Pancoast tumour, spinal cord, neck Flashcards
(160 cards)
1
Q
Where would pain be felt if a Pancoast tumour encases the C8 nerve root, and what would happen to the muscles in that area?
A
Medial two digits of the hand would be painful
The intrinsic muscles of the hand would atrophy
2
Q
Describe the pain that would be felt if a tumour interferes with the T1 nerve root?
A
Pain which radiates down the medial aspect of the arm and forearm, stopping at the wrist
3
Q
If there is a disruption to the sympathetic nerves of the eye, what symptoms occur?
A
- Ptosis
- Miosis
- Hemi-facial anhidrosis
- Loss of head and neck sympathetic tone
- Enophthalmos (sunken eyeball)
4
Q
What happens when tumour compresses the recurrent laryngeal nerve?
A
Hoarse voice and bovine cough
5
Q
Describe where first-order neuronal fibres arise and end in sympathetic innervation of the eye
A
Arise from postero-lateral hypothalamus
Descend through brainstem until termination at C8-T2
6
Q
Describe when second-order neuronal fibres arise and end in sympathetic innervation of the eye
A
Exit through T1 root, travelling close to lung apex through sympathetic chain and cervical-thoracic ganglion
Terminate in superior cervical ganglion
7
Q
Describe when third-order neuronal fibres arise and end in sympathetic innervation of the eye
A
Exit ganglion forming plexus around carotid internal.
Ascending into the cavernous sinus
Runs to eye via long and short ciliary nerves
8
Q
Describe the superior vena cava syndrome
A
Obstruction of the superior vena cava by a tumour (mass effect) causes facial swelling, cyanosis and dilatation of the veins of the head and neck
9
Q
Which fibres of the face cause sweating and tone to occur?
A
Vasomotor and sweat gland fibres - form plexus around external carotid artery
10
Q
Which order of neuronal fibres are affected by a pancoast tumour to cause horners syndrome?
A
Second order neuronal fibres- called a second order neuronal lesion
11
Q
Are pancoast tumours the only thing that can cause horners syndrome?
A
No - if any of the orders of neuronal fibres are affected in any way, the syndrome can appear
12
Q
Why does enopthalmos occur?
A
Loss of sympathetic supply to the eye causes narrowing of the palpebral fissure, causing the ILLUSION of enopthalmos
13
Q
How can upper limb swelling and discolouration be caused by a pancoast tumour?
A
Tumour growth in the lung apex can completely or partially compress the subclavian vein
14
Q
What problems in the upper limb can be caused by a pancoast tumour - and why?
A
Upper limb swelling and discolouration Loss of vascular tone (loss of sympathetic innervation) Oedema (failure of venous drainage) Tenderness Erythema Warmth
15
Q
Which anatomical structures allow the formation of three compartments within the thoracic inlet?
A
Insertion of the anterior and middle scalene muscle on the posterior scalene muscle (on second rib)
16
Q
What is found within the anterior compartment of the thoracic inlet?
A
Subclavian and internal jugular veins
17
Q
What is found in the middle compartment of the thoracic inlet?
A
Subclavian artery and some of its branches
18
Q
What is found in the posterior compartment of the thoracic inlet?
A
Brachial plexus branches, sympathetic trunk and cervical-thoracic ganglion
19
Q
What is a Pancoast tumour characterised by?
A
Malignant neoplasm of the superior sulcus of the lung with destructive lesions of the thoracic inlet and involvement of the brachial plexus and cervical sympathetic nerves
20
Q
What are the common clinical features of a Pancoast tumour?
A
- Pain radiating down the arm
- Atrophy of hand and arm muscles
- Horner’s syndrome
- Compression of blood vessels
- Oedema
21
Q
What type of cancer are Pancoast tumours normally?
A
Squamous cell carcinomas
Adenocarcinomas
22
Q
What is a main difference between a Pancoast tumour and classic lung cancers?
A
No breathlessness or coughing up blood
23
Q
How would a Pancoast tumour be diagnosed?
A
- Biopsy - supraclavicular incision
- Bronchoscopy
- X-ray
- CT
- MRI - spread
- PET - lymph node involvement
24
Q
What is the classical treatment for Pancoast tumours and what is the 5yr survival rate?
A
Pre-operative radiotherapy
Removal of chest wall, lower brachial plexus and part or the entire lung
Additional chemotherapy 30%
25
What is the management for disseminated pancoast tumours?
Palliative radiotherapy or surgery
26
What causes ptosis
Damage or lack of nerve supply to levator palpebrae superioris muscle and superior tarsal muscle
27
Give cause of miosis
The iris dilator muscle - responsible for dilatation of the pupil loses sympathetic innervation -inactivated
28
Which two sources do motor neurons receive input from?
Local sources - segmental reflexes
Descending tracts from brain - voluntary movement
29
Where does the lateral corticospinal tract decussate?
In the medulla
30
Where does the anterior corticospinal tract decussate?
At the level at which it leaves the spinal cord
31
Where in the white matter does the lateral corticospinal tract travel?
Immediately lateral to the dorsal horn
32
Where in the white matter does the anterior corticospinal tract travel?
Lateral to the anterior median fissure
33
Which two parts of the brain does the corticospinal tract travel through?
Internal capsule
Cerebral peduncle of the midbrain
34
Where do the axons of the corticospinal tract form ventral bulges, and what are they called?
In the medulla oblongata - known as pyramids
35
What is the difference in function between the lateral and anterior corticospinal tracts?
* Anterior - control trunk and proximal limb movement
* Lateral - precise, agile and highly skilled movements of hands and feet
36
What is the function of the corticobulbar pathway?
Controls skeletal muscles of the head
37
Which two areas of the brain does the corticobulbar tract pass through?
Internal capsule
Cerebral peduncle of the midbrain
38
Which nine cranial nerve motor nuclei, do axons of the corticobulbar tract terminate in?
* Oculomotor
* Trochlear
* Trigeminal
* Abducens
* Facial
* Glossopharyngeal
* Vagus
* Accessory
* Hypoglossal
39
What is the function of the tectospinal pathway?
Maintains balance and posture
40
Which neurons does tectospinal modulate the activity of?
Alpha and gamma motor neurons innervation muscles of the neck
41
What is the function of the vestibulospinal pathway?
Maintains balance and posture
42
What are the two parts of the reticulospinal tract?
* Pontine (extensor)
* Medullary (flexor)
43
What is the function of the reticulospinal tract?
Maintains balance and posture
44
What is the function of the rubrospinal tract?
Regulates upper limb muscle tone and movement
45
Where do the upper motor neurons arise in the rubrospinal tract?
The red nuclei of the midbrain
46
Where do upper motor neurons of the rubrospinal tract decussate?
Midbrain
47
Where in the White matter of the spinal cord will you find the dorsal column (medial lemniscus pathway)?
Posterior and medial to the dorsal horn
48
Why is the dorsal column/medial lemniscus path called this?
Dorsal column of the spinal cord
Medial lemniscus of the brainstem
49
Where do first order neurons of the dorsal column arise from and terminate at?
Arises from sensory receptors in limbs, trunk, neck, etc
Travels into the spinal cord, ascends up the ipsilateral side and terminates at the medulla (still ipsilaterally)
50
Where are the cell bodies for the first order neurons of the dorsal column found?
Dorsal root ganglion
51
What are the two dorsal columns in the white matter - and what sensations are carried in each?
Gracile fasciculus - touch, pressure and vibration from lower limbs Cuneate fasciculus - touch, pressure, vibration and conscious proprioception from the upper limbs, trunk and neck
52
Where do first and second order neurons synapse in the dorsal column?
In either the gracilis or cuneate nucleus
53
Where do the second order neurons of the dorsal column arise and terminate?
Arise in the cuneate of gracile nucleus, then decussate (in the medulla still) and enters the medial lemniscus Terminates in the ventral, posterior nucleus of the thalamus
54
Where do tertiary axons of the dorsal column arise and terminate?
Arise in the ventral, posterior nucleus of the thalamus
Terminates in the primary somatosensory area of the cerebral cortex
55
What sensations does the medial lemniscus pathway transmit?
Tactile sensations Proprioception
56
Where in the white matter is the spinothalamI c tract located?
Anterio-lateral to the ventral horn
57
What sensations does the spinothalamic tract carry?
* Pain
* Temperature
* Itch
* Tickle
58
Where do the first order neurons in the spinothalamic tract arise and decussate?
They arise at the receptor (in trunk, limbs, neck, posterior head)
They terminate in the dorsal horn on the ipsilateral side
59
Where do the second order neurons in the spinothalamic tract arise and decussate?
They arise in the dorsal horn, and then decussate to the contralateral side They pass up the spinal cord They terminate in the ventral, posterior nucleus of the thalamus
60
Where do the third order neurons in the spinothalamic tract arise and decussate?
They arise in the ventral, posterior nucleus of the thalamus and travel to the primary somatosensory area (on the same side as the thalamus)
61
Where are the pre-ganglionic neurons of the sympathetic nervous system located?
Thoracolumbar region - T1-L3
62
Where are the pre-ganglionic neurons of the parasympathetic nervous system located?
The brainstem - CN III, VII, IX and XSacral region- S2-4
63
Where are the ganglia of the sympathetic nervous system located?
In the sympathetic trunk - next to the vertebral column from T1 to the coccyx
64
Where are the ganglia of the parasympathetic nervous system located?
Near the targets organ - in the walls of the viscera they innervate
65
What is the function of the sympathetic nervous system?
Increased heart rate Decreases gut activity Dilates pupils
66
What is the function of the parasympathetic nervous system?
* Decreased heart rate Increased gut motility
* Pupil constriction
* Increase in secretions
67
What organs are only supplied by the sympathetic nervous system?
* Sweat glands
* Adrenal medulla
* Hair follicles
* Spleen
* Iris dilator
68
What organs are only supplied by the parasympathetic nervous system?
Ciliary muscles - focusing the eyeIris sphincter
69
Outline the basic segmental organisation of the spinal cord nerves
* Cervical (8)
* Thoracic (12)
* Lumbar (5)
* Sacral (5)
* Coccygeal (1)
Each segment gives rise to a pair of nerves
70
What is the lower limit of spinal cord?
* L1/2 in adults
* L3/L4 in newborn
71
Where do the spinal nerves leave the spinal cord?
Through intervertebral foramen C1 to C7 above their appropriate vertebrae C8 to Coc1 below ther appropriate vertebrae
72
What does the spinal cord develops from?
Neuro-ectoderm
73
From what does dorsal horn develop and what fibres it contain?
From alar plate, incoming sensory fibres
74
From what does ventral horn develop and what fibres it contain?
Basal plate, motor outputs to the periphery
75
Name the meninges from innermost to outermost layer
Pia mater, Arachnoid mater, dura mater
76
Describe dura mater
Thick elastic membrane, fuses with the endosteum of cranium at the foramen, epidural space separates the dura and the vertebrae
77
Describe arachnoid mater
Thin, fibrous membrane
Bridges the subarachnoid space which contains cerebrospinal fluid
78
Describe pia mater
Unicellular membrane
Forms 21 denticulate ligaments laterally
Separated from the cord by the subpial space
79
What is the cerebrospinal fluid?
A filtrate of blood made in the choroid plexus within the ventricular system of the brain
Affords mechanical and immunological protection to the brain and spinal cord
Reabsorbed into the venous drainage system of the head
80
How much cerebrospinal fluid is produced each and how much circulates at one time?
500 ml each day 140 ml within the subarachnoid space
81
What bridges the subarachnoid space?
Trabeculae
82
Describe the venous drainage of the spinal cord
By Batson veins which form vertebral/Batson plexus in the epidural spae and invade the pia mater
83
What arteries supple the spinal cord?
Intercostal arteries give of 2 posterior spinal arteries and one anterior spinal artery
84
What is the artery of Adamkiewicz?
Artery given of by left posterior intercostal artery that supplies lower 1/3 of the spinal cord
Also called major anterior segmental medullary artery
85
What is foramen magnum?
Opening in the ocipital bone for the spinal cord
86
What is the lowest point of spinal cord called?
Conus medullaris
87
What is the collection of nerves below the spinal cord called?
Cauda equina
88
What is filum terminale?
Ligament that attaches to the sacrum and holds the spinal cord in place
89
What is the difference between epidural and spinal tap?
Epidural injection only goes to epidural space Spinal tap involves piercing the subarachnoid space to either draw CSF or administer drugs
90
name the types of axons
Aα
Aβ
Aδ
C
91
What are the properties of Aα axons?
Largest diameter 13-20 um
Speed - 80-120 m/sec
Sensory receptors: proprioceptors of skeletal muscle
92
What are the properties of Aβ axons?
Diameter: 6-12 um
Speed: 35-75 m/sec
Sensory receptors: mechanoreceptors
93
What are the properties of Aδ axons?
Diameter 1 -5 um
Speed: 5-30 m/sec
Pain and temperature
94
What are the properties of C axons?
Diameter: 0.2 -1.5 um
Speed: 0.5 - 2 m/sec
Temperature, pain, itch
95
What are the borders of the posterior triangle of the neck?
* Posterior: Trapezius muscle
* Inferior: Omyhyoid muscle
* Anterior: Sternocleidomastoid muscle
96
Name the arteries that pass through the posterior triangle of the neck
* Transverse cervical artery
* Suprascapular artery
* Subclavian artery
97
Name the nerves that can be spotted in the posterior triangle of the neck
* Transverse cervical nerve
* Great auricular nerve
* Accessory nerve
* Phrenic nerve
* Brachial plexus
98
What lymph nodes are found in the posterior triangle of the neck
Superficial cervical nodes and supraclavicular nodes
99
What veins are associated with the posterior triangle of neck?
External jugular vein and subclavian vein
100
What does transverse cervical nerve supply?
Skin of the anterior neck triangle
101
Where does the phrenic nerve lie within the posterior triangle of neck
On the scalenous anterior muscle
102
Where does the brachial plexus lie within the posterior triangle?
Behind the scalenous anterior muscle
103
What is the origin and insertion of the scalenous medius muscle?
Cervical vertebrae to 1st rib
104
What do the superficial cervical nodes drain?
Skin area of posterior triangle and some anterior parts
105
Where is the stellate ganglion located?
Lies on the neck of the 2nd rib
106
What layers divide the lung from the other structures in the root of the neck?
Pleura and connective tissue
107
What are the boundaries of the root of the neck?
Top of the manubrium of the sternum + superior margin of the clavicle anteriorly,
Top of the thoracic vertebra TI + the superior margin of the scapula to the coracoid process posteriorly
108
What is the relationship of the lung with the root of the neck?
Upward projection of the pleural cavity, including the cervical part of the parietal pleura and the apical part of the superior lobes
109
To what vertebral level does the lung go?
Anteriorly: Above the the superior border of rib I Posteriorly: Below top of rib I
110
Where does the right subclavian artery begin?
Posterior to the sternoclavicular joint as a branch of brachiocephalic trunk
111
Where does the subclavian arteries become axillary?
As they cross the lateral border of rib I
112
How is the subclavian artery divided based on its relations to ___ muscle?
Anterior -\> posterio -\> lateral to anterior scalene muscle
113
What are the branches of the subclavian artery?
Vertebral artery, thyrocervical trunk, internal thoracic artery, costocervical trunk
114
Outine the course of vertebral artery
1st to branch 1. transverse foramen of C VI 2. crosses posterior arch of C I 3. enters the foramen magnum
115
Name the branches of the thyrocervical trunk
Inferior thyroid artery, transverse cervical, suprascapular arteries
116
Name the branches of costocervical trunk
Deep cervical artery, supreme intercostal arteries
117
Describe the course of the subclavian veins
Begin at lateral margin of rib I Anterior to scalene muscle Joined by internal jugular vein to form brachiocephalic trunk Tributary - external jugular veins
118
What is the origin of phrenic nerves
Cervical plexus - C3, C4, C5
119
Describe the course of the vagus nerve in the neck
Travels within the carotid sheath Posterior and in between the common carotid and internal jugular Gives of cardiac branches
120
How are the cervical ganglia of the sympathetic trunk connected to each spinal nerve?
By a gray ramus communicans
121
Name the cervical ganglia of the sympathetic trunk
Superior cervical ganglion Middle cervical ganglion Cervicothoracic ganglion / stellate ganglion
122
What fibers meet in the ganglia of the sympathetic chain? esp the cervical ganglia
Ascending preganglionic sympathetic fibres from upper thoracic spinal cord levels synapse with postganglionic sympathetic fibers
123
What does the superior cervical ganglion supply?
The internal and external carotid arteries Cervical spinal nerves C1 to C4 Pharynx Heart - superior cardiac nerves
124
What does the middle cervical ganglion supply?
Cervical spinal nerves C5-6 Heart - middle cardiac nerves
125
What does the cervicothoracic ganglion supply?
Spinal nerves C7-T1 Vertebral artery Heart - inferior cardiac nerves
126
What does the autonomic nervous system supply?
Eyes GI tract and glands Heart and blood vessels Lungs Reproductive and urinary systems Skin
127
What are the 2 divisions of the ANS?
Parasympathetic Sympathetic
128
What are the general roles of the sympathetic NS?
Dilates pupils Heart rate increased Constricts blood vessels Relaxes airways Stimulates secretions of epinephrine and norepinephrine Releases urinary bladder Stimulates male orgasm Gut activity decreased
129
Outline the general roles of the parasympathetic NS
Constrict pupils Decreased heart rate Increased gut motility and secretion Constricts airways Stimulates urinary bladder to contract Stimulates sexual arousal
130
What is the general anatomy of the fibres of ANS?
Preganglionic neuron and postganglionic neuron meet in ganglion where the body of the postganglionic neuron lies
131
Describe the anatomy of the sympathetic nervous system
T1-L3 Ganglia in sympathetic chain Axons enter ganglions through white rami comunicantes, Collateral ganglia - join spinal nerves through gray rami comunicantes and travel within their branches
132
Describe the anatomy of the parasympathetic nervous system
cranial nerves, sacral spinal cord S2-4, Ganglia in the walls of the viscera
133
Outline the sympathetic NS by its neurotransmitters
Preganglionic neuron - cholinergic (Ach) Postganglionic - Adrenergic, noradrenaline
134
Outline the parasympathetic NS by its neurotransmitters
Both neurons cholinergic
135
Outline the sympathetic supply to the eye
Cervical ganglions Internal carotid plexus 1. Branch of the ophtalmic nerve through the nasociliary root to become long ciliary nerve Through the sympathetic route to become short ciliary nerve Pupil dilation 2. Branch of occulomotor - superior tarsal muscles
136
What spinal nerves supply the brachial plexus?
C5, C6, C7, C8 and T1 = 5 roots
137
Name the trunks of the brachial plexus and what nerves supply them
* Upper/Superior - C5, C6
* Middle - C7
* Lower/Inferior - C8, T1 = 3 roots
138
How do the trunks of brachial plexus divide and what they produce?
Each trunk has posterior and anterior division = 6 divisions
139
What do the divisions of brachial plexus form?
3 cords
* Posterior cord - all the posterior divisions
* Lateral cord - anterior div of upper and middle trunks
* Medial cord - anterior division of lower trunk
140
What are the main branches of the posterior cord of the brachial plexus?
Axillary nerve and radial nerve
Other: upper and lower subscapular, thoracodorsal
141
Which branch of the brachial plexus is formed by lateral and medial cords?
Median nerve
142
What branches does the lateral cord of brachial plexus give of?
Musculocutaneous nerve
Median nerve
143
What branches does the medial cord of brachial plexus give of?
Ulnar nerve, median nerve
Others; medial cutaneous nerve of forearm and mc of arm
144
Describe the position of brachial plexus in relation to the clavicle
Roots and trunks are superior
Cords and their branches are inferior
145
What cervical nerve supplies elbow flexors?
C5
146
What cervical nerve supplies wrist extensors?
C6
147
What cervical nerve supplies elbow extensors?
C7
148
What cervical nerve supplies finger flexors?
C8
149
What cervical nerve supplies small finger?
T1
150
Draw and label a diagram of the posterior triangle of the neck
151
Draw and label a diagram of the root of the neck
152
Label the diagram, name the part of the spine and say what type of fibres is found in the area
153
Name the area of the spine, the circled area and what fibres are found there
154
What type of spine it is and what is the circled area
155
Name the are of the spine, the circled area and what nerve fibres are found there
156
157
158
Label
159
Name the vertebrae, label and state function of A and B
160
What are the dermatomes of the arm and where are they located? Draw a diagram
