Unit2_SpinalCord+Ojemann Lectures Flashcards
Immediate muscle weakness and hypotonia, hyporeflexia or areflexia (“Spinal Shock”)
Followed by spasticity and HYPERreflexia in days to weeks (including extensor plantar response: Babinski’s sign)
SPASTIC PARESIS
UMN or LMN?
UMN
Muscle weakness, hypotonia, hyporeflexia, areflexia are all immediate and long-lasting
FLACCID PARESIS
FASCICULATIONS
ATROPHY
UMN or LMN?
LMN
UMN or LMN?
SPASTIC PARESIS
UMN
UMN or LMN?
HYPERreflexia in days to weeks (including extensor plantar response: Babinski’s sign)
UMN
UMN or LMN?
Immediate muscle weakness and hypotonia, hyporeflexia or areflexia (“Spinal Shock”)
UMN
UMN or LMN?
Muscle weakness, hypotonia, hyporeflexia, areflexia are all immediate and long-lasting
LMN
UMN or LMN?
~w/ FASCICULATIONS
LMN
UMN or LMN?
~w/ ATROPHY
LMN
UMN or LMN?
~w/ FLACCID PARESIS
LMN
Hypoesthesia: ?
decreased sensation
Hyperesthesia: ?
excessive sensation
Anesthesia: ?
Loss of sensation
Paresthesia: ?
Dysesthesia: ?
Paresthesia: numbness, tingling, burning sensation
Dysesthesia same, but usually when this is more unpleasant
Paresis: ?
decreased strength
Plegia: ?
complete loss of strength
C5 is the _____ reflex
biceps
C6 is the _____ reflex
triceps
C7 is the _____ reflex
Biceps & Brchioradialis
What is the Motor function of C5?
Delts, INFRAspinatus, Biceps
What is the Motor function of C6?
Wrist Extensors, Biceps
What is the Motor function of C7?
Triceps
What is the sensory territory of C5?
shoulder, upper lateral arm
What is the sensory territory of C6?
1st & 2nd digits of hand
What is the sensory territory of C7?
3rd digit
What is the Motor function of L4?
Psoas, Quads
What is the Motor function of L5?
- Foot dorsiflexion
- big toe extension
- foot eversion & inversion.
What is the Motor function of S1?
Foot plantarflexion
What is the sensory territory of L4?
Knee, medial leg
What is the sensory territory of L5?
Dorsum of foot, great toe
What is the sensory territory of S1?
Lat foot, small tow, sole of foot
What is the L4 reflex?
Patellar
What is the L5 reflex?
NONE!
What is the S1 reflex?
Achilles
The _________ reflex elicited by drawing a line away from the umbilicus along the diagonals of the 4 abdominal quadrants. A normal reflex draws the umbilicus toward the direction of the line that is drawn.
abdominal
The _________ reflex elicited by drawing a line along the medial thigh and watching the movement of the scrotum in the male. A normal reflex results in elevation of the ipsilateral testis.
cremasteric
The ________ reflex elicited by gently stroking the perianal skin with a safety pin. It results in puckering of the rectal orifice owing to contraction of the corrugator-cutis-ani muscle.
anal wink
Clinical assessment of Reflexes:
0 = ? 1+ = ? 2+ = ? 3+ = ? 4+ = ? 5+ = ?
0 = Reflex is absent 1+ = trace 2+ = normal 3+ = brisk 4+ = nonsustained clonus (i.e., repetitive vibratory movements) 5+ = sustained clonus
Plantar Response is described as what? (3)
- Flexor
- Extensor (Babinski Sign)
- Ambivalent
Clinical Assesment of Strength:
0/5: ?
(0/5)
no contraction
Clinical Assesment of Strength:
1/5: ?
(1/5)
muscle flicker, but no movement
Clinical Assesment of Strength:
2/5: ?
(2/5)
movement possible, but not against gravity (test the joint in its horizontal plane)
Clinical Assesment of Strength:
3/5: ?
(3/5)
movement possible against gravity, but not against resistance by the examiner
Clinical Assesment of Strength:
4/5: ?
(4/5)
movement possible against some resistance by the examiner (sometimes subdivided further into 4–/5, 4/5, and 4+/5)
Clinical Assesment of Strength:
5/5: ?
(5/5)
normal strength
List some other additional sensory testing:
two-point discrimination
Double simultaneous stimulation (looking for extinction)
Testing higher order (cortical) sensory processing:
- Graphesthesia
- Stereognosis- ability to recognize based on: texture, size, temperature.
What is Cauda Equina Syndrome (ROOTS L1-S5)?
○ EARLY root pain radiating to legs ○ Leg weakness and decreased DTRs (LMN sign) ○ Patchy, ASYMMETRIC “saddle” ○ LATE bladder dysfunction ○ LATE bowel and sexual dysfunction
What is Conus Medullaris Syndrome (ROOTS L1-S5)?
S3-S5, tip of cord
○ Supplies bladder, rectum, and genitalia ○ LATE pain in thighs and buttocks ○ Pelvic floor muscle weakness ○ SYMMETRIC “saddle” anesthesia numbness ○ EARLY bladder dysfunction ○ EARLY bowel and sexual dysfunction
Thoracic dermatomes:
nipple line = ?
xypoid = ?
umbilicus = ?
nipple line=T4
xypoid=T6
umbilicus = T10
What is Radiculopathy:
Pain = shooting, burning, tingling, numbness
○ Radiates to dermatome or myotome.
○ Localization: determine which root of abnormal muscles and dermatomes have in common.
What shows up in the P.Exam of Radiculopathy?
LMN signs!
What are the common causes of Radiculopathy?
Common causes: compression by degenerative joint disease or herniated disc near intervertebral foramen
The Sx of Radiculopathy are Exacerbated by?
and relieved by?
○ Exacerbation by exam: neck flexion/extension/rotation, shoulder movements, cough, etc.
○ Relieving factors: rest, immobilization, graded therapy, NSAIDS +/- muscle relaxant.
pain syndrome arising from spinal cord is called __________ symptoms.
Lhermitte’s symptom:
In Lhermitte’s symptom, neck flexion results in what?
What what is it due to?
Neck flexion results in “electric shock” sensation down back and/or into arms
○ Due to posterior column disease
•
Spinal shock: ?
Spinal Shock = loss of all neurological activity below level of injury, including loss of motor, sensory, reflex, and autonomic function.
The loss of all neurological activity below level of injury, including loss of motor, sensory, reflex, and ANS function is known as what?
Spinal Shock.
Loss is BELOW level of injury!
hyperreflexia in upper extremity is known as ______ sign?
Hoffman’s sign
tapping medial aspect of adductor tendons near knee elicits scissoring of both legs is known as the ___________ response.
Cross ADDucter response.
What is Neurogenic Shock?
- Disruption of descending SNS outflow.
- No SNS response and unopposed Vagal tone.
What is Vagal tone?
- activity of the vagus nerve; which originates in the medulla oblongata of the brainstem.
- PNS branch of the ANS; homeostatically regulates the resting state of the majority of the body’s internal organ.
- vagal activity is continuous, chronic, and passive.
disease affecting nerve roots =?
Radiculopathy
Radiculopathy is do to?
○ Due to posterior/lateral displacement of nucleus pulposus outside → impinges on nerve root and stenosis/occludes the neural foramen → symptoms relative to that root.
○ Pain = shooting, burning, tingling, numbness.
Radiates to dermatome or myotome
On exam, is Radiculopathy ~w/ UMN or LMN?
LMN!
On exam, what are the two signs that are ~w/ Radiculopathy?
○ Spurling’s sign
○ Lasegue’s sign:
What is a straight leg raising test;
Sciatic nerve test - if sciatic nerve roots are under compression → shooting shock like sensation down legs called?
Lasegue’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.
This is called what sign?
Spurling’s sign
In Radiculopathy, what are exacerbating factors?
neck flexion/extension/rotation, shoulder movements, cough, etc.
Figure this out via P.Exam
In Radiculopathy, what are relieving factors?
rest, immobilization, graded therapy, NSAIDS +/- muscle relaxants
disease affecting spinal cord = ?
Myelopathy
Myelopathy:?
disease affecting spinal cord
Central displacement of nucleus pulposus of intervertebral disc out of annulus→ impinge spinal cord is the cause of what?
Myelopathy
What is the cause of Myelopathy?
Central displacement of nucleus pulposus of intervertebral disc out of annulus→ impinge spinal cord.
Lhermitte’s symptom ~w/ ?
“electric shock” down the back and/or into arms
What is Lhermitte’s symptom?
pain syndrome arising due to disease of spinal cord (posterior column)
pain syndrome arising due to disease of spinal cord is called what?
Lhermitte’s symptom
Neck flexion results in “electric shock” sensation down back and/or arms is ~w/ ?
Lhermitte’s symptom
Polyradiculopathy:?
impingement of collection of nerve roots within cauda equina (in lumbosacral spine below conus) → can cause problems with bowel/bladder function.
What is impingement of collection of nerve roots within cauda equina (in lumbosacral spine below conus) → can cause problems with bowel/bladder function called?
Polyradiculopathy
What is a physiologic disruption of all spinal cord function called?
Spinal shock
Spinal shock: ?
Spinal shock: physiologic disruption of all spinal cord function
What does a Bulbocavernosus reflex indicate?
Bulbocavernosus reflex indicates when spinal shock has resolved.
*If B.C. reflex is present and patient still is not moving/no sensation → anatomic transection of fibers.
What is a disruption of descending sympathetic outflow called?
Neurogenic shock
Neurogenic shock: ?
Neurogenic shock: disruption of descending sympathetic outflow.
○ No sympathetic response and unopposed vagal tone.
○ Cardiovascular instability
○ Treated with dopamine drip.
__________ lesions arise from outside cord.
Extramedullary
__________lesions: arise within cord
Intramedullary
The following describes what kind of lesion.
○ Early pain and UMN signs
○ Pain and temperature sensation evolves in ascending fashion (affects sacral, lumbar, then thoracic, etc.)
Extramedullary lesions: arise from outside cord
The following describes what kind of lesion.
○ Cause early bladder dysfunction with only late development of pain.
○ Loss of pain and temperature progresses in descending fashion (Cervical → thoracic early, then lumbar → sacral later)
Intramedullary lesions: arise within cord
________ sign = extension of big toe, fanning of other toes → HYPERREFLEXIA
Babinski
Babinski sign = extension of big toe, fanning of other toes → _____________
HYPERREFLEXIA
What response involves tapping medial aspect of adductor tendons near knee elicits scissoring of both legs.
Crossed adductor response: tapping medial aspect of adductor tendons near knee elicits scissoring of both legs
What are the 10 spinal cord lesions?
- Complete cord transection
- Central lesions
- Posterior column syndrome
- Combined anterior horn cell-pyramidal tract syndrome
- Brown-Sequard (hemi-section)
- Posteriolateral column syndrome
- Anterior Horn Cell syndrome
- Anterior Spinal Artery Occlusion
- Pyramidal Tract Syndrome
- Myelopathy w/ Radicuopathy
What are the features of Conus medullaris syndrome: S3-S5, tip of cord?
○ Supplies bladder, rectum, and genitalia ○ LATE pain in thighs and buttocks ○ Pelvic floor muscle weakness ○ SYMMETRIC “saddle” anesthesia numbness ○ EARLY bladder dysfunction ○ EARLY bowel and sexual dysfunction
What are the features of Cauda equina: ROOTS L1-S5 syndrome?
○ EARLY root pain radiating to legs ○ Leg weakness and decreased DTRs (LMN sign) ○ Patchy, ASYMMETRIC “saddle” ○ LATE bladder dysfunction ○ LATE bowel and sexual dysfunction
What is involved in the neural control of micturition?
○ Detrusor (smooth) muscle
○ Involuntary (smooth) sphincter
○ Skeletal muscle of pelvic floor
In the neural control of micturition, the Detrusor (smooth) muscle is activated by what?
○ Detrusor (smooth) muscle: activated by preganglionic parasympathetic outflow from S2-S4
In the neural control of micturition, the Involuntary (smooth) sphincter is controlled by what?
○ Involuntary (smooth) sphincter: controlled by sympathetic outflow, T10-L2
In the neural control of micturition, the Skeletal muscle of pelvic floor is controlled by what?
Skeletal muscle of pelvic floor: innervated by alpha motor neurons, S2-S4
What is involved in the higher order control of micturition?
○ Forebrain (medial frontal)
○ Pontine micturition center
In the higher order control of micturition, the forebrain (medial frontal) does what?
Forebrain (medial frontal):
voluntary inhibition of pontine center AND relaxation of voluntary sphincter
In the higher order control of micturition, the Pontine micturition center does what?
Pontine micturition center:
coordination of sympathetic and parasympathetic centers in spinal cord
When the bladder does not contract → overflow incontinence; this is called what?
Flaccid Bladder
What is injured in Flaccid Bladder?
Parasympathetic lower motor neuron injury, axon compression/disruption
Descending pathways cut or injured (BILATERALLY) → UMN injury; will result in what bladder issue?
Spastic Bladder
initial flaccidity of bladder, then spasticity
Urinary frequency and urgency ~w/ what bladder issue?
Spastic Bladder
Problems with coordination between sympathetic outflow (inhibited during voiding) and parasympathetic outflow (activated during voiding) is what bladder issue?
Spastic Bladder
Injury above S2-S4 (PNS of detrusor m.) –> what?
UMN or LMN
UMN
- ___ dermatome = nipple line
- ___ dermatome = xiphoid process
- ___ dermatome = umbilicus
- T4 dermatome = nipple line
- T6 dermatome = xiphoid process
- T10 dermatome = umbilicus
- T4 dermatome = ______________
- T6 dermatome = ______________
- T10 dermatome = ______________
- T4 dermatome = nipple line
- T6 dermatome = xiphoid process
- T10 dermatome = umbilicus
In the Neuro Exam, how do you test for the following?
Discriminative Touch →
Discriminative Touch → q tip testing light touch
In the Neuro Exam, how do you test for the following?
Vibration →
Vibration → use tuning fork to test vibration sense
In the Neuro Exam, how do you test for the following?
Joint position →
Joint position → toe down towards the floor or up to ceiling
In the Neuro Exam, how do you test for the following?
2-point discrimination →
2-point discrimination → paperclip, feel 1 point or two?
In the Neuro Exam, how do you test for the following?
Pain and temperature →
Pain and temperature → safety pins (sterilized) and cold handle of reflex hammer
