Approach to Patients With Motor and Sensory Disorder 3-2012

8/2/2019 Approach to Patients With Motor and Sensory Disorder 3-2012

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APPROACH TO PATIENTS WITH MOTOR AND SENSORY D/O

Dr. Alemani

***Nagsimula na ako sa pinaka-heart ng tranx haha. Dami kasing sinasabi pa sa unahan eh. Yung reference sa

baba jan kumuha si Doc Alemani as in parang copy paste and na-double check ko n rin if may discrepancy

Reference: Adams and Victor's principles of neurology ebook pages 138-140 and pates 53-56 By Allan H. Ropper,

Raymond Delacy Adams, Maurice Victor, Robert H. Brown; Retrieved from

http://books.google.com.ph/books?id=uqT4huHvBZ4C&pg=PA50&lpg=PA50&dq=crural+leg+monoplegia&source=

bl&ots=nb1-H-

mz0v&sig=OuYJXSmFa4u9byFESHpau6p5tmE&hl=en&sa=X&ei=kwRqT82tDqi0iQfznJWhCg&ved=0CCMQ6AEwAQ#

v=onepage&q=crural%20leg%20monoplegia&f=false

Upper Motor Neuron Signs Lower Motor Neuron Signs

Hypertonia Marked hypertonic in flexor muscles of the

arms

Marked hypertonic in extensor muscles of thelegs

Hyperreflexia (4/4) with or without clonus Upward plantar response (babinzki) Clasp-knife movement Spastic

Hypotonia No voluntary resonse Areflexia Atrophy Fasciculation Fibrillation seen in electromyography

Paralysis/Plegia Paresis/Palsy

o Abolition of functiono Loss of voluntary response secondary to

disrupted motor pathway

o Lesion at any point from cerebrum to musclefiber

o Lesser degree of paralysiso Partial loss of function

***However, as I consulted Google:

Paralysis loss of motor function only. Plegia loss of motor and sensory function. Paresis impaired function; meaning it is still there but it doesnt do its work well or as expected. Palsy loss of motor, sensation function; usually localized example face only, forearm and arm as seen in

brachial palsy.

***more or less ganun din naman haha

Anatomic Consideratios of the Upper Motor Neuron

***Alam nio na yang homunculus Siyempre kung may infarct ka sa Anterior Cerebral Artery, ang affected part ng

cerebrum ay yung sinusuplayan ni ACA. Accdg sa homunculus ang manifestation ay sa leg. Make sense d ba?

Hahaha
http://retrieved%20from%20http/books.google.com.ph/books?id=uqT4huHvBZ4C&pg=PA50&lpg=PA50&dq=crural+leg+monoplegia&source=bl&ots=nb1-H-mz0v&sig=OuYJXSmFa4u9byFESHpau6p5tmE&hl=en&sa=X&ei=kwRqT82tDqi0iQfznJWhCg&ved=0CCMQ6AEwAQ#v=onepage&q=crural%20leg%20monoplegia&f=falsehttp://retrieved%20from%20http/books.google.com.ph/books?id=uqT4huHvBZ4C&pg=PA50&lpg=PA50&dq=crural+leg+monoplegia&source=bl&ots=nb1-H-mz0v&sig=OuYJXSmFa4u9byFESHpau6p5tmE&hl=en&sa=X&ei=kwRqT82tDqi0iQfznJWhCg&ved=0CCMQ6AEwAQ#v=onepage&q=crural%20leg%20monoplegia&f=falsehttp://retrieved%20from%20http/books.google.com.ph/books?id=uqT4huHvBZ4C&pg=PA50&lpg=PA50&dq=crural+leg+monoplegia&source=bl&ots=nb1-H-mz0v&sig=OuYJXSmFa4u9byFESHpau6p5tmE&hl=en&sa=X&ei=kwRqT82tDqi0iQfznJWhCg&ved=0CCMQ6AEwAQ#v=onepage&q=crural%20leg%20monoplegia&f=falsehttp://retrieved%20from%20http/books.google.com.ph/books?id=uqT4huHvBZ4C&pg=PA50&lpg=PA50&dq=crural+leg+monoplegia&source=bl&ots=nb1-H-mz0v&sig=OuYJXSmFa4u9byFESHpau6p5tmE&hl=en&sa=X&ei=kwRqT82tDqi0iQfznJWhCg&ved=0CCMQ6AEwAQ#v=onepage&q=crural%20leg%20monoplegia&f=falsehttp://retrieved%20from%20http/books.google.com.ph/books?id=uqT4huHvBZ4C&pg=PA50&lpg=PA50&dq=crural+leg+monoplegia&source=bl&ots=nb1-H-mz0v&sig=OuYJXSmFa4u9byFESHpau6p5tmE&hl=en&sa=X&ei=kwRqT82tDqi0iQfznJWhCg&ved=0CCMQ6AEwAQ#v=onepage&q=crural%20leg%20monoplegia&f=falsehttp://retrieved%20from%20http/books.google.com.ph/books?id=uqT4huHvBZ4C&pg=PA50&lpg=PA50&dq=crural+leg+monoplegia&source=bl&ots=nb1-H-mz0v&sig=OuYJXSmFa4u9byFESHpau6p5tmE&hl=en&sa=X&ei=kwRqT82tDqi0iQfznJWhCg&ved=0CCMQ6AEwAQ#v=onepage&q=crural%20leg%20monoplegia&f=falsehttp://retrieved%20from%20http/books.google.com.ph/books?id=uqT4huHvBZ4C&pg=PA50&lpg=PA50&dq=crural+leg+monoplegia&source=bl&ots=nb1-H-mz0v&sig=OuYJXSmFa4u9byFESHpau6p5tmE&hl=en&sa=X&ei=kwRqT82tDqi0iQfznJWhCg&ved=0CCMQ6AEwAQ#v=onepage&q=crural%20leg%20monoplegia&f=falsehttp://retrieved%20from%20http/books.google.com.ph/books?id=uqT4huHvBZ4C&pg=PA50&lpg=PA50&dq=crural+leg+monoplegia&source=bl&ots=nb1-H-mz0v&sig=OuYJXSmFa4u9byFESHpau6p5tmE&hl=en&sa=X&ei=kwRqT82tDqi0iQfznJWhCg&ved=0CCMQ6AEwAQ#v=onepage&q=crural%20leg%20monoplegia&f=falsehttp://retrieved%20from%20http/books.google.com.ph/books?id=uqT4huHvBZ4C&pg=PA50&lpg=PA50&dq=crural+leg+monoplegia&source=bl&ots=nb1-H-mz0v&sig=OuYJXSmFa4u9byFESHpau6p5tmE&hl=en&sa=X&ei=kwRqT82tDqi0iQfznJWhCg&ved=0CCMQ6AEwAQ#v=onepage&q=crural%20leg%20monoplegia&f=falsehttp://retrieved%20from%20http/books.google.com.ph/books?id=uqT4huHvBZ4C&pg=PA50&lpg=PA50&dq=crural+leg+monoplegia&source=bl&ots=nb1-H-mz0v&sig=OuYJXSmFa4u9byFESHpau6p5tmE&hl=en&sa=X&ei=kwRqT82tDqi0iQfznJWhCg&ved=0CCMQ6AEwAQ#v=onepage&q=crural%20leg%20monoplegia&f=falsehttp://retrieved%20from%20http/books.google.com.ph/books?id=uqT4huHvBZ4C&pg=PA50&lpg=PA50&dq=crural+leg+monoplegia&source=bl&ots=nb1-H-mz0v&sig=OuYJXSmFa4u9byFESHpau6p5tmE&hl=en&sa=X&ei=kwRqT82tDqi0iQfznJWhCg&ved=0CCMQ6AEwAQ#v=onepage&q=crural%20leg%20monoplegia&f=false


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Paralysis due to lesions of the Upper Motor Neuron

- The Corticospinal tract may be disrupted anyway along its course producing upper motor neuron signs.- The lesions could be in any of the ff sites:

o Cortexo Subcotrical white mattero Internal capsuleo Brainstemo Spinal cord

PATTERNS OF PARALYSIS

Monoplegia

Weakness or paralysis of all muscles of one arm or leg Should not be isolated muscle that is supplied by a single nerve or motor root. Must not be interpreted as failure to move due to pain Ataxia and sensory disturbances = weakness Other diseases that can manifest this kind of paralysis are:

Parkinsons dse Other dse that can cause rigidity and bradykinesia Arthritis Bursitis Fracture

Forms of Monoplegia Etiology Manifestation

Monoplegia without muscular

atrophy

- Lesion in cerebral cortex- Secondary to ischemia,

small tumors or abscess

- Multiple sclerosis or SCtumor

Paralayze only half a hand orjust the thumb

May cause weakness of onelimb

Nerve conduction studies arenormal

Monolegia 2ndary to UMN willmanifest as UMN signs

If monoplegia 2ndary to LMNthen therefore will manifest as

LMN signs

Monoplegia with muscular atrophy

- More frequent than theprevious one

- Examples are completeatrophic brachia

monoplegia

- Crural (leg) monoplegiasecondary to letter c

etiology

- Diseases of Motor neurons- Atrophy secondary to

disuse of the muscle

- Trauma of the SC or tumor,myelitis, multiple sclerosis,

progressive muscular

atrophy, late radiation

Long continued disuse of onelimb may lead to atrophy but it

is usually of lesser degree than

atrophy due to lower motor

neuron disease (denervation

atrophy).

In disuse atrophy, tendon reflexare retained and nerve

conduction studies are normal.

Hemiplegia

Most frequent form of paralysis Secondary to lesion of the Corticospinal pathway Due to stroke, tumors, infections and vascular anomalies

Form of Hemiplegia Etiology Manifestations

Weber Snydrome - Disruption of the CST at themidbrain and CN3

- Secondary to midbraininfarct

Ipsilateral CN3 Palsy Contralateral hemiparesis


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Millard-Gubler syndrome (low

pontine lesion)

- Lesion at low pontine level Ipsilateral abducens or facialpalsy

Contralateral weakness orparalysis of the arm and leg

Rationale:

Recall ur anatomy, sa pons nalabas c

CNV, CNVI, CN7 kaya sila ang greatlyaffected

Medullary Lesion - Lessions in the medulla(obvious naman haha)

Tongue Sometimes pharynx and larynx

on one side

Arm and leg on the other sideMedulla, nag eexit sila CNIX, X and

XII

Crossed paralyses - Sabi sa past tranx lowpontine lesion daw

- Sabi ng book at sa google,characteristic of brainstem

lesion

Example, paralysis of right armand paralysis of left leg, gets?

Incomplete cervical spinal cord

lesion

- Brown sequard syndrome- Spinal cord lesion Ipsilateral hemiparesis that

spares the face

With loss of vibratory andpositon sense on the ipsilateral

side

Contralateral loss of pain andtemperature

Paraplegia

- Weakness or paralysis ofboth lower extremities- Occurs with the disease of the SC, nerve roots and peripheral nerves- Secondary to:

o Tumors, acute myelitis, trauma, vascular malformation in the SC, SC infarctiono SC infarction is usually due to air embolism that occurs in deep sea divers

- Difficult to distinguish with peripheral neuropathies because of the element of spinal shock which resultsin abolition of reflexes and flaccidity

- In Peripheral neuropathies, motor loss tends to involve distal muscles of the legs more than proximal oneswith the exception of Gullain-Bare Syndrome which starts with paraplegia to quadriplegia in ascending

pattern of paralysis

Form of Paraplegia Etiology ManifestationsA. TetraplegiaB. DiplegiaC. Triplegia

- Lesion is cervical area ratherthan thoracic

- Causes: Fracture dislocation

with SC involvement

Tumors, myelitis Foramen magnum

compression lesions

Disc dessication Mscular dystrophies

can cause paralysis of

all 4 extremities assoc

with muscle wasting

a. Affects all 4 extremitiesb. Legs are more affectedc. Occurs most often as a

transitional condition in

the devt of partial

recovery from

quadriplegia

Werdnig Hoffman Disease

- Pedia group (affects infants 6mos 1 year old)

- Autosomal recessiveneuromuscular disease

- Tetraplegia Floppy infant upon birth

Isolated paralysis of One or more

muscle groups

- Peripheral nerve disease or ofthe several adjacent nerve

roots

Weakness or paralysis ofa partical muscle of

group of muscles


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- Impairment or loss ofsensation in the

distribution of nerve

Non paralytic D/o of movement - No upper of lower motorneuron ds

- May be due to d/o of positionsense or cerebellarcoordination or dse of basal

ganglia

- If absence of the d/omentioned above, apraxia,

ataxia should be ruled in

No lesion in LMN orUMN but certain

movements are

nonetheless imperfectlyperformed

Apraxia and Ataxia, etc

Muscular paralysis without visible

changes in Motor Neurons, roots and

Nerves

- Disease due to NMJdysfunction or intrinsic to the

muscles

- Due to infections andmetabolic d/o

-

Examples are:

Myasthenia gravis Muscular dystrophies Myotonia congenital Familial periodic

paralysis

d/o of K, Na, Ca++, Mgmetabolism

tetanus, botiliniumpoisoning

black widow spider bite thyroid, endocrine,

sterioid, statin

myopathies

Hysterical Paralysis

- malingering patients- Do Hoover sign Test

o Examiner places hisone hand under the

heel of paralyzedleg

o Ask the patient flexhis/her hip (taas paa

using his thigh) of the

non-paralyzed leg

o If you feel downwardpressure with your

hand below sa

paralyzed leg ay

naku faker xa! Haha

therefore, (+) Hoover

sign

Try mo itaas ung isa mong leg using

your thigh (hip flex) as high as you can,

there would be pressure on your other

leg

True paralysis would be: kahit itaas mo

ung paa ng non-paralyzed leg, walang

pressure sa true paralyzed leg

For better visualization: youtube! Type

mo Hoover test! haha

- Trip niya lang haha Paralysis involving onearm or leg, both legs or

all of one side of the

body

Tendon reflex areretained

No atrophy Hysterical gait is often

diagnostic

When the hystericalpatient is asked to move

the affected limbs, the

movements tend to be

slow, hesitant and jerky,

often with contraction of

agonist and antagonist

muscles simultaneously

and intermittently

Inconsistent on repeatedexamination and

maneuvers


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APROACH TO SENSORY DISORDER

Considerations:

o Under normal conditions, motor and sensory functions are dependent of each othero However, interruption of other sensory pathways and destruction of the parietal cortex also has profound

effects on motility

o To a large extent, motor functions depend on sensory inputso Movement is inextricably dependent on sensation

Sensory Syndromes

o Sensory changes due to interruption of single peripheral nerveo Depends on whether the nerve involved is predominantly muscular, cutaneous or mixedo Localized to its dermatomal distribution if cutaneouso Example:Ulnar nerve in the arm patient woud have hyposthesia in the muscles innervated by ulnar

nerve (di ko na iisa-isahin kasi marami haha)

Sensory Syndromes

I. Polyneuropathiesa. Myelinopathyb. Axonopathy

II. Sensory Changes due to involvement of Nerve Rootsa. Radicular pain

III. Sensory Changes dude to involvement of Sensory Gaglia (Sensory Neuropathy, Gangliopathy)IV. Sensory Spinal Cord Lesions

a. Complete SC sensory Sydromeb. Posterior Cord Sydromec. Brown-Sequard Syndrome (Hemisection of SC)d. Syringomelic Syndrome

V. Hemisensory Loss due to a lesion of the Thalamusa. Thalamic pain syndrome

VI. Sensory Loss due to lesions in the parietal Lobea. Anterior Parietal Lobe syndrome

Sensory Syndromes Etiology Manifestation

Polyneurophathies

- Can be classified asdemyelinating or axonal

(discussed below)

- Multiple involvement ofperipheral nerve

Causes:

1. Metabolic2. Endocrine3. Post-infectious4. Toxic5. hereditary

Purely motor, sensory or mixed;

Mostly mixed;

Usually starts as sensory then progress to mixed

a. Myelinopathy - Lesionsprimarily

affecting

myelin or the

myelinating

Schwann cell

- Immunemediatedattakc on PNS

myelin

segmental

demyelination

- Acute onset in hours or days- Initially starts in the Lower extremities

but not always distally

- Generalized weakness- Mild sensory loss- (-) tendon reflex in all extremities- Mark slowing conduction velocities- Inc CSF protein since myelin is a protein- Rapid recovery

b. Axonopathy Metabolic abnormalityinitially occurs in the cell

body or throughout the

- Degeneration appears to advanceproximally toward the nerve cell body

as long as the metab abno is present


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axon

Long and large dm

fibers are usually

affected

Sensory Changes due toInvolvement of Nerve Roots

(Radiculopathy)

a. Radicular painPain arising from Dorsalroot or the dorsal root

ganglion

- Pain to be referred along a portion ofthe course of the nerve or nerves

formed by the affected dorsal root

- Dermatomal pattern:o Example: if the patient has L1-

L2 herniated disc in the nucleus

pulposus, the patient will

experience pain in the

dermatomal area of L1-L2.If L4

sciatic pain felt in the

back and radiate down to

lower extremities

Sensory Changes due to

Involvement of Sensory Ganglia

(Sensory neuropathy,

Gangliopathy)

Disease of dorsal root

ganglia

Caused by

paraneoplastic

syndromes, connective

tissue diseases, Sjogren

syndromes, toxic

exposure

Produces same sensory defects as nerve root

diseases but is unique because:

o Proximal areas of the body also showpronounced sensory sensory

(hyposthesia and hypoalgesia) in the

face, oral, mucosam scalp, trunk and

genitalia

o Propioceptions lost which gives rise toataxia

o Reflex are lostSensory Spinal Cord Lesions (please

refer to the figure in the last page)

a. Complete SC SensorySyndrome

- completetransversedisruption of

the SC

- No motor or sensory function- Loss of pain, temperature and touch

sensation

b. Posterior cord syndrome - Lesion in theposterior

portion of SC

- Due tointerruption to

the posterior

spinal artery

- Paresthesia in the form of tingling andpins and needles sensation or girdle and

band like sensation

c. Brown-sequard syndrome - Incompletespinal cord

lesion

- Due tohemisection of

the cord

- Loss of motor function, proprioceptionand kinesthesia on the same side of the

lesion

- Loss of pain and temperature on thecontralateral side and begins one or

two segments below the lesion

Example lesion at L1 the loss of

pain will be at L2 or L3 and

manifestations will be those supplied by

L2 and L3

- Associated spastic motor paralysis onthe same side of the lesion

d. Syringomyelic Syndrome(Lesion of the gray matter)

Long fluid spaces are

present in the central

gray matter of the SCsurrounded by thick

tissue made of glial cells

- Loss of Pain and temperature sensationdepends on extent

- Tactile sensation is spared

Hemisensory loss due to a lesion of

the Thalamus

Involvement of VPL and

VPM nuclei of the

thalamus

Usually due to vascular

- Loss or dimunition of all forms ofsensation on the contraleral side

- Position sense is affected morefrequently than any other sensory

function and is usually but not always


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lesion and less often

due to tumor

profoundly affected than loss of touch

and pinprick

a. Thalamic pain syndromeAka Syndrome of Dejerine-

Roussy

Damage to the thalamus - With partial recovery, some patientsmay exhibit spontaneous pain or

discomfort

- Example: patient had thalamic stroke,there is still sensory loss but the patienthas discomfort/non localizing pain on

the affected side

- Hypersensitivity to painSensory Loss due to lesios in the

Parietal Lobe

Aka Verger-Dejerine syndrome

- Disturbances in the discriminativesensory function of the contralateral

side without impairment of the primary

modalities of sensation unless the

damage is profound

- Loss of position sense and sense ofmovement

- Impaired ability to localize touch andpain stimuli (topagnosia)

- Widening of two point threshold(normal is 4-5 mm)

- Astereognosis- Other Cx Mx

Hemineglect Sensory Inattention

Example: a patient would dress

up only on the normal side

Extinction

Documents

Approach to Patients With Motor and Sensory Disorder 3-2012