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Lower Limb Neuro
 
Lower Limb Neuro
 

Power Assessment

 
 
 
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Overview

Power assessment is a key part of the motor examination, and can be used to identify focal or global weakness.
  • How to Perform

  • Ask the patient to move their hips, knees and ankles through each movement.
Start by asking the patient to move against resistance (5 / 4). If the patient cannot move against resistance, ask them to move the joint against gravity (3). If they still cannot move the joint, eliminate gravity (2). In the absence of signficant movement of the joint look for flicker movement (1 / 0). Grade as appropriate, comparing both sides.
  • Grading of Power

  • 0: no movement
  • 1: flicker of movement
  • 2 : movement without gravity
  • 3: movement against gravity
  • 4: against weak resistance
  • 5: normal power
  • Causes of Weakness

  • Upper Motor Neuron

  • Brain lesion - ischaemia, haemorrhage, tumour, trauma, encephalitis, vasculitis, demyelination
  • Spinal cord lesion - infarct, haemorrhage, abscess, transverse myelitis
  • Lower Motor Neuron

  • Nerve root pathology - trauma, radiculopathy, neoplasm
  • Brachial plexopathy
  • Focal peripheral nerve pathology - trauma, entrapment, focal ischaemia, sarcoidosis, tumour
  • Peripheral polyneuropathy - diabetic neuropathy, hypothyroidism, B12 deficiency, alcohol, paraneoplastic, Guillain-Barre, CIDP, Charcot-Marie-Tooth
  • Other

  • Neuromuscular pathology - myasthenia gravis, Lambert Eaton myaesthenic syndrome
  • Muscular pathology - muscular dystrophy, inflammatory myositis, paraneoplastic, thyroid disease, Cushing’s, statins, sarcoidosis
  • Poor compliance with examination
  • Interpretation

  • Weakness affecting an entire limb or entire side - likely due to central pathology
  • Weakness affecting a single myotome  - likely due to spinal nerve root pathology
  • Weakness affecting a single peripheral nerve distribution - likely due to a focal peripheral nerve palsy
  • Weakness affecting multiple peripheral nerve distributions - potentially due to a brachial plexus lesion
  • Generalised weakness - suggests a polyneuropathy, neuromuscular pathology or myopathy

Myotomes

Hip flexion: femoral nerve (L2-L4)Iliopsoas
Hip extension: sciatic nerve (L5/S1/S2)Biceps femoris, semitendinosus, semimembranosus
Hip adduction: obturator nerve (L2-L4)Adductor muscles, pectineus
Hip abduction: superior gluteal nerve (L4/L5/S1)Gluteus muscles
Knee flexion: sciatic nerve (L5/S1/S2)Bieps femoris, semitendinosus, semimembranosus
Knee extension: femoral nerve (L2-L4)Rectus femoris, vastus lateralis, intermedius & medialis
Ankle plantar flexion: tibial nerve (L5/S1)Gastrocnemius, soleus, peroneus muscles
Ankle dorsiflexion: deep peroneal nerve (L4)Tibialis anterior
Foot inversion: tibial nerve (L4/L5)Tibialis anterior & posterior
Foot eversion: peroneal nerve (L5/S1)Peroneus longus & brevis
Great toe extension: deep peroneal nerve (L5)Extensor hallucis longus, extensor digitorum longus

The Motor Pathway

Upper Motor Nucleus
Primary motor cortex (precentral gyrus)
 
Central Pathway
Corticobulbar tract
(via cerebral peduncle)
Decussation
Medullary Pyramids
Spinal Pathway
Lateral corticospinal tract
 
Lower Motor Nucleus
Ventral horn at the level of entry into the spinal cord
 
Neuromuscular Junction
 
 
Muscle
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