Part 39 Flashcards
(222 cards)
1
Q
Principles of treatment for parkinson’s disease (2)
A
- reduce incidence and severity of symptoms
- delay progression of symptoms and complications
2
Q
Surgical approach to treatment for Parkinson’s
A
Last resort therapy particularly when drug treatment loses effectiveness, deep brain stimulation of the subthalamic nucleus or globus pallidus with high frequency electrical stimuli from implanted electrodes is a treatment of choice
3
Q
Levodopa (dopar) function, ADR’s (3), mech of action, drug interactions (1)
A
- drug of choice for parkinson’s disease at controlling tremor, bradykinesia, and rigidity
- limited duration of efficacy that diminishes over years (on-off effect), acceleration of disease process, cannot stop suddenly
- Promotes synthesis of dopamine in the striatum after being taken across blood brain barrier, is then converted to dopamine by dopa decarboxylase, (dopamine cannot get across BBB on own and has too short half life)
- 1st generation antipsychotics directly decrease therapeutic action
4
Q
Reasons patients have declined response to levodopa after years of therapy
A
- progressing disease
- decreased sensitivity of post synaptic receptors to dopamine
5
Q
2 patterns of acute loss of effect of levadopa
A
1) gradual loss “wearing off” at end of dosing interval
2) “on-off” phenomenon that can happen any time during dosing interval with off periods lasting minutes to hours and suddenly changing from mobility to immobility
6
Q
Drug holidays
A
May benefit some patients taking levodopa, brief 10 day interruption of treatment, when successful, beneficial effects are achieved with lower doses but will not correct “on=-off” phenomenon, must be done in hospital as patient may become immobilized
7
Q
Carbidopa + levodopa (sinemet) function, mech of action
A
- Most effective therapy for parkinson disease, more effective than levodopa alone
- Carbidopa which has no therapuetic effects on its own enhances actions of levodopa by inhibitng decarboxylases in periphery making more levodopa available to CNS but carbidopa cannot cross BBB so doesn’t affect it in the CNS (recall only 2% levadopa normally reaches brain, goes up to 10%)
8
Q
MAO-B inhibitors (selegiline) function
A
-Selective inhibitors of enzyme that metabolizes dopamine in the brain increasing amount of dopamine that can produce therapeutic effect when used adjunct to levodopa, unfortunately resistance quickly builds within 12-14 months, can delay early progression of parkinson disease when used alone
9
Q
Recent studies indicate selegiline (MAO-B inhibitor) may actually…
A
….cause more death than benefit
10
Q
Amantadine (symmetrel) mech of action, function, ADR (1 big one)
A
- Developed as antiviral that may be employed alone in early parkinsons disease or in combo with other drugs to improve symptoms modestly and decrease levodopa induced dyskinesias
- improves symptoms in 20-50% of patients but rarely lasts more than 6 months
- Livedo reticularis (rose colored to purple mottling of skin and legs, nonharmful)
11
Q
Anticholinergics for parkinson disesase and 2 examples
A
- Can be useful in control of symptoms of PD by blocking ability of acetycholine to reach receptors thereby improving balance between dopamine and Ach
- benztropine and trihexphenidyl
12
Q
Dopamine receptor agonists for Parkinson’s disease, mech of action, ADR’s (3)
A
- Effective monotherapy in early mild disease but in few years often require addition of levodopa
- Stimulate effects of dopamine by binding postsynaptic receptors, do not undergo conversion process
- Nausea, confusion, psychosis
13
Q
What kind of dopamine agonists do we use today?
A
Nonergoline
14
Q
COMT inhibitors function
A
-approved for adjunctive use with levo/carbidopa in parkinson patients who have end dose wearing off symptoms by prolonging half life of levodopa and decreasing parkinsonian disability, but can increase dyskinesia
15
Q
Tolcapone (tasmar) drug class and mech of action
A
- COMT inhibitor
- Adjunct to levodopa/carbidopa that prolongs half life of levodopa increasing amount that can cross the BBB
16
Q
Principles of migraine headache treatment (2)
A
- Management at abortive or symptomatic therapy of onset attack
- prevention of attack all together
17
Q
Drug of choice in mild migraine, moderate, and severe
A
- nonopiod analgesic (NSAIDs, excedrin migraine (ibuprofen+caffeine)
- triptans
- opioid
18
Q
Excedrin migraine content, clinical usefulness
A
- Acetaminophen, aspirin, caffeine
- readily effective in studies
19
Q
Theories to how NSAIDs alleviate migraine pain (3)
A
- inhibition of PG synthesis
- blocking platelet aggregation
- reducing serotonin release
20
Q
Indomethacin has a very specific ADR that should make it avoided in use of migraine patients
A
AVOID it regarding migraine treatment because it causes headaches
21
Q
Injectable ketorolac function
A
highly useful in resolving nausea and vomiting in migraine patients
22
Q
Serotonin 1B/1D receptor agonists (triptans) function, mech of action, ADR’s (3), drug interactions
A
- Allow for relief generally 60 minutes after administration
- analogue of serotonin that stimulates receptor subtypes causing vasoconstriciton of intracranial blood vessels
- Chest pain, coronary vasospasm (contraindicated in CAD patients), vertigo
- MAOI’s increase half life, SSRI’s can lead to serotonin syndrome
23
Q
Ergotamine function, mech of action, ADR’s (2)
A
- Used to stop an ongoing migraine attack and to treat cluster headaches not to be used on a long term basis (especially not daily)
- Direct vasoconstrictor of smooth muscle in cranial blood vessels and an agonist at serotonin receptors
- Ergotism (headache, NVD, gangrene of fingers and toes), Ischemia resulting in cold limbs and potential gangrene
24
Q
dihydrogotamine function, contraindications (2)
A
- Nonsedating serotonin agonist used as DOC for terminating severe refracatory migraine and cluster headaches and provides minimal peripheral vasoconstriction and little physical dependence (unlike ergotamine)
- CAD, peripheral vascular disease
25
butorphanol nasal spray function, administration, ADR's (2)
- An opioid agonist-antagonist nasal spray effective for relief of moderate to severe migraine
- One spray in one nostril, another in the other following 60 min, same 2 dose sequence repeated next 3-5 min
- Syncope, respiratory depression
26
Butterbur definition and use
Extract supplement given prophylactically in migraine patients that has been shown to have a 50% reduction or greater in headaches, can cause mild GI upset as common side effect
27
Most common type of dementia in patients >65 years old
Alzheimer's disease
28
Dementia definition
Syndrome characterized by progressive loss of cognitive functions that interfere with patients daily living as well as anterograde amnesia (cannot learn new things and have difficulty with language, abstract reasoning, judgement, visuospatial processing, etc)
29
What is NOT affected in dementia but is in delirium? (2 things)
Arousal and alertness
30
Short term memory is stored in the ___, long term memory is stored in the ___ and acquired via ____. Remote memory (>6 months to years) is stored in the ___, no longer requiring ____ for retrieval
Pre-frontal cortex, hippocampus, rehearsal, neo-cortex, hippocampus
31
Alzheimer's disease epidemiology
1 in 9 people age 65 and older, 1/3 age 85 and older, mean survival is 8-10 years from onset without treatment, but 15+ with treatment
32
Alzheimer's disease Risk factors, which is the greatest? (4)
- Age (greatest)
- Family and genetics
- Past head trauma
- Lifestyle and heart health
33
Alzheimer's disease clinical features (5)
- Anosgnosia (loss of awareness of one's own deficits)
- memory dysfunction
- personality change
- psychiatric disturbance
- late stage motor involvement
34
Clinical course of alzheimer's disease
Mild: memory/orientation
Moderate: activities of daily living
Severe: behavioral disorders, nutrition, hygiene
35
Alzheimer's effect on memory
-Immediate and short term are affected first, remote not impaired until disease advances
36
Apraxia definition
loss or impairment of ability to execute complex coordinated movement usually a later finding of alzheimer's disease
37
Sundowning theory
Theorized to be due to remote memory remaining in an alzheimer's patient despite lack of short term memory causing them to be triggered at certain points later in the day to be confused as to why their routine from their remote memory is interrupted leading to distress
38
Alzheimer's disease diagnostic criteria (5)
- progression over 6 months
- anterograde amnesia
- multiple cognitive deficits
- impairment in functioning
- other conditions ruled out
39
Best diagnostic study for mild cognitive impairment
Montreal cognitive Assessment (MOCA) (better than the mini mental status exam)
40
Alzheimer's diagnostic studies (5)
- CBC, electrolytes, TSH, B12 (checking if infection or other cause for symptoms in elderly)
- CT or MRI (rule out)
- EEG (rule out nonconvulsive seizures)
- Lumbar puncture (not routine, rule out metastatic cancer, hydrocephalus, etc)
- Genetic councilor referral (amyloid ligand PET imaging not typically covered by insurance)
41
There is no ____ for screening for Alzheimer's
Gold standard
42
Alzheimer's disease is a diagnosis of...
...exclusion
43
MRI findings Alzheimer's disease (2)
- Diffuse cerebral atrophy in frontal, temporal, and parietal lobes
- Hippocampal atrophy
44
Microscopic findings of Alzheimer's disease (3)
- Neurofibrillary tangles in hippocampus
- neuritic plaques containing amyloid in cortical cells
- granular-vacular degernation of neurons especially in hippocampus
45
Alzheimer's disease pathophysiology
-Reduced amount of acetycholine and reduced activity in entire cholinergic pathway (basal forebrain to cortex and hippocampus)
46
Treatment for Alzheimer's is ____ not ____
palliative (preservative), curative
47
Drugs to slow progression of Alzheimer's (2)
- Acetycholine and butylcholine esterase inhibitors
- N-methyl-D-aspartate receptor antagonists (NMDA)
48
Alzheimer's disease admission criteria (5)
- acute illness cannot be managed by patient or caregivers at home
- short term admission for eval and adjustment to psychotropic meds
- short term respite care
- long term care facility if cannot be provided at home
- hospice care if <6 months
49
Mild cognitive impairment in alzheimer's disease treatment (4)
- pharmacologic treatment not effective!
- exercise
- cognitive interventions
- long term planning
50
Moderate cognitive impairment in alzheimer's disease treatment (3)
- cholinesterase inhibitors recommended but benefit is modest
- vit E supplementation
- exercise
51
Severe cognitive impairment in alzheimer's disease treatment (4)
- Cholinesterase inhibitors
- Memantine
- antipsychotics to treat severe agitation and psychosis if dangerous
- management of comfort
52
Alzheimer's disease medications do not....
....work well for everyone
53
Vascular dementia definition
Dementia brought on by either multiple or singular (rare) infarcts decreasing adequate blood flow to the brain (ischemia, not necessarily stroke), begins as mild changes and worsens gradually leading to cumulative damage
54
Vascular dementia epidemiology
2nd most common cause of dementia, prevalence rises steeply with age
55
Vascular dementia risk factors (4)
- TIA
- Age
- High blood pressure
- High cholesterol
56
Emotionally labile meaning
Easily fluctuating without warning or transition
57
Vascular dementia clinical features (5)
- Memory impairment
- language disturbance
- impairment of motor skills
- emotionally labile
- Loss of intellectual skills more abrupt (progress in steps (flat then decline rapidly)
58
Middle cerebral infarct signs
Aphasia, confusion, anosognosia
59
Anterior cerebral infarct signs
Frontal lobe syndrome (dis-inhibition, poor planning, lack of initiative)
60
Posterior cerebral infarct signs
Visual distortions, hallucinations, cortical blindness
61
Thalamic infarct signs
Global cognitive and psychiatric dysfunction
62
Vascular dementia studies and which one is diagnostic (3)
- Neurocognitive exam
- Lab tests to rule out other etiologies
- CT and MRI is diagnostic
63
Treating vascular dementia sees more ___ than other kinds of dementia treatment
Cognitive improvement
64
Frontotemporal dementia (Pick's disease)
Clinical syndrome associated with shrinking of the frontal and temporal anterior lobes of the brain
65
Frontotemporal dementia 2 clinical categories
- Changes in behavior
- Problems with language
66
Behavioral changes in frontotemporal dementia (4)
- Inappropriate social behavior (sexually)
- lack of empathy
- agitation or blunting emotions
- repetitive or compulsive behavior
67
Language changes in frontotemporal dementia (2)
- Difficulty making or understanding speech
- spatial skills and memory remain intact
68
Frontotemporal dementia epidemiology
-Mean onset is 58 years old, 10-15% of all dementia, highly heritable
69
Frontotemporal dementia diagnostic studies (2)
- Clinical
- PET and MRI***
70
Frontotemporal dementia treatment options (2)
- management of symptoms
- off label use of antidepressants or antipsychotics
71
Key differences between alzheimer's disease and frontotemporal dementia (4)
- Age at diagnosis is clue
- Memory loss more prominent in early alzheimer's
- Spatial orientation more common in alzheimer's
- speech changes differ
72
Dementia with lewy bodies definition
Progressive dementia that leads to decline in thinking, reasoning, and independent function due to abnormal microscpic protein deposits (alpha synuclein protein) that damage brain cells over time
73
Dementia with lewy bodies epidemiology
-3rd most common cause of dementia
74
Dementia with lewy bodies symptoms (4)
- Parkinson's symptoms (closely related)
- REM sleep disorder
- visual hallucinations
- less memory loss than other dementias
75
Dementia with lewy bodies is a....
...clinical diagnosis
76
Hallmark finding of parkinson's disease dementia
-hallucinations
77
Antipsychotic drugs need to be used with extreme caution in what type of dementia?
Dementia with lewy bodies (may impair swallowing, cause acute episodes of hallucinations, or worsen parkinson's symptoms)
78
Key differences between dementia with lewy bodies and alzheimer's (2)
- Memory loss is more prominent in early alzheimer's
- Hallucinations and REM sleep disorder normal to see in early stage DLB than alzheimer's
79
Normal pressure hydrocephalus definition
Brain disorder which excess CSF accumulates in brain ventricles but pressure level normalizes because brain becomes compressed resulting in thinking and reasoning problems, difficulty walking, and loss of bladder control
80
Normal pressure hydrocephalus epidemiology
-Idiopathic and secondary occur equal proportions, idiopathic most common in adultts >60
81
Normal pressure hydrocephalus triad of symptoms
- Gait apraxia (shuffling along, feet glued to deck)
- decline in thinking (dementia)
- Bladder incontinence (late stage, does not improve)
82
Diagnosis for normal pressure hydrocephalus (2)
- MRI detecting enlargement of ventricles
- CSF tap and removal to see if symptoms improve
83
Normal pressure hydrocephalus treatment (1)
-Shunt of CSF to peritoneum
84
Huntington's disease
Progressive brain disorder caused by single defective dominant gene on chromosome 4 in which certain areas of brain start to break down causing emotional disturbances, loss of intellectual abilities, and uncontrolled movements (chorea)
85
Huntington's disease epidemiology
Age of onset ranges from childhood to 8th decade, most often in mid life
86
Huntington's disease symptoms (3)
- Uncontrolled movement of arms, legs, head, face, upper body (chorea)
- progressive decline in thinking and reasoning skills
- OCD often
87
Huntington's disease treatment (1)
-Management of symptoms
88
Creutzfedlt-Jakob and other prion disease definition
-Class of dementias caused by abnormal form of proteins in brain known as prions, characterized by spongy appearance of brain tissue leading to classification as transmissible spongiform encephalopathies (TSE's)
89
Creutzfedlt-Jakob and other prion disease symptoms (3)
- Psychiatric symptoms
- rapid cognitive decline
- abnormalities in walking and balance
90
Creutzfedlt-Jakob and other prion disease diagnostic studies (3)
- CSF analysis
- Electroencephalogram
- MRI
91
Creutzfedlt-Jakob and other prion disease treatment and prognosis
- No cure, management of symptoms
- 2 year fatality
92
What kind of changes in the brain are hallmarks of alzheimer's?
-Amyloid plaques and neurofibratory tangles
93
What type of dementia is associated with chronic alcoholism
Korsakoff syndrome
94
Multiple sclerosis definition
Immune mediated process in which immune system attacks the CNS damaging the myelin sheaths that insulates the nerve itself and oligodendrocytes, damage disrupts the signal resulting in symptoms associated
95
MS pathophysiology
Autoreactive T cells cross the BBB start a series of cellular reactions secreting proinflammatory cytokines once in the CSF which causes microglia and astrocytes to activate and turn on proinflammatory cytokines that then causes demyelination and axonal injury, also damaging oligodendrocytes so they cannot repair the myelin sheaths
96
Theories of MS causes (4)
- Geography from equator (less vit D)
- smoking
- obesity
- infections such as epstein barr
97
MS epidemiology
Age range 20-40 most often to diagnose, more common in females 3:1 ratio, more common in whites
98
MS presentation (4)
- Episode of vision loss (typically 24 hours)
- one sided numbness
- vertigo of 24 hrs
- fatigue (85% of patients, huge underlying symptom)
99
Optic neuritis definition, 2 diagnostic studies, is it a diagnosis of MS?
- Blurred vision or vision loss in one eye or both (sometimes just the color) alongside pain with extraocular motion associated with demyelinating damage to the optic nerve
- MRI of orbits, ANA antibody
- Not always associated with MS, about 50%
100
Relapsing remitting MS
Most common form, 85%, characterized by clearly defined attacks of new symptoms of one sided weakness and numbness which are called relapses, symptoms may be permanent or improve, see periods of stability between relapses, disability accumulates after multiple relapses
101
Treatment of relapsing remitting MS episode (2)
- Steroids to shorten duration of attack but doesn't change disease outcome
- treat underlying cause of episode
102
Secondary progressive MS
A slow progressive worsening of neurological function with or without relapse that is a progression from relapsing remitting episodes (25-40%) usually occurs about 20 years after diagnosis
103
Primary progressive relapse
15% of MS that sees slow progressive worsening of neurologic function leading to disability that does not occur episodically, can overlap with relapsing remitting MS slightly
104
Mcdonald criteria and what does it include?
What are the criteria? (2)
Standard to see if individual meets criteria to meet diagnosis of MS and begin treatment
- 2 symptoms of MS that occurred on separate locations (over lifetime) and imaging locations (2 separate locations) (dissemination in space)
- non-enhancing lesions from a long time ago and enhancing lesions from now on an imaging study or oligoclonal bands (dissemination in time)
105
MS workup (3)
- MRI
- Labs
- Lumbar puncture for oligoclonal bands (helps diagnose but negative doesn't rule out)
106
Radiographically isolated syndrome and clinically isolated syndrome in regards to MS
When the Mcdonald criteria are only partially met putting at elevated risk for MS development and requiring further monitoring than other patiens
107
Primary progressive MS diagnostic criteria (3)
-Evidence of one year progression
one or more T2 lesions characteristic of MS in periventricular, cortical or juxtacortical or infratenntorial areas
-2 or more hyperintense T2 lesions on spinal cord
-Presence of CSF specific oligoclonal bands
108
Diseases that mimic MS (6)
- Lupus, Sjogren's, sarcoid
- Infectious
- Endocrine
- Nutritional deficiency
- NMO/MOG: other demyelinating diseases presenting with optic neuritis but feature different antibodies
- Acute disseminating encephalomyelitis (post infectious, acute and rapid presentation)
109
2 approaches to MS treatment
- Low efficiency start (in good prognosis patients with low relapse, typical clinical picture, and low lesion burden) that may see more relapses
- High efficiency start (in poor prognosis patients with multifocal onset, atypical clinical picture, and many lesions on MRI)
110
MS treatment principles (4)
- trick immune system
- modify how immune system functions
- decrease immune system function
- keep immune system away from vulnerable sites
111
Oral MS treatment examples and notes about each (3)
- Terifunamide (aubagio): LFT elevation and category X for males and females pregnancy
- Dimethylfumarate (tecfidera): improving efficacy to 40-50%
- Mayzent/fingilmod: more effective, sequester immune cells to lymph nodes, 60-70% effective
112
Concern with infusion treatments (Natalizumab) for MS
Progressive multifocal leukoencephalopathy viral infection
113
Multidisciplinary treatment for MS (5)
- muscle relaxants for spasm
- medical marijuana (muscle spasms and nerve pain)
- Urinary symptoms treatment
- Mood treatment
- PT and OT
114
Comorbidities of MS (5)
- Hypertension
- Diabetes
- hyperlipidemia
- obesity
- sleep apnea
115
McDonald Criteria
- 2 or more clinical attacks, with 2 or more lesions objectively obtained= positive
- 2 or more clinical attacks, with 1 lesion objectively obtained and historical evidence of previous= positive
- 2 or more clinical attacks, with 1 lesion objectively obtained and dissemination in space (clinical or MRI)
- 1 clinical attack with 2 or more lesions objectively obtained and dissemination in time (clinical or MRI or CSF)
- 1 clinical attack with 1 lesion objectively obtained and dissemination in space and time
116
Dissemination in space and time definition
In relation to MS diagnosis where there must be enhancing lesions that indicate various time progression of the MS and space meaning in different locations.
117
Meningitis definition
Inflammation of the meninges any part or all 3 layers, most often the arachnoid mater and CSF in the subarachnoid space initially, caused by bacterial or viral exposure most often, common in newborn in elderly
118
3 vaccines that have drastically decreased rate of meningitis
- HIB
- meningococcal
- pneumococcal
119
Pathogenesis of meningitis
-Infection enters body, invades bloodstream, crosses BBB, invades meninges, and multiplies in the CSF
120
Most common ways meningitis can spread (3)
- Mother to child during birth
- cough or sneezing
- food prep
121
Neisseria meningitis characteristic appearance
Rash (bleeding under skin), poor prognosis
122
Bacterial vs viral meningitis
Bacterial is much more severe and fatal than viral
123
When a patient has suspected bacterial meningitis, need...
....immediate antibiotic treatment ASAP to improve prognosis
124
Most common organisms that cause bacterial meningitis (5) and what is the leading cause?
- Neisseria meningitidis
- strep pneumonia (leading cause in US)
- Listeria monocytogenes (in children and elderly)
- Group B streptococcus (children)
- E coli (children)
125
Clinical presentation of bacterial meningitis (3)
-Fever
-nuchal rigidity
-mental status change
(sudden acute onset of this)
126
Kernigs sign
Place patient supine with hip flexed at 90 degrees, attempt to extend leg at knee, positive when there is resistance to extension or pain in lower back or posterior thigh
127
Brudzinski sign
Place patient in supine and passively flex the head toward the chest, positive when there is flexion of the knees and hips in response
128
Viral meningitis usually preceded by a ___. It is usually ___
URI, self limiting
129
#1 cause of acute viral meningitis
-Enterovirus
130
Symptoms of viral meningitis vs bacterial
Viral is same as bacterial but much less severe except sometimes in immunocompromised patients
131
How to differentiate between viral vs bacterial meningitis? (3)
- Blood cultures (start antibiotics after empirically and don't take them after giving medication otherwise false neg)
- Lumbar puncture with CSF analysis
- Polymerase chain reaction viral testing
132
How many tubes of CSF are typically sent for any kind of analysis? What about in suspected subarachnoid hemorrhage with blood tinge?
3 tubes, 4 tubes
133
CSF findings in bacterial vs viral meningitis
Bacterial: cloudy appearance, leukocyte count is high, glucose low, protein high
Viral: CSF is clear, wbc count lower predominant lymphocytes, glucose normal range
134
Before getting Lumbar puncture with any concern of increased intracranial pressure, need to get...
....CT
135
dexamethasone in meningitis treatment
Used in viral and bacterial, reduces cerebral edema, increases ICP, and decreases neurological complications and mortality
136
Antibiotics for meningitis treatment (2)
- <1 month use ampicillin (listeria concern)
- vancomycin + 3rd gen cephalosporin (cefatoxine in <1 month or cephtriaxone in >1 month)
137
Post exposure prophylaxis for meningitis (3)
- rifampin
- single dose quinolone
- ceftriaxone
138
Encephalitis
Acute inflammation of the brain parenchyma associated with neurological dysfunction, often co-occurring with meningitis
139
#1 organism causing encephalitis
-Arbovirus
140
Signs/symptoms of encephalitis (1)
-Very similar to meningitis
141
Diagnostic testing for encephalitis (3)
- CT/MRI if evidence of increased intracranial pressure
- Lumbar puncture if no contraindications
- Blood culture
142
Brain abscess definition
Focal collection of pus within the brain parenchyma that can arise from a variety of infections, trauma, or surgery
143
Space occupying lesions increase....
...intracranial pressure (dont do an LP on em!)
144
Diagnostic studies for brain abscess and which is the gold standard (3)
- MRI
- CT
- Aspiration and culture (gold standard)
145
Venous sinus thrombosis definition
Uncommon but life threatening condition where clot forms in cavernous sinus (unknown what causes propensity to form) resulting in increased pressure, decreased perfusion, and leaking of blood into interstitial space
146
Signs/symptoms of venous sinus thrombosis (3)
- New onset headache
- intracranial hypertension
- encephalopathy
147
Diagnostic studies for venous sinus thrombosis (3)
- MRI/MRV
- CBC
- Coag panel
148
Treatment for venous sinus thrombosis (4)
- early anticoag
- antibiotics if infection present
- corticosteroids
- surgery if needed
149
Transverse myelitis definition
Demyelination of both sides of one section of spinal cord due to inflammatory process that leads to sensory and motor changes below the lesion as well as autonomic dysfunction, often idiopathic
150
Transverse myelitis diagnosis (3)
- MRI with contrast
- CSF
- autoimmune tests
151
Transverse myelitis treatment (2)
- Short course high dose corticosteroids
-methotrexate alternative
152
If pressure is above __ on opening pressure of lumbar puncture, withdraw and do immediate CT
18 mmH2O
153
Ways to avoid spinal headache following lumbar puncture (5)
- lay supine 2-3 hours
- fluids
- no heavy lifting 2-3 days
- tyelonol
- blood patch
154
Electroencephalogram (EEG) (what is it primarily indicated for?)
Tool to assess physiological electrical activities of brain not used to screen but as a diagnostic aid to evaluate seizure activity
155
EEG measurement
MEasures synchronous summation of millions of neurons discharging electrical activity at a given frequency in a specific spatial area of brain (called a montage) and done under certain activities (sleep, awake, etc) at any given age (infants thru adults)
156
EEG types (4)
- Awake (stimulus evoked with strobes, sounds, or smells)
- Sleep/sleep deprived
- Ambulatory (for more than one day)
- Video monitored (over a few days in hospital
157
Limitations to EEG (4)
- Poor spatial resolution (does not localize foci accurately)
- Measures only gyri
- thick hair
- patient cooperation
158
EEG alpha wave
Located posterior, present when patient is relaxed with eyes closed, if abnormal think coma
159
EEG Beta wave
Located symmetrical anterior, present when patient is alert, active, busy, if abnormal think of medication cause
160
EEG Theta wave
Located somatosensory cortex parietal lobe, present in sleep at any age, if abnormal think cognitive decline
161
EEG delta wave
Located frontal lobe in adults and occipital in children, present in deep sleep, if abnormal think lesions (tumor) or hydrocephalus
162
Difference between nerve conduction study and electromyography
NCS detects problem with nerve while EMG detects whether muscle is functioning properly in response to nerve stimulus and can be much more painful/uncomfortable
163
Nerve conduction study and electromyography indications (4)
- Paresthesias
- numbness
- tingling
- pain
164
3 types of evoked potential and a brief description about each
- brainstem auditory evoked potential (noninvasive to evaluate hearing loss with clicks, beneficial to localize lesions distal to cochlea CN VIII and distal)
- visual evoked potential (screening to evaluate optic neve damage that affects sight)
- somatosensory evoked potential (Measure response from stimuli to the spinal cord to help determine causes of numbness to the arms or legs thru tiny electrical shocks delivered by an electrode to a nerve indicated for spinal cord injury)
165
Lower back pain is the ___ most common reason to visit healthcare providers, up to __% of people experience it during their lifetime. The same percent of those seen in primary care will have ____ type lower back pain
- 2nd
- 80%
- nonspecific
166
Nonspecific back pain definition
Back pain in the absence of an underlying cause that is mostly musculoskeletal pain (mechanical cause) and does not warrant diagnostic testing and improves in a few weeks
167
The C and L spine should have a ___ curvature while the T should have ___
Lordosis, kyphosis
168
When documenting, don't need to cite specific muscle but describe location using anatomic clues example
Ex) paraspinal tenderness (important to differentiate between on the spinous process and on the muscle
169
As we age, ligaments of the back can lose elasticity becoming...
...hypertrophic which can result in compression of the spinal cord on the thecal sac or a slip of the disks
170
Sciatic nerve is formed from these roots...
...L4 to S3
171
Herniated disks can heal on their own because...
....the nucleus pulposis will dry and shrink over time after being herniated
172
2 Classifications of back pain based on duration
Acute - <4 weeks
Subacute - 4-12 weeks
Chronic - >12 weeks
Recurring - intermittent episodes with pain free periods
173
3 broad categories of back pain
1) nonspecific low back pain
2) serious systemic etiologies (spinal cord compression/cauda equina, metastatic cancer, epidural abscess, vertebral osteomyellitis)
3) less serious specific etiologies (vertebral compression fracture, radiculopathy, spinal stenosis)
174
Some other common etiologies of back pain (5)
- ankylosing spondylitis
- osteoarthritis
- scoliosis
- psychological
- pancreatitis/nephrolithiasis/pyelonephritis/herpes zoster
175
Mechanical risk factors for back pain (5)
- heavy physical work
- heavy lifting
- twisting and vibration
- posture
- obesity
176
Serious systemic etiologies for back pain (3)
- spinal cord compression/cauda equina syndrome
- metastatic cancer
- spinal epidural abscess or other infection
177
Suspected musculoskeletal back pain lasting over ___ should raise concern and confirm need to complete diagnostic studies
4 weeks
178
Cauda equina syndrome and symptoms (1 big one and 3 others)
Compromised canal of the spinal cord beneath L1 that needs emergent referral to neurosurgery to prevent permanent loss of function
- Urinary retention***
- perianal anesthesia
- decreased anal sphincter (late finding)
- herniated nucleus pulposis
179
Radiculopathy definition
Dysfunction of the nerve root causing pain, sensory impairment, weakness, decreased DTR in a nerve root distribution including things such as sciatica
180
Vertebral compression fracture and 3 risk factors and a key treatment
- Collapse of the vertebral body most often nonemergent concern that self limits
- older age, osteoporosis, steroid use
- kyphoplasty
181
Piriformis syndrome
Thickened piriformis muscle that puts pressure on sciatic nerve seen often in those that sit a lot on a bike or even some runners that can be a source of sciatica
182
Spinal stenosis definition
Narrowing of spinal canal that results in bony constriction of the cauda equina in patients greater than 65 from neurogenic claudication resulting in pain walking or standing that decreases when sitting or in spinal flexion
183
Ankylosing spondylitis
Inflammatory arthritis of spine causing chronic back pain most common in men under 40 characterized by morning stiffness that is improved with exercise and worsened (often awakening) in the night
184
Waddells sign
Psychologic distress contributing to back pain symptoms and display associated and inappropriate physical signs (overreaction during physical exam, superficial tenderness, improvement upon distraction, nondermatomal distribution of sensory loss)
185
Differential diagnosis of back pain without radiculopathy (6)
- musculoskeletal pain
- retroperitoneal neoplasm
- ankylosing spondylitis
- depression
- epidural abscess
- malingering
186
Differential diagnosis of back pain with radiculopathy (4)
- herniated nucleus pulposis
- spinal stenosis
- compression fracture
- malingering
187
Constitutional red flags of lower back pain (5)
- unintentional weight loss
- fever/night sweats
- night pain
- history of malignancy
- IV drug use
188
Bowel/bladder red flags of lower back pain (2)
-retention
-incontinence
(these are LATE findings!)
189
Patrick's FABER test and what 2 things does it test?
A test of flexion, abduction, and external rotation of the hips and SI joints
190
Straight leg raising
A test of keeping the knee straight while lifting leg up, if decreased on one side indicative of nerve root irritation in sciatica
191
Physical exam red flag findings for lower back pain (7)
- saddle anesthesia
- loss of anal sphincter tone (late finding)
- major motor weakness
- elevated temp
- vertebral tenderness
- extremely limited range of motion
- pain not reproducible by exam
192
Musculogiamentous strain and treatment options (5)
- Usually brought on by a precipitating event that causes sensation of giving way of back associated with severe pain, radiation is rare
- Rest and moderate activity, ice, NSAIDs, muscle relaxants (make drowsy and can't drive), PT
193
Contraindications to NSAIDs for lower back pain (4)
- peptic ulcer disease
- bleeding
- anticoags
- renal dysfunction
194
NSAID medication options for lower back pain (5)
- ibuprofen
- naprosyn
- relafen
- meloxicam
- celebrex
195
Opioids and systemic steroids provide no better benefit than ___
NSAIDs
196
Lumbar disc herniation classic presentation
Radiculopathy, burning pain along distribution of affected nerve root
197
Lumbar disc herniation treatments (3)
- 80% self resolve
- NSAIDS
- epidural steroid injections
198
Spinal stenosis is worsened with what motion?
Increased spinal extension
199
Pharmacologic treatment options for spinal stenosis (3)
- NSAIDs
- Acetaminophen if cannot tolerate them
- tramadol
200
Spondylosis vs spondylolysis vs spondylolisthesis
- Spondylosis is osteoarthritis of the spine causing wear and tear
- Spondylolysis is a defeect or stress fracture in the pars interarticularis (young athlete) giving scotty dog appearance on oblique film
- spondylolisthesis is a defect or fracture of bilateral pars resulting in slippage graded 1-5 needed to be stabilized with rods
201
Imaging for lower back pain
- not indicated for mechanical or acute pain less than 4 weeks
- if red flag (under 18 over 50) or fever
- plain x ray first
- MRI test of choice
- CT for fractures
202
Plain films advantages and limitations
+readily available
+easy to interpret
-limited to calcified areas such as bone
203
Indications for a skull series (3)
Trauma, congenital anomalies, and bone neoplasms
204
Indications for a cervical spine series (3)
Fractures, subluxations, or dislocations
205
A cervical lateral projection needs to have visibility down to...
...T1
206
Jefferson fracture
C1 fracture caused by diving into shallow pool, unstable breaking of the atlas
207
Odontoid fracture
C2 fracture caused by hyperflexion, extension, rotation, lateral flexion, sheering forces, unstable breaking of the dens
208
Hangman fracture
C2 fracture caused by hyperextension, unstable
209
MRI takes approx ___ while CT is near ___
45 min, immediate
210
Spondylosis vs spondylitis vs spondylolysis vs spondylolethesis
Osteoarthritis of the spine vs inflammation of the joints (look fused) vs fracture of pars interarticularis (scotty dog) vs forward slippage of vertebral body (something leaning wayyy too forward)
211
When to order CT (5)
- Fall over age of 65
- alcoholics
- substantial trauma
- Changes in mental status or being knocked out for over a minute
- new onset seizure
212
Supra vs infratentorial components
4th ventricle is infra while the rest are supra, the cerebellum and brainstem is infratentorial while the thalamus, basal ganglion, and cerebrum are supra
213
Epidural hematoma are ___ in origin, subdural hematoma are ___ in origin
arterial, venous
214
Most common location of epidural hematoma, what is the nickname for this syndrome? How do they need to be treated?
Middle meningeal artery, talk and die syndrome, evacuation to relieve intracranial pressure
215
Subdural hematoma are often caused by ___ or ____
Falls or motor vehicle accident
216
Subarachnoid hemorrhage are often caused by ____, predisposition for them can be caused by...
Aneurysm (sudden tunderclap headache)
-...familial inheritance
217
T1 vs T2 vs Flair MRI
T1 images have CSF appear as dark and T2 images have CSF appear as bright and Flair has T2 images but CSF is attenuated and made dark
218
Limitations to MRI (2)
- Inferior to CT in acute hemorrhage
- Inferior to CT in detection of bony injury
219
Stroke initial assessment is done thru ___ to confirm diagnosis before giving thrombolytic therapy, while later date once stabilized can send thru ___
CT, MRI
220
Cervical meylopathy
Central compression of the spinal cord causing bilateral clumsiness in hands and gait imbalance at the cervical spine
221
PET scans and what 3 things is it used for
- Nuclear medicine exams using a radioactive tracer
- used to detect early stage malignant disease, epilepsy, and dementia
222
Myelogram
A plain x ray or CT with injected dye into the subarachnoid space
