Sensory Disorders

APPROACH TO DIAGNOSIS
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history and clinical signs of a patient with disorders of somatic sensation includes
sensations of touch or pressure, vibration, joint position, pain, temperature, and more
complex functions that rely on these primary sensory modalities (eg, two-point
discrimination, stereognosis, graphesthesia); it excludes special senses such as smell,
vision, taste, and hearing.

FUNCTIONAL ANATOMY OF THE SOMATIC SENSORY PATHWAYS

The sensory pathway between peripheral tissues (eg, skin or joints) and the cerebral cortex
involves three neurons and two central synapses

1st-order sensory neurons:

from the limbs and trunk have cell bodies in the dorsal root ganglia. Each of these neurons
sends a peripheral process that terminates in a free nerve ending or encapsulated sensory
receptor and a central process that enters the spinal cord. Sensory receptors are relatively
specialized for particular sensations and, in addition to free nerve endings (pain), include
Meissner corpuscles, Merkel corpuscles, and hair cells (touch); Krause end-bulbs (cold); and
Ruffini corpuscles (heat). Fibers mediating touch, pressure, or postural sensation in the limbs
and trunk ascend in the posterior columns of the spinal cord to the medulla, where they
synapse in the gracile and cuneate nuclei. Other fibers that mediate touch and those
subserving pain and temperature appreciation in the limbs and trunk synapse on neurons in
the posterior horns of the spinal cord, particularly in the substantia gelatinosa. First-order
sensory neurons from the face, which have cell bodies in the trigeminal (gasserian) ganglion,
travel in the trigeminal (V) nerve and enter the pons. Fibers mediating facial touch and
pressure synapse in the main trigeminal (V) nerve sensory nucleus, whereas those
conveying facial pain and temperature synapse in the spinal trigeminal (V) nerve nucleus.
2nd-order sensory neurons:
with cell bodies in the gracile and cuneate nuclei cross the midline and ascend in the medial
lemniscus. Second-order sensory neurons that arise in the posterior horns of the spinal cord
cross the mid-line and ascend in the anterolateral part of the cord: fibers mediating touch pass
upward in the anterior spinothalamic tract, whereas pain and temperature fibers generally
travel in the lateral spinothalamic tract. Second-order sensory neurons from the limbs and
trunk are joined in the brainstem by fibers from the face: those that mediate facial touch and
pressure sensation project from the main trigeminal (V) nerve sensory nucleus via the
trigeminal lemniscus, and those that convey facial pain and temperature project from the
spinal trigeminal (V) nerve nucleus via the trigeminothalamic tract, to the ipsilateral
thalamus. In the thalamus, medial lemniscal and spinothalamic fibers synapse in the ventral
posterolateral (VPL) nucleus; spinothalamic fibers also synapse in the ventral
posteroinferior (VPI) nucleus and intralaminar (ILa) nuclei; and fibers in the trigeminal
lemniscus and trigeminothalamic tract synapse in the ventral posteromedial (VPM)
nucleus. In addition, some second-order spinothalamic sensory neurons send collaterals to
the reticular formation.
3rd-order sensory neurons:
project from the thalamus to ipsilateral cerebral cortex. Fibers from VPL, VPI, and VPM
travel primarily to primary somatosensory cortex in the postcentral gyrus; fibers from ILa
also project to striatum, cingulate gyrus, and prefrontal cortex.
History
Sensory disturbances may consist of loss of sensation, abnormal sensations, or pain.
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Paresthesia: abnormal spontaneous sensations, such as burning, tingling, or pins and

needles.
Dysesthesia: denotes any unpleasant sensation produced by a stimulus that is
normally painless.
Numbness: is often used by patients to describe a sense of heaviness, weakness, or
deadness in the affected part of the bodyand sometimes to signify any sensory
impairment
Anesthesia: Complete loss of touch appreciation
Hypesthesia: Partial loss of touch appreciation

Hyperesthesia: Increased sensitivity

The integrative sensitivities are

1. Stereognosia
2. Dermolexia:
3. Topognosia: ability to recognize the place of touch
4. Somotognosia: ability to recognize different parts of the body
5. Nosognozia: ability to recognize the motor deficit.
6. Nosodiaphoria: ability to recognize the disorders anosodiaphoria
Disorders of integrative sensitivity:
atopognosia,
adermolexia,
astereognosia: inability to distinguish between various shapes or textures by
touch
tactile in-attention (cant recognize touch with closed eyes when touched
bilaterally),
asomatognosia,
anosognosia,

anosodiaphoria.

SYRINGOMYELIA AND SYRINGOBULBIA

Syringomyelia affects the spinal cord while syringobulbia affects the medulla.
Scoliosis is a common accompaniment of cord cavitation.
Definition:
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cystic cavitation of the spinal cord

presentation is highly variable, usually progresses over months to years
initially pain, weakness; later atrophy and loss of pain and temperature sensation

Etiology:
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70% are associated with Chiari I malformation, 10% with basilar invagination
post-traumatic
tumor
tethered cord

Clinical Features:
1.
2.
3.
4.
5.
6.
7.
8.

syringomelic dissociation,
symmetrical disorders of sensitivity in the hands, arms, fingers,
subjective symptoms: burning pain in both arms,
deep sensitivity is preserved,
atrophy of the muscles,
fasciculations,
deep reflexes disappears,
sometimes these cavities compress the pyramidal tract and lead to paraparesis with
Babinskis sign positive bilaterally

Investigations:
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MRI is best method, myelogram with delayed CT

Treatment:
- Roentgen therapy
- Surgical therapy
SYMPTOMS OF SYRINGOBULBIA:
1. vertigo,
2. nystagmus,
3. pain and disorders of sensitivities in the territory of CN V,
4. disorders of swallowing for solid and liquid,
5. disorders of fonation,
6. atrophy of tongue,
7. vegetative disorders with difficulty in breathing and irregularity of pulse.
DDx:
Tabes
Tumors of the spinal cord

Tx:

Amyotrophic lateral sclerosis

Symptomatic: Roentgen therapy

Surgical therapy