Chapter 9 - Clinical Neuro PDF

Major Plexuses and Peripheral Nerves Blumenfeld Chapter 9  Leson Spiral cord My leopathey...

Major Plexuses and Peripheral Nerves Blumenfeld Chapter 9  Leson Spiral cord My leopathey : in 11 "Roots-radicalopthy 11 "T/D/C : plexopathy Terminal branches : neuropathy Brachial Plexus ↓ TR Cords are named D Be in relation to the axillary artery ↑ I https://www.semanticscholar.org/paper/Surgical-Anatomy-of-the-Supraclavicular-Brachial-Leung-Zlotolow/e7a49e70cbb36a4869c7eb7b088d91cbf7baaf06/figure/0 https://www.brainkart.com/article/Lower-Extremity-Peripheral-Nerve-Blocks--Lumbar---Sacral-Plexus-Anatomy_27241/  Rad - my plex 6 neuro Brachial Plexus (Practice) 14U M R men https://atanatomy.weebly.com/iii17.html  Brachial Plexus The brachial plexus is formed by nerve roots arising from the cervical enlargement - at C5, C6, C7, C8, and - T1. Provides major sensory and motor innervation for the upper extremities. Blumenfeld, Hal Neuroanatomy through Clinical Cases  Brachial Plexus The brachial plexus is so clinically important this it is worth committing the structure to memory. It is important to know the muscles innervated by each of the nerve branches. Parts of the brachial plexus: Roots (Real) Trucks (Texans) Divisions (Drink) Google Images Cords (Cold) Mnemonics Branches (Beer) Posterior Cord Branches Lateral Cord Branches Medial Cord Branches STAR LLM(Lucy Loves Muscle) MMMUM (Most Medical 5 Most Important Braches: Men Use Morphine) 1. Radial 2. Median Subscapularis Lateral Pectoral per major Medial Pectoral Both peas - - 3. Ulnar Thoracodorsal - Lats Lateral Root of Medial Brachial Cutaneous median Nerve mediae ~ Medial Antebrachial Cutaneous 4. Musculocutaneous Axially - Delts Musculocutaneous & Medial root of median nerve Ulnar 5. Axially Radial post -. = Extensors ↓ ↓ d Musculocutaneous (BBC): Biceps, Brachialis, Coracobrachialis Cutaneous Nerve Branches Blumenfeld Hal Neuroanatomy Through Clinical Cases Five Important Nerves in the Arm 3 Nerves Acting on the Thumb O A - -... Mnemonic (RUM) - Radial/Ulnar/Median - G Radial - Abduction Abductor pollicis longus (Radial Nerve) Ulnar - Adduction Adductor pollicis (Ulnar Nerve) Median - Flexion /opposition Flexor pollicis longus and superficial head of the flexor pollicis brevis (Median) Abductor pollicis brevis abducts the thumb perpendicular to the plane of the palm. (Median)  Intrinsic and Extrinsic Hand Muscles Intrinsic Muscles 1. Thenar Eminence 2. Hypothenar Eminence 3. Interossei 4. Lumbricals Intrinsic Hand Muscles are all innervated by the Ulnar Nerve except for LOAF (Lumbricals 1 + 2, Opponens pollicis, Abductor pollicis brevis, 6 > NoTimermented by UIMAR Flexor pollicis brevis – superficial head) - All innervated by the median nerve and supplied by C8 and T1. Finger flexors should be tested at the DIP joint. (Flexor digitorum) Finger extension (Radial + C7) should be tested at the MCP joint.s Google Images - The lumbricals are primarily responsible for extension at PIP - and DIP joints median nerve (2nd 23rd digets) Palmar Interossei Adduct the Fingers - - Dorsal Interossei Abduct the Fingers y  Pathology Common Plexus and Nerve Syndromes y https://jaredleemd.com/blog/2020/03/26/cubital-tunnel-release/ Erb-Duchenne Palsy (Upper Trunk Palsy) Damage to upper trunk of the brachial plexus causing loss of function of C5/C6 innervated muscles, resulting in prominent weakness of the deltoid, biceps, infraspinatus and wrist extensors. The arm assumes a "waiter's tip" position (int. Rot of arm with flexed wrist. Differentials: C5/C6 radiculopathies. Common causes include:  Separation of the shoulder and the head  Lateral Whiplash  Traction on an infant's shoulder during a difficult delivery  Motorcycle accidents LMNL ↳ extensors to not oppose the flexors causing constant state of flexion putting the arm in a https://slideplayer.com/slide/3317568/  oknuckles Klumpke's Palsy - (Lower Trunk Injury) Damage to the lower trunk of the brachial plexus C8/T1 Symptoms: Gulner nerve ↓ J 1. Hand a finger weakness j T 2. Atrophy of hypothenar muscles 3. Sensory loss on the ulnar aspect of the hand and forearm. - medial> 4. If T1 is affected proximal to the sympathetic trunk, frected side droopy eye lid constrited pupli sweating In on a Horner's Syndrome may be present. - > , , atosis myosis anhydrosis Differentials: Ulnar neuropathy or C8/T1 Radiculopathies Causes: Grabbing a branch during a fall from a tree Thoracic Outlet Syndrome (TOS) https://www.kenhub.com/en/library/anatomy/upper-and-lower-brachial-plexus-injury Pancoast Tumor (Apical Lung Tumor)  Thoracic Outlet Syndrome The lower brachial plexus is compressed (C8-T1) due to: 1. Scalene muscles 2. Cervical rib (elongated C7) 3. Costoclavicular Space (clavicle and 1st rib) 4. Pectoralis minor. Symptoms: 1. Numbness and tingling in the arm (uhorside 2. Classically on inside of the arm down to pinky and ring finger 3. Made worse with overhead activity Management: Generally, conservative with an approach toward postural correction, stretching tight muscles, strengthening weak muscles. M/c neurogenic (brachal plexus : https://www.jvascsurg.org/article/S0741-5214(16)30191-4/fulltext Pancoast's Syndrome (Apical Lung Tumor) Tumor extends to the lower brachial plexus. lid jeye Possible Horner's Syndrome (Ptosis, Miosis, Anhidrosis). Gpupil Lodscreeting effected on side Possible recurrent laryngeal nerve involvement, producing hoarseness. https://step1.medbullets.com/oncology/117036/pancoast-tumor  Brachial Plexitis (Brachial Neuritis) Unknown cause, possible inflammatory. Burning shoulder or lateral neck pain followed by weakness of muscles innervated by the brachial plexus. Most patients recover within 6-12 weeks. https://www.epainassist.com/sports-injuries/upper-back-and-neck-injuries/brachial-neuritis-or-neuralgic-amyotrophy Axillary Neuropathy , minor Dislocation or fracture of the proximal Delts humerus can compress the axillary nerve causing deltoid weakness and numbness in the shoulder. ↑ DDX: C5 radiculopathy. Use biceps to differentiate ↳ musculocutaneous n. https://teachmeanatomy.info/upper-limb/nerves/axillary-nerve/ gwrist drop Radial Neuropathy 1. Crutch Palsy - Compression in the axilla by improper crutch use 2. Saturday Night Palsy - Arm slung over a park bench 3. Spiral Groove - Fracture of Proximal Humerus 4. Radial Tunnel Syndrome 5. Posterior Interosseous Nerve PIN – Purely motor branch Symptoms: 1. * Wrist Drop * 2. Weakness of all extensors of the arm, hand, and fingers. Triceps involved 3. Weakness of forearm supinator and sensory loss in the radial nerve distribution. - Dorsal web of the hand 4. Triceps may be spared depending on location of lesion Triaps are spared https://www.verywellhealth.com/radial-nerve-injury-2488802 G Below Axilla Cheiralgia Paresthetica (Handcuff Neuropathy) Compression of the superficial radial nerve. Tight wrist bands or handcuffs. Causing isolated sensory loss in the dorsal lateral (Dorsal Web). https://aneskey.com/cheiralgia-paresthetica-handcuff-neuropathy/  Carpal Tunnel Syndrome (Median Neuropathy) Compression of the median nerve as it passes together with the tendons of the hand under the flexor retinaculum Symptoms: # Initially, nocturnal paresthesia in the fingertips of 1st, 2nd, and 3rd digits. Sensory loss in the first, second, and third digits, as well as prominent paresthesia. D Most bothersome at night and can sometimes be relieved with the flick sign. Thenar sparing due to branch off. Most seen in women over 30, repetitive stress injuries, and inflammation at the wrist Other common causes include: 1. Pregnancy 2. Oral Contraceptives 3. Hypothyroidism 4. Arthritis (RA) 5. Diabetes Diagnosis Signs + Symptoms * manual & Best MMT for suspected carpal tunnel syndrome = Abductor pollicis brevis which abducts the thumb musch PERPENDICULAR to the plane of the palm. Thumb flexion and opposition may also be weak. Test Tinel's Sign/ Phalen's sign NCV/EMG Management surate Manipulation Radio/ulnar - articulation Removable wrist split at night Steroids Surgical decompression https://www.medicinenet.com/carpal_tunnel_syndrome/article.htm Ulnar Neuropathy "The Funny Bone" Cubital tunnel entrapment usually due to resting the elbows 8 on a hard surface or trauma. Findings include: 1. Weakness of wrist flexion and adduction, finger adduction and abduction, and flexion of the 4th and 5th digits 2. Sensory loss and paresthesia along the ulnar distribution DDX: C8 and T1 radiculopathy, Pancoast Tumor, TOS https://precisionemg.com/cubital-tunnel-syndrome-test/ OR Tunnel of Guyon as it passes over the hamate bone can happen from cycling and results in just weakness of abduction and adduction of fingers without sensory loss. 1 ↑ Funny bone" Lumbosacral Plexus Blumenfeld Hal Neuroanatomy Through Clinical Cases  Lumbosacral Plexus Quiz (Know Nerves + Innervations)  ↳ Y The hamstrings (semitendinosus, 6 Important semimembranosus, and biceps femoris) are innervated by the Nerves in the sciatic nerve before it branches to the tibial and common Leg peroneal. The tibial and Common Peroneal are the 2 most important branches of the sciatic nerve. The common peroneal divides into the superficial and deep branches Blumenfeld Hal Neuroanatomy Through Clinical Cases Sciatic Neuropathy Examination: 1. Weakness of all foot/ankle muscles and of knee flexion. whamstrings 2. Loss of achilles tendon reflex. 3. Sensory loss in the foot and lateral leg below the knee. roots verve Most commonly from sciatic radiculopathy from disc material or osteophytes. 2nd most common is piriformis syndrome. "Sciatica": Vague term that refers to all disorders causing painful paresthesia in a sciatic distribution. https://tacomachiropracticcenter.com/blog/177501-sciatica-back-pain-and-leg-pain  Foot drop - Common Peroneal Nerve Palsy Compression of the common peroneal nerve as it passes around the fibular head. Symptoms Include: 1. Foot Drop # 2. Weakness of foot dorsiflexion and eversion 3. Sensory loss over the dorsolateral foot and shin Causes include: 1. Crossing Legs (Slimmer's Palsy) - Lat /Ned Kee. injury 2. Trauma (Stretch injury or forcible foot inversion) 3. Tight Stockings H. Future Management: Most cases improve spontaneously when the mechanical cause is removed. Foot brace may help with the foot drop significantly. DDX: L5 Radiculopathy https://www.semanticscholar.org/paper/Explaining-peroneal-neuropathy-after-ankle-sprain-Hanneur-Amrami/020740169c33b8a3e1507830269140032eb2e925  belt sensory Loss - Tight a Meralgia Paresthetica only Entrapment of the lateral femoral cutaneous nerve (L2/L3). Entrapment at inguinal ligament. Paresthesia (burning) of the lateral thigh. Examination: Loss of sensation in the lateral thigh No motor or reflex changes. Common causes: Obesity, pregnancy, weight loss, or heavy equipment belts. Symptoms may be worse after prolonged walking, standing, or siting. Management: Avoidance of mechanical stress. https://roberthowells.com.au/conditions-and-treatment/meralgia-paraesthetica/  mabs 2 No ↑ Mortons2 =mass in the Morton's Neuroma Nerve * Metatarsalgia Guo ( Tight fitting shoes can compress the digital nerves, especially the 3rd and 4th toes. massi Usually caused by running or high heels. Morton's neuroma may feel as if you are standing on a pebble in your shoe or on a fold in your sock. Distal Symmetrical Polyneuropathies Something in our to es of both sides & hitting multiple Nerves  must hal Diabetes Diabetic Neuropathy Symptoms:  Numbness, tingling, and pain that starts in the toes and ascends (stocking glove)  Affects CN II, VI, III, and IV (in order of most common) LRG 504 Allels  Decreased visual acuity  Diplopia - > Double Vision https://www.medicalnewstoday.com/articles/245310 http://syllabus.cwru.edu/YearThree/neuroscience/NeurLrngObjectives/PN.htm Starts in to es G moves ↑ Legs to knes to hands thes goes Alcoholic  Present in 13 to 66% of chronic alcoholics (maybe) ? Polyneuropathy  Due to B1 (Thiamine) deficiency and/or toxic effects of ethanol  Pain and weakness in the distal parts of lower extremity No fix/resolve https://www.northpointrecovery.com/blog/alcoholic-neuropathy-hidden-alcoholism-effect-can-last-lifetime/  Viral &motor los -post. ↳ d Reflexes Guillain-Barre Syndrome ↑ Post viral infection – Immune- mediated ascending polyneuropathy. to weeks - Days &Rapid progressive symmetric ascending MOTOR polyneuropathy # (muscle paralysis) and of- > the d reflexes extremities and areflexia that reaches its maximum affects within 4 weeks. Possible sensory symptoms, ataxia, pain, paralysis, and cranial nerve https://splitrockrehab.com/guillain-barre-syndrome-causes-treatments/guillain-barre-syndrome/ deficits.  -kids Charcot-Marie- Tooth Disease The affected nerves slowly degenerate and lose the ability to communicate with their distant targets. Motor nerve degeneration results in muscle weakness and decrease in muscle bulk (atrophy) in the arms, legs, hands, or feet. Motor Loss > Sensory (Minimal Sensory Loss). - ↑arch Pes cavus and hammer toes – Primarily affects intrinsic foot muscles and anterolateral leg muscles. # Absent achilles reflex. Childhood Onset. (5 15 y(0) - -skinny legs jo https://zerotofinals.com/medicine/neurology/charcotmarietooth/ - Genetic Hummertons Electrodiagnosis NCS + EMG ↳ Nerv t Muscle Nerve Conduction Velocity (NCV): Testing Nerve Activity  Measures the speed of an impulse through the nerve (sensory and motor)  Slow impulses indicate nerve damage  Carpal tunnel syndrome, multiple sclerosis, diabetic neuropathy, etc.. Needle Electromyographic (EMG): Testing Muscle Activity  Records activity from muscle fibers to assess the integrity of the motor unit  Used to discover what is damaging muscle tissue, nerves, or neuromuscular junctions  Disc herniation, myasthenia gravis, amyotrophic lateral sclerosis https://www.verywellhealth.com/understanding-emg-and-ncs-results-2488642 Electromyography is often paired with nerve conduction studies to differentiate primary muscle conditions from muscle weakness caused by neurologic disorders. Done together Interactive Cases  Case #1 What is the most likely diagnosis? stack in flexion - Arm Waiters tip ↳ 1. Erb-Duchenne Palsy (Upper Truck) 2. Klumpke's Palsy (Lower Trunk) -hand/finger O 3. Brachial Plexitis weakness g 4. Apical Lung Tumor (Pancoast Tumor) 5. TOS 6. Median Neuropathy median serve Swelling in the right arm only - 7. Guillian-Barre Syndrome starts in toes - crainal norme involvement. 3 Not bl in the medial portion of the arm - 5 Only shows up  Case #1 What is the most likely diagnosis? 1. Erb-Duchenne Palsy (Upper Truck) - & 2. Klumpke's Palsy (Lower Trunk) 3. Brachial Plexitis 4. Apical Lung Tumor (Pancoast Tumor) 5. TOS ↳ can affect the sympathetic chain of NO sensation 6. Median Neuropathy Swelling in the right arm 7. Guillian-Barre Syndrome Refer l imaging  Case #2 What is the most likely diagnosis? 1. Tunnel of Guyon Syndrome 2. Carpal Tunnel Syndrome 3. Thoracic Outlet Syndrome 4. Median Neuropathy 5. Ulnar Neuropathy 6. Upper Trunk Palsy 7. Pronator Teres Syndrome  Case #2 What is the most likely diagnosis? 1. Tunnel of Guyon Syndrome 2. Carpal Tunnel Syndrome 3. Thoracic Outlet Syndrome 4. Median Neuropathy 5. Ulnar Neuropathy 6. Upper Trunk Palsy 7. Pronator Teres Syndrome  Case #3 7 Whe What is the most likely diagnosis? 1. TOS & ~ 8 dermator Tale Tal 2. C8 Radiculopathy 3. Median Neuropathy Sian 4. Ulnar Neuropathy 5. Lower Trunk Palsy 6. Cubital Tunnel Syndrome  Case #3 What is the most likely diagnosis? 1. TOS - would neck pain see 2. C8 Radiculopathy you > - NOT worsened w/ elbow Flexon 3. Median Neuropathy median - Nerve 4. Ulnar Neuropathy 5. Lower Trunk Palsy -weak hand/fings 6. Cubital Tunnel Syndrome  Case #4 What is the most likely diagnosis? 1. Diabetic Neuropathy 2. Meralgia Paresthetica 3. L4 radiculopathy 4. Femoral Neuropathy 5. Obturator Neuropathy 6. Sciatic Neuropathy  Case #4 What is the most likely diagnosis? 1. Diabetic Neuropathy on 2. Meralgia Paresthetica only - sensory of Lateral side 3. L4 radiculopathy -wantedument was 4. Femoral Neuropathy 5. Obturator Neuropathy medial thigh > - 6. Sciatic Neuropathy post Ley -.  Case #5 What is the most likely diagnosis? 1. Peroneal Neuropathy 2. Tibial Neuropathy 3. Sciatic Neuropathy 4. Diabetic Neuropathy  Case #5 Peroval of Tibial What is the most likely diagnosis? 1. Peroneal Neuropathy 2. Tibial Neuropathy 3. Sciatic Neuropathy 4. Diabetic Neuropathy  Case #6 What is the most likely diagnosis? 1. Sciatic Radiculopathy 2. Sciatic Neuropathy 3. Tibial Neuropathy 4. Common Peroneal Neuropathy 5. L5 Radiculopathy  peroneal ↑ Case #6 & What is the most likely diagnosis? speronea Nerve 1. Sciatic Radiculopathy 2. Sciatic Neuropathy 3. Tibial Neuropathy 4. Common Peroneal Neuropathy 5. L5 Radiculopathy ↳ good DDX w/ muscle testing  Case #7 What is the most likely diagnosis? 1. Obturator Neuropathy 2. Lateral Femoral Cutaneous Neuropathy 3. Cheiralgia Paresthetica 4. Meralgia Paresthetica  Case #7 What is the most likely diagnosis? r medial thigh 1. Obturator Neuropathy 2. Lateral Femoral Cutaneous W Syndrome sesory only 3. Cheiralgia Paresthetica - Radial N. (dorsal webbing) 4. Meralgia Paresthetica ↳ "Tight belt" of ↳ entrapment cut under inglal lig. Lat. Fermoval. N.