NEUROQBANK

Announcements: Neuromuscular section updated with more questions.

HISTORY: Timeline and pattern of weakness and numbness, leg heaviness or warmth, back pain, trauma history, bowel or bladder symptoms, sexual dysfunction, perianal or saddle anesthesia, recent infectious symptoms, baseline ambulatory status.

EXAM: In addition to standard exam, check pinprick and vibration on both sides of spine to assess for spinal cord sensory level, palpate / percuss for paraspinal tenderness, rectal exam  for perianal sensation and anal sphincter tone, palpate bladder, bulbocavernosus reflex (pull Foley or squeeze glans, S1-3), carefully assess muscle tone, skin exam for rash if you suspects an inflammatory disorder,  pay attention to DTRs (triceps C6-7, biceps C5-6, brachioradialis C5-6, knee L2-4, ankle S1) and cutaneous reflexes (upper abdominal T8-10, lower abdominal T10-12, plantar L5-S1) as well as check Hoffman’s and Clonus

DIFFERENTIAL: Herniated disc, myelitis, spinal tumor, AIDP (if reflexes are lost), neuropathy, neurosarcoidosis, syringomyelia.

CORD SYNDROMES:

Brown-Sequard: Hemisection leading to ipsilateral dorsal column signs, contralateral spinothalamic signs, usually spared bladder function.

Central cord: Segmental pain and temperature loss, segmental DTRs lost, segmental weakness/atrophy, UMN signs below the lesion, urinary urgency

Extrinsic compression: Segmental symptoms indicate nerve root involvement, long tract findings (UMN signs, numbness, weakness, urinary urgency) indicate cord involvement. Pain and temperature loss begins sacrally.

Spondylotic myelopathy: From disc disease or osteophytes, begin with segmental findings such as dropped reflexes at the level of the lesion and spastic weakness with hyperreflexia below the lesion, sensory findings usually come later.

Conus medullaris: Sudden, bilateral, symmetric, spastic distal lower extremity weakness, loss of ankle jerks, low back pain, perianal numbness, early onset of urinary retention and overflow incontinence, impotence.

Cauda equina: Flaccid lower extremity weakness, urinary retention late in the disease, decreased anal tone, occasional sexual dysfunction, saddle anesthesia, loss of knee and ankle reflexes, severe radicular pain, presentation may be asymmetric and gradual.

CORD TUMORS: Extramedullary (outside cord) may be intradural (meningiomas and schwannomas) or extradural (metastatic tumors from breasts, lungs, prostate, leukemia, or lymphomas).   Intramedullary are rare and usually gliomas (astrocytomas or ependymomas), in children usually low-grade astrocytomas.

WORKUP :

1.   PVR with bladder scan or catheter for urinary retention

2.   If you suspect acute cord compression, conus or cauda equina syndrome – this is a surgical emergency! Give dexamethasone 10 mg IV x 1, call spine service immediately (alternates between trauma and neurosurgery) for decompression, get STAT imaging

3. MRI spine w/wo, choose appropriate level; include diffusion if you suspect ischemia

4. Based on above, consider:  Brain MRI for MS plaques; serum RPR, copper, B12, NMO Ab, ACE, ESR, ANA, Lyme, HIV, HTLV-1, Mycoplasma, hep panel; CSF for basic studies and AFB / TB cx, crypto ag, fungal stain/cx, viral PCR, Lyme, VZV, EBV, CMV, enterovirus, ACE, HHV-6/7, WNV

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