Medical and Legal Aspects of Neurology

Jeffrey Wishik, M.D., J.D.

Table of Contents  (Back to book ordering page)

Preface xiii

Chapter 1: Introduction: Neurology and Neurologists 1
1.1 The Specialty of Neurology 1
1.2 The Making of a Neurologist 3
A. College and medical school 3
B. Neurology training 3
C. Subspecialties 4
1.3 Recognition of Competency: Certification 5
A. American Board of Psychiatry and Neurology (ABPN) 5
B. Other certifications 6
1.4 Professional Organizations 7
A. American Academy of Neurology (AAN) 8
B. American Neurological Association (ANA) 9
C. American Clinical Neurophysiology Society (ACNS) 9
D. American Headache Society (AHS) 9
E. American Association of Neuromuscular & Electro-diagnostic Medicine (AANEM) 10
1.5 Practice Standards and Guidelines 10
1.6 The Literature of Neurology 12
A. Learned treatises 12
B. Journals 12
Endnotes 13
Additional Reading 15

Chapter 2: The Diagnostic Process 17
2.1 Introduction 17
2.2 General Organization of the Nervous System 18
2.3 Localization and Diagnosis 21
2.4 The Neurologic History 22
Endnotes 24
Additional Reading 24

Chapter 3: Diagnostic Testing 27
3.1 Introduction 27
3.2 Imaging 28
A. X-ray 28
B. Computerized tomography (CT) 28
C. Magnetic resonance imaging (MRI) 29
D. Angiography 31
E. Myelography 31
F. Functional neuroimaging 31
3.3 Clinical Neurophysiology 33
A. EEG (electroencephalogram) 33
B. EMG (electromyography) and NCS (nerve conduction studies):
    Uses and limitations 37
C. Evoked potential (EP) studies 40
3.4 Lumbar Puncture 41
A. Postlumbar puncture headache 42
B. Other complications of lumbar puncture 43
3.5 Biopsies 44
3.6 Neuropsychology 44
3.7 Neurogenetics 46
Endnotes 47
Additional Reading 49

Chapter 4: Sensory and Motor Function 51
4.1 Sensory System 51
A. Peripheral receptors 53
B. Transmission to the brain 53
C. Central processing 58
D. Sensory examination 59
E. Interpretation of sensory symptoms and signs 59
F. Sensory syndromes by location 63
4.2 Central Control of Movement 64
A. Pathways to the periphery 64
B. Motor examination 68
C. Motor abnormalities 70
4.3 The Cerebellum and Coordination 73
Endnotes 74
Additional Reading 74

Chapter 5: Cranial Nerves: Organization, Function and Examination 75
5.1 Introduction 75
5.2 Olfactory Nerve (CNI) 75
5.3 Optic Nerve (CNII) 79
5.4 Oculomotor, Trochlear, and Abducens Nerves (CN III, IV, and VI) 81
5.5 Trigeminal Nerve (CN V) 84
5.6 Facial Nerve (CN VII) 85
5.7 Vestibulocochlear Nerve (CN VIII) 87
5.8 Glossopharyngeal Nerve (CN IX) 88
5.9 Vagus Nerve (CN X) 89
5.10 Spinal Accessory Nerve (CN XI)14 89
5.11 Hypoglossal Nerve (CN XII) 90
Endnotes 90
Additional Reading 91

Chapter 6: Brain and Higher Cortical Function 93
6.1 Basic Organization of the Brain 93
6.2 Evaluation of Cortical Function 97
6.3 Coma and Brain Death 98
A. Coma 98
B. Brain death 100
6.4 Language Disorders-Aphasias 101
A. Broca's aphasia 101
B. Wernicke's aphasia 102
C. Conduction aphasia 102
D. Transcortical aphasia 102
E. Other syndromes 103
6.5 Memory and Amnesias 103
A. Memory 103
B. Amnesias 104
6.6 Apraxia and Agnosia 105
Endnotes 107
Additional Reading 108

Chapter 7: Chronic Pain, Somatization, and Symptom Magnification 109
7.1 Introduction 109
7.2 Pain Assessment 111
A. Fundamentals 111
B. Pain assessment tools 111
C. Impairment ratings for pain 114
7.3 Pain Classification 115
A. Acute and chronic pain 116
B. Chronic neuropathic pain 116
7.4 Chronic Pain Syndrome (CPS): Nonorganic Pain 119
7.5 Somatization 120
A. Factitious disorders and malingering 121
B. Somatoform disorders 122
7.6 Assessing Symptom Magnification 123
7.7 Legal and Regulatory Aspects of Pain Management 126
Endnotes 127
Additional Reading 131

Chapter 8: Traumatic Brain Injury 133
8.1 Introduction 133
8.2 Assessment of Severity 135
8.3 Injury Mechanisms 136
8.4 Consequences of TBI 139
A. DAI and coma 139
B. Focal brain damage 139
C. Epilepsy 140
D. Hydrocephalus 142
E. Hematomas 142
F. Cranial nerve lesions 143
8.5 Mild Head Injury and Postconcussion Syndrome 145
Endnotes 148
Additional Reading 149

Chapter 9: Spine and Nerve Root Disorders 151
9.1 Introduction 151
9.2 Low-Back and Neck Pain 153
A. Acute neck and low-back pain 154
B. Chronic neck and low-back pain 156
9.3 Spinal Cord Injury 157
A. Background 157
B. Acute management 159
C. Rehabilitation considerations 160
9.4 Spinal Spondylosis and Disk Disease 162
9.5 Whiplash 165
Endnotes 168
Additional Reading 169

Chapter 10: Peripheral Neuropathy 171
10.1 Introduction 171
A. Classification of neuropathies 172
B. Evaluation 174
10.2 Peripheral Nerve Trauma 174
A. Mechanisms of damage 174
B. Double crush syndrome 175
10.3 Carpal Tunnel Syndrome 176
10.4 Other Mononeuropathies 177
A. Upper limb 177
B. Lower limb 179
10.5 Brachial Plexus Abnormalities 180
A. Anatomy 180
B. Brachial plexopathies 180
C. Thoracic outlet syndrome 182
10.6 Other Acquired Neuropathies 183
A. Acute acquired neuropathies 183
B. Subacute acquired neuropathies 184
C. Chronic acquired neuropathies 184
10.7 Inherited Neuropathies 185
Endnotes 185
Additional Reading 188

Chapter 11: Seizures and Epilepsy 189
11.1 Background 189
11.2 Diagnosis 191
11.3 Nonepileptic Seizures 192
A. Physiologic nonepileptic paroxysmal disorders 193
B. Psychogenic nonepileptic paroxysmal disorders 193
11.4 Seizure Types 195
A. Partial seizures 195
B. Generalized seizures 196
11.5 Epilepsy Syndromes 197
A. Localization-related epilepsies 197
B. Generalized epilepsies 197
11.6 Epilepsy Treatment 198
A. General considerations 198
B. Pregnancy and epilepsy 200
C. Surgical treatment 201
11.7 Sudden Unexpected Death in Epilepsy Patients (SUDEP) 202
11.8 Epilepsy and the Law 203
A. Driving 203
B. Aggression, criminal acts, and the epilepsy defense 204
Endnotes 205
Additional Reading 208

Chapter 12: Stroke and Other Cerebrovascular Diseases 209
12.1 Introduction 209
12.2 Transient Ischemic Attack (TIA) 210
A. Manifestations 211
B. Causation 212
C. Evaluation 213
D. Management 214
12.3 Stroke 215
A. Clinical manifestations 216
B. Initial management 216
C. Thrombolysis: Medical and legal aspects 218
12.4 Subarachnoid Hemorrhage (SAH) 219
12.5 Cerebral Venous Thrombosis 220
12.6 Temporal (Giant Cell) Arteritis 220
Endnotes 222
Additional Reading 224

Chapter 13: Multiple Sclerosis and Demyelinating Diseases 225
13.1 Introduction 225
13.2 Generalized Multiple Sclerosis (MS) 226
A. Trauma, stress, vaccines, and multiple sclerosis 226
B. Clinical manifestations 227
C. Course and prognosis 230
D. Diagnosis 231
E. Treatment 232
13.3 Isolated Demyelinating Syndromes 233
A. Optic neuritis 234
B. Transverse myelitis 235
C. Neuromyelitis optica (Devic's disease) 235
13.4 Other Demyelinating Syndromes 236
Endnotes 236
Additional Reading 238

Chapter 14: Brain and Spinal Cord Tumors 239
14.1 Introduction 239
14.2 Clinical Presentations 240
14.3 Basics of Treatment 241
14.4 Primary Intracranial Tumors 242
A. Gliomas 242
B. Meningiomas 243
C. Primary central nervous system lymphoma (PCNSL) 243
D. Acoustic neuromas (vestibular schwannomas) 244
E. Pituitary tumors 244
14.5 Metastatic Brain Tumors 245
14.6 Paraneoplastic Syndromes 245
14.7 Spinal Tumors 246
A. Background 246
B. Epidural metastases 246
Endnotes 247
Additional Reading 249

Chapter 15: Headache 251
15.1 Introduction 251
15.2 Migraine 253
15.3 Cluster Headaches 257
15.4 Tension-type Headaches 258
15.5 Cervicogenic Headache 259
15.6 Pseudotumor Cerebri (Benign Intracranial Hypertension) 259
Endnotes 260
Additional Reading 261

Chapter 16: Infectious Diseases 263
16.1 Introduction 263
16.2 Acute Meningitis 264
A. Pneumococcal meningitis 267
B. Meningococcal meningitis 267
C. Haemophilus influenzae meningitis 268
16.3 Chronic Meningitis 268
16.4 Syphilis and Lyme Disease 268
A. Neurosyphilis 269
B. Lyme neuroborreliosis (LNB) 270
16.5 Brain Abscess 271
16.6 Acute Viral Encephalitis 272
16.7 Human Immunodeficiency Virus 273
16.8 Prion Diseases 274
Endnotes 275
Additional Reading 278

Chapter 17: Neuromuscular Diseases 279
17.1 Muscle Diseases 279
A. Inherited myopathies 280
B. Acquired myopathies 283
17.2 Neuromuscular Junction Diseases 285
A. Myasthenia gravis (MG) 285
B. Lambert-Eaton myasthenic syndrome (LEMS) 287
17.3 Motor Neuron Diseases 288
A. Amyotrophic lateral sclerosis (Lou Gehrig's disease) 288
B. Spinal muscular atrophies (SMA) 290
C. Acute poliomyelitis and postpolio syndrome 291
Endnotes 291
Additional Reading 293

Chapter 18: Dementias 295
18.1 Introduction 295
A. Evaluation 296
B. Mild cognitive impairment (MCI) 297
C. Cortical and subcortical dementias 298
18.2 Alzheimer's Disease (AD) 298
18.3 Vascular Dementia 299
18.4 Frontotemporal Dementia 300
18.5 Dementia with Lewy Bodies (DLB) 301
18.6 Legal and Ethical Implications 301
Endnotes 303
Additional Reading 304

Chapter 19: Movement Disorders 305
19.1 Introduction 305
19.2 Parkinson's Disease (PD) 306
19.3 Parkinsonism-Plus Syndromes 308
19.4 Hyperkinetic Disorders 309
A. Dystonia 310
B. Chorea 310
C. Tremor 311
D. Myoclonus 312
E. Tics 312
19.5 Psychogenic Movement Disorders 313
19.6 Posttraumatic Movement Disorders: Legal Implications 314
Endnotes 316
Additional Reading 318

Chapter 20: Attention Deficit Hyperactivity Disorder (ADHD) 319
20.1 Introduction 319
20.2 Symptoms, Diagnosis, and Comorbidities 320
20.3 Etiologies and Neurobiology 321
20.4 Treatment 323
20.5 Medicolegal Concerns 324
A. ADHD and criminal law 324
B. ADHD and education 325
Endnotes 326
Additional Reading 328

Chapter 21: Iatrogenic Disorders 329
21.1 Introduction 329
21.2 Drug-Induced Neurological Disorders 329
A. Drug-induced movement disorders 330
B. Other drug-induced neurologic disorders 332
21.3 Complications of Vascular Disease Treatment 333
21.4 Iatrogenic Infections of the Central Nervous System 334
21.5 Neurologic Side Effects of Radiation Therapy 334
Endnotes 335
Additional Reading 336

About the Author 337
Index 339

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