Theme 2:
The nervous
system II
Summary
1
,Inhoud
Week 5: Pain...........................................................................................................................................6
Taxonomy of pain...................................................................................................................................6
A painful history.................................................................................................................................7
The (over)demanding and (over)sensitive patient..........................................................................7
Modern western medicine.............................................................................................................8
Somatic sensations: I. General organisation, the tactile and position senses...................................10
Detection and transmission of tactile sensations.........................................................................10
The dorsal column-medial lemniscal system (DC-ML system)......................................................10
Anterolateral pathway..................................................................................................................12
Somatic sensations: II. Pain, Headache and Thermal sensations......................................................14
Pain suppression: “analgesia”.......................................................................................................14
Clinical abnormalities of pain and other somatic sensations........................................................14
Headache......................................................................................................................................15
Thermal sensation........................................................................................................................15
Opioid analgesics and the management of pain...............................................................................16
Opioid analgesics..........................................................................................................................19
Pain management.........................................................................................................................21
Nonsteroidal anti-inflammatory drugs.............................................................................................23
Nonsteroidal anti-inflammatory drugs.........................................................................................24
Nonselective NSAIDs.....................................................................................................................24
Selective COX-2 inhibitors.............................................................................................................25
Paracetamol..................................................................................................................................26
Indications for using NSAIDs.........................................................................................................26
Multidisciplinary assessment of patients with chronic pain.............................................................27
Pain in the palliative phase...............................................................................................................28
Placebo and nocebo.........................................................................................................................29
Pain and occupation.........................................................................................................................30
Week 6: Headache................................................................................................................................33
Headache and facial pain......................................................................................................................33
Migraine.......................................................................................................................................33
Facial pain.....................................................................................................................................35
Cluster headache..........................................................................................................................36
Temporal arteritis.........................................................................................................................37
Tension-type headache................................................................................................................37
2
, Acute headache............................................................................................................................38
Red flags in cases of headache.....................................................................................................38
Infections of the central nervous system and meninges..................................................................40
Meningitis.....................................................................................................................................40
Brain abscess................................................................................................................................43
Viral encephalitis..........................................................................................................................44
Neurological complications of HIV infections...............................................................................46
Tuberculosis of the central nervous system.................................................................................47
Tetanus.........................................................................................................................................48
Syphilis..........................................................................................................................................48
Neuroborreliosis...........................................................................................................................49
Headache and fever..........................................................................................................................51
Pharmacotherapy in migraines.........................................................................................................52
Pathogenesis of migraine.............................................................................................................52
Drugs for migraines......................................................................................................................53
Management of migraine and other headaches...........................................................................54
Week 7.................................................................................................................................................55
Neuroanatomy: Diencephalon.............................................................................................................55
Neuroanatomy: Cerebral hemispheres/telencephalon....................................................................56
Anatomy of the cerebral hemispheres.........................................................................................56
Basal ganglia.................................................................................................................................59
Internal capsule............................................................................................................................61
Neuroanatomy: Ventricles and coverings of the brain.....................................................................63
The ventricular system.................................................................................................................63
Meninges and submeningeal spaces............................................................................................64
Skull..............................................................................................................................................66
Neuroanatomy: Vascular supply.......................................................................................................68
Arterial supply of the brain...........................................................................................................68
Venous drainage...........................................................................................................................71
Strength and sensation.....................................................................................................................74
The spinal reflex............................................................................................................................74
Sensory feeling.............................................................................................................................76
Central sensory pathways.............................................................................................................76
Segmentation of the spinal cord...................................................................................................77
Clinically relevant reflexes............................................................................................................78
Examination of the motor and sensory system............................................................................78
3
, Non-organic disorders..................................................................................................................81
Motor control...................................................................................................................................82
Central motor control...................................................................................................................82
The basal ganglia..........................................................................................................................82
The cerebellum.............................................................................................................................85
The higher cerebral functions...........................................................................................................87
Functions of the cerebral cortex...................................................................................................87
Aphasia.........................................................................................................................................87
Apraxia..........................................................................................................................................88
Agnosia.........................................................................................................................................88
Aprosody......................................................................................................................................89
Spatial disorders...........................................................................................................................89
Cognitive disorders.......................................................................................................................89
The visual system..............................................................................................................................91
Central visual information processing..........................................................................................91
Visual field defects........................................................................................................................92
Higher visual disorders.................................................................................................................93
Positive visual phenomena...........................................................................................................93
Diseases of the spinal cord...............................................................................................................94
Loss of function due to spinal injury.............................................................................................95
Traumatic spinal cord injuries.......................................................................................................96
Spinal cord compression due to non-traumatic causes................................................................97
Myelopathy without spinal cord compression..............................................................................98
The cerebrovascular system.............................................................................................................99
Arterial blood supply to the brain.................................................................................................99
Venous drainage.........................................................................................................................101
The blood-brain barrier..............................................................................................................101
The cerebral blood flow..............................................................................................................102
Pathological vascular changes....................................................................................................103
Cerebrovascular diagnostics.......................................................................................................105
Cerebral infarction and cerebral haemorrhage..............................................................................107
Terminology................................................................................................................................107
Causes and effects......................................................................................................................107
Clinical aspects of cerebral vascular occlusions..........................................................................108
Treatment for cerebral infarctions.............................................................................................109
Intracranial haemorrhages.........................................................................................................110
4
The nervous
system II
Summary
1
,Inhoud
Week 5: Pain...........................................................................................................................................6
Taxonomy of pain...................................................................................................................................6
A painful history.................................................................................................................................7
The (over)demanding and (over)sensitive patient..........................................................................7
Modern western medicine.............................................................................................................8
Somatic sensations: I. General organisation, the tactile and position senses...................................10
Detection and transmission of tactile sensations.........................................................................10
The dorsal column-medial lemniscal system (DC-ML system)......................................................10
Anterolateral pathway..................................................................................................................12
Somatic sensations: II. Pain, Headache and Thermal sensations......................................................14
Pain suppression: “analgesia”.......................................................................................................14
Clinical abnormalities of pain and other somatic sensations........................................................14
Headache......................................................................................................................................15
Thermal sensation........................................................................................................................15
Opioid analgesics and the management of pain...............................................................................16
Opioid analgesics..........................................................................................................................19
Pain management.........................................................................................................................21
Nonsteroidal anti-inflammatory drugs.............................................................................................23
Nonsteroidal anti-inflammatory drugs.........................................................................................24
Nonselective NSAIDs.....................................................................................................................24
Selective COX-2 inhibitors.............................................................................................................25
Paracetamol..................................................................................................................................26
Indications for using NSAIDs.........................................................................................................26
Multidisciplinary assessment of patients with chronic pain.............................................................27
Pain in the palliative phase...............................................................................................................28
Placebo and nocebo.........................................................................................................................29
Pain and occupation.........................................................................................................................30
Week 6: Headache................................................................................................................................33
Headache and facial pain......................................................................................................................33
Migraine.......................................................................................................................................33
Facial pain.....................................................................................................................................35
Cluster headache..........................................................................................................................36
Temporal arteritis.........................................................................................................................37
Tension-type headache................................................................................................................37
2
, Acute headache............................................................................................................................38
Red flags in cases of headache.....................................................................................................38
Infections of the central nervous system and meninges..................................................................40
Meningitis.....................................................................................................................................40
Brain abscess................................................................................................................................43
Viral encephalitis..........................................................................................................................44
Neurological complications of HIV infections...............................................................................46
Tuberculosis of the central nervous system.................................................................................47
Tetanus.........................................................................................................................................48
Syphilis..........................................................................................................................................48
Neuroborreliosis...........................................................................................................................49
Headache and fever..........................................................................................................................51
Pharmacotherapy in migraines.........................................................................................................52
Pathogenesis of migraine.............................................................................................................52
Drugs for migraines......................................................................................................................53
Management of migraine and other headaches...........................................................................54
Week 7.................................................................................................................................................55
Neuroanatomy: Diencephalon.............................................................................................................55
Neuroanatomy: Cerebral hemispheres/telencephalon....................................................................56
Anatomy of the cerebral hemispheres.........................................................................................56
Basal ganglia.................................................................................................................................59
Internal capsule............................................................................................................................61
Neuroanatomy: Ventricles and coverings of the brain.....................................................................63
The ventricular system.................................................................................................................63
Meninges and submeningeal spaces............................................................................................64
Skull..............................................................................................................................................66
Neuroanatomy: Vascular supply.......................................................................................................68
Arterial supply of the brain...........................................................................................................68
Venous drainage...........................................................................................................................71
Strength and sensation.....................................................................................................................74
The spinal reflex............................................................................................................................74
Sensory feeling.............................................................................................................................76
Central sensory pathways.............................................................................................................76
Segmentation of the spinal cord...................................................................................................77
Clinically relevant reflexes............................................................................................................78
Examination of the motor and sensory system............................................................................78
3
, Non-organic disorders..................................................................................................................81
Motor control...................................................................................................................................82
Central motor control...................................................................................................................82
The basal ganglia..........................................................................................................................82
The cerebellum.............................................................................................................................85
The higher cerebral functions...........................................................................................................87
Functions of the cerebral cortex...................................................................................................87
Aphasia.........................................................................................................................................87
Apraxia..........................................................................................................................................88
Agnosia.........................................................................................................................................88
Aprosody......................................................................................................................................89
Spatial disorders...........................................................................................................................89
Cognitive disorders.......................................................................................................................89
The visual system..............................................................................................................................91
Central visual information processing..........................................................................................91
Visual field defects........................................................................................................................92
Higher visual disorders.................................................................................................................93
Positive visual phenomena...........................................................................................................93
Diseases of the spinal cord...............................................................................................................94
Loss of function due to spinal injury.............................................................................................95
Traumatic spinal cord injuries.......................................................................................................96
Spinal cord compression due to non-traumatic causes................................................................97
Myelopathy without spinal cord compression..............................................................................98
The cerebrovascular system.............................................................................................................99
Arterial blood supply to the brain.................................................................................................99
Venous drainage.........................................................................................................................101
The blood-brain barrier..............................................................................................................101
The cerebral blood flow..............................................................................................................102
Pathological vascular changes....................................................................................................103
Cerebrovascular diagnostics.......................................................................................................105
Cerebral infarction and cerebral haemorrhage..............................................................................107
Terminology................................................................................................................................107
Causes and effects......................................................................................................................107
Clinical aspects of cerebral vascular occlusions..........................................................................108
Treatment for cerebral infarctions.............................................................................................109
Intracranial haemorrhages.........................................................................................................110
4
