Chapter 5 - Neurology
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Pt presents s/p dropping a sheet of metal on foot. There is no laceration. Pt complains of numbness to his lateral foot. Pt would like to know why he is feeling numbness and what it was caused by. Is this a neuropraxia, axonotmesis, or neurotmesis?
He is feeling numbness most likely from neuropraxia which is a bruised nerve. It results in numbness that is reversable.
- According to Seddon classification:
- Neurapraxia: bruised nerve, reversible
- Axonotmesis: Injury to axon that results in Wallerian degeneration. Will regenerate over several months as long as gap is not too big.
- Neurotmesis: Complete severance of the nerve resulting in irreversible numbness.
Your attending is discussing nerve blocks and turns to you and says "tell me what a bier block is?"
Intravenous regional anesthesia. Place tourniquet at calfYou inject local in vein and the anesthetic diffuses out into the surrounding nerves.
Patient is experiencing neuropathic pain medial foot, pt has history of back issues. What nerve root might be compressed? What if the pain was dorsal foot? How about lateral foot? Back of heel?
- Medial: L4
- Dorsal: L5
- Lateral: S1
- Heel: L5/S2
Pt presents with intrinsic minus foot type, which nerves may be contributing to this diabetic motor neuropathy?
Intrinsic minus foot type is typically the first stage of foot deformity to see in diabetics. It is a motor neuropathy of the intrinsic muscles of the foot that cause hammer toe deformity. The later plantar nerve supplies lumbricals 2-4, Medial plantar nerve supplies 1st lumbrical, deep br of lateral plantar nerve supplies most interosseus.
Pt is experiencing random pins and needles feeling in feet. Symptoms are exasterbated by activity such as prolonged weight bearing, walking, or running. As you force eversion of the foot it also produces symptoms. You want to perform tinels sign but the preceptor says, "tell me two other tests you can perform to help dx tarsal tunnel syndrome besides tinels?"
Turks test: Place tourniquet around calf at a pressure between systolic and diastolic. If symptoms are reproducible, varicosities may be the contributing factor to the TTS.
Valleix's sign: This describes what I thought was tinels sign. Using percussion hammer hit the area of possible entraptment, if it produces symptoms than it is positive.
Laseques sign (straight leg test): R/O sciatica
As you perform a basic podiatric foot exam on a 40 yr old man you notice increased DTR's. Pt has muscle spasticity. Also the pt speech has become more slurred. The patients mental status is preserved. What neurological disorder might the patient have? What is this patients prognosis?
ALS. Devastating progressive degenerative disease of UMNs and LMNs. Unknown cause. Usually occurs when patients are in their 40s. Usually fatal within 2-5 years of onset. Mental status is usually preserved
A 15 year old male who is very active has been experiencing weakness in b/l legs starting 1 week ago. Pt has decreased DTRs. What disease might the patient have?
- Guillian-Barre Syndrome
- It is thought that it is autoimmune, there is often a precipitating factor such as a viral infection, vaccination, or recent surgery.This disease will spontaneous recover 1-3 weeks post onset and complete recovery usually takes place withing 3-6 months.
8 year old presents with decreased eversion againts resistance and a cavus foot type and slapping gait. What might your initial diagnosis be?
- Charcot-Marie-Tooth disease: This presents with weakness in peroneal muscles
- Pes cavus
- "Stork leg"-skinny legs due to peroneal atrophy
- Foot drop
- Unsteady gait/tending to trip easily
- Stocking-glov sensory loss
- decreased ankle DTRs
Tell me the classic presentation of RSD
there are 3 stages of RSD
Acute: Constant burning pain, allodynia, hyperalgesia, hyperesthesia, hyperpathia. Localized edema. Initially the skin is warm, red, and dry but near the end of this stage it becomes cyanotic, cold, and sweaty. Days to weeks
- Dystrophic: 3-6 months. Continuous burning, aching pain, allodynia, hyperalgesia, hyperpathia.
- -Indurated edema
- -Skin takes on a cool, pale, discolored, and frequently mottled or cyanotic appearance.
- -dystrophic changes occur, hair growth is decreased and nails are brittle, cracked, and ridged. XRAYS may show spotty/diffuse osteopenia (sudeck's atrophy)
- -Greater than 6 months
- -Pain, allodynia, and hyperpathia extend proximally to involve the entire extremity, however the pain may beome less severe.
- -More advanced atrophic skin, nail, and soft tissue changes
- -skin becomes tightly stretched, smooth, pale, waxy, and cyanotic
- -marked muscle atrophy, particularly the interossei
Please review pages 128 - 154 of pocket podiatrics for detailed neuropathies.
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