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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_186_библиотеки_им_акад_М_И_Перельмана

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https://t.me/med1917
ExtrapyramidaldysfunctionisresponsibleformanyofthemanifestationsofParkinsondisease,including tremor,abnormalposture,andgaitdysfunction.
TheMotorExamination
Themotorexaminationisbrokendowninto3components:
1.  Musclebulk. Inspectandpalpate forevidence of atrophy.Keepin mindthat “normalbulk” for a collegeathlete means something differentthannormalbulkforanelderlygrandparent.
2. Muscletone.Askpatientstorelaxandletyoumanipulatetheirlimbs.Assessfor:
a.
Hypotonia:Decreasedresistancetopassivemanipulation.
b. Hypertonia:Increasedresistancetopassivemanipulation.Thiscomesinacoupleofflavors:
i.
Spasticity,usuallyduetop y ramidalt ractdisease(e.g.,afteraleft-sidedmiddlecerebralarterystroke;seeChapter2),isvelocit y dep endent;thetone increasesast helimbismovedmorequickly.
ii.
Rigidity,usuallyduetoextrapy ramidaldisease(e.g.,Parkinsondisease;seeChapter13),isvelocityindependent;thetonedoesnotchange,regardless ofmovement.
3. Muscle strength. Testonemuscleat a time,using onehandtoprovide resistanceandthe other to stabilizethe adjacentjoint, while askingpatientstopushorpullashardastheyareabletowardoragainstyou.Thisiscalled“confrontationtesting.”Neurologistsusea 5-point gradingscale,with additional pluses andminusestofurtherspecifythedegree of strength(e.g.,4+isstrongerthan4, but not quiteasgoodas5):
0:Nocontraction
1:Flickerofmovement
2:Abletomoveinahorizont alplanebutnotagainstgravity
3:Abletomoveagainstgravity,butnot againstresistance
4:Abletomoveagainstsomeresistance
5:Normal
https://t.me/med1917
Evaluatingmotorstrengthwithconfrontationtesting.
Box1.6PronatorDrift
Thistermreferstoapathologicsignthatindicatessubtlearmweaknessandmay betheonlymotorabnormalityyoudetect.Even(andespecially)inisolation,itis animportantphysicalfinding,solookforthisinallyourmotorexaminations. Haveyourpatientsextendbotharmsoutinfront,palmsup,eyesclosed.Ifboth armsremaininplace,strengthisintact.Ifonearmbeginstodriftdownwardand pronatesuchthatthepalmbeginstoturntowardtheground,yourpatienthasmild weaknessthatyoucouldeasilymissonformalconfrontationtesting.Thisisatest ofuppermotorneuronweakness.
https://t.me/med1917
Pronatordriftinapatientwithsmallstrokeinvolvingthemotorpathways.
TheSomatosensorySystem
SomatosensorySystemAnatomy101Thesomatosensorysystemarisesintheperiphery.Thereare severalsensorymodalities,includinglighttouch,vibration,pain,temperature,andproprioception(also knownasjointpositionsense,proprioceptionenablesyoutoknowwhereyourbodyisinspace).
Wesensethesevariousmodalitiesviadifferentsensoryreceptorsthatarelocatedinourskinand muscles.Neuronsextendfromthesereceptorsintothespinalcord,wheretheyascendviavarious pathwaysintothebrain.Thecellbodiesofthese“first-order”neurons(i.e.,thefirstneuronsinthe sensorypathways)arelocatedinthedorsalrootganglia(DRG),whichareclustersofcellbodieslocated alongsidethecord.
Therearetwomajorpathwaystoknow:
Thedorsal column/medial lemniscus pathwaycarries pressure, vibration, and proprioception fibers. Thefirst-order neuronenters the cord and ascends ipsilaterallyinthe dorsal columntract, thensynapsesintheipsilateralmedulla. Thesecond-orderneuronimmediatelydecussates,ascends contralaterallyinthe medial lemniscustract,thensynapsesinthethalamus.Thethird-orderneuron extendsfromthethalamustotheprimarysomatosensorycortex,locatedinthepostcentralgyrus.  Thespinothalamic tractcarries pain and temperature fibers. Unlike the dorsal column/medial lemniscus tract, the first-order neuron enters the cord and then immediately synapses in the ipsilateral dorsal horn. The second-order neuron then decussates (through the anterior white commissure), ascendscontralaterallyinthe spinothalamic tractand thensynapses inthethalamus. The third-order neuron thenjoins the neuronsfrom the dorsal column/medial lemniscustractas it risestothesomatosensorycortex.
Thesetractsarelesscomplicatedthantheysound.Spendaminutegoingthroughthesediagrams,and you’llknowallyouneedtoknow.
https://t.me/med1917
(A)Thedorsalcolumn/mediallemniscustractand(B)thespinothalamictract.Notethat,althoughthe pathwayscrossatdifferentlevelsintheneuraxis,bothenduponthecontralateralsidefromwherethey began.Thisiswhytheleftsideofthebrainisresponsibleforsensoryinputfromtherightsideofthebody, andviceversa.DRG:dorsalrootganglia.
Box1.7LissauerTract
Thefirst-orderneuronofthespinothalamictractactuallyrunsupalongsidethecord—in what’sknownasLissauertract—forabout2vertebralsegmentsbeforeitentersthecord. KnowingabouttheLissauertractcanbeimportantwhentryingtolocalizespinallesions,so fileitawayandwe’llcomebacktoitlater(seeChapter10).
https://t.me/med1917
Thereareseveralotherpathwaysthatcarrysensoryinformation,butwewon’tworryaboutthemfor now.Lighttouchfibersaredispersedthroughoutseveralofthesepathways,andthuslossoflighttouch cannotbelocalizedtoanyparticulartract.
TheSensoryExaminationHere’showtotestthevarioussensorymodalities:
1. Pain.Testwithacleansafetypinorthejagged,pointysideofatoothpicksnappedinhalf.
2. Temperature.Testwiththesideofametaltuningfork.
3. Vibration.Testwithatuningfork.
4. Proprioception(jointpositionsense).Tellyourpatientstoclosetheireyes. Then,withyour fingers,moveoneoftheir bigtoesupand down.Your patientsshouldknow,withoutlooking,whichdirectionthetoeispointing.Besuretoplace yourfingersonthesides ofthe toeandnotthetop andbottom;you’reeffectively allowing thepatientto“cheat” if he orshecanfeelthepressure fromyourfingers pushingupordown.
5. Lighttouch.Testwiththebedsofyourfingertips.
Box1.8TheRombergTest
TheRombergtestisanotherwaytoevaluateproprioception.Tellyourpatientstostandup
https://t.me/med1917
withtheirarmshanginglooselybytheirside,feetclosetogetherandeyesclosed,making surethatyouarepositionedtocatchthemiftheyfall.Thenwatchthemtoseehowsteady theyare.Aretheyabletomaintainperfectposture,dotheyswayfromsidetoside,ordo theybegintofall?Balancerequiresintactproprioceptionaswellasvisualfunctionand vestibularfunction.3Witheyesclosed,patientscanonlyrelyonproprioception,soif proprioceptionisimpaired,theywilllosetheirbalance.
https://t.me/med1917
PerformingtheRombergTest.
3
Ifvestibularfunctionisimpaired,patientswillswaywiththeireyesopenandclosed;thus, forpatientswithvestibulardysfunction,a“positive”Rombergisnotdiagnosticof proprioceptivedysfunction.
https://t.me/med1917
Reflexes
Deeptendonreflexesaresimplecircuitsmadeupofonesensoryneuronandonemotorneuron(and sometimesanintervening“interneuron”betweenthetwo;seethepicturebelow)thatsynapsewithinthe spinalcord.Thesensoryafferentnerve,activatedbythelighttapofareflexhammer,activatesthemotor efferentnerve,whichsubsequentlycausesmusclecontraction.Therearemultipletypesofreflexhammers andeveryonehastheirfavorite,butdon’tbefooled:it’sallinthewrist!
Asimplereflexarc.
Reflexesaregradedona4-pointscale.Clonus(4+),aseriesofinvoluntary,rhythmicmuscle contractionsandrelaxations,ispathologic,whereasbrisk(3+)canbenormalornot,dependingonthe context.Left-rightsymmetryisespeciallyimportanthere,becauseanyasymmetrymayindicateafocal neurologiclesion.
0:Noresponse 1+:Slightlydiminished 2+:Normal
https://t.me/med1917
3+:Brisk 4+:Clonus
Box1.9NerveRoots
Thespinalcordgivesoffpairednerverootsateachvertebrallevel.Thedorsalroot (containingthesensoryafferentfibers)andventralroot(containingthemotorefferentfibers) jointoformaspinalnerveasshowninthefigureonpage26.Specificnerverootsare responsibleforspecificreflexes.Theseareimportanttoknow,becausetheycanhelpyou localizethedamagewhenareflexisabnormal.
Brachioradialis:C5-6 Biceps:C5-6 Triceps:C7-8 Patellar(kneejerk):L2-4 Achilles(anklejerk):S1
https://t.me/med1917
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