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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
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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