Group-BasedLearningSessionDr.ChrisCohanDr.StuartInglis

Considertheaccompanyingexampleofclonus.Giventhatthedorsi andplantarflexorsareinnervatedbyspinalnerveL4throughS2,thisphysicalfindingisindicativeof…A. Centralnervoussystemlesion

aboveL4spinalcordsegmentB. Centralnervoussystemlesion

betweenL4andS2spinalcordsegment

C. CentralnervoussystemlesionbelowS2spinalcordsegment

D. Peripheralnervoussystemlesiontothesciaticnerve 00010203040506070809101112131415

Considertheaccompanyingexampleofclonus.Giventhatthedorsi andplantarflexorsareinnervatedbyspinalnerveL4throughS2,thisphysicalfindingisindicativeof…A. Centralnervoussystemlesion

aboveL4spinalcordsegmentB. Centralnervoussystemlesion

betweenL4andS2spinalcordsegment

C. CentralnervoussystemlesionbelowS2spinalcordsegment

D. Peripheralnervoussystemlesiontothesciaticnerve 00010203040506070809101112131415161718192021222324252627282930

Clonus

Netter,AtlasofAnatomy(3rded.),ICoN LearningSystems

Clonus

Formusclessuppliedbynervesexitingspinalcord…• Abovedamage

• Normalreflexes

• Withinthedamagedarea• Areflexia

• Belowdamagedarea• Hyperreflexia/clonus

Netter,AtlasofAnatomy(3rded.),ICoN LearningSystems

Clonus

Impulsesinhibitcontractionofantagonisticmuscles(reciprocalinhibition)

+ –

Anteriorspinalarterysyndromeisamedicalconditionwherethebloodsupplytotheanteriorportionofthespinalcordisinterrupted,resultinginlocalizedinfarction.

Whatistheprognosisfortheindividualwiththeindicatedlesion?A. Completemotor,general

sensation,painlossbelowlesionB. Completemotor,painlossbelow

lesion,noeffectongeneralsensation

C. Completemotor,generalsensation,painlossatlesionsite,butnotbelow

D. Completemotorlossatlesionsite,butnotbelow:painlossatlesionsiteandbelow:noeffectongeneralsensation

00010203040506070809101112131415

motor=voluntarymovement

Whatistheprognosisfortheindividualwiththeindicatedlesion?A. Completemotor,general

sensation,painlossbelowlesionB. Completemotor,painlossbelow

lesion,noeffectongeneralsensation

C. Completemotor,generalsensation,painlossatlesionsite,butnotbelow

D. Completemotorlossatlesionsite,butnotbelow:painlossatlesionsiteandbelow:noeffectongeneralsensation

00010203040506070809101112131415161718192021222324252627282930

Anotherpatientpresentswithasimilardamagepattern.Whatistheprognosis?A. Completemotor,general

sensation,painlossbelowlesionB. Completemotor,painlossbelow

lesion,noeffectongeneralsensation

C. Completemotor,generalsensation,painlossatlesionsite,butnotbelow

D. Completemotorlossatlesionsite,butnotbelow:painlossatlesionsiteandbelow:noeffectongeneralsensation

00010203040506070809101112131415

Anotherpatientpresentswithasimilardamagepattern.Whatistheprognosis?A. Completemotor,general

sensation,painlossbelowlesionB. Completemotor,painlossbelow

lesion,noeffectongeneralsensation

C. Completemotor,generalsensation,painlossatlesionsite,butnotbelow

D. Completemotorlossatlesionsite,butnotbelow:painlossatlesionsiteandbelow:noeffectongeneralsensation

00010203040506070809101112131415161718192021222324252627282930

Centralcordsyndrome(CCS)• Acutecervicalspinalcordinjury• Frequentamongolderpersonswithcervicalspondylosis.• MostcommonincompleteSCIsyndrome• Favorableprognosisforsomedegreeofrecovery.

ModifiedfromNetter,AtlasofAnatomy(3rded.),ICoN LearningSystems

AnindividualhasacentralcorelesionattheC6spinallevel.Theaffectedareaisoutlinedinorange.Whatistheprognosisformotorfunction?A. CompleteparalysisbelowthelesionB. Incompleteparalysis,withlowerlimb

musclesaffectedtoagreaterdegreeC. Incompleteparalysis,withupperlimb

muscleaffectedtoagreaterdegreeD. Incompleteparalysis,uniform

throughoutthebody

00010203040506070809101112131415

AnindividualhasacentralcorelesionattheC6spinallevel.Theaffectedareaisoutlinedinorange.Whatistheprognosisformotorfunction?A. CompleteparalysisbelowthelesionB. Incompleteparalysis,withlowerlimb

musclesaffectedtoagreaterdegreeC. Incompleteparalysis,withupperlimb

muscleaffectedtoagreaterdegreeD. Incompleteparalysis,uniform

throughoutthebody

00010203040506070809101112131415161718192021222324252627282930

Standring,Gray’sAnatomy(41st ed.),Elsevier ModifiedfromNetter,AtlasofAnatomy(3rded.),ICoN LearningSystems

SomatotrophyS5 S1 L1 C1C5C6C7C8T1T2T12

S5

S1

L1

C1

C5

C6

C7

C8

T1

T12

T2

Standring,Gray’sAnatomy(41st ed.),Elsevier

Standring,Gray’sAnatomy(41st ed.),Elsevier

S5 S1 L1 C1C5C6C7C8T1T2T12

S5

S1

L1

C1

C5

C6

C7

C8

T1

T12

T2

CaseStudy

OnOctober16,2010,RutgersplayedahomefootballgameagainsttheArmyBlackKnights.OnakickofftoArmy,defensivetackleEricLeGrand collidedwiththeballcarrier,MalcolmBrown.LeGrandwascreditedwiththetackle,buthelaidonthegroundforseveralminutesbeforebeingcartedoff,apparentlyonlyabletomovehishead.HewastakentotheintensivecareunitoftheHackensackUniversityMedicalCenter,wheredoctorsdeterminedthatLeGrand wasparalyzedfromtheneckdown.HefracturedhisC3andC4cervicalvertebrae.

ImaginethatyouwereaphysicianperformingaphysicalassessmentofLeGrand inthelockerroomimmediatelyfollowingtheinjury.Whatfindingswouldyouexpecttosee?A. NoabnormalfindingsB. Weakness,normaltoneandreflexesC. Weakness,spasticity,hyperreflexiaD. Weakness,flaccidity,hyperreflexiaE. Weakness,spasticity,areflexiaF. Weakness,flaccidity,areflexia

00010203040506070809101112131415

ImaginethatyouwereaphysicianperformingaphysicalassessmentofLeGrand inthelockerroomimmediatelyfollowingtheinjury.Whatfindingswouldyouexpecttosee?A. NoabnormalfindingsB. Weakness,normaltoneandreflexesC. Weakness,spasticity,hyperreflexiaD. Weakness,flaccidity,hyperreflexiaE. Weakness,spasticity,areflexiaF. Weakness,flaccidity,areflexia

00010203040506070809101112131415161718192021222324252627282930

ApatientisbeingevaluatedwhohasalesioninvolvingC5-C8cordlevelsintheregionindicatedinblackinthediagram.Whatsymptomswouldyouexpectthispatienttoexhibit?

A. Weakness,increasedmuscletone,increasedDTRsintheipsi armandleg

B. Weakness,decreasedtone,decreasedDTRsinipsi chestmuscles

C. Weakness,decreasedtone,decreasedDTRsinipsi lowerlimb

D. Weakness,decreasedtone,decreasedDTRsintheipsi upperandlowerlimb

E. Weakness,decreasedtone,decreasedDTRsinipsi upperlimb

ANSWER

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Apatientisbeingevaluatedwhohasalesioninvolvingseveralcordlevelsintheregionindicatedinblackinthediagram.Whatsymptomswouldyouexpectthispatienttoexhibit?

A. Weakness,increasedmuscletone,increasedDTRsintheipsi armandleg

B. Weakness,decreasedtone,decreasedDTRsintheipsi trunk

C. Weakness,decreasedtone,decreasedDTRsintheipsi lowerlimb

D. Weakness,decreasedtone,decreasedDTRsintheipsi upperandlowerlimb

E. Weakness,decreasedtone,decreasedDTRsintheipsi upperlimb

ANSWER

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AnteriorhornislocationofLMNs

LesionsofLMNsproducespecifictypesofdeficits andinvolvemusclessuppliedbyspecificandlimitedspinallevels.

Whatspinalcordlevelisthis?Anyidentifyingfeaturesnoticed?

Don’tforgetsensorypathways!!Youneedthemtolocalize.

•weakness•¯ muscletone•¯ DTRs

Motoneurons for limb muscles

Motoneurons for axial muscles

Youareexamining inyouroffice a42year-oldwomanshowninthepicture.Younotethatshecanopenandclosebotheyesnormallyandshecansmilenormally.Youdecidethattheindicateddeficitiscausedbyalesionrelatedto:

A.CNVIIontherightsideB.CNVIIontheleftsideC.CNVontherightsideD.CNVontheleftsideE.CNXIIontherightsideF.CNXIIontheleftsideG.Nuc Ambiguus ontherightsideH.Nuc Ambiguus ontheleftside

ANSWER

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Youareexamining inyouroffice a42year-oldwomanshowninthepicture.Younotethatshecanopenandclosebotheyesnormallyandshecansmilenormally.Youdecidethattheindicateddeficitiscausedbyalesionrelatedto:

A.CNVIIontherightsideB.CNVIIontheleftsideC.CNVontherightsideD.CNVontheleftsideE.CNXIIontherightsideF.CNXIIontheleftsideG.Nuc Ambiguus ontherightsideH.Nuc Ambiguus ontheleftside

ANSWER

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Youfindthatthiswomanhasnoothersymptoms.Themostlikelylocationofalesionthatwouldcausethiswoman’sdeficitis:

A.corticobulbartractontherightsideB.corticobulbartractontheleftsideC.corticobulbartractonthebothsidesD.CNVontherightsideE.CNVontheleftsideF.corticospinaltractontherightsideG.corticospinaltractontheleftside

ANSWER

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Youfindthatthiswomanhasnoothermotorsymptoms.Themostlikelylocationofalesionthatwouldcausethiswoman’sdeficitis:

A.corticobulbartractontherightsideB.corticobulbartractontheleftsideC.corticobulbartractonthebothsidesD.CNVontherightsideE.CNVontheleftsideF.corticospinaltractontherightsideG.corticospinaltractontheleftside

ANSWER

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MotorCranialNerveLesions•Cranial Nerve Lesions – ipsilateral effects on muscles

• CN V jaw deviates to weak side• Nuc Ambiguus uvula deviates to strong side• CN XII tongue deviates to weak side

Midline structures deviate to one side when muscles are weak/paralyzed on one side.

Muscle pulls toward midline – deviation to weak side

Moves toward weak sideLateral pterygoids pull jaw towards center

Jaw deviates to left =Weak side =CN V involved

Corticobulbar InnervationBilateral Innervation (redundant):

• CN V• CN VII – upper face muscles

Unilateral Innervation:• CN VII - lower facial muscles • CN XII – tongue

Corticobulbar lesions have little effect

Corticobulbar lesions cause deficit

VVIIXII

Nuc ambiguus

CST

travel together

Corticobulbarfiberstravelwithcorticospinalfibers.Lesionsofcorticobulbarfiberswouldalsobeexpectedtoaffectcorticospinalfibersandproducerelatedbodydeficits.