Table Of ContentCutaneous distribution of the nerves of the body
First of four views. The anterior cutaneous nerve of the neck has been
renamed the transverse cutaneous nerve of the neck. The lower lateral
cutaneous nerve of the arm is now recognized as part of the posterior
cutaneous nerve of the forearm. Lumboinguinal nerve refers to the
femoral branch of the genitofemoral nerve.
Reproduced with permission from Haymaker, W. and Woodhall, B. (1998). Peripheral Nerve
Injuries: Principles of Diagnosis, 2nd edn. American Association of Neurological Surgeons.
Second of four views. See comment opposite regarding the lower lateral
cutaneous nerve of the arm.
Reproduced with permission from Haymaker, W. and Woodhall, B. (1998). Peripheral Nerve
Injuries: Principles of Diagnosis, 2nd edn. American Association of Neurological Surgeons.
Cutaneous distribution of the nerves of the body
Third of four views. The inferior lateral and inferior medical clunical nerves
have been renamed perineal branches of the posterior cutaneous of the
thigh. See comment in Fig. A4 legend regarding the lower lateral cutane-
ous nerve of the arm.
Reproduced with permission from Haymaker, W. and Woodhall, B. (1998). Peripheral Nerve
Injuries: Principles of Diagnosis, 2nd edn. American Association of Neurological Surgeons.
Fourth of four views. The names of some nerves have been changed as
follows: The clunical nerves (inferoir lateral and inferior medial) are now
termed the perineal branches of the posterior cutaneous nerve of the thigh;
the inferior hemorrhoidal nerve is now called the inferior rectal nerve.
Reproduced with permission from Haymaker, W. and Woodhall, B. (1998). Peripheral Nerve
Injuries: Principles of Diagnosis, 2nd edn. American Association of Neurological Surgeons.
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Neurology
Hadi Manji
Consultant Neurologist and Honorary Senior Lecturer
National Hospital for Neurology and Neurosurgery
Queen Square, London; and Consultant Neurologist
Ipswich Hospital NHS Trust, UK
Seán Connolly
Consultant in Clinical Neurophysiology
St Vincent’s University Hospital Dublin, Ireland
Neil Dorward
Consultant Neurosurgeon and Honorary Senior Lecturer
Royal Free Hospital London, UK
Neil Kitchen
Consultant Neurosurgeon, National Hospital for
Neurology and Neurosurgery, Queen Square, London, UK
Amrish Mehta
Consultant Neuroradiologist, Hammersmith Hospitals
NHS Trust, London, UK
Adrian Wills
Consultant Neurologist, Queen’s Medical Centre,
Nottingham, UK
iv
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1 v
Foreword
Pass any young doctor in the corridor of a busy general hospital and the
chances are that person will be carrying an Oxford Handbook relevant
to their current clinical attachment. Surprise any consultant reviewing
notes from a recent clinic in the office and the same book may also be
(more discreetly) close at hand. Previously, those dealing with the intri-
cacies of clinical neurology were disadvantaged. Now, Hadi Manji, Seán
Connolly, Neil Dorward, Neil Kitchen, Amrish Mehta, and Adrian Wills
have put right this defect. The team offers expertise in clinical neurology,
neurosurgery, neurophysiology, and neuroradiology. And, as consultants
working in busy clinical neuroscience centres, each brings to his contribu-
tion the discipline of a classical approach to the neurological encounter
together with pragmatism, much common sense, and a good deal of
clinical experience.
This is not a book to read expecting the rich and discursive prose narra-
tives of the eloquent clinical expositor; nor, equally, one in which to be
ensnared by the weeds of descriptive reflexology or shackled by the
competitive impedimenta of eponymous hagiography—although a useful
appendix lists some names that have echoed through the corridors of
neurological establishments down the ages. Rather, it is a book for both
the specialist and generalist to consult when faced with the typical, but
nonetheless complex, presentations of neurological and neurosurgical
disorders; one from which to be reminded of how best to investigate and
manage the many conditions—common and otherwise—that affect the
central and peripheral nervous systems and muscle; and one that wisely
sets out what to expect from laboratory investigations, and how these
inform clinical formulations that remain the substance of clinical neurol-
ogy. Bullet points, lists, and algorithms for diagnosis and management may
not make for bedtime reading but they do provide an economic and
invaluable synthesis for others of what needs to be known in order to
manage diseases of the nervous system effectively. Having done this
successfully for themselves on many occasions in the clinic and on the
wards, the team of experts now passes on its experience and under-
standing of neurological and neurosurgical disease to a wider readership.
Do not look for copies of the Oxford Handbook of Neurology sitting undis-
turbed on dusty office shelves. This book will only be found alongside the
many dog-eared and well-thumbed copies of its 35 companion volumes
in the pockets and on the desktops of busy students of neurological
disease.
Professor Alastair Compston
University of Cambridge
October 2006
vi
Oxford University Press makes no representation, express or implied,
that the drug dosages in this book are correct. Readers must therefore
always check the product information and clinical procedures with the
most up-to-date published product information and data sheets provided
by the manufacturers and the most recent codes of conduct and safety
regulations. The authors and the publishers do not accept responsibility
or legal liability for any errors in the text or for the misuse or misapplica-
tion of material in this work.
1 vii
Preface
General physicians have always found neurology difficult and perhaps
intimidating. This is a reflection of inadequate training and perhaps per-
petuated by the neurologists of a bygone era. Neurology still remains the
most clinical of the medical subspecialities—investigative tools such as
MRI and DNA analysis will never replace the basic neurological history-
taking and examination, which when performed skilfully, is wonderful to
watch. This is not some voodoo technique revealed to the chosen few
but can be learnt from good role models and practise.
Even today, neurological training remains a clinical apprenticeship with
hints and ‘clinical handles’ that are passed down from teacher to pupil
and are not in the standard textbooks. In this book we have tried to
pepper these in when appropriate. In keeping with the style of the
Oxford Handbook series the format is necessarily didactic and hopefully
clear for the reader when faced with a patient with neurological symp-
toms and signs.
Neurology and neurologists have had a reputation for ‘being elephan-
tine in their diagnostic skills but murine in their therapeutic strategies’.
This has changed with numerous treatment options now being available.
Although neither dramatic in their benefit nor curative, options now exist
for patients with multiple sclerosis, Alzheimer’s disease, motor neuron
disease, Parkinson’s disease, and ischaemic stroke.
Our hope is that this book will go some way to smooth the neuro-
logical pathways for juniors in training and perhaps even some senior
colleagues!
‘…few patients oblige with the symptoms it is their duty to have
and not many refrain from complaining of those they ought
not to have. When I tried to teach the art of medical diagnosis
to students, I often used to ask them this riddle: “what runs
about farm yards, flaps its wings, lays eggs and barks like a dog?”
…the answer is a hen! Usually one of the more earnest and
innocent of the students would say: “but sir! I don’t understand
the bit about barking like a dog”. Ah yes, I must explain.
That was just put in to make it difficult.’
[Richard Asher quoted in British Medical Association (1984).
A sense of Asher; a new miscellany. BMA, London.]
Hadi Manji
September 2006
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1 ix
Acknowledgements
Dr Mike Lunn and Dr Andrew Graham for reading the manuscript and
making helpful suggestions; Dr Chris Hawkes for his help with ‘Clinical
Pearls’; Catherine Barnes and Elizabeth Reeve for their steadfast support
and encouragement.
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