Lesions of Upper Motor Neurons and Lower Motor Neurons

Upper and Lower Motor Neurons

All the neurons contributing to the pyramidal and extrapyramidal systems should be called upper motor neurons (UMN). The anterior horn cells and the related neurons in the motor nuclei of some cranial nerves are called lower motor neurons (LMN). Axons of these cells give rise to the peripheral motor nerves. These are lowest in position in the motor system and recieve all the inputs from higher centers like medulla, pons, mid-brain and cerebral cortex and transmit the same to the target organs. All impulses for motor activity are to be funelled into them and these are also called final common pathway. Signs of Upper Motor Neuron Lesions (UMNL) 1. Paralysis or weakness of movements of the affected side but gross movements may be produced. No muscle atrophy is seen initially but later on some disuse atrophy may occur.

2. Babinski sign is present: The great toe becomes dorsiflexed and the other toes fan outward in response to sensory stimulation along the lateral aspect of the sole of the foot. The normal response is plantar flexion of all the toes.

Babinski Reflex 3. Loss of performance of fine-skilled voluntary movements especially at the distal end of the limbs.

4. Superficial abdominal reflexes and cremasteric reflex are absent.

5. Spasticity or hypertonicity of the muscles.

6. Clasp-knife reaction: initial higher resistance to movement is followed by a lesser resistance

7. Exaggerated deep tendon reflexes and clonus may be present. Signs of Lower Motor Neuron Lesions (LMNL) 1. Flaccid paralysis of muscles supplied.

2. Atrophy of muscles supplied.

3. Loss of reflexes of muscles supplied.

4. Muscles fasciculation (contraction of a group of fibers) due to irritation of the motor neurons seen with naked eye.

5. Muscle fibrillation (contraction of individual fibers) detected only by EMG

6. Muscle contracture (shortening of paralyzed muscles)

7. Presence of muscle wasting

8. Reaction of degeneration: When the LMN is cut, a muscle will no longer respond to interrupted electrical stimulation 7 days after nerve section, although it will still respond to direct current. After 10 days, response to direct current also ceases.

Mnemonic for Medical Students

Upper Motor Neuron Lesion vs Lower Motor Neuron Lesion : Difference or comparison between upper motor neuron lesion (UMNL) and lower motor neuron lesion (LMNL) Mnemonic for basis of difference: STORM Baby Also remember: In a Lower motor neuron lesion everything lowers Basis of Difference (STORM Baby) S = Strength T = Tone O = Others UMNL Lowers Increases (spastic) Superficial reflexes absent Clonus R = Reflexes = DTR or Increased Deep tendon reflexes M = Muscle Mass Slight loss only Baby = Babinski Sign Positive (toe up) Popularity: 18% LMNL Lowers Decreases (flaccid) Fasciculations Fibrillations Reaction of degeneration Decreased Decreases / Atrophy Negative (toe down)

Understanding Upper and Lower Motor* Neuron Lesion Signs

An upper motor neuron connects the primary motor cortex of the precentralgyrus of a cerebral hemisphere with a synaptic junction to a lower motor neuron cell body (often located )in the ventral horn of the spinal cord

A lower motor neuron travel then from the ventral horn of the spinal cord, out the ventral root through the spinal nerve (to either or dorsal rami) and then to a named nerve (ex: musculocutaneousnerve) to a specific group of now innervated muscles (the musc. cutaneousnerve supplies the biceps brachiimuscle))ventral

Upper vs Lower Motor Neuron Lesions

Inspection MOSTLY SEEN IN SPINAL CORD INJURY Muscle Bulk

Loss of muscle bulk in LMN and late in UMN Symmetry

Muscle Girth

Fasciculations

present in LMN, none in UMN

Muscle Tone flexion/extension, pronation/supination of joint through its ROM

Hypotonia

o o

flaccidity LMN lesions, spinal shock, cerebellar lesions

Hypertonia

Spasticity

- UMN lesion. Pyramidal tract involved limb moves, then catches, and then goes past catch (clasp-knife) o test by rapidly supinating forearm Rigidity o UMN lesions, extrapyrimidal tract lesion o increased tone throughout ROM (cog-wheeling, lead-pipe) o circumducting the wrist

Power

UMN
o o

flexors > extensors in upper limbs extensors > flexors in lower limbs

LMN reduced power in specific motor neuron distribution deltoids - arm abduction - C5 C6 (axillary) biceps - elbow flexion - C5 C6 (musculocutaneous) triceps - elbow extension - C6 C7 C8 (radial) thumb flexion - C6 C7 (median) wrist extensors - C7 C8 (radial) interossei of hand - finger abduction/adduction - C8 T1 (ulnar) hip flexion - L1 L2 L3 (femoral) hip adduction - L2 L3 L4 (obturator) hip abduction - L4 L5 S1 (superior gluteal) knee extension - L2 L3 L4 (femoral) knee flexion - L5 S1 S2 (sciatic) ankle dorsiflexion - L4 L5 (deep peroneal) ankle plantar flexion - S1 S2 (tibial) foot inversion - L4 L5 (posterior tibial) foot eversion - L5 S1 (superficial peroneal)
o

compare between L and R GRADE o 0 nil o 1 flicker of movement o 2 movement cannot overcome gravity o 3 movement cannot overcome any resistance o 4 movement is weaker than normal o 5 normal

Special Tests

Pronator Drift have the patient stand with eyes closed and arms held straight out and hands supinated + patient cannot maintain this position o muscle weakness (pronation and outward drift) o UMN lesion (pronation and downward drift) standing problemes

Fine Finger Movements ask patient to touch each finger to crease of thumb (show patient how) and speed it up look for right and left differences, slow if UMN lesion

Clonus

Ankle or Patellaer clonus in UMN Lesion

Reflexes Deep Tendon Reflexes

biceps tendon (C5-6) brachioradialis tendon (C5-6) triceps tendon (C6-8) knee jerk (L2-4) Achilles tendon (S1-2) hyperactive ankle jerk examine for clonus at knee and

ankle absent use reinforcements (teeth clenching for UL, Jendrassiks maneuver for LL)

UMN hyperreflexia, but may be flaccid LMN diminished reflexes

Grading

0 nil 1 low normal 2 normal 3 high normal

4 clonus (sustained > 3 beats) note if reinforcements used (teeth clenching, hand grips)

Babinskis reflex (L5-S1) + dorsiflexion of the big toe with/without fanning of the other toes (UMN lesion)