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Neurology > Lumbosacral disease and neurological bladder dysfunction > Flashcards

Lumbosacral disease and neurological bladder dysfunction Flashcards

1
Q

Name 2 signs of LMN dysfunction

A
  • decreased reflexes

- decreased mm tone

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2
Q

Name 2 signs of UMN dysfunction

A
  • normal/increased reflexes

- normal/ increased mm tone

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3
Q

What is cauda equina syndrma?

A
  • dysfunction of tail, urinary and anal sphincters. Bladder and pelvic limbs affects (sciatic signs)
  • L7 caudal nn roots are affected
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4
Q

What is a ddx for cauda equina syndrome?

A

L4-S3 myelopathy

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5
Q

Ddx - chronic (acute exacerbation), progressive, asymmetrical but not markedly painful L4-S3 myelopathy

A
  • DLSS
  • IVDD (another site)
  • discospondylitis
  • myelitis
  • neoplasia
  • illiopoas mm injury
  • …
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6
Q

What is DLSS?

A

= Degenerative Lumbosacral stenosis

  • multifactoral disorder (combination of soft tissue and/or bony changes causing LS vertebral canal stenosis)
  • RESULT = cauda equina +/- L7 nn root compression (pain)
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7
Q

What is discospondylitis?

A

bacterial infection of the disc space - often febrile

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8
Q

List some soft tissue and bony changes that can cause LS vertebral stenosis?

A
  • intervertebral disk protrusion
  • ligamentous hypertrophy
  • articular process hypertrophy
  • osteophyte formation
  • vertebral misalignment
  • telescopy dorsal lamina
  • transitional vertebra
  • lumbosacral osteochondrosis (OCD)
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9
Q

Which animals are affected by DLSS?

A
  • typically adult/ older large breeds

- PREDISPOSITIONS: GSD, active/ working dogs, LS malformations

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10
Q

CS - DLSS

A
  • lumbosacral pain
  • pelvic limb lameness (root signature)
  • reluctance to jump, run stairs, jump into car
  • paraparesis/ ataxia
  • low tail carriage, flaccid tail
  • urinary and faecal incontinence
  • ORTHOPAEDIC EXAM: pain on direct lumbar spinal palpation, pain on hip extension
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11
Q

Where does the pudendal nerve originate?

A

comes off the sacral nn

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12
Q

How can you differentiate OA/ stifle disease from DLSS/ neuro conditions?

A

PAW POSITIONING REFLEXES: likely present with OA/ stifle disease and very reduced or absent with neuro disease

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13
Q

Dx - DLSS

A

IMAGING AND CS (consistent) +/- electrodiagnostics

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14
Q

What does a lumboscaral transitional vertebra in the dog predispose?

A

8 x increased risk of developing cauda equina syndrome

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15
Q

How useful is myelography?

A

rarely useful

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16
Q

Method - myelography

A
  • injection of radioopaque contrast into subarachnoid space
  • thecal sac generally narrows and ends near LS
  • may see attenuation of contrast over LS if severe midline compression
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17
Q

What is the thecal sac?

A

membrane of dura mater that surrounds SC and cauda equina, filled with CSF

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18
Q

What does CT show as surrounding the cauda equina nerve and thecal sac? How does this change in DLSS

A

epidural fat surrounds the cauda equina nn and thecal sac, providing a natural source of tissue contrast. In DLSS epidural fat is displaced: confuses differentiation compressive soft tissue and adjacent neural structures.

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19
Q

What does intravenous contrast-enhanced CT show?

A

discrimination of compressive soft tissues within the vertebral canal

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20
Q

What is the diagnostic imaging modality of choice for DLSS?

A

MRI (as a T1w image)

- shows displacement of epidural fat around the spinal cord and nn root compression as they come off the cauda equina

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21
Q

Overview - tx of DLSS

A

Medical or surgical

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22
Q

Medical tx - DLSS

A
  • activity restriction
  • +/- anti-inflammatories (NSAIDs)
    +/- analgesics
    +/- neuromodulatory drugs (gabapentin)
  • topical corticosteroids (epidural injection)
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23
Q

Sx tx - DLSS

A 
- decompressive laminectomy
\+/- discectomy
- foraminotomy
- stabilisation
- distraction + stabilisation
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24
Q

How do electrodiagnostics help in diagnosing DLSS?

A

MAY assist in determining clinical significance of radigraphic lesions

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25
Q

What do CT findings for DLSS suggest?

A

that some lumbosacral CT abnormalities may be clinically insignificant, especially in older dogs.

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26
Q

What is discectomy?

A

excision of protruding annulus fibrosus

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27
Q

How succesful is decompressive laminectomy?

A

Good to excellent outcome in 78% dogs. Significant correlation b/w presence of urinary incontinence prior to sx and poor outcome.

28
Q

What is gabapentin?

A

neuromodulator to control nn root pain

29
Q

CS - cauda equina syndrome - horses

A
  • tail paralysis
  • dilated anus
  • loss of perineal sensation
  • faecal retention
30
Q

Ddx - Equine cauda equina syndrome - 3

A
  • TRAUMA: sacral fracture (common)
  • INFECTIOUS: EHV-1 myeloencephalopathy (highly infectious and fatal)
  • INFLAMMATORY: polyneuritis equi
31
Q

Why might you have an absent cutaneous trunci lesion on RHS lumbar region?

A

Right brachial plexus lesion

32
Q

Describe the cutaneous trunic reflex pathway

A

= 3 neuron pathway:

  1. peripheral/sensory
  2. second order neuron - both sides of SC
  3. motor neuron
33
Q

What drug toxicity can cause Schiff-Scherrington posture?

A

Metronidazole.Tx is simply to stop giving the animal this drug. Usually a higher than recommended dose is being used (usually 30mg/kg +)

34
Q

T/F: don’t give animals a poor prognosis based on severity of CS

A

True. Don’t always impulse euthanase if your case has severe neuro signs.

35
Q

What is decompressive laminectomy?

A

sx to relieve pressure on nn roots. It removes part of vertebrae and/or thick tissue that is narrowing sinal cord and squeezing spinal roots

36
Q

Where will proprioceptive deficits be seen if lesion is in forebrain/ thalamus?

A

contralateral side

37
Q

Where will proprioceptive deficits be seen if lesion is in the brainstem?

A

ipsilateral side

38
Q

How do you differentiate a lesion in optic chiasm versus bilateral occulomotor paralysis?

A

menace reflex - present with occulomotor paralysis (turning head/neck/trunk away, blinking may be absent). Will be absent with optic chiasm lesion.

39
Q

T/F: if the limbs aren’t working, the bladder may not be either

A

True

40
Q

Name the bladder mm

A

Detrusor mm (SMC)

41
Q

What are the mm in the urethra?

A
  • Internal urethral sphincter (SMC)

- External urethral sphincter (skeletal mm)

42
Q

Location of micturition centre

A

pons

43
Q

Origin - hypogastric nn

A

L1-L4

44
Q

Origin - pelvic nn

A

S1-3

45
Q

Origin - pudendal nn

A

S1-3

46
Q

Describe bladder in storage phase

A
  • sympathetic dominance
  • bladder relaxes with stimulation of B-receptors
  • urethral sphincter contracts with stimulation of A-receptors
  • parasympathetic tone inhibited
47
Q

Describe the bladder in the voiding phase

A
  • parasympathetic dominance
  • bladder contracts with stimulation of muscarinic Ach-Rs
  • urethral sphincter relaxes
  • sympathetic tone inhibited
48
Q

Where does input come from for sympathetic dominance in storage phase?

A
  • cerebral cortex

- cerebellum

49
Q

Outline the somatic component of bladder storage phase

A
  • somatic control (voluntary motor control)
  • under the influence of pudendal nn –> Ach –> urethral sphincter mm contraction (nicotinergic cholinergic receptors)
  • pudendal nn arises from S1-S3
50
Q

Outline parasympathetic component of voiding phase

A
  • pelvic nn controls this
  • from S1-S3
  • causes bladder to contract by release of Ach onto muscarinic cholinergic receptors on bladder
51
Q

What is a UMN bladder?

A
  • lesion between pons and L7
  • L1-4 affected (hypogastric)
  • hallmark: increased bladder tone
  • turgid easily palpable bladder, increased urinary sphincter tone
  • EXPRESSION: difficult
52
Q

What is a ‘LMN bladder’?

A
  • lesion b/w sacral spinal cord or sacral nn
  • this is a potential finding of cauda equina syndroma
  • S1-3 affected (pelvic and pudendal nn)
  • HALLMARK: decreased bladder tone
  • other: flaccid, difficult to palpate bladder, difficult to express/ hard to palpate, decreased urinary sphincter tone
53
Q

Problems associated with neurogenic bladder dysfunction

A
  • incontinence
  • urine scalding
  • urine stasis
  • UTI
  • detrusor atony (more and UMN problem)
  • pain/discomfort (if bladder stretches +/- UTI but is unable to void, pain receptors continue to be stimulated)
54
Q

T:F both UMN and LMN bladder can dribble urine (incontinence)

A

True

  • UMN because high internal pressure
  • LMN because external bladder pressure and uncontracted outlow tract tone.
  • differentiate by palpating bladder
55
Q

How can neurogenic bladder dysfunction be managed?

A
  • AIM: help bladder empty
  • physical management
  • pharmacological management (physical managment usually still required)
56
Q

Physical management - neurogenic bladder dysfunction

A
  • manual expression
  • urethral catheterisation (indwelling or intermittent)
  • cystostomy tube placement (more long term)
57
Q

Diazepam - control of bladder function

A
  • ACTION: centrally acting skeletal mm relaxant
  • AIM: decrease external urethral sphincter tone
  • USE: 1hr before manual expression
58
Q

Bethanechol - control of bladder function

A
  • ACTION: muscarinic cholinergic agonist (parasympathomimetic)
  • AIM: facilitate detrusor mm contractility
  • USE: less popular, may be off market, care when high urethral sphincter tone as may increase risk of bladder rupture
59
Q

Phenoxybenzamine - control of bladder function

A
  • ACTION: alpha-adrenergic antagonist
  • AIM: decrease internal urethral sphincter tone
  • SIMILAR DRUG: prazosin
60
Q

Prazosin - control of bladder function

A
  • ACTION: alpha-adrenergic antagonist
  • AIM: decrease internal urethral sphincter tone
  • SIMILAR DRUG: phenoxybenzamine
61
Q

Phenylpropanolamine (PPA) - control of bladder function

A
  • ACTION: mixed (alpha and beta) adrenergic agonist
  • AIM: increase internal urethral sphincter tone
  • USE: treating incontinence rather than urine retention
62
Q

Of the urethral sphincter, which one holds the most pressure?

A

internal urethral sphincter

63
Q

Name 5 drugs used in bladder pharmacological manipulation

A
  • diazepam
  • bethanechol
  • phenoxybenzamine
  • prazosin
  • phenylpropanolamine (PPA)
64
Q

What is a very plantigrade stance in cats characteristic of?

A

sciatic involvement (lesion)

65
Q

What is the commonest feline spinal cord neoplasm?

A

lymphosarcoma

Neurology (26 decks)

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