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Syringomyelia
Sensory is the ability to experience at least external and internal stimuli. It can be
divided into general sensory (pain, temperature, tactile, etc.) and special sensory
(vision, hearing, smell, taste). This topic consider only general sensory.
The first neuron is the pathway of deep and tactile sensory (see Fig. 1), which receives
stimuli from definite receptor (tactile corpuscles of the skin, receptors of muscles,
ligaments, tendons, joint capsules), reaches in spinal ganglia. Initiation from receptor is
distributed according to its dendrite, incoming in the peripheral nerves and nerve
plexus and reaches the body of the neuron and extends on its axon, which is in the
posterior root enters posterior cord of its side, giving at this level branch for the
formation of the segmental reflex. Axons of neurons from the lower limb form a thin
bundle (bundle Gaulle/Голля), which is located medially; axon of neurons from the
upper limbs form klinovidniy bundle (Burdach's nucleus/Бурдаха), which is located
laterally in the posterior horn. Axons of neurons in the second part of the new bundle
(laminiscus medialis) go to the opposite side and join the fibers of pain and
temperature-sensitive, reaching with the thalamus. In the thalamus the excitation is
transferred to the third neuron, whose axon, forming TRACTUS THALAMOCORTICALIS
which passes through the posterior horn of internal capsule, white matter of brain and
reaches post central gyrus of parietal lobe. In the upper part of post central gyrus and
media part (paracentral lobe) of the parietal lobe, receives information from the lower
extremities, in the middle part - the trunk and upper extremity, the lower part - of the
face, the internal organs.
Thus, the different localization of conductors pain, thermo sensory and deep, tactile
sensory are observed in the spinal cord and medulla of brain, in other parts of the
nervous system of conductors of various types of general sensory are placed together.
Studies are started from clarifying the complaints (pain, numbness, the unpleasant
sensations) and, if they exist, must specify their nature and localization. Then put
different kinds of stimulation, determining the existence of sensations (pain, heat, etc.)
and comparing the sensations in symmetrical of body parts, distal and proximal parts
of extremities.
Sensory disorders can occur with lesions of conductors general sensory to different
levels: brain, cranial nerves, spinal cord, posterior root, plexus, and peripheral nerves.
They are show in the form of symptoms of irritation, such as pain and loss - loss of
sensitivity). As the basis symptoms of sensory disorders are distinguished pain,
paresthesia, hypoesthesia, anesthesia, hyperesthesia, dysesthesia and hyperpathia.
Paresthesia – discomfort feeling in the form of pricking, numbness and crawl of small
insects/ chills.
Hyperesthesia - increased perception of touch, or any other skin irritation.
Hypoesthesia – desensitization/decrease sensation, anesthesia - about the total loss.
The reduction in pain sensitivity is like hypalgesia, its total loss - analgesia. When there
is lesion in all conductors overall sensitivity (in example, when trauma of nerves)
develops a total anesthesia, when isolated lesions – loss of one type of sensory
(dissociated type of sensory disorder). Loss of deep sensitivity (joint – muscle sensory)
is accompanied by muscle hypotonia and hyporeflexia, it leads to movement disorders
- sensory ataxia. Loss of the ability to identify familiar objects by touch (with the
preservation superficial or deep sensitivity) occurs with lesions of the parietal lobe and
is defined as astereognosis or true astereognosis. Loss of the ability to identify familiar
objects by touch, caused by the loss of superficial or deep sensory, can be observed at
various levels of destruction of sensitive guide and be considered as a false
astereognosis.
Dysesthesia is characterized by change of sensation perception, for example the
appearance of pain in response to simple touch (tactile allodiniya) or touching of cold
objects (cold allodiya)
Neuropathic pain occurs when lesion in sensory conductors; it doesn’t coincide with
place of lesion and presents ¬ projection pain. A striking example of projection of
pain is phantom pain that occurs after amputation of limbs in the form of unpleasant
sensations and the absence of its parts (e.g. ; fingers). The defeat of sensitive
conductors can cause paresthesia, hyperesthesia and dysesthesia, which often
combined with neuropathic pain.
Pain regard as psychogenic in cases where I n case of nonexistent its organic cause
(somatic or neurologic disease) or the character and intensity of pain is clearly
inconsistent with an organic lesion. Psychogenic pain usually occurs on the background
of depression and anxiety disorders or other psychiatric disorders.
Polyneuropathic type of sensory disorders (see Fig. 2,b) manifest as sensory defect in
the distal extremities in type "socks" ( "golf", "stocking"), "gloves" and show lesion of
the distal peripheral nerves of limbs (polyneuropathy). The degree of sensory disorders
his fingers of limbs and weaker in proximal direction. Sensory disorders were
significantly more common in the lower extremities. The lesion of the peripheral nerves
of the extremities usually first manifests as pain, paresthesia and hyperesthesia, which
is gradually replaced hypoesthesia or anesthesia.
normal in the upper extremities, which indicates that the lesion of both posterior
funiculus of thoracic segments of the spinal cord.
Any damage to the brain stem may cause alternating hemianesthesia (see Fig. 2, e) -
loss of pain and temperature sensitivity in the face, in the one half of trunk and limbs -
contralaterally. This abnormal sensation indicate lesion of caudal part of brain, where
trigeminal nerve is located and responsible for sensation odf skin and passes
spinothalamic tract
Disorder may have a sensitivity and psychogenic character. In such cases, the
localization of sensitivity
defects usually do not correspond to the possible types of disorders of sensitivity
arising in organic defect of sensory; and in demonstration of anormal joint-muscular
sensation, patient does not have sensitive ataxia,
changes in muscle tone and the reflexes. In the examination of sensation with closed
eyes, patient in each
test (eg. Application ofpain stimuli) responds by saying that he feels nothing and tells
us thatsensation is preserved.
TYPES OF PAIN
Types of
Characteristics of pain
pain
Caused by activation of pain receptors (nociceptors) in response to
Nociceptive injury; can feel not only the site of damage, but also in other remote
areas (synalgia)
Lesion arises in the sensory conduction; does not coincide with the
Neuropathic place of lesion and presence of projection pain, often combined with
other sensory disorders
Nature and intensity of pain clearly does not correspond to organic
Psychogenic
lesion, often marked by depression or other mental disorders
Syringomyelia
Clinical picture:
Begin disease at 25 – 40 yrs old, Males are more often affected than woman.
Symptoms develop gradually; first of all usually appear derangement of sensation,
weight loss and weakness of small muscles of hand. Characteristics segment –
dissociative sensory disturbances in form of <jacket> or <half jacket> - loss of pain
and temperature sensation while other types of sensations are normal. In
syringobulbia, decrease sensation in facial region is also possible. Rarely derangement
of sensation and atrophy develop in lower parts of body and in legs. In consequences
of loss of pain sensation, often develop trauma, especially burns, which lead to
scarring changes of skin. In many cases, it is observed spontaneous pain, which may
be burning, acute or gunshot/ lighting pain.
Mostly early motor derangements are weakness and atrophy of hands muscle. Further,
it is possible to extend to peripheral paresis of proximal parts of arms and shoulder
girdle; some patients develop central paresis of lower limbs (in consequences of lesion
of lateral funiculus of SC).
Not frequently, seen trophic skin changes in hands, in 20% of cases observed
arthropathy (often of elbow and shoulder joints). In syringobulbia, may develop
paralysis of soft palate, pharynx and larynx, tongue atrophy, vertigo, nystagmus.
Patients with syringomyelia usually have dystrophic changes; unproportionate length
of arms in relation to body, finger distortion, anomalies of ears, short neck, kyphosis
and scoliosis of vertebra etc.
Diagnosis: Leading importance: MRI of SC. MRI allows to visualize cavity inside SC
and exclude other diseases. EMG (electromyography) – clarity lesion of anterior horn of
SC on cervical level; characteristic of syringomyelia.