Approach to patient with spinal cord lesions & diseases
Localize spinal cord lesions
Determining the Level of the Lesion in Myelopathy
Diseases of spinal cord
This document discusses various pathologies that can cause damage to the spinal cord as seen on MRI. It focuses on diseases that appear as high signal on T2-weighted imaging. The most common etiologies are degenerative compressive myelopathy, inflammatory disorders, and demyelinating diseases such as multiple sclerosis. Imaging is important for determining the location, extent, and severity of abnormalities in order to accurately diagnose the underlying cause and guide treatment.
Lecture by Prof. Osama Shukir Muhammed Amin FRCP(Edin), FRCP(Glasg), FRCP(Ire), FRCP(Lond), FACP, FAHA, to consolidate information pre-Task Based Learning about Limb Weakness. This lecture addresses upper motor neuron signs, their localization, and rationale for choosing diagnostic investigations. The next lecture will be about lower motor neuron lesions.
1. The document discusses various causes of myelopathy including infectious, autoimmune, demyelinating, paraneoplastic, metabolic, toxic, and vascular etiologies.
2. Clinical features, imaging, cerebrospinal fluid analysis and differential diagnosis for different types of myelopathies are provided with key distinguishing factors between compressive vs non-compressive, inflammatory vs non-inflammatory myelopathies.
3. Specific conditions like acute transverse myelitis, neuromyelitis optica, HIV myelopathy, syphilitic myelopathy, and acute disseminated encephalomyelitis are summarized in detail.
This document summarizes several spinal cord lesions and syndromes:
- Upper motor neuron lesions cause spastic paralysis and exaggerated reflexes while lower motor neuron lesions cause flaccid paralysis and diminished reflexes.
- Complete cord transection results in paralysis and loss of sensation below the level of lesion as well as loss of bowel and bladder control.
- Brown-Sequard Syndrome occurs due to hemicord injury and causes ipsilateral paralysis and loss of sensation as well as contralateral loss of pain and temperature sensation.
- Syringomyelia causes a cavitation of the spinal cord which can result in loss of pain and temperature sensation as well as muscle weakness and spastic paralysis depending in the level and extent
Clinical Syndromes of spinal cord lesionsNabil Khalil
This document summarizes various syndromes that can result from spinal cord lesions. It describes incomplete cord syndromes like Brown-Sequard Syndrome and central cord syndrome. It also describes complete cord transection and the resulting loss of all sensory, motor and autonomic functions below the level of lesion. Specific syndromes involving different regions of the spinal cord are outlined, including anterior/posterior cord syndromes, conus medullaris syndrome, and cauda equina syndrome. The causes, clinical findings and prognosis are summarized for each syndrome.
This document provides an outline and overview of localisation in neurology. It discusses the history and examination in neurology, focusing on good listening skills and avoiding assumptions. It then covers the anatomy and blood supply of the brain and cerebral cortex. Specific sections discuss lesions of the frontal, parietal, temporal and occipital lobes and their associated signs and symptoms. Other topics include the internal capsule, aphasia syndromes, stroke syndromes involving different arteries, and involvement of various cranial nerves.
The pyramidal tract (corticospinal tract) originates from motor areas of the cerebral cortex and descends through the brainstem and spinal cord. It crosses to the opposite side and terminates on internuncial neurons which connect to motor neurons in the anterior horn of the spinal cord. The extrapyramidal tracts include the rubrospinal, vestibulospinal, reticulospinal, and tectospinal tracts and are involved in motor control and coordination. Damage to upper motor neurons in the pyramidal tract causes different paralysis than damage to lower motor neurons in the spinal cord.
This document discusses various pathologies that can cause damage to the spinal cord as seen on MRI. It focuses on diseases that appear as high signal on T2-weighted imaging. The most common etiologies are degenerative compressive myelopathy, inflammatory disorders, and demyelinating diseases such as multiple sclerosis. Imaging is important for determining the location, extent, and severity of abnormalities in order to accurately diagnose the underlying cause and guide treatment.
Lecture by Prof. Osama Shukir Muhammed Amin FRCP(Edin), FRCP(Glasg), FRCP(Ire), FRCP(Lond), FACP, FAHA, to consolidate information pre-Task Based Learning about Limb Weakness. This lecture addresses upper motor neuron signs, their localization, and rationale for choosing diagnostic investigations. The next lecture will be about lower motor neuron lesions.
1. The document discusses various causes of myelopathy including infectious, autoimmune, demyelinating, paraneoplastic, metabolic, toxic, and vascular etiologies.
2. Clinical features, imaging, cerebrospinal fluid analysis and differential diagnosis for different types of myelopathies are provided with key distinguishing factors between compressive vs non-compressive, inflammatory vs non-inflammatory myelopathies.
3. Specific conditions like acute transverse myelitis, neuromyelitis optica, HIV myelopathy, syphilitic myelopathy, and acute disseminated encephalomyelitis are summarized in detail.
This document summarizes several spinal cord lesions and syndromes:
- Upper motor neuron lesions cause spastic paralysis and exaggerated reflexes while lower motor neuron lesions cause flaccid paralysis and diminished reflexes.
- Complete cord transection results in paralysis and loss of sensation below the level of lesion as well as loss of bowel and bladder control.
- Brown-Sequard Syndrome occurs due to hemicord injury and causes ipsilateral paralysis and loss of sensation as well as contralateral loss of pain and temperature sensation.
- Syringomyelia causes a cavitation of the spinal cord which can result in loss of pain and temperature sensation as well as muscle weakness and spastic paralysis depending in the level and extent
Clinical Syndromes of spinal cord lesionsNabil Khalil
This document summarizes various syndromes that can result from spinal cord lesions. It describes incomplete cord syndromes like Brown-Sequard Syndrome and central cord syndrome. It also describes complete cord transection and the resulting loss of all sensory, motor and autonomic functions below the level of lesion. Specific syndromes involving different regions of the spinal cord are outlined, including anterior/posterior cord syndromes, conus medullaris syndrome, and cauda equina syndrome. The causes, clinical findings and prognosis are summarized for each syndrome.
This document provides an outline and overview of localisation in neurology. It discusses the history and examination in neurology, focusing on good listening skills and avoiding assumptions. It then covers the anatomy and blood supply of the brain and cerebral cortex. Specific sections discuss lesions of the frontal, parietal, temporal and occipital lobes and their associated signs and symptoms. Other topics include the internal capsule, aphasia syndromes, stroke syndromes involving different arteries, and involvement of various cranial nerves.
The pyramidal tract (corticospinal tract) originates from motor areas of the cerebral cortex and descends through the brainstem and spinal cord. It crosses to the opposite side and terminates on internuncial neurons which connect to motor neurons in the anterior horn of the spinal cord. The extrapyramidal tracts include the rubrospinal, vestibulospinal, reticulospinal, and tectospinal tracts and are involved in motor control and coordination. Damage to upper motor neurons in the pyramidal tract causes different paralysis than damage to lower motor neurons in the spinal cord.
1) Paraplegia is defined as impairment of motor function in the lower extremities, which can be caused by lesions in the cerebral cortex, spinal cord, nerves supplying the lower limbs, or muscles directly.
2) Complete paralysis of both lower limbs is known as paraplegia, while partial paralysis is called paraparesis. Lesions that transect motor tracts cause spastic paraplegia or quadriplegia with heightened reflexes.
3) Determining the level and type of spinal cord lesion is important for diagnosis and involves assessing sensory loss, motor weakness, reflex changes, and associated symptoms.
Upper motor neurons originate in the brain and convey signals for voluntary movement through descending pathways to lower motor neurons. Lower motor neurons originate in the spinal cord and brainstem and directly innervate skeletal muscles. An upper motor neuron lesion causes spastic weakness without atrophy while a lower motor neuron lesion causes flaccid paralysis with atrophy.
This document discusses cerebrovascular diseases and provides details on various types:
1. It describes cerebrovascular disease as any abnormality of the brain caused by blood vessels, including thrombosis, embolism, and hemorrhage.
2. Stroke is defined as a sudden neurological deficit due to a vascular impairment, which is a common cause of death in the US.
3. Details are given on global cerebral ischemia from reduced blood flow and focal ischemia from localized vessel obstruction.
The medulla oblongata is located at the caudal portion of the brainstem. It is approximately 3cm long and its upper limit is the cerebello-pontine angle, while its lower limit intersects the upper border of the atlas dorsally and the center of the dens ventrally. Internally, the lower end contains the upward continuation of the central canal of the spinal cord (closed part), while the upper end is where the canal comes to the surface as the lower part of the fourth ventricle (open part). Lesions in different areas of the medulla can cause various syndromes, such as the medial medullary syndrome (Dejerine syndrome) and lateral medullary syndrome (
This document provides guidance on evaluating patients presenting with paraplegia. It outlines the key components of the clinical history and neurological examination needed to determine the cause and level of spinal cord injury. The history should ascertain details of onset and any associated symptoms. The exam focuses on assessing sensory and motor function at different dermatomal and myotomal levels to localize the lesion. Together this information can indicate if the injury is acute, subacute, or chronic, and identify potential etiologies like trauma, infection, inflammation, compression, or vascular causes. The goal is to arrive at a diagnosis and localization of injury within the spinal cord or vertebrae.
This presentation briefly summarizes pathophysiology, clinical features, diagnosis and treatment of different types of tuberculosis of brain and spinal cord.
This document provides an overview of the cerebellum presented by Prof. Dr. Ansari for BDS semester-II students. It describes the parts and lobes of the cerebellum, cerebellar peduncles, blood supply, functions, and lesions. Specifically, it notes that the cerebellum has right and left hemispheres connected by the superior and inferior vermis, and contains the primary, secondary, and flocculonodular lobes which control muscle tone, skilled movements, and balance respectively. It also discusses the cerebellar peduncles and blood vessels that supply the cerebellum.
Spinal shock is the immediate temporary loss of total power, sensation and reflexes below the level of a spinal cord injury. It occurs in four phases as the spinal cord recovers. Phase 1 is complete areflexia lasting 1-3 days due to loss of descending facilitation. Phase 2 sees initial reflex return from denervation supersensitivity. Phases 3-4 involve hyperreflexia and spasticity as the cord grows new synapses. Spinal shock is managed by immobilization, monitoring, and high-dose methylprednisolone to prevent secondary injury if given within 3 hours of the initial trauma.
The document discusses various spinal cord syndromes classified as either complete or incomplete cord syndromes. It provides details on complete cord transection which results in paralysis, loss of sensation, and autonomic dysfunction below the level of injury. Brown-Sequard syndrome and central cord syndrome are discussed as examples of incomplete cord syndromes characterized by mixed upper and lower motor neuron findings on one or both sides of the body. The document also covers syndromes involving specific regions of the spinal cord including conus medullaris, cauda equina, and anterior spinal artery syndromes.
Stroke Syndromes - By Prof. Dr.Dhanarj.M (Sr.Consultant Neurologist)Ramesh Babu
This document discusses the localization of stroke syndromes through clinical evaluation. It outlines three steps: 1) clinically localizing the site of the lesion, 2) identifying the involved vascular territory and vessel, and 3) correlating with imaging findings. It then describes in detail the various anterior and posterior circulation stroke syndromes, highlighting the characteristic clinical features associated with lesions in different areas supplied by major arteries. The importance of careful clinical localization in combination with imaging to determine etiology and guide treatment is emphasized. Limitations where clinical evaluation alone may not be definitive are also noted.
medicine.Diseases of the spinal cord.(dr.hawar)student
1) Diseases of the spinal cord can be categorized as intramedullary (intrinsic) or extramedullary (extrinsic). Common causes of acute transverse myelopathy include trauma, tumors, infections, vascular disorders, and demyelination.
2) Cervical spondylosis is a degenerative condition that can compress the cervical cord, resulting in neck pain and stiffness as well as arm and leg symptoms.
3) Multiple sclerosis is a frequent cause of symmetric or asymmetric paraparesis in young adults, presenting with hyperreflexia and sensory ataxia.
Bulbar palsy refers to impairment of function of the cranial nerves IX, X, XI and XII, which occurs due to a lower motor neuron lesion either at nuclear or fascicular level in the medulla oblongata or from lesions of the lower cranial nerves outside the brainstem.
This document defines and describes Fulminant Hepatic Failure (FHF), also known as Acute Liver Failure (ALF). It provides definitions for different types of liver failure based on duration and presence of pre-existing liver disease. The document discusses the etiology, pathogenesis, clinical manifestations and stages of hepatic encephalopathy in FHF. It outlines the diagnostic workup and management approach for FHF, including initial stabilization, monitoring for complications, supportive care to maximize survival, and consideration of liver transplantation.
Focal segmental glomerulosclerosis (FSGS) is a kidney disease characterized by scarring in the glomeruli. It can be primary/idiopathic or secondary to other causes like viral infections, drugs, ischemia, etc. Patients often present with nephrotic syndrome. Treatment involves controlling blood pressure and proteinuria with ACE inhibitors/ARBs initially. For idiopathic FSGS with nephrotic syndrome, the first line treatment is corticosteroids. Mycophenolate mofetil or calcineurin inhibitors can be used as steroid-sparing alternatives. For steroid-resistant FSGS, calcineurin inhibitors like cyclosporine A are recommended.
This document provides an approach to evaluating a case of quadriparesis (weakness of all four limbs). It discusses obtaining a detailed history regarding onset and progression of weakness, risk factors, and family history. A neurological examination including assessment of upper and lower motor neuron signs is recommended. Various etiologies are considered depending on examination findings such as compressive vs. non-compressive myelopathy, motor neuron disease, subacute combined degeneration, anterior spinal artery syndrome, and myasthenia gravis. Differential diagnoses are formulated based on characteristics such as sensory involvement, reflex changes, symmetry of weakness, and associated symptoms.
The document provides an overview of an introductory lecture on approaching cases of motor and sensory disorders. It discusses why these disorders are often considered together due to shared routes in the brain and identification based on associated symptoms. The overall objectives are to localize the lesion anatomically and recognize the pattern to make an etiological diagnosis. The lecture aims to recap neuroanatomy, neurophysiology, clinical features using a symptom-based approach, pattern recognition, investigations, and key takeaways. Common motor pathways, sensory pathways, and reflex pathways are summarized. Symptom profiles, temporal patterns, and example neurological patterns are also outlined.
1. The cardinal signs of cerebellar dysfunction are ataxia, tremor, hypotonia, and asthenia. Tests include finger-nose coordination, rapid alternating hand movements, and gait.
2. Cerebellar lesions can cause dysarthria, scanning speech, nystagmus, and impaired eye movements like dysmetric saccades.
3. Clinical exams test arm and leg coordination through tasks like finger tapping, heel-shin rubbing, and tandem walking. Hypotonia is shown through floppy posture and pendular reflexes. Strength and endurance may also be reduced.
1. Cerebral edema occurs when there is abnormal accumulation of fluid in the brain parenchyma, increasing brain volume and intracranial pressure.
2. It can be caused by traumatic brain injury, stroke, tumors, or other conditions that disrupt the blood-brain barrier.
3. Increased intracranial pressure from cerebral edema can cause neurological deterioration and herniation if not treated.
4. Management involves controlling intracranial pressure, optimizing ventilation and oxygenation, administering osmotherapy agents like mannitol to draw water out of the brain, and in severe cases surgery may be needed.
The document discusses coma, including its definition, causes, clinical assessment, investigations, differential diagnosis and management. Coma is characterized by a total lack of arousal and awareness lasting at least 1 hour. It can be caused by structural brain injuries or metabolic derangements and represents a severe impairment of cerebral function. A systematic clinical approach is needed to identify treatable causes of coma such as head injuries, infections, drugs or toxic exposures.
Motor neurons are neurons that control muscles and glands. Their cell bodies are located in the brainstem or spinal cord, and their axons project to muscles. Motor neuron disease (MND) refers to conditions where motor neurons degenerate, leading to muscle weakness and atrophy. The most common type is amyotrophic lateral sclerosis (ALS), where both upper and lower motor neurons are affected. In ALS, muscles weaken and waste away as motor neurons die, and symptoms may include limb weakness, bulbar problems like slurred speech, and respiratory issues. The disease progresses as motor neurons continue to deteriorate over time.
1) Paraplegia is defined as impairment of motor function in the lower extremities, which can be caused by lesions in the cerebral cortex, spinal cord, nerves supplying the lower limbs, or muscles directly.
2) Complete paralysis of both lower limbs is known as paraplegia, while partial paralysis is called paraparesis. Lesions that transect motor tracts cause spastic paraplegia or quadriplegia with heightened reflexes.
3) Determining the level and type of spinal cord lesion is important for diagnosis and involves assessing sensory loss, motor weakness, reflex changes, and associated symptoms.
Upper motor neurons originate in the brain and convey signals for voluntary movement through descending pathways to lower motor neurons. Lower motor neurons originate in the spinal cord and brainstem and directly innervate skeletal muscles. An upper motor neuron lesion causes spastic weakness without atrophy while a lower motor neuron lesion causes flaccid paralysis with atrophy.
This document discusses cerebrovascular diseases and provides details on various types:
1. It describes cerebrovascular disease as any abnormality of the brain caused by blood vessels, including thrombosis, embolism, and hemorrhage.
2. Stroke is defined as a sudden neurological deficit due to a vascular impairment, which is a common cause of death in the US.
3. Details are given on global cerebral ischemia from reduced blood flow and focal ischemia from localized vessel obstruction.
The medulla oblongata is located at the caudal portion of the brainstem. It is approximately 3cm long and its upper limit is the cerebello-pontine angle, while its lower limit intersects the upper border of the atlas dorsally and the center of the dens ventrally. Internally, the lower end contains the upward continuation of the central canal of the spinal cord (closed part), while the upper end is where the canal comes to the surface as the lower part of the fourth ventricle (open part). Lesions in different areas of the medulla can cause various syndromes, such as the medial medullary syndrome (Dejerine syndrome) and lateral medullary syndrome (
This document provides guidance on evaluating patients presenting with paraplegia. It outlines the key components of the clinical history and neurological examination needed to determine the cause and level of spinal cord injury. The history should ascertain details of onset and any associated symptoms. The exam focuses on assessing sensory and motor function at different dermatomal and myotomal levels to localize the lesion. Together this information can indicate if the injury is acute, subacute, or chronic, and identify potential etiologies like trauma, infection, inflammation, compression, or vascular causes. The goal is to arrive at a diagnosis and localization of injury within the spinal cord or vertebrae.
This presentation briefly summarizes pathophysiology, clinical features, diagnosis and treatment of different types of tuberculosis of brain and spinal cord.
This document provides an overview of the cerebellum presented by Prof. Dr. Ansari for BDS semester-II students. It describes the parts and lobes of the cerebellum, cerebellar peduncles, blood supply, functions, and lesions. Specifically, it notes that the cerebellum has right and left hemispheres connected by the superior and inferior vermis, and contains the primary, secondary, and flocculonodular lobes which control muscle tone, skilled movements, and balance respectively. It also discusses the cerebellar peduncles and blood vessels that supply the cerebellum.
Spinal shock is the immediate temporary loss of total power, sensation and reflexes below the level of a spinal cord injury. It occurs in four phases as the spinal cord recovers. Phase 1 is complete areflexia lasting 1-3 days due to loss of descending facilitation. Phase 2 sees initial reflex return from denervation supersensitivity. Phases 3-4 involve hyperreflexia and spasticity as the cord grows new synapses. Spinal shock is managed by immobilization, monitoring, and high-dose methylprednisolone to prevent secondary injury if given within 3 hours of the initial trauma.
The document discusses various spinal cord syndromes classified as either complete or incomplete cord syndromes. It provides details on complete cord transection which results in paralysis, loss of sensation, and autonomic dysfunction below the level of injury. Brown-Sequard syndrome and central cord syndrome are discussed as examples of incomplete cord syndromes characterized by mixed upper and lower motor neuron findings on one or both sides of the body. The document also covers syndromes involving specific regions of the spinal cord including conus medullaris, cauda equina, and anterior spinal artery syndromes.
Stroke Syndromes - By Prof. Dr.Dhanarj.M (Sr.Consultant Neurologist)Ramesh Babu
This document discusses the localization of stroke syndromes through clinical evaluation. It outlines three steps: 1) clinically localizing the site of the lesion, 2) identifying the involved vascular territory and vessel, and 3) correlating with imaging findings. It then describes in detail the various anterior and posterior circulation stroke syndromes, highlighting the characteristic clinical features associated with lesions in different areas supplied by major arteries. The importance of careful clinical localization in combination with imaging to determine etiology and guide treatment is emphasized. Limitations where clinical evaluation alone may not be definitive are also noted.
medicine.Diseases of the spinal cord.(dr.hawar)student
1) Diseases of the spinal cord can be categorized as intramedullary (intrinsic) or extramedullary (extrinsic). Common causes of acute transverse myelopathy include trauma, tumors, infections, vascular disorders, and demyelination.
2) Cervical spondylosis is a degenerative condition that can compress the cervical cord, resulting in neck pain and stiffness as well as arm and leg symptoms.
3) Multiple sclerosis is a frequent cause of symmetric or asymmetric paraparesis in young adults, presenting with hyperreflexia and sensory ataxia.
Bulbar palsy refers to impairment of function of the cranial nerves IX, X, XI and XII, which occurs due to a lower motor neuron lesion either at nuclear or fascicular level in the medulla oblongata or from lesions of the lower cranial nerves outside the brainstem.
This document defines and describes Fulminant Hepatic Failure (FHF), also known as Acute Liver Failure (ALF). It provides definitions for different types of liver failure based on duration and presence of pre-existing liver disease. The document discusses the etiology, pathogenesis, clinical manifestations and stages of hepatic encephalopathy in FHF. It outlines the diagnostic workup and management approach for FHF, including initial stabilization, monitoring for complications, supportive care to maximize survival, and consideration of liver transplantation.
Focal segmental glomerulosclerosis (FSGS) is a kidney disease characterized by scarring in the glomeruli. It can be primary/idiopathic or secondary to other causes like viral infections, drugs, ischemia, etc. Patients often present with nephrotic syndrome. Treatment involves controlling blood pressure and proteinuria with ACE inhibitors/ARBs initially. For idiopathic FSGS with nephrotic syndrome, the first line treatment is corticosteroids. Mycophenolate mofetil or calcineurin inhibitors can be used as steroid-sparing alternatives. For steroid-resistant FSGS, calcineurin inhibitors like cyclosporine A are recommended.
This document provides an approach to evaluating a case of quadriparesis (weakness of all four limbs). It discusses obtaining a detailed history regarding onset and progression of weakness, risk factors, and family history. A neurological examination including assessment of upper and lower motor neuron signs is recommended. Various etiologies are considered depending on examination findings such as compressive vs. non-compressive myelopathy, motor neuron disease, subacute combined degeneration, anterior spinal artery syndrome, and myasthenia gravis. Differential diagnoses are formulated based on characteristics such as sensory involvement, reflex changes, symmetry of weakness, and associated symptoms.
The document provides an overview of an introductory lecture on approaching cases of motor and sensory disorders. It discusses why these disorders are often considered together due to shared routes in the brain and identification based on associated symptoms. The overall objectives are to localize the lesion anatomically and recognize the pattern to make an etiological diagnosis. The lecture aims to recap neuroanatomy, neurophysiology, clinical features using a symptom-based approach, pattern recognition, investigations, and key takeaways. Common motor pathways, sensory pathways, and reflex pathways are summarized. Symptom profiles, temporal patterns, and example neurological patterns are also outlined.
1. The cardinal signs of cerebellar dysfunction are ataxia, tremor, hypotonia, and asthenia. Tests include finger-nose coordination, rapid alternating hand movements, and gait.
2. Cerebellar lesions can cause dysarthria, scanning speech, nystagmus, and impaired eye movements like dysmetric saccades.
3. Clinical exams test arm and leg coordination through tasks like finger tapping, heel-shin rubbing, and tandem walking. Hypotonia is shown through floppy posture and pendular reflexes. Strength and endurance may also be reduced.
1. Cerebral edema occurs when there is abnormal accumulation of fluid in the brain parenchyma, increasing brain volume and intracranial pressure.
2. It can be caused by traumatic brain injury, stroke, tumors, or other conditions that disrupt the blood-brain barrier.
3. Increased intracranial pressure from cerebral edema can cause neurological deterioration and herniation if not treated.
4. Management involves controlling intracranial pressure, optimizing ventilation and oxygenation, administering osmotherapy agents like mannitol to draw water out of the brain, and in severe cases surgery may be needed.
The document discusses coma, including its definition, causes, clinical assessment, investigations, differential diagnosis and management. Coma is characterized by a total lack of arousal and awareness lasting at least 1 hour. It can be caused by structural brain injuries or metabolic derangements and represents a severe impairment of cerebral function. A systematic clinical approach is needed to identify treatable causes of coma such as head injuries, infections, drugs or toxic exposures.
Motor neurons are neurons that control muscles and glands. Their cell bodies are located in the brainstem or spinal cord, and their axons project to muscles. Motor neuron disease (MND) refers to conditions where motor neurons degenerate, leading to muscle weakness and atrophy. The most common type is amyotrophic lateral sclerosis (ALS), where both upper and lower motor neurons are affected. In ALS, muscles weaken and waste away as motor neurons die, and symptoms may include limb weakness, bulbar problems like slurred speech, and respiratory issues. The disease progresses as motor neurons continue to deteriorate over time.
Human reflexes
Definition: It is involuntary response of an organ to a stimulus.
- It is the arrangement of neurons through which the reflex is carried out.
- It is usually formed of:
Afferent (sensory) neuron.
2) An interneuron (may be absent).
3) nerve center (cell body of the efferent neuron).
4) Efferent (motor) neuron.
USMLE NEUROANATOMY 03 Descending pathway motor tract anatomy .pdfAHMED ASHOUR
Descending tracts are neural pathways in the central nervous system (CNS) that carry motor signals from the brain to the spinal cord. These tracts are responsible for transmitting commands from the brain to motor neurons, which then execute voluntary movements. These descending tracts collectively contribute to the coordination and execution of voluntary and involuntary movements. Injuries or lesions affecting the descending tracts can lead to various motor deficits, depending on the location and extent of the damage. Understanding the organization and function of these tracts is essential for diagnosing and treating motor disorders and neurological conditions.
1) Paraplegia is defined as impairment of motor function in the lower extremities, which can be caused by lesions in the cerebral cortex, spinal cord, nerves supplying the lower limbs, or muscles directly.
2) The document provides details on the causes, features, levels of lesions, and approaches to examining a patient with paraplegia. Common causes include trauma, tumors, tuberculosis, thrombosis, and transverse myelitis.
3) Based on the level and completeness of the spinal cord lesion, the features of paraplegia such as muscle tone, reflexes, and sensory involvement will differ. Determining the level of lesion is important for diagnosing the underlying cause.
1. The document discusses various levels of impaired consciousness ranging from confusion to coma and defines them. It also describes the anatomy of the reticular activating system and two patterns of coma - diffuse cerebral injury or focal brainstem injury.
2. Specific causes of diffuse cerebral injury or focal brainstem injury that can lead to coma are provided. Evaluation of a comatose patient involves assessing level of consciousness, brainstem reflexes, and determining if focal neurological signs are present.
3. Management may involve giving thiamine, dextrose, naloxone and flumazenil in cases of diffuse injury without a known cause. For focal injuries, neuroimaging is important to identify structural
This document discusses neurological examination and localization of lesions in the nervous system. It describes the steps in neurological diagnosis and provides information on localization of lesions at different levels of the neuraxis from the cortex to muscles. Key signs and symptoms are outlined for upper motor neuron and lower motor neuron lesions, as well as peripheral nerve disorders, neuromuscular junction disorders, and muscle disorders. Specific examination findings that help localize lesions in different parts of the brain, spinal cord, nerves, and neuromuscular junction are also summarized.
This document provides an overview of topics in applied neurosciences. It discusses the sensory system, special senses including the eye and ear, the motor system, cranial nerves, nerve conduction studies, EEG, neuro-microbiology, and several neurological disorders. Specific signs and symptoms of lesions in different areas of the nervous system are described. Various examination techniques for assessing the sensory and motor systems are also outlined.
The document provides information about the nervous system and various types of headaches. It discusses the organization of the nervous system including the central nervous system (CNS), peripheral nervous system, and divisions of the nervous system. It then summarizes assessment of the neurological system including history, physical exam, and diagnostic tests. Specific types of headaches discussed include migraine headaches, which often have an aura phase and are exacerbated by light and sound, and cluster headaches, which occur in distinct cluster periods with pain-free intervals in between. Treatment options for both migraine and cluster headaches are also outlined.
The document discusses the examination of the motor system including inspection of body posture, gait, muscles, reflexes, and strength. It describes normal reflexes like superficial skin reflexes and deep tendon reflexes. It then discusses the effects of lesions in different parts of the motor system including the cortex, internal capsule, brainstem, spinal cord, and peripheral nerves. Lesions can cause symptoms like paresis, hyperreflexia, pathological reflexes, and changes in muscle tone and strength. The location of the lesion determines whether symptoms present on one side of the body or both sides.
This document discusses peripheral nerve injuries. It begins by describing the structure and components of peripheral nerves. It then discusses the signs and symptoms of different types of peripheral nerve injuries like radial nerve, ulnar nerve and median nerve palsies. The document also covers the pathophysiology of nerve injury including Wallerian degeneration. It describes the diagnostic tools like electrodiagnostic studies and various treatment options for peripheral nerve injuries including nerve repair techniques.
The document discusses the anatomy and function of white matter tracts in the spinal cord. It provides classifications of tracts including ascending tracts that transmit sensory information to the brain and descending tracts that transmit motor signals from the brain to the spinal cord. It describes several specific tracts such as the lateral spinothalamic tract involved in pain and temperature sensation and the corticospinal tract that controls voluntary movement. It also discusses clinical correlates of injuries to different tracts.
SPINAL CORD TRACTS for students and health care workersnandiopande
The document discusses the classification and clinical correlates of white matter in the central nervous system. It describes the different tracts that make up white matter, including ascending tracts that carry sensory information upwards and descending tracts that carry motor commands downwards. It discusses the anatomy and functions of specific tracts such as the lateral spinothalamic tract, dorsal column, corticospinal tract, and extrapyramidal tracts. It also summarizes the clinical signs that result from lesions to different white matter pathways.
This document summarizes motor lesions involving the upper and lower motor neurons. It describes how voluntary acts require the integrity of both upper and lower motor neurons. It then discusses the effects of lesions in different areas, including the cerebral cortex, brainstem, spinal cord, and internal capsule. Key points include how lesions can cause paralysis, spasticity, changes in muscle tone and reflexes on the side opposite or same as the lesion depending on location.
Upper motor neurons convey impulses for voluntary motor activity and exert control over lower motor neurons, which directly innervate skeletal muscle. Upper motor neuron cell bodies are located in the motor cortex and premotor areas. Their axons form tracts that project to lower motor neurons in the brainstem and spinal cord. Lower motor neuron cell bodies are located in the brainstem and spinal cord. Damage to upper motor neurons results in spasticity and hyperreflexia, while lower motor neuron damage causes weakness, atrophy, fasciculations and hyporeflexia. Amyotrophic lateral sclerosis is a motor neuron disorder characterized by both upper and lower motor neuron degeneration.
The brachial plexus is formed by the ventral rami of cervical and thoracic spinal nerves C5-T1. It is vulnerable to injury from trauma such as motor vehicle accidents, falls, or excessive traction during childbirth. Injuries are classified based on the location and roots involved. Evaluation involves neurological and sensory exams along with imaging like MRI. Management may include physiotherapy, splinting, nerve grafts or transfers to restore function. The goals are restoration of elbow flexion, shoulder abduction, and medial forearm sensation. Surgical options depend on if the injury is open or closed.
1. A 32-year-old woman presented with progressive weakness of all four limbs over two months. Examination showed moderate weakness equally in all limbs without wasting, normal tone and reflexes, and no sensory issues, consistent with ALS.
2. An 18-year-old presented with sudden onset weakness of all four limbs for three days. Examination found weakness, diminished tone and reflexes, and vibration sense loss in the toes, consistent with transverse myelitis.
3. A 15-year-old girl reported right abdominal pain and right leg weakness for six months without bladder issues. Exam found spastic right leg weakness, absent lower abdominal reflex, and right lower sensation loss, consistent with a right
This document provides guidance on performing a neurological examination on cats to localize neurological lesions. It describes observing the cat's mentation, posture and gait. It then details examining the cranial nerves through tests like the menace response and pupillary light reflex. It also covers assessing spinal reflexes, cutaneous sensation, and pain perception. The goal is to integrate these examination findings to determine if there is a neurological abnormality and specifically localize it within the central or peripheral nervous system.
The document describes the examination and assessment of the motor system. It discusses the motorpyramidal system, which includes neurons in the cortex and anterior horn of the spinal cord. The examination involves assessing body position, gait, muscle inspection and palpation, reflexes, tone, and strength. Various types of paralysis or paresis are defined based on the number of limbs or parts of the body affected. Central paresis symptoms include muscle hypertension, decreased force, hyperreflexia, clonus, and pathological reflexes. Lesions in different parts of the motor system cause distinct patterns of weakness, including hemispheric, brainstem, spinal cord, nerve root and peripheral nerve lesions.
Similar to Myelopathy - spinal cord lesions.pptx (20)
A 3-year-old girl has had loose stools for 2 months that often contain undigested food. She is otherwise well and thriving. The most probable diagnosis is chronic non-specific diarrhea (toddler's diarrhea). Management includes decreasing fluid intake, especially of fruit juice, providing high-fat foods to slow gastric emptying, and increasing fiber intake through bulking agents. Pharmacologic intervention is rarely required as symptoms usually resolve spontaneously by age 3-4 years.
The document discusses infant feeding and nutrition. It covers various topics including the types and definitions of breastfeeding, the physiology of lactation, problems associated with breastfeeding, infant growth phases and their energy requirements, and the importance of proper nutrition. The key components of human milk are discussed, including fat, proteins, carbohydrates, oligosaccharides, prebiotics and probiotics. Guidelines around establishing and maintaining breastfeeding are provided. Common breastfeeding and infant feeding problems are also outlined.
Postpartum hemorrhage (PPH) is excessive bleeding after childbirth, defined as blood loss over 500 ml for vaginal births or 1000 ml for C-sections. The main causes of PPH are uterine atony (failure of the uterus to contract), retained placenta, and trauma to the genital tract. Management involves bimanual uterine massage, uterotonic drugs, vaginal packing, balloon tamponade, and in severe cases surgical interventions like B-Lynch sutures or hysterectomy.
This document discusses the use of various imaging modalities for evaluating neck masses. Ultrasound is useful for differentiating cystic from solid lesions and assessing lymph node size and vascularity. CT provides details of soft tissues and their relationships. MRI is good for lesion detection and involvement of nearby structures but has limitations for nodal assessment. PET/CT is excellent for staging lymphoma and detecting unknown primary cancers. Biopsy is used when malignancy is suspected. The approach depends on whether the mass is in a child or adult, with ultrasound often the initial study. Location provides clues for cystic lesions. Features help characterize solid lesions and lymph nodes. Further tests are guided by ultrasound findings.
This document provides information about fetal cardiotocography (CTG), including:
1. CTG can be performed from 28 weeks of gestation as that is when the fetal autonomic nervous system is mature.
2. Normal CTG findings include a baseline heart rate between 110-160 bpm, variability between 5-25 bpm, and an absence of or early decelerations with at least 2 accelerations in 20 minutes.
3. Abnormal findings include bradycardia (<110 bpm), tachycardia (>160 bpm), decreased variability (<5 bpm), and late or variable decelerations which can indicate fetal hypoxia or distress.
This document discusses the partogram, a tool for recording the progress of labor. It explains that the partogram graphs cervical dilation, fetal descent, and uterine contractions on a chart to allow healthcare providers to monitor labor and identify complications early. The document outlines the components recorded on a partogram, including fetal heart rate, amniotic fluid, maternal vital signs, and medications. It describes how to interpret the alert and action lines plotted on the partogram to determine if labor is progressing normally or requires intervention. The partogram is an important tool that facilitates continuity of care during labor and allows early detection of problems like prolonged or obstructed labor.
Gestational trophoblastic disease (GTD) is a spectrum of tumors caused by abnormal proliferation of placental tissue. It includes hydatidiform moles (complete and partial), which are usually benign, as well as gestational trophoblastic neoplasms like invasive moles, choriocarcinoma, and placental site trophoblastic tumors, which are malignant. GTD is diagnosed using clinical features, ultrasound findings, and elevated human chorionic gonadotropin levels. Treatment may involve D&C for molar pregnancies as well as chemotherapy for malignant or persistent cases. Long term follow up is important to monitor for recurrence or progression to gestational trophoblastic neoplasia due to the
Gametogenesis conversion of germ cells into male and female gametes.pptJwan AlSofi
Gametogenesis refers to the formation of male and female gametes. It begins with primordial germ cells that migrate to the developing gonads. Oogenesis involves the formation of ova through meiotic divisions in females, arresting in prophase I until puberty. Spermatogenesis is the formation of sperm in males through mitotic and meiotic divisions of spermatogonia into spermatids. Spermiogenesis then transforms spermatids into mature spermatozoa through nuclear condensation and tail formation. Abnormal gametes can form with extra nuclei or morphological defects preventing fertilization.
Development of the male& female genital system.pptxJwan AlSofi
The document summarizes the development of the male and female genital systems from an indifferent stage. It describes how in males, the presence of SRY leads testes to develop from indifferent gonads, while in females without SRY ovaries develop. It outlines the development of testes, ovaries, male ducts including epididymis and vas deferens, and female ducts including uterus and vagina from indifferent ducts. External genitalia also develop differently in males under testosterone versus females.
First week of development: Ovulation to Implantation Jwan AlSofi
The document summarizes key aspects of ovulation, fertilization, and early embryonic development. It describes the ovarian and menstrual cycles controlled by hormones like FSH and LH. Ovulation occurs mid-cycle due to an LH surge, releasing an egg. Sperm travel through the reproductive tract while undergoing capacitation. Fertilization typically occurs in the fallopian tubes, involving penetration of the egg's layers and fusion of gametes. This activates the egg and forms pronuclei, leading to cell division and pregnancy if implantation occurs. Otherwise, the corpus luteum regresses and menstruation begins.
Multiple sclerosis is a chronic disease characterized by inflammation, demyelination, and gliosis in the central nervous system. It affects around 5 million people worldwide. The cause is unknown but involves genetic and environmental factors. Symptoms vary widely and can include sensory disturbances, motor symptoms, visual problems, ataxia, and cognitive impairment. Diagnosis involves demonstrating dissemination of lesions in the CNS over time via MRI imaging or evoked potentials testing, and sometimes analysis of cerebrospinal fluid. There are several disease courses including relapsing-remitting MS, primary progressive MS, and secondary progressive MS. Management aims to reduce inflammation and disability progression.
This is a comprehensive approach to a hypertensive patient presenting to the emergency department.
Discussing:-
- Hypertensive emergency
- Hypertensive Urgency
- Hypertensive Crisis
- Hypertensive encephalopathy and retinopathy
- Accelerated Hypertension
- Malignant hypertension
1. Short stature can be caused by familial, constitutional, or pathological factors. Familial short stature runs in families while constitutional short stature involves delayed puberty.
2. Pathological short stature can be disproportionate involving abnormal limb ratios, or proportionate involving prenatal issues like IUGR or postnatal diseases/nutritional disorders.
3. Evaluating a short child involves assessing growth charts, growth velocity, bone age, family history, and screening tests to classify the cause of short stature.
Headache is a common symptom in children and adolescents, with up to 75% experiencing a significant headache by age 15. Headaches can be primary, such as migraines or tension-type headaches, or secondary to other conditions such as viral infections. A thorough history and physical exam are usually sufficient for diagnosis, though imaging may be required if symptoms suggest increased intracranial pressure. Treatment involves acute medication to stop attacks as well as preventive medication and lifestyle modifications if headaches are frequent or disabling.
Neonatal seizures are the most common neurological emergency in newborns. The majority occur within the first day of life, and hypoxic ischemic encephalopathy is the most common cause, especially in term infants. In preterm infants, cerebral vascular events are more often the cause. Neonatal seizures are usually focal and often have identifiable underlying causes, unlike seizures in older children which are often idiophenic. The prognosis depends on the underlying etiology, with hypoxic ischemic encephalopathy carrying the worst prognosis. Phenobarbital remains the first-line treatment, though multiple anticonvulsants may be needed to control seizures.
this is a complete discussion and an approach to a child with febrile seizure / convulsion.
It contains:-
Case scenario
Causes of Seizures in the setting of fever
Definition of Febrile Seizure
Age of Occurrence
Types of Febrile Convulsions
Risks of Recurrent Febrile Seizures
Risk For Developing Epilepsy After Febrile Seizures
Workup for Febrile Seizure
Red Flags in Febrile Seizures
Treatment
Prognosis
Approach to Syncope in Children (Pediatric Syncope).pptxJwan AlSofi
Approach to Syncope in Children (Pediatric Syncope), includes:-
Introduction
Differential diagnosis of syncope
Syncope vs vertigo vs Presyncope vs light-headedness.
Comparison of Clinical Features of Syncope and Seizures
Neurocardiogenic (Vasovagal) syncope
MECHANISMS and Causes of Syncope
Cardiac causes of syncope
Life-threatening causes of syncope
Red Flags in Evaluation of Patients With Syncope
Non-cardiac causes of loss of consciousness.
Noncardiac Causes of Syncope
Differentiating Features for Causes of Syncope
EVALUATION of syncope:- History, Examination,Treatment.
Summary
The infant in choice c presents with signs of moderate encephalopathy after a known perinatal hypoxic event and meets criteria for therapeutic hypothermia based on guidelines. The other infants presented do not meet criteria either due to prematurity, mild encephalopathy findings, or presenting outside the time window.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
Integrating Ayurveda into Parkinson’s Management: A Holistic ApproachAyurveda ForAll
Explore the benefits of combining Ayurveda with conventional Parkinson's treatments. Learn how a holistic approach can manage symptoms, enhance well-being, and balance body energies. Discover the steps to safely integrate Ayurvedic practices into your Parkinson’s care plan, including expert guidance on diet, herbal remedies, and lifestyle modifications.
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
2. Contents
1. Cases
2. Anatomy: Review and Upper/Lower Motor
Neuron Lesions
3. Paraparesis: Definition and Differential
Diagnosis
4. Spinal Cord Disease:
a. Clinical Features and Investigations
b. Etiology
c. Classical Spinal Cord Clinical Syndromes
d. Treatment
Jwan Ali AlSofi 2
4. Case 1
A 16-year–old girl, who was completely healthy before,
presented with both lower limb weakness that progress over
few hours with loss of sphincter control.
On examination she had spastic weakness of lower limbs
with hyperactive tendon reflexes, extensor planter bilaterally
with sensory level at level of the nipple. Upper limbs are
normal
Answer: Transverse Myelitis
Sensory level, means patients
has no sensation until that level.
Jwan Ali AlSofi 4
5. Case 2
A 23-year-old female patient presented with lower limbs
weakness over a period of 2 days she give history of visual
change and pain in her left eye before 6 months and an attack
of sensory loss in right side of the body before 3 months .
Answer: Multiple Sclerosis vs devic’s disease
Sudden in neurology usually indicate a vascular cause
Jwan Ali AlSofi 5
6. Case 3
A 22-year-old girl who had a bariatric surgery for obesity before
one year, presented with weakness and numbness of lower
limbs for 1 month. Her examination revealed weakness of lower
limbs, hyperactive reflexes in both knees, absent both ankle
reflexes and extensor planters. Position sense was impaired.
Answer:
Vitamin
B12
Deficiency
Jwan Ali AlSofi 6
7. Case 4
A 54-year-old man presents complaining of weakness. He has a difficult
time pinpointing an onset. He believes he first noticed weakness in his
right foot and leg about 6 months ago. He reports that he frequently trips
over his toes and drags his foot. He also gets frequent cramps when he
stretches in bed in the mornings. The weakness is progressing to involve
both legs now. On examination, you note tongue fasciculations. Deep
tendon reflexes are 3+ at the knees and ankles. Strength is 4– at the
extensors and flexors of the right foot and 4+ at the left foot. Hand grip
strength is also 4+.
Which of the following is the suspected pathologic cause of this patient’s
symptoms?
Answer: Degeneration of the corticospinal tracts & Loss of anterior horn cells in the spinal cord
Jwan Ali AlSofi 7
9. • UPPER MOTOR NEURONS (UMN) start from
cerebral cortex, passes through internal capsule,
corticospinal tracts, and ends at cranial nerve nuclei
in brain stem or anterior horn cells of spinal cord at
different levels. The axons of upper motor neurons
are contained within the pyramidal system, which is
composed of the corticospinal (pyramidal) and
corticobulbar tracts.
• LOWER MOTOR NEURONS (LMN) start from nuclei
of cranial nerves or anterior horn cells of spinal cord,
extend through cranial /spinal nerves and ends at
motor end plate of concerned muscle.
Jwan Ali AlSofi 9
13. Lower Motor Neuron Lesions (LMNL)
- Lower motor neuron lesion:- Anterior horn cell nerve root plexus
peripheral nerve neuromuscular junction muscle
- Anterior Horn Cell (Polio and Motor Neuron Disorder)
- Nerve Root Plexus (Neuropathy, DM (cc), Nutritional and
Genetic)
- Peripheral Nerve (Weakness (Flaccid), Hypotonia,
Hyporeflexia/Areflexia, Abdominal Reflexes present, and
Wasting/Atrophy.
- Neuromuscular Junction Muscle
Atrophy is a late feature of UMNL, but an early feature of LMNL.
Jwan Ali AlSofi 13
14. UMN LESIONS LMN LESIONS CEREBELLAR
LESIONS
NM TRANSMISSION
DISORDERS
MYOPATHIC
DISORDERS
1. Weakness or
paralysis
2. Spasticity
3. Increased
tendon reflexes
4. Extensor
plantar
(Babinski)
response
5. Loss of
superficial
abdominal
reflexes
6. Little, if any,
muscle atrophy
1. Weakness or
paralysis
2. Wasting and
fasciculations of
involved muscles
3. Hypotonia
(flaccidity)
4. Loss of tendon
reflexes when
neurons
subserving them
are affected.
5. Normal
abdominal and
plantar reflexes—
unless the
neurons
subserving them
are directly
involved, in
which case reflex
responses are
lost.
1. Hypotonia
2. Depressed or
pendular tendon
reflexes
3. Ataxia—
- Dysmetria
- Dysdiadocho
kinesia
- Dyssynergia
- Intention
tremor
- Rebound
phenomeno
n
4. Gait disorder
5. Imbalance of
station
6. Nystagmus
7. Dysarthria
1. Normal or reduced
muscle tone
2. Normal or depressed
tendon and superficial
reflexes
3. No sensory changes
4. Weakness:
- often patchy in
distribution,
- not conforming to
the distribution of
any single
anatomic
structure;
- frequently involves
the cranial muscles
- may fluctuate in
severity over short
periods,
particularly in
relation to activity.
1. Weakness,
usually most
marked
proximally
rather
than distally.
2. No muscle
wasting or
depression of
tendon
reflexes,
at least until an
advanced stage
of the disorder.
3. Normal
abdominal and
plantar
reflexes.
4. No sensory
loss or
sphincter
disturbances.
Jwan Ali AlSofi 14
15. Why does Upper Motor Neuron Lesion presents this way?
One of the functions of the Corticospinal tract is the control of the
AHC through an inhibitory effect. When this is unable to function,
then the Motor Neurons work haphazardly by firing more than
normal due to lack of inhibition.
Why in Lower Motor Neuron Lesion, the reverse occurs?
Since the lesion is possibly in the AHC, then the action potential
does not travel to it’s intended destination, leading to lowered
action.
Jwan Ali AlSofi 15
19. Basic Neuroanatomy and
Function
1. Pyramidal Tracts (lateral corticospinal tract and anterior
corticospinal tract)(descending tract)
• Descending tracts originate in the cerebral cortex and
extend to the alpha (α) motor neuron in the ventral horn
of the spinal cord.
• About 90% of pyramidal neurons decussate as they pass
through the medulla and descend further as the lateral
corticospinal tract.
• The remaining 10% continue as the anterior corticospinal
tract and decussate a the segmental level.
• Function: controls motor function.
Jwan Ali AlSofi 19
20. 2. Posterior Column (posterior funiculus consisting of gracile
(Medial - LL) and cuneate (Lateral - UL) fasciculi)
• Decussation at the medulla oblongata.
• Remains ipsilateral in the spinal cord
• Function:
a)Conveys epicritic sensation: fine touch,
vibration, pressure
b)Conveys proprioception: awareness of position
in relation to one's body in space.
3. Spinothalamic Tract (anterior spinothalamic tract and lateral
spinothalamic tract) – Only cord that decussates!
• Decussation only at segmental level or shortly above.
• Function: conveys protopathic sensation (contralateral
temperature, pain stimuli, and crude touch).
Jwan Ali AlSofi 20
21. UMNL Disease:
1. Stroke (90%), main cause.
2. Space-Occupying Lesion.
3. Multiple Sclerosis.
4. Encephalitis.
• Hemiparesis occurs as the blood supply for the corticospinal
tract becomes affected and thus’ dies.
LMNL Disease:
1. Neuropathies, such as…
2. Disease of AHC, such as…
• Poliomyelitis, a virus that directly affects the AHC.
• ALS.
Jwan Ali AlSofi 21
23. Blood supply of spinal cord
■ Spinal cord is supplied by:-
1. One anterior spinal artery (from vertebral artery)
■ This artery perfuses the anterior portion of the spinal cord! The majority
of the spinal cord is perfused by the anterior spinal artery (with the
exception of the dorsal column which falls in the posterior spinal artery
territory).
2. Two posterior spinal arteries (from vertebral artery)
3. Radicular arteries
Jwan Ali AlSofi 23
24. Localise the lesion of
myelopathy:-
Localise spinal cord lesions
Determining the Level of the Lesion
Jwan Ali AlSofi 24
25. Lesion above C5 cause UMN signs in the arms and legs that
spares the face and cranial nerves.
Lesion below T1 affects only the leg. (will not involve the
arms)
Lesions between C5 and T1 affect the arm to a variable
extent as well as the leg. (LMN and sometime UMN signs in
the arm and UMN signs in the legs)
Lesions of the lumbar spinal cord (below L1-2) causing cauda
equina injuries No UMN / only LMN findings.
■ A unilateral spinal cord lesion causes ipsilateral paresis.
– E.g. A unilateral spinal cord lesion above (C5) causes an
ipsilateral hemiparesis that spares the face and cranial
nerves.
■ If both sides of the spinal cord are involved, quadriparesis or
paraparesis usually results.
■ Increased muscle tone (spasticity) may be more prominent
than weakness.
Jwan Ali AlSofi 25
29. Ipsilateral
• Loss of proprioception,
vibration, and tactile
discrimination below the level
of the lesion.
• Motor:
- Segmental flaccid paresis
at the level of the lesion
(LMNL),
- Spastic paralysis below
lesion (UML),
- Ipsilateral Babinski sign.
Contralateral
• Loss of pain and temperature
sensation one or two levels
below lesion.
Neurological findings in spinal cord lesion:-
Jwan Ali AlSofi 29
30. Cervical
Cord
Upper cervical cord
lesions produce
quadriplegia and
weakness of the
diaphragm.
The uppermost level of
weakness and reflex
loss with lesions
• at C5-C6 is in the biceps;
• at C7, in finger and wrist
extensors and triceps;
• at C8, finger, and wrist
flexion.
Horner’s syndrome
(miosis, ptosis, and
facial hypohidrosis)
may accompany a
cervical cord lesion at
any level.
Thoracic
Cord
Lesions here are localized
by
•the sensory level on the trunk
•if present, by the site of midline
back pain.
Useful markers of the
sensory level on the trunk
are the nipples (T4) and
umbilicus (T10).
Leg weakness and
disturbances of bladder and
bowel function accompany
the paralysis.
Lesions at T9-T10 paralyze the
lower—but not the upper—
abdominal muscles, resulting in
upward movement of the
umbilicus when the abdominal
wall contracts (Beevor’s sign).
Lumbar
Cord
Lesions at the L2-L4
spinal cord levels
paralyze flexion and
adduction of the
thigh, weaken leg
extension at the knee,
and abolish the
patellar reflex.
Lesions at L5-S1
paralyze only
movements of the
foot and ankle, flexion
at the knee, and
extension of the thigh,
and abolish the ankle
jerks (S1).
Jwan Ali AlSofi 30
31. • The uppermost level of a spinal cord lesion can be
localized by attention to the segmental signs
corresponding to disturbed motor or sensory innervation
by an individual cord segment.
1. A band of altered sensation (hyperalgesia or hyperpathia) at
the upper end of the sensory disturbance,
2. Fasciculations or atrophy in muscles innervated by one or
several segments, or a muted or absent deep tendon reflex
may be noted at this level.
• These signs also can occur with focal root or peripheral
nerve disorders; thus, they are most useful when they
occur together with signs of long tract damage.
Jwan Ali AlSofi 31
32. Spinal shock
• With severe and acute transverse lesions, the
limbs initially may be flaccid rather than spastic.
• This state of “spinal shock” lasts for several
days, rarely for weeks.
• May be mistaken for
1. extensive damage to the anterior horn cells over
many segments of the cord
2. an acute polyneuropathy.
Jwan Ali AlSofi 32
33. ACUTE POLYNEUROPATHY
VS
MYELOPATHY
■ An acute-onset myelopathy (e.g., transverse myelitis) can be
dicult to distinguish from an acute polyneuropathy, since
upper motor neuron signs may not yet be present at the time
of onset of a myelopathy.
■ The presence of bowel/bladder dysfunction and/ or a spinal
level on examination with acute-onset weakness is more
suggestive of myelopathy than polyneuropathy.
■ If symptoms progress in the lower extremities without any
involvement of the upper extremities, this also suggests a
spinal cord process (because a generalized polyneuropathy
would not be expected to remain isolated to the legs).
Jwan Ali AlSofi 33
35. THE CLINICAL SYNDROMES OF SPINAL
CORD DISEASE:-
■ Paralysis is the complete loss of voluntary movement
■ The words “plegia” “palsy” and “paresis” are sometimes used
interchangeably to describe weakness
■ Paresis is the correct term to describe incomplete paralysis,
■ Plegia means complete paralysis and Palsy used when the
paralysis affects cranial motor nerve (bell’s palsy,
pseudobulbar palsy) or a static weakness (cerebral palsy)
■ There are tree main motor syndromes associated with spinal
cord disease
1. Paraparesis (UMN involvement of legs only)
2. Tetraparesis (UMN involvement of all four limbs)
3. Brown-Sequard syndrome (Unilateral lesion causing UMN
involvement of one side)
Jwan Ali AlSofi 35
36. Paraplegia (Paraparesis)
■ Severe weakness that is complete or nearly complete of lower limbs.
■ Localize the lesion in paraplegia (paraparesis):-
1. Most of these lesions are located in Dorsal (=Thoracic) Spine.
2. Can also see paraplegia with a midline lesion in the brain.
If lesion includes C5-T1 Quadriplegia (Brachial Plexus)
Para – Lower Limbs
Paresis – Partial Weakness
Hemi – Out
Quadri – All Limbs
Mono – One Limb
Paresis - is incomplete paralysis
(weakness).
Plegia - is paralysis that’s complete.
Jwan Ali AlSofi 36
37. Causes of dorsal spinal cord
Paraplegia :-
1. Transverse Myelitis
2. Trauma.
3. Tumours.
4. Multiple Sclerosis
5. B12 Deficiency.
6. Infections of the spinal cord.
7. Vascular disease of the spinal cord.
8. Others.
Cerebral Lesions (uncommon):
• Thrombosis of superior sagittal sinus.
• Tumour of falx-cerebri.
• Hydrocephalus.
Before the diagnosis, we must
know where is the lesion.
Jwan Ali AlSofi 37
38. Causes of Cerebral Paraplegia :-
Causes in Parsagittal
Region
Traumatic
Depressed
fracture of
the vault of
the skull,
Subdural
hematoma
Vascular
Superior
sagittal
sinus
thrombosis
Inflammatory
Encephalitis
Meningocephalitis
Neoplasm
Parasagital
meningioma
Degenerative
Cerebral
palsy
Causes in Brain Stem
Syringobulbia Midline
tumors
• Midline brain stem tumours: These lesions arise in the midline and involve the innermost
pyramidal fibres which are those of the lower limbs.
• Parasagittal Lesions:- Because the cortical leg area and cortical area for control of the
urinary bladder are located on the medial surface of each hemisphere, parasagittal
lesions can cause spastic paraparesis with urinary problems and can, therefore, mimic a
myelopathy. Meningioma is a common lesion in this location and may also cause
seizures and headache.
Jwan Ali AlSofi 38
40. ■ When quadriparesis is observed, consider
1. a cervical spinal cord lesion,
2. a myopathy,
3. a polyneuropathy.
■ The reflexes will be most helpful in distinguishing a
spinal cord lesion (upper motor neuron) from a
neuropathy or myopathy (lower motor neuron).
■ Acutely, reflexes may be absent in a spinal cord
lesion. In this case,
– Weakness above the neck (e.g. of neck flexion
and the facial muscles) favours a neuropathy or
myopathy.
– A sensory level and sphincter involvement favour
a cord problem.
Jwan Ali AlSofi 40
42. ■ Weakness of both arms (bibrachial
paresis) is less common.
■ It can be caused by a lesion located in
1. the central cervical cord,
2. the cervical anterior horn cells,
3. the cervical nerve roots,
4. Brachial plexus.
Jwan Ali AlSofi 42
44. ■ Hemiparesis (weakness on one side of the body) points to a problem in
1. the brain
2. or, less commonly, one side of the cervical cord.
■ Facial weakness shows that the problem is in the brain.
■ The presence of other signs will help to localize this further.
■ Are there cortical signs, for example hemianopia, dysphasia, or neglect?
■ If not, are there symptoms or signs pointing to a brainstem problem, such
as vertigo, ataxia, or double vision? Brainstem lesions also frequently
produce bilateral signs, or a hemiparesis with ‘crossed’ signs, for example
contralateral ataxia or contralateral cranial nerve palsies. The latter may
help to pinpoint the lesions to the brainstem level involved, depending on
their site of origin (brainstem nuclei):
– Midbrain: Cranial nerves Ill (oculomotor) and IV (trochlear)
– Pons: Cranial nerves V (trigeminal), VI (abducens), and VII (facial)
– Medulla: Cranial nerves Vill (vestibulocochlear; also pons), and IX-XIl
(glossopharyngeal, vagus, accessory, hypoglossal)
Jwan Ali AlSofi 44
45. Approach to Spinal Cord
Disease
Clinical Features and Investigations
Jwan Ali AlSofi 45
46. Basic Features of Spinal Cord Disease
LMN findings at the level of lesion
UMN findings below the lesion:
o Hyperreflexia
o Babinski Sign is a sign of upper motor neuron
disease above the level of the S1 vertebra and is
characterized by paradoxical extension of the great
toe with fanning and extension of the other toes as
well.
Sensory (ipsilateral) and motor (LMNL) involvement that
localizes to a spinal cord level.
Bowel and Bladder dysfunction common.
Jwan Ali AlSofi 46
47. ■ The presence of a horizontally defined level below which sensory,
motor, and autonomic function is impaired is a hallmark of a lesion
of the spinal cord.
■ This sensory level is sought by asking the patient to identify a
pinprick or cold stimulus applied to the proximal legs and lower
trunk and successively moved up toward the neck on each side.
■ Sensory loss below this level is the result of damage to the
spinothalamic tract on the opposite side, one to two segments
higher in the case of a unilateral spinal cord lesion, and at the level
of a bilateral lesion.
■ The discrepancy in the level of a unilateral lesion is the result of the
course of the second-order sensory fibers, which originate in the
dorsal horn, and ascend for one or two levels as they cross anterior
to the central canal to join the opposite spinothalamic tract.
■ Lesions that transect the descending corticospinal and other motor
tracts cause paraplegia or quadriplegia with heightened deep
tendon reflexes, Babinski signs, and eventual spasticity (the upper
motor neuron syndrome).
Jwan Ali AlSofi 47
48. Spinal cord Lesions at frontal
lobe or spinal
cord can lead to
Bladder
dysfunction
Jwan Ali AlSofi 48
49. Effects of Spinal Lesions on
Bowel and Bladder Function
Jwan Ali AlSofi 49
51. ■ Remember that the spinal cord ends at about T12-
L1. Because growth of vertebrae is faster than
growth of spinal cord that’s why it ends in T12-L1.
– Below L1, no UMNL will appear, the lesions there
will affect LMNs.
■ Lesion at C5 (complete cut)
– Motor:
■ LMNL at level of injury
■ UMNL below C5
– Sensory (Dorsal column of STT) – C5 & below
– Autonomic dysfunction (Bowel & Bladder)
Jwan Ali AlSofi 51
53. History of Spinal Cord Disease
■ Onset
– Acute, subacute, chronic
■ Symptoms
– Pain:- Transverse Myelitis, Tabes Dorsalis, Cauda Equina
– Weakness
– Sensory
– Autonomic
■ Past history
■ Family history
Jwan Ali AlSofi 53
54. Tempo of Spinal Cord Disease
Cause Acute Sub-Acute Chronic
Trauma X
Mass Lesion X X
Infectious X X X
Inherited X
Vascular X X X
Autoimmune X X
Nutritional X
Jwan Ali AlSofi 54
55. Motor Examination
■ Strength - helps to localize the lesion
– Upper Cervical
■ Quadriplegia with impaired respiration (C3, C4, C5 for Diaphragm).
– Lower Cervical
■ Proximal arm strength preserved.
■ Hand (distal) weakness and leg weakness.
– Thoracic
■ Paraplegia.
– Can also see paraplegia with a midline lesion in the brain.
■ Tone
– Increased distal to the lesion
• Hydrocephalus
• Thrombosis of Sup. Venous
Sinus
• Tumour of Falx Cerebri
Jwan Ali AlSofi 55
56. Sensory Examination
Establish a sensory level
■ Dermatomes
– Nipples: T4-5
– Umbilicus: T8-9
■ Posterior Columns
– Pressure
– Vibration
– Joint position sense (romberg test)
** Dorsal column function is preserved in:-
- Anterior Spinal Artery Infarct
- Syringomyelia
■ Spinothalamic Tracts
– Pain
– Temperature
Jwan Ali AlSofi 56
57. Autonomic Disturbances
1. Neurogenic Bladder
– Urgency.
– Incontinence.
– Retention (becomes Incontinence, eventually).
2. Bowel Dysfunction
– Constipation more frequent than incontinence.
3. With a high cord lesion, Loss of BP Control.
4. Alteration in Sweating
Important Features of
Spinal Cord Disorders, so
if they are not present,
then Spinal Cord Disorder
is unlikely
Jwan Ali AlSofi 57
58. Investigation of Spinal Cord
Disease
■ Radiographic Examinations
– Plain films.
– Myelography.
– CT Scan with Myelography.
– MRI the investigation of choice.
■ Spinal Tap
– If you suspect: Inflammation, MS, Rupture of
a Vascular Malformation
Jwan Ali AlSofi 58
59. SPINAL CORD
DISEASE
Etiology
Common causes of LMN Facial Palsy:
1. Bell‘s Palsy.
2. DM.
3. Guillain-Barre Syndrome.
4. Myasthenia Gravis.
Common causes of UMN Facial Palsy:
1. Stroke.
2. MS.
3. SOL.
Jwan Ali AlSofi 59
60. 1. Traumatic Spinal Cord Disease
■ 10,000 new spinal cord injuries per year.
■ Motor Vehicle Accident (MVA) and sports injuries
are the most common.
■ Victims under 30 years old.
■ Males > Females
■ Fx/dislocation of vertebrae most likely to occur at:
– C1, C2
– C5 , C6
– T12 , L1
As these areas are more flexible
Jwan Ali AlSofi 60
61. 2. Spinal Cord Tumours
■ Metastatic or Primary
■ Extramedullary
– Extradural - most common
■ Bony - breast, prostate.
– Intradural - very rare
■ Meninges – Meningioma.
■ Nerve root – Schwannoma.
■ Intramedullary (inside the spinal cord, itself) - very rare
– Metastatic.
– Primary - Astrocytoma or Ependymoma.
Jwan Ali AlSofi 61
62. 3. Vitamin B12 deficiency
myelopathy
■ In severe VitB12 deficiency there is insidious, diffuse and uneven
demyelination. It may be clinically manifest as:-
1. peripheral neuropathy
2. spinal cord degeneration affecting both posterior-Dorsal and lateral
CST columns (subacute combined degeneration of the spinal cord).
3. there may be cerebral manifestations (resembling dementia)
4. optic atrophy
5. Autonomic neuropathy
■ Vitamin B12 Deficiency caused by:-
– Malabsorption of B12 secondary to Pernicious Anaemia or surgery
– Insufficient dietary intake - vegan
■ Subacute combined (both CST and peripheral nerves will be affected)
degeneration of the cord.
■ Posterior columns (proprioception & vibration) and CST involvement with a
superimposed peripheral neuropathy.
■ Vitamin B12 therapy improves symptoms in most cases
Jwan Ali AlSofi 62
64. ■ Clinical onset is with distal paresthesias and weakness in the extremities
(involvement of the hands occurs relatively early) - Peripheral neuropathy-.
■ Followed by the development of:
– Spastic paraparesis – lateral CST involvement-
– Sensory ataxia from impaired proprioception in the legs (+ Romberg
test) – dorsal column involvement .
■ a combined posterior column (vibration and joint position sense) and
pyramidal deficit in the legs.
■ Lhermitte sign may be present,
■ Plantar responses are extensor.
■ Tendon reflexes may be increased or depressed, depending on the site
and severity of the involvement.
■ Loss of reflexes due to an associated peripheral neuropathy in a patient
who also has Babinski signs, is an important diagnostic clue.
■ Centrocecal scotoma or optic atrophy from optic (II) nerve involvement.
■ Behavioral or psychiatric changes.
Jwan Ali AlSofi 64
65. 4. Transverse Myelitis
■ Is an acute, usually monophasic, demyelinating, neuro-
inflammatory disorder that produce anatomic and functional
disruption of the spinal cord.
■ It is usually thought to be
– post-infectious in origin
(bacterial, viral, fungal, parasitic)
– Non-infectious inflammatory disorders
(MS, NMO, ADEM, systemic autoimmune diseases)
– idiopathic
■ Treatment is with:
– high-dose intravenous methylprednisolone.
– steroid-unresponsive patients Plasma exchange, IVIG, or
cyclophosphamide
■ The outcome is variable:
– one-third have static deficit,
– one-third go on to develop MS
– one-third recover with no subsequent relapse – monophasic - .
Jwan Ali AlSofi 65
66. ■ It occurs at any age
■ Presents with a course of hours to days :-
– severe pain in the neck or back at the onset.
– a subacute paraparesis - bilateral sensory, motor, and
autonomic deficits in the limbs and trunk-
– a sensory level corresponding to the site of inflammation
in the spinal cord
■ MRI:
– an intrinsic spinal cord lesion that usually enhances with
gadolinium administration
– should distinguish this from an external lesion affecting
the spinal cord.
■ CSF examination shows
– Cellular pleocytosis, often with polymorphs at the onset.
– increased IgG index
– Oligoclonal bands are usually absent.
Jwan Ali AlSofi 66
67. 5. Spinal Cord Infections
■ Polio
– Only the anterior horn cells are infected
( Flaccid Paralysis).
■ Tabes Dorsalis (Tertiary Syphilis)
– Dorsal root ganglia (sensory) and dorsal columns are
involved.
– Sensory Ataxia,
– severe “lightening pains”.
■ HIV Myelopathy
– Mimics B12 Deficiency.
■ HTLV-1 Myelopathy
– Tropical Spastic Paraparesis.
TB affects the spine, not the spinal cord
Jwan Ali AlSofi 67
68. 6. Multiple Sclerosis
■ Demyelination is the underlying pathology.
■ Cord Disease can be presenting feature of MS or occur at
any time during the course of the disease.
■ Lesion can be at any level of the cord.
– Patchy
– Transverse
■ Devic’s Syndrome or Myelitis Optica.
– Is (Transverse myelitis + optic neuritis).
– For a long time, Neuromyelitis Optica was
considered a special form of MS;
– Nowadays, it is classified as a separate entity.
Jwan Ali AlSofi 68
69. NEUROMYELITIS OPTICA
(Devic’s disease)
■ Is demyelinating, neuro-inflammatory disorder
■ is the occurrence of “transverse myelitis AND bilateral optic neuritis”.
■ The majority of cases are associated with an antibody to a neuronal
membrane channel, aquaporin 4. (NMO-IgG).
■ If changes are seen on brain MRI (this is variable), they are typically high-
signal lesions restricted to periventricular regions.
■ Spinal MRI scans show lesions that are typically longer than three spinal
segments (unlike the shorter lesions of MS).
■ Unlike MS, the MRI typically does not show widespread white matter
involvement, although such changes do not exclude the diagnosis.
■ Clinical deficits tend to recover less well than in MS.
■ The disease may be more aggressive with more frequent relapses.
■ Treatment with glucocorticoids, azathioprine or cyclophosphamide, and/or
plasmapheresis seems to be more effective than in MS.
Jwan Ali AlSofi 69
70. 7. Vascular Disease of the Spinal Cord
A. SPINAL CORD INFARCTION
1. Anterior Spinal Artery Infarct (Anterior Two-Third Syndrome)
■ From atherosclerosis, during surgery in which the aorta is
clamped, dissecting aortic aneurysm
– Less often, chronic meningitis or following trauma
■ Weakness (CST):-
– acute onset of a flaccid, areflexic paraparesis - due to spinal
shock
– Followed , as spinal shock wears off after a few days or
weeks, by a spastic paraparesis with brisk tendon reflexes
and extensor plantar responses
■ Pain/temperature loss (Spinothalamic tracts) below the level of
the lesion
■ Posterior columns preserved (Joint Proprioception, Vibration) –
bcz posterior columns are supplied by the posterior spinal
arteries.
■ Bladder, bowel, and sexual dysfunction may occur
■ Hypotension
■ Neurologic deficits are typically bilateral, but unilateral
involvement sometimes occurs.
Jwan Ali AlSofi 70
72. 7. Vascular Disease of the Spinal
Cord
A. SPINAL CORD INFARCTION
1. Anterior Spinal Artery Infarct (Anterior Two-Third
Syndrome)
2. Posterior spinal artery infarction
■ It is rare.
■ leads to unilateral loss of vibration and joint position
sense below the level of the lesion,
■ sometimes accompanied by mild, transient weakness.
3. Artery of Adamkiewicz at T10-11 (Special Variant)
4. Watershed area
■ Upper thoracic
Jwan Ali AlSofi 72
74. B. Arteriovenous Malformation (AVM) and Venous
Angiomas
– Both occur in primarily the thoracic cord.
– May present either acutely, subacutely or
chronically (act as a compressive lesion).
– Can cause recurrent symptoms.
– If they bleed.
■ Associated with pain and bloody CSF.
– Notoriously difficult to diagnose.
C. Hematoma
– Trauma, occasionally tumour.
Jwan Ali AlSofi 74
75. 8. Other Diseases of the Spinal
Cord
A. Hereditary Spastic Paraparesis (HSP)
– Usually autosomal dominant
– Mainly affect the longest axons of the corticospinal tract and the dorsal
column (which supply the lower limbs).
– No s/s in hands or arms
– Sensory symptoms and signs are absent
■ “Pure HSP” presents with:
1. Progressive spasticity and weakness with UMN palsy of bilateral lower limbs “only” -
not always symmetrical
2. Gait abnormalities – Dragging of the feet, scissoring of the legs during ambulation.
3. Urinary urgency/urge incontinence.
4. Dorsal column dysfunction is usually mild – ↓ sense of balance is common
■ “Complicated HSP”: Patients with complicated HSP have all the features of pure HSP
as well as additional neurological features, such as:
1. Epilepsy, intellectual disability, dementia.
2. Cerebellar or extrapyramidal symptoms.
3. Peripheral neuropathy.
4. Loss of vision, due to optic nerve degeneration
Jwan Ali AlSofi 75
76. B. Infectious process of the vertebrae
– TB, bacterial
C. Herniated Disc with cord compression
– Most herniated discs are lateral and only compress a
nerve root
■ Degenerative Disease of the vertebrae
– Cervical spondylosis with a myelopathy
– Spinal stenosis
Jwan Ali AlSofi 76
80. 2. Brown Séquard Syndrome
■ Also known as Cord Hemisection
■ Trauma or tumour
■ With compressive lesions, there is usually a band of pain at the level of
the lesion in the distribution of the nerve roots subject to compression.
■ Dissociated sensory loss
1. Ipsilateral pyramidal dysfunction
– Weakness and UMN findings ipsilateral to lesion (Ipsilateral Babinski
sign).
2. Ipsilateral impairment of posterior column sensory function below the
level of the lesion
– Loss of vibration/proprioception ipsilateral to the lesion
■ These pathways cross at the level of the brainstem
3. Contralateral impairment of spinothalamic tracts sensory function.
– Loss of pain and temperature contralateral to lesion, one or 2 levels
below the level of the lesion
■ Crossing of spinothalamic tracts 1-2 segments above where they enter
Jwan Ali AlSofi 80
83. 3. Syringomyelia
■ Fluid filled cavitation in the center of the cord
■ Cervical cord most common site
– Loss of pain and temperature related to the crossing
fibers occurs early
■ Cape-like sensory loss
– Weakness of muscles in arms with atrophy and
hyporeflexia (Anterior Horn Cells (AHC))
– Later - CST involvement with brisk reflexes in the legs,
spasticity, and weakness
■ May occur as a late sequelae to trauma
■ Can be seen in association with Arnold Chiari malformation
- Cerebellum herniates through foramen magnum
- hydrocephalus,
- cerebellar ataxia,
- Pyramidal and sensory deficits in the limbs,
Jwan Ali AlSofi 83
86. Central Cord Syndrome
■ Results from selective damage to the gray matter nerve cells
and crossing spinothalamic tracts surrounding the central
canal.
■ In the cervical cord, the central cord syndrome produces
1. arm weakness out of proportion to leg weakness
2. a “dissociated” sensory loss, meaning loss of pain and
temperature sensations over the shoulders, lower neck,
and upper trunk (cape distribution), in contrast to
preservation of light touch, joint position, and vibration
sense in these regions.
Jwan Ali AlSofi 86
88. 4. Conus Medullaris vs. Cauda
Equina Lesion
Finding Conus Cauda Equina
Motor Symmetric Asymmetric
Sensory loss Saddle Saddle
Pain Uncommon Common
Reflexes Increased Decreased
Bowel/bladder Common Uncommon
Most commonly caused by
Lumber Disc Herniation
Sciatic Pain: sharp pain
going down the back and
legs. Caused due to nerve
root compression
Jwan Ali AlSofi 88
92. General Measures
■ Skin Care
– Change posture every 2-4 hourly, to avoid bed sores.
– Keep skin dry and clean.
■ Bladder Care
– Catheterization for urinary retention.
■ Bowel Care
– Avoid constipation by suitable diet and laxatives.
■ Prevention of Contractures
– By regular passive movements.
■ Rehabilitation
– By using wheel chair, standing frames, vocational training
and etc.
■ Treatment of the underlying etiology.
Jwan Ali AlSofi 92
93. Complications
1. Bedsores.
2. Bowel and bladder incontinence.
3. Deep Venous Thrombosis.
4. Pulmonary embolism.
5. Psychiatric layout.
6. Hypostatic Pneumonia.
7. Disease related complications.
Jwan Ali AlSofi 93
95. Hints and Tips:-
There are only a few common causes of absent ankle
jerks (i.e., lower motor neurone) and extensor plantar
responses (i.e., upper motor neurone). These include:
1. combined pathology, e.g., cervical spondylosis and
peripheral neuropathy motor neurone disease
2. conus medullaris lesions
3. subacute combined degeneration of the cord
(vitamin B12 myelopathy)
4. Friedreich ataxia
5. tabes dorsalis/tertiary neurosyphilis
Jwan Ali AlSofi 95
96. Summary
Paraplegia is mainly caused by Spinal
(dorsal) cord.
Localization of the site of the lesion can be
made by detecting motor, reflexes,
sensory and autonomic level.
Treatment directed to the underlying
cause with supportive care.
Jwan Ali AlSofi 96
Young age , female think about neuroinflammatory demyelinating
Young age , female think about neuroinflammatory demyelinating
255
Brachial Plexus is C5-T1
Motor lesions of spinal cord are ipsilateral.
If there is complete spinal cord lesion bilateral motor findings
If there is unilateral spinal cord lesion ipsilateral motor findings
Thoracic spine is the central part of the spine, also called as dorsal spine
You can depend on the LMN findings and sensory findings to localize a spinal cord lesion – since those are occurring at the level of lesion.
Whenever there is UMNL injury is above L1
Above C5 UL & LL
Below T1 only LL
Between C5-T1 LL & to a lesser extent UL
CST = corticoSpinal Tract
VB12 is responsible for both the CST and peripheral nerves.
Dorsal column will be affected, responsible for Position and Vibration
Peripheral Nerve gives feature of LMNL, will present with neuropathy and myelopathy.
Posterior column is responsible for position and vibration
Dorsal column is preserved in Anterior Spinal Artery Infarct and Syringomyelia
SYRINGOMYELIA Syringomyelia is a developmental cavity of the cervical cord that may enlarge and produce progressive myelopathy or may remain asymp- tomatic. Symptoms begin insidiously in adolescence or early adult- hood, progress irregularly, and may undergo spontaneous arrest for several years. Many young patients acquire a cervical-thoracic scoliosis. More than half of all cases are associated with Chiari type 1 malforma- tions in which the cerebellar tonsils protrude through the foramen mag- num and into the cervical spinal canal. The pathophysiology of syrinx expansion is controversial, but some interference with the normal flow of CSF seems likely, perhaps by the Chiari malformation. Acquired cav- itations of the cord in areas of necrosis are also termed syrinx cavities; these follow trauma, myelitis, necrotic spinal cord tumors, and chronic arachnoiditis due to tuberculosis and other etiologies. The presentation is a central cord syndrome consisting of a regional dissociated sensory loss (loss of pain and temperature sensation with sparing of touch and vibration) and areflexic weakness in the upper limbs. The sensory deficit has a distribution that is “suspended” over the nape of the neck, shoulders, and upper arms (cape distribution) or in the hands. Most cases begin asymmetrically with unilateral sensory loss in the hands that leads to injuries and burns that are not appreci- ated by the patient. Muscle wasting in the lower neck, shoulders, arms, and hands with asymmetric or absent reflexes in the arms reflects expansion of the cavity in the gray matter of the cord. As the cavity enlarges and compresses the long tracts, spasticity and weakness of the legs, bladder and bowel dysfunction, and a Horner’s syndrome appear. Some patients develop facial numbness and sensory loss from damage to the descending tract of the trigeminal nerve (C2 level or above). In cases with Chiari malformations, cough-induced headache and neck, arm, or facial pain may be reported. Extension of the syrinx into the medulla, syringobulbia, causes palatal or vocal cord paralysis, dys- arthria, horizontal or vertical nystagmus, episodic dizziness or vertigo, and tongue weakness with atrophy. MRI accurately identifies developmental and acquired syrinx cavi- ties and their associated spinal cord enlargement (Fig. 434-7). Images of the brain and the entire spinal cord should be obtained to delineate the full longitudinal extent of the syrinx, assess posterior fossa structures for the Chiari malformation, and determine whether hydrocephalus is present.
Spinal cord ends at L1. So lesions below L1 (Cauda Equina) No UMN / only LMN findings.
Sacral Cord/Conus Medullaris The conus medullaris is the tapered caudal termination of the spinal cord, comprising the sacral and single coccygeal segments. The distinctive conus syndrome con- sists of bilateral saddle anesthesia (S3-S5), prominent bladder and bowel dysfunction (urinary retention and incontinence with lax anal tone), and impotence. The bulbocavernosus (S2-S4) and anal (S4-S5) reflexes are absent (Chap. 415). Muscle strength is largely preserved. By contrast, lesions of the cauda equina, the nerve roots derived from the lower cord, are characterized by low back and radicular pain, asymmetric leg weakness and sensory loss, variable areflexia in the lower extremities, and relative sparing of bowel and bladder function. Mass lesions in the lower spinal canal often pro- duce a mixed clinical picture with elements of both cauda equina and conus medullaris syndromes. Cauda equina syndromes are also discussed in Chap. 14.
Saddle = Buttock, Inner Thigh & Perineum