Acute limb weakness
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- Created on: 13-03-16 19:15
UMN vs LMS lesion
- UMN
- increased tone/spasticity
- brisk reflexes and clonus
- weakness- NO wasting
- upgoing plantars
- LMN
- reduced tone (flaccid)
- reduced/absent reflexes
- weakness with wasting, fasciculations
- downwards (normal) plantars
1 of 15
Weakness
- duration
- acute (e.g. stroke)
- sub-acute
- chronic
- acute0on-chronic (e.g. relapsing/remitting MS)
- localisation
- unilateral
- bilateral
- proximal (think myopathy)
- distal (peripheral neuropathy)
- age
- FHx (genetic)
- sex & race
- otehr health problems, medication
2 of 15
Lacunar infarction case
- history
- 72M fell to ground when trying to get out of bed
- developed weakness in R arm and leg
- HTN for many years
- examination
- RS facial weakness w/ forehead sparring
- speech mildly slurred
- R arm and leg flaccid w/ brisk reflexes
- R plantar response was extensor (upgoing)
- RS mild reduction in pinprick sensation
- acute, HTN Hx, unilat, UMN signs, flaccid, CNv involvement (NB Cran nv=brain affected)
- many things affected: vascular
- Dx=spinal shock secondary to lacunar infarction
- acute, flaccid paralysis w/ loss of sensation w/ gradual dvlpmt of spasticity + recovery of reflexes
3 of 15
Space occupying lesion case
- history
- 72M progressive weakness of R arm and leg over 6/12
- HTN for many years
- examination
- RS facial weakness w/ forehead sparing
- speech mildly slurred
- R arm and leg ******* w/ brisk reflexes
- R plantar upgoing
- RS mild reduction in pinprick sensation
- chronic, unilat, HTN, UMN, CNv,
- Dx= space occupying lesion- left sided
- dd > primary brain tumour, secondary brian tumour, abscess, chronic subdural haemotoma
4 of 15
cervical spondylosis case
- Hx
- 65M
- tingling in fingers w/ weakness in hands over 6/12
- difficulty walking, tendency to catch feet over 2/12
- neck pain for many years
- Ex
- weakness in biceps and forearm, wrist extensors and flexors, small m of hands
- biceps and brachioradialis reflex absent, others v brisk
- plantar upgoing
- incr tone in lower limbs
- reduced pinprick sensation in hands and arms
- chronic, bilateral, specific weakness pattern, specific reflexes absent, neck pain, UMN
- cervical spondylosis causing radiculomyelopathy
- NB pyramidal weakness- antigravity m. weaker (normally stronger)
- cervical spondylosis causing radiculomyelopathy
5 of 15
MND case
- Hx
- 65M
- progressive weakness in both hands over 6/12
- difficulty in walking and foot drag over 2/12
- speech difficulties
- Ex
- global weakness, watsing and fasciculation in both upper limbs more prominent in small m. of hands
- incr tone in lower limbs
- all reflexes brisk and upgoin plantars
- no snesory abnormalities
- chronic, bilat, speech difficulties,UMN + LMN signs, no sensory signs
- Dx - motor neurone disease
6 of 15
Compressive lesion case
- Hx
- 65M
- 15/7 weakness in both legs and back pain
- Ex
- mod weakness in both lower limb, more prominent in flexor muscles
- reflexes brisk, upgoing plantars, reduction of pinprick snesation below umbilicus
- key points
- sub-acute, bilat, weakness in flexors, UMN signs, sensory reduction
- Dx
- compressive lesion - tumour around T10
7 of 15
Ischaemic cord case
- Hx
- 72M
- sudden onset weakness in both legs after AA stent
- Ex
- flaccid weakness in both lower limb
- reflexes depresses, upgoin plantars
- reduction of pinprick sensation up to level of umbilicus
- key points
- acute, bilateral, flaccid, upgoing plantar, sensory level
- Dx
- ischaemic cord
8 of 15
Transverse myelitis case
- Hx
- 44F
- 3/7 progressive weakness inboth limbs
- acute mid-dorsal pain ~30mins at onset
- 1/7 dicturbance of bladder func
- numbness and tingling in limbs
- 2/52 ago had mild URTI
- E
- severe flaccid paralysis in both lower limbs w/ depressed reflexes
- plantars upgoing
- reductaion in pinprick sensation up to umbilicus
- bladder palpable at umbilicus
- key points- acute, bilat, pain, URTI, sensory level, spinal shock signs
- Dx- transverse myelitis (inflammatory)
- MS most common cause, viral 2nd
9 of 15
Guillain barre syndrome case
- Hx
- 44F
- 1/52 progressiv eweakness in both lower limbs spread to involve upper limbs
- numbness and tingling in limbs
- 4/52 before onset had flu-like illness
- Ex
- not able to walk independently
- generalised m. weakness, reduced tone and absent weakness in all limbs
- plantars downgoing
- reduction in pinprick sensation below level of knees
- key points- acute, bilat, flu-like illness, LMN, mild sensory, ascending
- Dx - Guillain Barre syndrome
10 of 15
Spinal cord diseases
- acute
- vascular (infarc, haemorrhage)
- transverse myelitis (viral, MS, inflammatory)
- chronic
- disc disease
- inflammatory (MS, sarcoid),
- spinal tumours
- hereditary
- B12 deficiency
- vascular (AVM)
11 of 15
charcot marie tooth case
- Hx
- 55M
- 15yr progressive weakness o fm of feet and calves
- 10yr of sim in hands
- mother has same
- Ex
- distal weakness and watsing in upper and lower limbs
- absent reflexes in all limbs
- plantar reflexes downgoing
- mild distal sensory loss
- key points - chronci. bilat, distal, mild sensory symp, LMN signs, FHx
- Dx- Charcot-Marie-Tooth (CMT)
12 of 15
Peripheral neuropathy causes
- congenital (CMT)
- metabolic (B12 def)
- toxic (alcohol ,drugs)
- endocrine (DM, thyroid)
- inflammatory (GBS)
- neoplastic (paraneoplastci)
- infective (HIV. Lyme)
13 of 15
Proximal myopathy case
- Hx
- 55M
- 12/12 progressiv edifficulties in standing up from sititng
- 15yr RA
- long term prednisolone, methotrexate
- Ex
- moderate weakness proximal lower and upper limbs
- normal reflex all limbs
- planras downgoing
- no sensory loss
- key point - chronic, bilat, RA, steroids, methotexate, proximal weakness, no sensory
- Dx - proximal myopathy due to steroids
14 of 15
Myopathy causes
- congenital
- muscular dystrophies
- metabolic disorders
- mitochondrial myopathies
- acquired
- metabolic (osteomalacia0
- endocrine (thyroid, Cushing's)
- toxic (drugs, alcohol)
- inflammatory (polymyositis)
- neoplastic (paraneoplastic)
15 of 15
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