![]() Whilst this would have been more accurate, I opted rather to accentuate the principles of latitude and longitude by using a 3×9 grid. Originally, I wanted to draw these lines of latitude (rules 1 and 2) and longitude (rules 3 and 4) directly onto a picture of the brainstem (see background image). (I added a fifth column to help visualize the location of the lateral 5 nerves) There are 4 columns to the ‘side’ beginning with S.There are 4 columns in the ‘midline’ beginning with M.V, VII, IX and XI are in the lateral brainstem The 4 motor nuclei that are above the nuclei that are in the midline, are those that divide equally into 12, except for I and II, that is III, IV, VI and XII.There are 4 cranial nerves in the medulla, 4 in the pons and 4 above the pons.To this endeavor, I had to re-discover the essence of what made the paper so good, and create an illustration, which contained each of those elements.įirstly, my illustration had to include the structure of the brainstem with its 4 sets of 4 rules. It has been quite a few years now since my exams, but I promised myself then that I would revisit the paper and try to recreate an illustration that I would like to have seen in the original publication. ![]() Given the limitations of the images, I found myself having to rewrite the text into several tables in order to grasp the concept of the paper.ĭownload the full version – LITFL Rule of 4 JPG or LITFL Rule of 4 PDF Whilst well written, the illustrations unfortunately did not reflect the simplicity of the text. It is elegant, by explaining only that which can be detected by a basic neurological examination, and it is practical, by offering a system that can be easily remembered. In this beautifully written paper, Gates devises a system of approaching clinical brainstem neuroanatomy in a series of 4 simple rules. If you have ever wondered how a Horner’s syndrome could be associated with ipsilateral ataxia and contralateral alteration in temperature sensation? Or, why you should not be surprised to find a III nerve palsy, with a contralateral hemiparesis and loss of vibration sense? If you answered yes to these questions then you should read Peter Gates’ The Rule of 4 of the Brainstem ( Int Med J 2005 263-266 – PDF). ![]()
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