Neuro tract lesions

Vivian & slides from

ESA mentoring 2013
 Upper motor neuron lesions
Pyramidal
(Corticospinal tract)
Babinski sign
Absent superficial abdominal reflexes
Absent cremasteric reflex
Loss of performance of fine skilled
voluntary movements
In practice they occur together!
Extrapyramidal
Spastic paralysis increased muscular tone
and hyperactive reflexes
Little or no muscular atrophy
Exaggerated deep muscle reflexes
Flapping clonus
Hypertonia and clasp knife response
 Lower motor neuron lesions
Flaccid paralysis

tone, focal muscle atrophy

Focal muscle weakness

or absent reflexes

Fasciculations
 N.B.
Lesions of the basal ganglia and cerebellum are
also referred to as extrapyramidal but they are
different to the UMN lesions they dont
involve the descending motor tracts.
 Sensory & combined lesions
Subacute combined degeneration of the cord

Tabes Dorsalis

Brown-Sequard syndrome

Syringomyelia

Spinal shock
 Subacute combined degeneration of
the cord
Cause B12 deficiency (usually pernicious anaemia)

Pathology Degeneration of the dorsal columns (myelin degeneration)

Signs & Legs, arms, trunk progressive from tingling and numbness to
symptoms weakness
Visual impairment
Change in mental state
BILATERAL spastic paresis/paralysis
Sensations diminished = pressure, vibration and touch

Clinical +ve Babinski sign = extensor plantar reflex

tests +ve Rhomberg test

Treatment Reversible with B12 replacement if not been going on for too long
 Tabes dorsalis
Cause Untreated syphilis

Pathology Degeneration of the dorsal columns (myelin degeneration)

Signs & Weakness, episodes of intense pain & disturbed sensation

symptoms Ataxia (tabetic gait), loss of coordination
Change in mental state e.g. dementia
Visual impairment
Sensations diminished = pressure, vibration and touch

Clinical +ve Rhomberg test

tests

Treatment IV Penicillin
Analgesics
Contact tracing!
 Syringomyelia
What is it? Enlarged cavity or cyst in the cervical/upper thoracic region of
the cord
Cause Congenital e.g. Arnold-Chiari malformation
Tumours
Trauma, haemorrhage
Meningitis

Signs & symptoms Abnormal or loss of sensations

Chronic pain
Usually spare dorsal columns intact pressure, vibration,
touch, proprioception
May have ANS symptoms

Clinical tests Cervical/Thoracic MRI

Treatment Treat underlying causes
Surgery to drain cysts
 Brown-Squard syndrome
= hemisection of the cord

Also loss of movements on the same side (corticospinal tracts UMN signs
below lesion, LMN signs at level of lesion)
 Spinal shock
Follows acute severe damage to the spinal
cord.

<24 hours 4 weeks

Depression or total loss of sensation and
motor function below the level of the lesion.
Often associated with profound hypotension
due to loss of sympathetic vasomotor tone.
 How to approach a clinical case
1. Determine if there are any motor deficits
If yes what descending tracts are affected?
Is it pyramidal or extrapyramidal?
Is it an upper or lower motor neuron lesion?
2. Determine if there are any sensory deficits
If yes what ascending tracts are affected?
3. Determine if there are any cognitive problems
If yes then the damage probably has occurred in the brain?
What region effects the change in behaviour you have witnessed?
4. Where does the deficit start and end?
Torso/ limbs?
Dermatomes and myotomes are useful here
Is it sensory/ motor/ both & is the lesion central or peripheral?
5. What side of the body are they on?
Indicates side of lesion
6. Are the sensory and motor deficits on the same side?
Is the lesion above or below the level of decussation of the tracts involved
 Case 1
Pt presents with neck pain, paraesthesia in the
medial side of the arm and hand, weakness
affecting the whole hand and extension and
abduction of the wrist joint. Bicep reflexes are
normal but tricep reflex is absent.

1. Lower motor neuron (Weakness. Absent tricep

reflex)
2. Neither pyramidal or extrapyramidal signs
3. Level of the common root of the spinal nerve as
both sensory and motor signs
 Case 2
Pt presented with normal right arm and leg movement
and minimal/ absent movement of left side with
increased muscle tone and clasp knife rigidity. Pt had a
flexor plantar reflex on the right and a babinski reflex
on the left. Pt also had impaired facial movements on
the left but with forehead sparing.

1. Upper motor neuron (increased muscle tone and

clasp knife rigidity, babinski sign, forehead sparing)
2. Pyramidal and extrapyramidal signs
3. Most likely occurred in the brain because forehead
sparing so needs to occur above pons
 Case 3
Pt presents with weakness in his left arm and
hand. Has no sensory loss. Reduced grip on the left
side with increased muscle tone. Biceps and
brachioradialis jerks are exaggerated. Right side
grip is also reduced and reflexes are brisk.

1. UMN (weakness with increased tone and reflexes)

2. Extrapyramidal
3. Lower brain stem or upper spinal cord small
lesion as no sensory loss or corticospinal
involvement
 Case 4
Pt presents with mild slurring of speech,
blindness in right eye and tingling in the left side
of her face, difficulty swallowing, weakness,
numbness and hyperreflexia in the right leg with
a babinski sign in the right foot

1. Both upper and lower

2. Both pyramidal and extrapyramidal
3. Multiple anatomically unrelated lesions (MS)
Thank you!