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43 Cards in this Set
- Front
- Back
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Why must a patient lie in the fetal position for a lumbar puncture?
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Flexion will separate the space between the spinous processes and adjacent laminae and put tension in the ligamentum flavum
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At what level should the needle be inserted for a lumbar puncture?
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Between Ll3/4 and L4/5
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Why would lumbar levels L3/4 and L4/5 be safe for a lumbar puncture?
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Needle entry is inferior to the conus medullaris and, therefore, there is no danger of injuring the cord
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List the superficial to deep layers that will be penetrated during a lumbar puncture?
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1.Skin
2.Superficial fascia 3.Thoracolumbar fascia 4.intrinsic back muscles 5.Ligamentum Flavum 6.Epidural space 7.dura mater 8.subdural space (potential) 9.arachnoid mater 10. subarcachnoid space (CSF) |
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At what vetebral level does the spinal cord end?
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The spinal cord ends at disc L1/2
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Bullet wound:
At what level did the bullet enter? Caliber entry wound on the midline in the mid-lumbar region but no anterior exit wound. No apparent bleeding in the abdominal cavity. Paralysis, or weakness, of a number of muscles in both lower limbs. No sensation from dermatomes L3 and below |
The bullet entered the vertebral canal at the L3 vertebral level - this is apparent from the loss of sensation in the dermatomes L3 and below
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Bullet wound:
What structures did the bullet wound hit? Caliber entry wound on the midline in the mid-lumbar region but no anterior exit wound. No apparent bleeding in the abdominal cavity. Paralysis, or weakness, of a number of muscles in both lower limbs. No sensation from dermatomes L3 and below |
The cauda equina (dorsal and ventral roots) is found in the canal below vertebral level L1 and was damaged by the bullet
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Bullet wound:
Why are some muscles only weakened rather than paralyzed? Caliber entry wound on the midline in the mid-lumbar region but no anterior exit wound. No apparent bleeding in the abdominal cavity. Paralysis, or weakness, of a number of muscles in both lower limbs. No sensation from dermatomes L3 and below |
Because of the somatic plexus, many muscles of the limbs receive innervation from several cord levels. If a muscle received innervation from L2 and L3 then it will be weakened (L2 still intact) whereas if it is innervated by L3 and L4 then is will be paralyzed
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During surgical repair of an upper abdominal aortic aneurism, the aorta was clamped at the T11/T12 vertebral level. The patient recovered without any affect of the clamping of the aorta.
What ligaments connect vertebrae? |
One anterior and 2 posterior spinal arteries, and segmental medullary arteries
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How do arteries enter the vertebral canal to supply the spinal cord?
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Spinal arteries arise from vertebrals just after they pass through the foramen magnum, medullary arteries arise from the cervical,posterior intercostal, lumbar and lateral sacral arteries
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In which meningeal layer will the arteries of the spinal cord be located?
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The pia mater directly covers spinal blood vessels
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How did arterial blood get to the spinal cord below the T11/T12 vertebral level?
* the aorta was clamped at T11/T12 level for surgical repair of an upper abdominal aortic aneurism |
Via medullary arteries that arise from lumbar and lateral sacral arteries
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Discuss the difference between a dermatome and the region of innervation of a named cutaneous
nerve. |
Dermatome-a single pair of spinal nerves innervate a strip of skin extending from the midline posteriorly to the midline anteriorly
Cutaneous nerve-often contains afferent neurons from the several adjacent spinal cord levels and innervates a patch of skin that crosses dermatome boundaries |
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If an infant with spina bifida cystica is not operated on there is a high chance of what complication?
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Meningitis
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A 60 year old man was lifting a heavy object when he suddenly felt severe back pain that radiated
down the posterior aspect of his right thigh and leg. MRI revealed a ruptured and protruding intervertebral disc between L4 and L5 vertebrae. a) What ligaments connect vertebrae? b) What are the parts of an intervertebral disc? c) Which part of the disc would be protruding and in which direction would it usually herniate? d) Which spinal nerve would be compressed by the herniated disc and why? |
a. Supraspinous, interspinous, flavum, posterior and anterior longitudinal ligaments
b. Anulus fibrous and nucleus pulposus c.The nucleus pulposus will protrude postlaterally - The forces in the vetebral column push the protrusion posteriorly but the presence on the posterior longitudinal ligament results in it potruding postlaterally. d. L5 and L4 nerves leaves the vertebral canal above the level of the disc due to the height of the lumbar intervertebral foramina (deep inferior notch of L4) |
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A young male sustained an injury to that part of the axillary artery which is covered by the pectoralis minor muscle. The injury necessitated ligation of the vessel just proximal to the injury.
a) What part of the axillary artery was injured? |
The part of the axillary artery covered by the pectoralis major is the second part.
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What arteries provided collateral circulation for continued blood supply to
the upper limb? **A young male sustained an injury to that part of the axillary artery which is covered by the pectoralis minor muscle. The injury necessitated ligation of the vessel just proximal to the injury. |
Collateral circulation to the upper limb would be provided by the thyrocervical and the dorsal scapular artery from the subclavian artery. The suprascapular a. and the dorsal scapular a. contribute to the scapular anastomosis, and thus blood would flow from these arteries to the circumflex scapular a. to enter the brachial a. and the upper limb.
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A 55 year old male complains of a tingling sensation to the medial side of his left
hand. The sensation occurs mainly when he flexes his forearm. He was involved in an accident at work several years ago where he sustained a fracture of the olecranon process of his left ulna. a) What nerve is responsible for the tingling sensation? |
The ulnar nerve since it runs posteriorly in the groove of the medial epicondyle of the humerus, and mediates sensation along the medial side of the forearm.
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Explain what you believe may cause the sensation upon forearm flexion.-
**4. A 55 year old male complains of a tingling sensation to the medial side of his left hand. The sensation occurs mainly when he flexes his forearm. He was involved in an accident at work several years ago where he sustained a fracture of the olecranon process of his left ulna. |
It would appear that the healing process following the fracture of the olecranon process may have created scar and /or callous tissue that have entrapped the ulnar nerve, and is stretched upon flexion of the forearm.
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In a fight a person received a knife wound in the lateral aspect of the arm just above the elbow. The knife pierced the brachioradialis muscle and severed the nerve located just deep to this muscle.
a) What nerve was severed? |
The nerve is the radial which is located between the brachioradialis and the brachialis. At this point the nerve has not yet divided into the deep and superficial branches.
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Review the structures that are supplied by radial nerve
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The radial nerve give motor innervation to the
1. triceps muscles before coursing deep to the 2. brachioradialis which it supplies, as well as all the other muscles in the extensor compartment of the forearm. ** Its sensory innervation includes the skin over the lower posterior aspect of the arm, the posterior aspect of the forearm, and on the dorsum of the hand over the thumb and the adjacent 2 metacarpals, as well as adjacent areas of the corresponding phalanges. |
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What tests would you perform to determine functional loss?
**In a fight a person received a knife wound in the lateral aspect of the arm just above the elbow. The knife pierced the brachioradialis muscle and severed the nerve located just deep to this muscle. |
1. Ask patient to shake hand – he will not be able to do so (semipronated position produced by brachioradialis).
2. Patient will not be able to extend the wrist, or the thumb (as in hitchhiking). 3. Patient will have a “wrist drop” and will not be able to make a tight fist, for which the wrist extensors are needed. |
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MOTOR
How would you test for the motor loss in hand functions to determine possible compromise of the median, ulnar and radial nerves?. |
1. Testing for pulp to pulp opposition would be for the median n. since it supplies the thenar muscles.
2. Gripping a piece of paper between the digits (adduction of the digits) would test for the ulnar n. since it supplies the interossei mm. 3. Extension of the wrist would test for the radial n. |
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SENSATION
Where in the hand would you test for sensation loss from the median, ulnar and radial nerves? |
1. The median n. mediates sensation from the lateral aspect of the palm (including the thenar eminence) and the palmar aspects of the lateral 3 and ½ digits with some dorsal areas over the tips of the same digits.
2. The ulnar n. mediates sensation from the medial aspect of the palm (including the hypothenar eminence) and both palmar and dorsal aspects of the medial 1 and ½ digits, and the dorsal aspect of the hand adjacent to the medial 1 and ½ digits. 4. The radial n. mediates sensation from the lateral side of the dorsum of the hand. Testing by pinpricking in these areas must be done with the patient’s eyes closed. |
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While climbing a mango tree to pick fruit a boy lost his balance and started to fall. He managed to grab a branch which slowed his descent but he felt a strong pull in his armpit and had to let go. He landed on the shoulder of his friend who was standing below, forcefully spreading his friend’s shoulder and neck. At the local health center the boy who climbed the tree was diagnosed with a lower brachial plexus lesion and his friend with an upper brachial plexus lesion.
What nervous structures were injured to result in the lower brachial plexus lesion? |
A lower brachial plexus lesion typically involves the lower (inferior) trunk of the brachial plexus (C8 and T1).
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What motor and sensory loss may result from this lesion?
*MANGO TREE: . He landed on the shoulder of his friend who was standing below, forcefully spreading his friend’s shoulder and neck. At the local health center the boy who climbed the tree was diagnosed with a lower brachial plexus lesion and his friend with an upper brachial plexus lesion. |
Typically the sites of distribution of the ulnar nerve would be affected. Thus the
1. flexor carpi ulnaris, 2. the medial half of the flexor digitorum profundus, 3. all the interossei, 4. the medial 2 lumbricals, 5. and the adductor pollicis muscles would be affected. Sensory loss would be along the medial 1 and ½ digits. There may also be some loss along the medial side of the forearm. |
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What functions might be difficult or lost because of this lesion?
*MANGO TREE: . He landed on the shoulder of his friend who was standing below, forcefully spreading his friend’s shoulder and neck. At the local health center the boy who climbed the tree was diagnosed with a lower brachial plexus lesion and his friend with an upper brachial plexus lesion. |
With an ulnar loss, a patient will present a typical claw hand which involves hyperextension of the 4th and 5th digits at the MP joints (by the unopposed actions of the extensors of the digits) and flexion of the IP joints (by the unopposed actions of the flexor digitorum superficialis). Fine motor skills will be lost, including gripping power, adducting and abducting the digits and flexion and adduction at the wrist.
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What nervous structures were injured to result in the upper brachial plexus lesion?
*MANGO TREE: . He landed on the shoulder of his friend who was standing below, forcefully spreading his friend’s shoulder and neck. At the local health center the boy who climbed the tree was diagnosed with a lower brachial plexus lesion and his friend with an upper brachial plexus lesion. |
An upper brachial plexus lesion typically involves the upper (superior) trunk of the brachial plexus (C5, C6).
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What motor and sensory loss may result from this lesion?
*MANGO TREE: . He landed on the shoulder of his friend who was standing below, forcefully spreading his friend’s shoulder and neck. At the local health center the boy who climbed the tree was diagnosed with a lower brachial plexus lesion and his friend with an upper brachial plexus lesion. |
Typically the loss would be the distribution of the nerves that carry most of the fibers of C5 and C6. These would include primarly the distribution of the suprascapular n. (to supraspinatus and infraspinatus mm.), musculoctaneous n. (to coracobrachialis, brachialis and biceps brachii mm.) and the axillary n. (to deltoid and teres minor mm.), Sensory loss would typically be the upper lateral aspect of the arm and the lateral aspect of the forearm.
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What functions might be difficult or lost because of this lesion?
*MANGO TREE: . He landed on the shoulder of his friend who was standing below, forcefully spreading his friend’s shoulder and neck. At the local health center the boy who climbed the tree was diagnosed with a lower brachial plexus lesion and his friend with an upper brachial plexus lesion. |
patient will present with a “waiter’s tip”.
muscles affected are 1. the lateral rotators of the arm and 2.the flexors and great supinator of the forearm, the arm will be medially rotated (by the unopposed medial rotators), the forearm will be pronated (by the unopposed actions of the pronators), and the hand may show some flexion. |
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One week following coronary artery bypass graft (CABG) surgery, a 50 year old male experienced sharp and localized pain over areas of his thoracic wall whenever he moved as he was lying in bed. X-ray examination revealed that his left lung was compressed by fluid exudate, to the extent that the lowest point of the lung was at the level of the 8th rib at the paravertebral line. The pleural effusion (PEF) in the left pleural cavity is not an uncommon consequence of bypass surgery. A cardiothoracic (CT) resident removed the fluid compressing the left lung by needle aspiration from the back.
Why was the pain sharp localized and only occurred when he moved? |
Parietal Pleura
Pain was sharp because of somatic origin. When patient moves the parietal pleura is irritated which is innervated by somatic nerves. |
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What type of nerve fibers conducted the pain sensation, and which nerves were involved?
**One week following coronary artery bypass graft (CABG) surgery, a 50 year old male experienced sharp and localized pain over areas of his thoracic wall whenever he moved as he was lying in bed. X-ray examination revealed that his left lung was compressed by fluid exudate, to the extent that the lowest point of the lung was at the level of the 8th rib at the paravertebral line. The pleural effusion (PEF) in the left pleural cavity is not an uncommon consequence of bypass surgery. A cardiothoracic (CT) resident removed the fluid compressing the left lung by needle aspiration from the back. |
Somatic nerves, ventral rami from the intercostals
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What structure(s) would be innervated by the nerves involved?
**One week following coronary artery bypass graft (CABG) surgery, a 50 year old male experienced sharp and localized pain over areas of his thoracic wall whenever he moved as he was lying in bed. X-ray examination revealed that his left lung was compressed by fluid exudate, to the extent that the lowest point of the lung was at the level of the 8th rib at the paravertebral line. The pleural effusion (PEF) in the left pleural cavity is not an uncommon consequence of bypass surgery. A cardiothoracic (CT) resident removed the fluid compressing the left lung by needle aspiration from the back. |
Skin, superficial fascia, intercostals muscles (ext., int., innermost layer), parietal pleura
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What do you think he would experience if asked to take a deep breath?
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Would increase the pain
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Why was a needle aspiration done through the posterior thoracic wall instead through the anterior thoracic wall?
**One week following coronary artery bypass graft (CABG) surgery, a 50 year old male experienced sharp and localized pain over areas of his thoracic wall whenever he moved as he was lying in bed. X-ray examination revealed that his left lung was compressed by fluid exudate, to the extent that the lowest point of the lung was at the level of the 8th rib at the paravertebral line. The pleural effusion (PEF) in the left pleural cavity is not an uncommon consequence of bypass surgery. A cardiothoracic (CT) resident removed the fluid compressing the left lung by needle aspiration from the back. |
Cardiac notch on the left, recent operation through midline of sternum, post. Post. costo-diaphragmatic recess is the lowest part where fluid accumulates
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At what intercostal space could the needle be inserted, and what structure must the resident avoid during needle placement?
**One week following coronary artery bypass graft (CABG) surgery, a 50 year old male experienced sharp and localized pain over areas of his thoracic wall whenever he moved as he was lying in bed. X-ray examination revealed that his left lung was compressed by fluid exudate, to the extent that the lowest point of the lung was at the level of the 8th rib at the paravertebral line. The pleural effusion (PEF) in the left pleural cavity is not an uncommon consequence of bypass surgery. A cardiothoracic (CT) resident removed the fluid compressing the left lung by needle aspiration from the back. |
Between rib 10 and 12 posteriorly or 9th intercostal space mid-axillary line, avoid the VAN needle is placed superior to rib
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Following a 200 meter run, an aspiring athlete is gasping for breath and grabs onto the shoulders of his coach while breathing deeply.
Why did he grab onto his coach while gasping for breath? |
to enable the accessory muscle of respiration to function optimally
What additional muscles were called into play during this forced respiration? pectoralis mm, lat. dorsi, serratus ant., scalene mm., quadratus lumborum, sternocleidomastoid, rectus abdominis How were they functioning at this time? Origin and insertion change by fixing the appendicular skeleton for pectoralis, lat. dorsi and serratus ant mm. d) How do these muscles normally function? minimal on respiration in the normal state |
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A group of teenagers were throwing peanuts into the air and catching them with their mouths. One of the youths suddenly started gasping, coughing and showed respiratory distress. He was taken to the hospital where a radiograph showed a foreign object (a peanut) trapped in the secondary bronchus leading to the right inferior lobe. The peanut was removed by bronchoscopy.
Give the anatomical explanation for the peanut to be lodged in the bronchus leading to the right inferior lobe? |
Right bronchus in the anatomical position is more in line with trachea than the left right bronchus is shorter and wider
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What nerve was irritated that resulted in coughing?
What type of nerve is this and what fiber components does it carry? **A group of teenagers were throwing peanuts into the air and catching them with their mouths. One of the youths suddenly started gasping, coughing and showed respiratory distress. He was taken to the hospital where a radiograph showed a foreign object (a peanut) trapped in the secondary bronchus leading to the right inferior lobe. The peanut was removed by bronchoscopy. |
Vagus nerve
Parasympathetic, carries pre-ganglionic fibers up to the organ where it will synapse in the substance. Parasympathetic fibers are responsible for motor innervation of the smooth cells |
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A newborn male appears severely cyanotic 7 hours after birth. Saliva is accumulating in his mouth and he is unable to swallow milk. Two days later the baby develops pneumonia.
What is the most likely cause of this condition? |
Tracheosophageal fistula
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What is the embryologic mechanism responsible for this condition?
**A newborn male appears severely cyanotic 7 hours after birth. Saliva is accumulating in his mouth and he is unable to swallow milk. Two days later the baby develops pneumonia. |
Tracheosophageal septum failed to develop properly
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What is the most common type of this anomaly?
**A newborn male appears severely cyanotic 7 hours after birth. Saliva is accumulating in his mouth and he is unable to swallow milk. Two days later the baby develops pneumonia. |
Blind ending of the superior part of the esophagus (esophageal atresia) and a joining of the inferior part of the esophagus to the trachea near its bifurcation
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A 2-month-old male infant develops dyspnea. Radiographic examination shows the intestines in the right thoracic cavity. In addition, a pneumothorax is noted.
a) What is the most likely diagnosis? b) What is the embryologic mechanism for such condition? c) How you will explain the development of this pneumothorax. |
a.Congenital diaphragmatic hernia
b.Defective formation or fusion of the pleuroperitoneal membrane with the other three parts of the diaphragm. This defect produces a large opening in the posterolateral region of the diaphragm. c.Rupture of alveoli due to pulmonary hypoplasia |
