Gaitero - Neurology Flashcards
(84 cards)
1
Q
Neurological Exam (6 steps)
A
- Mental status
- Gait / posture
- CN exam
- Postural reactions: Proprioception/Hopping
- Spinal reflexes
- PL: Patellar / Withdrawal (flexor)
- TL: Withdrawal
- Cutaneous trunci, perineal
- Palpation (back / neck pain)
2
Q
3 goals of the neuro exam
A
- Identify/confirm presence of a neurological problem
- Localize the lesion within the nervous system
- Others
Assess severity/extension lesion Prognosis
3
Q
VITAMIN D stands for…
A
VASCULAR INFLAMMATORY / INFECTIOUS TRAUMATIC / TOXIC ANOMALOUS (congenital) METABOLIC IDIOPATHIC NEOPLASTIC / NUTRITIONAL DEGENERATIVE
4
Q
Spinal Cord Enlargements
A
There are two regional enlargements of the spinal cord for the innervation of the limbs:
· cervical intumescence C6-T2
composed of cord sections C6, C7, C8, T1, (T2)
· lumbosacral intumescence L4 to S3
composed of cord sections L4, L5, L6, L7, S1, S2, S3 (some say L5 to S1)
5
Q
Intervertebral disc disease
A
Degenerative changes increase with repetitive compression (e.g. heavy lifting in flexion) or trauma (e.g. fall); degenerative changes may be asymptomatic
6
Q
Where does the spinal cord terminate in large breed/small breed dogs & cats?
A
Large breed - L6
Small breed - L7
Cats - L7/S1
7
Q
Canine Vertebral Formula
A
C-7, T-13, L-7, S-3
8
Q
Spinal cord segmentation
A
Spinal cord divided in segments: 8 cervical 13 thoracic 7 lumbar 3 sacral >= 2 caudal
9
Q
3 types of ataxia
A
Proprioceptive
Cerebellar
Vestibular
10
Q
Where is the LMN Cell body? Axon?
A
Ventral Grey horn
From PNS to muscle
Reflex motor activity
11
Q
UMN Clinical signs
A
Paresis (weakness)
Decrease of inhibitory LMN reflex so spinal reflexes are increased or normal
Disuse mucle atrophy, increased muscle tone.
Usually proprioceptive ataxia
12
Q
LMN Clinical signs
A
Paresis/paralysis
Decreased or absent reflex
Loss of muscle tone
Neurogenic muscle atrophy
13
Q
Functional classification of the spinal cord (segments)
A
C1-C5
C6-T2
T3-L3
L4-S3
14
Q
Extradural
Intradural-Extramedullary
Intramedullary
A
Outside the dura matter, but pushing pressure on the spinal cord
Inside the dura matter, but not in the actual cord
In the actual spinal cord
15
Q
Clinical signs of spinal cord compression
A
- Back/neck pain
- Proprioceptive losses
- Loss of motor/paresis
- paralysis
- loss of nociception (deep pain)
16
Q
Differentials for acute myelopathies
A
Febrile cartilagonis embolism myleopathy
Spinal trauma
Intervertebral disc (IVD) herniation: extrusion
17
Q
Annulus fibrosus
A
fibrous ring of intervertebral disk
18
Q
Intervertebral disc (IVD) herniation: Extrusion vs. protrusion
A
Extrusion of mineralized nucleus pulposus into the vertebral canal (hansen type 1)- usually acute
Protrusion - usually chronic
19
Q
Chondrodystrophic breeds/ages (w.r.t IVD herniation)
A
Daschunds, beagles, cockers, shih tzu (3-6 years old, rare < 2)
20
Q
Location for IVD extrusion herniation
A
T11 - L3, cervical (uncommon to be T1-10;inter capital ligament)
21
Q
IVD Extrusion diagnosis
A
Thoracic rads
Myelogram (CT)
22
Q
IVD Extrusion treatment (surgical/when to use)
A
Surgical: Thoracic: Hemilaminectomy Pediculectomy Cervical: Ventral Slot Use surgical if pain or neurological deficits
23
Q
Hemilaminectomy
A
Remove part of a lamina of the vertebral arch in order to decompress the corresponding spinal cord and/or spinal nerve root.
24
Q
pediculectomy
A
surgical removal of portions of vertebral pedicles at the level of the intervertebral foramen.
25
IVD Extrusion emergency
Loss of deep pain
Quick onset
Non-ambulatory (thoracic)
Tetraplegia (cervical)
26
IVD Extrusion treatment (conservative)
```
Strict cage confinement for 3-4 weeks
Pain killers (NSAIDs Opioids) +/-
First episode of pain without deficits (50% get better)
```
27
IVD Extrusion treatment (what not to use)
Never use NSAIDs + steroids
Never use anti-inflammatories without cage rest
Steroid use at all is controversial
28
IVD Extrusion - prognosis
Deep pain present? Yes: 90%
| No? < 50%
29
Fibrocartilaginous embolic myelopathy (FCEM) - what is it?
Detachment of the IVD substance (nucleus pulposus) and lodging into a blood vessel - acute. Causes spinal cord ischemia due to the embolism in a spinal cord vessel
(thoracolumbar/cervical)
30
Fibrocartilaginous embolic myelopathy (FCEM) - breeds
Non-chondrodystrophic large breed dogs
| Miniature schnauzers
31
Fibrocartilaginous embolic myelopathy (FCEM) - clinical signs
Acute / hyper acute onset
Non-progressive
Asymmetrical CS
Non-painful
32
Spinal cord arterial supply
10 pm, 2pm = upper spinal cord
| 6 pm = lower spinal cord
33
Fibrocartilaginous embolic myelopathy (FCEM) - diagnosis
History/clinical signs
Rule out others
MRI - Intramedullary, focal, asymmetrical
34
Fibrocartilaginous embolic myelopathy (FCEM) - treatment & recovery
```
Treatment = supportive
Recovery = may do well if still have deep pain & start to get some recovery within the first 2 weeks
```
35
Spinal trauma types
Endogenous (e.g. IVD Extrusion)
Exogenous (e.g. HBC)
(spinal cord contusion, vertebral fracture/luxation, traumatic IVD extrusion, hemorrhage)
36
How do you deal with a life-threatening trauma injury
1. Airway/Breathing/Circulation
2. Minimal manipulation
Physical/Orthopaedic exam
Brief neurological exam (latera recumbency, localize severity, deep pain)
37
Treatment for primary vs. secondary injury
primary: decompression/stabilization
secondary: maintenance spinal cord perfustion (BP, PO2), steroids?
38
Acute, progressive, T3-L3 myelopathy
1. IVD herniation/extrusion
2. Inflammatory/Infectious (GME, infectious, spinal empyema
3. Neoplasia
4. Less likely: Spinal trauma, FCEM, others
39
Differentials for hemiparesis, delayed proprioception on the same side, and decreased flexor reflex in the same side thoracic limb?
1. FCEM (Fibrocartilaginous embolic myelopathy)
2. IVD herniation (extrusion)
3. Others
40
Myelopathies - chronic (5)
IVD herniation - protrusion
Atlantoaxial subluxation
Degenerative myelopathy (Genetic degeneration of the spinal cord white matter mainly from T3-L3)
Caudal cervical spondylomyelopathy (wobbler's)
Degenerative lumbosacral stenosis
41
IVD herniation - protrusion: what is it?
A fibroid degeneration of the intact disc (hansen type II degenration); part of the normal aging process.
Progressive thickening on the dorsal annulus. A chronic, slow, compressive myelopathy
42
IVD herniation - protrusion: Signalment & Clinical signs
```
Chronic, progressive (weeks, years)
Non-chondrodystrophic large dogs (or any)
Age > 5 years old (5-12 years)
Cervical/thoracolumbar
Spinal pain is mild/moderate vs. none
```
43
IVD herniation - protrusion: Diagnosis
Spinal radiographys/myelogram
CT-myelogram
MRI
44
IVD herniation - protrusion: Treatment
Restrict activity
Anti-inflammatory drugs
Steroids (useful for chronic spinal cord injury e.g. predinsone
Many can be controlled for a long time
45
IVD herniation - protrusion: Surgical treatment - success rate, reasons
Less successful than IVD herniation - extrusion
Deterioration after surgery (temp or permanent), reperfusion injury
Lack of spinal cord functional reserve capacity: chronic compression, irreversible damage
(assume: Thoracic:
Hemilaminectomy
Pediculectomy
Cervical: Ventral Slot
Use surgical if pain or neurological deficits)
46
Atlantoaxial subluxation - what is it?
Instability between C1-C2
Dorsal displacement of C2 (causes spinal cord compression)
Congenital & acquired forms
47
Atlantoaxial subluxation - Clinical signs
C1-C5 myelopathy (can be chronic or acute)
| progressive, severe neck pain, dyspnea
48
Atlantoaxial subluxation - Congenital form
Small toy canine breeds (yorkshire terrier, chihuahua, miniature schnauzer)
< 1 year old
Failure of ligament support or failure of C2 dens development (hypoplasia/absence/dorsal angulation)
49
Atlantoaxial subluxation - Acquired form
Traum -> acute; any dog/cat
50
Atlantoaxial subluxation - Diagnosis
Spinal radiographs (usually diagnostic)
Increased space dorsal lamina atlas - dorsal spinous process axis (C2)
Extreme care manipulation - better if awake patient
Myelogram, CT, MRI
51
Atlantoaxial subluxation - treatment
Stabilization +/- dens removal
High morbidity/mortality
Risk of respiratory arrest & death
52
Atlantoaxial subluxation - conservative treatment
Young animals with mild signs
External splint >= 6 weeks
Risk or recurrences
53
Degenerative myelopathy
Degeneration of the spinal cord white matter mainly from T3-L3 (genetic --> form of amyotrophic lateral sclerosis (ALS); genetic marker identified)
Pelvic limb ataxia, abnormal placement of the hind limbs, crossing over, reflexes are normal
54
Degenerative myelopathy - signalment
```
Large breed (german shepherd **, boxer, pembrokeshire welsh corgi, others
Age: > 5 years old (mean of 9)
```
55
Degenerative myelopathy - clinical signs
Chronic & progressive
T3 - L3 (severe pelvic limb proprioceptive ataxia, paraparesis/paraplegia, sometimes decreased patellar reflexes)
No spinal pain
56
Degenerative myelopathy - diagnosis
Rule-out other chronic T3-L3 myelopathies (IVD protrusion, neoplasia; normal spinal imagine)
Genetic marker present (DNA)
For a definitive diagnosis -> histopathology
57
Degenerative myelopathy - treatment & prognosis
Supportive/physical therapy
Vitamins/aminocaproic acid, steroids? (not proven)
Prognosis: poor -> euthanasia in 6-12 months (can progress to thoracic limbs if kept alive)
58
Caudal cervical spondylomyelopathy (CCSM)
Wobbler's syndrome (cervical stenotic myelopathy; cervical malformation/malarticulation)
Vertebral malformations/malarticulations affeting caudal cervical vertebrae & acssociated structures (liagments/facets/discs)
Deficits in the thoracic limbs may be less (at least initially) than the pelvic limbs
59
Caudal cervical spondylomyelopathy (CCSM) - pathogenesis
1. Malformation/malarticulation
2. Degenerative changes in the spine
- hypertrophic ligaments
- IVD protrusions (C5-C6, C6-C7)
- stenosis vertebral canal
- articular facets: DJD, cysts, hypertrophy
3. Spinal cord compression
60
Caudal cervical spondylomyelopathy (CCSM) - name the 2 forms
1. disc associated CCSM: large breed, middle aged 3-9 (IVD protrusion)
2. Osseous-associated CCSM. Giant breed (great dane) < 3 years old, articular facets DJD, canal stensosis
61
Caudal cervical spondylomyelopathy (CCSM) - clinical signs
Chronic, progressive
C6-T2 more likely than C1-C5
Tetraparesis (pelvic limbs much worse -> severe ataia & paresis); thoracic limbs (short, stilted, choppy gait -> hypometria)
Neck pain in 50% of cases
62
Caudal cervical spondylomyelopathy (CCSM) - diagnosis
Spinal radiographs
Myelogram
CT-myelogram
MRI (identifies intramedullary lesions)
63
Caudal cervical spondylomyelopathy (CCSM) - treatment -> conservative
Surgical treatment is usually recommended
Conservative therapy:
Restricted exercise; physical therapy;anti-inflammatories (steroids are beneficial in chronic spinal cord compression)
64
Caudal cervical spondylomyelopathy (CCSM) - treatment -> Surgical
None are very successful
1. Ventral approach: ventral slot; distration/stabilization; disc associated CCSM
2. Dorsal approach: dorsal laminectomy; osseous-associated CCSM; multiple ventral compressions (will deteriorate later)
65
Caudal cervical spondylomyelopathy (CCSM) - treatment -> Surgical prognosis
Surgical treatment - good 70-90% success
Recurrence rate >= 30%
can have domino-effect after surgical stabilization & long recovery period
66
Degenerative lumbosacral stenosis
| (DLSS) - what is it?
Compression cauda equine nerve roots due to degenerative changes at L7-S1
(Cauda equine syndrome/lumbosacral malarticulation, lumbosacral instability/lumbosacral spondylopathy)
67
Degenerative lumbosacral stenosis
| (DLSS) - pathogenesis?
1. Chronic instability
2. IVD protrusion between L7-S1
3. hypertrophy of the ligaments (interarcuaate-flavum) & articular facets (DJD, synovial cysts)
4. Subluxation of L7-S1
68
Degenerative lumbosacral stenosis
| (DLSS) - signalment?
- large-breed dogs (german shepherds)
- middle aged to older
- males more likely than females (?)
LMN lesion caudal to L7 (Sciatic, pudendal, coccygeal)
69
Degenerative lumbosacral stenosis
| (DLSS) - clinical signs
MAIN: Lumbosacral pain (reluctance to rise, sit, jump; lameness; PLs tucked under abdomen; low tail carriage)
Other clinical signs often not present
70
Degenerative lumbosacral stenosis
| (DLSS) - what is it?
TBD
71
How do you detect lumbo-sacral pain?
Dorsal palpation of the LS joint, hyperextension PLs, raising up of tail, rectal palpation of the lumbosacral joint
72
What neurologic signs do you expect with a lower motor lesion caudal to L7?
Paraparesis (short-stride gait, not ataxia or mild)
Mild proprioceptive deficits (pelvic limbs)
Tail paralysis (low tail carriage)
Pelvic limb muscle atrophy (sciatic innervated)
Decreased withdrawal reflexes (hock)
73
Degenerative lumbosacral stenosis
| (DLSS) - diagnosis?
```
Spinal radiographs
Myelogram (but spinal cord ends at L6 in large dogs)
Epidurogrpahy, discography
CT
MRI
```
74
Degenerative lumbosacral stenosis
| (DLSS) - treatment?
Conservative: (if first episode & intermittent pain) -> restricted exercise, anti-inflammatory with success 70%
75
Degenerative lumbosacral stenosis
| (DLSS) - prognosis?
Surgery requires >= 12 weeks of confinement
Recurrences are more likely in active working dogs.
If only pain - good to excellent
If motor deficits - good to guarded
If incontinence - guarded to poor
76
Spinal pain sources
1. Meninges
2. Nerve roots
3. Vertebrae & associated structures (periosteum, ligaments, joints, muscles)
77
Differentials for low head carriage, reluctance to walk, severe neck pain, pyrexic, lethargic, praying posture
1. Inflammatory / Infectious
78
Dyskospondylitis
Infectious disease in the spine & intervertibral disk & adjacent vertebrae.
Tends to be caused by bacteria more likely than fungal
Causes neck pain, systemic issues (fever, anorexia) and uncommonly neurological deficits
Can be diagnosed on spinal rads (CT/MRI)
Treatment is antibiotics (anti fungal, analgesics)
79
Steroid-responsive meningitis-
| arteritis (SRMA) - what is it? signalment? diagnosis? treatment? prognosis?
A non-infectious, immune-mediated disease causing neutrophylic pleocytosis in the CSF, neck pain, pyrexia, lethargy, anorexia that can be diagnosed on CSF and treated with corticosteroids with a good outcome. 8-18 month-olds, boxer, beagles, bernese mountain dogs, german pointers.
80
3 types of peripheral nervous system or neuromuscular diseases
1. Peripheral nerve
2. Neuromuscular junction
3. skeletal muscle
81
How do you tell if there is peripheral nerve disease?
1. Reflexes are decreased or absent
2. Reduced or absent muscle tone
3. Neurogenic muscle atropic
Note: CNs can be affected
82
How do you tell if there is neuromuscular junction disease?
1. Reflectes are normal to decreased to absent
2. There is a diffuse clinical signs or focal
3. There can be exercise induced weakness (MG)
Note: CNs can be affected
(examples are myasthenia gravis, botulism)
83
How do you tell if there is muscle disease (myopathy)?
1. Reflexes are usually normal
2. Can be focal or diffuse (exercise intolerance)
3. Severe muscle atrophy
4. Muscle pain is possible
Note: CNS are usually normal (masticatory muscle atrophy)
(examples are polymyositis, masticatory muscle myositis)
84
Name some types of mononeuropathies
1. Traumatic (brachial plexus avulsion, radial nerve, sciatic nerve damage)
2. Neoplastic (peripheral nerve sheath tumour (PNST))
3. Others (Ischemic, neuromyopathy, foraminal IVDD, inflammatory - abscess, brachial plexus neuritis)
