Neuro Medicine Lec 2

Front 1

Features of lesion of sensory system at different levels

Back 1

1.peripheral neuropathy (polyneuropathy)

2. Root affection (radiculopathy)

3.central spinal cord lesion

4. Brain stem

5. Thalamus

6. Sensory cerebral cortex (parietal lobe)

Front 2

Features of lesion of sensory system at peripheral neuropathy (polyneuropathy)

Back 2

Glove and stocking in distribution.

Character: numbness (sense of deadness) or tingling (sense of pin pricking)

Front 3

Features of lesion of sensory system at Root affection (radiculopathy) level

Back 3

Burning or scalding in character,

In the distribution of the affected dermatome

Front 4

Features of lesion of sensory system at central spinal cord lesion level

Back 4

Distribution: jacket sensory loss

Character: dissociated sensory loss (I.e., loss of pain and temperature sensation with preserved touch , in cauda equina syndrome s2-5 are commonly involved, the sensory loss over the buttock and back of the thigh I.e., saddle shaped area anesthesia)

Front 5

Features of lesion of sensory system at Brain stem level

Back 5

Crossed hemihypothesia as in lateral medullary syndrome (I.e., face on one side "trigeminal nerve" with the same side of lesion and the body on the opposite side of the face and also lesion)

Front 6

Features of lesion of sensory system at Thalamus

Back 6

Distribution is contralateral hemihyposthesia ,

Episodic paroxysms of contralateral pain, this is called "central pain or thalamic hyperpathia syndrome "

Front 7

Episodic paroxysms of contralateral pain, this is called

Back 7

"central pain or thalamic hyperpathia syndrome "

Front 8

Features of lesion of sensory system at Sensory cerebral cortex (parietal lobe) level

Back 8

Produces contralateral hemisensory loss:

1. Loss of joint sense, stereognosis, point Localization and two point discrimination

2. Pain and temperature sensation is not lost, but there's inability to assess differences in intensities

Front 9

UMNL pathway

Back 9

In the brain & spinal cord

Front 10

LMNL pathway

Back 10

In the peripheral nervous system

Front 11

UMNL Ms. Status

Back 11

Absent or trival disuse atrophy

Front 12

LMNL Ms. Status

Back 12

Wasting and atrophy

Front 13

UMNL Ms. Tone

Back 13

hypertonia

Front 14

UMNL Ms. Tone

Back 14

Hypotonia

Front 15

UMNL Ms. Power

Back 15

Selective pyramidal weakness :

Extensor of UL weaker than flexor of UL*Flexor of LL weaker than extensor of LL

Front 16

LMNL Ms. Power

Back 16

Distal weakness in PN and proximal in MS

Front 17

LMNL Ms. Power

Back 17

Distal weakness in PN and proximal in MS

-Proximal weakness in muscles as thigh and arm

Front 18

UMNL Deep reflex

Back 18

Exaggerate

Front 19

LMNL Deep reflex

Back 19

Diminished

Front 20

UMNL Superficial reflex

Back 20

Absent

Front 21

LMNL Superficial reflex

Back 21

Present

Front 22

UMNL Shock stage

Back 22

Present

Front 23

LMNL Shock stage

Back 23

Absent

Front 24

UMNL Vasomotor trophic changes

Back 24

Absent

Front 25

LMNL Vasomotor trophic changes

Back 25

Present:

Clod extreameBluish discolorationHairlessBrittle nails

Front 26

UMNL Neurophysiology

Back 26

Normal NCSNormal EMG ( may show diminished recruitment)

Front 27

LMNL Neurophysiology

Back 27

If PN: NCSIf MS: polyphasic

Front 28

Pseudobulbar Lesion

Back 28

Bilateral pyramidal "corticobulbar" tract

Front 29

Pseudobulbar Dysphagia

Back 29

Present

Front 30

Pseudobulbar Dys or anathesia

Back 30

Present

Front 31

Pseudobulbar Shocking, sneezing

Back 31

Present

Front 32

Pseudobulbar Sphincter

Back 32

Impaired

Front 33

Pseudobulbar Fasciculation

Back 33

Absent

Front 34

Pseudobulbar Tongue

Back 34

No atrophy, spastic

Front 35

Pseudobulbar Palatal, pharyngeal reflex

Back 35

Exaggerated

Front 36

Pseudobulbar Jaw jerk

Back 36

Exaggerated

Front 37

Pseudobulbar Emotional liability

Back 37

Exaggerated

Front 38

bulbar Lesion

Back 38

Motor cranial nerve nuclei

Front 39

bulbar Dysphagia

Back 39

Present

Front 40

bulbar Dys or anathesia

Back 40

Aphonia

Front 41

bulbar Shocking, sneezing

Back 41

Absent

Front 42

bulbar Sphincter

Back 42

Not affected

Front 43

bulbar Fasciculation

Back 43

Present

Front 44

bulbar Tongue

Back 44

Atrophy

Front 45

bulbar Palatal, pharyngeal reflex

Back 45

Absent

Front 46

bulbar Jaw jerk

Back 46

Absent

Front 47

bulbar Emotional liability

Back 47

Absent

Front 48

Motor system examination

Back 48

1) Posture

2) Unilateral pyramidal tract lesion cerebral or spinal

3) Bilateral pyramidal tract lesion cerebral or spinal

4) Extrapyramidal system

5) Myopathy -> lordotic posturing

6) Peripheral nerve

7) Myasthenia

Front 49

Posture:

Back 49

every lesion of nervous system leads to characteristic posture

Front 50

Unilateral pyramidal tract lesion cerebral or spinal

Back 50

 Unilateral flexion of the UL, wrist, MP, IP, dropped foot

Front 51

Bilateral pyramidal tract lesion cerebral or spinal

Back 51

 Scissoring of both LL (lower limbs)

Front 52

Extrapyramidal system

Back 52

 Dinner fork deformity -> chorea -> lesion in: caudateوال chorea دي عرفت انهاmovement involuntary dancing Flexed trunk posturing -> parkinsonism flexion of MP, extension of IP -> lesion substantia nigra Dystonic posturingبيكون واحد twisted عىل نفسه كده Athetoid posturing: Involuntary movement affects distal joint - slow twisting movement

Front 53

Myopathy ->

Back 53

lordotic posturing with Shoulder, pelvic girdle weakness, trunk muscle weakness ←

Front 54

Peripheral nerve

Back 54

 Dropped wrist in radial nerve lesion Ulnar claw hand -> common site of entrapment in guyon's tunnel Malunion of elbow fracture affect cubital tunnel Median claw hand -> wasting of first web space and medial three fingers Complete hand clawing Foot drop -> partial or complete, correctable or not

Front 55

Myopathy ->

Back 55

lordotic posturing

Front 56

Involuntary movements

Back 56

 All involuntary movements disappear during sleep

 All involuntary movements from diseases of Extrapyramidal system except fasiculation

 Seizures isn't an involuntary movement but it's cortical irritation phenomenon

Front 57

Types of involuntary movements:

Back 57

 Tremors: rhythmic regular alternating movements of the agonist and antagonist around joint Dystonia: torsion or slow twisting movements around an axis Chore: sudden jerky irregular distal movements

 Athetosis: slow twisting distal movement Ballismus: violent jerky irregular proximal movements

 Myoclonus: sudden jerky or shock like contraction

 Tics and habit spasm:

 Fasiculation: contractions of group of muscle fibers supplied by single degenerating AHC

Front 58

Muscle status

Back 58

 Examination of muscle status done by inspection for any wasting or hypertrophy

Front 59

Causes of wasting:

Back 59

a) Manifest wasting in lower motor neuron lesion (LMNL) Muscle -> proximal muscle wasting -> thigh, arm Peripheral nerve -> distal wasting, weakness, atrophy AHC -> patchy weaknessb) Mild disuse atrophy in UMNL

Front 60

Muscle power After examining Ms power against resistance we conclude one of three:

Back 60

1. Proximal weakness is more than distal weakness means Myopathy2. Distal weakness is more than proximal weakness means polyneuropathy3. Progravity is weak than antigravity muscles extensor of UL and flexors of LL meansselective pyramidal weakness

Front 61

Score 0 msc strength

Back 61

no movement

Front 62

Score 1 msc strength

Back 62

flicker contraction

Front 63

Score 2 msc strength

Back 63

movement with gravity eliminated

Front 64

Score 3 msc strength

Back 64

movement against gravity only

Front 65

Score 4 msc strength

Back 65

full movement against moderate resistance

Front 66

Score 5 msc strength

Back 66

full movement against maximum resistance

Front 67

Muscle tone

Back 67

Muscle tone based on the static component of the stretch reflex

Front 68

Muscle tone  Examined by:

Back 68

1. Palpation2. Complete passive flexion, extension around joint3. Shaking of distal joints

Front 69

Abnormalities of tone may be: 



Back 69

o Hypertonia

o Hypotonia

Front 70

o Hypotonia

Back 70

LMNL (MS, PN, root, AHC)  Plus:  C -> chorea  C -> Cerebellum  S -> shock stage of UMNL

Front 71

o Hypertonia

Back 71

Spasticity: clasp knife  Rigidity:  Cog wheel  Lead pipe

Front 72

Coordination

=Give a test for coordination and what's the type of lesion?

=Examined by:

Back 72

1. Finger to finger test2. Finger to nose with eye opened and eye closed3. Heel knee chain test4. Dysdiadokokinesia5. Rebound

Front 73

Definition of ataxia:

Back 73

lack of coordination

Front 74

Ataxia may be due to:

Back 74

1- Cerebellar ataxia:

2-Deep Sensory ataxia:

3- Mixed sensory and cerebellar:

Front 75

1- Cerebellar ataxia

Back 75

lack of coordination with eye opened

Front 76

2-Deep Sensory ataxia

Back 76

lack of coordination with eye closed

Front 77

Mixed sensory and cerebellar:

Back 77

lack of coordination with eye opened and closed

Front 78

Gait

Back 78

-Myopathy: waddling (with Shoulder, pelvic weakness)

-Peripheral nerve: high steppage gait(eg.drop foot)

- Deep sensory loss: stamping gait

-Unilateral pyramidal tract lesion cerebral or spinal: circumduction gait

- Bilateral pyramidal tract lesion cerebral or spinal: scissoring or spastic gait

-Extrapyramidal lesion: shuffling or festinating gait

-Cerebellum: ataxia or drunken gait

-Spastic ataxia: mixed bilateral pyramidal plus cerebellar lesion (with ataxia and scissoring)

Front 79

Stance

Back 79

-First noticed the stance of the patient on narrow or wide base

-Examined by asking the patient to stand with feet tightly close to each other

- Then ask the patient to close his eyes, while feet are firmly close to each other

-If the patient sways you said positive romberg test this finding means Impaired deep sensationر ل

Front 80

Deep reflexes (DR) based on?

Back 80

the dynamic component of stretch reflex

Front 81

Grading of deep reflexes:

Back 81

o Absent -> diminished -> present -> brisk

o Exaggerated without clonus -> exaggerated with clonus

Front 82

Causes of exaggerated DR:

Back 82

o Physiological (bilateral-symmetrically): 1. Thyrotoxicosis 2. Anxiety

o Pathological: UMNL

Front 83

Causes of absent or diminished DR:

Back 83

o Physiological 1. Infant before 1 year 2. Congenital absent DR

o pathological 1. LMNL 2. Shock stage of UMNL

Front 84

Superficial reflexes (SR) General speaking for any absent superficial reflex mean:

Back 84

1. Pyramidal tract lesion on side affected 2. Lesion in any component of reflex arc of examined refelx (rare)

Front 85

1) Plantar reflex:

Back 85

- Done by gentle firm scratch of outer border of sole by key or piece of tongue depressor but takecare of flexor or extensor withdrawal response.

- Segment: S1

- Normal response: plantar flexion of big toe and flexion and inversion of other toes- Abnormal response: Dorsi flexion of big toe and extension and Eversion of the other toes.Significant pyramidal tract lesion.

-Absent or unelicited: polyneuropathy or radiculopathy of segment S1

Front 86

2 ) Abdominal reflexes:

Back 86

-done by gentle scratch of from flank parallel to costal margin (upper abdominal) and parallel to groin (lower abdominal) 

-Segment: T7:12 (dorsal 7:12) 

-Normal response: brisk contraction of side examined 

- Abnormal response: absent contraction or easily fatigued (frequent scratch + fading of contraction till disappear -> significant pyramidal tract lesion)

Front 87

3) Cremasteric reflex:

Back 87

Scratch on upper inner aspect of the thigh 

-Segment: L1

Front 88

4) Anal reflex:

Back 88

 Segment: S5

Front 89

Bulbocavernous reflex:

Back 89

 Segment: S3,4,5

Front 90

superficial reflexes

Back 90

1) Plantar reflex:

2 ) Abdominal reflexes:

 3) Cremasteric reflex

4) Anal reflex:

5) Bulbocavernous reflex:

Front 91

Visceral reflexes

Back 91

1) Bladder: urgency, hesitancy

2) Rectal:Constipation, incontinence in case of diarrhea

3) Sexual: impotence

Front 92

Micturation abnormalities:

Back 92

1. Retention of urine: o Inability to pass or no urine flow

2. Urgency of micturation: o Inability to postpone the act of micturation

3. Hesitancy of micturation: o Difficulty in initiating the act of micturation

4. Precipitancy of micturation:o Inability to stop midway of micturation

Front 93

4. Precipitancy of micturation:

Back 93

o Inability to stop midway of micturation

Front 94

3. Hesitancy of micturation:

Back 94

o Difficulty in initiating the act of micturation

Front 95

2. Urgency of micturation:

Back 95

o Inability to postpone the act of micturation

Front 96

1. Retention of urine:

Back 96

o Inability to pass or no urine flow

Front 97

Pathological reflexes:

Back 97

1) Finger reflex 2) Hoffman's 3) Wartinberg's

Front 98

Palpation of Peripheral nerves:

Back 98

1) Common peroneal nerve

2) Ulnar nerve

Front 99

Myoneural Junction

Back 99

a) Fatigable weakness

b) Ptosis

c) No sensory C/O

d) No sphincter C/O

Front 100

Anterior horn cells

Back 100

-Patchy, muscle weakness 

-Flaccidity and profound weakness 

- Presence of fasciculation 

-No sensory C/O 

- No sphincter C/O 

-Acute e.g. Poliomyelitis 

- Chronic e.g. Motor neuron disease

Front 101

Lower motor neuron (MUSCULAR) causes of paraplegia

Back 101

- Bilateral and symmetricalweakness (proximal > distal)

- Bilateral and symmetricalwasting and / or hypertrophy

- No sensory C/O

-No sphincter C/O

Front 102

Lower motor neuron (Myoneural Junction) causes of paraplegia

Back 102

-Fatigable weakness

-Ptosis

-No sensory C/O

-No sphincter C/O

Front 103

Lower motor neuron (Peripheral nerve) causes of paraplegia

Back 103

-Bilateral and symmetrical weakness(distal > proximal)

-Bilateral and symmetrical glove andstocking hypothesia or anathesia

- No sphincter C/O

Front 104

Lower motor neuron ( Anterior horn cells) causes of paraplegia

Back 104

 -Patchy, muscle weakness

-Flaccidity and profound wasting

-Presence of fasciculation

-No sensory C/O

-No sphincter C/O

-Acute e.g. Poliomyelitis

-Chronic e.g. Motor neuron disease