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Sensory and its disorders. Pain.

Syringomyelia

Sensory is the ability to experience at least external and internal stimuli. It can be
divided into general sensory (pain, temperature, tactile, etc.) and special sensory
(vision, hearing, smell, taste). This topic consider only general sensory.

Brief anatomy and physiology of the general sensory

It depends on localization of receptors, it’s divided into superficial sensory (pain,


temperature, tie-straightening), or exteroreceptor and deep sensory (joint-muscular
sensory, vibration sensory), or proprioreceptor (receptors located in muscles, tendons,
ligaments, capsules of joints) and interoreceptor (baro-, chemoreceptor located in the
internal organs) as a complex species sensory allocate stereognosis (stereognosis
sense), two-dimensional sense.

Picture 1 shows the path of pain and temperature


sensory.

First neuron, which receives irritation from pain or


thermal receptor, situated in the spinal cord ganglia.
Excitation from the receptor spreads along its
dendrites, in coming in the part of peripheral nerve and
plexus and, reaches the body neuron and distributed by
its axon, which go thru posterior root and reaches the
posterior horn, where placed second neuron. More
excitation spread along the axon of the second neuron,
which passes on opposite side thru anterior commissure
and enter in the lateral funiculus, giving a branch for
the formation of segmental reflex pathway. Goes to the
opposite side occurs in the oblique plane, therefore
axon enters to lateral funiculus in 1 -2 segments level
higher than second neuron. Axon of the second neuron
passes through the spinal cord, brain stem and reaches
thalamus, forming TRACTUS SPINOTHALAMICUS. At the
level of the spinal cord in spinothalamic pathway
marked eccentric location axons, in which fibers carry
information from the lower limbs, located laterally, fiber
from upper limb - medially (fibers from the trunk
located between them). In thalamus excitation is
transmitted to a third neuron, axon which forms
TRACTUS THALAMOCORTICALIS, passes thru posterior
arm of internal capsule, white matter of cerebral
hemisphere and reaches post central gyrus of the
parietal lobe. In the upper part of the post central
gyrus and the medial part (paracentral lobe), parietal
lobe receives information about the lower extremities,
in the middle part - about trunk, upper extremity, and
the lower part - about the face and internal organs.

The first neuron is the pathway of deep and tactile sensory (see Fig. 1), which receives
stimuli from definite receptor (tactile corpuscles of the skin, receptors of muscles,
ligaments, tendons, joint capsules), reaches in spinal ganglia. Initiation from receptor is
distributed according to its dendrite, incoming in the peripheral nerves and nerve
plexus and reaches the body of the neuron and extends on its axon, which is in the
posterior root enters posterior cord of its side, giving at this level branch for the
formation of the segmental reflex. Axons of neurons from the lower limb form a thin
bundle (bundle Gaulle/Голля), which is located medially; axon of neurons from the
upper limbs form klinovidniy bundle (Burdach's nucleus/Бурдаха), which is located
laterally in the posterior horn. Axons of neurons in the second part of the new bundle
(laminiscus medialis) go to the opposite side and join the fibers of pain and
temperature-sensitive, reaching with the thalamus. In the thalamus the excitation is
transferred to the third neuron, whose axon, forming TRACTUS THALAMOCORTICALIS
which passes through the posterior horn of internal capsule, white matter of brain and
reaches post central gyrus of parietal lobe. In the upper part of post central gyrus and
media part (paracentral lobe) of the parietal lobe, receives information from the lower
extremities, in the middle part - the trunk and upper extremity, the lower part - of the
face, the internal organs.

Thus, the different localization of conductors pain, thermo sensory and deep, tactile
sensory are observed in the spinal cord and medulla of brain, in other parts of the
nervous system of conductors of various types of general sensory are placed together.

Methods of Diagnosis of General Sensory

Studies are started from clarifying the complaints (pain, numbness, the unpleasant
sensations) and, if they exist, must specify their nature and localization. Then put
different kinds of stimulation, determining the existence of sensations (pain, heat, etc.)
and comparing the sensations in symmetrical of body parts, distal and proximal parts
of extremities.

At identifying changes must determine their localization and borders, compare


external region with the limits of anatomical innervations.
Pain sensory is determined with the injection of needle, which should be strong and
frequent. For study of temperature sensory, must use test tube with cold (+15 ...+ 25
° C) and hot (+40 ... +50 ° C) water or with cooler or warmer (in comparison with
patient’s skin) objects, such as metal part of neurological hammer.
For assessment of deep sensory mostly always study joint-muscular sensory - a feeling
passive movements in the joints of limbs. Survey shows, types of movements that will
be produced, for example upwards or downwards, then asked to close their eyes and
determine patient doctor passive movement.
Usually, studies begin with the definition of passive movements in the terminal
phalanx of limbs, and then move to the larger big joints. Healthy people feel light
passive movement in the joint (change position at 1-2 °). With the help of a tuning fork
can be investigated - vibration sensation; leg vibrating tuning fork
will set on the bone protrusion and define whether patient feels the vibration or not, If
yes must measure the duration of vibration felt, which is normal 9 – 15 seconds.
Tactile sensory studies is done by light touch to soft skin of palm or sole ; patient is
asked to close their eyes and whether he feels the touch, say" yes ".

In complex forms of sensory usually investigate two dimensional senses and


stereognosis. To estimate two dimensional senses on patient’s skin must use blunt
objects, such as blunt end of the needle, drawing some shapes (circle, cross, triangle),
which he must identify with the eyes closed. To assess Stereognosis must asked
patient to close eyes, put his arm on known object (key, coin, pencil, etc.) and ask him
what the object is. A healthy person does flawlessly.
Symptoms of sensory disorders

Sensory disorders can occur with lesions of conductors general sensory to different
levels: brain, cranial nerves, spinal cord, posterior root, plexus, and peripheral nerves.
They are show in the form of symptoms of irritation, such as pain and loss - loss of
sensitivity). As the basis symptoms of sensory disorders are distinguished pain,
paresthesia, hypoesthesia, anesthesia, hyperesthesia, dysesthesia and hyperpathia.
Paresthesia – discomfort feeling in the form of pricking, numbness and crawl of small
insects/ chills.
Hyperesthesia - increased perception of touch, or any other skin irritation.
Hypoesthesia – desensitization/decrease sensation, anesthesia - about the total loss.
The reduction in pain sensitivity is like hypalgesia, its total loss - analgesia. When there
is lesion in all conductors overall sensitivity (in example, when trauma of nerves)
develops a total anesthesia, when isolated lesions – loss of one type of sensory
(dissociated type of sensory disorder). Loss of deep sensitivity (joint – muscle sensory)
is accompanied by muscle hypotonia and hyporeflexia, it leads to movement disorders
- sensory ataxia. Loss of the ability to identify familiar objects by touch (with the
preservation superficial or deep sensitivity) occurs with lesions of the parietal lobe and
is defined as astereognosis or true astereognosis. Loss of the ability to identify familiar
objects by touch, caused by the loss of superficial or deep sensory, can be observed at
various levels of destruction of sensitive guide and be considered as a false
astereognosis.
Dysesthesia is characterized by change of sensation perception, for example the
appearance of pain in response to simple touch (tactile allodiniya) or touching of cold
objects (cold allodiya)

Pain can be classified as nociceptive, non-nociceptive and psychogenic.


Nociceptive pain is caused by activation of pain receptors (nociceptors) in response to
damage of the skin, skeleto- muscular system and internal organs. It can be felt not
only in the place of damage, but also distant regions which innervate those same
segments of the spinal cord, that area of damage (synalgia). For example, during acute
myocardial ischemia (stenocardia or infarct) pain is often felt not only at the chest, but
also in the left arm and jaw.

Neuropathic pain occurs when lesion in sensory conductors; it doesn’t coincide with
place of lesion and presents ¬ projection pain. A striking example of projection of
pain is phantom pain that occurs after amputation of limbs in the form of unpleasant
sensations and the absence of its parts (e.g. ; fingers). The defeat of sensitive
conductors can cause paresthesia, hyperesthesia and dysesthesia, which often
combined with neuropathic pain.

Pain regard as psychogenic in cases where I n case of nonexistent its organic cause
(somatic or neurologic disease) or the character and intensity of pain is clearly
inconsistent with an organic lesion. Psychogenic pain usually occurs on the background
of depression and anxiety disorders or other psychiatric disorders.

Type (syndrome) of sensory disorders

Depending on the localization of sensory disorders, we can distinguish type


(syndrome), which indicates the location and destruction of sensitive conductors and
to put a topical diagnosis. Fig. 2 shows the main types of disorders of sensitivity.
Mononeuropathic type sensory disorders, (see Fig. 2, a) manifests as sensory disorders
in region of innervations of one nerve and indicate its damage (mononeuropaty).
Region of sensory impairment in of one nerve usually considerable lower than zone it
anatomically innervates, due to cross-innervation of the skin adjacent nerves. First
sensory symptoms are often are pain and parasthesia. Next to them usually is
associated loss of sensory in the form monoginestesia or monoanesthesia.

Polyneuropathic type of sensory disorders (see Fig. 2,b) manifest as sensory defect in
the distal extremities in type "socks" ( "golf", "stocking"), "gloves" and show lesion of
the distal peripheral nerves of limbs (polyneuropathy). The degree of sensory disorders
his fingers of limbs and weaker in proximal direction. Sensory disorders were
significantly more common in the lower extremities. The lesion of the peripheral nerves
of the extremities usually first manifests as pain, paresthesia and hyperesthesia, which
is gradually replaced hypoesthesia or anesthesia.

Segmental radicular-type of sensory disorders is sensory defect in the form of


horizontal lines on the trunk or vertical lines on the limbs (“stripe" on the leg) and
indicates the posterior spinal-cerebral roots (radiculopathy). Pain and paresthesias
usually appeared to be first symptom of lesion in spinal cord roots. Loss of sensory in
form of hypesthesia (rarely anesthesia) often is not detected in the all region that the
destructed radix innervates butonly in distal parts of limbs because of overlapping in
innervations zones by adjacent spinal cord roots/radix.

Segmental-dissociated-type of sensory disorders is characterized by loss of pain and


temperature sensation in form of "jacket" or "half jacket” indicating lesions of posterior
horns or anterior gray commissure of spinal cordin the level of the respective
segments of the spinal cord (in case of "jackets" or "half-jacket" there is a lesion on
cervicothoracic segments). Segmental-type sensory disorders occur rarely, the cause
more often are syringomyelia or tumour of spinal cord.
Segmental-conductor type of sensory disorders (see Fig. 2. ) manifests as abnormal
sensation more distal from the horizontal level of lesion on body. Loss of pain and
temperature sensation on the one hand shows lesion in contralateral spinothalamic
tract in the lateral funiculus of spinal cord by 1-2 segments above the level of
abnormal sensory of the skin. For example, loss of pain and temperature sensation on
the left half of body below the 8th thoracic segment and in the left leg indicates lesion
of the right lateral funiculus at the level of 6-7th segment of the thoracic segments. The
loss of deep sensation on the one hand points to the posterior cord lesion on the same
side. Often, the loss of deep sensation occurs only in the lower extremities when it

normal in the upper extremities, which indicates that the lesion of both posterior
funiculus of thoracic segments of the spinal cord.

Cerebral type of sensory disorders (see Fig. 2, ) characterized by decrease or loss of


sensation on one side of the body with hemihypoesthesa and hemianesthesia and
indicate the lesion of sensory conduction of brain on the opposite side. In
hemihypoesthesa and hemianesthesia, brain lesion on contralateral side may be at the
level of the parietal lobe (postcentral gyrus), corona radiata, internal capsule, thalamus
and the first half of the brain stem. Any damage of the thalamus or sensory conduction
in other parts of the brain, pain, paraesthesia and hemihypoesteziya is on contralateral
side of the body. Pain is of prickling, burning periodically intensified; light touching of
skin provoke pain attack. Threshold of pain stimulation perception is increased, but the
repeated irritation caused by several period of intense and distressing pain that
remains after the application of painful stimuli - hyperpahy. This pain syndrome is
defined as "central pain".

Any damage to the brain stem may cause alternating hemianesthesia (see Fig. 2, e) -
loss of pain and temperature sensitivity in the face, in the one half of trunk and limbs -
contralaterally. This abnormal sensation indicate lesion of caudal part of brain, where
trigeminal nerve is located and responsible for sensation odf skin and passes
spinothalamic tract

Cortical type of sensory disorders (Fig. 2, g) manifests as abnormal sensation, most


often hypoesthesia or paresthesia, only in the region, hands or feet, and shows lesion
corresponding parts postcentral gyrus of the parietal lobe of the opposite hemisphere.
When the cortical type of localization sensory disorders does not correspond to zones
of peripheral innervation, which is feature from mononeuropathy and segmental-
radicular-type of sensory disorders.

Disorder may have a sensitivity and psychogenic character. In such cases, the
localization of sensitivity
defects usually do not correspond to the possible types of disorders of sensitivity
arising in organic defect of sensory; and in demonstration of anormal joint-muscular
sensation, patient does not have sensitive ataxia,
changes in muscle tone and the reflexes. In the examination of sensation with closed
eyes, patient in each
test (eg. Application ofpain stimuli) responds by saying that he feels nothing and tells
us thatsensation is preserved.

For hysterical hemihypoestesia, shows characteristic abnormal sensation in one half of


the body (usually the left) with the border, along the medial line, differs from organic
hemihypoesthesia where the sensory abnormalities have no clear boundaries.

Additional methods of investigation used for objectification of sensory disorders,


clarification the localization of lesion and to ascertain the neurological disease.
Electroneuromyography (ENMG) allows us to identify signs of lesion in sensory
conduction of peripheral nerves, spinal roots. Sensory-triggering potentials
investigation allow us to clarify lesion of sensory conductors not only peripheral, but
also in spinal and cerebral level. To determine the level of lesions in the brain and
spinal cord, neurovisualization methods - computer X-ray and magnetic resonance
tomography of the head and spine.

Treatment of sensory disorders – is to treat main disease, if it is possible. In acute


pain, and as symptomatic treatment, analgesic may helps. In the case of chronic pain
rather than analgesics, drugs is given often in high doses, it is advisable to use
antidepressants and antiepileptic. Analgesic effect of antidepressants is not associated
directly with their antidepressant effect and appears at about no low doses.
Amitriptyline is used as increasing doses (from 10 mg to 75 mg / day) until a positive
effect is achieved. You can use other antidepressants such as mianserin (lerivon) from
30-90 mg/day. Antiepileptic especially effective in paroxysmal pain, carbamazepine is
used from 200-900 mg/day, clonazepam (antelepsin) for I 4 mg/day, valproic acid by
600-800 mg/day, lamiktal (lamotrigine) for 100-200 mg/day. In addition to medical
therapy, we can use physiotherapy, reflex therapy, blockade with local anesthetics and
corticosteroids.

TYPES OF SENSORY DISORDER


Type Localization of Sensory Damage Localization of Lesion
Mononeuropath In the area of innervations of a nerve Peripheral nerve
y
Distal part of limb, "socks" ("golf") type Distal peripheral nerves
Polyneuropathy on the lower limb, "gloves" type on the
upper extremities
In longitudinal lines form on the trunk or Posterior spinal cord roots
Segmental-
vertical lines on the limbs (“stripe" on
radicular
the leg)
Loss of pain and temperature sensitivity The lesion of the posterior
Segmental-
in different segments, most often in the horn or anterior gray
dissociated
form of "jacket" or "half jacket” commissure of spinal cord
Spinal Sensory disorder below the horizontal Lateral and/or posterior
conduction level on the trunk spinal cord
Sensory disorder at half of the head, Postcentral gyrus, corona
Cerebral
trunk and legs with one side radiata, internal capsule or
conductivity
thalamus
Alternating Sensory disorder in half of the face on Half of the brain stem
hemihypoestesi one side and the other side in trunk and
a limbs
Only in limited areas of head, hands or Postcentral gyrus of
Cortical
legs opposite hemisphere

TYPES OF PAIN
Types of
Characteristics of pain
pain
Caused by activation of pain receptors (nociceptors) in response to
Nociceptive injury; can feel not only the site of damage, but also in other remote
areas (synalgia)
Lesion arises in the sensory conduction; does not coincide with the
Neuropathic place of lesion and presence of projection pain, often combined with
other sensory disorders
Nature and intensity of pain clearly does not correspond to organic
Psychogenic
lesion, often marked by depression or other mental disorders

Syringomyelia

Syringomyelia - a chronic disease of the nervous system , characterized by formation


of cavities in central parts of spinal cord and frequently in medulla oblongata
(syringobulia). Cavities usually are formed in lower cervical and upper parts of spinal
cord. Incidence of syringomyelia is 8 -9 cases in 1000 000 population.
Causes of disease are unclear, pathogenesis of disease however, role of obstruction of
CSF flow/drainage from 4th ventricle into subarachnoid space, is assumed/ suggested,
in which hydrodynamics lead to dilatation/ widening of canalis centralis in SC.

Clinical picture:
Begin disease at 25 – 40 yrs old, Males are more often affected than woman.
Symptoms develop gradually; first of all usually appear derangement of sensation,
weight loss and weakness of small muscles of hand. Characteristics segment –
dissociative sensory disturbances in form of <jacket> or <half jacket> - loss of pain
and temperature sensation while other types of sensations are normal. In
syringobulbia, decrease sensation in facial region is also possible. Rarely derangement
of sensation and atrophy develop in lower parts of body and in legs. In consequences
of loss of pain sensation, often develop trauma, especially burns, which lead to
scarring changes of skin. In many cases, it is observed spontaneous pain, which may
be burning, acute or gunshot/ lighting pain.

Mostly early motor derangements are weakness and atrophy of hands muscle. Further,
it is possible to extend to peripheral paresis of proximal parts of arms and shoulder
girdle; some patients develop central paresis of lower limbs (in consequences of lesion
of lateral funiculus of SC).

Not frequently, seen trophic skin changes in hands, in 20% of cases observed
arthropathy (often of elbow and shoulder joints). In syringobulbia, may develop
paralysis of soft palate, pharynx and larynx, tongue atrophy, vertigo, nystagmus.
Patients with syringomyelia usually have dystrophic changes; unproportionate length
of arms in relation to body, finger distortion, anomalies of ears, short neck, kyphosis
and scoliosis of vertebra etc.

Duration/course of the disease is chronic, slowly progressive. Sudden intensification of


symptoms happen due to physical exercise, trauma or develop in bleeding/
hemorrhage into syringomyelic cavity.
In syringobulbia, possible disturbances in respiration due to stridor of larynx;
(obstruction) combined with bronchopulmonary complications, which may bring to
lethal outcome. However, in most patients, disease doesn’t shorten duration of life and
they, as a rule, maintain working capacity for a long time.

Diagnosis: Leading importance: MRI of SC. MRI allows to visualize cavity inside SC
and exclude other diseases. EMG (electromyography) – clarity lesion of anterior horn of
SC on cervical level; characteristic of syringomyelia.

Treatment: Recommend to be careful of damage injury to skin surface,


recommended medical gymnastics (physical trainings) and massage. In long and
intense pain, prescribe analgesics and antidepressants. Whenbig syringomyelic cavity
forms, operative drainage and shunting maybe effective to be done.