Beginning >> Articles >> Archives >> Workshop on nervous diseases and neurosurgery

Workshop on nervous diseases and neurosurgery

Table of contents
Workshop on nervous diseases and neurosurgery
Deep reflexes
Symptomatology and methods of research of a flaccid paralysis
Research and symptoms of defeat of motive cranial nerves
Methods of research and symptoms of defeat of extrapyramidal system
Symptomatology and methods of research of coordination of movements
Methods of research and symptoms of defeat of sensitivity
Dependence of disturbances of sensitivity on localization of the center of defeat
Methods of research and symptoms of defeat of sense bodys
Symptomatology and methods of research of aphasia, apraxia and agnosia
Methods of research and symptoms of defeat of a vegetative nervous system
Research of reflexes
Main syndromes of damage of a head and spinal cord
Brainstem, spinal cord, nerves
Somatoneurologic syndromes
Neurosomatic syndromes
Medullispinal liquid
Neurosurgical methods
Radiodiagnosis methods
Electrophysiologic methods
Ekhoentsefalografiya
Electromyography
Scheme of a case history of the neurologic patient

Workshop on nervous diseases and neurosurgery: Yu. S. Martynov, E. V. Malkova, V. K. Orlov, etc. — Moscow, 1988.
Data on a sindromologiya of nervous diseases contain, the main methods of research applied in neuropathology are described.
The practical work is intended for students of medical schools and doctors - neuropathologists. It is prepared at department of nervous diseases.

RESEARCH OF VOLUME AND FORCE OF MOVEMENTS

Motive function — walking, run, purposeful actions of production character, etc. — the difficult reflex act. Many levels of a nervous system take part in performance of movements: cerebral cortex, subcrustal nodes, brainstem, cerebellum, segmented device of a spinal cord and peripheral nerves.
All movements can conditionally be divided on any and involuntary, (automated). Autokinesias are carried out by the motor analyzer located in a frontal lobe.
The front central crinkle (field 4), back and upper parts of a frontal lobe (field 6 and 8) and back central crinkle (fields 1, 2, 3) are a part of a motor analyzer. The descending way of a motor analyzer (a pyramidal way) begins from Bets's cells located in the 3rd and 5th layers of a front central crinkle. The part of pyramidal fibers originates in a back central crinkle and a frontal lobe. Fibers of a pyramidal way, going to depth of a hemisphere, gradually gather in a compact bunch, pass through an internal capsule (lobbies 2/3 back hips), a brainstem (its ventral department) and further go down in a spinal cord. On border of an oblong and spinal cord nerve fibrils of a pyramidal way partially cross, the most part of fibers (about 90%) after a crossing comes over to the opposite side and goes as a part of a lateral trunk, smaller down, part, without crossing, passes into front trunks of a spinal cord of the party, forming Türk's bunch.
That part of pyramidal fibers which goes to motive cranial nerves carries the name of a kortikonuklearny way. The last begins from pyramidal cells of a lower part of a front central crinkle, enters a brainstem and after an incomplete crossing approaches kernels of motive cranial nerves. Fibers of a kortikonuklearny way cross at various levels of a brainstem as approaching a kernel of the corresponding cranial nerve.

Existence of not crossed bunch of pyramidal fibers creates certain opportunities for compensation of movements at defeat of the main crossed parts of a pyramidal way. Not crossed bunch of pyramidal fibers approaches kernels of motive cranial nerves and those levels of the segmented device of a spinal cord which innervate muscles of a neck, trunk, crotch that provides preservation of their function at hemilesions of cerebral hemispheres, an internal capsule, a trunk of a head and spinal cord.
But one motor analyzer cannot create the movement in general. There is a system which provides the automated movements and the numerous automated self-regulating elements of each autokinesia — inclusion and switching off of certain muscular groups, redistribution of a muscle tone, succession and sequence of movements. These functions are regulated by the extrapyramidal system and a cerebellum playing an important role in implementation of motor activity of the person. Therefore, motive function is provided with the interconnected work of the whole system of nerve centers, and each of them plays the specific role.
All pyramidal, extrapyramidal and cerebellar impulses on various descending ways come to the segmented device — to cells of front horns of a spinal cord or their analogs — cells of motive cranial nerves and from there to the corresponding muscles. The peripheral motor neuron begins from cells of front horns of a spinal cord or their analogs — kernels of motive cranial nerves. As a part of a front horn distinguish three sorts of cells:
a-big cells, their fibers terminate on white muscles and provide the fast movements;
a-small cells, their fibers innervate the red, slowly reduced muscles and make mainly tonic impact;
at - cells, their fibers approach proprioretseptor of muscles, i.e. with their help feedback of motive system with the perceiving device is carried out and the ring of the reflexes supporting a muscle tone becomes isolated.
Axons of a peripheral motor neuron leave a spinal cord in the form of ventral roots which, connecting, form peripheral nerves. The last carry out an innervation of all muscles of the person.
At a checkmate of the central or peripheral motor neuron of the movement become absolutely impossible — paralysis develops, at their partial defeat there is a reduction of volume and force of movements — paresis. Paralysis of one extremity carries the name of a monoplegia, paralysis hollow
fault of a body — a hemiplegia, paralysis of hands — an upper paraplegia, paralysis of legs — the lower paraplegia, paralysis of all four extremities — tetraplegias. At defeat of the central motor neuron there is the central paralysis, and at defeat of peripheral neuron — peripheral, or sluggish, paralysis.
The symptomatology of the central and sluggish paralyzes has one general, a sign — impossibility of autokinesias; on the whole some other signs they differ from each other. These distinctions are revealed by the doctor in the course of research of motive functions of the patient. Studying of motive functions is begun with research of volume and force of active movements, further a muscle tone, normal and pathological reflexes, synkineses, clonuses, protective reflexes.
For detection of paralysis or paresis investigate first of all the volume and force of active movements of muscles of extremities. Research of volume of active movements of muscles is made by an assessment of extremities, possible for sick bending, extension, pronation etc., in various joints in comparison with norm. Force of muscles is determined by resistance which the patient shows investigating in attempt, for example, to unbend the hand bent in an elbow, to part the fingers cramped together, etc. the Movements of a trunk are carried out by bending of a backbone forward, back and in the parties.
Usually force of active movements is estimated on 5-mark system by comparison of force of muscles on the struck and not struck parties: force and volume of active movements are normal — 5, small decrease in force without restriction of volume of active movements (very slight paresis) — 4, decrease in force with small restriction of volume of active movements (slight paresis) — 3, the expressed decrease in force with restriction of volume of active movements (paresis) — 2, sharply expressed decrease in force with big restriction of volume of active movements (deep paresis) — 1, total absence of force and activity of movements (paralysis) — 0.
In case of paralysis performance of a task is impossible as any active movements of muscles of extremities are absent. If there is paresis with restriction of volume of active movements, then performance of a task is possible not fully. For example, the patient will not be able to raise a hand or a leg to required level. At paresis without restriction of volume of active movements the task is performed in full, but decrease in force of these or those muscles is observed.
Disturbances of motive functions

  1. The central paralyzes or paresis of extremities are observed at defeat of nerve fibrils of a pyramidal way on all its extent — from a front central crinkle of cells of a front horn (i.e. within the 1st neuron).                                                                                                                                                                       
  2. Flaccid paralyzes or paresis of extremities are observed at defeat of front horns and ventral roots of a spinal cord, motive fibers of peripheral nerves (i.e. within the 2nd neuron).
  3. Mixed (central and peripheral) paralyzes or paresis are observed at simultaneous defeat of the central and peripheral neurons (i.e. the 1st and 2nd neurons).

RESEARCH OF THE MUSCLE TONE

Muscle tone — it a certain degree of the muscle tension observed normal. The tone of muscles is supported reflex. The afferent part of a reflex arc is formed by the conductors of muscular and joint sensitivity bearing in a spinal cord impulses from proprioretseptor of muscles, joints and sinews, the efferent part is made by a peripheral motor neuron. Besides, the cerebellum and extrapyramidal system participate in regulation of a muscle tone. At research of a tone of muscles of the patient has to lie, having completely relaxed all muscles. The tone of muscles is determined by degree of their tension at the passive movements in extremities (tab. 1). Increase of a muscle tone carries the name of a muscular hypertension, absence — atonies, decrease — hypotonias. In case of a hypomyotonia the doctor does not feel the muscle tension which is available normal, all passive movements in joints are excessive, muscles are to the touch flabby. At a muscular hypertension the expressed muscle tension is observed. In some cases the doctor hardly can overcome this tension.
Table 1
Research of a muscle tone


Type of the movement

Research technique

Bending and extension in an elbow joint

The doctor, having taken one hand a shoulder, another — the patient's forearm, several times makes the maximum bending and extension of a forearm, defining muscle tension degree

Pronation and supination of a forearm

The doctor takes the patient by hand (a palm in a palm) and makes several times pronation and supination of a forearm, defining muscle tension degree

Bending and extension in a knee joint

The doctor one hand undertakes a front surface of a hip, another takes a shin and several times carries out bending and extension of a shin, defining muscle tension degree

Distinguish spastic and plastic hypertensions. At a spastic hypertension the muscle tone is usually raised in any one group of muscles of extremities — sgibatel on hands, razgibatel standing. In process of research the muscle tone gradually weakens.

At plastic, or extrapyramidal, hypertensions the muscle tone is raised in all muscular groups of extremities — both sgibatel and razgibatel. In process of research there is as if an increase of a tone — strengthening of a muscle tension.
Disturbances of a muscle tone
Increase of a muscle tone is observed:
a)        at the central paralyzes — a spastic hypertension;
b)        at defeat of extrapyramidal system (an akinetiko-rigid syndrome) — a plastic hypertension.
Lowering of a muscle tone takes place:
a)        at flaccid paralyzes or paresis;
b) at damage of a cerebellum;
c)        at defeat of extrapyramidal system (hypotonic - a hyperkinetic syndrome);
d)        at loss of muscular and joint sensitivity.

RESEARCH OF REFLEXES

The reflex is a basis of activity of all nervous system. Reflexes are divided on unconditional (i.e. inborn reactions of an organism to various exteroceptive and interoceptive irritations) and conditional (i.e. the new temporary bonds developed on the basis of instinctive reflexes as a result of individual experience of each person).
All neurons participating in implementation of a reflex form its reflex arc. Reflex arcs of instinctive reflexes consist of three neurons: afferent, inserted and efferent. In some cases the impulse can pass from an afferent neuron directly on efferent, i.e. the reflex arc in this case consists only of two neurons. Each instinctive reflex is caused at irritation of a certain site mucous, skin, sinews etc. which carries the name of a reflexogenic zone, or zones of calling of a reflex.
Depending on the place of calling of a reflex (a reflexogenic zone) all instinctive reflexes can be divided on superficial, deep, distantny and from internals. In turn, superficial reflexes are divided on skin and from mucous membranes; deep — on tendinous, periosteal and joint; distantny — on light, acoustical and olfactory.
Major importance has research of superficial and deep instinctive reflexes. From these reflexes we will consider those which differ in constancy and are surely investigated at the patient.

Superficial reflexes

Superficial reflexes are caused by drawing on skin and mucous shaped irritation. When calling reflexes the doctor should not cause irritation too strongly. Reflexes from mucous membranes cause Reflexes from mucous membranes (tab. 2) in any position of the patient. Only the proctal reflex is caused in position of the patient on a stomach.
Table 2
Research of reflexes from mucous membranes


Reflex

Research technique

Reflex arc.

Corneal

The doctor touches with a piece of the cotton wool curtailed in the form of a spindle or soft paper serially a cornea of the right and left eyes. It is normal observed smykany centuries on the party of causing irritation

Reflex arc Sensitive and motive V—VII fibers of cherepnomozgovy nerves

Konjyunk-
tivalny

The doctor touches with a piece of the cotton wool curtailed in the form of a spindle or a soft piece of paper serially a conjunctiva of the right and left eyes. It is normal observed smykany centuries on the party of causing irritation

Sensitive and motive V—VII fibers of cherepnomozgovy nerves

Pharyngeal

With the pallet or a teaspoon the doctor touches a back wall of a throat of the patient. The emetic or tussive movement is normal observed

Sensitive and motive kernels IX and X cranial nerves

Palatal

With the pallet or a teaspoon the doctor touches a palatine velum. The raising of a palatine velum on the party of causing irritation is normal observed

Sensitive and motive kernels IX and X cranial nerves

Proctal

The doctor puts with a neurologic needle a prick on mucous about an anus. Reduction of a sphincter is normal observed

Nn. anococcygei S3 — S5 segments

It must be kept in mind that at patients with defeat of kortikoyaderny bonds when calling corneal and conjunctival reflexes mandible shift can be observed aside (a korneomandibulyarny reflex).
Pharyngeal and palatal reflexes do not differ in constancy therefore lack of reflexes on one party has great diagnostic value.

Cutaneous reflexes

Research of cutaneous reflexes

Cutaneous reflexes cause in position of the patient lying on a back (tab. 3). At research of belly reflexes for full relaxation of a wall of a stomach it is better for patient to bend several legs in knee joints.
Table 3


Reflexes

Research technique

Reflex
arch

Belly:

 

d7-d8

upper

Applies with the handle of a neurologic hammer, a goose quill blunted by a needle, a match the doctor shaped irritation on three-four fingers above a navel parallel to a costal arch. Reduction of belly muscles on the relevant party is normal observed

average

The doctor causes shaped irritation at the level of a navel. Reduction of belly muscles on the same party is normal observed

D9 — D10

lower

The shaped irritation is applied on three-four fingers below a navel. Reduction belly mice on the same party is normal observed

D11 — D12

Kremasterny

The doctor applies shaped irritation on skin of an internal surface of a hip. Reduction of a kremasterny muscle on the party of causing irritation with pulling up of a small egg is normal observed up

Li-L2 *

Bottom

The doctor causes irritation along the inner or outer edge of a sole. Bending of fingers of foot is normal observed

L5-S1

* With the subsequent short circuit in bark.



 
"After the had stroke   Practical hematology of children's age"