Examinations

Question 1

Examine this patient’s temporal lobe

Answer 1

Mnemonic = VOLMA 1. Introduce 2. Inspect for scars or features of any neurocutaneous conditions e.g. NF / tuberous sclerosis / Sturge-Weber 3. Visual field assessment to confrontation using a red hat pin 4. Object recognition / Facial recognition (BNT / Famous faces test). “Name these 3 objects…” 5. Language - receptive “fold this piece of paper in half, then half again and then place it under your chair” / conductive “repeat after me…” / expressive “how did you arrive here today?” / nominal “name as many animals as you can in one minute” (normal is 12) 6. Memory - short-term = recall of 3 items and long-term = dates of WW2 (1939-1945) 7. Auditory assessment with noise presented to the contralateral ear i.e. auditory extinction

Question 2

Examine this patient’s parietal lobe

Answer 2

Mnemonic = VNS ALFA ADC Introduce and inspect for scars. Both: Visual fields to confrontation Neglect - line bisection test “draw a line bisecting these three lines half way along them”. Sensation - UL and LL, sensory extinction and agraphaesthesia. Dominant: Astereoagnosis - “Can you identify these objects that I am placing in your hands?” Left/right disorientation - “place you left hand on the table” Finger agnosia - “show me your ring finger” Alexia without agraphia - “Can you write a sentence for me?” “Can you read the sentence for me?” Acalculia - “Subtract 7 from 100 and keep going…” Non-dominant: Dressing apraxia “Can you show me how you put your jacket on?” Constructional apraxia “Can you draw a clock face for me?” “Can you draw these two intersecting hexagons?” “Can you show me how you use a key to open a lock?”

Question 3

Examine this patient’s frontal lobe

Answer 3

Mnemonic = MPSRORACLEs Motor - power in the limbs Premotor -Luria’s hand test (fist, chop and palm), “Can you show me how you use a key to open a lock?” Smell - “Can you identify these smells please?” University of Pennsylvania Smell inventory Test (UPSIT - a booklet of 40 scratch and sniffs) Reflexes - Frontal release signs - palmar-mental, palmar-grasp and glabella tap. Orientation - Time person and place Recall - “Remember these 3 things…” Attention - “What are the months backwards” Concentration - “Spell WORLD backwards” Language - “Name as many animals as you can in one minute.” “How many words beginning with F can you name?” Eye movements - Frontal eye fields

Question 4

How does macular sparing with a homonymous hemianopia help with identifying the lesion site?

Answer 4

Macular sparing is found with an occipital lobe lesion. No macular sparing suggests an optic radiation lesion.

Question 5

Examine this patient’s head shape.

Answer 5

1. Introduction 2. Inspection for shunts / scars / tracheostomy etc 3. Inspect head shape from the front, side and on top. 4. Comment on head shape, occipital flattening, frontal bossing, eyes - exophthalmos, midface hypoplasia, malocclusion of the teeth, ear position 5. Feel sutures 6. Feel fontanelle 7. Head circumference 8. To complete my examination I would inspect the growth chart, undertake a developmental milestone assessment and request fundoscopy.

Question 6

Examine this patient’s autonomic function.

Answer 6

1. Introduction 2. Inspect for scars (DBS) 3. Eyes - Horner’s syndrome / Pupillary response 4. Sweating 5. Lying and standing BP 6. Pulse - effect of Valsalva (should cause slight hypertension and bradycardia) 7. Bladder control

Question 7

Examine this patient’s extrapyramidal system.

Answer 7

1. Introduce - ask to walk 2. Inspect for Tremor, PD features - facial expression / dyskinesias, Scars for DBS - ask if it is switched on? 3. Eye movements 4. Head position 5. Torticolilis / titubation 6. Arm / leg movements - resting tremor, action tremor, intention tremor, finger-nose-finger test 7. Tone 8. Fast alternating movements (dysdiadochokinesia UL and foot tapping LL) 9. Writing / Archimedes spiral (frequency, amplitude and direction) / Vertical and horizontal line drawing

Question 8

Examine this patient’s eyes

Answer 8

1. Introduce 2. Inspect for scars, ptosis, resting position of the eyes (squint), square wave jerks 3. Ask if they wear glasses and if they can see out of both eyes 4. Visual acuity using a Snellen chart and colour vision with Ishihara 5. Pupillary response to light and accommodation 6. RAPD 7. Visual fields 8. Eye movements in H-shape asking for double vision. Side by side or diagonal. 9. Cover test if has a squint to distinguish a phoria (only with other eye covered) from a tropia (squint).

Question 9

Examine these patients speech

Answer 9

1. Introduce - ask name, age and occupation
2. Inspect for scars (head and neck), tracheostomy, PEG
3. Ask about hand dominance
4. Dysphasia - Expressive, Receptive, Conductive and Nominal
5. Dyshonia - ‘eee’ and ‘aaa’, hoarse voice and bovine cough suggest recurrent laryngeal nerve palsy
6. Dysarthria - “Baby hippopotamus”, “Yellow lorry red lorry” and “British constitution”.

Question 10

Examine the lower cranial nerves

Answer 10

1. Introduce
2. Expose and inspect - ACDF / retrosigmoid / suboccipital scars, tracheostomy, PEG

**Look for Horner’s syndrome, facial asymmetry

3. Trigeminal nerve - sensation in the 3 divisions and onion bulb distribution

**Check the corneal reflex!

Motor - muscles of mastication: clench teeth = temporalis / masseter; open mouth = lateral pterygoids and mouth sided to side = medial pterygoids

4. Facial nerve - asymmetry, smile, close eyes, show teeth, blow out cheeks and ask about taste (ant 2/3 of tongue)
5. Vestibulocochlear nerve - nystagmus, vestibulo-ocular reflex and hearing (rub fingers over one ear and whisper in the other). Weber’s and Rinne’s 512Hz tuning fork test.
6. IX and X - speech - say ‘eee’ and ‘aaa’ - uvula central? *moves away from the side of the lesion. Hoarse voice? Test gag reflex and cough (bovine?)
7. XI - shrug shoulders and turn head to the left and right against resistance
8. XII - tongue fasiculations, symmetry, power and atrophy.

To complete my examination I would request a PTA, FNE for vocal cord assessment, a videofluoroscopy for swallowing. I would also complete the rest of the cranial nerve as well as upper and lower limb examination.

I would like to see an MRI scan of the brain.

Question 11

Examine this patients upper limbs

Answer 11

1. Introduce - ask if any pain
2. Expose and inspect the neck, the clavicle, the axilla, the arm and the hands for scars, any wasting, fasciculations or abnormal position such as clawing.
3. Tone
4. Maneouvres = Make a fist (Benediction sign), straighten out the fingers, OK sign, interossi movement and Froment’s test
5. Power: Shoulder abd (C5), Elbow flex and wrist ext (C6), Elbow ext and wrist flex (C7), Finger flex (C8), APB and interossei (Median), Finger abd (T1)
6. Reflexes - Biceps / Supinator (look for the inverted supinator reflex) / Triceps and Hoffman’s. Higher reflexes are Deltoid C5 > Medial pectoral C4 > Trapezius C2/3 > Jaw jerk (Trigeminal spinal nucleus)
7. Sensation
8. Proprioception
9. Coordination - dysdiadochokinesia / dysmetria / intention tremor

Question 12

Examine the lower limbs

Answer 12

1. Introduction and ask if any pain
2. Inspect for scars / wasting / trophic changes (venous / arterial skin changes). Look at the spine for scars! ?MMC repair
3. Assess gait - Trendelenburg, ataxic, apraxic, antalgic, circumducting and high stepping
4. Tone - Roll, lift knee, clonus
5. Power - Hip flex L1/2 (Lumbar plexus to iliopsoas), Hip add L2/3 (Obturator n), Knee ext L3/4 (femoral n), Ankle dorsiflexion L5 both inversion (tibial n) and eversion (supfl. peroneal n), EHL L5 (deep peroneal n), hip abduction (L5 superior gluteal n) and planar flexion S1 (tibial n). Knee flexion (S1 sciatic n) Hip ext (S1 inferior gluteal n)
6. Reflexes - Knee L4) and ankle jerk (S1) **Adductor reflex = L3 and Hamstring reflex = L5 but these are less reliable. Babinski
7. Proprioception
8. Sensation
9. Coordination - run heal down the shin

To complete my examination I would assess perineal sensation and anal tone. I would also assess the upper limbs and obtain an MRI scan and NCS/EMG

Question 13

Examine the gait

Answer 13

1. Introduce
2. Expose and inspect the head. spine and legs looking for scars, atrophy and fasciculations. Any cutaneous stigmata?
3. Ask to walk across the room. Comment on Facial expression, arm swing, shuffling, tremor and Pace (mnemonic = FASTPACE) posture, step size, slapping, stability, turning and balance. Swing and stance phases.
4. Walk heel toe
5. Walk on heels
6. Walk on tiptoes
7. Rhomberg’s sign
8. To complete my examination I would examine the upper and lower limbs, cerebellum and cranial nerves. Depending on my findings, I would request an MRI of the brain and spine.

Question 14

Examine the cerebellum

Answer 14

1. Introduce
2. Expose and Inspect for scars over the head and spine
3. Dysdiadochokinesia
4. Ataxia - assess the gait. Truncal only = vermis/ Extremities = hemispheric
5. Nystagmus
6. Intention tremor
7. Slurred speech
8. Hypotonia

Question 15

Examine the median nerve

Answer 15

1. Introduce
2. Expose and inspect - scars ?CTD ?spinal surgery
3. Make a fist (benediction sign), ‘OK’ sign (AIN) and lumbricals.
4. Power - APB, Wrist flexion (radial side vs ulnar side), pronation (pronator teres), finger flexion. **Wrist extension should be strong because this is radial nerve via the C6 root
5. Sensation over the thumb and palm
6. Tinel’s and Phalen’s signs

Question 16

Examine the ulnar nerve

Answer 16

1. Introduce
2. Expose and Inspect - scars, wasting of the hypothenar eminence and first dorsal interosseous, fasciculations, clawing of the hand. Comment on the carrying angle and
3. Make a fist and straighten fingers. Ulnar side lumbricals. Froment’s sign
4. Tone
5. Power - Wrist flexion (ulnar side vs radial side = median n), finger flexion (weakness in hypothenar eminence only). interossei (PAD and DAB), ulnar side lumbricals, thumb adduction.
6. Sensation - little and 1/2 ring finger, ulnar aspect of the palm, forearm and arm.
7. Tinels over Cubital tuneel and Guyon’s canal

Question 17

Examine the radial nerve

Answer 17

1. Introduce
2. Inspect - scars, wasting, fasciculations
3. Make a fist, straighten the fingers (PIN) and cock your wrist backwards (radial). Extend the elbow and abduct the shoulders (axillary involvement suggests posterior cord)
4. Power in radial nerve muscles direct (triceps, brachioradialis, ext. carpi radialis and supinator), power PIN (finger extension and thumb abduction = abductor pollicis longus as well as thumb extension). Power in deltoids. If deltoids weak then check lat dorsi (both are posterior cord).
5. Sensation over the dorsum of the 1st web space and check the regimental patch.
6. Elbow reflex C7 and inverted supinator jerk C6 myeloradiculopathy

Question 18

Examine the spine

Answer 18

1. Introduce
2. Expose and inspect - scars front of the neck, back of the neck, thoracotomy, spine, abdomen and wasting in the UL or LL. Look specifically for a Horner’s syndrome.
3. Cervical spine - flexion, extension, lateral flexion and rotation - Spurling’s sign
4. Thoracic spine - rotation
5. Lumbar spine - flexion, extension, lateral flexion and rotation
6. Do any deformities correct with bending?
7. SLR
8. Examination of the UL and LL.

Question 19

What causes a homonymous horizontal sectoranopia?

Answer 19

LGN lesions. IF the horizontal meridian is spared then it is an anterior choroidal artery infarct. If the horizontal meridian is affected then it is a posterior choroidal artery infarct.

Question 20

What is nystagmus, torticollis and head nodding called?

Answer 20

Spasms nutans. Seen in children with OPGs.

Question 21

How would you examine a patient with facial pain / Examine this patient’s face.

Answer 21

1. Introduce. Ask name, age and occupation.
2. Inspect for asymmetry of the face, scars, rashes, excess lacrimation and abnormal movement. Ask where the pain is.
3. Test sensation in V1/2/3 and from outside in (onion bulb) including corneal reflex
4. Test masseter strength
5. Test eye movements (Cavernous sinus involvement)
6. Test facial power
7. Test hearing
8. Dentition
9. I would complete my examination with fundoscopy looking for optic atrophy suggesting MS as well as an upper and lower limb examination.

Question 22

What is the differential diagnosis of hemifacial spasm?

Answer 22

Blepharospasm

Facial dyskinesia

Facial myokymia

Tics associated with Tourettes

Question 23

What is the differential diagnosis of Trigeminal neuralgia?

Answer 23

Trigeminal neuropathic pain

Post-herpetic neuralgia

Atypical facial pain

Trigeminal cephalalgias (SUNCT / SUNA)

Question 24

Which nuclei contribute to the CN7?

Answer 24

The facial nucleus motor nucleus, superior salivatory nucleus (lacrimation) and nucleus tractus solitarius (taste to anterior 2/3 of tongue).

Question 25

What are the segments of the facial nucleus?

Answer 25

Pontine (demylination / stroke / tumour / cavernoma) - syndromes are Gubler-Millard, Raymond-Cestan and Fovilles Cisternal (CP angle) - (VS / meningioma / epidermoid / met / glomus tumour) Meatal - (VS / meningioma) Labyrinthine - (Trauma / Ramsey Hunt syndrome) - dry eye Tympanic - (cholesteatoma) - hyperacusis Mastoid - (trauma / surgery ) - loss of taste

Question 26

What are the causes of conductive hearing loss?

Answer 26

Wax Middle ear effusion Otitis externa / media TM rupture Ossicular dislocation

Question 27

What are the causes of sensorineural hearing loss?

Answer 27

Sensory - cochlear pathology = drugs / meningitis / TORCH infection / trauma Neural = CN8/ brainstem = CP angle lesions, brainstem tumour, demyeliantion, stroke

Question 28

What are the causes of vertigo?

Answer 28

I separate these into: Peripheral causes = BPPV / Meniere's / drugs / viral infections / vascular Spontaneous semicircular canal dehiscence. Central = CP angle tumours / vestibular neuronitis / demyelination, / stroke / brainstem tumours

Question 29

Which Vagus nucleus is responsible for motor to the palate, pharynx and larynx?

Answer 29

Nucleus ambiguus

Question 30

What is Hitzelberger's sign?

Answer 30

Numbness in the posterior ear canal as a result of compression of nervus intermedius

Question 31

What are the features of Wallenberg's syndrome?

Answer 31

Facial numbness and loss of pain (spinal trigeminal) ipsilateral with loss of sensation over the contralateral body (dorsal columns) Dysphagia (Nucl ambiguus) Dysphonia (CN10) Ataxia and Nystagmus (inferior cerebellar peduncle) Horner's syndrome (sympathetic disruption) Palatal myoclonus (central tegmental tract - part of Mollaret's triangle)

Question 32

What are the types of pain associated with trigeminal neuralgia?

Answer 32

Burchiel type 1 = classical episodic lancinating pain with no pain between attacks. Burchiel type 2 = Episodc pain but with a constant background pain.

Question 33

What are the treatment options for TN?

Answer 33

Medical = AEDS = Carbamazepine (s/e diplopia / ataxia / myelosuppression / dizziness / drowsiness and siADH). Oxcarbazepine is a derivative of carbamazepine that has a better safety profile and does not need level monitoring. Gabapentine is less effective. Lamotrigine / botox / baclofen and phenytoin have also been used. Antidepressants = amitriptyline Analgesia = lignocaine nasal spray, Capsaicin cream and steroids. Percutaneous = RF, Balloon compression and Glycerol Radiosurgery Open surgery = MVD

Question 34

What are the outcomes for percutaneous ablative treatments in TN?

Answer 34

Immediately after the procedure, all have a good response ranging from 91% with glycerol to 98% with RF/ At 5 years, however, outcomes are 50% with glycerol and 65% with RF. GK is only 50-80% effective with 25% recurrence. Might be better for MS but has a latency of action (2-3 months). RF is better for V3 and Balloon is better for V1/2 as there is less risk of corneal numbness and loss of the corneal reflex. Glycerol is better for bilateral pain.

Question 35

What proportion of bilateral TN have MS?

Answer 35

20%

Question 36

Describe the sensation to the pinna?

Answer 36

Auriculotemporal (V3) anterior and superior helix Greater auricular (C2/3) lower helix CN7/9/10 supply the EAC Lesser occipital (C2/3) supplies behind the ear

Question 37

What causes TN?

Answer 37

Ignition theory = Ephaptic transmission due to partial demyelination of A-beta fibres to A-delta and C-fibres so that normal touch sensation is transmitted as pain.

Question 38

What distributions do TN effect?

Answer 38

Most commonly a combination of V2 and V3. V2\>V3 alone. V1 distribution is uncommon. Involvement of all 3 distributions in 5% of cases.

Question 39

What are the complications for percutaneous TN treatment?

Answer 39

Bleeding Infection - oral mucosal penetration V3 weakness - malocclusion of the jaw Loss of corneal reflex / corneal numbness Dysaesthesia / anaesthesia Dolorosa Hearing reduction (tensor tympani V3) Visual dysfunction / cranial nerve palsy (IOF) Carotid injury - stroke / CCF Lower cranial nerve palsy (jugular foramen) No response / recurrence of pain Intracranial injury - bleed / seizures Bradycardia / hypotension seen with 15% of balloon HSV eruption

Question 40

Describe Hartel's technique

Answer 40

I mark 2.,5 cm lateral from the angle of the mouth. I mark the midpupillary line and a point 3 cm anterior from the tragus. I aim for a target at the intersection of these points. I put LA in the cheek and use my finger in the mouth to prevent oral mucosal penetration. I utilise lateral fluoroscopy and aim for the intersection of the clivus and the petrous ridge. The jaw usually clenches upon entry into the F.Ovale (V3) and CSF egress can be seen from the needle.

Question 41

What stimulation parameters do you use for RF?

Answer 41

50Hz stimulation, 1 ms pulse starting at 0.1 mV and building up to 0.5 mV. The impedance when in the nerve should be 200-300 Ohms

Question 42

What are the complications associated with MVD?

Answer 42

Bleeding Infection Cerebellar injury Stroke - brainstem results in hemiparesis Cranial nerve dysfunction including hearing loss (1%), vertigo, dysphagia, dysphonia Numbness of the face Facial weakness Herpes reactivation Loss of corneal reflex / anaesthesia dolorosa CSF leak Wound complications

Question 43

Draw the brachial plexus.

Answer 43

Question 44

Where is the long thoracic nerve usually damaged?

Answer 44

It passes over the middle scalene muscle so can be damaged by overhead weight lifting.

Question 45

What are the causes of winged scapula?

Answer 45

1. Serratus anterior weakness - long thoracic nerve 2. Trapezius weakness - spinal accessory nerve 3. Rhomboids weakness - dorsal scapula nerve

Question 46

What are the C5 and C6 muscles?

Answer 46

C5 = rhomboids and supra/infraspinatus C6 = biceps. brachioradialis and deltoids

Question 47

How do you distinguish radial from posterior cord injury?

Answer 47

In posterior cord, triceps is likely to be involved with latissimus doris (thoracodorsal n.) and deltoid (axillary n.) weakness

Question 48

What muscles are innervated by the radial nerve directly or via the PIN?

Answer 48

Radial nerve = triceps, brachioradialis, ext. carpi radialis longus and brevis and supinator PIN = Ext. carpi ulnaris, ext digitorum / proprius / minimi, abductor and extensor pollicis longus Supfl radial nerve = sensory only.

Question 49

Where is the site of compression with PIN?

Answer 49

Arcade of Frohse under the supinator tendon.

Question 50

What nerve is likely to be affected with a dislocated humerus?

Answer 50

Axillary C5/6 \> deltoids weakness and numbness over the regimental patch

Question 51

Which muscles are supplied by the median nerve directly or by the AIN?

Answer 51

Median = Flex carpi radialis, FDS, pronator teres, palmaris longus and LOAF muscles AIN = Flex pollicis longus, flex digitorum profundus 1+2 and pronator quadratus.

Question 52

Sites of median nerve compression?

Answer 52

Carpal tunnel \> Pronator teres \> Stuther's ligament.

Question 53

What is Wartenberg's sign?

Answer 53

Little finger abduction due to weakness in the palmar interossei / abductor digiti minimi (uilnar nerve) so catches when putting hands in pockets.

Question 54

Sites of ulnar nerve compression?

Answer 54

Cubital tunnel (Osborn's ligament) Struther's arcade (between the median intermusclar septum and medial head of triceps) 2 head of FCU Guyon's canal (only motor deficit)

Question 55

Why does ulnar neuropathy cause clawing?

Answer 55

Due to weakness of the 4+5 lumbricals, which results in loss of flexion at the MCP joint and loss of extension at the PIP joint causing clawing.

Question 56

What is the Stewart classification for ulnar neuropathy?

Answer 56

Clinical classification 1. mild = sensory loss only 2. moderate = motor 4/5 3. Severe = motor \<4/5

Question 57

What are the EMG/NCS features of ulnar neuropathy?

Answer 57

CV \<50 m/s Drop \>10m/s across the elbow CMAP reduction \>20% across the elbow - more severe suggesting axonal loss

Question 58

Medical causes of entrapment neuropathy?

Answer 58

Pregnancy DM Hypothyroidism Acromegaly Rheumatoid PMR Gout

Question 59

What test do you perform for thoracic outlet syndrome?

Answer 59

Adson's test - rotate head to ipsilateral side and extend neck. Deep inspiration whilst feeling the pulse. Treatment is scalaenectomy and resection of the C7 rib

Question 60

What is Parsonage-Turner syndrome?

Answer 60

Intense pain which results in weakness with 2 weeks (80% weakness is at the time) Confined to the shoulder girdle in 50% Due to a viral neuroopathy.

Question 61

What are the alternative reflexes to Babinski?

Answer 61

Schaeffer (Achilles pinch) Gordan (Calf pinch) Oppenheim (Knuckles down shin) Stronsky (Little toe snapping out)

Question 62

What are the features of a spastic gait?

Answer 62

Spasticity is a velocity-dependent increase in tone in response to passive stretch. Assessed using the modified Ashworth scale. Gait is scissoring, may walk on tiptoes, stiff lower limbs and scuff the bottom of the foot. In cerebral palsy there is normal sensation.

Question 63

Why does cerebral palsy cause spasticity?

Answer 63

Due to periventricular WM lesions causing a loss of the descending inhibition to the spinal cord result in abbarent reflexes

Question 64

How do you grade function in cerebral palsy?

Answer 64

Using the Gross Motor Function Classification Score (GMFCS) 1. Normal 2. Difficulty walking long distances 3. Walks with a stick 4. Needs a wheelchair 5. Powered wheelchair due to loss of axial tone

Question 65

What is the differential diagnosis of cerebral palsy?

Answer 65

Neuromyotonia Hereditary spastic diplegia (That is why you need to see the WM periventricular damage on MRI)

Question 66

What are the treatment options for cerebral palsy induced spasticity?

Answer 66

1. Physiotherapy - orthotic devices 2. Medications - Botox / Baclofen and Tizanidine 3. Surgery - Orthopaedic tendon releases, SDR and Baclofen pumps SDR selection criteria = Peacock's criteria

Question 67

What is the Fasano / Park protocol for neurophysiological monitoring in SDR?

Answer 67

Sustained motor responses as a result of direct stimulation of sensory fibres 1 = single motor unit 2 = adjacent motor units 3 = all unilateral motor units 4 = contralateral motor

Question 68

What are the different operations for SDR?

Answer 68

Park procedure = T12 laminotomy to expose the bottom on the conus Peacock = T12-L5 laminoplasty

Question 69

Describe the gait in PD.

Answer 69

Festinating gait / Marche a petite pas Failure of arm swing Mask like facies Stooped posture Small steps En bloc turning (stiff) Arm tremor Imbalance Freezing Negative cueing from lines / doorways / shadows

Question 70

What is a Simian gait?

Answer 70

Flexed hip and knees with a boucing gait in a patient with PD. Suggests Multisystem atrophy.

Question 71

What gait is suggestive of PSP?

Answer 71

Upright posture (not stooped) Broad based / ataxic gait Loss of arm swing Difficulty turning

Question 72

What is the Canterbury classification of CTS?

Answer 72

1. Very mild - only with detailed tests 2. Mild - DML \<4.5 and SNAP CV \<50 m/s 3. Moderate - DML 4-5-6.5 SNAP present 4. Severe - DML 4.5-6.5 SNAP absent 5. Very severe - DML \>6.5 6. Extremely severe - DML \>6.5 and CMAP amplitude \<0.2 mA

Question 73

How do you distinguish C6 radiculopathy from CTS?

Answer 73

Spurling's sign Sensation over thenar eminence (spared in CTS) Wrist extension is weak in C6 radiculopathy and strong in CTS

Question 74

What does an inverted supinator reflex mean?

Answer 74

Supinator reflex is mute due to C6 radiculopathy There is flexion of the fingers due to hyperreflexia in C8 Suggests C6 myeloradiculopathy.

Question 75

What are the sites of compression of the radial nerve?

Answer 75

Axillary - saturday night palsy Spiral fractures of the humerus (spare the trapzius) Arcade of Frohse (supinator muscle) - PIN compression causing a finger drop

Question 76

What are the external (cutaneous) features of Spina bifida occulta?

Answer 76

Vary from pigmentation to hairy patch etc Benign sacrococcygeal dimple - pit between natal cleft Dermal sinus tract / LDM - skin punctum. Stains for GFAP. Should be explored and resected as risk of meningitis Diastematomyelia - hairy patch - Type 1 = fibrous or bony spur, 2 dural sacs. Type 2 = 2 spinal cords within one dural sac. Risk of tethering Sacrococcygeal teratoma - Currarhino triad (= sacral dysgenesis, tethered cord and presacral teratoma, MNX-1 mutation). Look for a cloacal anomaly! Terminal myelocystocele - big caudal lump. Spinal lipoma / lipomyelomeningocele - Pang classification - dorsal / caudal / transitional or chaotic.