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Module 204 MSK & Immune system > T2 L18 Lower limb nerve injuries > Flashcards

T2 L18 Lower limb nerve injuries Flashcards

1
Q

Describe how a lumbar puncture is done

A

Patient in lateral position, palpate iliac crests which are at level of L4/L5
Done in between L3/L4 as spinal cord ends at L1/L2

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2
Q

Compare the pain severity in cauda equina and conus medullaris

A

Cauda equina - radicular, more severe

Conus medullaris - less severe

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3
Q

Compare the location of pain in cauda equina and conus medullaris

A

Cauda equina - unilateral / asymmetric. Perineum, thighs, legs
Conus medullaris - bilateral, perineum, thighs

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4
Q

Compare the sensory distribution in cauda equina and conus medullaris

A

Cauda equina - saddle, unilateral / asymmetric

Conus medullaris - bilateral saddle distribution

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5
Q

Compare the motor loss in cauda equina and conus medullaris

A

Cauda equina - asymmetric, atrophy

Conus medullaris - symmetric

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6
Q

Compare the reflexes in cauda equina and conus medullaris

A

Cauda equina - ankle and knee reduced

Conus medullaris - ankle reduced

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7
Q

Compare the effects on bowel / bladder in cauda equina and conus medullaris

A

Cauda equina - late

Conus medullaris - early

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8
Q

What can cause damage to the cauda equina?

A

Disc herniation - L5/S1
Spinal fracture
Tumours

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9
Q

What can cause damage to the conus medullaris?

A

Disc herniation
Tumour
Inflammatory conditions - chronic inflammatory myelinating polyradiculopathy, sarcoidosis
Infection - CMV, HSV, EBV, lyme, TB

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10
Q

What can cause compression of a nerve?

A

Disc herniation
Formation of osteophytes
Ligaments
Small canal - stenosis

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11
Q

What pain is produced in a dermatome?

A

Sharp / superficial

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12
Q

What pain is produced in a myotome?

A

Deep ache

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13
Q

What is L1 dermatome?

A

Inguinal area

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14
Q

What dermatome supplies front of thigh?

A

L2

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15
Q

What dermatome supplies front of knee?

A

L3

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16
Q

What dermatome supples front-inner/medial leg?

A

L4

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17
Q

What area of skin is supplied by L5?

A

outer leg
dorsum of foot
inner sole

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18
Q

What area of skin is supplied by S1?

A

Little toe
Rest of sole
Back of leg

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19
Q

What area of skin is supplied by S2?

A

Thigh to top of buttocks

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20
Q

What dermatome supplies the concentric rings around the anus / genitalia?

A

S3-S5

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21
Q

What spinal root is the knee jerk reflex?

A

L4

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22
Q

What spinal root is the ankle jerk reflex?

A

S1

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23
Q

What spinal root allows hip flexion?

A

L1/2

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24
Q

What spinal root allows knee extension?

A

L3/4

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25
Q

What spinal root allows foot inversion?

A

L4

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26
Q

What movement does L5 allow?

A 
Knee flexion
Ankle dorsiflexion
Toe extension
Foot inversion
Foot eversion
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27
Q

What movement does S1 allow?

A

Knee flexion
Ankle plantar flexion
Toe flexion
Foot eversion

28
Q

What are some causes of lumbrosacral plexus lesions?

A 
Childbirth (large head, prolonged labour)
Structural
 - haematoma (on warfarin)
 - abscess
 - malignancy
 - trauma 
Non-structural 
 - inflammatory
 - diabetes
 - vasculitis
 - radiotherapy
29
Q

What muscles are affected if there is proximal damage (above inguinal ligament) to the femoral nerve?

A

Hip flexors

Ilipsoas

30
Q

What movement is affected if there is damage to the femoral nerve below the inguinal ligament?

A

Knee extension

31
Q

What symptoms does damage to the femoral nerve cause?

A 
Weakness
Poor hip flexion
Poor knee extension
Loss of knee jerk
Difficulty standing from seated
Difficulty up stairs
Knees buckle
32
Q

What do patients often complain of if there is damage to the lateral cutaneous nerve?

A

Tingling in outer aspect of thigh which is relieved by sitting

33
Q

Why is the lateral cutaneous nerve commonly affected in obesity?

A

It is superficial so the excess adipose tissue can push on it

34
Q

What can cause femoral nerve damage?

A

Trauma e.g. pelvic fracture
Childbirth
Gynae procedures e.g. hysterectomy
Femoral artery bypass / puncture

35
Q

Describe the sciatic nerve distribution of pain

A

From buttock

Down leg as far as feet and toes

36
Q

What is sciatica?

A

Pain in sciatic nerve distribution

37
Q

What can cause sciatica?

A

Trauma
Haematoma
Sciatic nerve compression (rare)
Misplaced IM injections

38
Q

What is piriformis syndrome?

A

Compression of piriformis muscle causing tingling in buttocks and down leg
Diagnosed by exclusion

39
Q

What movements are not affected in sciatic nerve injury?

A

Hip flexion
Knee extension
Hip adduction

40
Q

Describe the distribution of the tibial nerve

A

In popliteal fossa
Gives branches to gastrocnemius, popliteus, soles and plantaris
Branches to sural nerve

41
Q

What are indications that the tibial nerve is injured?

A

Can’t stand on tiptoes
Weak foot inversion
Painful, numb sole

42
Q

What can cause injury of the tibial nerve?

A

Trauma - haemorrhage
Baker’s cyst
Nerve tumour
Entrapment of tendinous arch by soleus muscle

43
Q

What is tarsal tunnel?

A

Compression of tibial nrve
Sole pain which is worse when walking / standing
No heal pain

44
Q

What is a differential diagnosis instead of tarsal tunnel?

A

Morton’s neuroma

45
Q

Why is the sural nerve often biopsied?

A

It is a sensory nerve so damaging it won’t cause loss of function
It is relatively superficial so easy to access

46
Q

What are the symptoms of damage to the common peroneal nerve?

A

Sensory loss to dorsum of foot and outer aspect of lower leg

Weakness of dorsiflexion and eversion of foot

47
Q

What can cause neurogenic foot drop?

A

Damage to:

  • upper motor neuron
  • conus
  • L4/L5
  • cauda equina
  • sacral plexus
  • sciatic nerve
  • common peroneal nerve
48
Q

What is polyneuropathy?

A

Generalised relatively homogenous process affecting many peripheral nerves with distal nerves affected most prominently

49
Q

What is peripheral neuropathy?

A

Any disorder of peripheral nervous system including radiculopathies and mononeuropathies

50
Q

What are the common causes of length dependent polyneuropathy?

A

Toxic / metabolic causes

  • diabetes
  • alcohol
  • B12 deficiency
  • chemotherapy
  • idiopathic
51
Q

What are the clinical symptoms of length-dependent polyneuropathy?

A

Numbness, paraesthesia, weakness

Pain

52
Q

What is Gullain-Barre syndrome?

A

Autoimmune condition - immune response to preceding infection
Also known as acute inflammatory demyelinating polyneuropathy
Rapidly progressive weakness
Absent reflexes

53
Q

What is neuronopathy?

A

Form of polyneuropathy

Disorders that affect specific population of neurons

54
Q

What is damaged in motor neuronopathy and what are the causes?

A

Damage to anterior horn cell

Causes: ALS, polio

55
Q

What is damaged in sensory neuronopathy and what are the causes?

A

Damage to dorsal root ganglia

Causes: Sjogren’s syndrome, paraneoplastic

56
Q

What is polyradiculopathy and what are the causes?

A 
Affects multiple nerve roots
Causes:
 - spinal stenosis
 - cancer (leptomeningeal metastases)
 - infection (Lyme disease, HIV)
57
Q

What compartments are in the leg?

A

Anterior muscle compartment
Lateral muscle compartment
Medial muscle compartment
Posterior muscle compartment

58
Q

What are shin splints?

A

Muscle bulk increases by 20% during exercise leading to transient increase in intra-compartmental pressure
Anterior and lateral compartments of lower leg are commonly affected
Causes pain during and post exercise

59
Q

What is compartment syndrome?

A

Increase in pressure within a myofascial compartment which has limited ability to expand

60
Q

What are the causes of compartment syndrome?

A 
Fractures
Crush injuries
Burns
Electric shock
Fluid injection
Drugs - warfarin, anabolic steroid use, IV drug use
Disease - haemophilia
External causes - tight splints / casts
61
Q

What is the consequence of compartment syndrome?

A 
Elevated compartment pressure leads to pressure on blood vessels including arteries
Reduced blood flow
Muscle and nerve ischaemia
Cytotoxic oedema
More swelling and pressure
62
Q

What is affected in acute anterior CS of the leg?

A

Dorsiflexion of muscles of ankle and foot - tibialis anterior, extensor digitorum longs, extensor hallucis longs, peroneus tertius
Anterior tibial artery
Deep peroneal nerve

63
Q

What is affected in acute posterior CS of the leg?

A

Plantar flexors of foot - gastrocnemius, planters, soleus

Sural nerve - loss of sensation to lateral aspect of foot and distal calf

64
Q

What are the signs of compartment syndrome?

A

Pain (out of proportion to original injury)
Pain which is severe on passive stretching
Tense limb
Decreased function of compartment muscles
Distal neurologic compromise
Reduced distal pulses

65
Q

What are the investigations for compartment syndrome?

A

Clinical suspicion
Measure intra-compartmental pressure
Measure CK
Check for myoglobulinuria

66
Q

What is the management of acute CS?

A

Surgery to release the pressure - fasciotomy

Check for external causes

67
Q

What are the complications of mismanagement of acute CS?

A

Little or no return of function
Rhabdomyolysis
Limb loss

Module 204 MSK & Immune system (44 decks)

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