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Flashcards in Neurology II Deck (49):
1

A 46-year-old man presents after penetrating injuries to his arm and forearm.
He is unable to extend his fingers. There is no sensory disturbance and there is no vascular injury.

Which nerve has been damaged?
Anterior interosseous nerve
Median nerve
Posterior interosseous nerve
Radial nerve
Ulna nerve

Posterior interosseous nerve

The posterior interosseus nerve supplies all the extensor muscles except for the brachioradialis, extensor carpi radialis brevis and longus.

It has no cutaneous branch

2

A 35-year-old man presents to the Emergency department complaining of severe pain in his lower back after lifting a heavy box at work. The pain radiates to his right buttock and thigh. He has had no urinary symptoms.

On examination he can straight leg raise to 90 degrees on the left side but only to 30 degrees on the right. Sciatic stretch test is positive.

He has difficulty plantar flexing his right ankle and has abnormal sensation on the plantar aspect of the foot. His right ankle reflex is absent but all other reflexes are normal. There is no other sensory disturbance.

What is the likely diagnosis?

Cauda equina syndrome
L3/L4 disc prolapse
L4/L5 disc prolapse
L5/S1 disc prolapse
Old Sheuermann's disease

An L5/S1 disc prolapse affects the S1 nerve root causing

Sensory loss to the posterior calf and the plantar surface of the foot
Motor loss to gastrocnemius and soleus and
Loss of ankle jerk.

3

Which is the principal root innervation for the small muscles of the hand?

C5
C6
C7
C8
T1

The small muscles of the hand are innervated principally by T1.

4

Which of the following is true regarding sensory neural hearing loss?

Approximately 1 per 1000 children will have greater than 40db hearing loss.
The incidence is half as high in babies admitted to neonatal intensive care units compared with the normal population.
The risk is increased in children who have had post-natal rubella.
The risk is increased in Down syndrome.
The risk is increased in Werdig-Hoffman syndrome.

Sensory neural hearing loss is caused by lesions in the cochlea or the auditory nerve or central connections. It may be unilateral or bilateral.

Language acquisition and secondary educational difficulties follow, with social isolation, and an increased risk of mental health problems. The approximate incidence is 1 per 1000 children.

Risk factors include:

NICU admission: low birth weight, less than 32 weeks gestation, prolonged ventilation, prolonged jaundice, ototoxic drugs, hypoxic ischaemic encephalopathy, neonatal meningitis
Congenital infection (rubella, CMV)
Dysmorphic syndromes (affecting head and neck)
Family history of a close relative needing a hearing aid below the age of 5 years
Infections: acute bacterial or TB meningitis, mumps (latter usually unilateral).
If all risk factors are considered only around 50% of cases could be identified by testing between 5 and 10% of all babies.

Conductive hearing loss is related to middle ear pathology. This is commoner in Down syndrome, cleft palate, Turner's syndrome, and facial malformation syndromes.

Werdig-Hoffman is associated with normal hearing.

5

A 34-year-old male presents with back pain and weakness.
Which of the following would support a diagnosis of prolapsed intervertebral disc?

Bilateral symmetrical nerve involvement
Loss of sensation over the left outer upper thigh
No evidence of nerve compression
Pain which is unremitting in character
Pain which is worse on resting

Prolapsed intervertebral disc is associated with pain and neurological loss in one nerve root.

Frequently roots of the sciatic nerve are affected. Compression of more than one root suggests an alternative diagnosis.

Pain at rest would suggest an alternative diagnosis such as infection, tumour or metabolic disease as would unremitting pain.

6

A 72-year-old male presents with diplopia.
Which one of the following features would suggest a third nerve palsy?

Constricted pupil
Convergent strabismus
Enophthalmos
Increased lacrimation
Unreactive pupil to light

Unreactive pupil to light

In a third nerve palsy there is typically ptosis with a dilated, unreactive pupil and the eyeball is displaced downwards and outwards.

Enophthalmos is seen in Horner's syndrome. There would be a dilated not constricted pupil and a divergent squint - affected eye deviated 'down and out'.

Increased lacrimation may be seen in VIIth nerve palsy.

7

Which of the following anatomical considerations is correct?

Midline cerebellar lesions cause marked horizontal nystagmus
In cortical blindness pupillary reactions are abnormal
Optic chiasm lesions characteristically produce a bitemporal hemianopia
Optic tract lesions produce an ipsilateral homonymous hemianopia
The physiological blind spot is unaffected by papilloedema

The physiological blind spot is enlarged in papilloedema as Peripapillary photoreceptors are displaced.

In cortical blindness, pupillary reflexes, eye movements and fundoscopy are all normal.

Optic tract lesions produce an contralateral homonymous hemianopia.

Horizontal nystagmus occurs in unilateral disease of the cerebral hemisphere, with the fast phase directed to the side of the lesion. Lateral cerebellar lesions classically cause pronounced nystagmus, whereas this is rarer and much more subtle with midline lesions.

8

Hearing Loss

A mother brings her 7-year-old girl to see you. She has had a moderate hearing loss and has coped well with hearing aids for the last three years, but she has been recently noted by her teacher to be more withdrawn towards her peers in class. In spite of her being teased for being a "teacher's pet" and now sitting at the front of the classroom constantly, her academic performance has deteriorated.

A Central hearing loss
B Conductive hearing loss
C High frequency hearing loss
D Mild hearing loss
E Moderate hearing loss
F Noise-induced hearing loss
G Ototoxic hearing loss
H Profound hearing loss
I Severe hearing loss
J Sensori-neural hearing loss
K Speech discrimination loss

Speech discrimination loss

Hearing loss should be considered in children if there is any suspicion from parents or teachers based on behavioural changes. Accurate electrophysiological testing can be easily and non-invasively carried out in children of any age.

Even in those patients known to have a hearing loss, vigilance is important as progressive changes often occur. A school age child may find increasing difficulty hearing the teacher and need to sit at the front of the room to hear better and lip-read. This indicates a loss of speech discrimination ability.

This loss can also occur in adults with a progressive loss, including those already using hearing aids. Some go on to receive a cochlear implant which can give them the ability to hear speech clearly again.

9

Hearing Loss

A 22-year-old man comes to see you. He was recently on holiday and learned to waterski. On the day before returning home, he fell while waterskiing at speed and sustained a blow to the right side of his head. On otoscopy you see a small hole in the tympanic membrane. You refer him for audiological assessment. He has a mild hearing loss on the right with normal bone conduction.

A Central hearing loss
B Conductive hearing loss
C High frequency hearing loss
D Mild hearing loss
E Moderate hearing loss
F Noise-induced hearing loss
G Ototoxic hearing loss
H Profound hearing loss
I Severe hearing loss
J Sensori-neural hearing loss
K Speech discrimination loss

Conductive hearing loss

Hearing loss is broadly categorised into two aetiological types: conductive and sensorineural.

Conductive losses affect outer and/or middle ear function (for example, tympanic membrane rupture) and will lead to impaired air conduction with normal bone conduction.

Sensorineural losses result from hair-cell losses in the cochlea (inner ear) and both air and bone conduction are affected.

10

Hearing Loss
A Central hearing loss
B Conductive hearing loss
C High frequency hearing loss
D Mild hearing loss
E Moderate hearing loss
F Noise-induced hearing loss
G Ototoxic hearing loss
H Profound hearing loss
I Severe hearing loss
J Sensori-neural hearing loss
K Speech discrimination loss

Any patient of any age with a bilateral severe to profound hearing loss should be considered a potential cochlear implant candidate.

The causes of sensorineural hearing losses include otoxicity (due to agents such as gentamicin, cisplatin and other chemotherapeutic agents), bacterial meningitis, skull fracture, noise exposure, presbycusis, genetic syndromes and hereditary deafness and many of the "unknown" causes of hearing loss.

Gentamicin is still used in some countries without the recommended strict monitoring of circulating levels, and hair cell toxicity results.

11

Hearing Loss

A 65-year-old man comes to see you complaining that he has been misunderstanding some words in conversation - even in quiet environments such as at home with his wife. He has no prior history of hearing loss. You send him for an audiogram which shows a dip in the 6-8 kHz range.

A Central hearing loss
B Conductive hearing loss
C High frequency hearing loss
D Mild hearing loss
E Moderate hearing loss
F Noise-induced hearing loss
G Ototoxic hearing loss
H Profound hearing loss
I Severe hearing loss
J Sensori-neural hearing loss
K Speech discrimination loss

High frequency hearing loss is known as the "invisible disability" as its presence is often not obvious from history and basic clinical examination. Early stages of some hearing losses can be as subtle as an adult having trouble understanding a few words of conversation - in age related hearing losses the high frequency sounds of some consonants (for example, "sss" or "fff") are lost first.

12

Hearing Loss

A child born in a hospital with a universal neonatal screening programme does not pass the first and second screening procedures and goes on for full diagnostic assessment. The child has a profound bilateral hearing loss. The outcome of the thorough investigations is that the child receives a cochlear implant.

A Central hearing loss
B Conductive hearing loss
C High frequency hearing loss
D Mild hearing loss
E Moderate hearing loss
F Noise-induced hearing loss
G Ototoxic hearing loss
H Profound hearing loss
I Severe hearing loss
J Sensori-neural hearing loss
K Speech discrimination loss

Sensori-neural hearing loss

Hearing loss is broadly categorised into two aetiological types: conductive and sensorineural.

Conductive losses affect outer and/or middle ear function (for example, tympanic membrane rupture) and will lead to impaired air conduction with normal bone conduction.

Sensorineural losses result from hair-cell losses in the cochlea (inner ear) and both air and bone conduction are affected.

Hearing loss is also classified according to degree of loss. It is expressed as the number of decibels of hearing loss that is present compared to someone with normal hearing.

Mild 25-40 dB loss
Moderate 40-70 dB loss
Severe 70-90 dB loss
Profound >90 dB loss

13

Hearing loss

A 70-year-old man presents to clinic complaining of progressive bilateral hearing loss over the last year. He accuses his grandchildren of mumbling. Rinne and Weber tests are both normal. He has a hearing test, which reveals high frequency hearing loss.

A Acoustic neuroma
B Acute suppurative otitis media
C Barotrauma
D Chronic suppurative otitis media
E Glue ear
F Meniere’s disease
G Presbyacusis
H Otosclerosis
I Vestibular neuronitis

Presbyacusis
This man has presbyacusis or senile deafness. It is caused by a gradual loss of hair cells in the cochlea and a loss of neurones in the cochlear nerve. Usually the high tones go first.

14

Hearing loss

A 35-year-old woman has developed deafness in her left ear. It became noticeably worse during a recent pregnancy and her mother had premature deafness. On examination both TMs are normal, the Rinne test is negative on the left and the Weber test lateralises to the left side.

A Acoustic neuroma
B Acute suppurative otitis media
C Barotrauma
D Chronic suppurative otitis media
E Glue ear
F Meniere’s disease
G Presbyacusis
H Otosclerosis
I Vestibular neuronitis

Otosclerosis
Conductive deafness(bone better than air) with a normal eardrum, is otosclerosis until proved otherwise. It is more common in women and typically deteriorates in pregnancy.

15

Causes of facial nerve palsy

A 32-year-old man presents with a one month history of offensive ear discharge from the left ear. Examination reveals a facial nerve palsy and there is an attic perforation of the tympanic membrane.

A Acoustic neuroma
B Bell's palsy
C Cholesteatoma
D Diabetes mellitus
E Guillain-Barré syndrome
F Motor neurone disease
G Otitis externa
H Parotid tumour
I Ramsay Hunt syndrome
J Sarcoidosis

Cholesteatoma
The presence of an attic perforation with ear discharge and facial palsy is indicative of a cholesteatoma.

16

Causes of facial nerve palsy

An 82-year-old woman presents with a one day history of a severely painful right ear, a right facial palsy and vesicular rash around the right ear.

A Acoustic neuroma
B Bell's palsy
C Cholesteatoma
D Diabetes mellitus
E Guillain-Barré syndrome
F Motor neurone disease
G Otitis externa
H Parotid tumour
I Ramsay Hunt syndrome
J Sarcoidosis

Ramsay Hunt syndrome

In herpes zoster otitis (Ramsay Hunt syndrome), severe pain precedes the emergence of the classical herpes zoster vesicles and facial palsy.

17

Causes of facial nerve palsy

A 53-year-old woman presents with a history of giddiness, impaired hearing and left facial numbness. Examination reveals left sensorineural deafness, and left trigeminal and facial nerve palsies.

A Acoustic neuroma
B Bell's palsy
C Cholesteatoma
D Diabetes mellitus
E Guillain-Barré syndrome
F Motor neurone disease
G Otitis externa
H Parotid tumour
I Ramsay Hunt syndrome
J Sarcoidosis

Acoustic neuroma
Acoustic neuromas are slow growing neurofibromas, often arising from the acoustic nerve's vestibular division, giving progressive ipsilateral tinnitus, sensorineural deafness, giddiness and may affect nearby cranial nerves.

Facial nerve palsies may be caused by lesions affecting any part of its course. It arises in the medulla and emerges between pons and medulla, passes through the posterior fossa in close proximity to the middle ear before emerging from the stylomastoid foramen to pass underneath the parotid gland.

Causes can be divided into:

Intracranial - brainstem tumours, stroke, multiple sclerosis, acoustic neuroma
Intratemporal - otitis media, Ramsay Hunt syndrome, cholesteatoma
Infratemporal - parotid tumours, trauma
Others - sarcoid, Guillain-Barré syndrome, diabetes, Bell's palsy.

18

Glasgow Coma Scale

An 80-year-old male is admitted after being found collapsed at home. No history is obtainable. On examination he has a pulse of 45 beats per minute, a temperature of 34°C, no eye opening to pressure over the eyebrows and he makes no audible sounds. No movements can be elicited and he has generally brisk reflexes with bilateral extensor plantar responses.

The 80-year-old male with what sounds like raised intracranial pressure has E1, V1, M1 = 3, suggesting a grave prognosis.

19

Glasgow Coma Scale

A 19-year-old female is brought to the Emergency department following a car accident. On examination she has a head wound, has a pulse of 110 beats per minute, smells of alcohol, is confused. She shouts for her boyfriend while thrashing around on the couch and is difficult to examine. Her eyes are fully open, pupils appear slightly dilated and reflexes appear brisk with down going plantar responses.

In the case of the 19-year-old female she would score E4, V4 (as confused) and M5 (purposeful movements towards changing painful stimuli) = 13.

20

Glasgow Coma Scale

A 54-year-old female is admitted after suddenly collapsing in the street whilst out shopping with her friend. On examination she appears drowsy, has a pulse of 110 beats per minute and a temperature of 37.1°C. She has nuchal rigidity which elicits a moan. There is no eye opening to pressure over the sternum, but pressure over the nail bed elicits this withdrawal of the limb. She is generally hyper-reflexic with bilateral extensor plantar responses.

The 54-year-old female who collapses in the street sounds as if she may have had a subarachnoid haemorrhage. Her GCS is E1, V2, M4 = 7.

21

Glasgow coma scale

The Glasgow coma scale is a vitally important piece of clinical information, having prognostic value in the assessment of neurological injury.

Therefore it is essential that trainees are familiar and confident in scoring this system accurately.

A coma score of 9 to 12 is moderate injury and 8 or less a severe brain injury.

It is scored as follows:

Best Eye Response. (4)

No eye opening
Opening to response to pain
Eye opening to verbal command
Eyes open spontaneously
Best Verbal Response. (5)

No verbal response
Incomprehensible sounds
Inappropriate words
Confused
Orientated
Best Motor Response. (6)

No motor response
Extension to pain
Flexion to pain
Withdrawal from pain
Localising pain
Obeys commands

22

Glasgow coma scale

A 67-year-old male is admitted after falling from a ladder and sustaining a head injury. He is brought to casualty unconscious with a pulse of 88 beats per minute and apyrexial. There is no eye opening following pressure over the sternum but upper limb extension is noted during this manoeuvre. He makes some spluttering noises during pain eliciting procedures.

In the 67-year-old male's case his GCS is E1, V2 (some spluttering noises) and M2 (extends to pain) = 5.

23

Glasgow coma scale

A 66-year-old alcohol dependent patient is brought to casualty after being found collapsed in the street. He is unkempt, smells of alcohol and is talking in a confused and disorientated manner. On sternal pressure, he opens his eyes briefly and grabs the examiner's hand with his left hand. He also opens his eyes to vocal stimulus. He has a right sided hemiplegia with extensor plantar response on the right and a left flexor plantar response and normal left reflexes.

This patient may well have a subdural haematoma and has E3 (eyes open to commands), V4 (confused speech caused by either or both intracranial pathology or alcohol intoxication), M5 (localising to pain) = 12.

24

Glasgow coma scale

A 23-year-old female is admitted after having taken unknown drugs at a rave. She smells of alcohol, does not open her eyes spontaneously but opens her eyes when the nurses talk to her or when her thumb is squeezed. Pressure over the sternum elicits some localisation of her right hand. She makes some incomprehensible noises when the nurses turn her onto her side as her chest is examined.

The young woman who has taken drugs has a GCS of E3, V2 and M5 = 10.

25

Glasgow coma scale

The Glasgow Coma Score (GCS) is a vitally important piece of clinical information, having prognostic value in the assessment of neurological injury. Therefore it is essential that trainees are familiar and confident in scoring this system accurately. A Coma Score of 9 to 12 is moderate injury and 8 or less a severe brain injury.

It is scored as follows:

Best Eye Response (4):

No eye opening
Eye opening to pain
Eye opening to verbal command
Eyes open spontaneously
Best Verbal Response (5):

No verbal response
Incomprehensible sounds
Inappropriate words
Confused
Orientated
Best Motor Response (6):

No motor response
Extension to pain
Flexion to pain
Withdrawal from pain
Localising pain
Obeys Commands

26

A 60-year-old woman has suffered three episodes of transient right monocular blindness.
Her rate is 88 beats per minute (regular) and she is in sinus rhythm.

Which is the single most appropriate investigation that would diagnose the condition?

Carotid duplex ultrasonography
CT scan
Echocardiography
Fasting lipid profile
MRI brain scan

Carotid duplex ultrasonography

This patient experienced amaurosis fugax caused by internal carotid artery atherosclerotic stenosis.

Other features include temporary paresis, aphasia, or sensory deficits.

Fundoscopic examination may reveal bright yellow cholesterol emboli in patients with retinal involvement.

The investigation to identify the significant stenosis or occlusive lesion usually greater than 70% is carotid duplex ultrasonography.

27

During a neurological examination of the lower limbs, you test the ankle reflex. You hold the foot in external rotation. The knee is flexed. You strike the Achilles tendon with your tendon hammer whilst watching the calf.

Which nerve is involved and what is its nerve root?


Deep peroneal nerve L5, S1
Deep peroneal nerve S1, S2
Tibial nerve L5, S1
Tibial nerve S1, S2
Tibial nerve S2, S3

Tibial nerve S1/2

The muscles involved in the ankle reflex are supplied by the tibial nerve which derives from the S1, S2 nerve roots.

The tibial nerve is a branch of the sciatic nerve. The tibial nerve forms in the popliteal fossa. When it leaves the popliteal fossa it runs inferiorly on the tibialis posterior. It supplies the posterior muscles of the leg and knee joint.

It terminates by dividing into the medial and lateral plantar nerves.

28

Differential diagnosis of vertigo

A 17-year-old female presents with vertigo one week after an acute catarrhal upper respiratory tract infection. She complains of episodes of giddiness especially after getting up in the morning which improves as the day progresses. She also has noticed positional vertigo.

A Benign positional vertigo
B Concussion injury
C Drug induced
D Meneire’s disease
E Transient ischaemic attack
F Vestibular neuronitis

Vestibular neuronitis

Vertigo is defined as a sense of imbalance associated with a sensation of the surroundings going around caused by specific damage to the vestibular system and its connections. Various other terminologies have been used to describe this condition.

Its cause could be central (vestibular nucleus) or peripheral (inner ear or vestibular apparatus). Its differentials include all forms of ataxia and transient ischaemic attacks (TIAs). In this question peripheral causes are discussed.

The 17-year-old probably has viral neuritis. The majority of these settle down by themselves and treatment is mainly symptomatic.

29

Differential diagnosis of vertigo

A 26-year-old female presents with tinnitus, deafness and vertigo.

A Benign positional vertigo
B Concussion injury
C Drug induced
D Meneire’s disease
E Transient ischaemic attack
F Vestibular neuronitis

Meneire’s disease

The 26-year-old has a classical presentation of Meneire's disease. It is caused by an increase of endolymph causing dampening of sounds at the extremes of the auditory range and exaggerated vestibular reflexes. Treatment is symptomatic with some relief with low potency diuretics.

30

A 27-year-old woman presented with a history of sudden onset right-sided weakness and dysphasia lasting eight hours. She had returned to the United Kingdom from Australia two days previously. There was no significant past medical history and physical examination was normal.

Chest x ray, ECG and a CT head scan were all normal.

Which one of the following investigations is most likely to reveal the underlying cause of this episode?

Carotid Doppler ultrasonography
Cerebral angiography
MRI of head
Transoesophageal echocardiography
Transthoracic echocardiography

Transoesophageal echocardiography

The history here suggests a lower limb deep vein thrombosis with peripheral embolus through a patent foramen ovale, leading to symptoms of left sided cerebral ischaemia.

This is termed the paradoxical embolus - so-called because a thromboembolus arising from the venous circulation can end up in the systemic circulation.

Transoesophageal echocardiography (TOE) is the investigation of choice to investigate for a patent foramen ovale, although transthoracic echocardiography with contrast may be an alternative. TOE offers better views of the anatomical area.

31

Meta-analysis of the prevention of stroke in elderly subjects reveals a 4% incidence of stroke in those not receiving aspirin compared with a 2% incidence in those receiving aspirin.
What would be the number needed to treat to prevent one stroke using aspirin?

50

Number needed to treat is defined as an estimation of the number of patients who would need to receive therapy in order for a defined event to be avoided.

In this example two in every 100 patients will be prevented from having a stroke if they are on aspirin, so in order to prevent one stroke, 50 patients would need to be treated.

32

A 21-year-old male is admitted with severe acute onset headache. He is disoriented and drowsy and has neck stiffness.
Investigations suggest a diagnosis of subarachnoid haemorrhage.
What grade of illness does this patient have on the Hunt and Hess scale?

Grade one
Grade two
Grade three
Grade four
Grade five

Grade 3

This gentleman's history is suggestive of subarachnoid haemorrhage (SAH).

The Hunt and Hess scale grades SAH thus:

Asymptomatic or minimal headache & slight neck stiffness.
Moderate or severe headache with neck stiffness, but no neurological deficit other than cranial nerve palsy.
Drowsiness with confusion or mild focal neurology.
Stupor with moderate to severe hemiparesis or mild decerebrate rigidity.
Deeply comatose with severe decerebrate rigidity.
Severity and mortality increase with grade.

33

A 23-year-old male is admitted following an altercation in which he is stabbed in the thigh by a bottle.
Which of the following features suggests injury to the femoral nerve?

Loss of knee reflex
Loss of sensation over lateral aspect of thigh Weakness of abduction of the hip
Weakness of adduction at the hip
Weakness of knee flexion

Loss of knee reflex

A lesion of the femoral nerve (L234) is characterised by weakness of the quadriceps femoris muscle and hence weakness of extension of the knee, loss of sensation over the front of the thigh and loss of the knee jerk.

The lateral cutaneous nerve of the thigh (L1,2) supplies the skin on the lateral aspect of the thigh and knee (plus the lower lateral quadrant of the buttock).

The obturator nerve (L2-4), which supplies adductors of the hip and, supplies sensation to the inner part of the thigh.

34

A 26-year-old man is assaulted, receiving direct blows to his head. He is brought to his local Emergency department where he is assessed by the casualty SHO.

On initial examination, he opens his eyes to speech, reaches up as you put pressure on his sternum, and answers questions with confused conversation.
What is his Glasgow coma scale (GCS) score?

12

Accurate recording of the patient's GCS is necessary so that any further change can be accurately assessed and information can be easily communicated to other health care professionals.

In this case, the patient scores:

3 out of 4 as he opens his eyes to voice
5 out of 6 as he localises to pain
4 out of 5 as his conversation is confused

35

A 32-year-old patient is involved in a severe road traffic accident.

On arrival in a district general hospital Emergency Department, he has a GCS of 3 and is intubated. He is taken to the CT scanner, where a right-sided subdural and a left-sided extradural haematoma plus multiple contusions are noted. The regional neurosurgery unit are contacted but no surgical intervention is advised and he is placed in the ITU. A few days later, his condition on ventilator has not improved and he is assessed for brainstem death.
Which of the following is a criterion for the diagnosis of brainstem death?

No spontaneous ventilatory effort

Brain stem death is diagnosed when the patient is deeply unconscious (GCS of 3) due to a known and irreversible structural injury.

There must be

Fixed and non-reactive pupils
No spontaneous ventilatory effort and
Absent brainstem reflexes.
The patient should have normal physiological parameters and not have any medication which could mimic brainstem death.

The diagnosis implies that there will be no recovery to normal brain function.

36

A 17-year-old male is returning from work as a painter and decorator. He is the passenger in a van, wearing a seatbelt. The van crashes and rolls over.
He is brought to the Emergency department where he is triple immobilised and on a spinal board, and is complaining of severe back pain. He cannot feel any sensation to pinprick or light touch below his nipples. He is unable to move his lower limbs.

At what level of the spinal cord is the lesion likely to have occurred?

T4
T5
T6
T7
T8

T4

The sensory level is defined as the lowest dermatome which has normal sensory function.

The nipples correspond to the T4 dermatome level.

37

A 57-year-old woman who has previously consulted a neurosurgeon due to neck problems falls from the
top of stairs.

She states that she landed directly on her face, with her neck being forced backwards.

On examination, the patient has loss of motor function of both the upper and lower limbs, but the upper limbs appear to be much more affected than the lower.

What is the name of this spinal cord syndrome?

Central cord syndrome classically occurs in a patient who already has cervical canal stenosis.

It is characterised by a greater loss of power in the upper (rather than the lower) limbs, with varying degrees of sensory loss.

Brown-Sequard syndrome is caused by hemi-section of the cord and results in ipsilateral motor loss and loss of position with contralateral pain and temperature loss.

38

A 32-year-old shop worker is seen in the neurosurgery outpatient clinic. She complains of a few months history of a tingling sensation in her left thumb and index and middle fingers.
As part of the assessment the surgeon places the patient's wrist in full flexion for one minute to see if this recreates the patient's symptoms.

What is the name of this test?

Froment's sign
Jeanne's sign
Phalen's test
Tinel's sign
Valgus stress test

Phalen's test

The test described is Phalen's test. It is used to test for carpal syndrome.

It is positive if the patient feels paraesthesia as the wrist is flexed for the full minute.

Tinel's sign can also be used to assess for median nerve symptoms. Tapping over the median nerve over the volar aspect of the wrist may recreate the symptoms and this regarded as a positive test.

Froment's sign and Jeanne's sign are used to test for ulnar nerve function.

39

A 13-year-old girl is brought to the Emergency department after being run over. The paramedics report a 'bullseye' mark on the car windscreen where she has hit it as she has been thrown in the air.
On arrival in Emergency department, she opens her eyes as you put pressure on her fingernail, and withdraws from pain. She does not answer questions, but only makes incomprehensible sounds.

What is her Glasgow coma scale (GCS) score?

5
6
7
8
9

8

The patient is likely to have sustained a severe head injury.

A GCS score of 8 or less is generally taken as the definition of coma or severe brain injury.

In her case, she scores 8 out 15:

2 for eye opening to pain
4 for withdrawing from pain
2 for incomprehensible sounds
When recording the GCS score, the individual marks for each of the three components should always be recorded rather than one individual score.

40

Nerve Damage

A 55-year-old male presents with tingling and numbness over the left thigh following repair of an inguinal hernia. On examination he has loss of light touch and pinprick sensation over the lateral aspect of the left thigh.

A Common peroneal nerve
B Deep peroneal nerve
C Femoral nerve
D Lateral cutaneous nerve
E Saphenous nerve
F Sciatic nerve
G Sural nerve
H Tibial nerve

Lateral cutaneous nerve

The second case of the male developing dysaesthesia and numbness after inguinal hernia repair with loss of sensation over the antero-lateral thigh suggests meralgia paraesthetica due to damage of the lateral cutaneous nerve of the thigh.

41

Back injuries

A 52-year-old nurse presents with pain in her back which radiates to the anterior aspect of the left thigh after lifting a patient on the surgical ward. On examination she has reduced straight leg raising on the left but unimpaired on the right and sciatic stretch test is positive on the left. She has weakness of left knee extension and there is reduced sensation to light touch and pinprick over the anterior left thigh and medial leg. There is normal flexor plantar responses but there is an absent knee reflex on the left.

A Cauda Equina syndrome
B L3/L4 disc prolapse
C L4/L5 disc prolapse
D L5/S1 disc prolapse
E Old Scheuermann's disease
F Osteoporotic vertebral collapse
G Vertebral artery dissection

L3/L4 disc prolapse

The second case has as revealed by the sensory loss over the anterior thigh and medial leg plus reduced quadriceps power and reduced knee reflex. The history is not suggestive of an osteoporotic vertebral collapse where features would be more likely to be bilateral.

42

A 70-year-old male presents with episodic giddiness which is exacerbated by sudden movements. These episodes last minutes and are associated with the room spinning. On examination, no specific abnormalities are detected.

Causes of vertigo

A Acoustic neuroma
B Benign positional vertigo
C Cholesteatoma
D Labyrinthitis
E Meniere's disease
F Vertebrobasilar ischaemic attacks

Benign positional vertigo

The second case presents with brief episodic vertigo associated with rapid head movements. Although no abnormalities are noted on examination this sounds like benign positional vertigo which is due to degenerative fragments impacting upon the hair cells. It may be demonstrated by the Hallpike's manoeuvre.

43

Head injury

An 82-year-old man had a fit and struck his head against the bath tub 10 days ago. He is brought to the emergency department unconscious. On examination, his Glasgow coma scale is 10 and his pupils are unequal.

A Basal skull fracture
B Brain concussion
C Compound skull fracture
D Diffuse axonal injury
E Extradural haematoma
F Haematoma of the scalp
G Subarachnoid haemorrhage
H Subdural haematoma

Subdural haematoma

Although most subdural haematomas are secondary to trauma (sometimes trivial), spontaneous subdural haematomas can occur in elderly patients with cerebral atrophy. Alcoholics, epileptics and patients on anticoagulants are also susceptible. About 20% of subdural haematomas are bilateral.

44

Head injury

A 45-year-old man was assaulted with a baseball bat and had momentary loss of consciousness. He walked into casualty but soon became confused and complains of headache. Skull x ray shows a linear fracture of the parietal area.

A Basal skull fracture
B Brain concussion
C Compound skull fracture
D Diffuse axonal injury
E Extradural haematoma
F Haematoma of the scalp
G Subarachnoid haemorrhage
H Subdural haematoma

Extradural haematoma

Extradural haematoma should be suspected after head injury where the patient has a fluctuating level of consciousness (though not always).

They are usually associated with trauma and are seen in the young.

Extradural bleeds are commonly due to fractured temporal or parietal bones causing laceration of middle meningeal artery or vein.

45

Head injury

A 70-year-old man is struck on the head with a dustbin lid and presents with an open scalp wound. Skull x ray confirms an underlying skull fracture. The dura is visible but intact and his Glasgow coma scale is 15.

A Basal skull fracture
B Brain concussion
C Compound skull fracture
D Diffuse axonal injury
E Extradural haematoma
F Haematoma of the scalp
G Subarachnoid haemorrhage
H Subdural haematoma

Compound skull fracture

An open scalp wound and a visible dura should be considered to be a compound skull fracture. The patient, along with adequate debridement and suturing of the wound, will need appropriate antibiotics and immunisation for tetanus.

46

Upper limb nerve injuries

An 83-year-old woman presents to the Emergency department after a fall. x Ray confirms a fractured distal radius. On examination, there is loss of sensation over the thumb, index and middle fingers.

A Anterior interosseous nerve
B Long thoracic nerve
C Median nerve
D Musculocutaneous nerve
E Palmar cutaneous branch of median nerve
F Posterior interosseous nerve
G Radial nerve
H Suprascapular nerve
I Ulnar nerve

Median nerve

Median nerve injury at the wrist causes sensory loss over the

Thumb
Index finger
Middle finger
Occasionally ring finger (lateral half).
Motor loss includes all thenar muscles except adductor pollicis (supplied by ulnar nerve) and lateral two lumbricals.

47

Upper limb nerve injuries

A 32-year-old man presents to the Emergency department with a deep laceration to his right wrist after he was involved in a fight in his local pub. On examination, he has loss of thumb adduction and loss of sensation over his little and ring fingers.

A Anterior interosseous nerve
B Long thoracic nerve
C Median nerve
D Musculocutaneous nerve
E Palmar cutaneous branch of median nerve
F Posterior interosseous nerve
G Radial nerve
H Suprascapular nerve
I Ulnar nerve

Ulnar nerve

Ulnar nerve is an important motor nerve of the hand. Lesion of this nerve at the wrist produces clawing of the hand due to the action of unopposed long flexors. Thumb adduction is lost, with the loss of sensation over the little and ring fingers.

48

A 65-year-old man is brought in to the the Emergency department following a fall from a ladder with a wrist drop. An x ray reveals a mid-humerus fracture.

Radial nerve

Radial nerve could be damaged at the mid-humerus level by fractures or pressure. This type of lesion causes wrist drop along with paralysis of extensors of the wrist, fingers and the thumb.

49

Lower Limb Nerve Injury

A 34-year-old motorcyclist is brought to the Emergency department after being involved in a road traffic accident. He is unable to dorsiflex his right foot and has got reduced sensation over the dorsum of his foot. x Ray shows fracture of the right fibular neck.

A Common peroneal nerve
B Femoral nerve
C Lateral cutaneous nerve of thigh
D Lateral plantar nerve
E Medial plantar nerve
F Saphenous nerve
G Sciatic nerve
H Sural nerve
I Tibial nerve

Common peroneal nerve

Common peroneal nerve (L4-S2) injury is common following fracture of the neck of fibula. This nerve supplies the extensor and peroneal group of muscles of the leg. The sensory branches supply the anterior and lateral aspect of the leg, and whole of the dorsum of the foot and toes except the skin between the great and the second toe (supplied by deep peroneal nerve). Injury to this nerve results in foot drop and sensory loss over the anterior and lateral aspect of the leg, and dorsum of the foot and the toes.