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109 Cards in this Set
- Front
- Back
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Differentiate infranuclear, nuclear, and supranuclear lesions of cranial nerves.
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Affecting the peripheral portion, the nucleus, or the connection between the central portion of the brain and the nucleus.
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Name the 12 cranial nerves
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1) Olfactory; 2) Optic; 3) Oculomotor; 4) Trochlear; 5) Trigeminal; 6) Abducens; 7) Facial; 8) Vestibulocochlear; 9) Glossopharyngeal; 10) Vagus; 11) Accessory; 12) Hypoglossal
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What are the three branches of the trigeminal nerve?
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CN V1: Ophthalmic; CN V2: Maxillary; CN V3: Mandibular
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What is the rhinencephelon? What are it's three parts? Their importance and conncections?
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The area of the brain that the rhinencephalon projects to. Made of the lateral, intermediate, and medial parts. The lateral conveys the sense impression of smell the most, the intermediate less so, and the medial connects with the limbic system to modulate emotional response to smell. The medial forebrain bundle carries info from all three areas to the hypothalamus. The stria terminalis carries info from the amygdala to the preoptic cortex. The stria medullaris from the bundles to the habenular nucleus, which interfaces with the cranial nerves to create visceral responses to pain.
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What is Refsum Disease
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a diffuse neurological disease presenting with cerebral and cerebellar damage, and peripheral neuropathy. Caused by the inherited inability to digest phytanic acid (a long chain branched fatty acid), a normal product of ruminant animals and fish. A peroxisomal disorder. Presents with ataxia, ichthyosis, night blindness, cataracts.
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List the major structures of the eye that light needs to pass through to get to the retina.
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Cornea, aqueous humor, lens (mediated by ciliary muscles), vitreous humor, retina
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What happens when the bipolar cells of the retina become depolarized? Hyperpolarized?
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Stimulated, inhibited
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What cells to the bipolar cells connect to? Where do these cells go? How does the optic chiasm decussate?
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The ganglion cells (secondary neurons of the visual pathway). The ganglion axons converge at the optic disc, form the optic nerve, traverse the optic canal to the middle cranial fossa, partially decussate at the optic chiasm, with the lateral axons staying laterally and the medial axons crossing, so all signals from the left hemifield stay right and all from the right hemifield left.
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From the chiasm, where do the optic fibers go?
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Most synaps with the tertiary fibers of the lateral geniculate nucleus of the thalamus, which, in turn, go to the occipital lobe via the optic radiations. A small portion goes to the pretectal area of the midbrain to mediate the pupillary light reflex.
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What is the name of the group of cells in the center of the retina? Where do these fibers go?
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The fovea. To the tip of the occipital pole.
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Name three neoplasms that most commonly directly affect the optic tract
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optic gliomas, melanoma, pituitary adenoma
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What percentage of men are colorblind? Women?
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3-4%, 0.3%
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What is homonymous hemianopia frequently associated with? Bitemporal hemianopia?
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Occipital lobe neoplasm, pituitary adenoma.
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In degrees, what is a normal visual field? What test is used to check this?
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90 laterally, about 60 medially, superiorly, and inferiorly.
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What is papilledema pathognomonic for? What other disease may make the optic disc look like it has papilledema?
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Increased intracranial pressure. Multiple sclerosis.
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If the retinal arteries have a "silver lining" appearance, what is this indicative of? A "cotton wool" appearance?
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Atherosclerosis. Hypertension.
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What is "Best Disease?"
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Vitelliform macular dystrophy. Genetic. AD. Lipofuscion builds up in the macula.
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Name common diseases resulting in visual impairment.
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HIV associated, such as CMV. Gonococcal, parasitic like onchocerciasis, trachoma (Chlamydia trachomatis aka granular conjunctivitis), spirochetes including syphilis, a variety of viral, leprosy.
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Name the five muscles of the eye that are innervated by the somatic efferents of the oculomotor nerve.
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Inferior rectus, inferior oblique (ipsilateral), superior rectus, medial rectus, levator palpabrae.
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Describe the course of the oculomotor nerve, starting at the oculomotor nucleus and ending at each muscle.
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Pass through the tegmentum of the midbrain, through the red nuclei and medial cerebral peduncle to teh interpeduncular fossa at the junction of the midbrain and pons. Pass between the posterior cerebral artery and the superior cerebellar artery. Penetrates the dura mater and enters the cavernous sinus. Runs along the lateral wall of the cavernous sinus superior to CN IV. Enters the superior orbital fissure. Passes through the tendinous ring of the extraocular muscles and divides into the superior and inferior divisions. Superior division travels lateral to the optic nerve and innervates the superior rectus and the levator palpabrae. Inferior division innervates the medial rectus, inferior rectus, and inferior oblique.
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Describe the course of the visceral efferents and their role
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Start at the Edinger-Westphal nucleus and run with the optic nerve. Carries parasympathetic fibers. Pregangionic fibers travel with the inferior branch of the oculomotor nerve and synapse with the ciliary ganglion by the tendinous ring of the extraocular muscles. Short ciliary nerves then enter the globe by the optic nerve, travel between the choroid and sclera and innervate the ciliary muscles, which changes the shape of the lens and the constrictor muscles of the iris, constricting the aperture of the iris (the pupil).
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What is the Argyll Robertson pupil?
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Loss of the consensual light reflex and/or accomodation from Syphilis.
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What is the main action of the superior oblique muscle? What is the best way to test the integrity of this muscle? What is the most common presentation?
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Intorsion. Have the patient look medially and downward. When the eye is deviated medially, the superior oblique's main role is depression. Inability to look inward and downward, often presenting with difficulty walking down stairs. The patient will typically tilt the head forward and rotate the chin toward the affected side.
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Describe the course of the trochlear nerve, starting at the nucleus
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The nerves go dorsally, in the tegmentum of the midbrain at the level of the inferior colliculus, wraps around the cerebral aqueduct and decussates in the superior medullary velum. Exits below the inferior colliculus, leave the subarachnoid space with the oculomotor nerve between the superior cerebellar and posterior cerebral arteries. Enters the cavernous sinus, travels with CN III to the superior orbital fissure, passes superiorly to the tendinous ring of the extraocular muscles to innervate the superior oblique on the medial aspect.
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What motor functions does the trigeminal nerve give?
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the muscles of mastication
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What is the largest of the cranial nerve nuclei? What are its divisions? What do they do?
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The trigeminal nuclei, which include the mesencephalic trigeminal nucleus (responsible for proprioception and mechanoreception from the mandible and teeth; the main trigeminal nucleus, which gets most of the touch and position input; spinal trigeminal nucleus, which receives pain and temperature.
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What is the route of the branches of the trigeminal nerve, starting at the pons, and going to the major branches of V1, V2, and V3?
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Starts at the mid pons and pass through the border of the petrous bone. Enter Meckel's cave (formed by an invagination of the surrounding dura mater in the middle cranial fossa). Forms the gasserian ganglion. Gives rise to the three branches. The ophthalmic division exits through the superior orbital fissure. The maxillary division exits the foramen rotundum into the pterygopalatine fossa then into the infraorbital canal to the intraorbital foramen. The mandibular division via the foramen ovale.
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What nerves do V1 give rise to?
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The frontal nerve, the supratrochlear nerve, and the supraorbital nerve.
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What nerves do V2 give rise to?
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The infraorbital nerve
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What nerves do V3 give rise to?
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The lingual nerve, the inferior alveolar nerve, and the mental nerve.
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What is a synonym for trigeminal neuralgia?
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tic dououreux.
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What is the most common cause of trigeminal neuralgia? What are five other common etiologies?
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Tortuous blood vessels present as the trigeminal nerve exits the brainstem. Acoustic neuromas, cholesteatomas, bony abnormalities, aneurysms, angiomas.
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About 2-3% of patients who have trigeminal neuralgia also have what systemic (autoimmune) disease?
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Multiple sclerosis.
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The Abducens Nerve innervates the lateral rectus muscle of which orbit (ipsi/contra)?
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ipsilateral
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What colliculus is the abducens nucleus at level with?
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The facial colliculus
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Describe the course of the abducens nerve from the nucleus.
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Exits at the junction of the pons and medullary pyramids. Travels along the ventral pons along the petrous bone. Turns to go into the cavernous sinus. Travels through the superior orbital fissue, through the tendinous ring of the extraocular muscles, and to the lateral rectus.
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What is the most common cause of isolated abducens nerve palsy?
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microvascular disease associated with diabetes.
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What are the four types of nerves associated with the facial nerve? What is the largest type of nerve?
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Branchial motor, visceral sensory, general sensory, special sensory. The branchial motor nerve.
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What does the branchial motor branch of the facial motor do?
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Provides voluntary control of the muscles of facial expression: buccinator, occipitalis, platysma, posterior belly of the digastric, the stylohyoid, and stapedius muscles.
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What does the visceral motor component of the facial nerve do?
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Provides parasympathetic efferent fibers to the mucous membranes of the nasopharynx, hard and soft palate, and the lacrimal, submandibular, and sublingual glands.
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What does the special sensory component of the facial nerve do?
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Provides sensory input of taste from the anterior two thirds of the tongue and the hard and soft palate.
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What does the general sensory component of the facial nerve do?
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Provides sensation of the skin of the concha and auricle and just behind the ear.
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What is believed to be the most common reason for Bell's palsy?
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inflammation of the facial nerve because of a virus. Thought to be most commonly the herpes simplex virus.
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How do you empirically treat Bell's Palsy? What is the time course for improvement?
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Eye lubricant and patch to protect the eye, as eye closure may be difficult. Acyclovir. Steroid taper. Most patients start to get better at 2-3 weeks and complete recovery by 3-6 months.
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After the branchial motor, special, and general sensory branches of the facial nerve exit the internal acoustic meatus, what other foramen to they need to pass through?
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The stylomastoid foramen.
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What is the foramen that make up the opening and closure of the facial canal? What bone do they run through?
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The internal acoustic meatus and the stylomastoid foramen. They run through the temporal bone.
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Describe in broad terms the course of the cochlear nerve, starting at the cochlear nucleus, to the auditory cortex.
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auditory nerve fibers synapse at the ipsilateral cochlear nucleus. This gives branches to the contralateral superior olivary nucleus. Fibers then go rostrally to the inferior colliculus. This then sends fibers to the opposite inferior colliculus (which is ipsilateral to the side of signal origin). Each inferior colliculus then sends signals to the medial geniculate nucleus on that side. From the MGN, fibers are then sent to the primary auditory cortex in the temporal lobe.
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What are the five fiber types making up the glossopharyngeal nerve and what are their function?
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1) The branchial motor efferent. Goes to the stylopharyngeus, which elevates the pharynx during swallowing and speech. 2) The visceral motor efferent. Parasympathetic innervation of the smooth muscle of the glands of the pharynx and larynx. 3) Visceral sensory afferent: baroreceptor information from the carotid sinus and chemoreceptors from the carotid body. 4) Somatic sensory afferent: cutaneous sensation from the posterior 1/3 of the tongue, the tympanic membrane, the upper pharynx. 5) Special sensory afferent: taste from the posterior 1/3 of the tongue.
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Where does the branchial motor branch originate in the medulla and exit the skull?
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The olivary nucleus. The jugular foramen.
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Describe the course of the cranial aspect of the spinal accessory nerve and what they do.
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They start from the caudal nucleus ambiguus, come out of the medulla between the olive and the inferior cerebellar peduncle. Join up with the spinal fibers briefly, enter the jugular foramen, split from the spinal fibers, exit the foramen, travel with the vagus nerve and help provide motor innervation to the larynx and pharynx.
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Describe the course of the spinal aspect of the spinal accessory nerve and its function.
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Exits laterally from the ventral grey of the first five or six segments of the cerivcal cord between then ventral and dorsal rami. Travels superiorly through the foramen magnum, exits out the jugular foramen, hits the deep aspect of the SCM, then goes posteriorly (in the posterior triangle of the neck) to innervate the trapezius.
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With hypoglossal neve palsy, what side does the tongue deviate to?
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The affected side.
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Where is the sphenopalatine ganglion located?
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In teh pterygopalatine fossa, posterior to the middle nasal turbinate.
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What are the major efferent pathways from the pterygopalatine ganglion?
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the gasserian ganglion, trigeminal nerves, carotid plexus, facial nerve, superior cervical ganglion.
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What are the three ways to to a pterygopalatine ganglion blockade?
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Topical local anesthetic from the transnasal approach, injection via the lateral approach, injection through the greater palatine foramen.
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What two nerves are implicated in occipital neuralgia?
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The greater and lesser occipital nerves?
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What is the distribution of sensation of the greater occipital nerve?
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the posterior medial occiput to the vertex
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What is the distribution of the lesser occipital nerve?
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the lateral posterior scalp to the cranial portion of the pinna.
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What is the course of the greater occipital nerve?
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From the dorsal rami of the second and third cervical nerves, superiorly through the facia just at the superior nuchal ridge, then to the vertex of the head.
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What other major structure runs with the greater occipital nerve in the scalp?
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the occipital artery.
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What is the course of the lesser occipital nerve?
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The ventral primary rami of the second and third cranial nerves, along the posterior aspect of the sternocleidomastoid, to the lateral portion of the scalp and the cranial part of the pinna of the ear.
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What is the most used joint in the body?
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The temporomandibular joint
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What are the two movements of the TMJ?
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A gliding and sliding movement.
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What are the two parts that make the articulation of the TMJ?
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The condyle of the mandible and the squamous portion of the temporal bone.
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What are the two movements that need to occur at the TMJ to open the moutn? Describe this in relation to the mandibular condyle and the meniscus.
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Rotation and translation. First is translation of the condyle from the posterior portion of the meniscus to the intermediate portion, on which it rotates. When the mouth is fully opened, it may lay on the anterior portion of the meniscus.
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What are the three muscles that receive innervation from the ansa cervicalis? Where does the ansa cervicalis run?
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sternohyoid, sternothyroid, omohyoid muscles. Superficial to the internal jubular vein in the carotid sheath.
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What innervates the thyrohyoid muscle?
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C1.
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What cervical nerves give innervation to the supraclavicular nerves?
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C3 and C4.
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What is the stellate ganglion formed by and where is it?
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A fusion of the ganglia from the first thoracic and the inferior cervical ganglia. Anterior to the vertebral body at C7.
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What lies anterior to the stellate ganglion?
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Skin, subcutaneous tissue, SCM, carotid sheath.
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What lies medial to the stellate ganglion?
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prevertebral fascia, vertebral body of C7, esophagus, thoracic duct.
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What lies posteriorly to the stellate ganglion?
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the longus colli, anterior scalene, neck of the first rib, brachial plexus, vertebral artery.
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In the cervical spine, where is the central canal the widest? The narrowest?
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The atlanto-axial space, C5/6.
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What shape is the cervical central canal typically? What variant predisposes one to increased pathology?
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Triangular. Trifoil.
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What innervates the pseudo-joint of Luschka and the intervertebral disk in the cervical cord/
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The first branch of the ventral portion of the combined spinal nerve.
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What kind of material is the nucleus pulposus made of?
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Water and mucopolysaccharides. More accurately, it has chondrocyte-like cells, colalgen fibrils, proteoglycan aggrecans that form hyaluronic chains with GAG chains of chondroitin sulfate adn keratan sulfate. It is negatively charged and hydrophilic (thus drawing in water).
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What layers are the dura mater made of? Name a clinical manifestion of what happens when these are separated.
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Two. An outer periosteal layer and an inner meningeal layer. They are usually fused but can separate with large venous channels in between (venous sinuses).
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What is the Virchow-robin space/
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Where the blood vessels pass through the pia mater to give blood supply to the brain and spinal cord.
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What are the most cranial and most caudal boundaries of the spinal epidural space?
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At the craniocervical junction, the fusion of the periosteal and spinal layers at the foramen magnum. At the sacrococcygeal area, the sacrococcygeal membrane.
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Where in the spine is the distance between teh ligamentum flavum and the dura the greatest? How much is this space?
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The L2 innerspace. 5-6 mm in the adult.
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What is the depth of the epidural space at C7 with the neck in neutral? In flexion?
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1.5-2 mm in neutral. 3-4 in flexion.
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Where are the epidural veins located in relation to the spine? What's the deal with their veins? What does this mean in regards to intrathoracic and abdominal pressures?
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Anterolaterally to the spine. They don't have valves. They thus directly transmit pressure from the thorax and abdomen, with increasing pressure (and thus less epidural space) with things like a gravid uterus or large tumor in this area.
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Where are the two places where the cervical epidural arteries come from?
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From the neuroforamina and from anastamoses from the cranial portion of the vertebral arteries.
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Where are the lymphatics of the cervical epidural space?
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At the dural roots.
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What kind of fibers primarily make up the ligamentum flavum?
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Elastin
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What type of joints are the cervical facet joints?
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Diarthroidal.
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What innervates the facets of the occipito-atlantal joint and the atlantoaxial joint?
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The ventral rami of the first and second cervical spinal nerves.
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What innervates the C2/3 facet joint?
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Two branches of the dorsal ramus of the third cervical spinal nerve.
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What innervates cervical facets C3/4 to C7/T1?
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The dorsal rami of the medial branches from one level cephalad adn one caudad to the joint.
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Describe the origin, insertion, and function of the cervical alar ligaments.
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Originate at the tip of the dens. Insert into the atlas and the medial occipital condyles. Limit rotation, flexion, and extension.
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Where does the anterior atlanto-occipital ligament start and what does it then become?
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Starts at the anterior margin of the foramen magnum to the anterior arch of hte atlas, then becomes teh anterior longitudinal ligament.
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Where does the posterior longitudinal ligament start and where does it go?
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Starts at the tectorial membrane and then runs down the posterior aspect of the vertebral body.
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Where does the ligamentum nuchae originate and insert?
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The occipital protuberance and the spinous process of the seventh cervical vertebra. Continues as the supraspinous ligament.
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Distinguish rib articulations of the different thoracic levels.
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From T1-10, there are two pairs of facets on the articular bodies (superior and inferior) and one on the transverse process. Ribs articulate with the inferior demifacet on the vertebral body (and the superior demifacet from the vertebral body inferiorly) and the facet on the transverse process. On T11 and T12, there is no inferior facet, so ribs only articulate on the superior facet and facet on the transverse process.
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Name the three most common anatomic landmarks for delineating thoracic dermatomes
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Nipples: T4; umbilicus: T10; Iliac crest: T12
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What type of cartilage is are the vertebral endplates made of?
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Hyaline
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What law of physics explains the distribution of pressure of the mucopolysaccharide fluid in an intervertebral disc?
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Pascal's
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Describe the MRI appearance of the annulus fibrosus as it starts to degenerate
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The interwoven fibroelastic fibers start to break down and cause richly innervated granulation tissue to grow within them instead.
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What do annular tears look like on T2 imaging?
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high (white) signal intensity.
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At what level does the dural sac terminate?
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S1 to S3
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What two nerves exit the sacral hiatus?
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S5 and coccyx 1
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Where is the sacral venous plexus located?
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The anterior aspect of the sacral vertebral canal, typically ending around S4.
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What portion of the pec major does the lateral pectoral nerve innervate? The medial?
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The clavicular head. The sternocostal head.
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What two muscles of the upper extremities does the brachial plexus not innervate?
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levator scapulae (this is not entirely correct as it gets innervation from the dorsal scapular nerve (C5) in addition to C3 and C4). Note, the dorsal scapular nerve also innervates the rhomboids. Trapezius, which gets its innervation from CN XI (accessory), C3, and C4.
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How is the brachial plexus structurally divided?
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Roots, trunks, divisions, cords, terminal branches
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Describe the three trunks of the brachial plexus
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Ventral rami (and gray rami communicates) of C5 and C6 = upper/superior trunk. C7 = middle trunk. C8 and T1 = lower/inferior trunk
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Describe the divisions of the brachial plexus and what broad groups of muscles these innervate
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All roots give an anterior and posterior division. The anterior division innervates the flexor musculature and the posterior division the extensor musculature. The anterior division of the middle trunk goes anteriorly to the posterior division of the upper trunk.
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Describe the three cords and their constituent divisions. The cords are named in relation to what anatomic landmark?
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The lateral cord is composed of the anterior divisions of the upper and middle trunks. The posterior cord is composed of the posterior divisions of the upper, middle, and lower trunks. The medial cord is composed of the anterior divisions of the lower trunk. They are named in relation to the axillary artery.
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What provides innervation to the serratus anterior muscle?
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The long thoracic nerve.
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