Presentation on theme: "Vivian & slides from ESA mentoring 2013"— Presentation transcript:
1Vivian & slides from ESA mentoring 2013 Neuro tract lesionsVivian & slides fromESA mentoring 2013
2Upper motor neuron lesions Pyramidal(Corticospinal tract)ExtrapyramidalBabinski signSpastic paralysis – increased muscular tone and hyperactive reflexesAbsent superficial abdominal reflexesLittle or no muscular atrophyAbsent cremasteric reflexExaggerated deep muscle reflexesLoss of performance of fine skilled voluntary movementsFlapping clonusHypertonia and clasp knife responseIn practice they occur together!
4N.B.Lesions of the basal ganglia and cerebellum are also referred to as “extrapyramidal” but they are different to the UMN lesions – they don’t involve the descending motor tracts.
5Sensory & combined lesions Subacute combined degeneration of the cordTabes DorsalisBrown-Sequard syndromeSyringomyeliaSpinal shock
6Subacute combined degeneration of the cord CauseB12 deficiency (usually pernicious anaemia)PathologyDegeneration of the dorsal columns (myelin degeneration)Signs & symptoms• Legs, arms, trunk – progressive from tingling and numbness to weakness• Visual impairment• Change in mental state• BILATERAL spastic paresis/paralysis• Sensations diminished = pressure, vibration and touchClinical tests• +ve Babinski sign = extensor plantar reflex• +ve Rhomberg testTreatmentReversible with B12 replacement if not been going on for too long
7Tabes dorsalis Cause Untreated syphilis Pathology Degeneration of the dorsal columns (myelin degeneration)Signs & symptoms• Weakness, episodes of intense pain & disturbed sensation• Ataxia (tabetic gait), loss of coordination• Change in mental state e.g. dementia• Visual impairment• Sensations diminished = pressure, vibration and touchClinical tests• +ve Rhomberg testTreatmentIV PenicillinAnalgesicsContact tracing!Tabetic gait = due to loss of proprioception, patient’s feet slap to the ground as they walk
8Syringomyelia What is it? Enlarged cavity or cyst in the cervical/upper thoracic region of the cordCauseCongenital e.g. Arnold-Chiari malformationTumoursTrauma, haemorrhageMeningitisSigns & symptomsAbnormal or loss of sensationsChronic painUsually spare dorsal columns – intact pressure, vibration, touch, proprioceptionMay have ANS symptomsClinical testsCervical/Thoracic MRITreatmentTreat underlying causesSurgery to drain cysts
9Brown-Séquard syndrome = hemisection of the cord Corticospinal tracts & dorsal columns decussate in the thalamus -> loss on same sideSpinothalamic tracts decussate as soon as they go into the cord (or 1-2 levels above) -> loss on contralateral sideAlso loss of movements on the same side (corticospinal tracts – UMN signs below lesion, LMN signs at level of lesion)
10Spinal shock Follows acute severe damage to the spinal cord. <24 hours – 4 weeksDepression or total loss of sensation and motor function below the level of the lesion.Often associated with profound hypotension due to loss of sympathetic vasomotor tone.
11How to approach a clinical case Determine if there are any motor deficitsIf yes what descending tracts are affected?Is it pyramidal or extrapyramidal?Is it an upper or lower motor neuron lesion?Determine if there are any sensory deficitsIf yes what ascending tracts are affected?Determine if there are any cognitive problemsIf yes then the damage probably has occurred in the brain?What region effects the change in behaviour you have witnessed?Where does the deficit start and end?Torso/ limbs?Dermatomes and myotomes are useful hereIs it sensory/ motor/ both & is the lesion central or peripheral?What side of the body are they on?Indicates side of lesionAre the sensory and motor deficits on the same side?Is the lesion above or below the level of decussation of the tracts involved
12Case 1Pt presents with neck pain, paraesthesia in the medial side of the arm and hand, weakness affecting the whole hand and extension and abduction of the wrist joint. Bicep reflexes are normal but tricep reflex is absent.Lower motor neuron (Weakness. Absent tricep reflex)Neither pyramidal or extrapyramidal signsLevel of the common root of the spinal nerve as both sensory and motor signs
13Case 2Pt presented with normal right arm and leg movement and minimal/ absent movement of left side with increased muscle tone and clasp knife rigidity. Pt had a flexor plantar reflex on the right and a babinski reflex on the left. Pt also had impaired facial movements on the left but with forehead sparing.Upper motor neuron (increased muscle tone and clasp knife rigidity, babinski sign, forehead sparing)Pyramidal and extrapyramidal signsMost likely occurred in the brain because forehead sparing so needs to occur above pons
14Case 3Pt presents with weakness in his left arm and hand. Has no sensory loss. Reduced grip on the left side with increased muscle tone. Biceps and brachioradialis jerks are exaggerated. Right side grip is also reduced and reflexes are brisk.UMN (weakness with increased tone and reflexes)ExtrapyramidalLower brain stem or upper spinal cord small lesion as no sensory loss or corticospinal involvement
15Case 4Pt presents with mild slurring of speech, blindness in right eye and tingling in the left side of her face, difficulty swallowing, weakness, numbness and hyperreflexia in the right leg with a babinski sign in the right footBoth upper and lowerBoth pyramidal and extrapyramidalMultiple anatomically unrelated lesions (MS)