Videos 1 Flashcards
Presentation: 32 y/o female G1P0 at 38 weeks gestation complains of bilateral hand numbness and pain for 2 weeks
Signs and symptoms: sharp pains in three fingers (thumb, index, middle), swelling, needles in tips of fingers, difficulty grasping, pain especially in the morning
Improvement after birth, but still some tingling
EMG: medial distal latency that was 0.3 ms slower than the ulnar distal latency; impression - abnormal study showing mild R median neuropathy at the wrist
Bilateral carpal tunnel syndrome in pregnancy
What is the nerve affected in carpal tunnel syndrome?
Median neuropathy
Most common symptoms of carpal tunnel syndrome?
Wrist, hand, and arm pain associated with paresthesias in the hand, typically worse at night and disturbs sleep, most frequently present in the thumb, index, middle, and lateral aspect of the ring finger
Diagnostic tests for carpal tunnel syndrome?
Tinel’s sign (elicit paresthesias by gentle tapping over the median nerve)
Phalen’s maneuver (elicit paresthesias by having patient hold wrist in flexed position)
Weakness of median innervated muscles, especially the abductor pollicis brevis
Atrophy of thenar eminence in more severe cases
Most useful tests: nerve conduction studies and EMG
Rx carpal tunnel syndrome?
Removal of provoking factors and a neutral wrist splint
Surgical decompression if unsuccessful
Role of steroids is controversial
Presentation: 65 y/o male with a history of carcinoid tumor with new onset L facial weakness
Signs and symptoms: left lip with pain and some paralysis, lip not functioning normally when eating and drinking, some discomfort over left mastoid, decreased L eye blinking speed, paralysis of L facial muscles, easier to raise L eyelid when held tightly closed, unable to whistle
Electrodiagnostic study: L facial motor nerve with markedly reduced amplitude and normal distal latency; R facial motor nerve study borderline low amplitude with normal distal latency -> abnormal study showing L facial axonal neruopathy
Peripheral facial nerve palsy (Bell’s palsy)
What does the facial nerve innervate?
Motor, sensory, and parasympathetics to the muscles of facial expression, mucous membranes of the oral and nasal cavities, salivary + lacrimal glands, taste sensation from anterior 2/3 tongue (via lingual nerve and chorda tympani)
Most common symptoms of facial nerve palsy?
Facial weakness
Aching of the ear or mastoid region may be present, possible numbness or unusual facial sensation, but sensory testing is normal
Taste may be impaired if lesion proximal to chorda tympani
Hyperacusis if proximal to nerve to stapedius
Bell’s palsy is common in what populations? What is a suspected inciting factor?
Adults, DM, pregnancy
HSV
Rx Bell’s palsy?
Short course steroids and oral antiviral agents
Artificial tears and ophthalmic ointment to prevent corneal exposure
Presentation: 60 y/o woman with new onset vertex headache radiating to the left orbital region, left auricular region, left retromandibular area, and left posterior neck; trouble chewing, swallowing, controlling tongue
Severe headache on top of head, radiating down left face and back of the neck, tongue felt very thick, protrusion of tongue demonstrates deviation to the L, felt like a dividing line existed in the middle of the tongue, difficulty speaking, chewing, swallowing
T2 MRI shows asymmetric high-signal intensity of L CN XII
Hypoglossal nerve palsy
Common signs and symptoms of hypoglossal nerve palsy?
Unilateral lesion -> trouble controlling the tongue when chewing, speaking, or swallowing, deviation of the tongue to the affected side, possible ipsilateral atrophy and fasciculations
Causes of hypoglossal nerve palsy?
Isolated palsy is uncommon; most common cause -> tumor; can also occur in MS, GBS, trauma, stroke, surgery, infection
Supranuclear lesions do not result in denervation atrophy
Causes of hypoglossal nerve palsy?
Isolated palsy is uncommon; most common cause -> tumor; can also occur in MS, GBS, trauma, stroke, surgery, infection
Supranuclear lesions do not result in denervation atrophy
Presentation: 53 y/o male complaining of L neck and shoulder pain and arm weakness
Severe pain in shoulder and neck, unable to raise L arm, loss of strength in L arm, hand muscles seem to be fine, more proximal muscle weakness
Wasting, atrophy of muscles in arm
Fasciculations present on flexor region of forearm
L scapula winging, decreased shoulder abduction, L arm drifting, decreased strength and muscle tone, finger strength seems intact, sharp pinprick intact, reflexes present
2 months later, pain gone, strength returning
4 months later, decreased winging, increased strength
EMG: L median and ulnar motor and sensory nerve conduction studies normal. Needle exam showed abnormal resting and voluntary activity in L pronator teres, bicep, and deltoid. Increased motor unit potential duration and a few large polyphasic potentials in each of these areas. L cervical parapsinal needle exam reveals normal resting activity -> abnormal study showing acute and chronic denervation in the C5-C6 myotomes without parapsinal abnormalities
Upper trunck brachial plexopathy (Parsonage-Turner syndrome)
Lack of cervical paraspinal abnormalities makes cervical radiculopathy less likely
The brachial plexus is formed from the ventral primary rami (spinal nerves or roots) of ___ through ___.
C5; T1
Note that a prefixed plexus (when C4 contributes a branch to the plexus) is seen in 2/3 of cases
The brachial plexus is divided into what 5 components?
Roots Trunks (upper, middle, lower) Divisions (anterior, posterior) Cords (lateral, posterior, medial) Branches
Typically, the brachial plexus is composed of ___ roots, ___ trunks, ___ divisions, and ___ cords.
5; 3; 6; 3
Brachial plexus injuries may be complete or incomplete. They may be pre-ganglionic or post-ganglionic. They can cause what symptoms?
Muscle weakness, nerve and shoulder pain, paresthesias or dysesthesias, absent muscle stretch reflexes, and sensory loss
Application of full pressure sensation to the thumb, middle finger, and little finger evaluates what nerves?
Thumb: C6 spinal nerve, median nerve, lateral cord
Middle: C7 spinal nerve, median nerve, lateral cord
Little: C8 spinal nerve, ulnar nerve, medial cord
Which is more prominent in plexopathy - motor or sensory changes?
Motor
What clinically relevant motor function should be tested in suspected plexopathy?
Shoulder abduction (C5)
Elbow flexion, forearm pronation/supination (C6)
Extensors of forearm, hand, fingers (C7)
Finger extensors, flexors, wrist flexors (C8)
Hand intrinsics (T1)
Causes of plexopathy?
High-energy trauma to the upper extremity and neck
Erb-Duchenne type (C5-C6, upper trunk) - traumatic separation fo the head and shoulder, birth injury, idiopathic brachial plexitis (Parsonage-Turner)
Characteristic features of Parsonage-Turner?
Intense cervical and shoulder pain
Shoulder girdle and upper extremity weakness and atrophy
Dx Parsonage-Turner
Electrophysiologic testing
MRI of the plexus (normal)
Causes of lower brachial plexopathies?
Trauma, especially traction in the abducted position
Malignancies (pancoast tumor)
Complication of CABG -> lower trunk or medial cord involvement
Presentation: 44 y/o female, progressive hand numbness and pain. Four years ago, she began to experience tingling in the medial aspect of her left hand. It progressed to involve her entire L hand and the fourth and fifth fingeres of her R hand. She also complained of electric shock-like pains down the medial aspect of both arms. Hot water made the symptoms worse. She had difficulty writing and holding objects. She can no longer exercise. The pain comes in waves that last approximately 15 minutes and then ease up. It is worse when she is hugged. No visual changes, double vision, weakness, dysarthria, vertigo, bowel/bladder issues
Pain radiates down through the arms and fingers when flexing or extending the neck
On exam, hyperreflexia of upper and lower extremities
Skin lesions on arms and leg, non-painful, present for at least 7 years
MRI spine: intramedullary enhancing mass with expansile surrounding edema from C3 to C7
MRI brain: no mass, enhancement, focal findings; cerebellar tonsils borderline low
CXR: bilateral hilar and R paratracheal LAD
Pathologic findings of skin biopsy
Subacute cervical myelopathy due to sarcoidosis
Radiologic DDx - intramedullary enhancing SC mass with surrounding edema
Ependymoma Demyelinating disease MS Mets Transverse myelitis
Rx sarcoidosis
Corticosteroids
Presentation: 48-year old F with bilateral lower extremity weakness and flexion spasms of both legs. Needs to catheterize every 2 hours
4 years ago, numbness of lower extremities began, preceded by low back pain, difficulty controlling bladder, bowel function normal
On exam: good UE strength, movement, LE hyperreflexic, pinprick sensation intact to level of umbilicus, dull sensation below umbilicus
Ischemic myelopathy (antiphospholipid antibody syndrome)
