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“ЗАТВЕРДЖЕНО” на методичній нараді кафедри нервових хвороб, психіатрії та медичної психології “______” _______________ 2008 р. Протокол № _____ Зав. кафедри нервових хвороб, психіатрії та медичної психології професор В.М. Пашковський METHODOLOGICAL INSTRUCTION № 6 THEME: SORTS AND TYPES OF SENSORY DISTURBANCES Modul 1. General neurology Сontents modul 1. introduction. symptoms of motor and sensory disturbanses Subject: Nervous deseases Year 4 Medical faculty Hours 2 Author of methodological instructions MD, Filipets O.O. Chernivtsy 2008 1. Scientific and methodological substantiation of the theme. Different specialists meet with disturbance of sensation in case of many different diseases, such as lues, diabetes mellitus, stroke, polyneuritis, radiculopathyes. That’s way knowledge of sensation disturbance signs has the large value for rendering a well-timed medical care to the patient and solution of questions of a working capacity. 2. Aim: students should be able to determine independently disturbance of sensation in the patients, types of sensory disturbance, level of localization of the pathological process (focus), to formulate and to explain the topical diagnosis. Students must know: 1. Anatomy of brain and spinal cord. 2. Anatomy of superficial sensory explorers. 3. Anatomy of deep sensory explorers. 4. Examination of sensation. 5. Classification of sensation. 6. Types and sorts of sensory disturbances. 7. Semiology of sensory explorers on different level. Students should be able to: 1. Collect the patient’s complaints (tingling, creeping, burning and numbness sensation) and to analyze them. 2. Examine patient’s neurological status. 3. Make a conclusion about the focus of lesion. 4. Make a topical diagnosis. 5. Point character of sensory disturbance. Student should gain practical skills: 1. To check superficial (pain, temperature, tactile) sensation 2. To check deep (joint sense, vibration sense, feeling of pressure, feeling of mass, kinesthesia) sensation 3. To check complicated sensation (stereognosis, graphism, localization sense, discrimination sense) 4. To examine different types of sensory disturbances: - peripheral - segmental - conductive 5. Make a conclusion about the focus of lesion. 3. Educational aim. To indicate that the somatic sensory system contains three primary components: receptor organs, sensory pathways and brain centers. Sensory systems have both a hierarchical and parallel organisation. In general, somatic sensory systems consist of a three-neuron projection system. 4. Integration (basic level). Subjects Anatomy Histology Physiology Gained skills Knowledge of anatomy of the brain and spinal cord. Knowledge of anatomy of sensory explorers. Knowledge of anatomic structures of analyzers and receptor apparatus. Hystological structure of analyzers and receptor apparatus Knowledge of function of the brain and spinal cord. Knowledge of physiologic function of sensory explorers. Knowledge of physiologic function of analyzers and receptor apparatus. Subject. Symptoms produced by lesions of the dorsal column-medial lemniscal pathway are manifest primarily as defects in joint position sense and stereognosis. Diffuse involvement of large-diameter neurons causes loss tactile discrimination and inability to detect joint position and vibration, which produces extreme difficulty in manipulating objects without visual guidance. These lesions also cause loss of muscle coordination and severe disturbances of locomotion because of loss of proprioception (sensory ataxia). The dorsal column system provides fast, accurate feedback about movement, and coordinated motor output suffers from lesions at any level of this system. Because of redundancy and parallel pathways for transmission of tactile and proprioceptive information, central lesions of the dorsal column system produce less severe or partial abnormalities. Because the system is uncrossed until the medulla, lesions in the peripheral or spinal levels, up to and including the nuclei, produce symptoms on the side of the lesion. Lesions of the medial lemniscus, thalamus, or sensory cortex will produce similar symptoms but on the side opposite the lesion. Symptoms produced by lesions of the anterolateral system vary according to the level of the neuraxis involved. Lesions outside the nervous system frequently stimulate adjacent free nerve endings, thereby producing the subjective sensation of pain. This symptom is most important in calling attention to pathological processes occurring in internal organs, most of which contain no pain receptors of their own. Lesions that involve the peripheral level may cause either the sensation of pain when involving nonneural tissue or the loss of pain and temperature sensibility in the area subserved by the affected nerves. Lesions of the central nervous system that involve the anterolateral system result in an inability to perceive pain or discriminate hot from cold on the contralateral side of the body below the level of the lesion. At the level of the brain stem, lesions produce loss of pain and temperature sensibility in the contralateral body and ipsilateral face. A lesion that affects the ventral posterior thalamic nucleus causes a complete loss of all general somatic sensory information from the contralateral face, trunk, and limbs. Thalamic lesions sometimes produce a severe burning pain in the area of sensory loss. The differences in the functional organization of the dorsal column-medial lemniscal and anterolateral systems are highlighted by the sensory symptoms that follow a hemisection of the spinal cord. Tactile discrimination and limb proprioception, which are relayed by the dorsal columns, are lost in the ipsilateral arm and leg, whereas pain and temperature sense, which are relayed by the anterolateral system, are lost in the contralateral arm and leg. The primary somatic sensory cortex plays an important role in processing all of the submodalities of the sensory system. It is located in the anterior region of the parietal lobe (postcentral gyrus) and consist of four anatomically distinct areas (1, 2, 3a, and 3b of Brodmann). Area 1 receives input from rapidly adapting receptors in the skin, area 2 receives input from the pressure and joint position receptors in deep tissue, area 3a receives input from muscle spindles, and area 3b receives input from rapidly and slowly adapting receptors in the skin. Each area contains a unique topographic representation. The input to the primary sensory cortex comes from the opposite side of the body and projects via the ventral posterior tier of the thalamus. Output from the primary motor cortex goes to several places: the contralateral primary sensory cortex; the contralateral dorsal column-medial lemniscal system and ipsilateral ventral posterior lateral thalamus to control input; the ipsilateral motor cortex and basal ganglia for motor control; and the secondary somatic sensory cortex. The secondary somatic sensory cortex is located on the superior bank of the lateral sulcus. Tertiary somatic sensory cortex is located in the insula (at the base of the lateral fissure) and posterior parietal lobe. These regions integrate somatic sensory information with other information (e.g., visual and memory) to form complex abstract perceptions. Lesions of the parietal lobe, seen commonly in cerebrovascular accidents involving the middle cerebral artery, affect the primary, secondary, and tertiary somatic sensory cortices. Cortical lesions alter all somatic sensory information from the opposite side of the body. Unlike thalamic lesions that produce severe disruption of all sensory modalities, cortical lesions produce only minimal disruption of primitive sensory discrimination involving pain, temperature, touch, and vibration but severe deficits in joint position sense, two-point discrimination, touch localization, and the ability to recognize objects placed in the hand (astereognosis). This pattern of loss is referred to as cortical sensory deficit. Primitive perception is formed in the thalamus and thus remains after cortical lesion; localization and discrimination are performed by the cortex and are thus severely diminished after cortical lesion. Self assessment: Tests for self-assessment: 1. Signs of irritation of the lower parts of post central gyruses of dominant hemisphere. 2. Signs of irritation of the middle parts of post central gyruses of dominant hemisphere. 3. Signs of irritation of the upper parts of post central gyruses of dominant hemisphere. 4. Signs of lesion of the radiate crown (corona radiata) on the right side. 5. Signs of lesion of the dorsal leg of internal capsule. 6. Signs of lesion of right thalamus. 7. Signs of lesion of right medial closed loop. 8. Signs of lesion of Burdach’s pathways in spinal cord. 9. Signs of lesion of Holl’ pathways in spinal cord. 10.Signs of lesion of dorsal root. 11.Signs of lesion of dorsal horn in spinal cord. 12.Signs of lesion of dorsal root ganglion. 13.Signs of lesion of front and dorsal roots. 14.Signs of lesion of lateral funicular of spinal cord on right Th10. Tests 1. What type of sensory disturbance occurs when medial lemniscus is damaged? a) conductive; b) cortical; c) segmental; d) polyneuritic; e) radicular. 2. Lesion of what kind of sensation occurs when dorsal horn is damaged? a) All kinds of sensation; b) Complicated sensation; c) Superficial sensation; d) Deep sensation; e) Special sensation. 3. What type of sensory disturbance occurs when front white soldering is damaged? a) conductive; b) cortical; c) segmental; d) polyneuritic; e) radicular. Real-life situations: 1. There are analgesiya and termoanesthesia along segments C5-Th5 on both sides in patient. Where is pathological focus? 2. There is a lesion of dorsal funiculus on Th7 level on left in patient. What sort and type of sensory disturbance is present? 3. The patient has half-transversal lesion of the spinal cord on level Th5 on the right. What sort and type of sensory disturbance is present? What is the name of this pattern? References: 1. Basic Neurology. Second Edition. John Gilroy, M.D. Pergamon press. McGraw Hill international editions, medical series. – 1990. 2. Clinical examinations in neurology /Mayo clinic and Mayo foundation. – 4th edition. –W.B.Saunders Company, Philadelphia, London, Toronto. – 1976. 3. McKeough, D.Michael. The coloring review of neuroscience /D.Michael McKeough/ - 2nd ed. – 1995. 4. Neurology for the house officer. – 3th edition. – howard L.Weiner, MD and Lawrence P. Levitt, MD, - Williams&Wilkins. – Baltimore. – London. – 1980. 5. Neurology in lectures. Shkrobot S.I., Hara I.I. Ternopil. – 2008. 6. Van Allen’s Pictorial Manual of Neurologic Tests. – Robert L. Rodnitzky. 3th edition. – Year Book Medical Publishers, inc.Chicago London Boca Raton. - 1981.