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128 Cards in this Set
- Front
- Back
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Blood supply to the brain?
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ICA and basilar artery
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What % of cardiac output goes to the brain?
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20%
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T/F - the concentrations of components of CSF vary with plasma concentrations?
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False - it is generally maintained despite fluctuations innplasma concentrations.
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Name the ares of the brain where the BBB is leaky.
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Hypothalamus, pituitary, Choroidal plexus & area postrema - need to sample blood
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T/F
In general men have more white matter than females? |
False
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T/F
The right side of the brain is important for language, mathematics and logic? |
False - these are features of the left side
The right side is associated with music, visual imagery, facial recognition and spatial abilities. |
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Autonomics are found in the intermediate grey - T/F?
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True
Dorsal horn - sensory Ventral horn - motor |
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Which part of the muscle are alpha motor cells associated with?
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Motor end plate
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Which part of muscle are gamma motor cells associated with?
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Spindles - parallel to the muscle
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What type of sensation are Messiner receptors associated with?
Name location and fibre type. |
Touch, press
Fibre - alpha -B - type II Location - hairless skin |
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What type of sensation are
Pacinian receptors associated with? Name location and fibre type. |
Deep press, vibration
Fibre - alpha B - type II Location - subcutaneous, myelin |
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What type of sensation are ruffini receptors associated with?
Name location and fibre type. |
Stretch
Fibre - alpha B - type II Location - all skin, myelin |
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What type of sensation are merkle receptors associated with?
Name location and fibre type. |
Touch, press
Fibre - alpha B - Type II Location - All skin, myelin, hair |
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What type of sensation are free ending receptors associated with?
Name location and fibre type. |
Pain
Fibre - C (IV) dull; A-Delta (III) sharp location - all skin, viscera |
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What type of sensation are muscle spindle receptors (and other proprioceptors) associated with?
Name location and fibre type. |
Muscle length and proprioception
Fibre - Ia/b, II Location - muscles |
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What are the 2 ascending pain pathways?
And which fibres do both use? |
Neospinothalamic (III)
Paleospinothalamic (IV) |
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What is the pathway taken by ascending pain signals?
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Free nerve ending - peripheral nerve - DRG - spinal nerve - spinal root - synapse in dorsal grey matter - decussate at level of entry via ventral white commisure - spinothalmic tract (lower limb peripherally) - VP (Ventral posterior of thalamus) - S1
Other pathways involved BRF, medial dorsal/intralamina (MD/IL - of thalamus) and insula and cingulate cortex |
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Hemisection to the spinal cord results in what change to pain sensation?
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Contralateral loss of pain and temperature (fibres together in spinothalamic tract)
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What type of fibres are used for tactile sensation?
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Type II
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Where do tactile signals travel within the SC?
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They travel within The dorsal column tracts -
Gracile tract - lower limb Cuneate tract - upper limb |
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Decussation of tactile sensory information occur where?
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Closed rostral medulla (after motor decussation)
These crossing fibres are called the internal acute fibres. |
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Following decussation where do sensory fibres travel?
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They travel in the medial lemniscus to the thalamus(ventral posterior - VP) and eventually to S1
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Spinal cord lesion leads to what change in sensation?
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Loss of ipsilateral touch and vibration
Loss of contrallateral pain and temperature |
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Where is the spinothalamic tract located in the spinal cord?
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Lateral /ventral
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T/F - propriocetion is carried in 2 tracts?
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True
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What are the tracts containing proprioception?
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Dorsal column tract - this contains conscious proprioception and travels with tactile information
Spinocerebellar tract - this contains unconscious proprioception - this fibres travel ipsilaterally and do NOT cross |
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Descending tracts are separated into basic and skilled tracts - which tracts fall into these categories?
And what are the functions of these categories? |
Basic - reticulospinal, vestibulospinal
--- FXN - Maintain posture and regulate autonomics Skilled - rubrospinal, Corticospinal ---FNX - skilled distal movements (limbs) |
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Which tract comes from the red nucleus?
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Rubrospinal nucleus - skilled movement pathway
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What are the parasympathetic ganglia within the head?
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Otic - IX - parotid gland
Pterygopalantine - VII - lacrimal gland and nasal septum Submandibular - VII - sublingual and submandibular glands Cillary - III - sphincter pupillae |
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Parasympathetic outflow from the spinal cord occurs at which areas
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Cranial
Sacral |
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SNS outflow from SC occurs at which level?
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Thoracolumbar - T1 - L2
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What receptor type is found at the NMJ?
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Nicotinic ACh
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What receptor type is found at within the SNS ganglia?
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NIcotinic ACh
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Which receptor type is involved in postganglionic autonomic neuron - end organ interaction?
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Muscarinic ACh -
Except for SNS blood vessels which use NA And SNS - adrenal gland -- no post synaptic neuron - presynaptic neuron synapses directly on adrenal medulla - nACh |
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Does adrenaline act on beta or alpha receptors ?
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Beta
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Does NA act on Beta or alpha adrenoceptors ?
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ALPHA
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Are PNS ganglia located close to the spinal cord or end organ?
And hence which is longer - pre or postsynaptic neurons? |
Close to end organ
Therefore the preganglionic neuron is much longer |
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White rami communicantes contain both pre and post synaptic autonomic neurons? T/F
Is this rami the closer one to the SC? |
True
No it is the further one Note Grey (closer) contains ONLY postsynaptic neurons |
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Sympathetic reflexes such as the cardio-cardiac reflex - are regulated by both descending pathways and also Afferent SNS neurons. T/F?
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True
It is important to remember that autonomic reflexes always go via INTERNEURONS - ei not monosynaptic like some somatic reflexes |
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T/F - detrusor contraction via PNS maintains continence?
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Detrusor contraction is via the PNS - but this allows for micturation
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Explain the main mechanisms involved in maintaining continence.
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SNS - relaxation of detrusor and contraction of internal sphincter.
On bladder filling - somatic pudendal nerve must contract external sphincter to maintain continence (input from higher centers - pons and micturation centers) |
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Explain the processes involved in micturation.
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Inputs from Afferent nerve - stretching of bladder wall and inputs from the cortex via the pontine micturation centers to the spinal cord
1) decrease pudendal activity -- external sphincter relaxation 2) increase PNS activity - contraction of detrusor and relaxation of internal sphincter 3) inhibit SNS output |
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There are descending pathways affect SNS actions. What are these?
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Rostroventral medulla - BP regulation
Raphe nuclei - Thermoregulation A5 cell group Paraventricular nucleus - fluid balance + thermoregulation |
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Biceps reflex tests which myotome?
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C5 (6)
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Triceps tests which myotome?
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C7
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Brachioradialis reflex tests which myotome? (supinator)
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C6
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Achilles reflex tests which myotome?
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S1
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Patella tendon reflex tests which myotome?
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L4
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What is the grading system for reflexes?
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0 absent
1 twitch present 2 present with reinforcement 3 normal 4 brisk |
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T/F the stretch reflex is monosynaptic?
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True
This is the reflex tested with a tendon hammer. |
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The flexor reflex is activate by touching a noxious stimuli- T/ F?
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True - this si the withdrawal reflex initiated by a sensory stimuli
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What is the golgi tendon reflex?
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Reflex initiated by stretch of the tendon - which results in relaxation of the muscle
Function - to prevent over stretching or tearing of the mucked with heap loads |
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Does spinal shock always occur with SCI?
When does it start and how long does it last? |
Yes
From injury and lasts hours to 6 weeks ~~ |
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What level of the SC must be injured for the heart and bladder to be involved?
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Heart - T5/6
Bladder - S2-4 |
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What is spinal shock?
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It is a inhibition of all neural activity below the level of injury
Example - no motor activity no sensation, and NO REFLEXES (these will return as spinal shock goes away, where as the others may not) |
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Signs of spinal shock?
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Low HR
Low BP Areflexia Bladder and bowel incontinence |
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What is the main clinical difference between hypovolemic and spinal shock?
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Both have low BP but hypovolemic shock is associated with raised HR, where are Spinal shock - low HR
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At what level must a spinal cord injury be, for a patient to get autonomic dysreflexia? And why?
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T5/6
because this causes disunity in the ANS |
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What occurs during autonomic dysreflexia?
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1) A noxious stimuli is sensed below the level of injury
2) input to spinal cord -- leads to increased SNS activity below injury 3) leads to vaso constriction -- raised BP 4) sensed by baroreceptors 5) signals to reduce SNS activity are blocked because of the SCI -- there the body compensates by increasing PNS activity via VAGUS 6) decrease HR and vasodliation above SCI |
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Cinical features of AD (autonomic dysreflexia)?
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Below SCI - hot and sweaty
Above SCI -cold and clammy Low HR, Raised BP (may appear normal as people with SCI often have low BP normally) |
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What are the 5 main causes of spinal cord lesions?
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Trauma, vascular (ischemic), demyelinating, infectious, tumour
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What is alodynia?
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Painful sensation to non painful stimulus
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What are the signs of LMN lesions?
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Atrophy
Flaccid paralysis Areflexia Fasciculations and fibrillations Bladder |
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What are the signs of UMN lesions?
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Hyperreflexia
Hypertonia/spasticity Paralysis Abnormal babinski's Bladder |
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What is nociceptive pain?
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Pain caused by a generally observable pathology or lesion
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Neuropathic pain?
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Due to lesions or damage to Nervous system (at any level - peripheral nerve, DRG, SC, Brainstem, thalamus, cortex)
Opioid resistant Chronic - usually Burning, sharp, shooting, electric |
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Name some conditions commonly associated with neuropathoc pain.
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Amputation - 60-80%
SCI - 20-30% VZV (herpes zoster) - 10-20% diabetic neuropathy - 16-26% MS - 22% Guillain Barre - 33% stroke - 8% |
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MOA of neuropathic Pain ?
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Ectopic activity in primary afferents following injury due
to ↑ Na Channel expression in Nerve and DRG ↑ AP ↑ ascending signals Sensitised – Hypersensitivity glutamate release- NMDA & Ca2+ --2nd messengers (PKC, cAMP) Alter gene transcription long term changes receptor function and transmitter production Spontaneous Activity – Afferent nerve cut but the 2° Neuron fires spontaneously in the dorsal horn Descending inhibitory pathways inhibit pain signals via inhibitory interneurons these can be lost (=↑ pain) – GABA, 5HT, NA, opioids GLIA in Pain Processing - Release of - proinflammatory cytokines (IL1b), glutamate, NO, ATP Sprouting (re-wiring) damage to 1 nerve (pain) may lead to the crossing over of light touch fibres activating 2° pain fibres Brain Plasticity – changes in brain function – (maladaptive) |
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Treatment of neuropathic pain?
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Analgesics – simple, compound, strong opioid
Anti-Inflammatory – steroidal, non steroidal Analgesic Adjuvants – tricyclic antidepressants, anticonvulsants, membrane stabilisers (Las, mexiletine), NMDA antagonist (ketamine), benzo (clonazepam), alpha adrenergic agonists (clonidine), minocycline Stimulation Produced Analgesia – peripharl nerve stimulation, TENS, acupuncture, dorsal column stimulation, deep brain stimulation, motor cortex stimulation (epidural, transcranial) |
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What is usually the main cause of coma following CNS trauma?
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Brain swelling
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What are the main focal brain injuries? (3)
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Contusions
Hemorrhage (subdural, epidural, intracerebral, subarachnoid) Lacerations |
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What is the main cause of epidura/extradurall hemorrhage?
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Rupture of middle meningeal artery or vein following temporal skull fracture
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Subdural haematoma is commonly associated with trauma involving angular accelerations - T/F?
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True - the brain moves but the sinuses are fixed.
Often picked up late (chronic SDH) - and often subacute |
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Intracerebral haemorrhage is associated with high mortality rate T/F?
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True
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Diffuse Axonal injury is NOT generally associated with acceleration/deceleration or rational forces - T/F?
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False
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What are the causes of progressive cell injury following trauma?
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Glutamate excitotoxicity - via NMDa and Ca entry into cells
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Swelling/odema in the brain or SC can be due to ?
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Vasogenic odema
Cytotoxic odema Increased blood volume (backing up of venous blood) |
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Mortality following Subdural haematoma and diffuse Axonal injury due to CNS trauma are relatively similar - T/ F?
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FALSE
Subdural haematoma - 70% mortality DAI - 10% mortality |
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What is the main cause of traumatic SCI?
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MVA - 50%
This number includes motorcycles and pedestrians |
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What is brown-sequard syndrome?
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Lateral half of SC
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What is anterior cord syndrome and common causes?
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Lesion to only anterior portion of SC - with DCT intact
Ruptured disc or burst fracture of vertebra |
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With SCI paraplegia is 2x more common than quadriplegia - T/F?
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False
About 1:1 |
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Females are more likely to have Tramatic SCI - T/ F?
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False ~80% males
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What can cause non-traumatic SCI?
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Causes –
Spinal stenosis, IVD herniation, RA, vascular, inflammatory (infectious, non-infectious – transverse myelitis, MS, polio), tumour, iatrogenic (radiation, contrast arachnoiditis), other (syringomyelia, MND, Vit B12, Friedreich ataxia) |
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What is the most common spinal level injury?
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C5 (C4 close behind)
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What should you do when someone presents with autonomic dysreflexia?
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Sit patient as upright as possible
Call for help & monitor blood pressure Remove or loosen all tight clothing (TEDS& abdominal binder) Check drainage system for kinks/clots/sediment – irrigate catheter or place catheter Empty leg bag Attempt to identify cause Refer to AD Treatment Card/Algorithm and RSCIP - Fact sheet (most Pt with have this with them) If not easily remediable or over 170mmHg GTN spray or tablet or Captopril (do not use GTN post PDE5I-viagra) Analgesia Bowel – lignocaine (wait 3-5min), rectal exam, manual evacuation if full If still high BP – look for other cause – infection, trauma etc *** Susceptibility to AD is increased for 48Hr after an episode must be monitored, no invasive procedures *** |
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Main causes of death following SCI?
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Pneumonia and influenza 14%
Septicemia Cancer Ischemic heart disease Urinary problems Suicide 7.7% Cerebrovascular |
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What is an example of primary prevention of SCI?
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Work place safety
Seat belts, child restraints, speeding restrictions, RBTs Safer cars |
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What is an example of secondary Prevention os SCI?
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Improved retrieval/care, early decompression, wider first aid training
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What is an example of Tertiary prevention for SCI?
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Rehab
Education Care and monitoring - check ups - health, nutrition, exercise, pressure care etc |
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What is the most common cause of SCI in over 45YO?
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Falls
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What is the most dangerous part of autonomic dysreflexia?
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rapid rise in BP
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What are the signs of Neurogenic Shock?
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hypotension, bradycardia, hypothemia
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T/F - sustained priapism indicates SCI in trauma.
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True
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Immediate management of SCI includes:
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increase BP
Identify injury - Scan Empty Bladder - catherization Oxygen therapy Peptic Ulcer Prevention - PPIs Prevent DVT - Anticoagulate Stabilise Spine - hard collar, spine board Pain relief nasogastric tube pressure sores prevent contracture development establish IV access |
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With Low Cervical and High Thoracic injuries problems can occur with certain muscles cause serious problems - what are these?
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Respiratory insufficiency due to paralysis of intercostal and abdominal muscles
Cough severely impaired due to paralysis of forced expiratory muscles |
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What is sprouting of nerves?
And why is it a problem? |
When a peripheral nerve is cut - the nerve it would innverate is not denervated --> this can lead the nearby cells growing to innervate these secondary neurons
Bad when a pain fibre is cut - and its secondary neurons become innervated by tactile neurons--- whenever tactile sensed - this is also now sent via PAIN secondary fibres - seen as pain |
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What arteries serve the SC?
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Paired posterior spinal arteries and single anterior spinal artery
These are fed via segmental medullary Arteries and vertebral arteries |
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T/F
The spinal level of injury corresponds to the adjacent vertebral body. |
False
The level of spinal cord injury refers to the lowest neurological intact segment with normal motor and sensory function. The spinal cord segments do not relate exactly to the vertebral bodies. In the cervical regions, there are 7 vertebrae but 8 cervical nerve roots leaving the cord. In the thoracic region, the 12 thoracic cord segments are found between the T1-T10 vertebral bodies, with the lumbar and sacral segments adjacent to the T11 and T12 vertebrae and the spinal cord usually ending at the level of the T12/L1 intervertebral disc. |
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T/F
Absence of anal and bulbo-cavernosus reflexes after spinal cord injury always indicates the presence of spinal shock. |
False
The anal and bulbo-cavernosus reflexes both depend on intact sacral reflex areas. In an upper motor neurone (suprasacral) lesion, these reflexes are usually first to return after spinal shock, however, in a lower motor neurone (infrasacral) lesion affecting either the conus medullaris or cauda equina, reflexes remain absent unless neurological recovery occurs. |
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T/F
The classical signs of intra-abdominal pathology are often absent after acute spinal cord injury. |
True
During the initial phase of spinal shock with impairment of abdominal sensation and flaccid paralysis, signs of peritoneal irritation with local or generalised rigidity and rebound tenderness do not develop. Peritoneal lavage or even laparotomy may be necessary if intra-abdominal injury is suspected. |
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Which one of the following spinal cord injuries results in loss of pain and temperature sensation on the side opposite to the muscle paralysis?
a) Anterior Cord Syndrome b) Posterior Cord Syndrome c) Central Cord Syndrome d) Hemi-section of Cord e) Cauda Equina Injury |
D is True
Often resulting from penetrating injury or asymmetrical fracture from lateral flexion causing damage to one side of the spinal cord, the Brown-Sequard Syndrome presents as motor paralysis and loss of deep touch, vibration and proprioception on the same side as the damage with loss of pain, temperature and light touch on the opposite side (due to crossing of the spino-thalamic tracts). |
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Which of the following factors is/are associated with a complete spinal cord lesion in the lower cervical region?
a) Diaphragmatic breathing. b) Long-term dependence on mechanical ventilator. c) Stuptum retention and atelectasis. d) Ventilation-perfusion mismatch. |
A,C, D are TRUE
B is False A- A complete injury in the lower cervical cord causes paralysis of all intercostal muscles and therefore reliance on diaphragmatic function for breathing. B - Pressure support or full mechanical ventilation may sometimes be necessary initially after injury, if ascending post-traumatic cord oedema or pneumonia develops. However, longer term artificial ventilation is not required when innervation to the diaphragm from C3-5 cord segments through the phrenic nerves remains intact. C- Loss of intercostal muscle function results in impairment of coughing and effective clearance of secretions which commonly leads to atelectasis. Regular chest physiotherapy with postural drainage, assisted coughing and breathing exercises are essential to prevent chest complications. D- Alterations in ventilation and perfusion after cervical and high thoracic spinal cord injury result in 1) underventilation of perfused alveoli, leading to shunting of venous blood through the lungs and 2) underperfusion of ventilated alveoli, which increases the dead space. |
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T/F
Hypotension following acute injury to the cervical or high thoracic spinal cord indicates the need for active fluid resuscitation. |
False
Hypotension resulting from spinal shock is due to interruption of supraspinal inputs to preganglionic sympathetic neurons or interruption of sympathetic outflow, whereas hypotension in surgical shock is due to significant blood loss. Thus, low blood pressure does not necessarily mean volume loss. Overinfusion in patients with uncomplicated spinal shock may cause pulmonary oedema. |
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The results of hemisection of the spinal cord at T6 include:
a) Loss of all tactile sensibility in ipsilateral lower limb. b) Loss of Proprioceptive sensibility in the contralateral lower limb. c) loss of voluntary movement in the ipsilateral lower limb. d) Loss of temperature sensibility in the ipsilateral lower limb. |
C is TRUE
Voluntary movement of the lower limb on the same side as the lesion (ipsilateral) is lost because of disruption to descending motor pathways (eg, corticospinal) to lumbosacral spinal segments. |
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T/F
In the spinal cord motor neurones located in the medial part of the ventral horn primarily innervate muscles of the distal parts of the upper and lower limb |
False
Motor neurons in medial part of ventral horn innervate axial (neck/trunk) muscles. |
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T/F
In the spinal cord pain (nociceptive) information is received in the dorsal horn by cells whose axons cross the midline and form the spinothalamic tract |
TRUE
Nociceptive information is relayed by neurons, predominantly laminae I and V of the dorsal horn, whose axons cross the midline to form the spinothalamic tract. |
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T/F
In the spinal cord the lateral cortiospinal tract extends only to L3 segment |
FALSE
The lateral corticospinal tract extends the length of the spinal cord, although it gets progressivly smaller in size. |
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T/F
In the spinal cord dorsal and ventral roots arise from cells in the dorsal and ventral horns, respectively |
False
Dorsal roots are axons of dorsal root ganglia. |
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T/F
In the spinal cord corticospinal fibres terminate exclusively on ventral horn ('lower') motor neurones |
False
Corticospinal fibres terminate directly onto ventral horn (lower) motor neurons, or onto interneurons. |
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T/F
The Cauda Equina consist of dorsal and ventral roots from lumbar, sacral and coccygeal segments of the spinal cord |
TRUE
Caudal equina is indeed formed by dorsal and ventral roots of spinal segments L2 and below. |
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T/F
The Cauda Equina if damaged results in spastic paralysis of the lower limbs |
False
Damage results in a flaccid paralysis of the lower limb, ie, a 'lower' not 'upper' motor neuron distrubance. |
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T/F
The Cauda Equina lies in the subdural space |
False
Lies in the subarachnoid space. |
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T/F
The Cauda Equina contain nerve fibres that form part of the spinothalamic tract |
False
The spinothalamic tract is found only in the spinal cord proper |
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T/F
The Spinothalamic Tract originates primarily in the contralateral substantia gelatinosa |
It originates primarily from neurons in laminae I and V, not the substantial gelatinosa (lamina II).
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T/F
The Spinothalamic tract conveys exclusively pain and temperature information from the contralateral half of the body |
False
It carries also tactile (touch, pressure) information from the contralateral half of the body. |
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T/F
The Spinothalamic Tract is somatotopically organised |
True
The tract is somatotopically organised and this provides the basis for our ability to localise the site of pain. |
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T/F
The Spinothalamic Tract converys primary afferent information from nociceptors |
FALSE
The spinothalamic tract originates from second order neurons in the spinal cord. |
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T/F
In the cervical region of the spinal cord the enlargement of the cord in lower cervical segments is formed primarily by an expansion of grey matter |
TRUE
represents cells innervating the upper limb |
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T/F
In the cervical region of the spinal cord the dorsal column is subdivided into medial (gracile) and lateral (cuneate) fasciculi |
True
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T/F
In the cervical region of the spinal cord most corticospinal fibres have yet to decussate |
False
Most crossed in the medulla (85-90%) |
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T/F
In the cervical region of the spinal cord fibres in the dorsal column are ipsilateral to their cells of origin |
True
The fibres cross in the medulla |
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T/F
The Dorsal Columns contain axons of primary afferent neurons located in dorsal root ganglia |
True
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T/F
The Dorsal Columns carry proprioceptive information from the contralateral side of the body |
False
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T/F
The Dorsal Columns consist of the gracile and cuneate tracts |
True
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T/F
The Dorsal Columns carry information relevant to the conscious appreciation of touch, pressure and vibration sensibility from the ipsilateral side of the body. |
True
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T/F
Clinical features of LMN paralysis include: a) absent deep tendon reflexes b) increased muscle tone c) severe muscle wasting d) hyper-reflexive bladder |
A,C - TRUE
B,D - FALSE a) absent deep tendon reflexes b) increased muscle tone c) severe muscle wasting d) hyper-reflexive bladder |
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T/F
Thoracic levels of the spinal cord contain preganglionic autonomic neurons |
True
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