Case Studies I.

Somatic Sensory and Pain

It is highly recommend that students work through each case for themselves prior to the class discussion session, using the information provided in the lectures that cover the relevant systems and pathways, as well as in the lecture on the neurological exam. Each sign and symptom will provide you with information about the integrity of a specific pathway or neuroanatomic structure. Loss of function will denote damage to a specific structure or pathway. Normal function will signify that the structures or pathways mediating that function are intact. For each sign/symptom, list all possible neuroanatomic structures involved in mediating that particular function, and indicate whether they are damaged or intact by entering them into the appropriate column. The resolution of the case will involve determining a single site of damage that will explain the particular set of signs and symptoms presented by the patient. These cases are adapted from the textbook: Neuroanatomy through Clinical Cases Hal Blumenfeld, M.D., Ph.D. Sinauer Associates, 2002 This reference is provided for purposes of acknowledgment, and for those students who may be interested in reviewing the cases after the class discussion. Note: In the description of each case, the term physical exam refers to the non-neurologic portion of the exam that includes vital signs and examination of the neck, heart, lungs and abdomen.

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Case Studies I: Somatic Sensory and Pain

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Case 1: A 24-year old man was drinking heavily with some friends on the July 4th weekend
and fell from a second-floor balcony. He struck his back on a hard object as he fell and landed in a seated position. He noticed an immediate and complete loss of movement and sensation in his lower extremities. He was transported to the emergency room and examined. The muscles in the patients lower limbs showed flaccid tone and no contraction. On sensory testing, there was decreased sensation bilaterally in all modalities (pinprick, touch, vibration and joint position sense) at T10 and below.

Signs and Symptoms

Loss of tone and contraction in muscles of lower limbs

Possible Site(s) of Lesion

Medial precentral gyrus bilaterally Part of internal capsule bilaterally Part of crus cerebri bilaterally Part of base of pons bilaterally Part of medullary pyramids bilaterally Anterior and lateral funiculi of spinal cord at L1 or above (upto about T2) Cauda equina at L1-L2 All ventral roots at L1 and below on both sides

Loss of pinprick (pain) sensation bilaterally at T10 and below

Loss of touch, vibration and joint position sense bilaterally at T10 and below

Conclusion:

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Case Studies I: Somatic Sensory and Pain

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Case 2: A 62 year old female presented with numbness on her right side, particularly in the
upper and lower extremities and face. The numbness began 2 days ago when the patient awoke with numbness in the right face and arm as if they were asleep. She noticed no problems with language, movement or vision. The symptoms persisted until the next morning, when she also noticed numbness in her right foot. Her past medical history was notable for hypertension, cigarette smoking and depression. Her father had a stroke at age 64. The physical exam was normal, except for a blood pressure reading of 198/114.

Neurologic Exam
Mental Status: Alert and oriented to person, place and time Recalled 3/3 words after 5 mins. Language and computation normal Cranial Nerves: Pupils reactive to light; normal visual fields and eye movements Decreased pinprick and temperature sensation in right face, especially around the mouth Facial muscle strength normal Articulation and palate movements normal Sternocleidomastoid muscle strength normal Tongue midline Motor: Normal tone, reflexes and strength Normal rapid alternating movements and finger-to-nose and heel-to-shin testing Normal coordination and gait Sensory: Decreased pinprick, temperature and vibration sense on right side of body, especially in right hand and foot 2-point discrimination in right index finger = 15 mm, compared to 4 mm in left index finger Normal graphesthesia Conclusion:

Structure(s) Intact

Possible Site(s) of Lesion

Podiatry Neuroscience 2012

Case Studies I: Somatic Sensory and Pain

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Case 3: A 46 year old man presented with symptoms that had gradually worsened over the past
few years, including pain and numbness in the shoulders and arms, and difficulty walking. The patients history was notable for a motor vehicle accident at age 18, when he sustained fractures of C2 and C3. These fractures resulted in a quadriparesis that had gradually improved until the onset of his current symptoms.

Signs and Symptoms

Decreased pinprick sensation and painful numb parasthesias in shoulders bilaterally and in left upper extremity Vibration sense normal Weakness, increased tone and hyperreflexia in all extremities Slow, shuffling gait

Structure(s) Intact

Possible Site(s) of Lesion

Lateral funiculus of cervical spinal cord bilaterally

Conclusion:

Podiatry Neuroscience 2012

Case Studies I: Somatic Sensory and Pain

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