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8/2/2019 Neurology Revision Lecture
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GUMSA teaching
Clinical Neurology
Mohamed Abdelhalim
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Main topics
Back pain
Spinal cord injury
Motor neurone lesions Peripheral neuropathy
Head injury
Assessment of conscious level
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Back Pain
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3 categories
Serious pathology (tumour or infection)
1-2%
Disc prolapse 5%
Non-specific low back pain
The rest
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Serious pathology RED FLAGS
Non-mechanical backpain
Thoracic pain
Past medical history
Unwell, fever, weight loss
Widespread neurologicalsymptoms
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And especially
Incontinence
Gait disturbance
Saddle anaesthesia
Cauda equina
syndrome!!
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Disc prolapse
Unilateral leg pain radiating to foot
Numbness and tingling in samedistribution
Localised symptoms/signs
Straight leg raise
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Non-specific low back pain
Lumbosacral, buttocks, thighs
Mechanical pain
Patient otherwise well
History of heavy lifting, twisting, etc
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Pathophysiology of non-specificlow back pain
musculoskeletal
soft tissue
degenerative changes
Psychological factors important in chronicpain
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Serious pathology (tumour or infection)
Refer NOW
Disc prolapse Refer soon
Non-specific low back pain
Treat with analgesia and keeping active Do not recommend bed rest
Rehabilitation if >6 weeks
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Spinal Cord Injury
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Questions to ask!
Is there leg weakness?
Is there sensory involvement?
Is there a motor and sensory level? Is there bowel and bladder involvement?
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Presentation
Depends on the level of the lesion
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Levels to remember
C3, 4, 5 keep the diaphragm alive
C3-T1 arms
T4 nipple line T10 umbilicus
L1-S3 legs
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Spinal Shock
Areflexia Hyperreflexia
Flaccidity Spasticity3 days
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A definition
A phase beginning immediately after aspinal cord injury during which all functionsof the distal segment of spinal cord are
depressed
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Spinal shock
X
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The bladder reflex
C
T
L2
L3
L4L5S1
L1
S2
S3S4
S5
Brain
+
-Consciousinhibition
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During spinal shock
C
T
L2
L3
L4L5S1
L1
S2
S3S4
S5
Brain
+
-Consciousinhibition
Retention withoverflow
X X
X
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After spinal shock
C
T
L2
L3
L4L5S1
L1
S2
S3S4
S5
Brain
+
-ConsciousinhibitionX
Automaticbladder
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Lumbar injury
C
T
L2
L3
L4L5S1
L1
S2
S3S4
S5
Brain
+
-ConsciousinhibitionX
Neurogenicbladder
X
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Sacral injury
C
T
L2
L3
L4L5S1
L1
S2
S3S4
S5
Brain
+
-ConsciousinhibitionX
Permanent
retention withoverflow
X
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Motor neurone lesions
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Brain
Medulla
Spinal Cord
Upper motorneurone
Lower motor
neurone
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UPPER LOWER
Power
Tone
Reflexes
Babinski
Musclewasting
Fasciculations
Weak Weak
Increased Reduced
Exaggerated Reduced
Upgoing + Downgoing -
No Yes
YesNo
Motor neurone lesions
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Peripheral Neuropathy
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Mononeuropathies
Mononeuropathy Multiple mononeuropathy
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Polyneuropathy
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Mechanisms
Demyelination
Axonal degeneration
Wallerian degeneration Infarction
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Common causes
Diabetes
Infarction
Alterations in polyol pathway cause
accumulation of fructose & sucrose inSchwann cells
Alcohol
Toxic to nerves
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Other causes
Autoimmune (RA, SLE)
Infection (HIV)
Hypothyroidism Kidney disease
Vitamin deficiencies
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Head Injury
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Classification
Primary
Local contusions
Shearing of axons
Secondary
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Bleeding
Extradural Subdural
Dura
Dura
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Intracerebral bleed
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Intracranial pressure
Munro-Kellie pressure/volume curve
Critical volume
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Midline shift
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Herniation
Tonsillarherniation
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Low BPHigh ICP
Reduced cerebralperfusion
CerebralIschaemiaHypoxia
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The ischaemic cascade
d
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The ischaemic cascade for 2nd yearexams
ISCHAEMIA
Glutamaterelease
Ca2+ influx Phospholipidpathway
Free radicals
Cell damage& infarction
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Assessment of conscious
level
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Glasgow Coma Scale
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Glasgow Coma Scale
Minimum score = 3
Maximum score = 15
Below 8 = ventilate
Why do we use it?
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Acute management of head injury
A Airway
B Breathing
C Circulation
D Disability
E Exposure
CT scan if indicated
Call neurosurgeon if necessary
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Questions?
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Spinal levels to remember
C3, 4, 5
C3-T1
T4
T10
L1-S3
keep the diaphragm alive
arms
nipple line
umbilicus
legs
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UPPER LOWER
Tone
Power
Reflexes
Babinski
Musclewasting
Fasciculations
Increased Reduced
Weak Weak
Exaggerated Reduced
Upgoing + Downgoing -
No Yes
YesNo
Motor neurone lesions
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Bleeding
Extradural haematoma Subdural haematoma
Dura
Dura
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Peripheral neuropathy
Mono- Multiple Poly-