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Numbness and Neuroscience for the Non-Neurologist/FRIDAY... · PDF file Conus Medullaris Cauda Equina Central Disc Herniation: •Saddle numbness •Bowel/bladder dysfunction •Neurosurgical

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Text of Numbness and Neuroscience for the Non-Neurologist/FRIDAY... · PDF file Conus Medullaris...

  • NUMBNESS AND TINGLING

    Neurology for the Non Neurologist

    Marcus Neuroscience Institute

    Update 2019

  • WHAT DO PATIENTS SAY?

    • If a patient complains of a “numb” body part,

    it may ironically mean lack of strength.

    • It is essential to then ask,

    • “Are you able to move the body part in question?”

    • This will help localize the lesion in the nervous system.

    • Lack of sensation seems less threatening than paralysis but may be serious.

    • Stroke patients when faced with a numb body part are unalarmed and may fail to seek help escaping the therapeutic window.

    • Sensory loss may be from a neoplasm in the sensory cortex or along a nerve.

  • WHAT DO PATIENTS SAY?

    • Patients believe numbness means “lack of circulation”. Two similar scenarios:

    • “My hand feel asleep.”

    • They shake their hand to “restore circulation”.

    • Median nerve compressed by flexed wrist whilst sleeping.

    • “My leg feel asleep.”

    • Shake the leg until sensation and strength returns.

    • Sciatic nerve compression against a hard chair edge

    • Unaware that moving the limb decompresses a nerve to allow it to recover.

  • LOCALIZATION

    • Is numbness from the central nervous system or peripheral nervous system?

    • Either location may be life threatening.

    • Brainstem stroke.

    • Acute polyradiculoneuropathy(Guillain Barre).

    • Both may progress to quadriparesis and respiratory compromise.

    • In the emergency department, diagnosis is a critical.

    • MRI and Reflex hammer are important.

  • •Central Nervous System

    • Cerebral Cortex

    • Basal ganglion

    • Brainstem

    • Spinal Cord

    •Peripheral Nervous System

    • Spinal Roots

    • Plexus

    • brachial or lumbar

    • Peripheral Nerves

    • Neuromuscular Junction

    • Muscles

    •Visceral Nervous System

    • Sympathetic

    • Parasympathetic

    SUBDIVISIONS OF THE NERVOUS SYSTEM

    On which floor will I spend my time?

    Neurology

    Department

    Store

  • THE TENDON REFLEX

    • Examiner must be confident that the absence of a reflex is not artifact.

    • Key clinical situations where reflexology is diagnostic.

    • Disappearing reflexes in GBS (diagnostic and for tracking progression)

    • Absent biceps reflex with thumb paresthesia (radiculopathy vs CTS)

    • Absent Achilles reflex with a foot drop (partial sciatic verse peroneal neuropathy)

    • Peripheral neuropathy pattern vs radicular pattern (bilateral vs. unilateral loss of ankle

    jerk)

    • Hyperreflexia with upper motor neuron weakness (stroke, ALS, tumor)

    • Decreased or increased reflexes showing metabolic state (calcium, magnesium)

  • PRIMARY SENSORY CORTEX (POST CENTRAL GYRUS)

    INFLOW

    1

    2

    3

    Anatomy determines clinical signs

    •Three neuron system organized somatotopically. • Dorsal Column

    • Large fiber system (waxed Lexus)

    • Proprioception and vibration

    • Cross at medullary level

    • Spinothalamic

    • Small fiber system (unpainted KIA)

    • Pain and temperature

    • Cross at spinal level (through Kissimee)

    Magic Kingdom

  • Kim, J. S. Neurology 2007;68:174-180

    CORTICAL REPRESENTATION OF PARESTHESIA

    Perioral or Finger Numbness

  • GBM PRESENTING AS NUMBNESS

    T1Flair

    C+

    T1 Flair

    C+

    T1Flair C-

  • HEMISENSORY LOSS

  • THALAMUS & VASCULAR SUPPLY

    From Stroke Made Simple by permission of the author N. Razack, M.D.,J.D. 2018

  • POSTERIOR INFERIOR CEREBELLAR (PICA) VERTEBRAL ARTERY STROKE

    • Glossopharyngeal and vagal fibers • Dysphagia, hoarseness, ipsilateral paralysis of vocal cord; ipsilateral loss of

    pharyngeal reflex, tachycardia

    • Vestibular nuclei • Vertigo, nystagmus, lateropulsion

    • Descending tract and nucleus of fifth nerve • Ipsilateral facial numbness

    • Spinothalamic tract • Contralateral body numbness

    • Solitary nucleus and tract • Taste loss on ipsilateral half of tongue posteriorly

    Adapted from Merritt’s Neurology From Ovid Full Text. NovaSoutheastern Institutional Subscription

    MNI 8/2018

  • CROSSED SENSORY LOSS

    Pain and Temperature

    Lateral Medullary Syndrome

  • T-4 nipple

    T-10 umbilicus

    L-5 big toe

    S-1 little toe

    SPINAL CORD SENSORY LEVELS

    Netter atlas

    Sacral Sparing in

    Central Cord lesion

  • PARESTHESIA

    • Thirty y/o woman presents with 2 week

    history (10/2018) of right leg numbness,

    thoracic dysesthesia that spread to the

    left foot then upward to the T4 level

    • Mild urinary urgency

    • Sent to emergency room for admission

    • ER physician was convinced she had a

    conversion reaction.

    • She had Multiple Sclerosis.

  • Netter Atlas

    CENTRAL CORD SYNDROME: SYRINGOMYELIA

    Shawl Hypalgesia

  • Sagástegui-Rodríguez, J. A. et. al. N Engl J Med 2002;346:1e

    CENTRAL CORD SYNDROME: SYRINGOMYELIA

    24 year old man with 3 years of progressive muscle wasting and sensory loss in his arms, dysphonia and dysphagia.

  • Netter Atlas

    VITAMIN B12 DEFICIENCY

    Paresthesia, loss of vibratory and position sense and glossitis

    myelopathy

  • Netter Atlas

    ROMBERGISM /SENSORY ATAXIA

  • Netter Atlas

    VITAMIN B12 DEFICIENCY

  • Scherer, K. N Engl J Med 2003;348:2208

    56-year-old woman with 4 months of progressive cognitive decline, weakness, incoordination, and gait disturbance

    SUBACUTE COMBINED DEGENERATION

  • VITAMIN B12 DEFICIENCY

    • Encephalopathy

    • Dementia and depression

    • Myelopathy (lower cervical first)

    • Peripheral neuropathy

    • Optic neuropathy

    • May have acute deficiency if borderline and exposed to NO either medically or recreationally

  • Conus Medullaris

    Cauda Equina

    Central Disc Herniation:

    •Saddle numbness

    •Bowel/bladder dysfunction

    •Neurosurgical emergency •Non-somatic nerves sensitive to pressure

    and may not recover

    CAUDA EQUINA SYNDROME

  • RADICULOPATHY

    • Shingles (herpes zoster)

    • Anesthesia dolorosa

    • Diabetes mellitus

    • Thoraco-abdominal radiculopathy

  • BRACHIAL PLEXOPATHY

    Parsonage Turner Syndrome

    Pain, paresthesia

    along with weakness

  • LENGTH DEPENDENT PERIPHERAL NEUROPATHY

    Vibratory loss

    Foot Drop

    Common Length Dependent Neuropathy

  • PERIPHERAL NEUROPATHY

    Sensory Ataxia

    Absent ankle

    jerk

    Cause of

    unexplained

    dizziness and

    falls

  • MONONEURITIS MULTIPLEX

    25 y/o woman

    presented to BRRH ED

    with numbness in left sup

    peroneal, right med cut n of

    forearm and right Ulnar n

    distribution underlying

    MCTD and vasculitis 8/2018

  • NEUROPATHY EXAMINATION

    • Pattern of weakness

    • Distribution and character of sensory loss

    • Nerve enlargement

    Above ulnar groove, Greater auricular nerve,

    Peroneal Nerve at the fibular head

    • Skeletal exam to exclude foot deformities

  • INHERITED PERIPHERAL NEUROPATHY

    Pes Cavus

  • CHAMPAGNE GLASS ATROPHY

    Loss of Medial Gastrocnemius Bulk

  • FOCAL PERIPHERAL NEUROPATHY WITH SENSORY COMPLAINTS

    • Median Nerve at the wrist

    • Carpal tunnel syndrome

    • Ulnar Nerve at the elbow

    • Cubital tunnel syndrome

    • Lateral cutaneous nerve of the thigh

    • Meralgia paresthetica

  • CARPAL TUNNEL SYNDROME

    • Paresthesia and pain in the wrist, hand and fingers, typically worse at night or on awakening from sleep

    • Paresthesia usually present in median distribution, often only at the tips of fingers

    • Pain and discomfort may involve the arm, shoulder and scapular

    • Weakness of thenar muscle occurs late

  • CARPAL TUNNEL SYNDROME SIGNS

    • Sensory impairment median distribution

    • Weakness of abductor pollicis brevis

    • Atrophy of thenar eminence (usually late)

  • CARPAL TUNNEL SYNDROME ETIOLOGY

    • Idiopathic

    • Reduced space in the carpal tunnel

    • Increased susceptibility of nerves to pressure

    • Associated conditions

    • Hypothyroidism, diabetes mellitus, pregnancy, acromegaly, wrist

    fracture, rheumato

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