2.

3-D
August 11, 2014
PLM CM

SENSORY EXAMINATION
Dr. Guzman
Legend: normal text lecture/old trans; Bates italics; transers
notes red text.

INTRODUCTION
Steps in the Diagnosis of Neurologic Diseases:
1. Mental Status Exam
2. Gait and Station
3. Cranial Nerves
4. Motor System
5. Coordination
6. Reflexes
7. Sensation
8. Head and Neck
9. Spine and Skin
IMPORTANCE: By identifying the distribution of sensory
abnormalities and the kinds of sensations affected, you
can infer where the causative lesion might be.
SENSORY PATHWAY
Sensory input travels up through the spinal cord along
specific paths, with the precise route defined by the type of
sensation being transmitted.
Ultimately, the sensory nerves terminate in the brain,
where the impulses are integrated and perception occurs.
To evaluate the sensory system, you will test several kinds
of sensation:
o Pain and temperature (spinothalamic tracts)
o Position and vibration (posterior columns)
o Light touch (both of these pathways)
o Discriminative sensations, which depend on some
of the above sensations but also involve the cortex
Face
Sensory testing of the face is discussed in the Cranial
Nerves
Extremities
Testing of the extremities focuses on the two main afferent
pathways:
o Spinothalamics:
- These nerves detect pain, temperature and crude
touch.
- Pathway: peripheral impulses enter spinal cord
cross to the other side within one or two
vertebral levels of entry point continue up that
side to the brain terminate in the cerebral
hemisphere on the opposite side of the body from
where they began.
o Dorsal Columns:
- These
nerves
detect
position
(a.k.a.
proprioception), vibratory sensation and light
touch.
- Pathway: peripheral impulses enter spinal cord
move up to the base of the brain on the same
side of the cord as where they started upon
reaching the brain stem they cross to the
opposite side terminate in the cerebral
hemisphere on the opposite side of the body from
where they began.
lesion of the sensory
cortex

disease of the posterior

columns

may not impair the

perception of pain, touch,
and position but does
impair finer discrimination
Loss of position and
vibration sense with
preservation of other
sensations

transection of the spinal

cord

Loss of all sensations from

the waist down, together with
paralysis and hyperactive
reflexes in the legs
Crude and light touch are often preserved despite partial
damage to the cord, because impulses originating on one
side of the body travel up both sides of the cord.

CALDERON, GARCIA, HARDIN, MANABAT, SOLIS

Dermatomes
Dermatome: a band of skin innervated by the sensory
root of a single spinal nerve.
Knowledge of dermatomes helps you localize neurologic
lesions to a specific level of the spinal cord, particularly in
spinal cord injury.
In spinal cord injury, the sensory level may be several
segments lower than the spinal lesion, for reasons that are
not well understood. Tapping for the level of vertebral pain
may be helpful.
Dermatome levels are more variable than the diagrams
suggest (see page 4). They overlap at their upper and
lower margins and also slightly across the midline.
SENSORY FUNCTION EXAMINATION
GENERAL INSTRUCTIONS AND PATTERNS OF
TESTING
(not in particular order)
1. Sensory testing quickly fatigues many patients, producing
unreliable results conduct the examination as efficiently
as possible
2. Pay special attention to areas
o where there are symptoms (e.g. numbness or pain)
o where there are motor or reflex abnormalities that
suggest a lesion of the spinal cord or peripheral
nervous system
o where there are trophic changes (e.g. absent/
excessive sweating, atrophic skin, or cutaneous
ulceration
3. Repeat testing at another time is often required to confirm
abnormalities.
4. Compare symmetrical areas on the two sides of the body.
o A Hemisensory loss pattern suggests a lesion in
the opposite cerebral hemisphere
o A Sensory level loss pattern suggests a spinal
cord lesion
5. Compare distal and proximal areas of the extremities.
o Further, scatter the stimuli so as to sample most of
the dermatomes and major peripheral nerves.
o One suggested pattern of testing:
1. both shoulders (C4)
2. inner and outer aspects of forearms (C6&T1)
3. thumbs and little fingers (C6 and C8)
4. fronts of both thighs (L2)
5. medial and lateral calves (L4 and L5)
6. little toes (S1) medial buttock (S3)
o Symmetric distal sensory loss suggests a
polyneuropathy. You may miss this finding unless
you compare distal and proximal sensation.
o When testing vibration and position sensation, first
test the fingers and toes. If these are normal, you
may safely assume that more proximal areas will
also be normal.
6. Vary the pace of your testing so that the patient does not
merely respond to your repetitive rhythm.
7. When you detect an area of sensory loss or
hypersensitivity, map out its boundaries in detail.
o Stimulate first at a point of reduced sensation, and
move by progressive steps until the patient detects
the change.
8. When you detect abnormal findings, correlate them with
motor and reflex activity. Assess the patient carefully as
you consider the following questions:
o Is the underlying lesion central or peripheral? Is the
sensory loss bilateral or unilateral?
o Does it have a pattern suggesting a dermatomal
distribution, a polyneuropathy, or a spinal cord
syndrome with a loss of pain and temperature
sensation but intact touch and vibration?
9. Explain each test before you do it.
10. Unless otherwise specified, the patients eyes should
be closed during the actual testing.
PRIMARY MODALITY TESTING
(See pages 3-4)

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SENSORY EXAMINATION
Dr. Guzman
SPECIAL TESTING FOR EARLY DIABETIC
NEUROPATHY
A careful foot examination should be performed on all
patients with symptoms suggestive of sensory neuropathy
or at particular risk for this disorder (e.g. anyone with
diabetes).
Monofilament Testing
Disposable monofilaments are small nylon fibers designed
such that the normal patient should be able to feel the
ends when they are gently pressed against the soles of
their feet.
Have the patient close their eyes.

Touch the monofilament to 5-7 areas on the bottom of the

patient's foot. Pick locations so that all of the major areas of
the sole are assessed. Avoid calluses, which are relatively
insensate

Normal Result (left pic): Patient is able to detect the

filament when the tip is lightly applied to the skin
Impaired sensation (right pic): If the force required to
provoke a sensory response is strong enough to bend the
monofilament
Neuropathic Ulcer

A large ulcer has developed

in this patient with severe
diabetic neuropathy.

August 11, 2014

PLM CM
Glove (if hands) Distribution Impairment, as the area
involved covers an entire distal region, much as a sock
or glove would cover a foot or hand. Such deficits may
be associated with neuropathic pain, a continuous
burning sensation affecting the distal extremity.
Glove and stocking sensory loss of a polyneuropathy is
often seen in alcoholism and diabetes.
This is more common in the feet than in the hands. The
more advanced the disease, the higher up the leg this
will occur.
Hands are less commonly affected than feet as the
nerves traveling to the legs are longer and thus at much
greater risk.
Peripheral Nerve Palsy
A specific peripheral nerve can become dysfunctional, for
example, as the result of trauma or infarction (another
complication of diabetes).
There will be a pattern of sensory impairment that follows
the distribution of the nerve.
Radial nerve palsy
o May occur if an intoxicated person falls asleep in a
position that puts pressure on the nerve as it travels
around the humerus
o Intoxication-induced loss of consciousness then
prevents the patient from reflexively changing position
(normally, this is how we prevent nerves from being
exposed to constant direct pressure).
o The resultant sensory loss would involve the back of
the hand and forearm. Motor function would also be
affected.
Testing of the sacral nerve roots, serving the anus and
rectum, is important if patients complain of incontinence,
inability to defecate/urinate, or there is otherwise reason to
suspect that these roots may be compromised (e.g. in
cauda equine syndrome).
Cauda Equina syndrome
o Multiple sacral and lumbar roots become compressed
bilaterally (e.g. by posteriorly herniated disc material
or a tumor).
o Patient is unable to urinate, as the lower motor
neurons carried in these sacral nerve roots no longer
function
- No way to send impulse to the bladder instructing
it to contract
- No way to be aware that bladders are full
- Loss of anal sphincter tone, as appreciated on
rectal exam
- Ability to detect pin pricks in the perineal area
(a.k.a. saddle distribution) also diminished

SELECTED SENSORY PROBLEMS

Diffuse Distal Sensory Loss
A number of chronic systemic diseases affect nerve
function; most commonly occurring is diabetes.
This first affects the most distal aspects of the nerves
and then moves proximally. Thus, the feet are the first
area to be affected.
As it is a systemic disease, it occurs simultaneously in
both limbs.
Example: In the picture,
all sensation in the hand
is lost. Repetitive testing
reveals
a
gradual
change
to
normal
sensation at the wrist.
This fits neither a
peripheral nerve nor a
dermatomal distribution.
If bilateral, this pattern of
loss is referred to as a
Stocking (if feet) or

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August 11, 2014
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SENSORY EXAMINATION
Dr. Guzman

PRIMARY MODALITY TESTING

Primary modality to
be tested

LIGHT TOUCH
(using cotton wisp)

VIBRATION
(using 128 Hz tuning
fork: relatively lowpitched)

POSITION SENSE
(PROPRIOCEPTION)

PAIN
(using sterile, sharp
pin, broken cotton
swab)

TEMPERATURE
(Using a cold tuning
fork or hot and cold
water in a test tube)

Procedure

1. Touch skin lightly, avoiding pressure

2. Ask the patient to respond whenever a touch is felt
and compare one area with another

1. Test with a non-vibrating tuning fork first to ensure

that the patient is responding to the correct stimulus.
2. Tap tuning fork on the heel of your hand
3. Place the stem of the fork over the distal
interphalangeal joint of the patient's index fingers
and big toes.
4. Ask what the patient feels
5. If you are uncertain whether it is pressure or
vibration, ask the patient to tell you when the
vibration stops, and then touch the fork to stop it.
6. If vibration sense is impaired, proceed to more
proximal bony prominences (e.g. wrist, elbow,
medial malleolus, patella, anterior superior iliac
spine, spinous processes, and clavicles)
1. Grasp the patient's big toe, hold it by its sides
between your thumb and index finger.
2. Pull it away from the other toes to prevent
extraneous tactile stimuli from affecting testing.
3. Demonstrate "up" and "down as you move the
patients toe clearly upward and downward.
4. With the patient's eyes closed, ask the patient to
identify the direction as you move the toe.
5. If position sense is impaired move proximally to test
the ankle joint.
6. Test the fingers in a similar fashion. If indicated
move proximally to the metacarpophalangeal joints,
wrists, and elbows.
1. Touch the patient with the sharp or dull end and ask
them to identify sharp or dull.
2. One can also ascend from the foot upwards and ask
the patient to identify the level where appreciation of
sharpness occurs or where an appreciable increase
in sensation occurs.

Ask them to identify when touched with hot or cold.

Graphesthesia (Number Identification)
1. With the blunt end of a pen or pencil, draw a
large number in the patient's palm.
2. Ask the patient to identify the number.

DISCRIMINATION
(Since these tests are
dependent on touch
and position sense,
they cannot be
performed when the
tests above are
clearly abnormal)

Remarks
Anesthesia: absence of touch
sensation
Hypesthesia: decreased sensitivity
Hyperesthesia: increased sensitivity
Calloused skin is normally relatively
insensitive and should be avoided.
DO NOT TEST IF THERE IS
ALREADY NUMBNESS OR
NEUROPATHY!
Vibration sense is often the first
sensation to be lost in a peripheral
neuropathy. Common causes include
diabetes and alcoholism.
Vibration sense is also lost in posterior
column disease (e.g. tertiary syphilis or
vitamin B12 deficiency)
Testing vibration sense in the trunk
may be useful in estimating the level of
a cord lesion.
Greater deficits are characterized by
having to move a more proximal joint
such as ankle, knee or hip for the
patient to appreciate the movement.
Loss of position sense, like loss of
vibration sense:
o tabes dorsalis
o multiple sclerosis
o B12 deficiency from posterior
column disease
o peripheral neuropathy from
diabetes
Analgesia: absence of pain sensation
Hypalgesia: decreased sensitivity to
pain
Hyperalgesia: increased sensitivity to
pain
To prevent transmitting a blood-borne
infection, discard the pin or other
device safely. Do not reuse it on
another person.
Often omitted if pain sensation is
normal
Levels and laterality can also be tested
as described for pain and light touch..
Tested when motor impairment,
arthritis, or other conditions prevent the
patient from manipulating an object
well enough to identify it
The inability to recognize numbers
suggests a lesion in the sensory
cortex

Stereognosis (Use as an alternative to

graphesthesia): The ability to recognize an object by
feeling it.
1. Place a familiar object in the patient's hand
(coin, paper clip, pencil, etc.).
2. Ask the patient to tell you what it is.

Normally a patient will manipulate it

skillfully and identify it correctly within 5
seconds.
Asking the patient to distinguish
heads from tails on a coin is a
sensitive test for stereognosis
Astereognosis: inability to recognize
objects placed in the hand

Two-Point Discrimination
1. Use an opened paper clip to touch the patient's
finger pads in two places simultaneously.
2. Alternate irregularly with one-point touch.
3. Ask the patient to identify "one" or "two."
4. Find the minimal distance at which the patient
can discriminate (normally less than 5 mm on
the finger pads)

These stimuli are carried via the

Dorsal Columns.
It is a useful test if a discrete
peripheral neuropathy is suspected
(e.g. injury to the radial nerve).

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SENSORY EXAMINATION
Dr. Guzman

Extinction
1. Touch the same spot on both sides of the body
at the same time (e.g. the left and right
forearms.)
2. Ask the individual to describe how many spots
are being touched.

Normal: both sides are felt

(+) sensory lesions: the individual will
sense only one. The stimulus on the
side opposite the damaged cortex is
extinguished.

Point Localization
1. Touch the surface of the skin and remove the
stimulus quickly while patients eyes are
closed.
2. Ask to open his/her eyes and ask to touch the
spot where the sensation was felt.

This test, together with extinction, is

especially useful on the trunk and the
legs.
Lesions of the sensory cortex impair
the ability to localize points accurately

Common peripheral nerves, territories of innervation, and clinical correlates.

Peripheral
Nerve

Sensory
Innervation

Motor Innervation

Radial Nerve

Back of thumb,
index, middle, and
ring finger; back of
forearm
Palmar and dorsal
aspects of pinky and
of ring finger

Wrist extension and

abduction of thumb
in palmer plane

Ulnar Nerve

Median Nerve

Lateral
Cutaneous
Nerve of Thigh
Peroneal
Nerve

Contributing
Spinal Nerve
Roots
C6, 7, 8

Clinical Correlate

At risk for compression at humerus,

known as "Saturday Night Palsy

Abduction of fingers
(intrinsic muscles of
hand)

C7, 8 and T1

At risk for injury with elbow fracture.

Can get transient symptoms when
inside of elbow is struck ("funny
bone" distribution)

Palmar aspect of the

thumb, index, middle
and ring finger;
palm below these
fingers.
.Lateral aspect thigh

Abduction of thumb
perpendicular to
palm (thenar
muscles).

C8, T1

Compression at carpal tunnel

causes carpal tunnel syndrome

L1, 2

Can become compressed in obese

patients, causing numbness over its
distribution

Lateral leg, top of

foot

Dorsiflexion of foot
(tibialis anterior
muscle)

L4, 5; S1

Can be injured with proximal fibula

fracture, leading to foot drop
(inability to dorsiflex foot)

^FIGURE: Peripheral Nerve and Dermatomal Distributions on anterior surface (left) and posterior surface (right)

CALDERON, GARCIA, HARDIN, MANABAT, SOLIS

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