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Congenital anomalies
Types & definitions
Encephalocele
Craniosynostosis
Arachnoid cyst
anomalies
Arnold-chiari
malformation
Dandy-walker cyst
Aqueductal
stenosis
Congenital
hydrocephalus
Spina bifida
occulta
The skin overlying the defect is often marked with a colored nevus
or tuft of hair
Spinal
anomalies
Meningocele
Myelomeningo-
cele
Myeloschisis
spina bifida
deeper tissues
Sacrococcygeal
teratoma
Tethered cord
syndrome
intradural abnormality
Diastematomyelia
Congenital
syringomyelia
Hydrocephalus
Definition
CSF
CSF is produced by filtration from choroid plexus, in lateral and 4th ventricles
It passes from lateral ventricles through foramina of Monro to 3rd ventricle
The main volume of CSF then passes through the central foramen of Magendi and lateral
circulation
In the sub-arachnoid space it is absorbed through arachnoid villi and granulations into
the superior sagittal sinus
A small volume of CSF exits 4th ventricle to the central canal of the spinal cord
1. Genetic-induced hydrocephalus (Bickers Adams syndrome)
Congenital causes
2. In utero infections/Ischemia
3. Aqueductal stenosis
Causes
Post meningitic
Brain tumors
Obstruction
Pathogenesis
Malabsorption
Exvacu
ventricles
Communicating
classification
Hyper-secretion
Pathologic
(non-obstructive)
Non-
communicating
(obstructive)
Post-meningitic
Post-haemorrhagic
Aqueductal stenosis
Brain tumors
Infantile
Clinical
picture
Seizures
In children and adults after closure of the skull sutures, manifested by symptoms
Adult
Normal
pressure
Elderly patients
Diagnosis
Plain skull
radiography
brain
communicating hydrocephalus
DD of large head
Aim
Procedures
(Strictly
surgical)
Ventriculoperitoneal
Ventriculoatrial
Ventriculopleural
Lumboperitoneal shunt
c) Endoscopic procedures
Complication to
shunts
Endoscopic aqueductoplasty
Endoscopic aqueductoplasty
Obstruction
Craniosynostosis
Definition
It is the condition in which one or more of the fibrous sutures in an infant skull
prematurely fuses by ossification, thereby changing the growth pattern of the skull
Because the skill cant expand perpendicular to the fused suture, it compensates by
growing more in the direction parallel to the closed sutures
Frontal
(metopic;
Trigonocephaly)
Saggital
Types
(Scaphocephaly)
Unicoronal
(anterior
plagiocephaly)
There is ridging of the fused saggital suture with frontal and occipital
bossing and flattening of parietal bones
Bicoronal
(brachycephaly)
The skull is broad and short, with expansion in the lateral directions
and bilateral harlequin configuration of the orbit
Lambdoid
(posterior
plagiocephaly)
Ridging of the fused lambdoid suture with flattening of the parietooccipital region ipsilateral to the fused suture
Pansynostosis
(craniostenosis;
oxycephaly)
Cosmotic disfigurement
Clinical
o Restrained brain growth: this may result in mental retardation, motor impairment and
manifestations
optic atrophy
o Increased ICP: estimated risk: 50% pansynostosis 26% bicoronal 12% unicoronal
8% saggital 6% frontal
DD
Microcephaly
Plain skull radiography: shows the suture fusion and the associated cranial and orbital
deformity, if present
Investigations
CT/MRI brain: required in patients with coronal metopic or lambdoid synostosis it may
show associated intracranial anomalies such as hydrocephalus, agenesis of the corpus
callosum
Treatment
Myelomeningocele
Definition
Clinical
picture
It is a herniation of dysplastic neural tissue in a dural lined sac filled with CSD through a
The lesion is soft, but the fluid is usually cant be compressed easily from the sac into the
spinal canal owing to the small communication with the subarachnoid space
Neurological examination shows variable degrees of motor weakness, sensory deficits and
sphincteric disturbances
DD
Investigations
MRI spine
Hydrocephalus
Chiari malformation
Excision of the sac, untethering of the cord and repair of the dysrahphic defects
Meningocele
Definition
Clinical picture
Herniation of a sac of dura and arachnoid filled with CSF through a localized posterior
spina bifida
The lesion is soft, and the fluid is compressed easily from the sac into the spinal canal
The head circumference is usually normal, and the anterior fontanelle is lax because
active hydrocephalus is rare in the immediate neonatal period
Myelomenongocele
Meningocele
Overlying skin
Defective
Intact
Cosistency
Doughy
Soft
Compressibility
Partially compressible
Totally compressible
Transilluminatn
Partially illuminated
Totally illuminated
Associated
Intact
65%
Rare
Neurological
deficits
Hydrocephalus
Head trauma
Epidemiology
Causes
Blast injuries
Birth injuries
2 main
groups
Compound: head injury associated with scalp wounds, bone fractures and/or brain injury
Concussion
It means transient loss of consciousness after head trauma without evidence of brain
damage
Scalp wounds
Types
Cut wounds
Penetrating wounds
Blood collection under the scalp, usually it resolves spontaneously without aspiration or
Scalp
hematoma
o Subcutaneous
hematoma)
o Subglial: moves freely between the subtemporal line, supraorbital and superior nuchal
(Cephal-
Skull fractures
Vault fractures
Types
Treatment
hematoma
Depressed and comminuted fractures: the fracture site is explored and the depressed
fracture must be elevated to its original site. Debridement will be required in compound
fracutres
Depression is > 1 cm
Indications
for elevation
of depressed
fracture
include
May include cranial nerve injuries and more commonly, injury of the basal dura with CSF fistula formation
Anterior cranial
fossa fracture
Classification
fracture
Posterior cranial
fossa fracture
Treatment
CSF otorrhea
Atlanto-axial sublaxation
Broad spectrum antibiotic must be given to safe guard against meningitis, especially, in
cases with CSF leak
Cranial nerve repair may be done in some cases as the facial nerve
Growing skull fractures
The cyst lies in between the bone edges and by continuous pulsations, the fracture gap grows and widens
Treatment
Repair of the post-traumatic cyst, but if the gap is wide, cranioplasty is indicated either by an
artificial material or bone graft
Occurs in penetrating head injuries; in contrast with blunt trauma which produces
trauma
widespread effect
Definition
Brain edema
Causes
Increase of the interstitial fluid in the brain leading to the increase of ICP
Hypoxia, hypercapnia
Electrolyte imbalance
Treatment
Cerebral
A bruise of the brain tissue, which can be associated with multiple microhemorrhages, small
contusion
Cerebral
A similar injury except that the pia-arachnoid membranes are torn over the site of injury in
laceration
Burst lobe
Coup and
countercoup
The coup injury occur under the impact point where countercoup injuries occur at areas
distant from the point of impact, as a result of shock waves across the brain causing
injuries
stress/cavitations effects
Despite the absence of any intracranial mass lesion or history of hypoxia, some patients
remain unconscious after a TBI
Diffuse
axonal
injuries (DAI)
The usual cause for persistent impairment of consciousness is the condition referred to as
diffuse axonal injury
It is the result of traumatic shearing forces that occur when the head is rapidly accelerated
or decelerated
It results in injury of the axons at the interface between the grey and the white matter
Hydrocephalus
swelling
Communicating: due to subarachnoid hemorrhage that will decrease the absorption from
the arachnoid villi
Intracranial hemorrhage
More common in the younger age group as the dura is able to strip more readily from the
overlying bone
Extradural
hematoma
Source of
bleeding
Site
Clinical
Slowly
presentation accumulating
Stage of concussion
Rapidly
accumulating
Stage of compression
increased
ICP
Stage of
compression
Signs of
lateralization
Contralateral hemiparesis
herniation
No clinical effect
Lateral
tentorial
(uncal)
Brain shift
Tentorial
Central
tentorial
Diabetes insipidus
herniation
herniation
Hypertension
Bradycardia
Diagnosis
Cheyne-stoke breathing
Treatment
Usually presents in the context of a patient with severe head injury whose
neurological state is either failing to improve or deteriorating
Acute
Over 80% have associated fracture of the cranial vault or the skull base
Source
Diagnosis
Treatment
Sub-acute
Bad prognosis
4-21 days
hematoma
(Adults)
Subdural
Source
Bridging veins
Clinical
Chronic
presentation
trivial trauma
Diagnosis
Treatment
(IV fluids)
Good prognosis
Birth trauma
Subdural
hematoma in
infancy
Site
Clinical
Usually presents with large sized head (as the sutures are non-fused) and
Sub-arachnoid hemorrhage
presentation
Intracerebral
Diagnosis
hemorrhage
Depends upon the site and size of the hematoma as well as its clinical
presentation
Treatment
Eye opening
Best verbal
Neurological
response
assessment
Best motor
response
Spontaneous
To speech
To pain
None
Oriented
Confused conversation
Inappropriate words
Incomprehensible sounds
None
Obey commands
Localizes pain
Extension (Decorticate)
None
The 15 points GCS is the most commonly used neurologic injury severity scale for adults
because of its high inter-observer reliability and generally good prognostic capabilities
Severity of TBI: it is generally agreed that TBI with GCS of 13 or above is mild, 9-12 is
moderate and 8 or below is severe
Intubation is mandatory if GCS <8 as the patient wont be able to protect his airway
Lab
Investigations
CBC
ABG
Plain X-ray chest and U/S abdomen if needed for associated injuries in
Radiology
Compression of the cord can occur at any level from the cervicomedullary junction to the
Overview
conus medullaris at L1
It this condition is not recognized and treated, the eventual outcome will be disabling
paralysis and sphincteric disturbance
Traumatic
Tumors
Causes
(surgical
causes of
back pain)
Infection
Acute: staphylococcal
cystic lesions
AVM
Spontaneous
Spondylolithesis
Clinical presentation
Root: severe, sharp, shooting, burning pain radiating into the cutaneous distribution or
muscle group supplied by the root; aggravated by movement, straining or coughing
Pain
Segmental: continuous, deep aching pain radiating into whole leg or one half of the body;
not affected by movement
Bone: continuous dull-aching pain and tenderness over affected area, may or may not be
aggravated by movement
Neurological
deficit
According to
the level of
compression
Cervical
spine
upper/lower limbs
Dorsal
spine
in lower limbs
medullaris
Complete
cord syd
level of injury
Anterior
Posterior
cord syd
sense
Central
cord syd
cord syd
According to
cord
compressed
At level of lesion:
Brown-
Same side
Sequard
syndrome
(Cord
hemi
(posterior column)
section)
UMNL
LMNL
Minimal wasting
Maximal wasting
Increased
Decreased
Clonus
Present
Absent
Fasciculation
Absent
Present
Paralysis
Muscle state
Tone
Reflexes
Sphincters
Deep: Hyperreflexia
Deep: Hyporeflexia
plantar: flexor/absent
Spinal fracutre
Epidemiology
Fracture of the spine is rare in children due to laxity of the ligaments, however, spinal cord
injury can occur
Spinal cord injury without fracture can occur also in old age in the cervical region when
there is pre-existing cervical canal stenosis
Etiology
Flexion
e.g. seat belt (dorsal spine injury), diving (cervical spine injury)
Mechanisms
Extension
of spinal
Torsion
Compression
Distraction
injury
Pathology
Trauma to the spine can lead to various degrees of injury to the vertebral column and/or the
neural structures
Bony injuries e.g. fracture of the vertebral body, lamina, spinous process, transverse
process etc
Vertebral
column
o Burst fracture: when there is disruption of upper end plate, the lower end plate or both
injuries
o Wedge fracture: no disruption of the end plates but there is decrease in height of the
anterior border of the vertebral body
Assessment of bony instability: the spine is divided into 3 columns: anterior, middle and
posterior. More than one column affection leads to instability
Cord and
root injuries
Vascular
Loss of muscle tone in the lower half of the body will lead to decrease in the
venous return and decrease cardiac output resulting in hypotension
Spinal shock
Neurologic
Clinical
picture
Tenderness
Due to
Muscle spasm
trauma
spine
Deformity
Different degrees of weakness in the lower limbs (in case of dorsal spinal
Due to
cord injury) or in both upper limbs and lower limbs (in case of cervical
neurological
injury
cord injury)
Sphincteric disturbances
Respiratory difficulty (the higher the lesion the more the respiratory
difficulty)
According to the site of cord injury, the patient will manifest with one of the cord syndromes
Initial
Radiological
investigations
Medical
treatment
Management
Hospital
treatment
Cervical disc prolapse occurs when the soft nucleus pulposus herniates through teat in the
annulus (peripheral fibrous cartilage)
Patho-
physiology
The cervical spine exhibits a great deal of mobility but little weight bearing function
The intervertebral discs serve as mechanical buffers that absorb axial loading, bending and
shear forces
Site
Symptoms
Pain radiating down the arm and hand (brachialgia) exacerbated by neck
motion (extension)
Motor weakness
Sphincteric dysfunction
Clinical
Root
picture
compressed/
Signs of
sensory loss
radiculopathy
deficit
Signs
C4-C5
C5-C6
C6-C7
C7-T1
C4
C5
C6
C7
C8
Diaphragm Deltoid
Reflex lost
Signs of
myelopathy
(cord
compression)
Investig.
Motor
C3-C4
Biceps and
Spastic quadriparesis
Gait disturbance
Sphincteric disturbance
MRI
Myelography
Triceps
brachiradialis
Plain Xray
CT scan
Hand
Biceps
muscles
Surgical
Procedures
Cervical spondylosis
Definition
It is a degenerative change including vertebral bodies, neural arches, facet joints, ligaments
and blood vessels, which may or may not cause neurological manifestations
Reduction of the sagittal diameter of spinal canal (less than 12 mm) can be associated with
cord compression leading to myelopathy
Clinical
picture
Spastic weakness of lower limbs with clonus and +ve babiniski sign
Invest.
Insidious onset
Manage.
Surgical
Pathophysiology
Site
Lumbar disc prolapse occurs when the soft nucleus pulposus herniates through tear in the
annulus (peripheral fibrous cartilage)
There is a history of falling or lifting heavy weights preceding the onset of symptoms
The majority of lumbar disc prolapse occurs at L4-L5 and L5-S1 (95%)
The typical patient with acute lumbar disc prolapse is from 30-50 years of age in the most
productive period of his life; and has complained of chronic low back pain for some time prior to
onset of acute disorder
Clinical
picture
Symptoms
Back pain
Sciatica (pain in the leg in the distribution of the affected root) aggravated by
Motor weakness
Back signs
Signs of
radiculopathy
Signs
Local tenderness
Scoliosis
Motor weakness
Compressed
root
Motor
Reflex changes
L3-L4
L4-L5
L5-S1
L4 root
L5 root
S1 root
Dorsiflexors of the
Planterflexors of the
foot
foot
Quadriceps
weakness
Sensory
calf, medial
impairment
malleolus and
medial foot
Reflexes
Clinical
tests
(nerve
root
tension
signs)
Straight leg
Femoral
stretch test
(Reverse
SLRT)
malleolus, lateral
raising test
(SLRT)
Motor (LMNL): bilateral weakness of dorsal and platar flexion of the foot + weakness of hip
flexors and/or extensors + weakness of knee flexors and/or extensors may also occur
Sensory: hypoesthesia bilaterally accoding to the spinal roots affected and saddle-shaped
hyposthesia
Reflexes: ankle reflex is lost bilaterally and also may be the knee reflex
Plain X-ray
Invest.
Detects lumbar canal stenosis; hypertrophied facet joint, and narrow canal
dimension
Myelography
Nerve conduction velocity: precise information on root lesion
Conservative
Health education
Indications
Urgent surgery:
Treatment
Surgical
Methods
Intradiscal procedures :
49 years old female patient know to be diabetic had a history of fall downstairs 2 years ago. Now she has
severe low back pain and bilateral sciatica. She has mild weakness of both dorsi-flexors with numbness of
both feet and hands: The cause Possible signs Investigations Treatment
A 60 years old patient with spinal compression of gradual onset at D7 level. C/P, investigations and
treatment
Brain tumors
Fewer patients with metastatic tumors reach a neurosurgical center, it is estimated that 25% of
patients with a malignancy have a CNS metastasis
Adults
Overview
Children
Commonest tumors are gliomas, metastasis and meningiomas and most of them lie in
the supratentorial compartment
Commonest tumors are medulloblastoma, cerebellar astrocytomas and
craniopharyngiomas
Benign
May have devastating effects if allowed to expand within the rigid confines of
the skull cavity
A benign astrocytoma may invade widely throughout the brain tissue preventing
complete removal or may occupy a functionally-critical site preventing even
partial removal
Malignant
Implies rapid growth, poor differentiation, increased cellularity, mitosis, necrosis and
vascular proliferation, but metastases to extracranial sites rarely occur
Astrocytoma
Tumors of
neuro-
epithelial
tissue
Oligodendroglioma
Ependymoma
Mixed tumors
As oligoastrocytoma
Pineal tumors
Pineocytoma
Enlarged tumors
Tumors of
Meningiomas are mostly benign tumors but sporadic cases of aggressive meningiomas may
meninges
the
It is considered an extra-axial tumor as they arise from the meninges not from the brain
tissue
Germ cell
tumors
They usually occur in the midline especially in the pineal or the suprasellar region
Cysts and tumor like conditions: Not true tumors but they represent space-occupying lesions mimicking the
clinical picture of the brain tumors as: Dermoid cyst - Colloid cyst of the 3rd ventricle
They are classified according to the size into microadenoma (<1cm) or macroadenoma
(>1cm)
Pituitary
tumors
Pituitary adenomas usually grows upward, compressing the optic chiasm causing
bitemporal hemianopia
If the tumor grows further upward, it can compress the 3rd ventricle and hypothalamus
causing obstructive hydrocephalus and hypothalamic manifestations
Less commonly, pituitary adenoma can grow laterally into the cavernous sinus leading to
compression of the 3rd, 4th and 6th cranial nerves and cause strabismus or ophthalmoplegia
(Micro/cushing) TSH (2ry thyrotoxicosis) rarely the tumor may secrete several hormones
at the same time
Cranio-
pharyngio
ma
It arises from embryonic remnants of Rathkes cleft present in the pituitary stalk
Pituitary hypofunction and diabetes insipidus are commonly associated due to pituitary stalk
compression
Medullo-
It is the most common malignant pediatric brain tumor and the most common PNET
blastoma
It usually arises from the roof of the 4th ventricle producing obstructive hydrocephalus
10-35% of cases develop spinal metastasis (drop metastasis) via CSF
General
Regional manifestations:
Frontal lobe
tumor
manifestatn
Parietal lobe
tumors
Temporal
lobe tumors
Psychomotor epilepsy
Occipital lobe
tumors
cortical blindness
Supra-sellar
Tumors of
corpus
tumors
callosum
Posterior
fossa tumors
Cerebello-
pontine angle
tumors
Lower cranial nerves: difficult swallowing, loss of gag reflex and frequent
aspiration
MRI brain
gadolinium
tentorium cerebelli
with
tumor to the sulci and gyri, the ventricles, the falx and
Investigatns
Radiological
investigatns
CT brain
with contrast
Angiography
Plain X-ray
SPECT and
PET scan
Routine
Lab
investigatns
Surgical
excision
Biopsy
Conventional
radiotherapy
Treatment
Stereotactic
radiosurgery
Proton beam
Chemo-
therapy
therapy
Medical
treatment
Cerebrovascular disorders
I. Stroke
Clinical symptoms of focal and/or global disturbance of cerebral function lasting more
than 24 hours or leading to death, with no apparent cause other than vascular
Stroke is one of the leading causes of permanent disability and is the 3rd largest cause of
death in western countries
Definition
o Ischemic cerebral infarction results from occlusive disease of the extracranial or major
intracranial arteries (AS lesions) and the majority of these strokes (around 85%) are of
ischemic origin
Ischemic stroke
Classification
(according to
source of
embolism)
Large artery strokes (lesions in the aortic arch, extracranial vessels or the major
intracranial branches)
Clinical
presentation
RIND (Reversible ischemic neurological deficit): It lasts more than 24 hours but resolve within
one week
Complete
stroke
Carotid
territory
Vertebro-
basilar
territory
In this type, there is transient ischemia of the brain stem, occipital lobes,
Imaging
(Amourosis Fugax)
and dysphasia
Site of
affection
Extracranial, intracranial carotid or middle cerebral artery stenosis can be diagnosed and
measured using different imaging modalities
The golden standard used in the majority of large RCTs is digital substraction angiography
(DSA)
Treatment
Stroke prevention is primarily based on medical treatment, but in some situations, surgical
or endovascular treatment becomes the method of choice
Medical treatment to reduce the overall risk includes: antiplatelet medications, statins, and
anticoagulation for AF, smoke cessation, control of HTN, and metabolic control in diabetic
patients
Management
for acute
ischemic
stroke
Management
ABCs
Lab: CBC platelet coagulation profile blood glucose level, lipid profile
Establish IV access
Baseline vitals, most important = BP, SBP must be less than 185/110 for the acute
intervention
Exam/NIHSS
IV-tPA if no contraindication
for
extracranial,
intracranial
middle
carotid or
Percutaneous balloon angioplasty has been reported in several retrospective case series to
cerebral
be useful and safe for the treatment of stenotic intracranial arteries, but still holds a risk of
stenosis
artery
vascular dissection, elastic recoil vasospasm, and high grade residual stenosis because of
Hemorrhagic stroke
Hypertension
common)
(most
Etiology
Clinical
picture
basal ganglia and thalamus and less commonly may involve the
Lobar
Amyloid deposits
hematoma
Vasculitis
Secular aneurysm
Vascular malformations
o Cerebrum: hemiparesis, hemisensory loss, 3rd nerve palsy tentorial herniation and
coma
CT scan (best for intracranial hemorrhage) and MRI: site, size, mass effect, extent,
associated pathologies
Hospitalization
ABC
IV fluids
Surgical:
Treatment
II. Aneurysms
Definition
Intracranial aneurysms are common acquired lesions commonly located at the branching
points of the major intracranial arteries coursing through the subarachnoid space at the
base of the brain
Prevalence
Subarachnoid
Clinical
hemorrhage
presentation
bilateral radicular leg pain due to the subsequent circulation of blood CSF
down the spinal axis
Mass effect
Cerebral
ischemia
intracranial
With the widespread use of helical (spiral) CT angio and MRA, many
unruptured asymotomatic intracranial aneurysms can now be detected
aneurysms
CT scanning
Diagnostic
imaging
Conventional
angiography
characteristics
MRA
CT angio.
Complete anatomical exclusion of the aneurysmal sac from the intracranial circulation
with parent artery preservation is the main treatment goal to prevent future rupture or
Treatment
III.
Definition
Brain AVMs are composed of a network of blood channels (nidus) supplied by cerebral
arterial feeders, drained by veins emptying into the venous sinuses, and surrounded with
gliotic non-functioning brain parenchyma
Natural
history
The risk of hemorrhage from a brain AVM has an average 2-4% yearly risk of hemorrhage
from brain AVM
Clinical
presentation
Intracranial
hemorrhage
Epilepsy
Headache
30% of cases
Focal
neurologic
deficits
CT scan
CT angio
The brain AVM anatomical characteristics such as the size, location of the
nidus and the proximity of the AVM nidus to eloquent brain regions are
best defined by MRI
Diagnostic
imaging
MRI
Selective and
superselective
cerebral
angiography
Treatment
Treatment should be done after a careful consideration of clinical data & AVM anatomy
Potential risks must be carefully balanced against the benefits in each patient
o Endovascular embolization
It occurs as a result of compression of the median nerve beneath the carpal transverse
ligament, affects 1% of the population and more frequent in females
Definition
The carpal tunnel syndrome should be considered when there is any unexplained pain or
sensory disturbance (e.g. intermittent numbness and pain of the hand that is worse at
night) and weakness of abductor pollicis brevis, the lateral two lumbricals, the opponens
pollicis and the flexor pollicis brevis muscles)
Contributing
factors
Physical tests
Positive when tapping the area over the median nerve at the wrist
percussion test
Carpal tunnel
Phalen wrist
Positive when full flexion of the wrist for 60 seconds produces the
flexion test
patients symptoms
compression test
Electrodiagnostic
tests
Most sensitive
Brachial plexopathy (upper and lower plexus paralysis; also thoracic outlet syndrome)
DD
Pronator teres syndrome: compression of median nerve between the 2 heads of the
pronator teres
Anterior interosseous syndrome: loss of flexion of the terminal phalanx of the thumb and
the index (pinch sign), and no sensory loss
Management
NSAID
Results from entrapment of ulnar nerve as it enters the forearm through the narrow opening
(the cubital tunnel) formed by medial humeral epicondyle, medial collateral ligament of the
joint & the firm aponeurotic band, to which flexor carpi ulnaris is attached
Overview
Elbow flexion reduces the size of the opening under the apneurotic band, while extension
widens it
Symptoms include paresthesia, numbness or pain in the 4th and 5th fingers, occasionally
provoked by prolonged elbow flexion, associated with decreased vibratory perception and
abnormal 2-point-discrimination
Weakness affects the 1st dorsal interosseous muscle first and most severely
Weakness and wasting of the hypothenar and intrinsic hand muscles result in the loss of
power
Syringomyelia: dissociated sensory loss is characteristic, there are often associated long track
findings in the legs, and the MRI is diagnostic
DD
Motor neuron disease: there is weakness and wasting of intrinsic hand muscles. Thenar
muscles as well as the hypothenar muscles are often affected
o The palmar and dorsal surfaces of the hand are spared due to sensory nerve had branched
proximal to the wrist level
Meralgia Paresthetica
o It passes obliquely across the iliac muscle, and enters the thigh under the lateral part of the
inguinal ligament
Overview
Patients also complain of pain, paresthesias (tingling and burning) and often touch-paintemprature hypestheasia over the anterolateral aspect of the thigh
Could be
Obese individuals who wear constricting garments (e.g. belts, tight jeans, corsets)
also due
to
Removal of an iliac crest bone graft if it is taken too close (2 cm) from ASIS
Manage.
Surgical neurolysis and decompression of the nerve where it passes through its canal within
the inguinal ligament
Overview
Involves compression of the posterior tibial nerve at the ankle behind the medial malleolus,
where the laciniate ligament connecting the distal tibia to the calcaneous covers it
The entrapment results in hypoesthesia in the sole of the foot, a positive Tinels sign with
percussion, or pressure over the flexor retinaculum below the medial malleolus
Manage.
NSAID with the conservative measures such as external ankle support (e.g. shoe orthoses) to
improve foot mechanics
Surgical release of the entrapment is not rewarding as often as in carpal tunnel syndrome
The thoracic outlet syndrome may be purely vascular, purely neuropathic or rarely mixed
The true neurogenic thoracic outlet syndrome occurs more frequently in young women and
affecting the lower trunk of the brachial plexus
Intermittent pain is the most common symptom, referred to the medial arm, forearm and the
ulnar border of the hand
Overview
The motor and reflex findings are essentially those of lower brachial plexus palsy, with
particular involvement of the C8 root causing weakness and wasting of the thenar muscles
similar to carpal tunnel syndrome
However, in contrast to the latter, in the thoracic outlet syndrome wasting and paresis also
tend to involve the hypothenar muscles
Manage.
Removal of the cervical rib or sectioning of the fibrous band of the anterior scalene muscle
Traumatic lesions
Concussion
(Neuropraxia)
Pathology
(types)
Contusion
Such injuries occur after blunt trauma or penetrating trauma in the nerve
(Axonotenesis)
vicinity
Complete
disruption
It occurs in cut and gunshot injuries and with fracture of long bones
(Neurotemesis)
Cutting
injuries
Traction injuries
Electric
High voltage current may cause disruption of the nerve all the way back to the
traumatic
trauma
agents
Ischemic
Types of
damage
plaster cast
Gunshot injury Causes severe laceration of the nerve and difficulty in approximation
Chemical injury
Upper
plexus
(trunk)
muscles)
Produces a characteristic limb position known as the Policemans tip position (internal
paralysis
rotation and adduction of the arm, extension and pronation of the forearm, and with the
Duchenne)
(Erb
There may be some sensory loss over the deltoid muscle area
The muscles supplied by C8 and T1 roots are paretic and possibly atrophic (weak wrist and
Lower
plexus
(trunk)
finger flexion and weakness of the small hand muscles), producing a claw hand deformity
paralysis
(Dejerine
Sensation may be intact or lost over the medial arm, forearm and ulnar aspect of the hand
Klumpke
type)
Weakness of the biceps and brachialis muscles and sensory deficit in the lateral forearm
Radial n.
Median n.
Ulnar n.
Sensory loss: in the dorsum of the hand and the base of the thumb
Sensory loss in lateral 2/3 of the palm and the lateral 3 fingers
This results in weak abduction and adduction of the fingers, and weak adduction of the
thumb
Sensory loss: of the palmar and dorsal aspect of the medial 1/3 of the hand; and medial 1
fingers
There is wrist and finger drop with preservation of the elbow extensors
Posterior
Motor: paralysis of all extensors of fingers and most of the extensors of the wrist
interosseus
in forearm
Deformity
Median
Atrophy of the flexor muscles, tips of the index and thumb, with or without
skin atrophic changes
nerve injury
(Medial
injury)
Special
motor
tests
Sensory
system
Pencil test (thumb abduction test): abducting the thumb 90o from the plane of
the palm to test for the action of abductor pollicis brevis
Buttoning test fails with closure of the eyes due to loss of deep sensation
Partial claw hand: due to affection of the little and ring fingers only flexion
of the interphalangeal joint, hyperextension of metacarpophalangeal joints of
the medial 2 fingers especially the little finger
Ulnar nerve
injury
(medial
injury)
Deformity
Radial deviation of the hand: due to paralysis of the flexor carpi ulnaris muscle
Atrophic changes
o Sunken interossei spaces on dorsum of the hand esp. 1st space (most imp.)
o Atrophy of the hypothenar muscles and the tip of little finger
o Wasting of the muscles of the medial side of the forearm
interossei) of fingers fails; the patient is unable to hold a card between two
Specific
motor
tests
Ulnar
paradox
fingers
Paper test (Fromants sign): for the thumb to test for the action of the adductor
pollicis: the patient will hold the paper by flexing the terminal phalanx
The higher the lesion of the ulnar nerve, the lesser the claw hand, because the
flexor digitorum profundus is completely paralyzed and no flexion of
interphalangeal joint takes place
Lesions above 5 cm from the wrist: palmar and dorsal surfaces of the medial
1 fingers and the medial 1/3 of the palm
Sensory
system
Lesions below 5 cm from the wrist: only the palmar surface is affected because
the dorsal branch arises above that level
Lesions below the wrist: have no sensory changes, because the superficial
branch escapes
Median
nerve injury
Motor paralysis: of the thenar muscles and firs and 2nd lumbricals
Sensory changes: loss of sensation on the lateral 3 fingers, dorsal nail beds and lateral
half of the palm
Ulnar nerve
injury
Same motor affection as injury in the forearm, with the exception that the partial claw
hand is more severe (ulnar paradox)
No sensory affection
Femoral n.
perineal
injury
The tibial
nerve
The sciatic
nerve
In cases of neuropraxia or axonotemesis nerve regeneration is possible, so operative repair is not required;
It occurs usually after blunt trauma
Crushed and contaminated wounds, nerve repair should be delayed for 3-6 weeks (2ry sutures)
Strategies for management of nerve gaps include: neurolysis, transposition, flexion of the limb and
autologous nerve graft (sural nerve)
o Distance: between the site of injury and peripheral nerve (terminal branches)
o Regeneration: 1-2 mm/day
o Type of nerve: pure motor/sensory do better than mixed nerves
o Care of the injured extremities is also important. And the joint should be held in functional position
o Physical therapy is needed postoperatively
Qs:
In fracture spine: paraplegia with sensory level will occur below the dorsal lesion
Brain tumors that may commonly show calcification: All (Meningioma craniopharyngioma
oligodendroglioma)
In complete cauda equina syndrome: All (flaccid paralysis of ankles sphincteric impairment saddle
shaped hypoesthesia)
Cervical disc prolapse there may be: All (radiculopathy myelopathy radiculomyelopathy)
In extradural hematoma all are wrong: hypotension and tachycardia are cardinal signs of brain
compression surgery can be planned at a later date (not an emergency) there must be a lucid interval
in order to diagnose - CT has no value in diagnosis
Diffuse axonal injury: in the deep regions of the brain, this impairment of the white matter, corpus
callosum and subcortical structures (nerves in interface between grey and white matter)
Infantile large head: All (Familial rickets hydrocephalus chronic infantile subdural hematoma
cephalhematoma)
A patient with frontal lobe tumor may present with: All (epilepsy hemiparesis mental changes
dysphasia)
A patient with stable fracture spine and cord contusion should have: corticosteroids in high doses during
the 1st 24 hours
A patient with deteriorating consciousness because of large acute traumatic extradural hematoma on CT
scan must have: urgent surgical evacuation and decompression
Posterior fossa tumors may commonly present with: All (ataxia frequent chocking and nasal tone 6th
nerve palsy hemiparesis)
A patient with cauda equine syndrome due to lumbar disc prolapse will have: hemiplegia and hemianesthesia
In a dorsal spinal tumor at D10 segment: spastic paraparesis extensor plantar response sensory level at
D10 BUT NOT spastic quadriparesis
Main cause of spontaneous subarachnoid hemorrhage is: bleeding from cerebral aneurysm
Weakness of the dorsal flexors of the foot is one of the cardinal signs of compression of nerve root: L5
Sphincteric disturbance is one of the cardinal symptoms of: cauda equina syndrome
Meningioma: adults
4. Extradural hematoma
5. Subarachonoid hemorrhage
6. Rupture meningeocele
7. Hydrocephalus
-
o Congenital hydrocephalus: sunset eye appearance dt pressure on the tectum of the midbrain -->
upward gaze of the eyes + squint dt 6th nerve palsy dt large IC course
3. Myelomeningeocele
4. Meningeiocele
5. Sarcococcygeal teratoma
6. Diastomatomyelia
7. Arachnoid cyst mcq: not spina bifida occulta
4. Familial
-
brain tumors:
C/P
1. left frontal lobe: increased ICP epilepsy according to the site : speech- behavior- contralateral
weakness no sensory loss "mcq"
Pit. adenoma: mico --> inc secretion macro --> ICP and compression manifestations like bitemporal
hemianopia
Single disc compressing the cord --> anterior cervical discectomy not llaminectomy "only in cervical
canal stenosis"
Causes of complete claw hand --> 1. brachial 2. ulnar + median 3. non neurologic : volkman ischemic
cord
Entrapment neuropathy: carpal tunnel --> median tarsal --> post medial cubital tunnel --> ulnar
* extradural hematoma --> middle meningeal - diploid- venous sinus c/p: slow- rapid "
concussion"transient loss of con <24 hr" - lucid- compression --> spastic not flaccid paralysis"
* subdural : acute --> middle meningeal - hyperdense at CT chronic --> bridging veins- better
skull fracture:
Glasgow coma scale : lowest = 3 highest = 15 no 1 "mcq" <7 has bad prognosis extension to pain = 2
spontaneous eye movement = 4
radial --> wrist and finger drop while post interosseous --> finger drop only - Ape --> median - claw -> ulnar