Major sensory (ascending) tracts and senses

u Spinothalamic tracts (aka anterolateral tracts)

u Light touch
u Pain
u Temperature
u Dorsal columns

Sensory loss and pain u

u
Proprioception (conscious)
Vibration
u Spinocerebellar
u Proprioception (unconscious)

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Localising the lesion Dermatomes

Site Distribution of sensory loss Motor losses Other u Correspond to area of skin innervated by a single spinal level
Cerebrum Contralateral half of body and face + (usually) Higher cortical dysfunction u Key dermatomes
u C6 - thumb
e.g. dysphasia, dyspraxia, u C7 middle finger
neglect u C8 little finger
u T4 nipples
Thalamus Contralateral half of body and face +/- Thalamic pain syndromes u T10 umbilicus
intense pain on one side of the u Help to localise lesions at the spinal cord level
body u E.g. sensory loss to L1, where is the lesion?
Brainstem Contralateral half of body, ipsilateral + (usually) Cranial nerve dysfunction u L1
u OR 1-2 levels above L1 as spinothalamic fibres can travel upwards 1-2 levels in Lissauers tract
face (if at pons) Horners syndrome
Spinal cord Facial sparing and sensory level + (usually) See later

Peripheral nerves Usually confined to one limb +/- Pattern of a specific nerve,
glove and stocking distribution
in diabetics

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Sour

Spinal cord syndromes

Spinothalamic Dorsal columns Corticospinal Other

Anterior cord syndrome + + Vascular insult only one

artery supplies anterior cord

Central cord syndrome + cape-like distribution of In late stages Expanding lesion e.g. syrinx
loss (arms + thorax); of syringomyelia. Impinges
suspended affected the crossing fibres of the
areas are suspended spinothalamic tract.
between face and legs that
are unaffected

Posterior cord syndrome + In late stages Neurosyphillis, vitamin B12

deficiency

Cord hemisection (Brown-
Sequard syndrome)
Source:
http://www.iwsf.com/06Disabled/
06Handbook_files/image016.jpg
+ (opposite side of lesion)
+ (same side as lesion) + (same side as lesion) Rare usually due to
penetrating knife injuries.
Spinothalamic loss is on the
opposite side as
spinothalamic fibres cross at
the spinal cord level.

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 Radiculopathy and neuropathy Important upper limb mononeuropathies

u Radiculopathy Sensory loss Motor loss Other

u Sensory loss due to pathology affecting the nerve root
u Common causes osteophyte impingement, disc herniation; rarer tumours Median nerve Thenar eminence, thumb, 1st LOAF muscles Commonly carpal tunnel
u Usually results in sensory loss confined to single dermatome +/- loss of motor two digits, radial half of ring Lateral lumbricals, Opponens syndrome, tapping elicits
finger policis, Abductor policis tingling (Tinels test)
function of that specific nerve (myotome) brevis, Flexor policis Claw hand most severe
over first two digits
u Neuropathy
u Damage to nerve fibres beyond the root Ulnar nerve Hypothenar eminence, little Hypothenar muscles e.g. Claw hand ring finger and
finger and ulnar half of ring abductor digiti minimi little finger
u Mononeuropathy damage to a single nerve finger
u Polyneuropathy damage to multiple nerves
Radial nerve Posterior aspect of forearm, Extensor muscles of upper Saturday night palsy due to
anatomical snuffbox limb pressure on radial nerve at
spiral groove of humerus
Long thoracic nerve - Serratus anterior protracts winged scapula
upper limb

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Important lower limb mononeuropathies Polyneuropathies

Sensory loss Motor loss Other u Alcohol

Obturator nerve Medial thigh Adductors at hip - u B12 deficiency
u Charcot-Marie Tooth, Chronic kidney disease, Cancer
Femoral nerve Anterior thigh Hip flexors and knee -
extensors u Diabetes, Drugs
Sciatic nerve Below knee Knee flexors and foot -
dorsiflexors/plantar flexors
u Every vasculitis
Common peroneal (aka Lateral aspect of leg (below Foot dorsiflexors Usually due to pedestrian u Friedrichs ataxia
fibular) nerve knee) accidents, car bumper vs.
lateral aspect of leg over u Guillain-Barre syndrome
fibular head, where the nerve
runs

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Sensory loss workup Pain

u History and examination will help to localise the lesion Type Cause(s) Features

u Investigations should be directed to possible cause, not all are necessary Musculoskeletal Trauma, muscle fatigue, Dull ache, generalised, worse with
u Blood tests basic bloods, B12 levels, HBA1c osteoarthritis, inflammation (e.g. movement, muscular tenderness,
costochondritis) history of trauma/over-training
u CT-brain
u MRI spine if suspecting spinal cord lesion
u Nerve conduction studies and electromyelography (EMG) if suspecting a Ischaemic Peripheral vascular disease Burning, worse with movement
peripheral neuropathy and better with rest, vascular risk
factors
Neuropathic Spinal cord injury, peripheral Electric shock-like/sharp, with
neuropathy focal deficits, may radiate in
particular nerve distributions
Tumour-related Cancer Dull constant ache, wakes patient
up from sleep, bony tenderness

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Principles of pain management

u Stepwise approach or pain-ladder

u (1) Non-opioid simple analgesic (paracetamol)
u (2) +Weak opioid e.g. codeine
u (3) +Strong opioid e.g. morphine

u Remember to increase the dose and dosing schedule of each drug to maximum
before moving to the next step
u Adjuvants can be added at any step
u Non-steroidals good for musculoskeletal and neuropathic pain
u Gabapentin/pregabalin good for neuropathic pain
u Tricyclic antidepressants good for neuropathic pain

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