GUMSA teaching

Clinical Neurology

Mohamed Abdelhalim

Main topics
Back pain Spinal cord injury Motor neurone lesions Peripheral neuropathy Head injury Assessment of conscious level

Back Pain

3 categories
Serious pathology (tumour or infection)
1-2%

Disc prolapse
5%

Non-specific low back pain

The rest

Serious pathology RED FLAGS

Non-mechanical back pain Thoracic pain Past medical history Unwell, fever, weight loss Widespread neurological symptoms

And especially
Incontinence Gait disturbance Saddle anaesthesia
Cauda equina syndrome!!

Disc prolapse
Unilateral leg pain radiating to foot Numbness and tingling in same distribution Localised symptoms/signs Straight leg raise

Non-specific low back pain

Lumbosacral, buttocks, thighs Mechanical pain Patient otherwise well History of heavy lifting, twisting, etc

Pathophysiology of non-specific low back pain

musculoskeletal soft tissue degenerative changes

Psychological factors important in chronic pain

 Serious pathology (tumour or infection)

Refer NOW

Disc prolapse
Refer soon

Non-specific low back pain

Treat with analgesia and keeping active Do not recommend bed rest Rehabilitation if >6 weeks

Spinal Cord Injury

Questions to ask!
Is there leg weakness? Is there sensory involvement? Is there a motor and sensory level? Is there bowel and bladder involvement?

Presentation
Depends on the level of the lesion

Levels to remember
C3, 4, 5 keep the diaphragm alive C3-T1 arms T4 nipple line T10 umbilicus L1-S3 legs

Spinal Shock
Areflexia Hyperreflexia

3 days
Flaccidity Spasticity

A definition
A phase beginning immediately after a spinal cord injury during which all functions of the distal segment of spinal cord are depressed

Spinal shock

The bladder reflex

Brain
C T

Conscious inhibition

L1 L2 L3 L4 L5 S1 S2 S3 S4 S5

During spinal shock

Brain
C T

Conscious inhibition

Retention with overflow

L1 L2 L3 L4 L5 S1 S2 S3 S4 S5

After spinal shock

Brain
C T

Automatic bladder

Conscious inhibition

L1 L2 L3 L4 L5 S1 S2 S3 S4 S5

Lumbar injury
Brain
C T

Neurogenic bladder

Conscious inhibition

L1 L2 L3 L4 L5 S1 S2 S3 S4 S5

X +

Sacral injury
Brain
C T

Conscious inhibition

L1 L2 L3 L4 L5 S1 S2 S3 S4 S5

Permanent retention with overflow

+ X

Motor neurone lesions

Brain
Upper motor neurone Lower motor neurone

Medulla

Spinal Cord

Motor neurone lesions

UPPER Power Tone Reflexes Babinski Muscle wasting Weak Increased Exaggerated Upgoing + No LOWER Weak Reduced Reduced Downgoing Yes Yes

Fasciculations No

Peripheral Neuropathy

Mononeuropathies

Mononeuropathy

Multiple mononeuropathy

Polyneuropathy

Mechanisms
Demyelination Axonal degeneration Wallerian degeneration Infarction

Common causes
Diabetes
Infarction Alterations in polyol pathway cause accumulation of fructose & sucrose in Schwann cells

Alcohol
Toxic to nerves

Other causes
Autoimmune (RA, SLE) Infection (HIV) Hypothyroidism Kidney disease Vitamin deficiencies

Head Injury

Classification
Primary
Local contusions Shearing of axons

Secondary

Bleeding
Dura Dura

Extradural

Subdural

Intracerebral bleed

Intracranial pressure
Critical volume

Munro-Kellie pressure/volume curve

Midline shift

Herniation

Tonsillar herniation

High ICP

Low BP

Reduced cerebral perfusion

Hypoxia

Cerebral Ischaemia

The ischaemic cascade

The ischaemic cascade for 2nd year exams

ISCHAEMIA Glutamate release Phospholipid pathway

Ca2+ influx

Free radicals Cell damage & infarction

Assessment of conscious level

Glasgow Coma Scale

Glasgow Coma Scale

Minimum score = 3 Maximum score = 15

Below 8 = ventilate
Why do we use it?

Acute management of head injury

A Airway B Breathing C Circulation D Disability E Exposure

CT scan if indicated Call neurosurgeon if necessary

Questions?

ma.abdelhalim@gmail.com

Spinal levels to remember

C3, 4, 5 C3-T1 T4 T10 L1-S3 keep the diaphragm alive arms nipple line umbilicus legs

Motor neurone lesions

UPPER Tone Power Reflexes Babinski Muscle wasting Increased Weak Exaggerated Upgoing + No LOWER Reduced Weak Reduced Downgoing Yes Yes

Fasciculations No

Bleeding
Dura Dura

Extradural haematoma

Subdural haematoma

Peripheral neuropathy

Mononeuropathy

Multiple mononeuropathy

Polyneuropathy