Introduction Department of Neurology CPC
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Transcript of Introduction Department of Neurology CPC
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Department of Neurology,Sawai Man Singh Medical College Hospital, Jaipur
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
FACULTY and RESIDENTS
Faculty Position Numbers
Senior Professor 4
Professor 3
Associate Professor 3
Assistant Professor(Ad hoc)
1
Senior specialist 1
Senior Resident `24
•Total Three Neurology units in SMS
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Department of Neurology
• Total OPD attendance in yr. 2015 : 107069 (January to July 2016- >80,000)
• Total IPD attendance in yr. 2015 : 6195
• Operated daily at ground floor of the Dhanwantri OPD block
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Workload &Facilities Available in the Department Investigation Number (2015)
Digital EEG 3966
NCS(VEP/BAEP) 4381
EMG 500
Video EEG 312
Ambulatory EEG 64
Total 9223
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Labs in Dept. of Neurology
Machines Numbers
NCS/EMG 4
Digital EEG 3
Conventional EEG
1(out of working order)
Video EEG 1
Ambulatory EEG 1
Polysomnography
1
Total 11
• Number of lab technicians- 6
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Neurointervention (DSA)
• Providing Diagnostic and Therapeutic services in collaboration with Neurosurgery Dept.
• Our’s was the first unit in Rajasthan to start neurointerventional work in 2007
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Dept. of Neurology Neurointerventional procedures from
June 2007 onwards
Total DSA
Types of NeurointerventionCoiling
of Aneurysm
Tumour Embolizaion
AVM Embolization
Carotid Angioplasty &
Stenting
Spinal AVM/Tumour Embolization
Intra-arterial thromobolysis/
Intra-cranial angioplasty/Mechanical
Thrombectomy
1034 154 38 28 26 18
6
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Other Specialty Services
• Botulinum toxin therapy for focal dystonias, and spasticity
• Local steroid inj. in carpal tunnel syndrome • Plasmapharesis in Neurological disorders like - GBS - MG - NMO Spectrum disorder• Regular OPD in Kanwatiya Hospital
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Emergency Neurology
• 24 hour emergency services in CNM Centre• Special treatments-IV thrombolysis for
ischemic stroke patients who present within 4.5 hours of onset
• Speciality ICU – only 4 beds
• Stroke unit awaited
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Publications, Awards, Honours & Achievements of Faculty
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Department of Neurology
• The current faculty of the department has more than 400 publications in national and international journals to its credit.
• Regular CME Programs are being organized in the department.
• National and State Level Conferences have been organized by the department
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Fellowships awarded to Dr. R S Jain • National –Senior Research Fellowship, Council of
Scientific & Industrial Research, New Delhi• National –Fellow Indian Academy of Neurology (FIAN) (1st Neurologist from Rajasthan honoured with FIAN) • International –World Federation of Neurology
Fellowship, London (U.K.)• International –Alzheimer’s Disease&Related
Disorders Fellowship, Stockholm (Sweden)
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Fellowships
• Fellowship of Borengham in Parkinson’s disease 2007 awarded to Dr.Anjani Kumar Sharma
• Fellowship of Indian College of Physicians (FICP) 2009 awarded to Dr.Anjani Kumar Sharma
• Junior Research Fellowship by CSIR in 1995 awarded to Dr. Bhawna Sharma
• Senior Research Fellowship by CSIR in 2000 awarded to Dr. Bhawna Sharma
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Fellowships
• Fellowship in Cerebrovascular intervention(Beijing China 2005-2006) awarded to Dr. Trilochan Srivastava
• Indian Academy of Neurology fellowship (2004) to study at The Institute of Neurology, Queen Square, London awarded to Dr. Dinesh Khandelwal
• Commonwealth Scholarship (2007) to study at Southern General Hospital, Glasgow, UK awarded to Dr. Dinesh Khandelwal
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Awards - Dr.R S Jain
• Awarded first ever Times Wellness Rajasthan Health Award 2013 for “Best Doctor in Neurology” in Rajasthan
• Honoured with State Award by Hon. Chief Minister, Rajasthan on 15th August,2013.
• Raja Pajvan Dev Award by Her Highness Padmini Devi Ji in Sawai Jaipur Alankaran Samaroh 2014.
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
• Honoured with State Award by Hon. Chief Minister, Rajasthan on 15th August,2013
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
• Raja Pajvan Dev Award by Her Highness Padmini Devi Ji in Sawai Jaipur Alankaran Samaroh 2014
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Letters of Appreciation
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
First women Super-specialist awarded State
Merit Certificate by Hon'ble Chief Minister of
Rajasthan on 15th August, 2010 for outstanding
contribution in Medical Field
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Palatucci Advocacy Leadership award
(2012) by American Academy of Neurology
toDr Dinesh Khandelwal
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Chapters in books
Dr. R S Jain :• Neurosarcoidosis –Reviews in Neurology,
Indian Academy of Neurology • Primary CNS Lymphoma - Reviews in
Neurology, Indian Academy of Neurology Dr. Bhawna Sharma :• Contributor - Year Book of Neurology, 2012• Contributed chapters in Annual reviews of
Neurology
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
CHAIRPERSONS – Dr. U.S.Agarwal , Principal and controller,
Dr. Hemant Malhotra , PHOD, Dept. of Medicine and CPC convener
Dr.R.S.Jain, PHOD, Dept.of Neurology
CPC MEET DEPARTMENT OF NEUROLOGY,
SMS Medical College & HOSPITAL,JAIPUR
DATE-12TH AUGUST 2016TIME-8:00AM-9:00AM
VENUE-COLLEGE AUDITORIUM
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
SMSMC-CPC:The TEAM
• DR. U.S. AGARWAL, Principal & Controller• DR. HEMANT MALHOTRA, CONVENER (9829062040,
[email protected])• DR. PUNEET SAXENA, Dept. of Medicine (9414079182,
[email protected])• DR. ARADHANA SINGH, Dept. of Medicine (9166916692,
[email protected])• DR. MONICA JAIN, Dept. of Pharmacology (9828786533,
Presenter – Dr. Tushar Desai , SR Neurology
Neurology discussant – Dr. Trilochan Srivastava, Professor , Dept. of NeurologyOrthopaedic discussant – Dr. Narendra Joshi, Professor , Dept. of orthopaedics
Endocrinology discussant – Dr. Sandeep Mathur,
PHOD, Dept. of Endocrinology CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Radiology discussant – Dr. Naima Mannan ,Professor,
Dept. of Radiology
Neurosurgery discussant – Dr.Achal Sharma,Professor, Dept. of Neurosurgery
Physical Medicine and Rehabilitation discussant – Dr. Mrinal Joshi ,PHOD ,
Dept. of PMR
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Presenter – Dr. Tushar Desai , SR Neurology (3rd yr)
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Foot Drop
Common Entity - Uncommon Etiology
Department of Neurology SMS Medical College, Jaipur
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
History• 51-year-old male , garment shop worker• Admitted in Neurology ward in Nov 14 • Insidious onset, gradually progressive, right foot
drop for six months on the background of low-backache for last 5 years
• There were no radicular pains, sensory symptoms, bladder/bowel or erectile dysfunction.
• Diabetes Mellitus diagnosed 6 months back
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
• No h/o trauma, weightlifting or weight loss • No h/o intramuscular injection• Past history - Not significant• Personal history - Non addict, vegetarian
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
General Physical Examination
• Patient was conscious oriented• No Pallor, icterus, clubbing, cyanosis,
lymphadenopathy and pedal edema • P-80 ,BP-130/90• All Peripheral vessels palpable ,no bruit
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Local examination
• Skin -no discolouration or thickening.• No hair loss • No joint pain • No bony deformity in foot
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Systemic Examination
• Chest-NAD • CVS- NAD• Per abdomen –NAD
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Neurological examination• Higher mental function-Normal• Speech -Normal• Cranial nerves-Normal• Motor exam Right Left
Bulk Normal Normal
Tone NormalDecreased slightly in foot dorsiflexors
Normal
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Power Right LeftUpper limb 5/5 5/5Lower limb-hip joint
5/5 5/5
knee joint 5/5 5/5
ankle -dorsi-flexion
2/5 5/5
ankle plantar-flexion
5/5 5/5
EHL weak strong
Dorsiflexion-2/5
Plantarflexion-5/5
RIGHT ankle joint
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Superficial reflexes
• Abdominal and cremasteric reflex –normal• Anal sphinchter tone and Bulbocavernous reflex-
normal• Plantars –B/L mute
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Deep tendon reflexes
Deep tendon reflexes
Biceps reflex
Triceps reflex
Supinator reflex
Knee reflex
Ankle reflex
Right Normal Normal Normal Brisk Absent
Left Normal Normal Normal Brisk Absent
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
• 50% sensory loss to pinprick at the right L4 dermatome level .
• Cerebellar signs- absent• No spinal or cranial deformity• SLR test -Negative
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Summary• 50 year old ,non addict ,presented with insidious
onset, gradually progressive, right foot drop on the background of low backache for last 5 years with
• LMN + subtle UMN signs • Right ankle dorsiflexors MRC grade 2/5, B/L absent ankle reflex, B/L brisk knee reflex with
B/L mute plantars along with sensory loss in right L4 dermatome and negative SLR.
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Diagnostic possibilities
• Orthopedic• Medical
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Orthopaedic discussant
Dr. Narendra Joshi Professor , Dept. of orthopaedics
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Endocrinology discussant
Dr. Sandeep Mathur
PHOD, Dept. of Endocrinology
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
LOCALIZATION OF LESIONLMN causes of foot drop
MUSCLE NEURO-MUSCULAR JUNCTION
NERVE PLEXUS RADICLE ANTERIOR HORN CELL
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
LOCALIZATION OF LESION
UMN LMN
BRAIN SPINAL CORD
FOOT DROP
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Investigations
• Hemogram, biochemistry including thyroid function tests and vitamin B12 level were normal.
• Serum HIV was negative• B. Sugar controlled on OHA
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Nerve conduction Studies
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Motor nerve conduction studies
Right Left
Peroneal NR(Non recordable) S/O axonal affection
Decreased amplitude(>50% loss) S/O axonal affection
Tibial nerve Normal Normal
Sensory nerve conduction studies
Sural Normal Normal
F WAVE
Peroneal NR NR
Tibial Normal Normal
H Reflex
Tibial NR NR
Nerve conduction Studies
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
? Asymmetric Diabetic Neuropathy(Rt>>Lt)
Points in favour• Common cause of
neuropathy.• B/L ankle reflex absent• B/L common peroneal
nerve conduction affected
Points against• B/L knee reflex brisk• Tibial and sural nerve
conduction normal
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Classification of diabetic neuropathiesGeneralised symmetric neuropathies
Focal and Asymmetric neuropathies
Combinations
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Classification of diabetic neuropathiesGeneralised symmetric neuropathies• Distal sensory or sensorimotor polyneuropathy• Small fibre neuropathy• Autonomic neuropathy• Large fibre sensory neuropathy
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Classification of diabetic neuropathiesFocal and Asymmetric neuropathies• Cranial mononeuropathy(single or multiple)• Truncal mononeuropathy (thoracic radiculopathy)• Limb mononeuropathy (single or multiple)• Proximal motor neuropathy (lumbar
radiculoplexopathy ,amyotrophy)Combinations• Polyradiculoneuropathy• Diabetic neuropathic cachexia
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Diabetic neuropathy and foot drop• Common peroneal neuropathy is the most common
of all lower limb mononeuropathies.• Diabetes mellitus responsible for 10-12 % cases.• Sensory deficit not accompanied by pain or
paresthesia
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
MRI LS Spine
Mild L4-L5 disc indentation
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
MRI LS Spine
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
? L4-L5 Radiculopathy
Points in favour• Age• Chronic low back pain• Unilateral foot drop • Sensory loss in right L4
dermatome.• B/L F wave and H reflex absent. • Mild nerve root compression at
L4-L5 disc.
Point against• No H/O radicular pain• B/L brisk knee reflex
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Myeloradiculopathy
• Chronic low back pain• B/L knee jerk were brisk• B/L ankle jerks were absent• Mild nerve root
compression at L4-L5 disc.• B/L F wave and H reflex
absent.
Point against• B/L plantars were not
extensors
Points in favour
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
MRI Cervical & Dorsal spine
Serpinginous lesion
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Neuroimaging• Neuro-Radiologist
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Department of RadiodiagnosisCPC August 2016
Dr. Ravi Prakash SainiGuided By : Dr. Naima Mannan
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
MRI Cervical & Dorsal spine
Serpinginous lesion
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
• Spinal cord edema plus dilated perimedullary vascular channels seen as vascular flow voids from C7 to D8 without an intramedullary lesion are typical for an Spinal AVM (dAVF)
Spinal cord with
edema
Perimedullary flow voids
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
CT Angiography Spine
Tortuos dilated vascular channels
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
CT Angiography Spine
Tortuos dilated vascular channels
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
CT Angiography Spine
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
CT Angiography Spine
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
CT Angiography Spine
• There is long segment collection of tortuous vessels channel noted in posterior part of spinal cord extending from C7 TO D8 levels
suggestive of spinal cord AVM.
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Four types of AVM
• Type 1- single coiled vessel (dural AV fistula)• Type 2- intramedullary glomus AVM• Type 3- juvenile• Type 4- intradural perimedullary (AV fistula) Subtype i- single arterial (ASA) small fistula Subtype ii- multiple arterial (ASA & PSA), multiple
medium fistulae Subtype iii- multiple arterial (ASA & PSA), single
giant fistula
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
• Feeding artery is not visualised.• DSA to look for feeding artery
NEUROLOGY
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Neuro-intervention-Dr.Trilochan Srivastava
Spinal digital subtraction angiography
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Spinal DSA
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Spinal DSA
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Spinal DSA
AP View
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Spinal dAVF
Intercostal art
Perimedullary vein
Radicular art
Fistula
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Oblique View
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
FINAL DIAGNOSIS
Myeloradiculopathy
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Management of Spinal dAVF
• Neurosurgery• Glue Embolization
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Neurosurgery
Dr. Achal Sharma , Professor , Dept. of Neurosurgery
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Micro-catheterization of fistula(dAVF)
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Micro-catheterization of dAVF
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
After Embolization
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Glue (nBCA) Embolization(Nov 14)
Glue cast
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Follow-up (April 15)Rt DF 3/5 PF 5/5
Relief in back pain
Absent prominent flow voids
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Follow-up (April 15)
Glue cast
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Follow-up (April 15)
Normal cord with subtle hyperintensity
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
MRI SPINEPre-Embolization Post Embolization
Prominent flow voids Absent
flow voids
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
MRI SPINEPre-Embolization Post Embolization
Cord edema with prominent perimedullary vessels
Absent cord edemaand perimedullary vessels
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Spinal CT Angiography (Sept 15)Rt DF 4/5, Rt PF 5/5
Glue cast
Glue cast
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
CT Angiography SpinePre-Embolization Post -Embolization
Serpinginous lesion Absent Serpinginous lesion
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Clinical Improvement in patient
• Relief in backpain• Improvement in power of dorsiflexors of right ankle
joint from MRC grade 2/5 to 4/5
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Foot Drop• Foot drop is defined as
weakness of the anterior tibialis and is frequently accompanied by weakness of the extensor hallucis longus (EHL) and extensor digitorum longus (EDL)
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
LOCALIZATION OF LESIONLMN causes of foot drop
MUSCLE NEURO-MUSCULAR JUNCTION
NERVE PLEXUS RADICLE ANTERIOR HORN CELL
Motor neuron disease-ALS
Anterior compartment syndromeInclusion body myositis,Myotonic dystrophy,Scapuloperoneal myopathy
Myaesthenia gravis
Common peroneal ,Sciatic neuropathy
Lumbosacral plexopathy
L5 radiculopathy
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
LOCALIZATION OF LESION
UMN LMN
BRAIN SPINAL CORD
FOOT DROP
StrokeParasagittal tumours-Meningioma , metastasis
MyelopathySpondylosismetastasis
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Foot Drop – LMN causes
• It is usually caused by LMN pathology, commonly disruption of conduction from the common peroneal nerve (L4-L5)
• L4-L5 radiculopathy is the next most common recognized cause of foot drop, usually caused by herniated nucleus pulposus or foraminal stenosis
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Common Peroneal neuropathy is the most common cause
• Nerve entrapment• Diabetes mellitus• Inflammatory neuropathy• Trauma, masses or pressure near the fibular head• Intraneural tumors• Vascular pathology
Foot Drop – LMN causes
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
WEAKNESS OF DEEP PERONEAL NERVE
COMMON PERONEAL NERVE
SCIATIC NERVE
LUMBOSACRAL PLEXUS
L5 RADICULOPATHY
FOOT DORSIFLEXION
PRESENT PRESENT PRESENT PRESENT PRESENT
FOOT EVERSION
PRESENT PRESENT PRESENT PRESENT
FOOT INVERSION
PRESENT PRESENT PRESENT
KNEE FLEXION PRESENT PRESENT PRESENT
GLUTEI MUSCLES
PRESENT PRESENT
DECREASED ANKLE REFLEX
PRESENT PRESENT PRESENT
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
SENSORY LOSS IN
DEEP PERONEAL NERVE
COMMON PERONEAL NERVE
SCIATIC NERVE
LUMBOSACRAL PLEXUS
L5 RADICULOPATHY
WEBSPACE OF GREAT TOE
PRESENT PRESENT PRESENT PRESENT PRESENT
DORSUM OF FOOT
PRESENT PRESENT PRESENT PRESENT
LATERAL CALF PRESENT PRESENT PRESENT PRESENT
LATERAL KNEE PRESENT PRESENT PRESENT
POSTERIOR THIGH
PRESENT PRESENT
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Central or UMN causes of Foot Drop
• Central or UMN causes are extremely rare but must be considered
• Compression of these fibers along the path from the cortex, internal capsule , the cerebral peduncles, and the ventral spinal cord, can potentially result in disruption of signal to the lumbar nerve roots
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Myelopathy & foot drop The UMNs of the leg are
organized somatotopically from the medial motor cortex down the internal capsule to the ventral gray matter of the spinal cord, where they are grouped in longitudinally oriented columns
Foot area
Affected area
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
Spinal dAVF• They comprise 3%–16% of all
compressive spinal cord lesions
• Attributed to 30% of idiopathic myelopathies.
• They are most often diagnosed on imaging by a neuroradiologist
• They can present with symptoms of myelopathy and radiculopathy mimicking a plethora of pathologies.
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
ONLY SINGLE CASE REPORTEmbolization of a spinal dural AV fistula after super selective
WADA test spinal AV fistula presenting as foot drop• NeuroIntervent Surg 2012;4:A70-A71 ,V Nduku et al
• Reported a case of a 79-year-old female who presented with back pain and a left foot drop. MRI suggested edema in the conus medullaris
• Spinal angiogram revealed serpiginous enhancement from T11-L1 consistent with a type I AVM (Dural AV fistula)
• She eventually underwent successful embolization with complete occlusion of the Spinal AVF
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
TAKE HOME MESSAGE
• Although rare and underappreciated, Central causes of foot drop must be included in the workup once peripheral causes have been ruled out
• A thorough history and physical examination may reveal signs of UMN disease, including hyperreflexia, and Babinski response
• Neurophysiology studies should be included in the workup and can assist in ruling out peripheral causes
• Most central causes of foot drop(identified on imaging) can have rather dramatic recovery following resection or decompression
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator
NEXT CPC MEET
• DEPARTMENT OF GASTROENTEROLOGY
9TH SEPTEMBER 2016
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator