TSM1.

15: Case 23 Round Up

Professor Philip Bradley

 Outcomes
• Describe the effects of lesions of the spinal
cord
• Describe sensory and motor pathways which
run through the spinal cord
Reminder of anatomy
 1.
• Right handed.
• Gait disturbance – stiffness and lack of control LEFT leg.
• Raised muscle tone both legs. Power reduced in the LEFT leg.
• Light touch sensation and proprioception reduced in the LEFT leg.
• Loss of pain and temperature sensation in the RIGHT leg.
• Pain/temperature/light touch sensory normal above level T6.
 1.
• Brown-Sequard syndrome
• Hemisection of the spinal cord on the right in mid thoracic region
• Damage to descending corticospinal pathways from left hemisphere (crossed to
right at pyramidal decussation)
• Other descending motor pathways on right will be interrupted (rubrospinal,
reticulospinal, vestibulospinal)
• Upper motor neuron lesion and therefore exaggerated reflexes below level of
lesion
• Anterior corticospinal tract (running on left) should be intact and will supply right
proximal musculature (minor)
• Lesion of dorsal columns on right will affect fine touch and conscious
proprioception on the right below the level of the lesion (fibres don’t cross to left
until medulla)
• Lesion of spinothalamic tract on the right will affect pain and temperature on the
left below the level of the lesion (These fibres cross in the spinal cord just above
point of entry and are running on the right )
• Right anterior and posterior spinocerebellar tracts would also be affected – gait
disturbance both sides
 2.
Patient is a 62 year old male who presents with tingling
(paraesthesia) in both hands
On examination:-
• Broad based gait with a stamping action
• Two-point discrimination is poor
• Romberg’s sign is positive
Tabes dorsalis
• Diminished reflexes e.g patellar reflex
may be lacking (Westphal’s sign)
• Paraesthesias (shooting and burning
pains, pricking sensations)
• Hypoaesthesia (abnormally diminished
cutaneous, especially tactile, sensory
modalities)
• Paresis
• Sensory ataxia
• positive Romberg’s test
• The skeletal musculature is hypotonic
due to destruction of the sensory limb
of the spindle reflex.
• The deep tendon reflexes are also
diminished or absent; for example, the
"knee jerk"
 3.
Patient is a 72 yr old male with a history of hypertension and angina. He
presents with acute urinary retention and weakness
On examination:-
• There is flaccid paralaysis of the lower limbs
• There is bilateral loss of pain and temperature sensation in the lower
legs and feet
• Proprioception and vibratory sensation are normal
• Tendon reflexes are absent in the ankle and knee
 3.
• Anterior spinal cord syndrome is normally caused
by blockage of the anterior spinal artery and less
of structures in the anterior half of the spinal
cord on both sides. These include:-
• Ventral horns (LMN)
• Anterior and lateral spinothalamic tracts
• Anterior spinocerebellar tracts (masked)
• Bladder control (parasympathetic from
lumbar/sacral regions)
 4.
The patient is a 42 yr old woman who presents with
weakness (paresis) of proximal musculature in the
arms. Examination shows:-
• Loss of pain and temperature sensation bilaterally
in the upper arms and chest
• Fine touch in the fingers and lower torso and legs
is normal
 4. Syringomyelia
• Growth in the central canal of the spinal cord
• Damages crossing fibres of the spinothalamic
tract
• May affect motoneurons in the medial aspect
of ventral horn
 5. Cordotomy
• Surgical elimination of the anterolateral
spinothalamic tract at C1 on the left
• What would you see?
 6.
• Patient is a 55 yr old male who
presents with low back pain which
occurred while digging the garden.
Examination shows:-
• Weakness and pain over lower
part of right leg
• Reflexes reduced at the ankle and
in the foot (weak plantar reflex)
 6. Nerve compression/ disc prolapse
• Symptoms caused by pressure of herniated
disc on spinal nerve at a single spinal level
(L5/S1)
 7.
• Patient is a 70 year old female with a history
of coronary artery disease and transient
ischaemic attacks. Examination shows:-
• Vertigo
• Cerebellar ataxia on the left
• Loss of pain and temperature sensation on the
left side of the face
• Horner syndrome on left (ptosis, miosis (small
pupils), anhidrosis)
• Hoarseness and difficulty swallowing
• Loss of pain and temperature sensation in
trunk and limbs on the right hand side
• Normal touch and conscious proprioception
both sides
7. Lateral medullary syndrome

• Vertebral or posterior inferior cerebellar

artery occlusion
• Hypothalamospinal tract runs through
lateral medulla - controlling
sympathetic fibres in thoracic region
• Inferior cerebellar peduncle damaged
• Nucleus ambiguus (motor component
of IX, X, XI)
• Solitary nucleus damaged (visceral
sensory component of cranial nerves)
• Spinal nucleus of V involved (pain and
temp ipsilateral)
• Damage to vestibular nuclei - balance
• Medial lemniscus spared
• Cochlear nucleus involved but hearing is
bilaterally represented
 8.
• Patient is a 62 yr old
male. A history of type II
diabetes. He presents
with sudden onset
complete motor
paralysis of right side
• No sensory deficit
 8. Lacunar stroke internal capsule
• Lacunar stroke (blockage of striate artery)
affecting internal capsule on the left side.
 9.
Patient is a 65 yr old female who
wakes up with a weakness of her
right face (except forehead) and
right upper limb. She also shows
sensory loss (touch, pain and
temperature) from right hand and
face. Her speech is slurred.
 9. Cortical stroke
• Blockage of middle cerebral artery affecting lower
part of primary motor and somatosensory cortex
on the left side. Broca’s area is also affected.
(n.b. Primary cortex supplying leg is supplied
through anterior cerebral artery)
• Lower face on left does not have a crossed
innervation and so is affected whereas forehead
on left has a bilateral innervation and so is still
innervated from right facial nerve nucleus.