neurology revision lecture

8/2/2019 Neurology Revision Lecture

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GUMSA teaching

Clinical Neurology

Mohamed Abdelhalim


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Main topics

Back pain

Spinal cord injury

Motor neurone lesions Peripheral neuropathy

Head injury

Assessment of conscious level


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Back Pain


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3 categories

Serious pathology (tumour or infection)

1-2%

Disc prolapse 5%

Non-specific low back pain

The rest


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Serious pathology RED FLAGS

Non-mechanical backpain

Thoracic pain

Past medical history

Unwell, fever, weight loss

Widespread neurologicalsymptoms


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And especially

Incontinence

Gait disturbance

Saddle anaesthesia

Cauda equina

syndrome!!


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Disc prolapse

Unilateral leg pain radiating to foot

Numbness and tingling in samedistribution

Localised symptoms/signs

Straight leg raise


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Lumbosacral, buttocks, thighs

Mechanical pain

Patient otherwise well

History of heavy lifting, twisting, etc


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Pathophysiology of non-specificlow back pain

musculoskeletal

soft tissue

degenerative changes

Psychological factors important in chronicpain


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Serious pathology (tumour or infection)

Refer NOW

Disc prolapse Refer soon


Treat with analgesia and keeping active Do not recommend bed rest

Rehabilitation if >6 weeks


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Spinal Cord Injury


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Questions to ask!

Is there leg weakness?

Is there sensory involvement?

Is there a motor and sensory level? Is there bowel and bladder involvement?


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Presentation

Depends on the level of the lesion


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Levels to remember

C3, 4, 5 keep the diaphragm alive

C3-T1 arms

T4 nipple line T10 umbilicus

L1-S3 legs


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Spinal Shock

Areflexia Hyperreflexia

Flaccidity Spasticity3 days


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A definition

A phase beginning immediately after aspinal cord injury during which all functionsof the distal segment of spinal cord are

depressed


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Spinal shock

X


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The bladder reflex

C

T

L2

L3

L4L5S1

L1

S2

S3S4

S5

Brain

+

-Consciousinhibition


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During spinal shock

C

T

L2

L3

L4L5S1

L1

S2

S3S4

S5

Brain

+

-Consciousinhibition

Retention withoverflow

X X

X


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After spinal shock

C

T

L2

L3

L4L5S1

L1

S2

S3S4

S5

Brain

+

-ConsciousinhibitionX

Automaticbladder


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Lumbar injury

C

T

L2

L3

L4L5S1

L1

S2

S3S4

S5

Brain

+


Neurogenicbladder

X


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Sacral injury

C

T

L2

L3

L4L5S1

L1

S2

S3S4

S5

Brain

+


Permanent

retention withoverflow

X


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Motor neurone lesions


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Brain

Medulla

Spinal Cord

Upper motorneurone

Lower motor

neurone


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UPPER LOWER

Power

Tone

Reflexes

Babinski

Musclewasting

Fasciculations

Weak Weak

Increased Reduced

Exaggerated Reduced

Upgoing + Downgoing -

No Yes

YesNo



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Peripheral Neuropathy


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Mononeuropathies

Mononeuropathy Multiple mononeuropathy


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Polyneuropathy


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Mechanisms

Demyelination

Axonal degeneration

Wallerian degeneration Infarction


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Common causes

Diabetes

Infarction

Alterations in polyol pathway cause

accumulation of fructose & sucrose inSchwann cells

Alcohol

Toxic to nerves


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Other causes

Autoimmune (RA, SLE)

Infection (HIV)

Hypothyroidism Kidney disease

Vitamin deficiencies


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Head Injury


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Classification

Primary

Local contusions

Shearing of axons

Secondary


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Bleeding

Extradural Subdural

Dura

Dura


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Intracerebral bleed


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Intracranial pressure

Munro-Kellie pressure/volume curve

Critical volume


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Midline shift


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Herniation

Tonsillarherniation


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Low BPHigh ICP

Reduced cerebralperfusion

CerebralIschaemiaHypoxia


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The ischaemic cascade

d


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The ischaemic cascade for 2nd yearexams

ISCHAEMIA

Glutamaterelease

Ca2+ influx Phospholipidpathway

Free radicals

Cell damage& infarction


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Assessment of conscious

level


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Glasgow Coma Scale


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Glasgow Coma Scale

Minimum score = 3

Maximum score = 15

Below 8 = ventilate

Why do we use it?


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Acute management of head injury

A Airway

B Breathing

C Circulation

D Disability

E Exposure

CT scan if indicated

Call neurosurgeon if necessary


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Questions?

[email protected]


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Spinal levels to remember

C3, 4, 5

C3-T1

T4

T10

L1-S3

keep the diaphragm alive

arms

nipple line

umbilicus

legs


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UPPER LOWER

Tone

Power

Reflexes

Babinski

Musclewasting

Fasciculations

Increased Reduced

Weak Weak

Exaggerated Reduced

Upgoing + Downgoing -

No Yes

YesNo



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Bleeding

Extradural haematoma Subdural haematoma

Dura

Dura


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Peripheral neuropathy

Mono- Multiple Poly-

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