Lecture 43 March 28th-nervous

1DDX: LECTURE 43 – MARCH 28th, 2007 CONDITIONS OF THE NERVOUS SYSTEM DDX feature of subarachnoid hemorrhage: pain does not go away. This is a headache telling you that there is bleeding somewhere: it is trying to tell you something. INTRACEREBRAL HEMATOMA • Result of severe head trauma that destroys part of the brain. Not usually something you need to DDX: trauma will be obvious. • Symptoms will depend on the part of the brain that is affected. Can be fatal, or full recovery is possible. • On CT: the hemorrhage is white in colour. Looks like bone. SPINAL CORD INJURY • Nerves can stretch, withstand some shearing force, don’t like compression, and cuts easily. • Transection: can cut cord, or lose part of it: will have different symptoms. • There is redundancy in our “wiring” to protect from injury • • •

In case of overextension of neck, chin, will always injure the part that is being stretched. Injuries that will cause this: whiplash (improperly positioned head rest in car accident). If head goes back, anterior part of cord will be stretched, and posterior will be compressed. Flexion injury (example given was hanging!): stretch posterior aspect, compression of anterior. Cause of death in hanging is shearing force applied to C1-C0. Transection: motor vehicle accident, surgical mistakes, space-occupying lesions. If you survive this, there is permanent disability. Loss of autonomic functions.

CORD SYNDROMES • Presentation of pathologies that are clinically relevant. • The history is about 80% of the case: helps you find out where damage is. • Upper motor neurons: injury to these causes spastic paralysis. “Upper” is above decussation (where the neuron crosses the spinal cord.) This happens in an area, around mid-brain (above and below this too). Reflexes still work. • Injury to lower motor neuron: no reflexes, flaccid paralysis. • Look at injury and see if it is unilateral or bilateral. BROWN-SEQUARD’S SYNDROME • Severed half of spinal cord. • Can trace the areas of sensory deficit on their skin. • Clean-cut vs. slanted cut: pattern to loss of sensation. • See functions of tracts in notes. • Cut to the “middle” of the spinal cord, but a partial cut may have the same effect as a cut to the absolute centre of cord. • Patient can still feel crude touch, but not pain. Can tell that they are being touched, but can’t determine what it is, quality. CENTRAL CORD SYNDROME • Several patterns: LMN pattern. • Lesion: would be weakness in hands, not in legs. Nothing is cut, they still have movement, but weakness. Something is being bothered, but function is not lost completely. Hands and legs? Lesion may be higher up. • • • • • •

Radicular disease: refers to anything happening at the nerve root. Can be from inflammation: deposit of calcium, narrowing of foramena. Narrowed foramena where spinal roots pass. Can tolerate some narrowing. Look at the symptoms to see where the problem is. See chart in notes. Causes weakness, not absence. C5 is one of nerve roots that affects abduction of shoulder. Other nerve roots have the same function, but this is the main one. If it is non-functional, you will see a change in function. Your treatment plan would change based on whether this is a nerve root or a peripheral nerve. Is it inflammation? Are there calcium deposits? Or is it transient? (treat it as a wound, acute). Would change your TCM diagnosis, DDX LECTURE 43, MARCH 28th, 2007 – PAGE 1

homeopathic treatment. • • •

Re: dermatome chart: there is always overlap between these areas. When you identify an area as “L3”, this is the nerve that dominates it, but L2 and L4 probably have some function here. Muscles don’t have this kind of overlap (not as much). Peripheral nerves are made of more than one root. Cut these nerves, you lose all of their function. Complete loss. Read the rest of this page, but chart and “myelopathy due to mass lesions” not covered in class. We are still responsible for it, but he is highlighting the most important sections.

HEADACHES • What is a “serious” headache? ALARM SIGNS: One that won’t go away. One that is recurrent that is now happening more frequently, with more intensity, longer duration. Loss of vision, flashes of light. Crescendo: headache that keeps getting worse, worse worse, then gives you a break. (Like an obstruction colic in the head). Meds have stopped working that used to work. Headaches that wake someone up at night (sleep usually relieves headaches), signs of meningial inflammation. • (A “worst _______ ever!” should always get your attention) • If you get a headache every day at the same time, for the same length of time, it is probably something in your environment that you are reacting to. • Most headaches are benign. If you get the flags above, there is a much more serious underlying cause: no watching/waiting. See list of “factoids and red flags” • “palpatory tenderness over temples”: You touch their temples and they feel pain. This may be Giant cell arteritis, exists with other AI conditions. Sudden loss of vision (usually comes back after first attack). See chart of differentiation between migraine, tension, cluster headaches. SEIZURES • Rigor: children that have seizures. Not related to epilepsy • Seizures in children are NOT a sign that the body isn’t doing well. Children may just have a slightly higher incidence of epilepsy. • Doesn’t mean that you don’t need to address it. Is there an underlying cause? Dehydration, electrolyte imbalance… ETIOLOGY OF EPILEPSY • Can measure electrical activity during seizure. Electro-chemical, magnetic event. • Hypoxia: can get seizures from this. Pass out and have seizures while regaining consciousness. • Storage diseases: make you more susceptible to seizures. • Epilepsy is a diagnosis of exclusion THE NEXT 6 ARE ALL DIFFERENT TYPES OF EPILEPTIC SEIZURE SIMPLE PARTIAL SEIZURE Consciousness never impaired. This can be epilepsy, OR this can be a sign of a space-occupying lesion. Have to rule out focal neurological disease. COMPLETE PARTIAL SEIZURE Same as above, but with loss of consciousness. Happens in a paroxym, then it goes away. Don’t restrain in seizures, they won’t swallow tongue (may bite it, but will bite your finger too if you try to pull it out) PETIT MAL (ABSENCE SEIZURE) Loss of awareness, not consciousness. Looks like they are purposely ignoring you! Can happen up to 100x / day GRAND MAL SEIZURE Postictal state: they want to retreat and heal.

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STATUS EPILEPTICUS Grand mal, but it lasts for 30 minutes. Think of vitals: what will happen? Extreme hypertension, can’t breathe… life threatening. Medical intervention is required. Death from anoxia, stroke.

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