Approach to a case of motor and sensory disorders
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The document provides an overview of an introductory lecture on approaching cases of motor and sensory disorders. It discusses why these disorders are often considered together due to shared routes in the brain and identification based on associated symptoms. The overall objectives are to localize the lesion anatomically and recognize the pattern to make an etiological diagnosis. The lecture aims to recap neuroanatomy, neurophysiology, clinical features using a symptom-based approach, pattern recognition, investigations, and key takeaways. Common motor pathways, sensory pathways, and reflex pathways are summarized. Symptom profiles, temporal patterns, and example neurological patterns are also outlined.
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Approach to a case of motor and sensory disorders
- 1. APPROACH TO A CASE OF MOTOR AND SENSORY DISORDERS Introductory Lecture Series Dept. of Medicine IV Term Dr C Khati
- 2. Why Motor and Sensory Disorders together?
- 3. Why Motor and Sensory Disorders together? Shared routes
- 4. Why Motor and Sensory Disorders together? Shared routes Identification by the company kept
- 5. Overall Objective To identify 1. Where is the lesion? Neuro-Anatomical Localization 2. What is the lesion? Pattern Recognition Etiological Diagnosis
- 7. How to go further? • Basic Neuroanatomy • Basic Pathophysiology Symptom Based Approach Pattern Recognition Etiological List
- 8. How to go further? • Basic Neuroanatomy • Basic Pathophysiology Symptom Based Approach Pattern Recognition Etiological List
- 9. How to go further? • Basic Neuroanatomy • Basic Pathophysiology Symptom Based Approach Pattern Recognition Etiological List
- 10. Specific Learning Objectives • Recapitulate Neuro-anatomy • Recap Neurophysiology • Clinical Features (Symptom based approach) • Pattern Recognition (Symptoms and signs) • Etiological List • Investigation List • Take Home Messages • Videos/ Case studies
- 11. Neuroanatomy • Motor Pathways – Pyramidal Tract – Motor unit • Sensory Pathways – Dorsal Columns – SpinothalamicTract • Reflex Pathway
- 12. Neuroanatomy • Motor Pathways – Pyramidal Tract – Motor unit • Sensory Pathways – Dorsal Columns – SpinothalamicTract • Reflex Pathway
- 13. Neuroanatomy • Motor Pathways – Pyramidal Tract – Motor unit • Sensory Pathways – Dorsal Columns – SpinothalamicTract • Reflex Pathway
- 14. Motor Pathway • Pyramidal or Corticospinal tract
- 15. MOTOR PATHWAY
- 16. UMN Lesion 1. Weakness 2. No atrophy (No fasciculation) 3. Increased tone 4. Increased DTR 5. Extensor Plantar (Babinski Positive)
- 17. Motor unit – a motor neuron and all the muscle fibers it innervates
- 18. • Motor unit – a motor neuron and all the muscle fibers it innervates
- 19. Motor unit Structural Organization of PNS in Region of a Spinal Nerve
- 20. LMN Lesion • All lesions involving a motor unit are LMN (Lower Motor Neuron) lesions 1. Weakness 2. Atrophy (with fasciculation &/fibrillation) 3. Decreased tone (hypotonia) 4. Decreased DTR (hyporeflexia) 5. Flexor Plantar (Downgoing toes)
- 21. Extra Pyramidal System (Basal Ganglia) 1. Chorea 2. Athetosis 3. Hemiballismus Cerebellum 1. Intention tremor 2. Ataxia 3. Nystagmus 4. DTR/tone ipsilaterally 5. Asthenia
- 22. Ascending Pathways • Dorsal Column/Medial Lemniscal Pathway: Touch, vibration, proprioception • Anterolateral System: Spinothalamic tract- pain & temp
- 23. At medulla Dorsal column- Medial Lemniscus Pathway
- 24. Ascending tracts & their crossings • Dorsal Column: As internal arcuate fibers in Medulla • Lateral Spinothalmic tract: Fibers cross at the same level of segment where they enter the spinal cord
- 25. Reflexes • Superficial reflexes: – All sup reflexes lost in pyramidal lesions – Local reflex lost to a local arc lesion (eg cremasteric reflex) • Deep Tendon Reflexes – Exaggerated: Pyramidal lesions – Absent/Reduced: LMN lesions – Nerve lesions (e.g.Radial N lesion - triceps jerk C7-8)
- 26. Reflexes • Superficial reflexes: – All sup reflexes lost in pyramidal lesions – Local reflex lost to a local arc lesion (eg cremasteric reflex) • Deep Tendon Reflexes – Exaggerated: Pyramidal lesions – Absent/Reduced: LMN lesions – Nerve lesions (e.g.Radial N lesion - triceps jerk C7-8)
- 27. Reflexes • Superficial reflexes: – All sup reflexes lost in pyramidal lesions – Local reflex lost to a local arc lesion (eg cremasteric reflex) • Deep Tendon Reflexes – Exaggerated: Pyramidal lesions – Absent/Reduced: LMN lesions – Nerve lesions (e.g.Radial N lesion - triceps jerk C7-8)
- 28. STRETCH REFLEX & RECIPROCAL INNERVATION
- 29. Neurophysiology • Impulse generation • Impulse conduction - in axons - across synapses • Energy dependant electrochemical gradient • Neurotransmitters
- 30. Neurophysiology • Impulse generation • Impulse conduction - in axons - across synapses • Energy dependant electrochemical gradient • Neurotransmitters
- 31. Neurophysiology • Impulse generation • Impulse conduction - in axons - across synapses • Energy dependant electrochemical gradient • Neurotransmitters
- 32. Neurophysiology • Hierarchy of control mechanisms – Posture and baseline muscle tone – Superimposed movement – Coordination for targeted movement • UMN regulatory control on LMN (inhibitory)- modulates tone and reflex – Monosynaptic axn- withdrawal response – Polysynaptic axn- for coordinated action
- 33. Neurophysiology • Hierarchy of control mechanisms – Posture and baseline muscle tone – Superimposed movement – Coordination for targeted movement • UMN regulatory control on LMN (inhibitory)- modulates tone and reflex – Monosynaptic axn- withdrawal response – Polysynaptic axn- for coordinated action
- 34. Neurophysiology • Hierarchy of control mechanisms – Posture and baseline muscle tone – Superimposed movement – Coordination for targeted movement • UMN regulatory control on LMN (inhibitory)- modulates tone and reflex – Monosynaptic axn- withdrawal response – Polysynaptic axn- for coordinated action
- 35. Pathophysiology • Larger fibres • Smaller fibres
- 36. Pathophysiology • Neuronal Necrosis (energy failure) • Apoptosis (programmed death- gradual) • Axonal Degeneration • Demyelination
- 37. Pathophysiology • Neuronal Necrosis (energy failure) • Apoptosis (programmed death- gradual) • Axonal Degeneration • Demyelination
- 39. Symptom Based Approach I System Disorder Sensory (-)Numbness (Hypoaesthesia) (+)Tingling (dysaesthesia) (+)Pain (Neuralgia/ Poorly localised) (+)Hyperpathia &Causalgia (non sensory stim.)
- 40. Symptom Based Approach I System Disorder Sensory (-)Numbness (+)Tingling (+)Pain (+)Hyperpathia &Causalgia (non sensory stim.) Motor •Weakness – Proximal vs Distal, Regional •Movement Disorder- Initiation, Coordination, Tremors, spasms/ jerks
- 41. Symptom Based Approach I System Disorder Sensory (-)Numbness (+)Tingling (+)Pain (+)Hyperpathia &Causalgia (non sensory stim.) Motor •Weakness – Proximal vs Distal, Regional •Movement Disorder- Initiation, Coordination, Tremors, spasms/ jerks
- 42. Symptom Based Approach I System Disorder Sensory (-)Numbness (+)Tingling (+)Pain (+)Hyperpathia &Causalgia (non sensory stim.) Motor •Weakness – Proximal vs Distal, Regional •Movement Disorder- Initiation, Coordination, Tremors, spasms/ jerks
- 43. Symptom Based Approach I System Disorder Sensory (-)Numbness (+)Tingling (+)Pain (+)Hyperpathia &Causalgia (non sensory stim.) Motor •Weakness •Movement Disorder Associations & Accompaniments •Sphincter (incontinence/ retention) •Cranial Nerves • EPS/ Cerebellum •Autonomic disturbance
- 44. Symptom Based Approach I System Disorder Sensory (-)Numbness (+)Tingling (+)Pain (+)Hyperpathia &Causalgia (non sensory stim.) Motor •Weakness •Movement Disorder Associations & Accompaniments •Sphincter (incontinence/ retention) •Cranial Nerves • EPS/ Cerebellum •Autonomic disturbance
- 45. Symptom Based Approach I System Disorder Sensory (-)Numbness (+)Tingling (+)Pain (+)Hyperpathia &Causalgia (non sensory stim.) Motor •Weakness •Movement Disorder Associations & Accompaniments •Sphincter (incontinence/ retention) •Cranial Nerves • EPS/ Cerebellum •Autonomic disturbance
- 46. Symptom Based Approach I System Disorder Sensory (-)Numbness (+)Tingling (+)Pain (+)Hyperpathia &Causalgia (non sensory stim.) Motor •Weakness •Movement Disorder Associations & Accompaniments •Sphincter (incontinence/ retention) •Cranial Nerves • EPS/ Cerebellum •Autonomic disturbance
- 47. Symptom Based Approach I System Disorder Sensory (-)Numbness (+)Tingling (+)Pain (+)Hyperpathia &Causalgia (non sensory stim.) Motor •Weakness •Movement Disorder Associations & Accompaniments •Sphincter (incontinence/ retention) •Cranial Nerves • EPS/ Cerebellum •Autonomic disturbance
- 48. Symptomatic Approach II Temporal Profile Condition Continuous •Static •Progressive •Improving Vascular Infections and Para-infectious Processes Degenerative Demyelinating Tumor Trauma Metabolic Nutritional Drugs and Toxins Episodic •Intermittent •Remittent •Abnormal Movement •Hypo and Hyperkalemia •Porphyria •TIA •Seizure •Demyelination
- 49. Symptomatic Approach II Temporal Profile Condition Continuous •Static •Progressive •Improving Vascular Infections and Para-infectious Processes Degenerative Demyelinating Tumor Trauma Metabolic Nutritional Drugs and Toxins Episodic •Intermittent •Remittent •Abnormal Movement •Hypo and Hyperkalemia •Porphyria •TIA •Seizure •Demyelination
- 50. Symptomatic Approach II Temporal Profile Condition Continuous •Static •Progressive •Improving Vascular Infections and Para-infectious Processes Degenerative Demyelinating Tumor Trauma Metabolic Nutritional Drugs and Toxins Episodic •Intermittent •Remittent •Abnormal Movement •Hypo and Hyperkalemia •Porphyria •TIA •Seizure •Demyelination
- 51. Symptomatic Approach II Temporal Profile Condition Continuous •Static •Progressive •Improving Vascular Infections and Para-infectious Processes Degenerative Demyelinating Tumor Trauma Metabolic Nutritional Drugs and Toxins Episodic •Intermittent •Remittent •Abnormal Movement •Hypo and Hyperkalemia •Porphyria •TIA •Seizure •Demyelination
- 52. Symptomatic Approach II Temporal Profile Condition Continuous •Static •Progressive •Improving Vascular Infections and Para-infectious Processes Degenerative Demyelinating Tumor Trauma Metabolic Nutritional Drugs and Toxins Episodic •Intermittent •Remittent •Abnormal Movement •Hypo and Hyperkalemia •Porphyria •TIA •Seizure •Demyelination
- 53. Present Illness • Symptoms Clarify Symptoms Onset, Duration and Progression Onset Some Disability
- 54. Pattern List • Hemiplegia- • Crossed • Uncrossed • Quadriplegia • Paraplegia • Plexuspathy • Radiculopathy (mono/poly) • Monoplegia • Muscle groups • Hemisensory loss – Complete (Thalamus) – Harlequinn (Brain Stem) • Sensory loss below a level • Brown Sequard (hemi-cord) • Dissociated/suspended loss • Radiculopathy (mono/poly) • Peripheral Neuropathy • Mononeuropathy • Mononeuropathy Multiplex
- 55. Pattern List • Hemiplegia- • Crossed • Uncrossed • Quadriplegia • Paraplegia • Plexuspathy • Radiculopathy (mono/poly) • Monoplegia • Muscle groups • Hemisensory loss – Complete (Thalamus) – Harlequinn (Brain Stem) • Sensory loss below a level • Brown Sequard (hemi-cord) • Dissociated/suspended loss • Radiculopathy (mono/poly) • Peripheral Neuropathy • Mononeuropathy • Mononeuropathy Multiplex
- 56. Pattern List • Hemiplegia- • Crossed • Uncrossed • Quadriplegia • Paraplegia • Plexuspathy • Radiculopathy (mono/poly) • Monoplegia • Muscle groups • Hemisensory loss – Complete (Thalamus) – Harlequinn (Brain Stem) • Sensory loss below a level • Brown Sequard (hemi-cord) • Dissociated/suspended loss • Radiculopathy (mono/poly) • Peripheral Neuropathy • Mononeuropathy • Mononeuropathy Multiplex
- 57. Pattern List • Hemiplegia- • Crossed • Uncrossed • Quadriplegia • Paraplegia • Plexuspathy • Radiculopathy (mono/poly) • Monoplegia • Muscle groups • Hemisensory loss – Complete (Thalamus) – Harlequinn (Brain Stem) • Sensory loss below a level • Brown Sequard (hemi-cord) • Dissociated/suspended loss • Radiculopathy (mono/poly) • Peripheral Neuropathy • Mononeuropathy • Mononeuropathy Multiplex
- 58. Pattern List • Hemiplegia- • Crossed • Uncrossed • Quadriplegia • Paraplegia • Plexuspathy • Radiculopathy (mono/poly) • Monoplegia • Muscle groups • Hemisensory loss – Complete (Thalamus) – Harlequinn (Brain Stem) • Sensory loss below a level • Brown Sequard (hemi-cord) • Dissociated/suspended loss • Radiculopathy (mono/poly) • Peripheral Neuropathy • Mononeuropathy • Mononeuropathy Multiplex
- 61. Sensory loss below a level
- 62. COMPLETE CORD TRANSECTION • Sensory: All sensations impaired below level of lesion • Motor: Quadriplegia/ Paraplegia depending on level of lesion
- 63. UNILATERAL HEMISECTION OF CORD (Brown Sequard Syndrome) • Motor: I/L UMN • Sensory: I/L sensation loss • Pain: C/L Pain & Temp. Loss
- 64. Sensory loss below a level
- 65. LESIONS AFFECTING SPINAL CORD CENTRALLY • Seen in Syringomyelia- cavitation central grey matter of spinal cord • Sensory: Spinothalamic are first to be affected followed by dorsal column • Motor: Affected last- initially LMN then UMN type
- 66. LESIONS AFFECTING SPINAL CORD CENTRALLY • Seen in Syringomyelia- cavitation central grey matter of spinal cord • Sensory: Spinothalamic are first to be affected followed by dorsal column • Motor: Affected last- initially LMN then UMN type
- 67. LESIONS AFFECTING SPINAL CORD CENTRALLY • Seen in Syringomyelia- cavitation central grey matter of spinal cord • Sensory: Spinothalamic are first to be affected followed by dorsal column • Motor: Affected last- initially LMN then UMN type
- 68. Sensory -1st Order Neuron Spinothalamic • Crude Touch • Pain • Temperature • Superficial reflexes (afferent) Dorsal Column • Fine Touch • Pressure • Stretch • Position • Vibration • 2 point discrimination • Deep reflexes (afferent)
- 69. Thalamic Sensory Features (2ndOrder neuron) • Deep seated poorly localised pain • All modalities of sensations • Always opposite side
- 70. Cortical Sensory Features (3rd order Neuron) • Hemi- neglect • Hemi –inattention • Inability to localise touch • Agraphaesthesia • Asteriognosis • 2 Point -Discrimination
- 71. Motor Symptoms • Weakness – Reduction in normal power of one or more muscles • Proximal Vs Distal • Groups vs Regions • Plegia vs Paresis
- 72. Motor Symptoms • Weakness • Fatiguability- Inability to sustain activity (comparative) • Twitching in muscles (fasciculation) • Spasms and Cramps • Myalgias • Dyskinesias • Imbalance/ unsteadiness • Difficulty in movement
- 73. Motor Signs UMN • Weakness(Pyramidal / regional distribution) • No Atrophy • Spasticity (Ridgity in EPS) • Exaggerated Deep Tendon Jerks (DTJs) • Extensor Plantar • Tremors (in EPS and Cerebellar involvement ) • Gait LMN • Weakness (Segmental / distal distribution) • Atrophy • Flaccidity (Decreased tone) • Diminished DTJs • Flexor Plantar • Fasciculations • Gait
- 74. Motor Signs UMN • Weakness(Pyramidal / regional distribution) • No Atrophy • Spasticity (Ridgity in EPS) • Exaggerated Deep Tendon Jerks (DTJs) • Extensor Plantar • Tremors (in EPS and Cerebellar involvement ) • Gait LMN • Weakness (Segmental / distal distribution) • Atrophy • Flaccidity (Decreased tone) • Diminished DTJs • Flexor Plantar • Fasciculations • Gait
- 75. Motor Signs UMN • Weakness(Pyramidal / regional distribution) • No Atrophy • Spasticity (Ridgity in EPS) • Exaggerated Deep Tendon Jerks (DTJs) • Extensor Plantar • Tremors (in EPS and Cerebellar involvement ) • Gait LMN • Weakness (Segmental / distal distribution) • Atrophy • Flaccidity (Decreased tone) • Diminished DTJs • Flexor Plantar • Fasciculations • Gait
- 76. Gait
- 77. Etiological List • Vascular • Infections and Para-infectious Processes • Degenerative • Demyelinating • Vasculitis • Metabolic • Nutritional • Tumor • Trauma • Drugs and Toxins
- 78. Investigations • Routine Haematology and Biochemistry • Imaging and Contrast Studies • Nerve Conduction Studies • CSF • EMG • Nerve Biopsy • Muscle Biopsy • Special Tests- B12 assay, Copper, Neuronal/receptor antibodies, Serology for infections, Hormone assays, Porphobilinogens, Immunological &Tumour Markers, etc
- 79. Take Home Messages: Shared routes MOTOR • Cerebral Cortex • Internal Capsule • Mid Brain (peduncles) • Pons • Medulla • Spinal Cord • Nerve Roots • Plexuses • Peripheral Nerves • Motor end plates • SENSORY • Cortex • Internal Capsule • Thalamus • Pons • Medulla • Spinal Cord • Roots • Plexuses/Cords • Peripheral nerves • Receptors
- 80. Take Home Messages: Shared routes MOTOR • Cerebral Cortex • Internal Capsule • Mid Brain (peduncles) • Pons • Medulla • Spinal Cord • Nerve Roots • Plexuses • Peripheral Nerves • Motor end plates • SENSORY • Cortex • Internal Capsule • Thalamus • Pons • Medulla • Spinal Cord • Roots • Plexuses/Cords • Peripheral nerves • Receptors
- 81. Take Home Messages: Shared routes MOTOR • Cerebral Cortex • Internal Capsule • Mid Brain (peduncles) • Pons • Medulla • Spinal Cord • Nerve Roots • Plexuses • Peripheral Nerves • Motor end plates • SENSORY • Cortex • Internal Capsule • Thalamus • Pons • Medulla • Spinal Cord • Roots • Plexuses/Cords • Peripheral nerves • Receptors
- 82. Take Home Messages: Shared routes MOTOR • Cerebral Cortex • Internal Capsule • Mid Brain (peduncles) • Pons • Medulla • Spinal Cord • Nerve Roots • Plexuses • Peripheral Nerves • Motor end plates • SENSORY • Cortex • Internal Capsule • Thalamus • Pons • Medulla • Spinal Cord • Roots • Plexuses/Cords • Peripheral nerves • Receptors
- 83. Take Home Messages: Shared routes MOTOR • Cerebral Cortex • Internal Capsule • Mid Brain (peduncles) • Pons • Medulla • Spinal Cord • Nerve Roots • Plexuses • Peripheral Nerves • Motor end plates • SENSORY • Cortex • Internal Capsule • Thalamus • Pons • Medulla • Spinal Cord • Roots • Plexuses/Cords • Peripheral nerves • Receptors
- 84. Take Home Messages: Shared routes MOTOR • Cerebral Cortex • Internal Capsule • Mid Brain (peduncles) • Pons • Medulla • Spinal Cord • Nerve Roots • Plexuses • Peripheral Nerves • Motor end plates • SENSORY • Cortex • Internal Capsule • Thalamus • Pons • Medulla • Spinal Cord • Roots • Plexuses/Cords • Peripheral nerves • Receptors
- 85. Take Home Messages: Shared routes MOTOR • Cerebral Cortex • Internal Capsule • Mid Brain (peduncles) • Pons • Medulla • Spinal Cord • Nerve Roots • Plexuses • Peripheral Nerves • Motor end plates • SENSORY • Cortex • Internal Capsule • Thalamus • Pons • Medulla • Spinal Cord • Roots • Plexuses/Cords • Peripheral nerves • Receptors
- 86. Take Home Messages: Shared routes MOTOR • Cerebral Cortex • Internal Capsule • Mid Brain (peduncles) • Pons • Medulla • Spinal Cord • Nerve Roots • Plexuses • Peripheral Nerves • Motor end plates • SENSORY • Cortex • Internal Capsule • Thalamus • Pons • Medulla • Spinal Cord • Roots • Plexuses/Cords • Peripheral nerves • Receptors
- 87. Take Home Messages: Shared routes MOTOR • Cerebral Cortex • Internal Capsule • Mid Brain (peduncles) • Pons • Medulla • Spinal Cord • Nerve Roots • Plexuses • Peripheral Nerves • Motor end plates • SENSORY • Cortex • Internal Capsule • Thalamus • Pons • Medulla • Spinal Cord • Roots • Plexuses/Cords • Peripheral nerves • Receptors
- 88. Take Home Messages: Shared routes MOTOR • Cerebral Cortex • Internal Capsule • Mid Brain (peduncles) • Pons • Medulla • Spinal Cord • Nerve Roots • Plexuses • Peripheral Nerves • Motor end plates • SENSORY • Cortex • Internal Capsule • Thalamus • Pons • Medulla • Spinal Cord • Roots • Plexuses/Cords • Peripheral nerves • Receptors
- 89. Take Home Messages: Shared routes MOTOR • Cerebral Cortex • Internal Capsule • Mid Brain (peduncles) • Pons • Medulla • Spinal Cord • Nerve Roots • Plexuses • Peripheral Nerves • Motor end plates • SENSORY • Cortex • Internal Capsule • Thalamus • Pons • Medulla • Spinal Cord • Roots • Plexuses/Cords • Peripheral nerves • Receptors
- 90. Take Home Messages: Shared routes MOTOR • Cerebral Cortex • Internal Capsule • Mid Brain (peduncles) • Pons • Medulla • Spinal Cord • Nerve Roots • Plexuses • Peripheral Nerves • Motor end plates • SENSORY • Cortex • Internal Capsule • Thalamus • Pons • Medulla • Spinal Cord • Roots • Plexuses/Cords • Peripheral nerves • Receptors
- 91. Take Home Messages: Different Directions • MOTOR- Descending . SENSORY -Ascending
- 92. Take Home Messages- Motor System Motor System consists of 2 neurons (UMN &LMN) • Pyramidal Tract (UMN) . • Motor Unit (LMN) • Extrapyramidal Tracts • Cerebellar Pathway
- 93. Take Home Messages –Motor System Only 1st Order neurons cross (UMN) • Lesions before the crossing of pyramidal tract cause contra-lateral features • Lesions after the crossing of pyramidal tract cause ipsi-lateral features
- 94. Take Home Messages –Motor System • Alteration in bulk, tone, power and reflexes help in pattern recognition and to differentiate between UMN and LMN lesions Motor testing is objective More accurate
- 95. Take Home Messages –Motor System • Alteration in bulk, tone, power and reflexes help in pattern recognition and to differentiate between UMN and LMN lesions Motor testing is objective More accurate
- 96. Take Home Messages –Sensory System Sensory System consists of • 3 neurons (1st, 2nd and 3rd order neurons) and • 2 Pathways- carrying different sensations • Spinothalamic • Dorsal Columns Beyond Thalamus the pathways merge
- 97. Take Home Messages –Sensory System Sensory System consists of • 3 neurons (1st, 2nd and 3rd order neurons) • 2 Pathways- carrying different sensations • Spinothalamic • Dorsal Columns Beyond Thalamus the pathways merge
- 98. Take Home Messages –Sensory System Sensory System consists of • 3 neurons (1st, 2nd and 3rd order neurons) • 2 Pathways- carrying different sensations • Spinothalamic • Dorsal Columns Beyond Thalamus the pathways merge
- 99. Take Home Messages –Sensory System Sensory System consists of • 3 neurons (1st, 2nd and 3rd order neurons) • 2 Pathways- carrying different sensations • Spinothalamic • Dorsal Columns Beyond Thalamus the pathways merge
- 100. Take Home Messages –Sensory System Only 2nd order neurons cross in both pathways • Spinothalamic- at spinal level • Dorsal Columns –at medulla • Lesions before the crossing cause ipsi-lateral features • Lesions after the crossing cause contra-lateral features • Throughout the length of the spinal cord, both sensory pathways run on different sides of the cord • Complete anesthesia is a rare finding
- 101. Take Home Messages –Sensory System Only 2nd order neurons cross in both pathways • Spinothalamic- at spinal level • Dorsal Columns –at medulla • Lesions before the crossing cause ipsi-lateral features • Lesions after the crossing cause contra-lateral features • Throughout the length of the spinal cord, both sensory pathways run on different sides of the cord • Complete anesthesia is a rare finding
- 102. Take Home Messages –Sensory System Only 2nd order neurons cross in both pathways • Spinothalamic- at spinal level • Dorsal Columns –at medulla • Lesions before the crossing cause ipsi-lateral features • Lesions after the crossing cause contra-lateral features • Throughout the length of the spinal cord, both sensory pathways run on different sides of the cord • Complete anesthesia is a rare finding
- 103. Take Home Messages –Sensory System Only 2nd order neurons cross in both pathways • Spinothalamic- at spinal level • Dorsal Columns –at medulla • Lesions before the crossing cause ipsi-lateral features • Lesions after the crossing cause contra-lateral features • Throughout the length of the spinal cord, both sensory pathways run on different sides of the cord • Complete anesthesia is a rare finding
- 104. Take Home Messages –Sensory System Only 2nd order neurons cross in both pathways • Spinothalamic- at spinal level • Dorsal Columns –at medulla • Lesions before the crossing cause ipsi-lateral features • Lesions after the crossing cause contra-lateral features • Throughout the length of the spinal cord, both sensory pathways run on different sides of the cord • Complete anesthesia is a rare finding
- 105. Take Home Messages –Sensory System • Clinical features help in pattern recognition and differentiate Dorsal Column from Spinothalamic lesions. Sensory testing is subjective Less accurate
- 106. Take Home Messages –Sensory System • Clinical features help in pattern recognition and differentiate Dorsal Column from Spinothalamic lesions. Sensory testing is subjective Less accurate
- 107. Take Home Messages – Motor & Sensory • Gait is an important clue to localization • Being part of the reflex arc, involvement of reflexes is seen in both • Accompanying features (motor/sensory/ cranial nerve/ cerebellar/EPS/ autonomic) also help in localisation • Temporal profile and other history give clue to the etiology
- 108. Take Home Messages – Motor & Sensory • Gait is an important clue to localization • Being part of the reflex arc, involvement of reflexes is seen in both • Accompanying features (motor/sensory/ cranial nerve/ cerebellar/EPS/ autonomic) also help in localisation • Temporal profile and other history give clue to the etiology
- 109. Take Home Messages – Motor & Sensory • Gait is an important clue to localization • Being part of the reflex arc, involvement of reflexes is seen in both • Accompanying features (motor/sensory/ cranial nerve/ cerebellar/EPS/ autonomic) also help in localisation • Temporal profile and other history give clue to the etiology
- 110. Take Home Messages – Motor & Sensory • Gait is an important clue to localization • Being part of the reflex arc, involvement of reflexes is seen in both • Accompanying features (motor/sensory/ cranial nerve/ cerebellar/EPS/ autonomic) also help in localisation • Temporal profile and other history give clue to the etiology
- 111. Case1 : 25 year old soldier on leave Brought by relatives • Weakness of all 4 limbs X 5 days • Difficulty in breathing X 1 day • Noticed weakness of left LL on waking up. A few hours later similar complaint started in the right LL. A day later same problem developed in the upper limbs too. There has been rapid worsening. For the past 2 days he is unable to get up from the bed. Since yesterday he has developed difficulty in breathing. No cough…… • No sensory complaints. No suggestion of cranial nerve involvement/ seizures/ bowel & bladder disturbances • Diarrheal illness 2 weeks ago
- 112. 25 year old soldier on leave • Clinically- T 99 degree F • Pulse 120/ min • BP 160/100 • Tachypnea- shallow respiration • Chest expansion 1 cm • Wasting • Decreased tone • Grade 0 to 2 power • Areflexia- all 4 limbs
- 113. 25 year old soldier • Where & • What is the lesion ?
- 114. 25 year old soldier • Acute, Asymmetric, Areflexic, Quadriparesis (Polyradiculopathy) • Post infective Gullian Barre Syndrome
- 115. 25 year old soldier • What are the urgencies?
- 116. 25 year old soldier • Respiratory Neuromuscular Failure • Dysautonomia
- 117. Case 2: 30 year old lady • Burning pain like a band on the right side of the chest X 2 days • Few blisters over the same area- this morning • What? • Where?
- 118. Case 3: 45 year old Hypertensive • Weakness left side of body X 6 hours • Sudden onset, while sitting at the table, progressed rapidly over 1 hour, no improvement • Where is the lesion? • What is the lesion?
- 119. Case 3: 45 year old Hypertensive What if- • Was irregular with medication ? • Had an argument with his wife ? • Had intense headache preceding the event ? • Had a seizure (focal with secondary generalization) on the way to the hospital ?
- 120. Case 3: 45 year old Hypertensive • BP 200/120 mm • Pulse 56/ min regular • Resp20/ min • Altered sensorium • Bulk & tone- equal • Left sided hemiparesis; power grade I • Exaggerated deep tendon jerks • Neck stiffness
- 121. Diagnosis • Right Sided Hemiparesis • Intracerebral Hemorrhage • Hypertensive Etiology
- 122. Case 4: 18 year old girl • Fever X 1 Month • Backache X 1 month • Numbness and weakness of both lower limbs X 7 Days • Severe burning pain around the middle X 7 Days • Inability to control urination X 2 Days
- 123. Case 4: 18 year old girl • Thin built, poorly nourished • T 100 degree F • P 110/ min • BP, Resp- N • Pallor + • Cervical matted lymphadenopathy + • Smell of urine+
- 124. Case 4: 18 year old girl Motor: • Lower Limbs • Bulk equal • Tone increased in both lower limbs • Power grade 0 to 1 • Reflexes – Brisk knee jerks and ankle jerks with ankle clonus • Plantars extensors • Upper limbs normal
- 125. Case 4: 18 year old girl • Sensory: • All modalities of sensation diminished below the umbilical level • Definite upper level • Band of hyperaesthesia at the level • Abdominal reflexes - absent
- 126. Case 4: 18 year old girl • Where ? • What ?
- 127. Case 2:55 year old diabetic • Tingling & numbness both lower limbs X 2M • Tingling & numbness both upper limbs X 1M • Weakness in both lower limbs X 1 month • What is the lesion? • Where is the lesion?
- 128. Case 2:55 year old diabetic • Control has been poor • Has been having indigestion • He is a strict vegetarian
- 129. Case 2:55 year old diabetic • Vitals normal • Pallor • Hypovitaminosis • Mild pitting edema • Trophic ulcers on feet
- 130. Case 2:55 year old diabetic Sensory: Glove and Stocking distribution of sensory loss -Pain, Temp, touch, proprioception and vibration (variable levels) Motor system: LL • Bulk & Tone – equal on both sides • Power -grade IV in lower limbs • Ankle Jerks- absent • Knee Jerks –normal UL Normal
- 131. Case 2:55 year old diabetic • What if she had additional weakness and stiffness in lower limbs with bladder complaints of frequency and incontinence?
- 132. Case 2:55 year old diabetic And- • Bulk – equal on both sides • Tone increased in thigh muscles • Grade IV weakness in both lower limbs • Ankle jerks absent • Knee Jerks brisk with clonus • Plantars extensors • Bladder incontinence – empty bladder
- 133. Diagnosis • Peripheral Neuropathy • Myelopathy • Diabetes and Nutritional etiology