Unit2_NTK Flashcards
LA: Topical:
○ tetracaine, lidocaine, cocaine
○ Superficial anesthesia
○ Disadvantage = considerable absorption into circulation
LA • Infiltration/Injection into tissue:
lidocaine, procaine, bupivacaine
○ Superficial anesthesia, function of underlying organ unaffected
○ Disadvantage: significant absorption into circulation
LA • Nerve block:
injection of high concentration near peripheral nerve/nerve plexus
○ Lidocaine (2-4 hours), bupivacaine (longer duration)
○ Anesthetize larger body regions
LA • Intravenous regional anesthesia (Bier’s Block):
tourniquet applied, inject anesthetic via catheter for limb anesthesia.
LA • Spinal anesthesia:
inject into CSF
○ Anesthetize large body areas with low plasma level of drug.
LA • Epidural anesthesia:
inject just outside dura-enclosed spinal canal
○ Allows repeated/continuous anesthetic application
Higher plasma level of anesthetic
How are both types of LA excreted?
Via kidneys
Which type of LA is Hydrolyzed in plasma by an esterase (pseudocholinesterase), also hydrolyzed in liver?
ESTERS:
think PLASMA esterases
Which LA typically has a longer DOA?
amides typically have longer duration of action
wrt, Giant cell arthritis, what are the Sx:
○ Symptoms: jaw claudication, temporal artery region scalp tenderness, joint pain, constitutional symptoms (fever, malaise, weight loss)
○ Elevated ESR and CRP
○ Must biopsy temporal artery to confirm dx
how do you Tx Giant cell arthritis?
TX = steroids
What Diz has the following:
○ Elevated ICP ○ Normal CSF and Neuro Exam except for: ○ Papilledema ○ 6th Nerve Palsies ○ Normal neuroimaging and no other Etiology. ○ Obese Women
Pseudotumor Cerebri
Complete Cord Transection:
a. Tracts: all ascending and descending
b. Deficit: sensory + motor levels below lesions, may also have root → Spinal shock, followed by UMN signs
Central Lesions:
a. EX) syringomyelia (fluid filled cavity in cord)
b. Tracts: initially involve crossing spinothalamic tract
c. Deficit: pain/temp loss at level of lesion with sparing of position sensation → “Cape-like” distribution if in C-spine
Posterior Column Syndrome
a. EX) Tabes dorsalis (neurosyphilis)
b. Tracts: Dorsal (posterior column)
c. Deficit: bilateral loss of position and vibration sensation
Deficit in Posterior Column Syndrome?
Deficit: bilateral loss of position and vibration sensation
Tracts of Posterior Column Syndrome?
Dorsal (posterior column)
Tracts in Complete Cord Transection?
Tracts: all ascending and descending
Tracts in Central Lesions?
Tracts: initially involve crossing spinothalamic tract
Deficit in Complete Cord Transection?
sensory + motor levels below lesions, may also have root
→ Spinal shock, followed by UMN signs
Deficit in Central Lesions?
Deficit: pain/temp loss at level of lesion with sparing of position sensation → “Cape-like” distribution if in C-spine
Combined anterior horn cell-pyramidal tract syndrome:
a. EX) ALS
b. Tracts: corticospinal and LMN cells in cord
c. Deficit: loss of bilateral strength. Fasciculations, atrophy, decreased or increased deep-tendon reflexes, normal sensation.
Tracts in Combined anterior horn cell-pyramidal tract syndrome?
Tracts: corticospinal and LMN cells in cord
Deficit in Combined anterior horn cell-pyramidal tract syndrome?
Deficit: loss of bilateral strength. Fasciculations, atrophy, decreased or increased deep-tendon reflexes, normal sensation.
Brown-Sequard (hemi-section):
a. EX) Compression by herniated discs, tumor, extramedullary abscess, etc.
b. Tracts: crossed spinothalamic, uncrossed dorsal column, crossed corticospinal
c. Deficit: Below lesion, loss of: contralateral pain/temp, ipsilateral, position and strength
Tracts in Brown-Sequard (hemi-section)?
Tracts: crossed spinothalamic, uncrossed dorsal column, crossed corticospinal.
Deficits in Brown-Sequard (hemi-section)?
Deficit: Below lesion, loss of: contralateral pain/temp, ipsilateral, position and strength.
Posterolateral column syndrome: ?
a. EX) B12 deficiency
b. Tracts: dorsal column, corticospinal tract
c Deficit: bilateral loss of position, vibration, strength
Tracts in Posterolateral column syndrome?
Tracts: dorsal column, corticospinal tract
Deficits in Posterolateral column syndrome?
Deficit: bilateral loss of position, vibration, strength
Anterior Horn Cell Syndrome:
a. EX) spinal muscular atrophy, poliovirus
b. Tract: none - lower motor neurons only
c. Deficit: bilateral loss of strength
i. Fasciculations, decreased tone, decreased deep-tendon-reflexes
Spares sensory tracts and bladder functions
Tracts in Anterior Horn Cell Syndrome?
Tract: none - lower motor neurons only
Deficits in Anterior Horn Cell Syndrome?
Deficit: bilateral loss of strength
i. Fasciculations, decreased tone, decreased deep-tendon-reflexes
Spares sensory tracts and bladder functions
Anterior Spinal Artery Occlusion:?
a. EX) Anterior spinal artery occlusion
b. Tracts: spinothalamic and corticospinal tract
c. Deficit: bilateral loss of strength, pain/temp.
Spare position sense
Tracts in Anterior Spinal Artery Occlusion?
Tracts: spinothalamic and corticospinal tract
Deficits in Anterior Spinal Artery Occlusion?
Deficit: bilateral loss of strength, pain/temp.
Spare position sense
Pyramidal Tract Syndrome: ?
a. EX) Primary lateral sclerosis
b. Tract: corticospinal tract
c. Deficit: bilateral UMN weakness with spastic gait
- Increased deep-tendon-reflexes
- Complete sparing of all sensory tracts and bladder function.
Tracts in Pyramidal Tract Syndrome?
Tract: corticospinal tract
Deficits in Pyramidal Tract Syndrome?
Deficit: bilateral UMN weakness with spastic gait
- Increased deep-tendon-reflexes - Complete sparing of all sensory tracts and bladder function.
Myelopathy with Radiculopathy: ?
a. Tracts: any or all 3 tracts
b. Deficit: bilateral UMN syndrome with spastic gait
i. Increased DTRs + ipsilateral or contralateral root signs
Possible bladder dysfunction
Tracts in Myelopathy with Radiculopathy?
Tracts: any or all 3 tracts
Deficits in Myelopathy with Radiculopathy?
Deficit: bilateral UMN syndrome with spastic gait
i. Increased DTRs + ipsilateral or contralateral root signs
Possible bladder dysfunction
Detrusor (smooth) muscle: activated by preganglionic parasympathetic outflow from _______
Detrusor (smooth) muscle: activated by preganglionic parasympathetic outflow from S2-S4
_________ muscle: activated by preganglionic parasympathetic outflow from S2-S4
Detrusor (smooth) muscle: activated by preganglionic parasympathetic outflow from S2-S4
Involuntary (smooth) sphincter: controlled by sympathetic outflow, in _________
Involuntary (smooth) sphincter: controlled by sympathetic outflow, T10-L2
____________________ : controlled by sympathetic outflow, T10-L2
Involuntary (smooth) sphincter
Involuntary (smooth) sphincter: controlled by _____________ outflow, T10-L2
sympathetic outflow
___________ of pelvic floor: innervated by alpha motor neurons, S2-S4
Skeletal muscle
Skeletal muscle of pelvic floor: innervated by ______ ______ neurons, S2-S4
Skeletal muscle of pelvic floor: innervated by alpha motor neurons, S2-S4
Skeletal muscle of pelvic floor: innervated by alpha motor neurons, __-__?
Skeletal muscle of pelvic floor: innervated by alpha motor neurons, S2-S4
• ____________Bladder: bladder does not contract → overflow incontinence.
Parasympathetic lower motor neuron injury, axon compression/disruption
Flaccid
Flaccid Bladder: ?
bladder does not contract → overflow incontinence
Parasympathetic lower motor neuron injury, axon compression/disruption
• Spastic Bladder: “
Spastic Bladder:
○ Descending pathways cut or injured (BILATERALLY) → UMN injury = initial flaccidity of bladder, then spasticity
○ Problems with coordination between sympathetic outflow (inhibited during voiding) and parasympathetic outflow (activated during voiding)
○ Urinary frequency and urgency
Injury above S2-S4 (PNS of detrusor m.) –> what Sx?
UMN Sx
○ Spurling’s sign: ?
foraminal compression test.
Turn head towards a narrowed neural foramen → tight foramen can cause acute pinching of nerve root → pain radiates out with nerve root into arms
Lasegue’s sign: ?
○ Lasegue’s sign: straight leg raising test
Sciatic nerve test - if sciatic nerve roots are under compression → shooting shock like sensation down legs
straight leg raising test = __________ sign?
Lasegue’s sign
Sciatic nerve test = _________ sign?
Lasegue’s sign
foraminal compression test = ____________ sign?
Spurling’s sign
Turn head towards a narrowed neural foramen → is a test for what sign?
Spurling’s sign
Lhermitte’s symptom: ?
pain syndrome arising due to disease of spinal cord
Neck flexion results in “electric shock” sensation down back and/or arms
pain syndrome arising due to disease of spinal cord.
Neck flexion results in “electric shock” sensation down back and/or arms
IS CALLED WHAT?
Lhermitte’s symptom:
Neck flexion results in “electric shock” sensation down back and/or arms is a sign of what syndrome.
Lhermitte’s symptom
__________ reflex indicates when spinal shock has resolved.
Bulbocavernosus reflex
If BC reflex is present and patient still is not moving/no sensation → anatomic transection of fibers
What are the UMN signs?
Plantar response: normal = flexion of toes
□ Babinski sign = extension of big toe, fanning of other toes → HYPERREFLEXIA
Hoffman’s sign = hyperreflexia in upper extremity.
Crossed adductor response: tapping medial aspect of adductor tendons near knee elicits scissoring of both legs
hyperreflexia ~ with _____ motor neuron
Upper motor neuron
hyperreflexia in upper extremity = ____________sign?
Hoffman’s sign = hyperreflexia in upper extremity.
tapping medial aspect of adductor tendons near knee elicits scissoring of both legs = _____________ sign.
Crossed adductor response: tapping medial aspect of adductor tendons near knee elicits scissoring of both legs
C-fibers: ?
small, unmyelinated axons, 1 um in diameter, slow conduction velocity. Warm temperature, burning pain, itch, crude touch
C-Fiber detect ?
warm temperature, burning pain, itch, crude touch
Alpha, Alpha → most rapidly conducting, largest diameter.
What is: □ Ia → ____________
□ Ib → ____________
Ia → muscle spindle afferent
Ib → tendon organ afferent
What is common to all Alpha Fibers?
All Alpha FIbers are myelinated.
Alpha-Beta → slower and smaller diameter than Aa, but still fast detect what?
Mechanoreceptors of skin, secondary muscle spindle afferents
Alpha-Delta → slower and smaller diameter than AB.
Detect what?
Sharp pain, cool temp, EXTREME hot Temps.
___________ System: ascending pathway for pain and temperature information, axons of dorsal horn second order neurons that cross midline and ascend anterolaterally
Anterolateral
_____________ tract: pain pathway to thalamus
Spinothalamic Tract.
□ Projects to nuclei of ventrobasal thalamus (includes VPL)
□ Processes information related to localization of pain
□ Projects to somatosensory cortex
___________ tract: pain pathway that leads to forebrain arousal and elicits emotional/behavioral responses
Spinoreticular Tract.
Connects to limbic system
Terminates in pons and medulla
______________ tract: projects to midbrain periaqueductal gray region (PAG).
Spinomesencephalic tract:
descending control of pain.
First pain: __ fibers → detect tolerable, localized, “pricking pain”
Ad fibers.
Faster conduction velocity than C fibers
Smaller receptive field = better localized spatial discrimination
Second pain: __ fibers → intolerable, diffusely localized, “burning” pain
C-fibers.
Slower conduction velocity than Ad fibers
Larger receptive field = dull, aching, poorly localized pain
First pain: Ad fibers → detect tolerable, localized, “_________ pain”
“pricking pain”
Second pain: C fibers → intolerable, diffusely localized, “______” pain
burning
____?____: decrease threshold for activation of nociceptors
• Sensitizers: decrease threshold for activation of nociceptors ○ Prostaglandin ○ Substance P ○ ATP ○ Acetylcholine ○ Serotonin (5-HT)
___?___: lead to direct activation of nociceptors
Activators: lead to direct activation of nociceptors
○ Bradykinin → Ad and C fiber activator; Also increases synthesis of prostaglandins (Sensitizer).
○ Potassium
○ Acid
○ Serotonin (5-HT)
Burning pain = _fiber?
C-Fiber
- __1__ receptor → rapid synaptic response
* __2__ receptor → slower excitatory potential
- AMPA
2. NMDA
Substance P: Released by C fibers in response to Neurokinin 1 receptor (NK-1)repetitive stimulation in CNS at site of first synapse → binds _________ receptor → close K+ channel, depolarization.
Neurokinin 1 receptor (NK-1)
__________: Released by C fibers in response to repetitive stimulation in CNS at site of first synapse → binds Neurokinin 1 receptor (NK-1) → close K+ channel, depolarization.
Substance P (sensitizer)
Substance P: Released by __1__ fibers in response to repetitive stimulation in CNS at site of first synapse → binds Neurokinin 1 receptor (NK-1) → __2__ K+ channel, depolarization.
- C-Fibers
3. closes K+ ch.
_____?______ in midbrain → analgesia (pain sensation attenuated) while touch, pressure and temperature sensation persists
PAG stimulation
PAG stimulation in midbrain → ___?___ (pain sensation attenuated) while touch, pressure and temperature sensation persists
analgesia
What inhibits secondary neurons in the spinal cord to by exciting INTERNEURONS to secrete enkephalin and results in PRE-synaptic Inhibition?
Serotonin
Describe mechanisms underlying neuropathic pain.
- Peripheral mechanism: ?
- Central Mechanism: ?
- Peripheral mechanism = sodium channels
* Central Mechanism = GABA content and receptors, sprouting and rewiring, glia and immune system