1/Neurology trainees! Does neuromuscular medicine make you feel off balance or week at the knees? Does even thinking about the brachial plexus give you PTSD? Don't fret and use my systematic approach with "neuromuscular buckets"!
#neurotwitter #medtwitter #neuromuscular #MedEd
#neurotwitter #medtwitter #neuromuscular #MedEd
2/When you're sure a patient has something neuromuscular but that's where you get stuck, try to localize from proximal to distal and keep it SIMPLE.
The buckets:
🪣 Motor Neuron
🪣 Root
🪣 Plexus
🪣 Nerve
🪣 Neuromuscular Junction
🪣 Muscle
The buckets:
🪣 Motor Neuron
🪣 Root
🪣 Plexus
🪣 Nerve
🪣 Neuromuscular Junction
🪣 Muscle
3/See if your patient fits into any of these buckets and consider this:
-Is there sensory involvement, motor involvement or both?
-Is it proximal, distal, asymmetric or patchy?
-Are the reflexes brisk, normal or reduced?
-Is the face involved?
-Acute, subacute or chronic?
-Is there sensory involvement, motor involvement or both?
-Is it proximal, distal, asymmetric or patchy?
-Are the reflexes brisk, normal or reduced?
-Is the face involved?
-Acute, subacute or chronic?
4/Example: 56 year old F with 2 months of progressive pain and tingling in the hands and feet, weakness/heaviness in the legs and tendency to fall. She's started using a walker.
The buckets:
🪣 Motor Neuron❌
🪣 Root
🪣 Plexus
🪣 Nerve
🪣 Neuromuscular Junction❌
🪣 Muscle❌
The buckets:
🪣 Motor Neuron❌
🪣 Root
🪣 Plexus
🪣 Nerve
🪣 Neuromuscular Junction❌
🪣 Muscle❌
5/Exam shows absent reflexes, 3/5 b/l proximal leg weakness, and patchy sensory loss (bit distal predominant), and sensory ataxia.
The buckets:
🪣 Motor Neuron❌
🪣 Root
🪣 Plexus ❌
🪣 Nerve
🪣 Neuromuscular Junction❌
🪣 Muscle❌
The buckets:
🪣 Motor Neuron❌
🪣 Root
🪣 Plexus ❌
🪣 Nerve
🪣 Neuromuscular Junction❌
🪣 Muscle❌
6/
-Mixed sensory and motor rules out motor neuron, NMJ and muscle.
-Bilateral involvement makes plexus unlikely.
-That leaves nerve roots and peripheral nerves.
-Now, consider the time course of 8 weeks (subacute) making me wonder about an inflammatory neuropathy like CIDP.
-Mixed sensory and motor rules out motor neuron, NMJ and muscle.
-Bilateral involvement makes plexus unlikely.
-That leaves nerve roots and peripheral nerves.
-Now, consider the time course of 8 weeks (subacute) making me wonder about an inflammatory neuropathy like CIDP.
7/ Finally! I have some theories that can guide my workup.
-An EMG will help differentiate axonal vs demyelinating neuropathies
-MRI L spine with and without contrast and/or LP may help as ancillary tests
-Patient may need early intervention with steroids or IVIG
-An EMG will help differentiate axonal vs demyelinating neuropathies
-MRI L spine with and without contrast and/or LP may help as ancillary tests
-Patient may need early intervention with steroids or IVIG
8/Follow me as I attempt to make neuromuscular cases less cringy for trainees! Let me know if you'd like me to dive further into the "buckets" 😎
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