Upper Limb

Question 1

Features of a UMN lesion

Answer 1

Tone - increased (spastic)
Power - reduced
Reflexes - brisk
Plantars - up
Coordination - down
Other - clonus

Question 2

Features of an extrapyramidal lesion

Answer 2

Tone - increased (rigid)
Power - normal
Reflexes - normal
Plantars - down
Coordination - reduced 
Other - resting tremor, bradykinesia, postural instability

Question 3

Features of a cerebellar lesion

Answer 3

Tone - reduced
Power - normal
Reflexes - normal
Plantars - down
Coordination - reduced +++
Other - intention tremor, nystagmus, cerebellar speech

Question 4

Core features Parkinsonism

Answer 4

TRAP

Tremor (resting)
Rigidity (cogwheeling)
Akinesia (Bradykinesia)
Postural instability (hesitancy, shuffling gait, loss of arm swing)

Question 5

Causes of Parkinsonism

Answer 5

Idiopathic Parkinson’s disease

Drug induced Parkinsonism (Lithium, antipsychotics, metoclopramide)

Atherosclerotic pseudoparkinsonism (legs only, less tremor)

Dementia pugilistica (Parkinsonism secondary to repeated head trauma eg boxing)

Question 6

Conditions with similar presentation to Parkinsonism

Answer 6

Benign essential tremor

Wilson’s disease

Question 7

Treatment for Parkinson’s disease

Answer 7

L-Dopa
Dopamine agonists
Anticholinergics
COMT inhibitors
MAO inhibitors
Glutamate agonists

Question 8

Ddx tremor

Answer 8

Resting - Parkinsonism

Flapping - hepatic failure, respiratory failure (CO2 retention), renal failure

Intention - cerebellar lesion

Postural - benign essential tremor, physiological tremor (fever, anxiety, medication)

Question 9

Outline the sensory modalities carried in the spinal cord i.e. Which tract for what?

Answer 9

Spinothalamic - pain, temperature & crude touch

Dorsal columns - vibration, joint position sense, fine touch

Question 10

Ddx spinal cord pathology

Answer 10

Spinothalamic - Syringomyelia , Anterior spinal artery occlusion

Dorsal column - Tabes dorsalis (syphilis)

Any - MS

Question 11

Describe the presentation of syringomyelia

Answer 11

Spinothalamic fibres principally affected

Loss of pain and temp in cape-like distribution over arms, shoulders and upper body

LMN in upper limbs, spastic parapesis of lower limbs

Dorsal column signs develop as canal expands

Question 12

Describe Erb’s palsy

Answer 12

Upper brachial plexus (C5-C7) - shoulder dystocia during birth

Sensory loss down lateral arm

Waiter’s tip position - shoulder ADducted, arm internally rotated, forearm pronated

Question 13

Describe the cause and presentation of Klumpke’s palsy

Answer 13

Lower brachial plexus (C8- T1), excessive arm traction

Sensory loss in medial forearm and hand
Complete claw hand
Wasting of small muscles in hand

Horner’s syndrome may co-exist

Question 14

Concluding remarks

Answer 14

I would like to complete a full neurological examination

Investigations: nerve conduction studies, imaging (CT, MRI)

Question 15

Features of a LMN lesion

Answer 15

Tone - normal or reduced 
Power - reduced
Reflexes - reduced
Plantars - down
Coordination - normal
Other - wasting & fasciculation