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The Nervous System:

A Basic Approach to Recognizing Neuropathology

Julie Dylla Moczygemba, PA-CNeurosurgery

Department of Veteran Affairs

Course Objectives Review of Basic Neuroanatomy

Review Physical Exam of brain, spine, peripheral nerves, neuromuscular system

Workshop practice on Cranial Nerve Exam, Upper Extremity Exam, Lower Extremity Exam

Case studies

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NeuroAssessment

Brain

Cerebellum

Cranial Nerves

Cervical

Lumbar

Peripheral nerves

Neuro Assessment ToolsReflex hammer

Tuning fork

Safety pin, monofilament

Tuning fork

Ophthalmoscope

Visual Acuity card

Cotton swab or tissue

Soap and or coffee

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Gestalt Psychology

"The whole is other than the sum of the parts"

Kurt Koffka

Presenting symptom“How are you feeling?”

Headaches? Trauma? Pain? Worsening pain? Uncontrolled pain? Use Pain scale

Nausea/Vomiting?

Numbness?

Weakness?

Difficulty swallowing?

Change in voice?

Anxious?

Abnormal body movement?

Trouble staying awake?

**** Does the family see a change???? ****

History of Present IllnessOnset- events around the initial symptoms

Provoke- Alleviating and aggravating factors

Quality- burning, sharp, cutting, aching, change since onset

Region/Radiation

Severity- Pain Scale

Time- start time, occurred before?, sudden, gradual

Associated symptoms- numbness, paresthesias, “swelling”, “cold” sensation, edema

Adaptations

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Physical Exam

Focused exam

Identify trauma

Vital signs

Review of all medications

Labs

EEG

Imaging--CT, MRI, CTA, MRA, plain xrays, Bone Density studies, PET scans, Angiograms

Vital SignsRespirations- quality, pattern, distress, rate

Heart Rate- regular, brady, tachy, rhythm

Blood Pressure

Temperature

Pain level

Oxygen Saturation- RA or O2?

Review of MedicationsPrescribed- steroids, blood thinners,

antihypertensives, pain medications, gabapentin, pregabalin, amitrityline, dilantin, keppra, parkinsons, restless leg

OTC- tylenol, nsaids

Illicit- marijuana, cocaine, opiates, stimulants

Herbs, holistic, teas – Kratom?, fish oil

Hormone replacement- cortisone, thyroid

Taking prescriptions as prescribed?

Changes in prescription recently

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Past Medical History Seizures, Parkinson's, Tremor, Huntington disease

Migraines- cluster, ice pic, acephalgic, with aura, without aura, abdominal… ~21 different types

Cerebral aneurysm

Low back , neck pain, trauma

Cancer Diabetes

Untreated infection, prolonged infection, use of unclean needles, Dental work

TIA, Stroke, Wax/Wane difficulty in mentation or use of extremity

Chemical exposure, frostbite Bowel/Bladder problems

hydrocephalus

Depression, Anxiety

Past Surgical HistoryAneurysm clipping

Spine surgery

Craniotomy

Craniectomy- skull defect

Extremity Surgeries- knee replacement , carpal tunnel, ulnar decompression, shoulder

Abdominal surgery- free air, manipulation of peritoneal catheters/shunts, malabsorption

Labs and Imaging BMP- Sodium, OsmolalityCBC-H/H, WBC, PlateletsCoagCulturesUrine electrolytes, osmolalityB12, Vitamin D, toxins Hormone levels- cortisol, prolactin, TSH AED levels- DilantinCSF studies – Lumbar puncture, drain tapCT, MRI, Bone Density, MRA, CTA, Angio, plain xraysEMG, nerve conduction study

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Cerebrospinal fluidCSF production

Clear fluid

Produced by choroid plexus

450-750 ml/day in adults

25ml/day in peds

Absorbed by arachnoid villi, choroid plexus and lymphatics

Rate of absorption is pressure dependent

CSF studies

CSF studies include WBC, RBC, protein, glucose

In adults, CSF normally has 0-5 lymphocytes otherwise there should be no polys(PMN’s) or RBC’s

Protein 30mg/dl

Glucose 40-80 mg/dl

Focused Neuro Exam

Where do we start?

General Appearance alone, family present or outside the room

level of consciousness

dress and hygiene

posture

symmetry

involuntary movement, tremors at rest or motion, tics

behavior- consistent with pain, irritable,

what is on their bedside table

lines, IV, drips, monitors

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Inspection and Palpation

Inspect for atrophy, signs of trauma (ecchymosis, open wounds, rhinorrhea, otorrhea), incisions for errythema, edema, drainage

Palpation of skull, spine, shunt sites (head and peritoneum)

Cerebral ExamMini-mental exam

Cerebellum- Balance, coordination

GCS, Brain Death

ICP- intracranial pressure should be equal to central venous pressure 8-12mmhg, Monroe-Kellie Hypothesis

Motor exam

Ulnar drift

Sensory exam

Cranial Nerve exam

Mini Mental Status Exam Date orientation Place orientation Register 3 objects Serial sevens Recall 3 objects Naming Repeat a phrase Verbal commands Written commands Writing DrawingScoring 24-30 wnl, </= 23 cognitive impairment (needs further testing)

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Cerebellar function

Finger to nose

Point to Point

Heel to shin

Rapid alternating movement

Gait- Tandem, Poor balance- Veers

Rhomberg???

Glascow Coma Scale

Eye Opening 1-4

Verbal Response 1-5

Best Motor Response 1-6

Maximum Score 15

Minimum Score 3T

Glascow Coma ScaleEye Opening

4 awake and alert, looking around, watching tv, can wake with soft touch or normal voice

3 sleeping but awake easily with a loud voice, may fall back to sleep without verbal stimulus

2 patient wakes to painful stimulus

1 does not wake at all to painful stimulus

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Glascow Coma ScaleVerbal Response

5 “oriented” x4 (person, place, date and to reason they are in the hospital or to their health problem)

4 confused or disoriented- does not meet above criteria for orientation

3 inappropriate words- not only confused, but is using words that are out of context

2 incomprehensible sounds

1 none

Glascow Coma ScaleMotor Response

6 obeys commands

5 localizes to pain

4 withdraws to pain

3 abnormal flexion posturing, decorticate (pull in to the core/chest)

2 abnormal extension posturing, decerebrate

1 none

http://accesspharmacy.mhmedical.com/data/Books/gano24/gano24_c012f013.png

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Brain Death ExamGCS 3T

1. Absence of Brainstem reflexes- fixed pupils, absent corneal reflex, absent oculovestibular reflex, absent oculocephalicreflex, absent gag

2. Apnea test

3. No response to deep central pain

4. Vitals- core temp > 32.2, SBP > 90mmhg (must have the absence of complicating conditions such as hypothermia, intoxication, shock, drug induced coma

Observation period- varies on injury, need for clinical confirmatory tests, anoxic brain injury, 0-24 hours

Intracranial Monitoring and Assessment

Normal ICP in adults= <10-15mmhg

Cerebral perfusion pressure(CPP) =MAP-ICP

Normal CPP in an adult is >50mmhg

Intracranial hypertension=>20mmhg

Primary causes of elevated ICP >15mmhg

Cerebral edema

Hyperemia: normal response to a head injury

Traumatic masses: epidural, subdural, and intraparenchymalhemorrhages, foreign body, depressed skull fractures

hydrocephalus

Hypoventilation

Systemic hypertension

Venous sinus thrombosis

Increased muscle tone and Valsalva maneuver as a result of agitation or posturing

Sustained posttraumatic seizures (status epilepticus)

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Secondary causes of elevated ICPDelayed epidural

hematoma

Delayed acute subdural hematoma

Delayed traumatic intracerebral hemorrhage

Cerebral vasospasm- as seen in subarachnoid hemorrhage

Severe ARDS

Delayed edema-more common in pedi

hyponatremia

Cerebral Motor and Sensory Exam

Homunculus

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Cerebral Exam- PearlsCerebral aneurysm rupture around the circle of Willis-->

subarachnoid hemorrhage--> worst headache, n/v, altered consciousness, sentinel bleed

Seizure- abnormal movement of the entire body or a body part which may or may not be associated with head turning, hallucinations, tingling, flashing lights, flushing, pallor, sweating, deja vu, dreamlike states, illusions. May be followed by aphasia, paralysis, loss of time (absence), impaired consciousness.

Migraine - unilateral head pain, ice pic, aura(contralateral), cluster, associated with n/v, light/sound sensitivity, plegia

Cerebral Exam- PearlsStroke- hemiplegia, facial droop, speech impairment,

hypertension, hypotension, hemianesthesia, visual field deficits

Brain tumor- visual field deficits, ataxia, headaches, seizures, weight loss, hx cancer

Meningitis- Meningismus(stiff neck, dural irritation), headache, AMS, fever, rash, (caused particles in the subarachnoid space-blood, virus, bacteria, chemicals)

Subdural hematoma- GCS, hx head injury, hx blood thinners, elderly, alcoholic, ulnar drift, ataxia, hemiparesis, fatigue/sleepy

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http://www.jkns.or.kr/fulltext/Fig/0042002100f2.jpg

Cranial Nerve Exam

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Cranial Nerve ExamCN I Olfactory- smell

CN II Optic- vision

CN III Oculomotor- eyelid movement, eye movement , parasympathetic pupil control

CN IV Trochlear- turns eye down and out

CN V Trigeminal- Facial sensation, chewing

CN VI Abducens-Lateral eye deviation

CN VII Facial- Facial muscle control

Cranial Nerve Exam CN VIII Vestibulocochlear- hearing, equilibrium

CN IX Glossopharyngeal- taste, senses carotid blood pressure

CN X Vagus-slows heart rate, stimulates digestion, senses aortic blood pressure

CN XI Spinal Accessory- shoulder strength and turning of the head, swallowing

CN XII Hypoglossal- movement and protrusion of the tongue

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CN 0- Terminal NervePhermones- studied in animals and humans and studied in humans. Thought to play in a role in the release of luteinizing hormone (LHRH) and is therefore thought to play role in reproductive behavior.

CN 1- Olfactory (Sensory)Transmits sense of smell to the brain

Coffee

Soap

Damage occurs commonly with head injuries, sinus surgery. Associated CSF rhinorrhea?

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CN II- Optic Nerve (Sensory) Transmits images on retina to the brain

Visual acuity (eye chart test)

Visual fields

Papillae function

Fundus (optic disc to cup ratio)

CN III- Oculomotor (mainly motor)Motor to most eye movements and sphincter pupillae,

medial rectus, inferior oblique, superior rectus, inferior rectus

Eye movement - up, down, inward/down

Eyelid placement- ptosis?

Eye displaced inferiorly and laterally

Fixed and dilated pupil, constrict with pilocarpine?--think intracranial

Pupil ExamPupil reaction (1-9mm)

Pinpoint pupils opioid and parasympathetic medications (pilocarpine)

Dilated pupils sympathomimetic meds, adrenaline, compression/damage of the ipsilateral cervical sympathetic chain, amphetamines, LSD, Atropine, psychedelic cocaine, mushrooms, Ecstasy, 3rd Cranial Nerve palsy, cataract surgery

Accommodation- CN II and CN III, pupil dilation with distance vision and pupil constriction with near vision

Convergence- Medial rectus, pupil constriction

Papilledema- Optic disc swelling (elevated ICP)

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Anisocoria (unequal pupils)Mydriasis (blown pupil)

Vision

Acuity

Double vision-CN defect

Peripheral Field-

Optic Chiasm-> Sellar mass

Mass along the Optic Radiation anywhere from the Occipital lobe through the Optic nerve.

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CN IV- Trochlear (Motor)Superior Oblique- depresses and rotates eye laterally

Think… LR6 SO4

Motor test: Eye movement , vertical/horizontal double vision

Superior Oblique Palsy- Stroke, trauma, birth, concussion, whiplash, aneurysm

CN V- Trigeminal (Sensory and Motor)

Sensory: Face sensation, corneal sensation

Motor: mastication muscles

Sensory test:

V1 Ophthalmic nerve

V2 Maxillary nerve

V3 Mandibular nerve

Corneal reflex- touch cornea with soft cotton swab

Motor test: Clench jaws, palpate masseter

CN V problems Trigeminal neuralgia

CN VI-Abducens (mainly motor)Motor: Lateral rectus (SO4 LR6)

Motor test: Eye abduction

Lateral rectus palsy- diabetes, stroke, trauma, viral illness, brain tumor, vascular inflammation, severe infections, migraines, elevated ICP

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CN VII- Facial (Sensory and Motor)Sensory: anterior 2/3 of tongue

Motor: muscles of facial expression, posterior belly of the digastric muscle, stylohyoid, stapedius, salivary glands secretion (except parotid), lacrimal gland

Sensory test: Taste- sweet, salty

Motor test: Raise eye brows, close eyes tightly, show teeth, puff out cheeks

Facial Nerve Palsy Bell’s Palsy

CN VIII- Vestibulocochlear (mostly sensory)

Vestibular-equilibrium

Cochlear- hearing

Mediates sensation of sound, rotation and gravity essential for balance and movement

Cochlear- rub fingers, tap fingers, snap

Vestibular- Syringe ears with water

Tuning fork

CN IX-Glossopharyngeal (Sensory and Motor)

Sensory- Taste for posterior 1/3 of the tongue and palatine tonsils

Motor- secretion from parotid gland, stylopharyngeus-elevates larynx and pharynx, dilates pharynx to allow passage of large food bolus

Gag reflex – tests CN IX sensory

CN X (Vagus) motor

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CN X-Vagus (Sensory and Motor)Sensory Taste (posterior 1/3 tongue), outer ear, meninges

MotorMuscles used in swallowing and speech, heart rate control (parasympathetic), peristalsis

Motor test: Gag reflex (sensory IX, motor X), phonation, swallowing , heart rate

Sensory: Taste, ear manipulation may cause coughing

CN XI- Spinal Accessory (Motor)Motor: Sternocleidomastoid, trapezius

Motor test: Shoulder shrug, head turning

CN XII-Glossopharyngeal (motor)Motor: Movement of the tongue

Motor test: Move protruded tongue side to side

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Cranial Nerve Exam Practice

Spine Assessment

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Neuro Spine AssessmentMotor- myotome

Sensory- dermatome

Reflexes- UMN vs LMN, Deep Tendon

Gait

Pain - radiation, reproducible with walking, coughing, sneezing, moving head, at night, am, pm

Tinels, straight leg raise

Muscle Strength Grading 5-> Normal strength

4-> Movement against resistance

4- slight resistance

4 moderate resistance

4+ strong resistance

3-> Movement against gravity

2-> Movement with gravity eliminated

1-> Trace or flicker of contraction. No joint motion

0-> No evidence of contractility

Cervical Spine-MyotomeC 3-4--> C4 nerve root- trapezius,

origination of phrenic n.

C4-5--> C5 nerve root - deltoid (arm abduction)

C5-6--> C6 - biceps, wrist extensors

C6-7--> C7- triceps, finger flexors and extensors

C7-T1--> C8- triceps, finger flexors

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Sensory Hemifacial pain- Trigeminal Nerve Dermatome pain- Nerve Root Impingement Peripheral Nerve distribution- CTS, guyon canal, cubital

tunnel, tarsal tunnel, Peroneal, Lateral Femoral Cutaneous Hemianesthesia- Thalamic stroke Sock distribution numbness-Peripheral Neuropathy Shoulder pain with abdominal free air- phrenic n.

irritation

Think symmetry and nerve distribution patterns. Use monofilament, pointer on reflex hammer, soft tissue, safety pin, light touch

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SensoryVibration

Position Sense- proprioception

Pin prick

Temperature

Light touch

Higher sensory functions

Deep Tendon Reflexes C6 nerve root- biceps tendon

C7 nerve root- triceps tendon

C6, C7 Brachioradialis- Supinator

L2,L3,L4 nerve roots - knee jerk reflex

S1 nerve root- ankle jerk

Upper motor neuronBrain and spinal cord injury

Hyperreflexia

+babinski

Clonus – 1-2 beats may be normal

+Hoffmann (cervical)

Spasticity

Bladder urgency, urge incontinence, frequency

Muscle cramping

Lhermittes

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Hoffmann’s reflex- UMNLift patient’s relaxed hand at the wrist with your non-dominant hand and take your dominant hand and place your thumb over the patient’s middle fingernail and put your index finger under the patient’s middle fingertip and flick the patient’s nail with your thumb. Watch for finger flexion response.

Gait Toe and heel Steppage Tandem SpasticWide basedMagneticAtaxicAntalgic

Observe rising from the sitting position. Wide based? Shuffle? Small steps? Speed? Ambulatory aides?

Balance and CoordinationBalance requires input from 2 of 3 inputs to the cortex

1. Visual confirmation of position

2. Non-visual confirmation of position (vestibular and proprioception)

3. Cerebellum

Rhomberg??

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Upper extremityCervical nerve root impingement

Brachial plexus

Ulnar nerve

Median Nerve

Serratus AnteriorC5,C6, C7- long thoracic nerve

Winging of scapula with wall push ups

Brachial plexusC5, C6, C7- wings from heaven, scapula

elevation

Tinels over the brachial plexus

Severe whole arm pain

History of arm injury

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Radial Nerve PalsySaturday night palsy caused by compression

of the radial nerve at the mid upper arm for an extended period of time

Painless wrist drop

Wrist extension 0/5

Ulnar NerveTinels at the cubital tunnel or guyon canal

Dropping things

Hyphothenar wasting

Pinky adduction weakness

Pinky and ring finger contraction spasms

Intrinsic wasting

Intrinsic weakness

Numbness of pinky and ring finger and medial middle finger

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Median Nerve+tinels at volar wrist

+phalens

Abductor pollicus weakness ( point thumb to floor and back to patient)

Abduction of pinky to thumb

Thenar wasting

Upper Extremity Exam PracticeVisual inspect for atrophy

Motor Exam –finger (abductors, adductors, flexors, extension and opposition) grips, wrist extensor/flexor, biceps, triceps, deltoid

Sensory Exam-Dermatome (nerve roots C4-8), median n., ulnar n., radial n.

Reflexes –biceps, triceps, brachioradialis, knee, ankle, crossed adductors

Proprioception-great toe

Tinels at wrist (carpal tunnel and guyon canal), elbow, brachial plexus

Gait- spastic, toe/heel

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Upper Extremity Neuro Exam Practice

Lower extremityLumbar nerve root impingement- herniated

disc, osteophytes

Cauda Equina Syndrome

Lumbar Plexitis

Peroneal nerve Palsy

Lateral Femoral Cutaneous- meralgia paresthetica

Peripheral Neuropathy

Lumbar spineHip flexor T12, L1, L2, L3- iliopsoas m.Hip adductor L2,L3,L4 -obturator n.Hip adductor L5 or gluteal n.Knee extensor L2,L3,L4 -femoral n., quadriceps m.Knee flexor - L5, S1- hamstring m.Dorsiflexor/inversion -L4, deep peroneal n., tibialis

anterior m.Dorsiflexor, EHL - L5, deep peroneal n., anterior

tibialis m. Plantarflexor, S1, gastrocnemius m.

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Lumbar Spine- nerve impingementL 4-5--> L4, knee jerk (can be absent after knee

surgeries especially knee replacement), quad weakness

Lateral disc at L5-S1--> L5, dorsiflexor weakness, EHLweakness, dermatomal numbness (top of foot to great toe), unable to heel gait, common herniation, distinguish between peroneal palsy

Medial disc at L5-S1 --> S1, toe gait weakness, calf and bottom of foot numbness, plantar flexor weakness, absent Ankle jerk (also seen in peripheral neuropathy)

Lower motor neuronClauda Equina syndrome- sacral anesthesia, urinary retention and overflow incontinence, focal lumbar radicular weakness, paraplegia, focal anesthesia, poor or no rectal tone.

Cause: sudden large herniated disc, large tumor causing severe cauda stenosis

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Peroneal PalsyProlonged pressure on lateral distal knee at

tibial head, painless foot drop

Can occur after knee surgery or injury

Lumbar plexitisPainful burning in multiple dermatomes of

one leg

Diabetes

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Lower Extremity Exam PracticeVisual inspection for atrophy

Motor Exam

hip flex, knee extension, dorsiflex, extensor hallicus longus, plantar flex, knee flexion

Gait- Toe, heel

Sensory Exam- Dermatome, peripheral nerve, sock distribution

Lower Extremity Exam

Reflex- Knee and Ankle, Clonus**, Babinski** (If has + UMN signs, must do UE exam including hoffmans)

Tinels at iliac crest

Straight Leg raise (tested when knee extended during motor exam)

Lower Extremity Neuro Exam Practice

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Case presentation #1

61 yo WM with Brooks-Spiegler syndrome (multiple dermatologic neoplasms) presented to the ER with progressive left sided weakness, short term memory , balance and vision problems and decreased in concentration over the past several months.

Physical ExamOverall, affect pleasant and appropriate, oriented to

self and place but not time, calculation slow.

Grossly preserved strength throughout. Left drift present.

Left homonymous hemianopsia. EOMs intact. Facial movement, sensation intact.

Sensation--light tough appears intact however proprioception impaired on the left side and some left/right confusion present.

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Case presentation #2Mr. P is a 44 y/o m with hx of chronic neck pain

presents with worsening right arm pain x 2 years. Has associated tingling and numbness of the right hand, specifically the middle 2 fingers and for arm. Worse when turning the head to the right. This position also reproduces arm pain in the same distribution. Has associated pain in the right shoulder and hand with motion and the symptoms do not wake him at night. Denies lhermittes, b/b problems, balance disturbances, finger infacility, dropping things.

Medications – Case #2Lithium 450mg bid

Lexapro 20mg daily

Gabapentin 300mg at bedtime

Hydrocodone 10mg q6 hour prn

Flexeril 10mg daily

Methacarbamol ?dose

tramadol 50mg bid prn

Physical Exam- Case #2Healthy WM, NAD, GCS 15, MAEW

Gait: steady, good stride

Strength testing: Right Left

Deltoid 5/5 5/5

Biceps 5/5 5/5

Triceps 4/5 5/5

Wrist flex 5/5 5/5

Wrist ext. 5/5 5/5

Grip 5/5 5/5

Interossei 5/5 5/5

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Physical Exam- Case #2DTR's Right LeftBiceps 2/4 2/4Triceps 0/4 2/4Brachiorad. 2/4 2/4Knee 2/4 2/4Ankle 2/4 2/4

Hoffman's - negativeBabinski – not testedClonus - negativeCrossed tibioadductors- not tested

Physical Exam- Case #2

Tender right trapezius and rotator cuff

Negative tinels at the wrist and elbow

+spurlings- reproducible arm symptoms

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Case Presentation #3Pt is a 38 yo male who has had >10 years of low back pain with intermittent lower extremity pain, radicular in nature. ~6 weeks ago, he was washing his car and the next day had a worsening of his low back pain. He came into the ER and was to follow up with neurosurgery in clinic with an MRI of his lumbar spine but for various reasons did not come to clinic. He was instructed upon discharge if his symptoms worsen to immediately return to the ER. 1 week later, he began having lower extremity weakness and urine dribbling. He presents today to the ER after 3 weeks of the above listed symptoms which include low back pain, bilateral lower extremity burning, mainly L5 distribution, bilateral lower extremity weakness, and urinary dribbling.

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Physical Exam-Case #3 Motors: 5/5 BUE 4+/5 BLE all muscle groups except dorsiflexion 4/5 bilateral dorsiflexion, very slow to initiate dorsiflexion

but once initiated can resist moderate force sensation to soft touch diminished in bilateral feet sensation to temperature grossly intact Knee jerk 2+/4 bilateral Ankle jerk 0/4 bilateral No clonus Normal response to sole stroke (babinski) Normal rectal tone Post void bladder scan 40cc

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Case Presentation #4(April 2016)

50 y/o female with hx of obesity, depression, HTN, uterine fibroids, presents to the ER for pelvic pain that radiates to the lower legs bilaterally, is a 8-9/10, sharp burning, intermittent.

Exam:

Motor 5/5

2+ DTR

-SLR

Labs, pelvic studies, plain xrays all normal, hcg negative, UA neg

Plan: consider MRI , NS consult

methylprednisolone 4mg dose pack

gabapentin 300mg po QHS for neuropathic discomfort

tramadol 50mg po QID PRN for severe discomfort

Case presentation #4Patient did not show for nerve conduction studies and did not return call for initiating PT.

MRI results came back and PCP placed consult to NS.

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Lumbar MRI without contrastMay 2016

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Neurosurgery ConsultJuly 2016- Presents to clinic with continued low back pain and left leg pain. States pain continues to radiate down the leg to the foot. Denies bowel or bladder changes, urinary retention, perineal or sacral numbness or paresthesia. Prefers surgery.

Exam: Normal 5/5 strengthNormal KJ and AJ reflexesNeg straight leg raise

Plan: Wait and watch. RTC 6 weeks.

Over the next 5 months…There are 6 documented phone calls, appointment cancellations with final decision to proceed with surgery.

Another MRI was scheduled and a preop visit was made.

January 2017…now 9 months after acute herniation

Patient returns to preop clinic with improved but not completely resolved radiculopathy.

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MRI reviewed with patient and surgery was cancelled. Patient has been offered steroid injections through pain management.

Studies show that most lumbar disc herniation syndromes resolve without surgical intervention.

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Thank You

Citations1. "Brain and Heart labeled images." Cool MRI Stuff.

Turbospinecho , 19 Jan. 2013. Web. 3 Jan. 2017. <https://coolmristuff.wordpress.com/2013/01/19/brain-and-heart-labeled-images/>. Brain Anatomy

2. Greenberg, Mark S., and Mark S. Greenberg. Handbook of neurosurgery. 5th ed. Tampa, FL: Greenberg Graphics, 2001. Print.

3. Hoppenfeld, Stanley, and Richard Hutton. Physical examination of the spine and extremities. New York: Appleton-Century-Crofts, 1976. Print.

4. "Neuroscience: week 2." ProProfs Flashcards. N.p., 19 Jan. 2013. Web. 3 Jan. 2017. <http://www.proprofs.com/flashcards/cardshowall.php?title=neuroscience-week-2>. (855) 776-7763