TEST 2 Flashcards
There are ____ pairs of cranial nerves
12
What Nuclei of origin are found in the medulla?
CN IX, X, XI, XII
CN IX, X sensory nucleus
Nucleus solitarius
CN IX, X motor nucleus
Nucleus ambiguus
Nuclei of origin located in the Pons
CN V, VI, VII, VIII
Nuclei of origin located in the midbrain
CN III, IV
These CN do not have a nuclei of origin
CN I, II
Name the CN
I Olefactory II Optic III Oculomotor IV Trochlear V Trigeminal VI Abducens VII Facial VIII Vestibulocochlear/acoustic IX glossopharyngeal X vagus XI spinal accessory XII Hypoglossal
Which CN have sensory fibers only?
CN I, II, and VIII
A CN that has motor fibers will also have _______ fibers
Proprioceptive
CN that have parasympathetic fibers
CN III, VII, IX, X
Major parasympathetic nerve
CN X: vagus
Which CN have ALL 4 types of fibers? (Motor, sensory, proprioceptive and parasympathetic)
CN VII, IX, X
CN pathways are similar to descending motor pathways because they have ___ neurons in sequence.
What is the difference between the pathways?
2 neurons in sequence
CN pathways have upper motor neuron from both the left AND the right
Sensory fibers in CN have ____ neurons in sequence
3
Only sensory fibers, provides for sense of smell
Olefactory fibers
Olefactory fibers originate in the _________ and terminate in the __________.
Originate in the nasal passages
Terminate in the olefactory cortex
Olefactory fibers have collaterals to what two things?
Habenular nucleus
Limbic system
Located in epithalmus; plays role in gut responses to odors
Habenular nucleus
Plays a role in emotional responses to the environment, which is highly associated with smell
Limbic system
CN II pathways start where? Terminate where?
Start in rods and cones of the retina
Terminate in primary visual cortex
CN that provides motor innervation to most of the extraocular muscles; responsible for majority of the extraocular movements.
CN III Oculomotor
Parasympathetic fibers in CN III innervate the pupil and cause pupillary ________.
Constriction
Fibers that cause pupil dilation
Sympathetic
How do you test parasympathetic rxn of CN III?
Shine a light in the eye
When testing parasympathetic fxn of CN III with a light, you should have direct constriction, and also have ___________ constriction of the opposite eye.
Consensual
CN that pulls the eyelids open
CN III
CN that closes the eyelids
CN VII
Ptosis is indicative of a CN ____ lesion
III
Trochlear CN IV brings eyeball DOWN and OUT.
TRUE/FALSE
FALSE
Brings eyeball DOWN and IN
CN that moves the eyeball laterally
CN VI Abducens
What 3 CN’s move the eyeball
CN III, IV, and VI
If you look to the right, your left eye moves to the right via CN ___; your right eye moves laterally via CN __.
III; VI
3 branches of CN V (trigeminal)
Opthalamic
Maxillary
Mandibular
CN responsible for most sensations through the head and face
CN V Trigeminal
Branch of CN III; only sensory fibers, innervates upper part of head
Opthalamic branch
Trigeminal branch; only sensory fibers; innervates middle face/head
Maxillary
Trigeminal branch; motor fibers for chewing and proprioceptive feedback from these muscles
Mandibular branch
Facial CN VII is responsible for the majority of facial _________.
Expressions
CN VII provides sense of taste for what part of the tongue
Anterior 2/3
CN VII provides for sensory fibers from what 2 areas?
SKIN of the external ear
Palate
Parasympathetic fibers of CN VII to submandibular and sublingual glands for ___________ production
Saliva
CN VII parasympathetic fibers to lacrimal glands for ____ production
Tear
CN VII Parasympathetic fibers to glands of the palate and nasal cavity. TRUE/FALSE
TRUE
To assess facial nerve you may ask someone to raise their eyebrows, smile, frown, or puff their cheeks out; you are looking for ________ when you do this
Symmetry
CN VIII provides for special sense of ________ and _________.
Sense of hearing and balance
CN that provides motor input to pharyngeal muscles; responsible primarily for the function of swallowing
CN IX Glossopharyngeal
CN IX provides for sense of taste to what area of the tongue
Posterior 1/3
Contain sensory fibers that innervate the baroreceptors and chemoreceptors of internal carotids.
CN IX
Baroreceptors monitor ______
Pressure
Chemoreceptors at the carotid bodies are primarily monitoring ______
PaO2 (peripheral)
How do you assess CN IX?
Open mouth and say AHHH
When assessing CN IX, uvula should rise where?
In the midline
If uvula deviates to one side, it deviates towards the affected side. TRUE/FALSE
FALSE
Uvula Deviates towards the NORMAL side
Provides motor innervation to allow for voice production
CN X
Sensory fibers that Innervate the aortic arch where baroreceptors and chemoreceptors located
CN X
CN X parasympathetic fibers provide for innervation of many of the organs in what areas
Thoracic
Abdominal
CN X does NOT have parasympathetic fibers that innervate what 4 things that are innervated by sacral segments of the SC. (S2-S4)
Sigmoid colon
Rectum
Anus
Genitals
Nuclei of origin for CN XI is not in the cranium, where does it sit?
Below the foramen magnum; upper SC
CN XI provides for motor input to the ______ and ______ muscles
Trapezius
Sternocledomastoid
What two movements does CN XI allow us to do?
Rotate head
Shrug shoulders
Provides motor innervation to many of the tongue and throat muscles
CN XII
How do you assess the hypoglossal CN XII; normal result?
Have pt stick tongue out; should be midline
If pts tongue deviates to one side when assessing CN XII, it will deviate towards the side with the lesion. TRUE/FALSE
TRUE
Sits right above optic chiasm
Hypothalamus
Sits right below optic chiasm in the sella turcica of the sphenoid bone
Pituitary
Passes right through the optic chiasm; connects hypothalamus to pituitary
Infundibulum
Visual field projected onto the R lateral retina
R medial visual field
If rods and cones of retina from R lateral are excited, sends impulses to towards the optic chiasm through lateral fibers. TRUE/FALSE
TRUE
Lateral fibers cross over at the optic chiasm . TRUE/FALSE
FALSE
Lateral fibers DO NOT cross over at the optic chiasm
Lateral optic fibers synapse in ___________ ; part of the thalamus
Lateral geniculate bodies
Lateral optic fibers will go around the optic radiations, eventually terminate in primary visual cortex on the SAME side they originated; never crossing over. TRUE/FALSE
TRUE
The “optic radiations” are where the fibers have to radiate around the _________ of the brain
Lateral ventricles
Visual field projected to the medial part of the right retina?
Right lateral visual field
If rods and cones of retina are are excited on the right medial eye, then impulses are transmitted through medial fibers to get to the _________; where medial fibers cross over to the other side.
Optic chiasm
_________ fibers CROSS; _________ fibers DO NOT CROSS.
Medial fibers cross
Lateral fibers do not
Where do the medial fibers synapse with the second group of fibers before continuing on to the primary visual cortex.
Lateral geniculate bodies
Medial fibers synapse in the primary visual cortex of the same side that it originated from. TRUE/FALSE
FALSE
Medial fibers synapse in the primary visual cortex of the OPPOSITE side they originated from
Left lateral visual field is projected where?
medial part of the Left retina
Left medial visual field is projected where?
Lateral part of the left retina
Where are the superior visual fields projected?
Inferior part of the retina
Where are the inferior visual fields projected?
Superior part of the retina
Lesion anterior to optic chiasm that involves both right lateral and medial fibers causes what type of vision loss?
Total blindness in right eye
If location of lesion is anterior to optic chiasm that involves only Right lateral fibers leads to what visual loss?
Hemisphere loss in one eye; right medial visual field loss in this case.
Lesion anterior to optic chiasm that involves only Left medial fibers leads to loss of what visual field?
Left lateral visual field loss (hemisphere loss)
Lesion posterior to optic chiasm that involves only right lateral fibers lead to loss of what visual field?
Right medial visual field
Lesion posterior to optic chiasm that involves only left Medial fibers leading to loss of what visual field?
Right lateral visual field
Lesion on the right side posterior to the optic chiasm that involves both lateral and medial fibers leads to what visual field losses?
What is the term used?
Left lateral and right medial visual field losses
Left sided homonymous hemianopsia
If you had 100% occlusion of the Left posterior cerebral artery, you would have a _________ sided homonymous hemianopsia.
RIGHT sided homonymous hemianopsia
Lesion at the optic chiasm that involves medial fibers from Both eyes leads to what visual field losses?
Right and Left lateral visual field losses
Right and left lateral visual field loss is referred to as ___________ hemianopsia; loss of peripheral vision.
Bitemporal
Bitemporal hemianopsia is many times the first sign of a __________ tumor.
Pituitary
Triggers for oculocardiac reflex (OCR)
- Direct eye pressure (globe of eye)
- Pain
- Traction on extrinsic eye muscles
Traction of the MEDIAL/LATERAL rectus muscle is a stronger trigger for OCR.
Medial rectus is a stronger trigger for OCR
The pathway for the OCR starts with ___________ nerves; part of CN III.
Afferent Ciliary nerves
Afferent ciliary nerves terminate in ciliary ganglion and synapse with CN ______ ophthalmic division
CN V Trigeminal
After ciliary nerves synapse with CN V, a collateral of CN V terminates and integrates with CN ___ efferent fibers.
CN X
In the OCR, when CN X results in _________ outflow
Parasympathetic
OCR parasympathetic outflow; vagus innervation of the heart– what symptoms would you see?
Bradycardia Junctional rhythm AV block Ventricular tachycardia Asystole Hypotension
What is the FIRST thing you do for management of OCR?
DC the stimulus; tell the surgeon to STOP!!!
Besides stopping the stimulation with OCR, what else can you do to manage?
- Increase anesthetic depth (blunts OCR)
- IV glycopyrrolate/atropine
- lidocaine infiltration into eye (also blunts)
OCR will eventually fatigue with repeated manipulation of the eye; does not continue to cause bradycardia. TRUE/FALSE
TRUE
Purpose of pain
Protective mechanism to protect body from unwanted tissue damage
Pain is a VERY _______ experience; extremely difficult to measure ________.
Subjective; Objective
2 types of pain
Fast pain
Slow pain
Fast pain is felt within ______ sec after stimulus
0.1 sec
Fast pain is usually localized; superficial and not deep tissue. TRUE/FALSE
TRUE
Fast pain activated the _______ nervous system
Sympathetic
Slow pain is felt ~ ____ sec after stimulus
1 sec
Type of pain usually related to tissue destruction and poorly localized; felt either superficial or deep tissue/organs
Slow pain
Slow pain activated the ___________ nervous system
Parasympathetic
This type of pain is highly associated with depression, Loss of E, and insomnia.
Slow pain
Pain receptors are also called ________
Nociceptors
Pain receptors start with _______ nerve endings; as opposed to pacinian corpuscles or golgi tendon bodies.
Free nerve endings
Pain receptor free nerve endings are SCARCELY distributed throughout skin, periosteum, arterial walls, joint surfaces, falx cerebri, tentorium cerebelli, parietal peritonium, pericardium, pleura. TRUE/FALSE
FALSE; widely distributed in these areas
This type of tissue has very few pain receptors
Deep tissue
The ________ has absolutely no pain receptors
Brain
Pain receptors DO NOT adapt to the stimulus. TRUE/FALSE
TRUE
What 3 types of stimulants activate pain receptors
Chemical
Mechanical
Thermal
Chemical stimulant of pain; very strong inflammatory mediator
Bradykinin
Widely distributed NT throughout the CNS that can stimulate pain receptors
Serotonin
Histamine is an inflammatory mediator and a _______ stimulant for pain receptors
Chemical
Why would potassium ions stimulate pain receptors ?
Tissue destruction;
K primarily found intracellular, and K released bc of cell lysis, important that it stimulates pain receptors to let the brain know that there is tissue destruction present
When excercising, ______ acids are released which are chemical stimulants for pain receptors
Lactic
Condition that is a direct result of build up of proteolytic enzymes, activated pain receptors
Pancreatitis
Ach can activate pain receptors. TRUE/FALSE
TRUE
Prostaglandins can enhance pain receptors or make them more sensitive, TRUE/FALSE
TRUE
When substance P is near pain receptors, it will decrease pain. TRUE/FALSE
FALSE; substance P can ENHANCE pain when at receptors
Thermal stimulant can affect pain receptors especially WARM temperatures > ______ C.
45 degrees C
Fast pain is typically transmitted bc of what two stimuli
Mechanical
Thermal
Slow pain is primarily transmitted bc of what type of stimuli? But can be all 3!!!
Primarily Chemical stimuli
The faster the rate of tissue damage, the greater the pain intensity. TRUE/FALSE
TRUE
Fast pain is transmitted through the _________ pathway
Neospinothalamic
The primary neuron for fast pain transmission is what type of neuron
Type A delta
Type A delta fibers are typically multipolar neurons. TRUE/FALSE
FALSE
Unipolar neurons
Type A delta fiber for fast pain will enter the spinal cord at the ________ horn of the gray matter and enter lamina of Rexed _____.
Dorsal horn; LofR 1
NT for fast pain; excites secondary neuron
Glutamate
Secondary neuron in fast pain pathway moves up the SC towards the thalamus; _____________ are sent to the RAS so that person is awake and removing painful stimulus
Collaterals
Fast pain pathways terminate here for localization and interpretation of painful stimulus.
Sensory cortex/postcentral gyrus (according to layout of homunculus)
Slow pain is transmitted through the ________ pathway; subdivision of spinothalamic; “Old pathway”
Paleospinothalamic
Primary neuron for slow pain
Type C unmyelinated
Primary NT for substance for slow pain
Substance P
Maybe a little glutamate
Slow pain enters SC through dorsal horn of the gray matter, excites secondary neuron, and eventually crosses over to __________ tract.
Anterolateral
With slow pain there are MULTIPLE collaterals. TRUE/FALSE
TRUE
Slow pain pathways terminate here, then to sensory cortex/postcentral gyrus for interpretation and poor localization
Thalamus
Slow pain activates the reticular formation. TRUE/FALSE
TRUE
Slow pain has collaterals that terminate in this area of the brain; near 3rd and 4th ventricles– lead to pain modulation.
Periaqueductal gray matter
Periventricular areas
Slow pain pathways terminate at the tectum in the midbrain at the superior/inferior colliculi, and are responsible for ________ response.
Reflex
Slow pain has collaterals to the hyothalamus as well. TRUE/FALSE
TRUE
How our body modulates and decreases the intensity of pain
Endogenous pain suppression systems
Major components for endogenous pain suppression systems
PAGM (periaqueductal..) PV areas (periventricular) RMN(Ralphe Magnus nucl) PGC (perigigantocellularis) Dorsal horns of gray matter
Painful stimulus occurs, primary neuron enters the _________ root, _______ rootlets, into the _________ horn of the gray matter
Dorsal
Dorsal
Posterior horn
NT for pain (fast/slow) will eventually activate the _______ neuron, which crosses over through ant white commissure into the _________ pathway of the anterolateral system.
Secondary; spinothalamic
Secondary neuron ascends up SC, when gets to Medulla, sends collaterals to _________ neuron; part of the RAS to make sure alert/aware to painful stimuli.
Medullary reticular neuron
Secondary neuron also has a collateral in the midbrain to what two areas?
PGM
PV areas
The collateral at the PGM and PV areas excites a neuron that contains __________, which is released, and excites a descending pathway to the medulla.
Endorphins
Enkephalins
After endorphins/enkephalins released the first time, descending pathway gets to medulla where end/enk are realeased again; activates _______ pathway which descends down SC and terminates at the short interneuron
SEROTONIN
What NT is released at the interneuron?
Serotonin
Serotonin release excites the interneuron and endorphins/enkephalins are released and bind to _______ neuron, which then decreases release of what NTs?
Primary neuron
Decrease release of glutamate and substance P
How does the inhibition of glutamate and substance P modulate pain?
Less ascending sensory pain pathways are activated
Exogenous opioids bind to different pain receptors (mu, kappa, delta) than endogenous opioids to modulate pain transmission. TRUE/FALSE
FALSE
They bind to the same receptors!
Once Mu, Kappa, Delta pain receptors are activated (by enkephalins), all are VERY potent and cause prolonged target cell response—– days, weeks, months. TRUE/FALSE
TRUE
Normal processing of painful stimuli; can be somatic or visceral.
Nociceptive pain
Arrises from bone, joint, muscle, skin, connective tissue; aching, throbbing, well localized.
Somatic nociceptive pain
Transmitted through type C fibers; usually related to ischemia, chemical damage, spasm, distention; usually referred to a surface of the body.
Visceral nociceptive pain
Example of visceral distention pain
Gas pains
Pain that is remote from the tissue causing the pain; usually from a visceral organ and referred to an area on the surface of the body.
Referred pain
There are internal organs present on the sensory homunculus in order to localize pain there. TRUE/FALSE
FALSE
No internal organs present on homunculus
The brain does not interpret pain from internal organs because there are no organs on the sensory homunculus; pain is referred to other areas because primary neurons of organs and skin synapse with the same secondary neuron. This explains what?
Theory of referred pain
Referred pain from heart
Side of neck
Shoulder
Down the arm
Substernal area
Referred pain from stomach
Anterior epigastrium
Referred pain from appendix
Umbilical area
Referred pain from kidneys
Right or left hypogastric area
Referred pain from ureters
Groin
Headache is a type of _______ pain
Nociceptive
Pain referred to the surface of the head from deep inside the cranium or from sinuses
Headache
Brain tissue has NO pain receptors. Pain receptors are found where in the brain
Venous sinuses
Tentorium cerebelli
Dura mater
Blood vessels in meninges
Pain is __________ if referred to from half of head
Supratentorial
Pain stimulus is _________ if referred to posterior part of head; such as pain from meninges/BS
Infratentorial
Usually describes as the worst headache you have ever had in your life
Meningeal inflammation
Headaches from low CSF pressure can be cause by what anesthesia intervention?
Postdural puncture; too far with epidural needle.
Causes the aura in a migraine headache
Initial Intense vasoconstriction
Causes throbbing, pulsating migraine headache
Rebound vasodilation from intense vasoconstriction
Prevention of migraine is directed at preventing what?
Intense vasoconstriction
Acute treatment of migraine is directed at
Throbbing/pulsating vasodilation
Abnormal processing of painful stimuli
Neuropathic pain
Neuropathic pain can be __________ or __________ generated
Centrally; peripherally
Examples of centrally generated neuropathic pain
Deafferentation pain: phantom pain
Sympathetically maintained pain: reflex sympathetic pain (complex regional pain syndrome)
Type of pain when amputees feel pain in the absent extremity; probably due to the same primary neuron from the distal extremities to the SC
Phantom pain
Examples of peripherally generated neuropathic pain
Polyneuropathies
Mononeuropathies
Pain distribution along many peripheral nerves
Polyneuropathies
Type of neuropathy caused by malnutrition and vitamin deficit
Alcoholic neuropathy
Polyneuropathic virus that effects motor fibers, but does not effect sensory fibers.
Guillain Barre
Lays dormant in dorsal root ganglion; stress activated; manifests in the dermatomes on the trunk usually
Herpes zoster
Examples of mononeuropathies
Nerve root compression
Nerve entrapment
Trigeminal neuralgia
CN V nerve is sitting up against a blood vessel as it pulsates; causing excruciating pain not relieved by medication; “suicide disease”
Trigeminal neuralgia
Sx intervention for trigeminal neuralgia
Craniotomy; stick a little piece of gauze between trigeminal and blood vessel. (4-5 hr case)
Chronic pain condition most often affecting one of the limbs, usually after an injury or trauma; cause unknown
Complex Regional Pain Syndrome (CRPS)
CRPS is characterized by ? (4)
- Prolonged/excessive pain
- Mild/dramatic changes in skin color
- Changes in temperature
- Swelling in affected area
Treatments for CRPS are the same, whether type I or II. TRUE/FALSE
TRUE
Treatments for CRPS from most conservative to most invasive
1) Physical therapy
2) medications (antidepressants, anti inflammatory, gaba analogs, opioids, lidocaine injections, …)
3) surgery (SC stimulators, sympathectomy, amputation)
Type of CRPS in individuals without confirmed nerve injury
CRPS I
What is the most common form of CRPS
Type I
CRPS I was previously called ?
Reflex sympathetic dystrophy syndrome
Type of CRPS in individuals with confirmed nerve injury
CRPS II
Type of CRPS that is more painful and difficult to control
Type II
CRPS II previously called ?
Causalgia
