c-spine injury be assumed in unconscious trauma pt
always
until ruled out by exam and appropriate imaging
hypotension from spinal injury aka
“spinal shock”
from loss of sns output to vasculature
what level spine injury can cause bradycardia
cervical or high thoracic
from loss of sns output to heart
(T/F) Internal fixation (instrumentation) of the unstable spine is not a substitute for fusion (arthrodesis)
t
Most processes which cause spinal cord compression are dorsal or anterior processes?
anterior
motor level spinal cord inj at risk for atelectasis or pneumonia
c6-t12
The most common mechanism of spinal injury in the United States is:
Motor vehicle crashes
The motor level in a spinal cord injury is defined as
The most caudal level with antigravity strength
think it gets the nerves below the injury level…
Signs of spinal cord injury in the comatose or intoxicated patient include
Flaccid areflexia
Diaphragmatic breathing
Priapism
The Frankel grade of a patient with sensation below the level of the injury but no motor function below the level of the injury is
B
Frankel grading system
(for spinal cord injuries)
A complete neuro injury - no motor or sensation below lesion
B preserved sensation only - no motor, some sensation below lesion
C preserved motor, nonfunctional - some motor below lesion but not useful… sensation may be intact or compromised either way
D preserved motor, funcitonal - funcionally useful motor below lesion
E normal motor function - normal motor and sensory, abnorm reflexes may persist
Appropriate methods of immobilizing the cervical spine include
Cervical orthosis and bed rest
In-line cervical traction
Placement of a halo vest orthosis
In the patient who has sustained a spinal cord injury five hours prior to the initiation of treatment, the currently most appropriate steroid regimen is
Methylprednisolone 30mg/kg IV over 15 minutes, wait 45 minutes, then an infusion of 5.4mg/kg/hr IV for 47 hours
(steroids within 3 hours of injury - give for 24 hrs; within 3-8 hours of injury, give for 48 hours)
duration of steroid therapy for spinal cord injury
within 3 hours of injury - give for 24 hrs; within 3-8 hours of injury, give for 48 hours
(e.g. 30mg/kg IV over 15 minutes, wait 45 minutes, then an infusion of 5.4mg/kg/hr IV for 23 or 48 hours)
first priority in the management of the trauma patient is
Maintenance of an adequate airway
Spinal instability has been defined as
bility of the spine, under physiologic loads, to maintain relationships between vertebrae in such a way that:
There is neither damage nor subsequent irritation of the spinal cord or nerve roots There is no development of incapacitating deformity or pain due to structural changes
tf
Sterile, intermittent catheterization is preferable to the long-term use of an indwelling urinary catheter
in a spinal cord injured pt
t
tf
intermittent catheter urinary volumes should not exceed 450cc
in a spinal cord injured pt
t
tf
spinal cord injured patients should not be allowed to perform self-catheterization
f
if possible, they may be taught
how often should sterile intermittent catheterization be performed in a pt suffering spinal cord injury
initially every 4 hours
volumes should not be permitted to exceed 450cc
collagen makeup of intervertebral disc
type I AND II collagen
more type I at outer rings of annulus… type II in annulus as well… pulposus is “jelly” and “collagen”…
cervical spine root exam
muscle, ok, tip, fist, five
c5 (muscle man) shoulder abduction, elbow flexion
c6 (ok) elbow flexion, wrist extension, thumb and index “ok”
c7 (waiter tip) elbow extension, wrist flexion, finger extension
c8 (fist) finger flexion
t1 (five) finger abduction
tf
c5 radiculopathy can produce deltoid weakeness
t
c5 muscle man
(shoulder abduction, elbow flexion)
how many Americans will seek health care attention for low back pain at some point in their lives
how many will complain of low back pain on the spot if asked
75% will seek attention for lbp in life
20% prevalence if asked
Lhermitte’s sign
electric, shock-like pain radiating down the spine on neck flexion
classic exam finding in cervical spondylotic myelopathy
Lhermitte’s sign
(electric, shock-like pain radiating down the spine on neck flexion)
-classically described but Really only occurs in Minority of pts
define cervical spondylotic myelopathy
clinical entity produced by cervical stenosis
tf
An L5 radiculopathy rarely produces reflex changes in the lower extremities
f
There is not a reliably reproducible reflex associated with L5 (ankle dorsiflexion… no reflex for that…)
tf
Patients who undergo surgery for severe cervical myelopathy should be counseled that they will return to normal
f
tf
Low back pain worse in the morning and improving with activity is suggestive of a spinal malignancy
Morning stiffness and pain that relents as the day progresses suggests an inflammatory disorder
nocturnal pain associated with recumbency is a much more ominous symptom, being seen with malignant, destructive lesions.
(T/F)
A C7 radiculopathy will frequently produce triceps weakness
T
(aka) and ddx for cervical spondylotic myelopathy
(clinical entity produced by cervical stenosis)
The differential diagnosis of CSM includes
multiple sclerosis,
syringomyelia,
spinal cord tumor,
subacute combined degeneration,
normal pressure hydrocephalus
-Special care should be taken in patients with both upper and lower motor neuron signs, as amyotrophic lateral sclerosis and CSM can be difficult to distinguish.
define myelopathy
ddx
clinical presentation of pathology affecting spinal cord function
differential diagnosis for causes of myelopathy is large and includes trauma, metabolic, degenerative, inflammatory, toxic, infectious, and neoplastic
tf
Cervical Spondylitic myelopathy can present with
washing of the hand instincts
Lower extremity spasticity and hyperreflexia
Neck pain
Bulbar palsies
Bladder dysfunction
t t t f not bulbar palsy (IX X XI XII lower motor CN palsy) t
define bulbar palsy
impairment of cranial nerves IX, X, XI and XII,
due to a lower motor neuron lesion
either at nuclear or fascicular level in the medulla oblongata or from lesions of the lower cranial nerves outside the brainstem
An L5 radiculopathy from a herniated disc generally is associated with which of the following:
Anterior thigh pain
Weakness in the extensor hallicus longus
Weak or absent Achilles reflex
MRI demonstrating a ruptured disc at L5-S1
L5 weakness of EHL
Which of the following is true about lumbar spinal stenosis
.Surgery produces good results in approximately 2/3 of patients
.Lumbar stenosis is generally seen in the 3rd and 4th decades of life
.Sensory changes are an uncommon presenting complaint
.Neurogenic claudication can usually be relieved by cessation of activity and standing
yes good surg results in about 2/3 of pts
no, 6th or 7th decade or beyond
no, sensory changes common
no, relieved by a change of position such as squatting, leaning over or sitting down
define neurogenic claudication
-eg caused by spinal stenosis
leg pain produced by walking or standing that is typically relieved by a change of position such as squatting, leaning over or sitting down. Leg pain can be in a variety of distributions, and becomes quite debilitating. Patients often report associated paresthesias
(Approximately 2/3 of patients with symptomatic spinal stenosis will present with some variety of the classic picture of neurogenic claudication)
which of the following are true of cervical radiculopathy
.C5-6 and C6-7 are the most common levels affected
.Radiculopathy due to soft disc herniations are less likely to improve spontaneously than that caused by osteophytes and foraminal stenosis
.Acute cervical disc herniation can infrequently cause quadriplegia
.Most cervical disc herniations are due to trauma
.Surgery produces good results in more than 90% of well selected patients
t c56 c67 most common
t cervical radic from soft disk hern less likely to spontaneously improve than from osteophytes or foraminal stenosis
t can Infrequently cause quadriplegia
F most are not due to trauma… guessing degenerative
t surg good for Cerv disk hern in ^90% well-selected pts
42 y/o man presents with abrupt onset of pain, weakness, and muscle wasting of the L shoulder and upper arm 5 days following a tetanus vaccination. The most likely diagnosis is
brachial neuritis
nerves involved in thoracic outlet syndrome
medial cord of brachial plexus C8-T1
16 y/o man presents 10 days following a gunshot wound with weakness of leg extension with an absent knee jerk. The most likely diagnosis is
Femoral nerve entrapment secondary to a pseudoaneurysm
role of percutaneous steroids in the management of carpal tunnel syndrome
Diagnostic relief only
Wallerian degeneration may occur following which grades of peripheral nerve injury
axonotmesis and neurotmesis
3 grades of Peripheral nerve injury
neurapraxia, axonotmesis, and neurotmesis
neuropraxia - mildest, partial or complete block in a segment but prox and distal conduction in same nerve intact w axonal continuity maintained
axonotmesis - intermediate injury, interruption of axon but surrounding connective tissue (schwann cells and basal laminae) intact to support regeneration - recovery in months usually (peripheral nerves recover 1mm per day… 1 inch per month… so more proximal injuries take longer to recover (wallerian deveneration is distal)
neurotmesis - severest, axon and myelin and connective tissue disrupted - will not heal without surgery to remove road-blocks (scar tissue) and reestablish continuity
define wallerian degeneration
DISTAL wallerian degeneration
(axon and myelin degenerate distal to site of nerve injury)
-e.g. from axonotmesis or neurotmesis
55 y/o man develops fasciculations of his forearm muscle with progressive weakness and atrophy of his hands with diffuse hyperreflexia. Sensory examination is normal. The above history is most consistent with which diagnosis
Amyotrophic Lateral Sclerosis
40 y/o woman presents with progressive R hand weakness and atrophy of the 1st dorsal interosseus muscle. The most likely diagnosis is
C8/T1 radiculopathy
or
Ulnar neuropathy…? per neurosurg questions…
Which is most helpful to differentiate foot drop due to an L5 radiculopathy from a peroneal nerve injury
Weakness of foot inversion
(tibialis posterior (L5…?) inversion and plantarflexion
approximate rate of peripheral nerve regeneration
1mm per day
1inch per month
60 year old man develops progressive intermittent tingling of his entire right hand. The most appropriate diagnostic test is
carotid duplex exam
presentation: Premature infant with post-hemorrhagic hydrocephalus
27 week gestation premature infant who is now 1 week of age and whose head circumference has increased by 2 cm in the last 3 days. The infant is noted by the nurses to have intermittent episodes of bradycardia. An ultrasound of the head demonstrates bilateral Grade III intraventricular hemorrhages
presentation: Newborn with congenital hydrocephalus
term newborn returns to your office for a routine 3 month well-baby visit and is noted by your nurse to have a head circumference which has crossed from the 50th percentile at birth to above the 95th percentile. The infant otherwise appears perfectly normal but has a full anterior fontanelle.
presentation: Infant with post-meningitic hydrocephalus
infant born with Group B Strep meningitis successfully completes a course of antibiotics and appears to have been cured of the meningitis. His mother calls because he is irritable, feeding poorly, and spits up frequently. She also notes that his eyes have been crossed for the last several days. On physical exam, his anterior fontanelle is bulging and his sutures are mildly separated.
presentation: 3 year old with obstructive hydrocephalus from a brain tumor
mother brings her 3-year-old to your office because he has been complaining of a headache off and on for 4 months. He has become clumsy and falls a lot and has recently vomited first thing in the morning. He will not cooperate for a fundoscopic exam but has mildly increased lower extremity reflexes and a broad based gait. His pediatrician has been treating him for otitis and sinusitis for 4 weeks with no improvement
presentation: 8 year old with aqueductal stenosis
8-year-old is brought to your office with a history of headaches off and on for six months. Recently she has been falling a lot and has complained of difficulty seeing the chalkboard at school. On physical exam, she has florid papilledema, a broad based ataxic gait, and a head circumference of 53 cm.
Trigeminal neuralgia is usually caused by…
idiopathic/unknown cause USUALLY,
but some known compressive or inflammatory causes eg:
- posterior fossa tumor compressing the nerve
- ms plaque in brainstem
also aneurysms, sarcoidosis, scelorderma, lupus, lyme…
treatment of glossopharyngeal neuralgia
may try cocaine over the tonsillar pillars and fossa but usually will require surgical treatment (meds don’t work on it like trigeminal neuralgia)
-Surgical microvascular decompression
or sectioning of the glossopharyngeal nerve via either an extra or intracranial approach - usually intracranial with sectioning of all of the preganglionic glossopharyngeal nerve fibers as well as the upper one-third or two fibers (whichever is larger) of the VAGUS nerve….Occasionally patients may have problems either with their cardiovascular system or with their swallowing and therefore require monitoring, particularly over the first 24 to 48 hours in order to treat any vagus nerve complication
causalgia aka define pathogenesis dx tx
-reflex sympathetic dystrophy
aka complex regional pain syndrome CPRS
- usually show some manifestation of a partial peripheral nerve injury including autonomic dysfunction, severe burning or gnawing type of pain, and trophic changes in the involved extremity
- theories: electrical transmission between sympathetic nerves and afferent pain fibers…vs… norephinephrine released at sympathetic terminals, together with hypersensitivity secondary to denervation or sprouting
- no good tests yet other than subjective pt report of pain and improvement
-v1/4 pts find satisfactory tx
no helpful meds yet
surgical sympathectomy…
spinal cord stimulation…
4.(T/F) A new fairly effective way to manage cancer pain includes a morphine pump with intrathecal infusion.
T
where are dbs electrodes placed for parkinson’s
subthalamic nucleus
treat dystonia
no generally accepted surgical tx yet… in works…
- pallidotomy (heat ablation of globus pallidus w probe)
- dbs of globus pallidus and stn
(T/F) Spasticity can be treated effectively in the lower extremities of cerebral palsy patients with a selective dorsal rhizotomy.
t
(T/F) Hemifacial spasm should first be treated with extensive medical means prior to consideration of microvascular decompression.
F
botox maybe some but generally need surgery
-microvascular decompression (MVD), in which the offending vessel is physically moved off of the nerve and cushioning material similar to that utilized in the treatment of trigeminal neuralgia is interposed
define microvascular decompression
eg microvascular decompression OF A NERVE
eg for trigeminal neuralgia or hemifacial spasm - offending vessel is physically moved off of the nerve and cushioning material is interposed
Temporal lobe resection for treatment of seizures emanating from the temporal lobe including amygdala and hippocampal resection for seizures originating from mesial temporal sclerosis show what cure rate
60-70% “cure” aka seizure control aka no seizures - with or without adjunctive medications
additional pts may experience partial reduction of frequency
differential diagnosis of trigeminal neuralgia
herpes roster dental disease temporal arteritis orbit disease compressive tumor or aneurism inflammatory ms, sarcoidosis, scelorderma, lupus, lyme
surgical treatments for trigeminal neuralgia
microvascular decompression
percutaneous trigeminal radiofrequency rhizotomy
percutaneous microcompression rhizolysis
Gamma Knife radiosurgery
Causalgia is characterized by which of the following burning pain trophic changes autonomic dysfunction deep profound weakness loss of sensory function
burning pain
trophic changes
autonomic dysfunction
All the major aspects of spasticity can be treated by a pump infusing
baclofen
(skeletal muscle relaxant - inhibits monosynaptic and polysynaptic reflexes at spinal cord level, possibly by hyperpolarizing primary afferent fiber terminals)
Phenergan aka, moa
promethazine
Antiemetic;
Histamine H1 Antagonist;
Histamine H1 Antagonist, First Generation;
Phenothiazine Derivative
-blocks postsynaptic mesolimbic dopaminergic receptors in the brain
-strong alpha-adrenergic blocking effect and depresses the release of hypothalamic and hypophyseal hormones
-competes with histamine for the H1-receptor;
-muscarinic-blocking effect may be responsible for antiemetic activity
-reduces stimuli to the brainstem reticular system
Hemifacial spasm is usually most commonly caused by compression of the facial nerve by which posterior fossa artery
anterior inferior cerebellar artery
Primary generalized seizures can be readily treated by which:
resective surgery
medical management
disconnection surgery
medical management
surgeries performed for the treatment of temporal lobe epilepsy secondary to mesial temporal sclerosis the following structure or structures are removed
the first few centimeters of the anterior temporal lobe
the amygdala
portions of the hippocampus
