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