Neurological Conditions of relevance to Podiatry Mike Potter

Transcription

1 Neurlgical Cnditins f relevance t Pdiatry Mike Ptter 1

2 Divisins f the nervus system: a reminder Central nervus system (CNS) Brain Spinal crd Peripheral nervus system (PNS) Cranial nerves Smatic nervus system (innervatin f skeletal muscle) Autnmic nervus system (sympathetic and parasympathetic supply) 2

3 Divisins f the nervus system: a reminder the Brain Cerebrum Cerebellum Basal Ganglia Diencephaln Brainstem (pns varlii, midbrain, medulla blngata) Limbic system 3

4 Cerebrum 4

5 Cerebral crtex Functinal areas f crtex 5

6 Crnal crss sectin: basal ganglia, diencephaln (thalamus, hypthalamus) 6

7 Limbic system: hippcampus, amygdala, cingulate gyrus: emtins and memry 7

8 Cerebral crtex Functinal areas f crtex 8

9 Key categries f neurlgical disrders in pdiatric practice: Mtr disrders Sensry disrders Autnmic disrders Mixed cmplex disrders

10 Mtr disrders: key categries intracranial vascular accidents (eg. CVA) infectin & inflammatin (eg. plimyelitis, syphilis) tumurs (eg. cerebral, cerebellar) cngenital & genetic (eg. spina bifida, syringmyelia) demyelinative (eg multiple sclersis) degenerative (eg. Parkinsnism, mtr neurne disease) txic, metablic, deficiency (eg. pernicius anaemia)

11 Lesins f the mtr system Upper mtr neurne Lwer mtr neurne Extra-pyramidal Cerebellar

12 Where the damage ccurs determines hw extensive the disability becmes: Upper Mtr Neurne

13 Upper mtr neurne lesin signs Weakness r paralysis f mvements n ne side f the bdy Increase in tne f spastic type ( clasp-knife phenmenn) Increase in amplitude f tendn reflexes ( clnus ) Lss f abdminal reflexes Extensr plantar respnse ( Babinski reflex ) N muscle atrphy (aside frm disuse wasting) Nrmal electrical excitability f muscles

14 upper mtr neurne signs Muscle pwer is graded frm 0 t n mvement 1 - flicker is perceptible in the muscle 2 - mvement nly if gravity eliminated 3 - can mve limb against gravity 4 - can mve against gravity & sme resistance exerted by examiner 5 - nrmal pwer

15 Walking after strke: what des it lk like?

16 Intracranial vascular accidents: Strke Etilgy: haemrrhage, infarctin (thrmbus), emblus Types: Acute fcal strke Strke-in-evlutin (gradual step-wise extensin f infarct) Haemrrhage f the majr vessels f the Circulus arterisis (Circle f Willis)

17 Intracranial vascular accidents: acute fcal strke (athermatus blckage) Patient may awake with an established lesin Frequently evlves during a perid f 1 r 2 hurs Lss f cnsciusness may ccur, drwsiness cmmn Severe headache unusual (cf haemrrhagic) Paralysis develps rapidly (may be initially flaccid but becmes spastic with hyperreflexes

18 Intracranial vascular accidents: cerebral haemrrhage Strngly assciated with hypertensin Usually presents abruptly, ften during exercise Premnitry severe headache with lss f cnsciusness cmmn Internal capsule cmmnly invlved with hemiplegia supervening Paralysis develps rapidly (may be initially flaccid but becmes spastic with hyper-reflexes)

19 Intracranial vascular accidents: cerebral emblus 50% f cerebral infarcts are emblic, frm heart r athermatus vessels in neck and thrax TIA are ften emblic in rigin Abrupt nset (if the embli blcks vessel cmpletely, then cllateral circulatin ges int spasm = felled immediately)

20 Upper and Lwer Mtr Neurne arrangement

21 Lwer Mtr Neurne: 1. lwer mtr neurne cell bdy 2. mixed nerve sheath 3. mtr end plates 4. muscle fibres (muscle belly)

22 lwer mtr neurne signs Weakness r paralysis f muscles, whether vluntary r invluntary Lss f tne n passive mvement ( flaccidity ) Wasting f affected muscles (atrphy) Absence f reflexes sub served by affected neurnes (abdminal and plantar reflexes remain nrmal unless thse neurnes affected) fibrillatin (single fibres cntract spntaneusly) fasciculatin spntaneus cntractin f bundles f muscle fibres cntractures f muscle & trphic changes eg skin dryness and cyansis, brittle nails Electrical excitability f muscles lst

23 plimyelitis

24 Infective disrders: plimyelitis 3 pssible pliviruses (entervirus grup) rare tday due t Sabine vaccine (superceded Salk) causes lymphcytic meningitis: affects brain stem, spinal crd and crtex, but with a prpensity t damage anterir hrn cells, especially in lumbar segments Incubatin 7-14 days Clinical features: Aseptic meningitis (abut 2 days f fever and headache, meningism) A week f well-being Recurrence f pyrexia, headache and meningism Weakness develps gradually, with paresis (maximum after ne week)

25 Infective disrders: plimyelitis Bed rest key exercise wrsens paralysis Residual effects (seen by pdiatrists): Anterir hrn cell damage in lumbar segment f crd leads t LMN signs in lwer limb Marked muscle wastage especially f anterir and lateral muscle cmpartments, giving fixed equinus defrmity Autnmic effects giving cld, blue limb Usually affects leg nly, thigh musculature ften escapes Use f calliper r brace devices cmmn

26 Perneal muscular atrphy Charct-Marie-Tth s disease first develps in adlescence (10-12), mre cmmn in males, hereditary Early develpment f brad based high steppage gait Wasting first evident in legs, later in hands and frearms Bi-lateral ft drp, per cavus, feet and hands blue & cld Wasting clear, but stps suddenly half-way up thigh ( champagne bttle appearance) Sme glve and stcking sensry lss, and vibratin sense impaired Slwly prgressive

27 Mtr neurne disease Lss f mtr neurnes: Mtr crtex Mtr nuclei in brain stem Anterir hrn cells in crd Crtic-spinal tract in crd i.e. mixed UMN & LMN signs 3 syndrmes: Prgressive muscular atrphy Prgressive bulbar palsy Amytrphic lateral sclersis

28 Mtr neurne disease Onset: Insidius, uninterrupted prgressin f cmbinatins f UMN and LNM signs Prgressive bulbar palsy Dysarthria (earliest) Dysphnia (< vlume) Dysphagia Wasting and fasciculatin f tngue with spasticity

29 Mtr neurne disease Amytrphic lateral sclersis LMN signs in upper limb UMN signs in lwer limb Wasting and weakness f small muscles in hand (early) Spasticity in legs with extensr plantar respnses Prgressive muscular atrphy Only LMN signs fr lng perids Ft drp usual initial presentatin Wasting and weakness f hands, spreading prximally Late UMN signs intervene

30 Extra-pyramidal tract signs Disturbance f vluntary mvement (nt paralysis, but slwness r pverty f mvement: spntaneus gestures and initiating mvements lst) Disturbance f tne: increased in Parkinsnism, decreased in Chrea Increased muscle tne: cg wheel r lead-pipe rigidity Invluntary mvements: tremr (Parkinsnism), chreifrm, athetsis

31 Parkinsnism Disturbance f vluntary mvement Slw t initiate mvement (hypkinesis) eg. getting ut f a chair Slw t respnd with spntaneus gestures eg. smiling Difficulty with fastening buttns, tying laces etc micrgraphia (can be early) Disturbance f tne: cg wheel r lead-pipe rigidity Stped (flexed at neck, hips elbws and knees due t rigidity) Invluntary mvements: tremr pill rlling initially, spreads t arms, tngue & legs tremr at present: lessens n purpsive mvement (but stress > it)

32 Parkinsnism Disturbance f gait Slw t initiate walking Lss f nrmal arm swinging during gait festinatin f gait (shrt shuffling) prpulsin and retrpulsin Other features Blinking usually decreased Impaired pupillary accmmdatin Oculgyric crises Dysarthria (cadence slw) and dysphnia (reduced vlume)

33 Gait abnrmalities in neurlgical disrders 33

34 Sensry Tests Light tuch thigmesthesia : cttn wl Pain (spinthalamic tracts): unppular! Temperature: vials f water r ther device Vibratin: 128Hz tuning frk Pressure: 10gm mnfilament Psitin sense (prpriceptin): ext & flex digit Tactile mvement: directin f stimulus 2-3cm acrss skin (parietal lbe) 2 pint discriminatin (parietal lbe): callipers r paper clip

35 Mtr tests Tne: passive range f mtin (< LMN, > UPM, EPT) Strength: grade 0-5 Deep tendn reflexes: ankle (TA) and patellar Plantar reflex (clnus in UPNL) Observe fr fasciculatin, cntracture and bulk Tremr at rest: extrapyramidal Past pinting: cerebellar (dysmetria, intentin tremr) Walk arund chair: cerebellar Prpulsin /retrpulsin: extrapyramidal Rebund phenmenn: cerebellar

36 Gait Hemiplegic (UMN) Parkinsnism (EPT) Chreifrm (EPT) Ataxic (sensry) Cerebellar gait: reel and stagger twards side f lesin, head tilt