transverse myelitis
TRANSCRIPT
Acute Peripheral WeaknessAcute Peripheral Weakness
Peter Shearer, MDAssistant Residency DirectorMt. Sinai School of Medicine
Peter Shearer, MD
ObjectivesObjectives
l Acute Extremity Weaknessl Levels of potential involvement_ Key Elements of History and Physical for
each level• CNS• PNS
l Diagnostic Optionsl Therapy
Peter Shearer, MD
Question #1Question #1
At which level of the CNS can a lesion produce motor weakness without affecting mental status?
A. Brainstem
B. Dorsal root ganglia
C. Spinal Cord
D. Cerebellum
Peter Shearer, MD
Question #2Question #2
Which of the following can differentiate between acute transverse myelitis and Guillain-Barre Syndrome?
A. ascending vs. descending paralysis
B. presence of slight lymphocytosis in CSF
C. increased vs. decreased reflexes
D. acuity of onset
E. presence of a preceding respiratory or GI illness
Peter Shearer, MD
Question #3Question #3
Which of the following does NOT produce a myelopathy?
A. Spinal cord infarct
B. Transverse Myelitis
C. Spinal cord metastasis of lung cancer
D. Tick Paralysis
Peter Shearer, MD
Question #4Question #4
Which of the following illnesses has a well evaluated, prospectively studied therapy?
A. Guillain-Barre Syndrome
B. Acute Transverse Myelitis
C. Acute Spinal Cord Hemorrhage
D. Botulism
Peter Shearer, MD
case-historycase-history
l 30 year old woman l diffuse weaknessl lower extremities > upper extremitiesl over 3 daysl preceding diffuse vesicular rashl difficulty voiding
Peter Shearer, MD
case-historycase-history
l 30 year old woman l diffuse weaknessl lower extremities > upper extremities
ascendingl over 3 daysl preceding diffuse vesicular rashl difficulty voiding
Peter Shearer, MD
case-details of the physicalcase-details of the physical
l BP 140/86, P 90, RR 18, T 99, 99%O2 sat
l CN intactl Motor: 4/5 in UE, 3/5 in LEl Sensory intact but sharp/dull less
pronounced in the LEl Reflexes 3+ in all extremitiesl palpable bladder
Peter Shearer, MD
Case - summaryCase - summary
l Acute ascending symmetrical paralysis following a recent infection with slight sensory impairment and hyperreflexia.
Peter Shearer, MD
Could this be a CNS lesion?Could this be a CNS lesion?
Peter Shearer, MD
Could this be a CNS lesion?Could this be a CNS lesion?
Yes
Can a CNS lesion produce bilateral weakness and sensory deficits and have
a normal mental status?
Peter Shearer, MD
Could this be a CNS lesion?Could this be a CNS lesion?
l CNS = Upper motor neuron_ cerebral cortex to, but not including the
anterior horn cell
l UMN lesions produce:_ increased tone_ increased DTR_ extensor plantars_ no fasiculations
Peter Shearer, MD
levels of the CNSlevels of the CNS
l Cerebral Cortex
l Cerebellum
l Brainstem
l Spinal Cord up to the Anterior Horn Cell
Peter Shearer, MD
Could this be a PNS lesion?Could this be a PNS lesion?
Peter Shearer, MD
Could this be a PNS lesion?Could this be a PNS lesion?
Yes
Where?
Peter Shearer, MD
levels of the PNS levels of the PNS
l Spinal cord - Anterior horn cell of the Lateral Corticospinal tract
l Peripheral nervel NMJ l Muscle
Peter Shearer, MD
MyelopathyMyelopathy
l A Lesion in the cord produces A Level of deficit
l Division of labor_ Dorsal columns - position/vibration_ Lateral corticospinal tract - motor function_ Lateral spinothalamic tract -
pain/temperature
l Preserved mental status
Peter Shearer, MD
Myelopathy - etiologyMyelopathy - etiology
l Infarctl Trauma_ Brown-Sequard_ Central cord syndrome_ Anterior cord syndrome
l Mass lesionsl Inflammation/Infection
Peter Shearer, MD
myelopathy - details of historymyelopathy - details of history
l Acuity of onsetl Traumal Distal > Proximall Pain at sitel Preceding Illness
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myelopathy - details of physicalmyelopathy - details of physical
l Weaknessl Spasticityl Atrophyl Fasciculationsl Bowel and bladder complaintsl Increased tonel Sensory findingsl DTR’s may be increased (not if ALS)
Peter Shearer, MD
Cord InfarctCord Infarct
l Anterior Spinal Artery_ anterior cord - dissociation of sensory
findings_ symmetric flaccid paralysis_ loss of sphincter tone_ Dorsal columns prevail
l Posterior Spinal Artery_ proprioceptive and vibratory sensation
Peter Shearer, MD
Acute Peripheral NeuropathyAcute Peripheral Neuropathy
l Motor and/or sensory_ disorder of transmission along peripheral
nerve • axon• myelin
_ Guillain-Barre_ Tick Paralysis_ Toxic
Peter Shearer, MD
Acute Peripheral Neuropathy - Acute Peripheral Neuropathy - details of physicaldetails of physical
l Weaknessl Absent DTR’s (all outflow from the cord
is affected)l Affects longer nerves first - ascending
Peter Shearer, MD
Guillain-Barre SyndromeGuillain-Barre Syndrome
l Post infectiousl mononuclear inflammatory infiltrate of
myelinl dymyelinatingl may be axonal injury and degeneration
Peter Shearer, MD
Guillain-Barre SyndromeGuillain-Barre Syndrome
l Symmetric ascending paralysisl areflexicl possible sensory - paresthesias, position
and vibrationl Progression over 1 - 3 weeks - may be
more rapidl 1/3 progress to respiratory failure
Peter Shearer, MD
Guillain-Barre SyndromeGuillain-Barre Syndrome
l CSF - Albuminocytologic dissociationl Stool for C. jejuni
Peter Shearer, MD
NMJNMJ
l Presynaptic - disorder of ACh release_ will affect nicotinic and muscarinic_ weakness_ anticholinergic symptoms
l Postsynaptic - will just be nicotinic_ weakness_ NO anticholinergic findings
Peter Shearer, MD
NMJ - details of historyNMJ - details of history
l Exposure_ botulism_ snake bites
l fatigue
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NMJ - details of physicalNMJ - details of physical
l Proximal>distal musclesl Bulbar musclesl May have anticholinergic signs if
presynampticl Fatigability
Peter Shearer, MD
Examples of NMJ disordersExamples of NMJ disorders
l Myasthenia Gravisl Botulisml Tick Paralysis
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MyopathiesMyopathies
l Periodic Paralyses
l Electrolyte Abnormalities_ Hypermagesemia_ Hypophosphatemia
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Metabolic AbnormalitiesMetabolic Abnormalities
l Periodic Paralysesl Hypermagesemial Hypophosphatemia
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Work upWork up
l CBC and serum chemistry
l CSF for signs of GBS or myelitis
l Radiography_MRI vs CT
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ManagementManagement
l Corticosteroids_ not supported by prospective placebo
controlled studies