[LEC] Lec 5.1 - Neuroana 1.docx

Glasgow Coma Scale

A neurological scale used to assess the level of consciousness and severity of brain injury, based on eye opening, verbal response, and motor response.

Rancho Los Amigos

A scale used to assess the level of cognitive and behavioral functioning in individuals with brain injuries, ranging from a state of coma (Level 1) to a state of independence (Level 10).

Basal ganglia

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Not part of the brain


1. Cerebrum
2. Cerebellum
3. Brainstem
4. Basal ganglia

C4

What level of SCI can use a universal cuff?


1. C4 - shoulder shrug
2. C5 – elbow flexion
3. C6
4. C7 – elbow extension

C4

Above what SCI level would need artificial ventilation

C5

C3

C4

C8

LML & hypotonia

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Peripheral nervous system

UML OR LML

Hypertonia or hypotonia

UML & hypertonia

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Central nervous system

UML OR LML

Hypertonia or hypotonia

Visceral organs

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W/c of the ff is not part of the PNS?

Ganglia

Spinal nerves

Plexuses

Visceral organs

Cranial Nerves

Dorsal root ganglion - 1st order neuron

False

Modified true or false:

The ganglia has the ventral root ganglion

31 pairs

* Cervical: 8 pairs (horizontal)
* Thoracic: 12 pairs
* Lumbar: 5 pairs
* Sacral: 5 pairs
* Coccygeal: 1 pair (horsetail)

How many pairs of spinal nerves? Give its components

..

* **12 pairs of Cranial nerves**
* **Plexuses and their largest nerves**
* __**Cervical**__**: Phrenic N. (C3 C4 C5 – diaphragm)**
* __***Brachial**__**: Radial / Musculospiral N. (C5 – T1)**
* **located posteriorly**
* __**Lumbar**__**: Femoral / Ant. Crural N. (L2 L3 L4)**
* __**Sacral**__**: Sciatic N. (L4 L5 S1 S2 S3)**

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* **Plexuses and their largest nerves**
* **Cervical: _____**
* **_____: Radial / Musculospiral N. (C5 – T1)**
* **located posteriorly**
* **Lumbar: _____(L2 L3 L4)**
* **________: Sciatic N. (L4 L5 S1 S2 S3)**

.

* **Autonomic Nervous System**
* **Visceral organs: involuntary**
* **Subdivided into Parasympathetic and Sympathetic**
* **Splanchnic: inside the cavity only**

* **____ Nervous System**


* **___** __**organs:**__ **_______**
* **Subdivided into ____** __**and**__ **______**
* **_____: inside the cavity only**

.

* **Somatic Nervous System**
* **voluntary**
* **Skeletal muscles: voluntary, striated, efferent**
* **skin: afferent**
* **joints**

* **____Nervous System**
* **_____**
* **___** __**muscles: voluntary, striated,**__ **___**
* **skin: ____**
* **joints**

* __Ganglion__: Outside the CNS
* __Nucleus__: Inside the CNS
* Basal ganglia → Basal nuclei
* __Sympathomimetic medicine__: mimics action
* Epinephrine 
* __Sympatholytic medicine__: opposite action
* Beta blockers

* __Ganglion__: _____ the CNS
* __Nucleus__: ____ the CNS
* Basal ganglia → Basal nuclei
* _________ medicine__: mimics action
* _____ 
* _________ medicine__: opposite action
* _______

.

* **Regulated by hypothalamus**
* **Maintains homeostasis (balance)**
* 2 neuron hook-up

__Sympathetic__: diffused, mass discharge

* **Regulated by ____**
* **Maintains _____ (balance)**
* ____neuron__ ____

__________: diffused, mass discharge

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* Salivary glands
* __Parotid__: CN 9
* Parotiditis / Mumps (Beke): viral thru droplets
* __Sublingual__: CN 7
* __Submandibular__: CN 7

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Q1: Px has excessive drooling. What CN is damaged?

A: CN 9 (Cannot swallow saliva)

* If CN 7: no saliva

* Salivary glands
* __Parotid__: ___
* Parotiditis / Mumps (Beke): viral thru droplets
* __Sublingual__: CN ___
* __Submandibular__: CN __

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Q1: Px has excessive drooling. What CN is damaged?

A: CN __ (Cannot swallow saliva)

* If CN ___: no saliva

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1. All autonomic preganglionic are **cholinergic**.
2. All parasympathetic postganglionic are **cholinergic**.
3. Almost all sympathetic postganglionic are **adrenergic**

* Except for __sweat glands & piloerector muscles__ 🡪 **cholinergic**

1. All autonomic preganglionic are **_____**.
2. All _____ postganglionic are **cholinergic**.
3. Almost all sympathetic postganglionic are **_____**

* Except for _______&______ muscles__ 🡪 **cholinergic**

Parasympathetic

Para or sympa:

↓ HR

\n

Sympathetic

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* ↑ HR
* ↑ CO
* ↑ SV
* ↑ Force

Para or sympa

Sympathetic

* Con**s**tipation
* ↓Peristalsis

Parasympathetic

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* ↑ Motility
* ↑ Digestion
* ↑ Gastric Juice Secretion
* ↑ Pancreatic Ax 
* ↑ Salivation
* ↑ Defecation 
* ↑Peristalsis

(CN7&9)

Sympathetic

\
* ↑ Peripheral Vasoconstriction \[BV away fr ♥\]
* ↑ Coronary Artery Dilation

Parasympathetic

Bronchospasm

\

Sympathetic

Bronchodilation

Salbutamol

Parasympathetic

Bronchospasm

Sympathetic

Mydriasis

Parasympathetic

Mitosis

Sympathetic

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* ↓ Urinary Output (UB Relaxation + Sphincter Constriction)

Parasypathetic

\
* ↑ Urinary Output (UB Contraction + Sphincter Relaxation)
* Detrusor ms

Sympathetic

\
* P**s**ychogenic Erection L1, L2, L3
* Ejaculation

Parasympathetic

\
* Reflexogenic Erection S2, S4

Dysparema

Dry vagina / lack of lubrication

Vaginismus

Vaginal spasm or lock

Priapism

Painful ejection of penis

Caudal Aquino

Horsetail

Psychogenic (+) erection

(-) reflexogenic ejection

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CLINICAL CORRELATION:

* Horner’s Syndrome: may result from sympathetic damage
* Ptosis: drooping of eyelids (partial)
* Muller’s ms (20%)
* levator palpebrae superioris (CN3) 80%
* Miosis: pupils constricted
* Does not belong: Pupils Dilated: T1
* Anhydrosis: no sweating 
* Enophthalmos: sunken eyes
* Does not belong: Exophthalmos: bulge eyes

CLINICAL CORRELATION:

* _____ Syndrome: may result from sympathetic damage
* ____: drooping of eyelids (partial)
* Muller’s ms (20%)
* levator palpebrae superioris (CN3) 80%
* ____: pupils constricted
* Does not belong: Pupils Dilated: T1
* _____: no sweating 
* _____: sunken eyes
* Does not belong: _____: bulge eyes

Termination of spinal cord: L1 L2 Vertebral levels

Termination of spinal cord: ______Vertebral levels

* Best site for lumbar puncture: L4-L5
* Common for meningitis
* Fetal position in sidelying

* Best site for lumbar puncture: ____
* Common for _____
* ____ position in sidelying

* Tip on Spinal cord
* Adult: end at lower border of L1
* Children: end at L3
* L2 vertebral fracture: No SCI (+) PNI → good prognosis

* Tip of Spinal cord
* Adult: end at lower border of ___
* Children: end at __
* ___ vertebral fracture: No SCI (+) PNI → good prognosis

**Components of Spinal Nerves**

* **Grey matter** 
* **White Matter** 
* **Dorsal Root** - sensory; dermatome 
* **Ventral Root** - myotome 
* **Spinal Nerve** 
* **Gray Ramus** 
* **White Ramus** 
* **Dorsal Ramus** - supplies dorsal aspect of trunk, skin, & ms
* **Ventral Ramus** - supplies anterior trunk, skin, & ms 
* **Dorsal Root Ganglion** - round cells with 1 process leaving the body

**Components of Spinal Nerves**

* **Grey matter** 
* **White Matter** 
* **___ Root** - sensory; dermatome 
* **_____ Root** - myotome 
* **Spinal Nerve** 
* **Gray Ramus** 
* **White Ramus** 
* **____ Ramus** - supplies dorsal aspect of trunk, skin, & ms
* **_____ Ramus** - supplies anterior trunk, skin, & ms 
* **____ Root Ganglion** - round cells with 1 process leaving the body

Brachial plexus supplies?

* Ans: **Ventral Rami** 

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__Bell Magendie Law__

* Dorsal root of the spinal cord is sensory in function while the ventral root is motor functions

Brachial plexus supplies?

* Ans: **____**

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_______________

* Dorsal root of the spinal cord is sensory in function while the ventral root is motor functions

Detmatomes

* **A strip of skin supplied by a single root** 
* Dorsal root

. **28 Key Sensory Areas** 

* No C1 Dermatome
* No coccygeal
* S4-S5 Combined (one level)

Dermatomes

___**Key Sensory Areas** 

* No ___ Dermatome
* No ____
* ____ Combined (one level)

SCI px, Upon evaluation, it was noted that there is a partial sensation below xiphoid process 1 inch above umbilical partial sensation 

* Ans: T6

The skin just above the patella: L3

L5 derma


1. big toe (L5 myotome)
2. 3rd MTP

SCI px, Upon evaluation, it was noted that there is a partial sensation below xiphoid process 1 inch above umbilical partial sensation 

* Ans: _____

The skin just above the patella: ____

L5 derma


1. ____ (L5 myotome)
2. ____ MTP

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\

Dermatomes

Dermatomes

Dermatomes

Dormatomes

**MYOTOMES**

* **A ms of group of ms supplied by a single root** 
* Ventral root 
* ASIA = 10 myotomes
* start with C5 
* most common level of SCI (admitted)
* most common Quadri (incomplete) 
* Paraplegia - T1
* Above T1 - quadriplegia 

**_______**

* **A ms of group of ms supplied by a ____ root** 
* _____ root 
* ASIA = ___ myotomes
* start with ____
* most common level of SCI (____)
* most common _____ (incomplete) 
* Paraplegia - __
* Above T1 - ______

Upper Ex Myotomes: C5

* Elbow flexion
* Biceps brachialis
* Shoulder Abduction
* Deltoid
* Rhomboids 
* Dorsal Scapular nerve
* Levator Scapulae

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__*External Rotators of shoulder:*__

* Supraspinatus
* Infraspinatus
* Teres Minor

C5

* Elbow flexion
* _____
* Shoulder Abduction
* _____
* R________
* D_______ nerve
* L_________

\
__*External Rotators of shoulder:*__

* _________
* _________
* _________

Upper Ex Myotomes: C6

* Primary wrist extensors 
* ECRL/ECRB
* Brachoiradialis
* Pronator Teres
* Serratus Anterior 
* long thoracic nerve (c5, c6, c7)
* best 3 nerves get the middle 

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__*Additional Notes:*__

* TenodiSIX
* allow tightness in FDS & FDP
* To promote/presence the tenodesis, what combination should be AVOIDED (wrist ext & finger ext)

Upper Ex Myotomes: C6

* Primary wrist extensors
* ___ (2)
* B______
* P__________
* S______
* L____ nerve (c5, c6, c7)

\
__*Additional Notes:*__

* TenodiSIX
* allow tightness in ______ (2)
* To promote/presence the tenodesis, what combination should be AVOIDED (_____ )

Upper Ex Myotomes: C7

* Elbow extensors (triceps)
* Wrist Flexors (FCR/FCU)
* Finger Extensors (EDC/ERC)
* Scapular mobilizer: Latissimus Dorsi
* Thoracodorsal Nerve
* Prop-up: no need for sliding board

* Elbow extensors (T____)
* Wrist Flexors (F___) (2)
* Finger Extensors (E_____) (2)
* Scapular mobilizer: L_______
* T_____ Nerve

\

Upper Ex Myotomes: C8

* Finger flexors
* FDS/FDP
* standard handrim/wheelie wheelchair
* FPL
* thumb flexors
* Adductor Pollicis (thumb adduction)
* C8 primary root
* FCU/ECU
* ulnar deviators

* Finger flexors
* F______ (2)
* standard handrim/wheelie wheelchair
* F______
* thumb flexors
* A_______ (thumb adduction)
* C_ primary root
* F_______ (2)
* ulnar deviators

Upper Ex Myotomes: T1

* Finger abductors
* Abd. Digiti Minimi
* Interossei
* PAD - Palmar Interossei Add
* DAB - Dorsal Interossei Abd

* Finger abductors
* A_____
* Interossei
* ____
* ____

**Cervical Myotomes**

C1/C2

Neck flexion

C3

Neck lateral flexion

C4

Shoulder elevation/shrug

* Traps
* diaphragm

**Cervical Myotomes**

C1/C2

Neck _______

C3

Neck _______

C4

Shoulder elevation/shrug

* _____
* _____

LE MYOTOMES

L2

* Hip Flexion 
* Iliopsoas (L2,L3,L4)
* Hip adduction

L3

* Knee extension (QUADS)
* critical level for community/outdoor mobility

L4

* Ankle DorsiFlexion (Tibialis Anterior)

LE MYOTOMES:

L2

* Hip Flexion
* I______ (L2,L3,L4)
* Hip a___

L3

* Knee ____ (_____)
* critical level for _______

L4

* Ankle DorsiFlexion (T_______)

LE MYOTOMES:

L5

* Big toe extensor
* EHL
* Test: walk on heels
* Gluteus Medius
* SGD
* L4, L5, S1

S1

* Toe flexors
* Ankle plantar flexion (Gastrocs)
* Hip Extensors
* G. Max
* Inferior Gluteal N (L5, S1, S2)
* Ankle elevators ( peroneus longus, peroneus brevis)

\

LE MYOTOMES:

L5

* B______ extensor
* E______
* Test: walk on heels
* Gluteus Medius
* SGD
* L4, L5, S1

S1

* Toe ___
* Ankle plantar flexion (G_____)
* Hip Extensors
* G_____
* I_____nerve (L5, S1, S2)
* Ankle elevators ( P __*_*___) (2)

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**DTR NEUROLOGIC LEVELS: C5, C6**

\
**C5** Biceps Reflex

**C6** Brachioradialis Reflex

\

DTR NEUROLOGIC LEVELS: C5, C6

**C5** _____Reflex

**C6** _____ Reflex

DTR NEUROLOGIC LEVELS: **C7, C8**

**C7** Triceps Reflex

DTR NEUROLOGIC LEVELS: **C7, C8**

**C7** T____Reflex

DTR NEUROLOGIC LEVELS: **L3, L4**

**L4** Patellar Reflex

DTR NEUROLOGIC LEVELS: **L3, L4**

**L4** _____ Reflex

DTR NEUROLOGIC LEVELS: S1, S2

**S1** Achilles Reflex

Lateral Hamstring Reflex *BF*

DTR NEUROLOGIC LEVELS: S1, S2

**S1** _____ Reflex

________ Reflex (ms: )

DTR NEUROLOGIC LEVELS: L5, S1

Medial Hamstring Reflex *ST SM*

DTR NEUROLOGIC LEVELS: L5, S1

_______ Reflex *ST SM*

DTR NEUROLOGIC LEVELS: L4, L5

Tibialis Posterior Reflex (*behind med. malleolus)*

DTR NEUROLOGIC LEVELS: L4, L5

____ __Reflex (____*behind*__ *_____)*

DTR NEUROLOGIC LEVELS: CN5

Jaw Jerk

DTR NEUROLOGIC LEVELS: CN5

____________

AMBULATION:

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**SO - ↑ T2 -** Standing

**TA - T3-T11 -** Therapeutic

**HA - T12-L2 -** Household

**CA - ↓ L3 -** Community

AMBULATION:

\
**SO - __ → _**

**TA - __ →** _

**HA - __ →** _

**CA - __ →** _

**Cranial Nerves**

\
**CN 1 → Olfactory**

CN 1

**CN 2 → Optic**

CN 2

**CN 3 → Oculomotor**

**CN 3**

**CN 4 → Trochlear**

**CN 4**

**CN 5 → Trigeminal**

**CN 5**

**CN 6 → Abducens**

**CN 6**

**CN 7 → Facial**

**CN 7**

**CN 8 → Vestibulocochlear** 

**CN 8**

**CN 9 → Glossopharyngeal**

**CN 9**

**CN 10 → Vagus**

**CN 10**

**CN 11 → Spinal Accessory** 

\

CN 11

**CN 12 → Hypoglossal**

**CN 12**

\
**Exit Points:**

**Cribriform Plate →** CN 1 Olfactory

**Optic Canal →** CN 2 Optic

\

**Exit Points:**

**_______ →** CN 1 Olfactory

**_______ →** CN 2 Optic

__Exit points:__

**Superior Orbital Fissure**

* CN 3 Oculomotor
* CN 4 Trochlear
* CN 5v1 Trigeminal (Ophthalmic br.)
* CN 6 Abducens

__Exit points:__

**_______Fissure**

* CN 3 Oculomotor
* CN 4 Trochlear
* CN 5v1 Trigeminal (Ophthalmic br.)
* CN 6 Abducens

\
**Foramen Rotundum**

* CN 5v2 (Maxillary br.) 

\
EXIT POINTS:

**_______**

* CN 5v2 (____ br.) 

__Exit points:__

**Foramen Ovale**

* CN 5v3 (Mandibular br.)

**Internal Acoustic Meatus**

* CN 7 Facial 
* CN 8 Vestibulocochlear

**Exit points:**

\
**_______**

* CN 5v3 (___ br.)

**_______**

* CN 7 Facial 
* CN 8 Vestibulocochlear

__**Exit Points:**__

**Jugular Foramen**

* CN 9 Glossopharyngeal
* CN 10 Vagus
* CN 11 Spinal Accessory

**Hypoglossal Canal**

* CN 12 Hypoglossal

__**Exit Points:**__

**______**

* CN 9 Glossopharyngeal
* CN 10 Vagus
* CN 11 Spinal Accessory

**______**

* CN 12 Hypoglossal