Clinical Neurology Conditions Notes

**Clinical Neurology Conditions** [Spinal nerve root lesions 4](#spinal-nerve-root-lesions) [Disc Herniation 4](#disc-herniation) [Spinal Stenosis 7](#spinal-stenosis) [Lateral Lumbar Stenosis 8](#lateral-lumbar-stenosis) [Spinal cord lesions 9](#spinal-cord-lesions) [Central Lumbar Stenosis 9...

**Clinical Neurology Conditions** [Spinal nerve root lesions 4](#spinal-nerve-root-lesions) [Disc Herniation 4](#disc-herniation) [Spinal Stenosis 7](#spinal-stenosis) [Lateral Lumbar Stenosis 8](#lateral-lumbar-stenosis) [Spinal cord lesions 9](#spinal-cord-lesions) [Central Lumbar Stenosis 9](#central-lumbar-stenosis) [Syringomyelia 11](#syringomyelia) [Cauda Equina 12](#cauda-equina) [Spinal Infection 12](#spinal-infection) [Multiple Sclerosis 13](#multiple-sclerosis) [Peripheral nerve lesions 15](#peripheral-nerve-lesions) [Neuropathies 15](#neuropathies) [**Effects of peripheral nerve lesion** 15](#_Toc162434713) [**Mononeuropathy of peripheral nerves** 15](#_Toc162434714) [Thoracic Outlet Syndrome 16](#thoracic-outlet-syndrome) [Pancoast Tumour 17](#pancoast-tumour) [Peripheral neuropathologies 18](#peripheral-neuropathologies) [**Vitamin B12 and Folate Deficiency** 18](#vitamin-b12-and-folate-deficiency) [Diabetic Neuropathy 19](#diabetic-neuropathy) [Chronic Pain Syndromes 20](#chronic-pain-syndromes) [Pain Definitions (NICE) 20](#pain-definitions-nice) [Central Sensitisation 20](#central-sensitisation) [Myofascial pain 22](#myofascial-pain) [Discogenic Low Back Pain 23](#discogenic-low-back-pain) [Complex Regional Pain Syndrome 24](#complex-regional-pain-syndrome) [Fibromyalgia 25](#fibromyalgia) [Hypermobility Hallmarks 27](#hypermobility-hallmarks) [Benign Hypermobility Joint Syndrome 27](#benign-hypermobility-joint-syndrome) [Ehlers Danlos Syndrome 27](#ehlers-danlos-syndrome) [Marfan's Disease 28](#marfans-disease) [Trigeminal Neuralgia 29](#trigeminal-neuralgia) [Weakness 30](#weakness) [Types of Weakness 30](#types-of-weakness) [Muscular Dystrophy -- as a group 31](#muscular-dystrophy-as-a-group) [Duchenne's Muscular Dystrophy 31](#duchennes-muscular-dystrophy) [Becker Muscular Dystrophy 32](#becker-muscular-dystrophy) [Inflammatory Myopathies -- covered in more detail in CM1 32](#inflammatory-myopathies-covered-in-more-detail-in-cm1) [Endocrine Myopathies -- covered in more detail in CM1 32](#endocrine-myopathies-covered-in-more-detail-in-cm1) [Motor Neuron Disease 32](#motor-neuron-disease) [Guillan-Barre Syndrome 33](#guillan-barre-syndrome) [Bell's Palsy 34](#bells-palsy) [Myasthenia Gravis -- covered in more detail in CM1 34](#myasthenia-gravis-covered-in-more-detail-in-cm1) [Movement Disorders 35](#movement-disorders) [Cerebellar Disease 35](#cerebellar-disease) [Parkinson's Disease 36](#parkinsons-disease) [Huntington's Disease 37](#huntingtons-disease) [VBAI 38](#vbai) [PICA occlusion 38](#pica-occlusion) [Dandy-Walker Syndrome -- not examined 38](#dandy-walker-syndrome-not-examined) [Tremor 39](#tremor) [Arnold-Chiari Malformation -- not examined 40](#arnold-chiari-malformation-not-examined) [Impaired Mental Status 41](#impaired-mental-status) [Acute / Gradual onset 41](#acute-gradual-onset) [Amnesia 42](#amnesia) [Mild Cognitive Impairment 42](#mild-cognitive-impairment) [Dementia - overview 43](#dementia---overview) [Alzheimer's 45](#alzheimers) [Vascular Dementia 46](#vascular-dementia) [Language deficit - Dysarthria 47](#language-deficit---dysarthria) [Language deficit - Dysphasia 47](#language-deficit---dysphasia) [Altered Consciousness 48](#altered-consciousness) [Consciousness 48](#consciousness) [Epilepsy 48](#epilepsy) [Vasovagal Syncope 50](#vasovagal-syncope) [Hypoglycaemia 51](#hypoglycaemia) [Traumatic Brain Injury 51](#traumatic-brain-injury) [Head Trauma -- Concussion 52](#head-trauma-concussion) [Head Trauma - Haematomas 53](#head-trauma---haematomas) [Chronic Traumatic Encephalopathy 54](#chronic-traumatic-encephalopathy) [Headache -- benign stable 55](#headache-benign-stable) [Benign, stable headache 55](#benign-stable-headache) [Migraine - primary 56](#migraine---primary) [Tension-type headache - primary 57](#tension-type-headache---primary) [Cluster headache - primary 57](#cluster-headache---primary) [Cervicogenic HA - secondary 58](#cervicogenic-ha---secondary) [Myofascial Headache - secondary 58](#myofascial-headache---secondary) [Dehydration Headaches - secondary 59](#dehydration-headaches---secondary) [Sinusitis - secondary 59](#sinusitis---secondary) [Temporomandibular disorder (TMJ) - secondary 60](#temporomandibular-disorder-tmj---secondary) [Medication overuse headache - secondary 60](#medication-overuse-headache---secondary) [Headache -- red flags (Vascular) 61](#headache-red-flags-vascular) [Headache assessment principles 61](#headache-assessment-principles) [Cerebrovascular Disease 61](#cerebrovascular-disease) [Transient Ischaemic Attack (TIA) 63](#transient-ischaemic-attack-tia) [TIA v Migrane 64](#tia-v-migrane) [Spontaneous Arterial Dissections 64](#spontaneous-arterial-dissections) [Cervical arterial dissection 64](#cervical-arterial-dissection) [Cerebral aneurysm (focus on this one) 66](#cerebral-aneurysm-focus-on-this-one) [Subarachnoid Haemorrhage 68](#subarachnoid-haemorrhage) [Temporal Arteritis 68](#temporal-arteritis) [Headache -- Red flag (Infection/Trauma) 69](#headache-red-flag-infectiontrauma) [Intracranial Pressure (ICP) 69](#intracranial-pressure-icp) [Benign Intracranial Hypertension 71](#benign-intracranial-hypertension) [Arterial Hypertension Headache 71](#arterial-hypertension-headache) [Intracranial Tumours 71](#intracranial-tumours) [Brain Infection 72](#brain-infection) [Meningitis 73](#meningitis) [Dizziness 74](#dizziness) [Impact of dizziness 74](#impact-of-dizziness) [Vertigo 74](#vertigo) [BPPV (Benign Paroxysmal Positional Vertigo) 75](#bppv-benign-paroxysmal-positional-vertigo) [Meniere's Disease 76](#menieres-disease) [Labyrinthitis 77](#labyrinthitis) [Vestibular Neuritis 77](#vestibular-neuritis) [Vestibular Migraine 78](#vestibular-migraine) [PICA TIA/Stroke 79](#pica-tiastroke) [Vertebrobasilar Arterial insufficiency 80](#vertebrobasilar-arterial-insufficiency) [Acoustic Neuroma 81](#acoustic-neuroma) [Disequilibrium 82](#disequilibrium) [Cervicogenic Disequilibrium 82](#cervicogenic-disequilibrium) [Canadian C-Spine Rule 83](#canadian-c-spine-rule) [Light-headedness -- mostly covered in CMI 83](#light-headedness-mostly-covered-in-cmi) Spinal nerve root lesions ========================= +-----------------------------------+-----------------------------------+ | ### Disc Herniation | | +===================================+===================================+ | Tear in the annular fibres | | | allowing the nucleus pulposus to | | | push outwards\ | | | Typically tends to go to the | | | posterior-lateral aspect of | | | discs\ | | | Cervical spine -- lower cervical | | | most common\ | | | Lumbar spine -- lower lumbar most | | | common\ | | | Thoracic spine rarely affected | | | due to stabilisation of rib cage\ | | | May see from trauma or conditions | | | that predispose uneven weight | | | transfer such as Schauermann's | | | | | | Image result for central disc | | | protrusion | | | | | | **Stage 1 -- Disc Degeneration ** | | | | | | Due to chemical changes, years of | | | physical labour or acute or | | | chronic stress\ | | | Flexion/rotation injury often\ | | | Annular fibres weaken, but | | | nucleus remains encased\ | | | May be present if had previous | | | prolapse but elasticity in fibres | | | not able to allow for full | | | resorption\ | | | EG Older patients on an MRI\ | | | EG Someone with repetitive damage | | | to same disc | | | | | | **Stage 2 -- Prolapsed Disc ** | | | | | | The inner disc pushes further | | | into the outer layer of the disc, | | | giving it a prolapsed appearance\ | | | This is also considered a bulging | | | disc\ | | | The inner nuclear material has | | | still not broken through the | | | fibrous wall\ | | | 2 clinical outcomes:\ | | | The bulge may lead to chemical | | | irritation of nearby nerves | | | without actual compression\ | | | the bulge itself may compress | | | nearby nerves or other spinal | | | structures | | | | | | **Stage 3 -- Extrusion** | | | | | | The gel-like nucleus eventually | | | breaks through the outer wall\ | | | Even though it breaks through, | | | the nucleus remains within the | | | disc\ | | | May have more severe symptoms due | | | to greater damage\ | | | Confirmation of MRI finding used | | | to be a clinical indication of | | | surgical requirements in past\ | | | Recent evidence extrusion has | | | greatest tendency to decrease in | | | size with conservative management | | | | | | **Stage 4 -- Sequestration ** | | | | | | The nucleus breaks through the | | | outer wall and eventually spills | | | out of the spinal disc into the | | | spinal canal\ | | | The chemical components of the | | | nucleus material can cause nerve | | | inflammation, irritation or pain | | | to: | | | | | | Effected nerve root\ | | | Nerve roots above/below\ | | | Cauda equina (if in lumbar spine) | | | | | | **Location classification** | | | | | | Classified by axial (from | | | underneath) view on MRI\ | | | Disc = clock\ | | | 6 o\'clock = central disc | | | herniation\ | | | 5 or 7 o'clock -- paracentral | | | disc herniation\ | | | AKA posterolateral disc | | | herniation\ | | | 4 or 8 o'clock -- foraminal disc | | | herniation\ | | | Located lateral to formina = far | | | lateral disc herniation\ | | | Central (patient leans towards) | | | and paracentral (patient leans | | | away) most common\ | | | Forminal and far lateral less | | | common but more severe\ | | | Conservative care not as | | | beneficial | | +-----------------------------------+-----------------------------------+ | **Who gets it** | Acute disc -- 25-50. Usually late | | | 30-s into 40's. | | | | | | Typically acute disc occur from | | | 25-50 | | | | | | Younger discs are stronger unless | | | put into early, heavy challenge | | | or trauma | | | | | | Older discs desiccate and so are | | | more stable | | | | | | Disc bulge possible but is due to | | | loss of elasticity in annular | | | fibres | | | | | | Often not symptomatic | | | | | | Is a long term flexion/rotation | | | type injury over months-years | | | | | | Often have an "inciting event" | | | which triggers pain -- e.g. | | | lifting | | | | | | Event may be "non traumatic" -- | | | Valsalva type manoeuvre, rotation | +-----------------------------------+-----------------------------------+ | **Symptoms** | Severe pain: rated 6-10 on VOS | | | | | | Hallmark characteristic is | | | burning/electrical LEG or ARM | | | pain\ | | | Back pain -- results from annular | | | tear but is not patient's main | | | focus\ | | | 2 main pain mechanisms for lower | | | extremity pain:\ | | | Inflammatory mediators irritating | | | nerve root (prostaglandins, | | | leukotrienes, nitric oxide...) | | | | | | mechanical pressure onto the | | | nerve root | | | | | | Other symptoms: | | | | | | Myotomal weakness -- flaccid | | | type\ | | | Reduced reflex\ | | | May have exaggerated reflex below | | | level of bulge\ | | | if severe and affecting nerve | | | roots below it -- lumbar spine | | | more common | | | | | | Antalgic gait -- subconscious | | | mechanism by body to avoid | | | putting pressure onto nerve root | +-----------------------------------+-----------------------------------+ | **Signs** | Myotomal weakness -- flaccid. | | | | | | Testing -- O/P. Antalgic gait. | | | Guarding. Muscle spasm on | | | palpation maybe. ROM -- flexion | | | -- pushing all disc contents back | | | towards area of injury. | | | | | | If have right L5 nerve root is | | | being compressed, it will be | | | ipsilateral and unilateral. Left | | | nerve not impacted. | | | | | | Ipsilateral lateral flexion -- | | | also pushing contents backwards. | | | Ipsilateral rotation. Extension | | | pushes contents the other way -- | | | not relief but Mckinsey technique | | | -- to try to manage. Reflexes. | | | SMRs. SLR, Slump etc. | | | | | | Will hurt for around 3 weeks. | | | | | | If seqestration or big enough to | | | high cauda equina - Exaggerated | | | reflex at level of bulge, more | | | severe if pressing on UMN reflex. | | | | | | *Bulge and thick sack compressing | | | nerve root and hitting thecal | | | sack. If L5/S1 if sequestration | | | compressing L5 segment but also | | | hitting thecal sack where it's | | | coming down, nothing is touching | | | LMN but UMNs travel through | | | thecal sac.* | | | | | | Antalgic gait. Paracentral | | | usually lean to opposite side. | | | Medial usually lean toward. | | | Mostly away from side of pain. | | | | | | Imaging advantages/disadvantages | | | -- 30% have bulge/degeneration. | | | MRI expensive. Only image if it | | | will affect treatment plan as | | | suspect surgery is needed or not | | | getting better and elasticity is | | | lost so may need surgery. | +-----------------------------------+-----------------------------------+ | **Treatment** | Improve blood flow, biomechanics, | | | advice to avoid ROM that | | | exacerbates. Teach how to | | | offload.\ | | | Rotatory adjustments at level are | | | contraindicated -- McTIm and | | | NEVER diversified.\ | | | Can massage, adjust around it but | | | not ON it. | | | | | | Nerve tension tests based around | | | a straight leg raise\ | | | Most important are slump, SLR and | | | well leg raise\ | | | Slump is most sensitive to early | | | stage without mechanical | | | compression\ | | | Will also trigger positives for | | | sciatic pain from glute | | | med/piriformis as stretching the | | | involved muscle so not diagnostic | | | alone!\ | | | SLR is more specific and will | | | detect a more severe disc | | | herniation | +-----------------------------------+-----------------------------------+ | **Imaging** | ***Advantages*** | | | | | | If you have severe neurological | | | compression may require surgery | | | to remove | | | | | | The longer a nerve is compressed, | | | the more likely permanent damage | | | is to occur | | | | | | Conservative Rx not appropriate | | | | | | ***Disadvantages*** | | | | | | MRI 2-3 months via NHS | | | | | | Many disc herniations likely | | | resorbed | | | | | | Private MRI fast but expensive | | | | | | If minor -- won't change your | | | treatment plan! | | | | | | 30% of population =asymptomatic | | | disc herniation | | | | | | "label" onto patient effecting | | | behaviour | | | | | | ***Image or refer*** | | | | | | If pain unusually severe | | | | | | MSK pain 1-6, disc 6-8 | | | | | | if 9-10 refer! | | | | | | Severe functional weakness | | | | | | Minor weakness (4/5) -- monitor | | | | | | Unable to... (≤3/5) -- needs | | | investigation | | | | | | Progressive neurological deficit | | | (worse not better) | | | | | | Time expected recovery not be met | | | -- persistent pain despite course | | | of treatment | | | | | | Signs of cauda equina | | | | | | If occurred due to trauma -- e.g. | | | car accident -- possible referral | | | depending on mechanism/onset ect. | +-----------------------------------+-----------------------------------+ | **Natural history** | Natural history | | | | | | Most disc prolapse will fully | | | resorb on their own | | | | | | Typically should have symptomatic | | | reduction around 3 weeks | | | | | | Typically should have resorption | | | and symptomatic resolution 6-8 | | | weeks | | | | | | Some patients experience | | | symptomatic resolution but | | | "bulging disc" may remain visible | | | on an MRI | | | | | | Loss of elasticity of annular | | | fibres although disc is healed | | | | | | NO surgery required typically | | | | | | Some patients continue to have | | | residual symptoms from bulge | | | remaining as above or nerve not | | | gliding well in its sheath | | | | | | If due to annular fibres losing | | | elasticity, may need surgery to | | | remove | | | | | | Treatment may help to reduce | | | symptomatic period | | | | | | Improving blood flow | | | | | | Improving biomechanics around the | | | effected level | | | | | | Advice to avoid exacerbation of | | | inflammatory cycle | | | | | | Avoid things that make the pain | | | go towards the extremity (e.g. | | | flexion) | | | | | | Positions that alleviate the pain | | | or make it disappear from | | | extremities are recommended | | | (antalgic) | | | | | | Rotatory adjustments at the level | | | - CONTRAINDICATED | +-----------------------------------+-----------------------------------+ +-----------------------------------------------------------------------+ | ### Spinal Stenosis | +=======================================================================+ | Stenosis = narrow | | | | Can be anything from a cyst, tumour, syrinx | | | | Most commonly is degenerative changes to the spine | | | | In class -- this is the type we are discussing! | | | | 3 major types: | | | | Central --Compresses the central cord | | | | Discussed in the spinal cord lecture | | | | Lateral --compression as it exits the spinal canal | | | | Foraminal -- compression around the IVF | | | | Foraminal and lateral look exactly the same clinically -- unilateral | | presentation on a nerve root | | | |  | | | | Central stenosis -- bilateral symptoms | | | | Lateral stenosis -- unilateral symptoms | | | | Severe lumbar stenosis can lead to cauda equina -- rare but RF | | | | Pathophysiology | | | | Osteoarthritis | | | | → formation of synovial cysts | | | | → hypertrophy of the facet joints enclosing IVF | | | | → bone spur formation (osteophyte) | | | | Considered somewhat part of aging process | | | | Not predictable who will become symptomatic | | | | DJD and DDD are aspects of this | | | | No clear correlation between symptoms and race, occupation, sex, or | | body type | | | | The degenerative process can be managed, but it cannot be prevented | | by diet, exercise, or lifestyle | | | | Made worse by: obesity, smoking, alcohol... | | | | Takes years to develop if degenerative cause | | | | If related to trauma, congenital malformation, AS, fusion ect may be | | earlier | | | | Many people over 50 have a mild, totally asymptomatic stenosis | | | | Which is one reason imaging not really recommended! | | | | For symptomatic occurrence -- possibly 10% population in UK 60+ | +-----------------------------------------------------------------------+ +-----------------------------------+-----------------------------------+ | ### Lateral Lumbar Stenosis | | +===================================+===================================+ | Degenerative change compressing | | | the nerve root where it exists | | | the intervertebral foramina | | | (looks like disc herniation). | | | | | | Foraminal stenosis -- looks | | | exactly the same as lateral | | | stenosis. | | | | | | Only affects area spinal nerve | | | innervates | | | | | | Overgrowth on facet and pinches | | | nerve on one side. Asymmetrical. | | | Overgrowing where exiting or in | | | the canal. Pinches one nerve | | | root. Just the single nerve root | | | affected. | | +-----------------------------------+-----------------------------------+ | **Who gets it** | Effect 65+ unless have risk | | | factors for earlier degeneration | | | | | | Trauma, contact sports, | | | smoking... | +-----------------------------------+-----------------------------------+ | **Symptoms** | May report insidious, | | | intermittent diffuse, crampy pain | | | with paraesthesia | | | | | | If outright nerve compression: | | | Burning or electrical pain | +-----------------------------------+-----------------------------------+ | **Signs** | Flaccid weakness, atrophy, | | | a/hyporeflexia | | | | | | Would be relieved by opening | | | manoeuvres | | | | | | Flexion, contralateral lateral | | | flexion | | | | | | Aggravated by closing manoeuvres | | | | | | Extension, ipsilateral lateral | | | flexion | +-----------------------------------+-----------------------------------+ Spinal cord lesions =================== +-----------------------------------+-----------------------------------+ | ### Central Lumbar Stenosis | | +===================================+===================================+ | Narrowing in the lumbar spinal | | | column leading to compression | | | into the cord. | | | | | | Ligament comes down through the | | | back starting to compress as well | | | as to sides. Compresses the cord. | | | Is overgrowth on facet and | | | calcification of ligaments. | | | Bilateral. All dermatomes and | | | myotomes below affected. | | | | | | *Cervicali -* Cord tends to be | | | compressed from spur formation at | | | C5-6 and C6-7 | | | | | | Abnormal motion | | | →spondylolisthesis (ante/retro) | | | and resulting compression at C3-4 | | | and C4-5 | | | | | | Also have posterior canal | | | compromise from ligamentum flavum | | | hypertrophy | | +-----------------------------------+-----------------------------------+ | **Who gets it** | 65+ unless risk factors for early | | | degeneration | +-----------------------------------+-----------------------------------+ | **Symptoms** | Gradual onset of | | | numbness/paraesthesia, | | | burning/crampy pain in calves | | | | | | Can affect the thigh muscles if | | | stenosis higher | | | | | | Occasionally will get an | | | inflammatory "flare" which is | | | more acute in onset | | | | | | Often aggravated by walking and | | | extension | | | | | | Shopping cart sign | | | | | | Relieved by flexion | | | | | | May impact on balance -- steppage | | | gait | | | | | | May impact on coordination -- | | | wide based gait | | | | | | May lead to weakness in | | | musculature | | | | | | ***Central Cervical Stenosis*** | | | | | | Neck pain and limited RoM -- due | | | to degenerative changes | | | | | | Subtle loss of hand dexterity and | | | strength | | | | | | Buttons, writing, texting, | | | computer | | | | | | Subtle reduction of balance, gait | | | clumsiness | | | | | | Needing to use handrail to | | | negotiate stairs often an early | | | sign | | | | | | Paraesthesia and weakness | | | effecting upper extremities | | | | | | Radicular pain possible if nerve | | | root being compressed | | | | | | Cervical spondylotic myelopathy | | | | | | https://neckandback.com/wp-conten | | | t/uploads/2014/07/J2-myelopathic- | | | hand-with-thenar-wasting.jpg | +-----------------------------------+-----------------------------------+ | **Signs** | At level of lesion -- flaccid | | | weakness, hyporeflexia | | | | | | Below the level: generalised | | | spastic weakness, hyporeflexia | | | | | | Limb palpation | | | | | | Standing neutral stance/extension | | | will aggravate the leg pain! | | | | | | Sitting neutral stance will not | | | aggravate it as the spine is | | | still gently opened | | | | | | Possible: positive Babinski | | | | | | Possible: Balance impairment, +ve | | | eyes open Romberg, steppage gait, | | | wide based gait | | | | | | Testing -- Observe and palpate. | | | Loss of height, kyphosis in | | | lumbar spine, hypertonic muscles | | | around it. ROM, reduced lumbar | | | extension. Lateral flexion | | | lumbar. | | | | | | SMRs (mild reduction on cotton | | | wool and pin prick in S1 and | | | maybe L5). Mild weakness | | | affecting plantar flexion, if L5 | | | toe into foot. Stenosis at L4/L5 | | | -- achilles probably increased. | | | Chaddick/babinski -- hallux | | | extension. | | | | | | Toe proprioception and fingers. | | | If lumbar fingers unaffected but | | | toes may be.\ | | | Rhombergs -- if can't do with | | | eyes open, could be | | | proprioception problem. If small | | | problem will only be present when | | | take away eyes in Rhombergs. | | | | | | Vibration -- reduction of | | | vibration at the DIP and maybe | | | medial malleolus. | | | | | | At the Level of the Lesion it's a | | | Lower motor neuron sign. Flaccid, | | | hyporreflexia. Pinching on LMN. | | | | | | Below the level of the lesion -- | | | LMN are fine -- spastic, | | | hyporeflexia. | | | | | | ***Cervical Central Spinal | | | Stenosis*** | | | | | | Observe for steppage gait or | | | wider based stance\ | | | Romberg's positive possible with | | | eyes open or closed\ | | | Difficulty with balance tests\ | | | Observe for myelopathy hand\ | | | Hand dexterity - 15 sec | | | grip-and-release test\ | | | Normal to open/close hand 25-30x | | | in 15 sec\ | | | Cervical screen -- positives as | | | expected for degeneration\ | | | "Rough" static palpation\ | | | Reductions in RoM -- likely in | | | extension, lateral | | | flexion/rotation\ | | | Compression type testing likely | | | positive | | | | | | SMR | | | | | | ↓ sensory variable depending on | | | compression but likely to be | | | somewhat reduced globally\ | | | Loss/reduction vibration | | | sensation good indicator\ | | | Finger/toe proprioception, | | | stereognosis, graphesthesia\ | | | Sensory ataxia -- coordination | | | changes due to loss of | | | proprioception\ | | | Myotome -- flaccid weakness at | | | level, spastic below\ | | | Bilateral presentation\ | | | Palpate for tone as well as | | | testing global strength\ | | | Hyporeflexia at level of lesion, | | | hyper-reflexive below | +-----------------------------------+-----------------------------------+ | **Treatment** | Conservative management most | | | effective in lumbar spine | | | | | | Supine, hip flexion 90° may be a | | | good pain relief position | | | (sustain for approximate 5 | | | minutes+) | | | | | | Flexion based exercises | | | | | | Posterior pelvic tilt when | | | walking | | | | | | Stationary bike (upright or | | | "armchair") | | | | | | Strengthen core/glute/paraspinals | | | | | | Patient needs to understand that | | | treatment will not totally | | | alleviate pain -- goal is walking | | | independence | | | | | | Decompression surgery next step | | | | | | ***Central Cervical spinal | | | stenosis*** | | | | | | Investigations - X-ray | | | | | | MRI for extent of stenosis | | | | | | Rx | | | | | | Conservative therapy | | | | | | Surgery | | | | | | Cochrane Review of RCT for | | | surgery in mild CSM concluded | | | early results of surgery were | | | superior to non-operative | | | treatment in terms of pain, | | | weakness, and sensory loss | | | | | | No significant differences were | | | found at 1 year follow-up | | | | | | Another trial found no | | | significant differences between | | | operative and non-operative care | | | up to 2 years after treatment | +-----------------------------------+-----------------------------------+ +-----------------------------------+-----------------------------------+ | ### Syringomyelia | | +===================================+===================================+ | **Development of a fluid-filled | | | cavity or syrinx within the | | | spinal cord** | | | | | | **Can also extend up surrounding | | | brainstem (syringobulbia)** | | | | | | **Multiple causes** | | | | | | **CSF blockage -- 50%** | | | | | | **EG. Arnold-Chiari | | | malformation** | | | | | | **Post-traumatic injury** | | | | | | **Spinal infection (abscess, | | | transverse myelitis...)** | | | | | | **Intramedullary tumour** | | | | | | **Idiopathic** | | +-----------------------------------+-----------------------------------+ | **Who gets it** | **Typically appears 30's** | | | | | | **Slight M prevalence** | | | | | | **Slow progression to disease | | | over years** | | | | | | **More acute if syringobulbia due | | | to brainstem compression** | | | | | | **Usually effects lower cervical | | | area** | +-----------------------------------+-----------------------------------+ | **Symptoms** | **Dissociated sensory loss in | | | both arms or in a "shawl-like" | | | distribution** | | | | | | **Interruption of LST fibres ?** | | | | | | **Preservation of DCML fibres | | | ?** | | | | | | **Later lose DCML fibres also** | | | | | | **Neurogenic pain in | | | neck/shoulders** | | | | | | **deep, aching and often severe** | | | | | | **Syrinx extension damages lower | | | motor neurons** | | | | | | **diffuse muscle atrophy in the | | | hands and progresses proximally | | | to forearms/shoulder girdles.** | | | | | | **Claw hand** | | | | | | **If syrinx extends into | | | brainstem (syringobulbia)** | | | | | | **dysphagia, nystagmus, | | | pharyngeal and palatal weakness, | | | asymmetric weakness and atrophy | | | of the tongue** | | | | | | **Spinal nucleus -- CN5 effects** | | | | | | **Late symptoms: B&B impairment, | | | sexual dysfunction** | +-----------------------------------+-----------------------------------+ | **Signs** | Disassociated sensory testing\ | | | pin prick +ve, soft touch NAD | | | (shawl)\ | | | Diminished arm reflexes\ | | | Spasticity (palpable)\ | | | hyperreflexia lower limb\ | | | Clonus, Babkinski -- both | | | possible positives\ | | | Cranial nerve testing -- for | | | syringobulbia\ | | | Investigations - MRI | +-----------------------------------+-----------------------------------+ | **Treatment** | No pharmacological Rx | | | | | | focus on rehab to maintain | | | neurological function | | | | | | Analgesics and muscle relaxants | | | | | | Decompression surgery | | | | | | Shunts | +-----------------------------------+-----------------------------------+ +-----------------------------------+-----------------------------------+ | ### Cauda Equina | | +===================================+===================================+ | **Compression of cauda equina can | | | be caused by Tumour, | | | Trauma/spondylolisthesis, | | | Infection, Ankylosing Spondylitis | | | (late), Lumbar central stenosis | | | (rare), Disc herniation -- 2% | | | patients with lumbar disc** | | +-----------------------------------+-----------------------------------+ | **Who gets it** | | +-----------------------------------+-----------------------------------+ | **Symptoms** | **Saddle anaesthesia** | | | | | | **Test: can you feel it when you | | | wipe yourself after stool?** | | | | | | **Bowel and bladder | | | disturbances** | | | | | | **Difficulty initiating/stopping | | | urination first → retention of | | | urine→ overflow incontinence** | | | | | | **Bowel --incontinence, but | | | sometimes constipation** | | | | | | **Unilateral or bilateral | | | sciatica** | | | | | | **Low back pain** | | | | | | **Leg weakness and sensory | | | deficits** | | | | | | **Reduced or absent leg | | | reflexes** | +-----------------------------------+-----------------------------------+ | **Signs** | Sensory -- may see dermatomal | | | changes | | | | | | Muscle -- may see myotomal | | | weakness (LMN) | | | | | | Reflex -- hypo/areflexia often | | | present | | | | | | Does it feel different/can you | | | feel it when you wipe yourself | | | after passing stool? | +-----------------------------------+-----------------------------------+ | **Treatment** | **This is an IMMEDIATE referral | | | to A&E** | | | | | | **If you miss this, the person | | | will become permanently | | | incontinent** | | | | | | **Rx -- surgery to decompress.** | +-----------------------------------+-----------------------------------+ +-----------------------------------+-----------------------------------+ | ### Spinal Infection | | +===================================+===================================+ | **An infectious disease that | | | affects** | | | | | | **Vertebral body -- 95% cases** | | | | | | **AKA vertebral osteomyelitis** | | | | | | **Most common in lumbar spine | | | involving 2 vertebra and a disc** | | | | | | **Next common is thoracic spine** | | | | | | **Intervertebral disc | | | (discitis)** | | | | | | **Adjacent paraspinal tissue -- | | | e.g. Dural abscess following | | | surgery** | | | | | | **It accounts for 2-7% of all | | | musculoskeletal infections** | | | | | | ***Vertebral osteomyelitis*** | | | | | | Caused bacterial or a fungal | | | infection | | | | | | Vertebra well vascularized so | | | pathogen carried via bloodstream | | | to spine | | | | | | Post-trauma | | | | | | Post-surgery or dental procedure | | | | | | Intravenous drug users | | | | | | ***Discitis*** | | | | | | Rare occurrence | | | | | | Fast spread via bloodstream | | | | | | Peaks in children and then again | | | in older adults | | +-----------------------------------+-----------------------------------+ | **Who gets it** | **Anybody who has had an | | | infection that has migrated to | | | blood stream. Medical procedure, | | | catheter, transfusion, drug | | | abusers, tattoos.** | +-----------------------------------+-----------------------------------+ | **Symptoms** | **Early signs are localised | | | central, spinal back pain** | | | | | | **Insidious progression of pain | | | and enlargement of pain location | | | over weeks to couple of months** | | | | | | **If spread by the blood may be | | | much, much quicker** | | | | | | **Pain on any movement as | | | vertebral body inflamed** | | | | | | **Malaise, fever, chills as | | | progresses** | | | | | | **Weight loss, fatigue with | | | TB/endocarditis as causes** | | | | | | **Later stage -- pathological | | | fracture leading to nerve root | | | compression (radiculopathy)** | +-----------------------------------+-----------------------------------+ | **Signs** | **Fever** | | | | | | **Severe pain on palpation / | | | percussion of spine** | | | | | | **Pain on any RoM** | | | | | | **Nuchal / neck rigidity | | | (meningism - cervical spine)** | | | | | | **Possible para-spinal spasm to | | | stabilise spine** | | | | | | **If radiculopathy: SMR** | | | | | | **Reflexes -- may vary from | | | absent to clonus, possible | | | Babinski** | | | | | | **A&E referral -- MRI, bloods | | | (ESR/CRP)** | | | | | | **Rx: antibiotics and possible | | | surgical decompression/abscess | | | drainage** | +-----------------------------------+-----------------------------------+ | **Treatment** | **Antibacterials for bacteria / | | | anti fungals for fungus. | | | Potentially decompression | | | surgery. Abscess drainage.** | +-----------------------------------+-----------------------------------+ +-----------------------------------+-----------------------------------+ | ### Multiple Sclerosis | | +===================================+===================================+ | **Immune mediated inflammatory | | | disease which destroys the myelin | | | and the axons leading to varying | | | neurological and physical | | | deficits in relapsing/remitting | | | pattern** | | | | | | **Prominent in optic nerves, | | | brainstem, cerebellum, | | | periventricular and spinal cord** | | | | | | **Cause unknown but likely a | | | genetic predisposition and | | | environmental trigger** | | | | | | **Infection, low vitamin D, | | | chemical exposure...** | | | | | | **F\>M 3:1** | | | | | | **Peak incidence 20-40** | | | | | | **10% of cases late onset -- | | | 50+** | | | | | | ***Relapsing remitting MS*** | | | | | | **85% of cases** | | | | | | **Episodes of neurological | | | dysfunction followed by complete | | | or incomplete recovery** | | | | | | **Gradual progression over days** | | | | | | **10-15 years may become | | | gradually progressive** | | | | | | **disease overtakes body's | | | ability to heal myelin sheath** | | | | | | ***Primary Progressive MS*** | | | | | | **15% cases** | | | | | | **Gradually progressive disease | | | from onset within 12 months** | | | | | | ***Pathophysiology*** | | | | | | **White plaques on MRI = | | | demyelination of neurons** | | | | | | **Typically w/ axonal sparing | | | initially** | | | | | | **Aggressive cases -- axons | | | destroyed** | | | | | | **Some re-myelination occurs when | | | neural inflammation ↓** | | | | | | **Also some neural plasticity | | | helps ↑ function** | | | | | | **Eventual destruction of | | | oligodendrocytes → reduced | | | regeneration** | | | | | | **Disease outstrips bodies | | | capacity to compensate overtime** | | +-----------------------------------+-----------------------------------+ | **Symptoms** | ***Cranial nerves* - Variable | | | depending on where affect | | | brainstem** | | | | | | **Diplopia, facial sensation | | | loss, dysarthria and vertigo | | | possible** | | | | | | **May see medially deviated eyes | | | (CN6 palsy) or nystagmus** | | | | | | **Often optic neuritis is | | | earliest complaint** | | | | | | **unilateral gradual visual loss | | | in one eye, pain on moving the | | | eye due to inflammation of the | | | nerve and altered colour vision** | | | | | | **Visual acuity is typically | | | reduced** | | | | | | **Pupillary reaction to light may | | | be reduced in both eyes** | | | | | | **Papilledema on fundoscopy** | | | | | | ***Spinal cord*** | | | | | | **Gradual onset of sensory/motor | | | symptoms in the limbs over | | | hours/days with variable | | | severity** | | | | | | **Cervical cord - Lhermitte\'s | | | phenomenon - electric shock-like | | | sensation down neck/back on | | | cervical flexion** | | | | | | **Thoracic cord lesions - tight | | | band-like sensation around the | | | trunk/abdomen** | | | | | | **May be misinterpreted as a | | | cardiac event** | | | | | | **Exam typical findings:** | | | | | | **DCML interruption** | | | | | | **Motor signs -- UMN type, muscle | | | weakness to paralysis** | | | | | | **Positives on Babkinski/Chaddock | | | and ankle clonus possible** | +-----------------------------------+-----------------------------------+ | **Investigations** | **MRI** | | | | | | **Cannot be used exclusively to | | | confirm diagnosis** | | | | | | **90-95% pts show plaque | | | development in brain** | | | | | | **Up to 75% show abnormalities in | | | spinal cord** | | | | | | **Particularly elderly patients** | | | | | | **Evoked potentials -- measuring | | | time for brain to respond to | | | sensory stimulation** | | | | | | **CSF analysis -- may be useful | | | in diagnosing later onset MS** | | | | | | **Diagnosis of exclusion overall | | | -- labs + McD Criteria** | | | | | | **McDonald Criteria -- clinical | | | presentation** | | | | | | **evidence of damage ≥2 separate | | | areas of the CNS** | | | | | | **Symptoms must last more than 24 | | | hrs** | | | | | | **Damage occurred at least one | | | month apart** | | | | | | **Exclusion of other possible | | | diagnoses** | +-----------------------------------+-----------------------------------+ | **Treatment** | **Lifestyle** | | | | | | **Research suggests that poor | | | sleep quality may be linked to MS | | | relapse** | | | | | | **Exercise encouraged** | | | | | | **2 simultaneous medical | | | approaches** | | | | | | **DMARDs to slow/stop progression | | | of auto-immune disease** | | | | | | **Rx to modify or relieve the | | | symptoms** | | | | | | **Amatryptaline -- depression and | | | neuro pain** | | | | | | **Gabapentin/pregabalin -- | | | neurological | | | pain/spasticity/other neuro | | | symptoms** | +-----------------------------------+-----------------------------------+ Peripheral nerve lesions ======================== +-----------------------------------------------------------------------+ | ### Neuropathies | +=======================================================================+ | ***Mononeuropathy*** -- 1 peripheral or cranial nerve effected | | | | May be due to entrapment -- e.g. carpal tunnel -- by surrounding | | structure, fluid or protein deposition | | | | ***Polyneuropathy*** -- multiple peripheral or cranial nerves | | effected | | | | ***Peripheral neuropathy*** -- multiple nerves effected at distal | | extremities (glove/stocking) | | | | ***Plexopathy*** -- plexus effect (e.g. TOS) | +-----------------------------------------------------------------------+ +-----------------------------------------------------------------------+ | []{#_Toc162434713.anchor}**Effects of peripheral nerve lesion** | +=======================================================================+ | ***Sensory*** | | | | DCML- reduced discriminative touch, proprioception, vibration, or | | paraesthesia distally\ | | LST -- reduced pain/temp or hyperalgesia, allodynia | | | | ***Motor*** | | | | Flaccid muscle weakness\ | | A/hyporeflexia\ | | Fasciculation and atrophy\ | | ***Trophic*** | | | | cold/blue extremities, cutaneous hair loss, brittle nails (PAD) | +-----------------------------------------------------------------------+ +-----------------------------------------------------------------------+ | []{#_Toc162434714.anchor}**Mononeuropathy of peripheral nerves** | +=======================================================================+ | **Median Nerve** -- Common site -- wrist. Pain, numbness, P&N, | | weakness. Repetitive strain (typing), pregnancy, hypothyroidism. | | Questions about whether "true compression" occurs. Questions about | | true efficacy of decompression surgery. | | | | ***Pronator Teres Syndrome*** - Occurs in the proximal forearm. As | | passes between 2 heads of pronator teres. Ligament of Struthers | | (rare). Bicipital aponeurosis (rare). Less common than carpal tunnel. | | Similar symptoms +. Palpable tenderness pronator teres muscle. Pain | | with resisted pronation of the forearm | | | | **Ulnar Nerve** - ***Cubital Tunnel***. Start intermittent sensory | | changes in hand. Often triggered by prolonged elbow flexion or direct | | compression. May occur at night. Progressive pain and weakness as | | continues.\ | | Tunnel of Guyon Rare structurally -- consider fracture or ganglion | | cyst. Can be secondary to direct pressure. Prolonged writing. Using a | | computer/mouse. Bicycling. Respond well to rest/behaviour | | modification | | | | **Radial Nerve** - Elbow and forearm -- radial tunnel. Tunnel formed | | from muscles of forearm. Brachioradialis and 2 x extensor muscles. | | Then runs under supinator muscle. PIN (posterior interosseous | | branch). | | | | Radial tunnel entrapment. Some controversy b/c not objectively | | clinically measurable. Clinically presents similar to lateral | | epicondylitis (tennis elbow). Consider if epicondylitis doesn't | | respond to Rx, tenderness in radial tunnel at rest. | | | | PIN - branch off radial nerve. Can become entrapped in supinator | | muscle Symptoms - Pain localised to supinator muscle. Pain worsens | | after a few minutes of forced supination. Sudden or progressive | | finger extension weakness. | | | | **Sciatic Nerve** - Tightness into the muscle from overuse. SIJ | | dysfunction -- arthro-kinetic reflex. Receptors in joint give poor | | feedback to muscle leading to atrophy and weakness/tightness. Buttock | | and posterior thigh pain (early stages). Prolonged/severe cases | | --peroneal distribution | | | | laterally and into dorsum of foot. May lead to weakness in ankle | | dorsiflexion and toe extension | | | | Typically occurs in 40-50's. May have SIJ signs of dysfunction. Back | | pain: Sit/stand agg., prolonged sitting agg, prolonged stand/walk | | agg. Leg pain will be aggravated by sitting/lying/standing | |