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

2. 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

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

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

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

6. 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

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

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

17. 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

18. 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

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

20. 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°)

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

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

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

24. 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

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

26. 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

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

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

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

30. 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

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

32. 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

33. 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

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

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

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

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

38. 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)

39. 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

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

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

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

43. 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

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

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

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

47. 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

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

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

50. 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

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

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

53. 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

54. 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

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

56. 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)

57. 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

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

59.
The agony of trying to make himself understood was, if anything, topped by the agony of his listeners, trying to comprehend.