Clinical Case Correlations - 1 1. Sensory Systems: Peripheral Neuropathy, Radiculopathy, Spinal Cord Pathology William C. Broaddus

Case 1- Herniated Lumbar Disc - History 29 year old male, c/o low back pain 6 to 7 month history of low-grade LBP “snap in back” about 1 month ago, lifting object pain from L-S region to buttock, down back of left leg pain with coughing, sneezing

Chusid JG: Correlative Neuroanatomy & Functional Neurology, 18th Edition, Lange, 1982.

Chusid JG: Correlative Neuroanatomy & Functional Neurology, 18th Edition, Lange, 1982.

Clark RG: Manter & Gatz’s Essentials of Clinical Neuroanatomy and Neurophysiology, Ed. 5, Davis, 1975.

Case 1 - Herniated Lumbar Disc - Findings antalgic gait, lumbar muscle spasm positive straight-leg-raising (SLR) decreased sensation S1 dermatome weakness plantar flexion (and great toe extension) decreased ankle reflex

Case 1 - Herniated Lumbar Disc - Management conservative management imaging - lumbar spine MRI surgery (if necessary) rehabilitation

Rodnitzky RL: Van Allen’s Pictorial Manual of Neurologic Tests, Third Edition, Yearbook, 1988.

Case 1. Herniated lumbar disc Sensory Features A. Pain in the dermatomal distribution of the compressed nerve root(s) B. Positive straight leg raising test C. Decreased dermatomal sensation

Case 1. Herniated lumbar disc Sensory Features A. Pain in the dermatomal distribution of the compressed nerve root(s) due to compression and inflammation of the root

Chusid JG: Correlative Neuroanatomy & Functional Neurology, 18th Edition, Lange, 1982.

Case 1. Herniated lumbar disc Sensory Features B. Positive straight leg raising test reproduction of pain in radicular distribution with SLR due to stretching the sciatic nerve and nerve root (30° to 70°)

Case 1. Herniated lumbar disc Sensory Features C. Decreased dermatomal sensation due to compression of the root

Netter FH: Volume 1, Nervous System, Part II, Neurologic and Neuromuscular Disorders, CIBA, 1986.

Case 2 - Peripheral Neuropathy - History 40 year old male history of alcohol abuse seizure, confusion leg pain, difficulty walking after mental status improves

Case 2 - Peripheral Neuropathy - Findings pain, severe dysesthesias in both legs bilateral leg weakness, distal > proximal, bilateral foot drop “stocking” distribution sensory decrease in both legs bilateral distal muscle atrophy in legs

Peripheral Neuropathies Netter Illustration of Etiologies and Manifestations Netter FH: Volume 1, Nervous System, Part II, Neurologic and Neuromuscular Disorders, CIBA, 1986.

Case 2. Peripheral Neuropathy Sensory Features A. “Stocking” and “stocking/glove” distribution of sensory deficits B. Dysesthesia and hyperesthesia - often characterized as “pain” C. Note that mononeuropathies result in sensory (and motor) changes in the innervated area

Case 2. Peripheral Neuropathy Sensory Features A. “Stocking” and “stocking/glove” distribution of sensory deficits related to length of sensory fibers innervating limbs

Polyneuropathy Stocking-Glove Distribution of Sensory Disturbances Chusid JG: Correlative Neuroanatomy & Functional Neurology, 18th Edition, Lange, 1982.

Case 2. Peripheral Neuropathy Sensory Features B. Dysesthesia and hyperesthesia - often characterized as “pain” related to pathologic involvement of nerve fibers

Case 2. Peripheral Neuropathy Sensory Features C. Mononeuropathies result in sensory (and motor) changes in the innervated area (e.g. from diabetes or structural lesions) distinct from “stocking/glove” AND from dermatomal distributions

Rodnitzky RL: Van Allen’s Pictorial Manual of Neurologic Tests, Third Edition, Yearbook, 1988.

Case 3 - Syringomyelia - History 40 year old male, c/o hand weakness several months right, then left, hand weakness loss of sensation, right > left hand burns on right fingers

Case 3 - Syringomyelia - Findings decreased pain/temperature sensation right hand/forearm, left hand, shoulders touch sensation relatively preserved mild atrophy of hands left ptosis, miosis decreased right biceps reflex brisk lower reflexes

Case 3 - Syringomyelia - Management imaging - cervical spine MRI observation surgery

Okazaki and Scheithauer: Slide Atlas of Neuropathology, Gower, 1991.

Okazaki and Scheithauer: Slide Atlas of Neuropathology, Gower, 1991.

Okazaki and Scheithauer: Slide Atlas of Neuropathology, Gower, 1991.

Case 3. Syringomyelia Sensory Features A. Loss of pain and temperature sensation in involved dermatomes B. Preservation of touch and vibratory sense (until late in process)

Case 3. Syringomyelia Sensory Features A. Loss of pain and temperature sensation in involved dermatomes due to interference with decussating spinothalamic fibers in the anterior commissure

Glick TH: Neurologic Skills; Examination and Diagnosis, Blackwell, 1993.

Case 3. Syringomyelia Sensory Features B. Preservation of touch and vibratory sense due to sparing of posterior columns by central spinal cord cavitation

Case 4 - Tabes Dorsalis - History 51 year old male progressive episodic leg pain over 4 - 5 years 6 month H/O difficulty walking

Case 4 - Tabes Dorsalis - Findings broad-based flapping gait Romberg’s sign pupils small, unequal pupils constrict on accommodation, not to light absent knee and ankle reflexes position, vibratory sensation markedly decreased

Chusid JG: Correlative Neuroanatomy & Functional Neurology, 18th Edition, Lange, 1982.

Roberts, Hanaway, Morest: Atlas of the Human Brain in Section, Second Edition, Lea & Febiger, 1987.

Adams, Duchen: Greenfield’s Neuropathology, Fifth Edition, Oxford, 1992.

Case 4. Tabes Dorsalis Sensory Features A. Sharp, brief severe pain in lower extremities B. Markedly decreased vibratory sensation, proprioception, fine touch, especially in lower extremities C. Romberg’s sign D. Wide-based unsteady gait, with slapping feet E. Absent knee and ankle reflexes

Case 4. Tabes Dorsalis Sensory Features A. Sharp, brief severe pain in lower extremities due to involvement of dorsal roots

Case 4. Tabes Dorsalis Sensory Features B. Markedly decreased vibratory sensation, proprioception, fine touch, especially in lower extremities due to involvement of dorsal columns

Case 4. Tabes Dorsalis Sensory Features C. Romberg’s sign D. Wide-based unsteady gait, with slapping feet due to loss of proprioception, as above

Case 4. Tabes Dorsalis Sensory Features E. Absent knee and ankle reflexes due to loss of afferent (sensory) limb of spinal reflex arc

Case 5 - Brown-Sequard Syndrome - History 42 year old male, shot in chest immediate quadriplegia improved to paraparesis left leg movement returned over months

Case 5 - Brown-Sequard Syndrome - Findings right leg trace movement only hyperreflexia, clonus, increased tone pain/temperature, touch sensation intact proprioception absent left leg slight weakness decreased pain/temperature sensation

Case 5. Brown-Sequard Syndrome Sensory Features A. Loss of position sense in ipsilateral trunk and leg B. Loss of pain and temperature sensation in contralateral trunk and leg

Glick TH: Neurologic Skills; Examination and Diagnosis, Blackwell, 1993.

Case 5. Brown-Sequard Syndrome Sensory Features A. Loss of position sense in ipsilateral trunk and leg due to involvement of ipsilateral dorsal column (fasciculus gracilis)

Case 5. Brown-Sequard Syndrome Sensory Features B. Loss of pain and temperature sensation in contralateral trunk and leg due to involvement of lateral spinothalamic tract

Glick TH: Neurologic Skills; Examination and Diagnosis, Blackwell, 1993.

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