The sensory system

Vth year 2002/2003

The sensory system

Spinothalamic system (tractus spinothalamicus) exteroceptive sensation) : pain temperature light touch Dorsal column pathway ( lemniscus medialis) conscious proprioception: joint position vibration deep pressure two point discrimination graphaesthesia, stereoaesthesia Dorsal and ventral spinocerebellar pathway unconscious proprioception

Spinothalamic system
Pain perception
C fibers: thin, unmyelinated A delta: thinly myelinated

Temperature A delta: thinly myelinated

Dorsal column pathway/lemniscus medialis

Spinal cord pathways - somatotopia

Segmental innervation (dermatomes) Peripheral innervation

Sensory disturbances
Positive symptoms: Pain Hyperalgesia: when threshold to pain appears lowered Hyperpathia: pain threshold elevated, but once reached, the painful stimulus is excessively felt Hyperaesthesia Paraesthesia:pins and needles sensation,burning feeling Dysaesthesia/allodynia: when touching is painful Neuralgia Causalgia: spontaneous burning sensation in the distribution of the injured nerve with increased sensitivity to painful stimuli (efferent sympathetic fibers link up to afferent somatic fibers ?) Phantom limb pain

Sensory disturbances
negative symptoms: Hypaesthesia: decreased sensation Anaesthesia: loss of feeling

Examination of the sensory system 1.

Special standpoints: Subjective examination Requires good cooperation on the patient`s side. Allows accurate localisation of the pathology. Preliminary diagnosis is needed. Examine according to the expected damage ! Most often we compare different parts of the body. Do not tell the patient what should be felt ! The patient should not see the examined part of the body ! Subjective sensory disturbance ( pain, paraesthesia ) is not necessarily accompanied by objective sensory disturbance (hypaesthesia, anaesthesia )

Examination of the sensory system 2.

Pain: pin prick, tooth picks Light touch: use a wisp of cotton wool ! Temperature: use a cold (5-10 0C) or a hot (40-45 0C object (test tubes) ! Depends on the duration of the stimulus, size of the surface of contact. - Examine the patient with his/her eyes closed ! - Instruct the patient to reply: Tell me if you feel the stimulus ! Name the area stimulated ! State the nature of the stimulus ! What do you feel? Is it equal on both sides? What is the difference ? - Map out the extent of abnormality ! - Move from the abnormal to the normal area (Tell me if sensation changes!) - Pin must be discarded after single use

Examination of the sensory system 3.

Joint position / motion: - Hold the sides of the patients finger ! - Move it up and down at random ! - Ask to specify the direction of movement ! - Normal individual is able to detect movement of 1 2 0 at the interphalangeal joints - If these senses are lost in the digits examine joints further up (wrist, elbow) ! - Note the promptness or the hesitation of the response ! - Disturbance of deep sensation are accompanied by abnormal movements ( pseudoathetosis, ataxia ) especially with closed eyes.

Examination of the sensory system 4.

Vibration: - Place a vibrating tuning fork on a bony prominence ( ankle, knee, processus spinosus, processus styloideus radii et ulnae, elbow, clavicula) - < 128 c/s - Ask the patient to indicate when the vibration ceases ! - If impaired, move more proximally and repeat ! - Vibration sense does not necessarily change parallel with joint position sense. - Patients may use different words for the description of the vibration (shaking, tingling, itching)

Examination of the sensory system 5.

Two point discrimination: -The ability to discriminate two blunt points when applied simultaneously. -3-5 mm on the finger, 4-7 cm on the trunk
Sensory inattention (perceptual rivalry) -The ability to detect sensory stimuli applied simultaneously on both limbs. -Subdominant parietal lobe, associative areas Stereoaesthesia - An object is placed in the patients hand. - Ask patient to describe its size, shape, surface, material ! - Stereoanaesthesia:disturbance of the sensory afferent tracts.

Examination of the sensory system 6.

Astereognosis -Inability to identify an object by palpation -The primary sense data being intact -Lesion of the opposite hemisphere, postcentral gyrus Tactile agnosia : -The patient is unable to recognize an object by touch in both hands -Disorder of perception of symbols. -Lesion of the dominant parietal lobe, associative areas Graphaesthesia - The ability to recognize numbers of letters traced out on the palm.

Examination of the sensory system

Nerve conduction studies: sensory antidrom neurography median nerve, ulnar nerve Somatosensory evoked potentials (SEP) median nerve, tibial nerve

Sensory syndromes 1.
Peripheral nerve: according to the distribution area of the affected nerve

Polyneuropathy: glove stocking distribution, more pronaunced distaly, more on the lower extremities
Dorsal root ganglia or radicular laesions: segmental, localised to dermatomes

Sensory syndromes 2.
Spinal cord: -complete cord lesion -hemisection of spinal cord : Brown Sequard syndrome -central cord lesion (Syringomyelia, dissociated sensory loss: loss of pain and temperature, preservation of proprioception) -posterior tract lesion (funicular myelosis: loss of proprioception, ataxia) -conus laesion (sensory loss of sacral area, saddle anaesthesia) Brain stem: Wallenberg syndrome Thalamus: Dejerine Roussy syndrome (contralateral hemihypaesthesia, ataxia, pain) Sensory cortex: contralateral hemihypaesthesia

Sensory syndromes spinal ganglion

Sensory syndromes funicular myelosis

Sensory syndromes

Sensory syndromes

Sensory syndromes

Sensory syndromes

Sensory syndromes visceral pain