Charisma

T. Evangelista, MD, FPNA

San Beda College of Medicine
July 8, 2013

 To review the somatosensory pathways

To recall the technique of neurologic

examination of the somatosensory system

To be able to give a localization based on the

pattern of sensory loss

I. Anatomic Considerations

The Sensory Pathways General Schema

II. The Sensory Syndromes
A.
B.
C.
D.
E.

Peripheral peripheral nerve, roots, dorsal root ganglia

Spinal Sensory Syndromes
Brainstem
Thalamus
Parietal Lesions

A.
B.
C.

History-taking
Techniques of Examination
Final Reminders

III. Approach to the Patient with Sensory Loss

IV. Etiologic Diagnoses

V. Ancillary Diagnostics

 Pain
Light touch
Temperature Warmth and cold
Vibration sense
Position sense
Deep pressure

 Receptor
Peripheral Nerve
Spinal Root

Sensory Tract (Ascending tracts)

Thalamus
Sensory Cortex

Encapsulated receptors

Non-encapsulated
receptors

Merkels disk -
pressure

Free nerve endings -

pain

Insert pic of
dermatomes

Dermatomes
represent the
surface innervation
of the sensory nerve
roots.

C3 front of neck
C6 thumb
C7 middle nger
C8 little nger
T4 nipples
T6 xiphoid process
T10 umbilicus
L1- bikini line
L4 knee, big toe
L5 Shin
S1 little toe
S2- s3 - genitalia

Back:
C2 back of the head
C5 tip of shoulder
S2-S5 buttocks

Will vary depending on whether the nerve

involved is predominantly muscular,
cutaneous or mixed
If a cutaneous nerve is involved, the area of
sensory loss is always less than its anatomic
distribution because of overlap from
adjacent nerves.
Deep pain and perception may be intact.

 Usually the sensory impairment is bilaterally

symmetrical.

In most types of polyneuropathy, the longest

and largest bers are the most aected,

giving rise to a glove-and-stocking
distribution of sensory loss.

 Usually all modalities of sensation are

involved, but to varying degrees, with one

modality impaired out of proportion to the
others.

May be accompanied by varying degrees of

motor and reex loss.

 Follows dermatomal distribution.

If pain is present, it may be intensied by

movement of the spine and radiate in

proximal-distal fashion.

 Shooting or lancinating pains and burning

sensations arise from diseases of the nerve

roots, e.g. Sciatica, pain from the shoulder to
the upper arm from cervical disc protrusion.

Tendon and cutaneomuscular reexes may

be lost.

 Widespread disease may produce the same

sensory defects as diseases of the posterior

nerve roots.

Proximal areas of the body also show

pronounced sensory loss: face, oral mucosa,

scalp, trunk, genitalia

 Tendon reexes are also lost.

+/- dysautonomia

Main causes: paraneoplastic, connective

tissue diseases (Sjgren syndrome), toxic

exposure, idiopathic inammation.

1.
2.
3.

4.
5.

Complete spinal sensory syndrome

Hemisection of the spinal cord (Brown-
Squard Syndrome)
Syringomyelic Syndrome (Lesion of the
Central Gray MaHer) or Central Cord
Syndrome
Posterior (Dorsal) Column Syndrome
Anterior Myelopathy

Loss of ALL forms of sensation below a

level that corresponds to that lesion.
The subacute evolution of a transverse
spinal cord lesion may show a discrepancy
between the level of the lesion and that of
the sensory loss.

 Aectation of the pain and thermal sensation

on the side contralateral to the lesion

Ipsilateral proprioceptive aectation

Associated spastic motor paralysis on the

ipsilateral side

CTLS

 Abolition of pain and temperature on one or

both sides over several segments (in

dermatomal distribution) but with sparing of
tactile sensation (dissociated sensory loss)

There may be varying degrees of segmental

amyotrophy and reex loss.

 If the lesion has spread to the white matter,

corticospinal, spinothalamic, and posterior

column signs will be conjoined.

Most common etiologies: developmental

syringomyelia (especially in the cervical

region), intramedullary tumors
(ependymomas), trauma, hemorrhage

 Paresthesias may be common complaints.

Vibration and position senses are more

aected.

Usual causes: multiple sclerosis, vitamin B12

Deciency, tabes dorsalis, HIV and HTLV-1

infection.

 Loss of pain and temperature sensation

below the level of the lesion but with

relative or absolute sparing of
proprioceptive sensation.
Spastic paralysis is a prominent feature (since
the corticospinal tracts and the ventral gray
matter also lie within the distribution of the
anterior spinal artery)
Causes: Infarction of the spinal cord in the
territory of the ASA

Medullary lesions may cause crossed sensory

disturbance

Upper medulla, pons, midbrain the crossed

trigeminothalamic and lateral spinothalamic
tracts run together; lesions at this level may
cause loss of pain and temp on the opposite half
of the face and the body

Cranial nerve palsies, cerebellar ataxia, and

motor paralysis are almost invariably associated.

 Loss or diminu+on of all forms of sensa+on

on the opposite side of the body

Spontaneous pain or discomfort may appear
on the aected side of the body (thalamic
pain)
There may be hypalgesia with hyperpathia
(due to an elevated pain threshold)
Causes: Vascular (strokes), less oTen tumors

 Disturbance of discriminative sensory

functions without impairment of the primary

modalities of sensation (unless the lesion is
extensive and deep)
Sensory inattention, extinction and neglect

Examination may sometimes include

overtly hysterical ndings like ipsilateral
reduced hearing, sight, smell and taste
Impaired vibration over half the skull and
sternum
Anesthesia not conforming to the
distribution of a root or cutaneous nerve

Namamanhid
ang _____ ko.

 Ask the patient about their symptoms this

may pose a problem as the symptoms may be

unlike anything the patient has experienced
before

Ask how the sensory disturbance was rst

noted

Generally Accepted Denitions of Commonly Used Terms Regarding

the Sensory System and Abnormalities of Sensation
Allodynia*

Increase in sensibility to pain, pain in response to a stimulus not normally

painful

Alloesthesia

Perception of a stimulus at a site other than where it was delivered.

Analgesia

Absence of sensibility of pain

Astereognosis Absence of spatial tactile sensibility; inability to identify objects by feel

Anesthesia

Absence of all sensation

Dysesthesias

Unpleasant or painful sensations, either spontaneous or after a normally

nonpainful stimulus

Hypalgesia

Decrease in sensibility to pain

Hyperalgesia* Increase in sensibility to pain, pain in response to a stimulus not normally

painful
Hyperpathia* Increase in sensibility to pain, pain in response to a stimulus not normally
painful
Pallesthesia

Vibration sense

Paresthesias

Abnormal spontaneous sensations experienced in the absence of stimulation

If the complaint is arm numbness...

Symptoms constant or intermittent?
Relationship to activities
Any involvement of the arm, face, leg
Any problems with speech or vision
Neck pain?
Hand/arm weakness
Any history of injury
Any involvment of the opposite hand

If the complaint is numbness of the feet...

Whether symptoms are constant or
intermittent
If intermittent, any relation to posture,
activity or movement
Any associated pain in the back, legs, or feet
Any weakness of the legs or feet
Any history of back injury, disc herniation, or
back surgery

Symmetry of symptoms
Any bowel, bladder, or sexual dysfunction
Any history of underlying systemic disease
Any weight loss
Drinking habits
Smoking history
Any history to suggest toxin exposure, vocational, or
recreational
Dietary history
Medication history, including vitamins
Family history of similar symptoms
Family history of diabetes, pernicious anemia or
peripheral neuropathy

A.

Tools

1.

Pin

2.

Wisp of cotton

3.

Tuning fork (128 or 256 Hz)

1. Testing touch sensation

For screening purposes test only the dorsum

of the hands and feet (DeMyer)

Test each area as required by the history

(DeMyer)

2. Testing temperature sensation

Use the tuning fork versus nger or hot and

cold tubes (DeMyer)

Remember you are testing temperature

discrimination, not how much heat/cold the
patient can tolerate! (DeMyer)

3. Testing pain sensation

Use of a pin, with both blunt and sharp ends

(DeMyer).
Alternate blunt and sharp ends.
Make 3 successive pricks.
Ask the patient to respond dull or sharp.
Have the patient close his eyes.
Start with a normal area.
Avoid the thick skin of the palms and the soles.

4. Testing proprioception

Support the part to be tested.

Wiggle the digit up and down, stopping in one
direction randomly.
Make the patient watch rst, before asking
him/her to close his eyes.
Patient should not move the other digits.
You may give three alternatives (up, down, or
neutral, to reduce the chances of guessing)

5. Testing for loss of vibration sense

(pallanesthesia)

Start with the patients eyes open.

Strike the tuning fork and apply to the
patients nger- and/or toenails.
If the patient cannot feel the vibration at the
nails for as long as you can, apply the fork to
proximal bony prominences.

50%

100 % sensory
decit to pain,
t e m p e r a t u r e
and light touch
f r o m T 1 0
downwards

C. Final reminders
The sensory examination is dicult and
tedious.
The patient should be alert and attentive, full
cooperation is necessary.
Objective evidences: withdrawal of the part
stimulated, wincing, blinking, and changes in
countenance; pupillary dilation, tachycardia
and perspiration may accompany painful
stimulation.

 Obtain patient condence

Areas under examination should be

uncovered but it is best to expose various

parts of the body as little as possible.
Compare homologous areas.
Examination depends on the history.
Positive and negative symptoms may occur
together!
In patients with limited cooperation, the
abnormal area may be surveyed rst.

 There are 2 screening patterns: side to side

(usually compares the major dermatomes

and peripheral nerve distributions), and distal
to proximal (when peripheral neuropathy is a
dierential).
Sensory changes due to suggestion are
notoriously frequent in emotionally labile
individuals, but suggestion can produce
non0rganic ndings in patients with organic
disease.

Uncooperative vs. overly cooperative

Some areas of the body are more sensitive than
the others: antecubital fossae, supraclavicular
fossae, neck
Obstacles: low intellectual endowment,
language diculties, or a clouded sensorium
With altered mental status: pain may be tested
grossly by pricking or pinching the skin
In a child: it may be best to delay sensory testing
until the end of the examination

V Vascular occlusion, hemorrhage, vasculitis

I Infectious tabes dorsalis, HIV, abscesses,
granulomas
T Traumatic, Toxic gross trauma, radiation, drugs,
vertebral fractures, skull fractures
A Autoimmune SLE
M Metabolic DM, Uremia
I Inammatory Guillain-Barre Syndrome
N Neoplastic, Nutritional Leukemias, Vitamin B12
deciency, Spinal cord tumors
D Degenerative, Developmental (including
Congenital), Demyelinating Multiple sclerosis,
HSMN, Disc herniations

 Electrophysiologic testing EMG-NCV,

Somatosensory evoked potentials

Imaging tests MRI, CT scan

Blood chemistry
Fecalysis
Vitamin B12 assays

Thank you.