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1

What are some common complaints that warrant an exam of the PNS?

Shooting pain down entire limb

loss of strength

tingling/parasthesias

chicken pox sequelae

 

2

What questions should you ask to help take a good history for a neuro-related complaint?

Local or diffuse?

Restricted to NS (nervous system) or includes other symptoms? fracture, subdural hematoma, tumor growth

CNS, PNS or both

Is your professor a guy named Dr. Vosko?

3

What is the goal of taking a history with a NS related complaint?

Find where lesion is, then develop good differentials.

4

What is the scope of the PNS?

Cranial nerves

Motor efferents

Sensory afferents

Neuromuscular junction

Muscle itself

5

What is the scope of the CNS?

Cortex

Basal Ganglia

Brain stem

Cerebellum

Spinal Cord

6

Generally, what are the basic parts of the NS exam - history and physical?


¢Central Nervous System
—Mental Status and Cognition
—Coordination
—Cranial Nerves (technically peripheral nerves)

 

¢Peripheral Nervous System
—Motor: Strength and Motion
—Sensation
—Reflexes
 

7

What is the origin and course of the upper motor neurons?


¢Upper Motor Neurons: Originate in the cortex to become the motor fibers above the anterior horn of the spinal cord or motor nuclei of the cranial nerves
 

8

What is the origin and course of the lower motor neurons?


¢Lower Motor Neurons: Emanate from the anterior horn of the spinal cord and take the motor signal peripherally to the muscle.
¢Peripheral motor sensory system
 

9

What are the most common NS-related complaints?


—Pain
—Weakness
—Paresthesia (numbness/tingling)
 

10

What are other important parts of a patient history with a NS-related complaint?


¢Associated Features: swelling, rash, spasm,  deformities, mental status
 

Trauma/Surgery/Medications/Supplements

 

¢Personal/Family History - autoimmune, dystrophies, diabetes, DJD, exposures

11

What are the most common causes of NS (nervous system) disorders?


—Ischemia (arterial stenosis)
—Bleeding (TIA,CVA)
—Masses (impingement)
—Peripheral nervous disorders (MS, Guillian Barre)
—Neuromuscular disorders (myasthenia gravis)
—Muscular disorders (dystrophies) 
 

12

What is dyesthesia?


¢Dysesthesia: all types of abnormal sensation including pain regardless of a stimulant being present or not

Often described by patient
 

13

What is a paresthesia?


¢Paresthesia: mostly numb, tingling, pins & needles without pain and without apparent stimulus
 

14

What is anesthesia, in the context of an NS exam?


oAnesthesia: absence of senstion
 

15

What is hypoesthesia?


¢Hypesthesia or hypoesthesia: reduced sensitivity 
 

16

What is hyperesthesia?


¢Hyperesthesia: Increased sensitivity
 

17

What is hyperalgesia?


¢Hyperalgesia: significant pain in response to mildly painful stimulus (sharp)
 

18

What is allodynia?


¢Allodynia: non-painful stimulus perceived as painful on the skin, sometimes severe
 

19

What are the 5 types of sensation tested in a PNS exam?

Spinothalamic:

¢Pain: pin or sharp end of broken Q-Tip
¢Temperature: Metal hammer handle is cool


¢Light touch: Q-Tip Cotton wisp

 

Posterior Column:
¢Proprioception (Position): Large Toe: up? down?
¢Vibration: Tuning fork on boney prominence 
 

20

In addition to types of touch, what 3 other things should be done when testing sensation in a PNS exam?

 

COMPARE SIDE TO SIDE , proximal and distal in a pattern that covers both dermatomes and major peripheral cutaneous regions.

 

¢Instructing the patient to close their eyes enhances sensitivity


¢Map out any area found abnormal, find the boundaries

21

What is being tested during a discriminative sensation exam?

Test of cortical sensory function


¢Stereognosis: Identify an object by feel
¢2-point discrimination
¢Number Identification: Identify shapes/numbers
 

22

What 4 things should be tested with a motor exam? On what side should testing be done?


¢Inspection: atrophy
¢Palpation: tone, soft, firm.  Spasm?
¢Strength testing: major muscle groups
¢Reflexes: brainstem, superficial, deep, clonus
 

Testing should always be done bilaterally

23

What is the scale for muscle strength? What is the scale relative to?


¢Measurement Scale of 0-5

0= no movement

1= muscle twitch without joint movement

2= movement with gravity eliminated

3= full strength against gravity only

4= partial strength against resistance

5= full strength against resistance

 

Relative to patient's full, non-pathological strength

 

Examine and compare bilaterally

24

How is muscle strength named?


¢Name for joint motions or muscle group

  “4/5 left bicep” or “4/5 flexion at left elbow” 

25

What are some DTRs that are commonly tested? How are they tested and what do they signify?


¢Brachioradialis- C5, C6
—Point end into proximal muscle belly
—Flat end on distal tendon


¢Biceps- C5, C6
—Point end onto thumb lying over tendon


¢Triceps- C6, C7
—Flat or point end on triceps tendon above olecranon


¢Patellar- L2,3,4
—Flat end on patellar tendon below patella above tibia


¢Achilles- S1
—Flat end on achilles tendon above calcaneus
 

26

What is the grading scale for DTRs?


¢0 = Absent
¢1+ = Diminished
¢2+ = Normal/Average
¢3+ = Mildly over-active
¢4+ = Highly over-active 
 

27

How does reinforcement work in regards to DTRs?

Reinforcement:  engage bilateral muscle groups ABOVE the level being tested to block any run away motor neuron signals going up to enhance the reflex signal.

28

What are hallmark symptoms of an UMN (upper motor neuron) lesion?

Upper Motor Neuron Lesion

vSpasticity is hallmark (not 100%)
vLoss of dexterity
vUp Going Babinski (abnormal)
vLoss of superficial reflexes
vWeakness without atrophy of muscle
vHyperreflexia of deep tendon reflex (DTR)


¢Paralysis of movement, not muscle
¢Atrophy from disuse, slight
¢Spasticity, hypertonic
 

29

What are some common causes of UMN lesions?


 

  Stroke

         Multiple Sclerosis

               Cerebral Palsy

        Traumatic Brain Injury

            Amyotrophic Lateral Sclerosis

30

What are some hallmark symptoms of an LMN (lower motor neuron) lesion?

Lower Motor Neuron Lesions

Flaccid paralysis
Muscle atrophy/wasting
Hyporeflexia

 


¢Paralysis from muscle atrophy
¢Wasting pronounced
¢Flaccid, hypotonic
¢DTR low or absent
 

31

What are some common causes of LMN lesions?

Polio

     Guillain-Barre

         Amyotrophic Lateral Sclerosis (ALS)

32

What are some common PNS disorders?

Polio, Amyotrophic Lateral Sclerosis

   2. Herniated Disc

   3. Carpel Tunnel Syndrome, Bell’s Palsy

   4. Diabetes, Alcoholic Neuropathy

   5. Myesthenia Gravis

   6. Muscular Dystrophy

33

What can affect the anterior horn of the spinal cord? What symptoms will present?


¢Anterior Horn Cell: Polio, Amyotrophic Lateral Sclerosis (ALS)
—Fasciculations and weakness in a segmental pattern
—Sensation intact (why?)
—Weak DTR
 

34

What are fasciculations?

Fasciculations:  small, local contractions seen thru the skin.  Typically rapid, and from a single motor nerve filament

35

What commonly affects spinal nerve roots? What are the symptoms? Why is it so painful?


¢. Spinal nerve roots: Herniated disc
—Dermatomal Sensory Changes
—Weakness ⇨ Atrophy  
•Weak DTR
 

Spinal nerve is very short, 5 mm, just where the sensory and motor nerve tracts merge.  Intractable pain and weakness or atrophy make it  surgical to treat

Pops posteriorly catching sensory tracts most.  

36

What are some common symptoms of peripheral mononeuropathy? Symptoms?


¢Peripheral mononeuropathy: Carpal Tunnel Syndrome, Bells Palsy
—Weakness and sensory loss in that peripheral nerve distribution
—Weak DTR
 

37

What are some common causes of peripheral polyneuropathy? Symptoms?


¢Peripheral polyneuropathy: Diabetes, Alcoholic Neuropathy
—Distal weakness and stocking-glove distribution sensory loss
—Weak DTR
 

38

What is a common cause of pathology at the NMJ? Symptoms?


¢Neuromuscular junction: Myasthenia Gravis
—Muscular fatigability
—Sensation intact
—DTR intact
 

39

What are some common causes of NS-related muscle pathology? Symptoms?


Muscle: Muscular Dystrophy
—Weakness primarily in proximal muscles
—Sensation intact
—DTR intact or possibly decreased
 

40

What are the causes of thoracic outlet syndrome?


Cause: Compression of the brachial plexus
—Between anterior scalene and medial scalene or cervical rib
—Between the clavicle and 1st rib
—Between the ribs and the pectoralis minor m.
 

41

What are the results of thoracic outlet syndrome?


Results: Weakness and numbness of the hands and arms due to compressed neurovascular supply.
 

42

How do you test for thoracic outlet syndrome?

Roo's Test

Adson's Test

43

What can cause an upper brachial plexus injury? What is damaged?


Stretching of the neck away from the shoulder
 

Often due to birth trauma or falling

 

Damage to C5 C6 nerve root motor and sensory most common

44

What position is the arm held in with an upper brachial plexus injury?

Waiters Tip position commonly seen.

45

What can cause a lower brachial plexus injury?


¢The arm being pulled superiorly
—Catching something overhead
—Birth trauma (pulling out by the arm)

 

¢Thoracic outlet syndrome


¢C8,T1 motor palsy/weakness

46

What is the cause and the result of an injury to the long thoracic nerve?


¢Causes
—Compression between clavicle and 1st rib
—Axillary surgery


¢Results
—Damage in C5-7 region
—Weak Serratus Anterior m. (winging of the scapula)
 

47

What are some causes of injury to the median nerve?


¢Crush Injury
¢Pronator syndrome
¢Carpal tunnel syndrome - Entrapment of median nerve in the carpal tunnel

¢Wrist slashing
¢Palm injury/laceration - Recurrent Branch of the Median Nerve

48

What are some test for carpal tunnel syndrome?


¢Tinels sign
¢Phalens test
¢Reverse Phalens (Prayer Test)  
 

49

What are the results of an injury to the median nerve?


¢Damage in the C6-T1 region proximally or distally
—Weak forearm pronation, wrist and digit flexion, thumb abduction and opposition;  dropping things. 
—Atrophy of the thenar muscles
—Paresthesias or loss of sensation to lateral palm, thumb, index & middle finger
 

50

What is the test for pronator syndrome (median nerve)?


¢Resisted Pronation
—Examiner resists the patient’s effort to pronate.  Tingling along the forearm and lateral hand indicates a positive test for median nerve impingement by the pronator teres (the most powerful pronator m)
 

51

What are the causes of an anterior interosseus neuropathy of the median nerve?


¢Causes:
—Pronator teres impingment of Anterior Interosseus N.
—Trauma; Tennis Elbow strap too tight 
 

52

What is the result of an anterior interosseus neuropathy (median nerve)?


¢Results:
—Weak flexor digitorum profundus & flexor pollicis longus
 

53

What is the test for an anterior interosseus neuropathy?


¢Test: Pinch grip “OK” sign
—Inability to pinch the fingers together tip to tip
—Can also check muscle strength
¢5-10% difference in strength in normal persons between dominant and non-dominant
 

54

What are some common causes of an ulnar nerve injury?


¢Fracture of the humerus near medial epicondyle

¢Cubital Tunnel Syndrome
—Trauma or entrapment of the ulnar nerve as it passes behind the medial epicondyle

¢Laceration near the wrist

¢Entrapment at Guyon’s canal

55

What is the result of damage to the C6-C8 region?


¢Damage in the C6-8 region
—Paresthesias or loss of sensation of the medial part of the palm and 4th & 5th digits
—Weak wrist flexion and adduction (weak flexor carpi ulnaris)
—Weak finger abduction & adduction (weak interossei)
—Loss of thumb adduction (lost adductor pollicis)
—Loss of MCP flexion in 4th & 5th digits (lost lumbricals)


¢Claw Hand
 

56

What muscle deficits create claw hand?


¢CLAW HAND
—Extended 4th and 5th MCP joints (lost 3rd and 4th lumbricals)
—Flexed 4th and 5th PIP (functional flexor digit. Superficialis)
—Weak flexion of 4th and 5th DIP joints (weak flexor digit. profundus)
 

57

What are some causes of radial nerve injury?


—Fracture of the humerus near the radial groove

—“Saturday Night Palsy” compression by sleeping with arm under head

58

What are some results of a radial nerve injury?


—Damage in the C7-T1 region
—Sensory loss to the back of the hand
—Wrist Drop - Weak brachioradialis, supinator, wrist & digit extensors
 

59

What is a test for cubital tunnel syndrome?


¢Tinels sign (at the elbow)
—“Funny Bone”
 

60

What are some causes of sciatic nerve injury?


¢Causes
—Disc compression on the L4 &/or L5 nerve roots
—Piriformis Syndrome
—Posterior hip dislocation
—Misplaced intramuscular injection
—Gunshot or stab wounds to the medial buttock
—Surgery
 

61

What are the results of a sciatic nerve injury?


¢Results
—SCIATICA- pain in the path of the sciatic nerve
—STEPPAGE GAIT- weakness or paralysis of hamstring muscles and thigh extensors and all muscles below the knee: Bates 11th p. 759
 

62

What is the result of a superior gluteal nerve injury?


¢Results
—TRENDELENBURG GAIT- weak hip abductors and external rotators (gluteus medius)
Weak gluteus medius on standing side:  cannot hold the opposite hip level. 

63

What are some causes of a lateral femoral cutaneous nerve injury?


—Compression at the iliac crest (belts, seats, large   bellies)
 

64

What are the results of an injury to the lateral femoral cutaneous nerve?


—Numbness over the lateral thigh
 

65

What are some causes of common fibular/peroneal nerve injury?


¢Causes 
—Impingement by piriformis (sciatic n.)
—Proximal fibular fracture
—Stretched from a varus stress (with lateral collateral ligament )

—Compressed by casting
—Surgery

66

What are the results of a common fibular/peroneal nerve injury?


¢Results
—Paralysis of dorsiflexors and everters
—Loss of sensation of anterolateral leg & dorsum of foot
—FOOT DROP
¢Patient displays HIGH STEPPING GAIT and FOOT SLAP
 

67

What are some common causes of a superficial fibular nerve injury?


¢Causes
—Proximal fibular fracture
—Stretched with varus stress
—Compressed by casting
—Surgery
 

68

What are the results of a superficial fibular nerve injury?


¢Results
—Paralysis of foot everters; NO foot drop
—Loss of sensation of the anterolateral leg and dorsum of the foot
 

69

What are some causes for deep fibular nerve injury?


¢Causes
—Anterior Compartment Syndrome
—Anterior Tarsal Tunnel Syndrome
—Pes Cavus (high arch)- less space under the retinaculum
—Tight shoelaces
—Trauma
 

70

What is the result of a deep fibular nerve injury?


¢Results
—Weak dorsiflexors
—FOOT DROP
 

71

What are the causes and results of a medial plantar nerve injury?


¢Causes
—Entrapment in the longitudinal arch
—Joggers Foot- valgus hindfoot & pes planus


¢Results
—Aching pain in arch and burning/paresthesia in the medial plantar surface
 

72

What is the result of diabetic peripheral neuropathy?


—Paresthesias and pain of feet > hands
¢Intense burning especially at night in the distal extremities (Bilateral Stocking and Glove distribution)
—Loss of vibratory, pain, temperature, light touch sensations.
—Loss of proprioception can cause ataxia and steppage gait (Bates p. 730)
—Decreased reflexes may occur
—Weakness and atrophy of interossei mm. (later stages)
 

73

What percentage of patients with DM will develop diabetic peripheral neuropathy?


¢Diabetic Peripheral Neuropathy

  Estimated 42% of DM patients will develop neuropathy 10 years after diagnosis.

74

What are the common symptoms of myasthenia gravis? 


—Common presenting complaint/signs:
¢Fatigue or proximal muscle weakness
¢Droopy eyelids (ptosis)
¢Double vision (diplopia)
¢Trouble swallowing (dysphagia)
¢Trouble speaking (dysarthria)
¢Dyspnea and respiratory muscle weakness (later stages)
—No sensory loss or altered reflexes.
 

75

What are the 5 components of a screening neurological exam?

The exam should contain assessment of:

1.Mental Status:  alertness, appropriate responses, orientation to date and place
2.Cranial Nerves:  acuity, pupillary light reflex, eye motion, hearing, facial strength
3.Motor: major muscle group strength upper and lower extremity, gait, coordination (finger to nose)
4.Sensory: test toes/feet – one modality of light touch, pain, temp or proprioception
5.Reflexes: DTR upper/lower, Babinski

76