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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3230_Библиотеки_им_академика_М_И_Перельмана
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CHAPTER 13 Neurological signs
342
Muscle wasting
This must be assessed in the context of the bulk of other muscles.
Some differential diagnoses and typical outline evidence
Adjacent bone,
joint, or muscle
disease
Suggested by: wasting, with pain and limitation of
movement. Visible swelling or deformity of bone or
joint
Confirmed by: X-ray of affected part. EMG
Lower motor
neuron lesion
Suggested by: wasting and fasciculation. Tone
decreased. Weakness and diminished reflexes
Confirmed by: nerve conduction studies
Muscle disease Suggested by: wasting. Tone decreased. Weakness
and diminished reflex
Confirmed by: EMG
WEAKNESS AROUND ONE LOWER LIMB JOINT1
343
Weakness around one lower limb joint
These weaknesses may point strongly to one nerve root lesion. Test by
asking the patient to perform the movement against your resistance.
Some differential diagnoses and typical outline evidence
L1/2 root lesion
or femoral
nerve
Suggested by: weakness of hip flexion alone
Confirmed by: X-ray of lumbar spine and sacrum.
Nerve conduction studies. MRI scan where lesion
is localized clinically
L2/3 root lesion
or obturator
nerve
Suggested by: weakness of hip adduction alone
Confirmed by: X-ray of lumbar spine and sacrum.
Nerve conduction studies. MRI scan where lesion
is localized clinically
L3/4 root lesion
or femoral
nerve
Suggested by: weakness of knee extension alone
Confirmed by: X-ray of lumbar spine and sacrum.
Nerve conduction studies. MRI scan where lesion
is localized clinically
L4/5 root lesion
or tibial nerve
Suggested by: weakness of foot dorsiflexion and
inversion at the ankle
Confirmed by: X-ray of lumbar spine and sacrum.
Nerve conduction studies. MRI scan where lesion
is localized clinically
L5/S1 root
lesion or
common
peroneal nerve
Suggested by: weakness of knee flexion alone
Confirmed by: X-ray of lumbar spine and sacrum.
Nerve conduction studies. MRI scan where lesion
is localized clinically
S1/2 root lesion
or sciatic nerve
Suggested by: weakness of toe flexion alone
Confirmed by: X-ray of lumbar spine and sacrum.
Nerve conduction studies. MRI scan where lesion
is localized clinically
Lateral popliteal
nerve palsy
(usually
traumatic)
Suggested by: flaccid
foot drop, with weakness of
eversion and dorsiflexion of the foot and a sensory
loss over lateral aspect of leg
Confirmed by: nerve conduction study result
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
CHAPTER 13 Neurological signs
344
Bilateral weakness of all foot
movements
Some differential diagnoses and typical outline evidence
Guillain–Barré
syndrome
Suggested by: onset over days, preceding viral illness.
Confirmed by: high CSF protein. Progressive course
then variable recovery
Lead poisoning Suggested by: gradual onset over weeks to months
Confirmed by: nerve conduction studies, and history of
exposure
Porphyria Suggested by: onset over months to years. Usually
known to have porphyria
Confirmed by: EMG
and iurine or fecal
porphobilinogens
Charcot–
Marie–Tooth
disease
Suggested by: onset over years. Associated with foot
drop and peroneal atrophy, upper limbs affected later
Confirmed by: EMG
SPASTIC PARAPARESIS1
345
Spastic paraparesis
Bilateral lower limb paresis with increased tone. This is a medical emergency
if acute.
Some differential diagnoses and typical outline evidence
Prolapsed disc
(anteriorly, thus
compressing spinal
cord)
Suggested by: sudden onset often associated with
change in spinal posture
Confirmed by: MRI scan appearance
Traumatic
vertebral
displacement or
fracture
Suggested by: sudden onset associated with violent
injury
Confirmed by: MRI scan appearance
Collapsed
vertebra
(due to secondary
carcinoma or
myeloma)
Suggested by: sudden onset over minutes or hours.
Other symptoms suggestive of neoplasia over
months
Confirmed by: nerve conduction studies. MRI scan
appearance
Spondylitic bone
formation
compressing
spinal cord
Suggested by: onset over months to years. Often
past history of spondylitic back pain
Confirmed by: MRI scan appearance
Multiple sclerosis
affecting
spinal cord
Suggested by: this and other intermittent
neurological symptoms disseminated in site
and time
Confirmed by: MRI scan appearance
Infective space
occupying lesion
e.g., TB or abscess
Suggested by: onset over days or weeks with fever
from low grade to spiking
Confirmed by: MRI scan and findings at surgery,
histology and microbiology
Glioma or
ependymoma in
spinal cord
Suggested by: gradual onset over months
Confirmed by: MRI scan and findings at surgery,
histology
Parasaggital
cerebral
meningioma or
other tumor
Suggested by: gradual onset over months
Confirmed by: MRI scan and findings at surgery,
histology
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CHAPTER 13 Neurological signs
346
Hemiparesis (affecting arm and leg)
Some differential diagnoses and typical outline evidence
Occlusion of
upper branch of
middle cerebral
artery with
infarction
including
Broca’s area
Suggested by: expressive dysphasia and contralateral
lower face and arm weakness
Confirmed by: MRI or CT scan appearance
Occlusion of
perforating
branch of
middle cerebral
artery with
lacunar
infarction
Suggested by: hemiparesis alone with subsequent spas-
ticity (or receptive dysphasia alone or hemi-anesthesia
alone)
Confirmed by: MRI or CT scan appearance
Total middle
cerebral artery
territory
infarction
(usually
embolic)
Suggested by: contralateral flaccid hemiplegia (with
little subsequent spasticity) and hemi-anesthesia with
deviation of head to side of lesion. Also homonymous
hemianopia with aphasia if dominant hemisphere
affected or neglect if nondominant hemisphere affected
Confirmed by: MRI or CT scan appearance
Posterior
cerebral artery
infarction
Suggested by: contralateral homonymous hemianopia
or upper quadrantanopia, mild contralateral hemipare-
sis and sensory loss, ataxia and involuntary movement,
memory loss, dyslexia, and ipsilateral third-nerve palsy
Confirmed by: MRI or CT scan appearance
Anterior
cerebral artery
infarction
Suggested by: paresis of contralateral leg, rigidity,
perseveration, grasp reflex in opposite hand, urinary
incontinence, and dysphasia if in dominant hemisphere
Confirmed by: MRI or CT scan appearance
DISTURBED SENSATION IN UPPER LIMB1
347
Disturbed sensation in upper limb
This is elicited by testing touch (with a piece of cotton wool), heat (with a
cold metal object), and pain (through pinprick with a sterile needle)
in each dermatome distribution. Note any discrepancy between these
modalities of sensation.
In the palm, examine the radial 3.5 fingers and the ulnar 1.5 fingers.
Test joint position sense (by holding digits at their sides) and vibration
with a tuning fork over bony prominences. Then use a two-pointed
device (2-point discrimination), placing objects in the patient’s hand and
asking them to guess what they are with eyes closed, e.g., a quarter
(stereognosis), and drawing figures on the palm (graphesthesia).
Consider if you have discovered any of the patterns described below.
Some differential diagnoses and typical outline evidence
Contralateral
cortical
(pre-central
gyrus) lesion
Suggested by: astereognosis, diminished 2-point
discrimination, and graphesthesia
Confirmed by: CT or MRI scan of brain
Peripheral
neuropathy
Suggested by: loss of touch and pinprick sensation
worse in hand, progressing upwards
Confirmed by: Nerve conduction studies
Spinothalamic
tract damage
(no dorsal
column loss)
due to
syringomyelia in
cervical cord
Suggested by: loss of pinprick and temperature
sensation, normal or disturbed touch but normal
joint position and vibration sense in hand
Confirmed by: Nerve conduction studies. MRI of
cervical cord
Cervical or
thoracic nerve
root lesion
Suggested by: loss of sensation in dermatome
distribution in hand or forearm or upper arm
Confirmed by: nerve conduction studies. X-ray and MRI
scan of neck
Peripheral
nerve lesions
in arm
Suggested by: loss of sensation localized to the forearm,
upper arm, or radial 3.5 fingers or ulnar 1.5 fingers in
the palm
Confirmed by: nerve conduction studies
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
CHAPTER 13 Neurological signs
348
Diminished sensation in arm
dermatome
Some differential diagnoses and typical outline evidence
C5 posterior
root lesion
Suggested by: loss of sensation of lateral aspect of
upper arm
Confirmed by: nerve conduction studies. MRI scan
appearance
C6 posterior
root lesion
Suggested by: loss of sensation of lateral forearm and
thumb
Confirmed by: nerve conduction studies. MRI scan
appearance
C8 posterior
root lesion
Suggested by: loss of sensation of palmar and dorsal
aspect of ulnar 1.5 fingers and the ulnar border of the
wrist
Confirmed by: nerve conduction studies. MRI scan
appearance
T1 posterior
root lesion
Suggested by: loss of sensation of ulnar border of the
forearm
Confirmed by: nerve conduction studies. MRI scan
appearance
T2 posterior
root lesion
Suggested by: loss of sensation of inner aspect of uppe
r
arm and breast
Confirmed by: nerve conduction studies. MRI scan
appearance
DIMINISHED SENSATION IN THE HAND1
349
Diminished sensation in the hand
Some differential diagnoses and typical outline evidence
Median nerve
lesion
due to carpal
tunnel syn-
drome, oral
contraceptives,
pregnancy,
hypothyroidism,
acromegaly,
rheumatoid
arthritis or
nerve trauma
Suggested by: loss of sensation of palmar aspect of
radial 3.5 fingers (in carpal tunnel syndrome, also
discomfort in forearm and tingling if front of wrist
tapped). If nerve severed, wasting of thenar eminence
and thumb opposition
Confirmed by: X-ray wrist and elbow. Nerve
conduction studies, and thyroid function tests,
rheumatoid factor etc.
Ulnar nerve
lesion
due to compres-
sion of deep
palmar branch
from trauma or
ulnar groove at
elbow from
trauma or
osteoarthritis
Suggested by: loss of sensation of palmar and dorsal
aspect of ulnar 1.5 fingers but not the ulnar border of
the wrist
Confirmed by: nerve conduction studies. X-ray wrist
and elbow
Radial nerve
lesion
due to local
compression
(e.g., arm left
hanging over a
chair)
Suggested by: loss of sensation of dorsal aspect of
radial 3.5 fingers
Confirmed by: nerve conduction studies
C7 posterior
root lesion
due to cervical
osteophytes
Suggested by: loss of sensation of middle finger alone
Confirmed by: nerve conduction studies. MRI scan
appearances
C8 posterior
root lesion
due to cervical
osteophytes
Suggested by: loss of sensation of palmar and dorsal
aspect of ulnar 1.5 fingers and the ulnar border of the
wrist
Confirmed by: nerve conduction studies. MRI scan
appearances
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
CHAPTER 13 Neurological signs
350
Disturbed sensation in lower limb
Look for specific patterns, as indicated below.
Some differential diagnoses and typical outline evidence
Contralateral
cortical
(pre-central gyrus)
lesion
Suggested by: graphesthesia
Confirmed by: CT or MRI scan of brain
Peripheral
neuropathy
(due to diabetes
mellitus, carci-
noma, vitamin B
12
deficiency, drugs
therapy, heavy-
metal or chemical
exposure
Suggested by: loss of touch and pinprick sensation,
worse in foot (e.g., stocking distribution), progress-
ing upward
Confirmed by: nerve conduction studies. MRI scan
appearance
Spinothalamic
tract damage
(no dorsal
column loss) due
to contralateral
hemisection of
the cord
Suggested by: loss of pinprick and temperature
sensation, normal or disturbed touch, but normal
joint position and vibration sense in foot
Confirmed by: nerve conduction studies. MRI of
cervical cord
Dorsal column
loss
due to vitamin B
12
deficiency, ipsilat-
eral hemisection
of the cord, rarely
tabes dorsalis
Suggested by: loss of joint position and vibration
sense in foot. Pinprick and temperature sensation
normal
Confirmed by: nerve conduction studies. B
12
levels
L1 posterior root
lesion
Suggested by: loss of sensation in inguinal region
Confirmed by: nerve conduction studies. X-ray of
lumbar spine and sacrum
DISTURBED SENSATION IN LOWER LIMB1
351
L2/3 posterior
root lesion
Suggested by: loss of sensation in anterior thigh
Confirmed by: nerve conduction studies. X-ray of
lumbar spine and sacrum
L4/5 posterior
root lesion
Suggested by: loss of sensation in anterior shin
Confirmed by: nerve conduction studies. X-ray of
lumbar spine and sacrum
S1 posterior
root lesion
Suggested by: loss of sensation in lateral border
of foot
Confirmed by: nerve conduction studies. X-ray of
lumbar spine and sacrum
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
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