Sensory Pathway Review

Katie Raiti, MSIV

Ashlee Stutsrim, MSIV
Tactile Sensation and Proprioception
Nerve Cell Body Axon

1 Dorsal root ganglion Spinal nerve/ Fasciculus gracilis and

cuneatus

2 Nucleus gracilis and cuneatus (caudal Medial lemniscus

medulla) Internal arcuate fibers cross
and form medial lemniscus on
opposite side
Changes orientation in pons

3 Ventral Posterior Lateral (thalamus) Posterior limb of internal capsule

and corona radiata

Cortical area: somatosensory cortex (postcentral gyrus and paracentral lobule)

Tactile and Proprioceptive Pathway
 Pain/Temp - Lateral Spinothalamic Tract
Nerve Cell Body Axon

1 Dorsal root ganglion Dorsal root

2 Spinal cord Anterior white commissure ALS

Marginal zone and nucleus on opposite side of spinal cord
proprius Travel rostrally two levels as
cross midline

3 VPL Internal capsule and corona radiata

Cortical area: somatosensory cortex (postcentral gyrus and paracentral lobule)

Pain/Temp Pathway
Trigeminal Nerve - CN V
Four nuclei found along brainstem
Mesencephalic nucleus (proprioception)
Motor nucleus (jaw movement)
Principal Sensory nucleus (touch)
Spinal Trigeminal nucleus (pain/temperature)
 Trigeminal Nerve - Touch Pathway
Nerve Cell Body Axon

1 Trigeminal ganglion - found at Enter at midpontine level

midpontine level

2 Principal sensory nucleus Crosses to travel in VTT

3 Ventral posterior medial Internal capsule and corona

radiata

Cortical area: postcentral gyrus and paracentral lobule (somatosensory cortex)

 Trigeminal Nerve - Pain Pathway
Nerve Cell Body Axon

1 Trigeminal ganglion - found at Enter midpontine level - travel

midpontine level in Spinal Trigeminal Tract

2 Spinal trigeminal nucleus Crosses to travel in VTT

3 VPM Internal capsule and corona

radiata

Cortical area: postcentral gyrus, cingulate gyrus, insula

Trigeminal Nerve- VTT
 Trigeminal - Proprioception - Jaw Jerk Reflex

Nerve Cell Body Axon

1 Mesencephalic nucleus To motor nucleus

2 Motor nucleus V3 motor branch

Practice Drawing
Practice Case
A 28 year-old man presents via ambulance to the emergency department with
complaints that he cannot move his left leg and numbness on the right side of his
abdomen down his leg. He provides little history as he continues to yell for someone to
fix his legs. On exam, you note decreased sensation to a cotton ball on his left leg and
decreased pinprick sensation on his right leg extending to the umbilicus. He has a left
upgoing toe. Where is the injury?

a. Left L1
b. Right L1
c. Left T10
d. Right T10
e. Left T8
f. Right T8
Practice Case
A 28 year-old man presents via ambulance to the emergency department with
complaints that he cannot move his left leg and numbness on the right side of his
abdomen down his leg. He provides little history as he continues to yell for someone to
fix his legs. On exam, you note decreased sensation to a cotton ball on his left leg and
decreased pinprick sensation on his right leg extending to the umbilicus. He has a left
upgoing toe. Where is the injury?

a. Left L1
b. Right L1
c. Left T10
d. Right T10
e. Left T8
f. Right T8
Brown-Sequard Syndrome
History
Classically a knife or gun injury resulting in hemisection of the spinal cord
Physical exam
UMN signs
Paralysis
Increased tone
Hyperreflexia
Positive Babinski (upgoing plantar reflex)
Loss of light touch/proprioception
Contralateral loss of pain/temperature
Pathophysiology
Ipsilateral paralysis (lateral corticospinal tract) and sensory loss (dorsal columns)
Contralateral pain/temperature loss (lateral spinothalamic tract)
Remember secondary neurons of pain pathway ascend two levels as they decussate
so to have complete loss of sensation, the injury must be two levels rostral
Practice Case
A 73 year-old veteran with PMH significant for HTN presents with numbness and
tingling in both of his feet. He has had several falls over the past few weeks which he
states are due to frequently tripping. On exam, he has decreased light touch sensation
to both feet. When he stands with both his eyes closed and arms extended, he sways
and you must catch him so he does not fall. As an astute MSII, you check his pupils and
find they do not constrict to direct light, but do constrict when he follows your finger
toward his nose. Basic labs (CBC, CMP) are unremarkable. What is the most likely cause
of his frequent falls?

a. Diabetic neuropathy
b. Tabes dorsalis
c. B12 deficiency
d. Poor fitting shoes
e. Alcohol abuse
Practice Case
A 73 year-old veteran with PMH significant for HTN presents with numbness and
tingling in both of his feet. He has had several falls over the past few weeks which he
states are due to frequently tripping. On exam, he has decreased light touch sensation
to both feet, but feels pinprick. When he stands with both his eyes closed and arms
extended, he sways and you must catch him so he does not fall. As an astute MSII, you
check his pupils and find they do not constrict to direct light, but do constrict when he
follows your finger toward his nose. Basic labs (CBC, CMP) are unremarkable. What is
the most likely cause of his frequent falls?

a. Diabetic neuropathy
b. Tabes dorsalis
c. B12 deficiency
d. Poor fitting shoes
e. Alcohol abuse
Tabes Dorsalis
Advanced syphilis
Dorsal column damage = damage to fasciculus gracilis and cuneatus
Therefore, there is loss of tactile sensation and proprioception
Exam findings
Argyll Robertson pupil (accommodates, but doesnt react)
Romberg positive
Decreased light touch sensation
Differential may include
B12 deficiency
Evidence of megaloblastic anemia on CBC/peripheral smear
Would expect UMN signs as well (LCST affected)
Diabetic neuropathy
Patient would have long-standing diabetes (abnormal BG on labs, history of
diabetes, etc)
Alcoholic neuropathy
Similar exam findings, however more likely to also have abnormal CBC/peripheral
smear
Practice Case
An 80 year old male comes into the ED complaining of vertigo, hoarseness, difficulty
swallowing, and a droopy left eyelid. On examination you notice a loss of painful
sensation over the left half of his face and the entire right half of the body. He has intact
discriminative touch in those areas. He has a history of 50 pack years of smoking and
poorly controlled high blood pressure. Where is the most likely location of the lesion?

A. Lower cervical spinal cord

B. Medulla
C. Thalamus
D. Cerebral cortex
Practice Case
An 80 year old male comes into the ED complaining of vertigo, hoarseness, difficulty
swallowing, and a droopy left eyelid. On examination you notice a loss of painful
sensation over the left half of his face and the entire right half of the body. He has intact
discriminative touch in those areas. He has a history of 50 pack years of smoking and
poorly controlled high blood pressure. Where is the most likely location of the lesion?

A. Lower cervical spinal cord

B. Medulla
C. Thalamus
D. Cerebral cortex
Can you identify
the lesion?
Answers
A. Polio / Werdnig-Hoffman
B. MS
C. Tabes Dorsalis
D. ALS
E. Brown Sequard
F. Anterior Spinal Artery Occlusion
G. Subacute combined Degenerative Disease (B12 def)
H. Syringomyelia
E-mail us with questions/concerns!
Katie: katerait@buffalo.edu

Ashlee: astutsri@buffalo.edu