SENSORY LOSS (Algorithmic Diagnosis of Symptoms and Signs)
SENSORY LOSS
Ask the Following Questions:
- Is it intermittent? The presence of intermittent sensory changes would suggest a transient ischemic attack, migraine, and epilepsy.
- Is there loss of vibratory and position sense only? The finding of loss of vibratory and position sense only, particularly if it involves all four extremities, would suggest pernicious anemia. If the loss of vibratory and position sense is on one side of the body only, a parietal lobe tumor should be suspected. Diffuse loss of vibratory and position sense only may also be seen in multiple sclerosis, cervical spondylosis, and Friedreich's ataxia.
- Is there loss of pain or temperature only? The presence of loss of pain and temperature on one side of the body is more likely to occur with posterior inferior cerebellar artery occlusions. Rarely, syringomyelia may cause loss of pain and temperature only in the lower extremities if the syringomyelia is in the thoracic cord and in the upper extremities if it is in the cervical cord. Anterior spinal artery occlusions may cause loss of pain and temperature in the lower extremities. Multiple sclerosis can occasionally cause loss of pain and temperature in a diffuse manner.
- Is there loss of all modalities together? If all modalities are lost together on one-half of the body, one should consider thalamic syndrome due to vascular occlusion of the thalamogeniculate artery or its branches. Loss of all modalities in the lower extremities and up to a certain sensory level would probably be due to spinal cord trauma, a space-occupying lesion, or transverse myelitis. However, this condition can also be seen with multiple sclerosis. Loss of all modalities together in the upper extremity may be found in brachial plexus neuropathy or injuries. It may be found with malingering as well. Loss of all modalities in a glove and stocking distribution would suggest peripheral neuropathy. Loss of all modalities in a dermatomal distribution would suggest radiculopathy due to herniated disk, tumor, or arthritic spurs. Platybasia and foramen magnum tumors may cause selective loss of vibratory and position sense in one or more extremities or loss of sensation to all modalities in one or more extremities.
DIAGNOSTIC WORKUP
Routine diagnostic studies include a CBC, sedimentation rate, urinalysis, chemistry panel, ANA, serum protein electrophoresis, VDRL test, chest x-ray, and x-ray of the spine. Findings of a clear-cut sensory loss are a good reason to consult a neurologist at this point. When one is not available, further workup depends on what part of the body is affected.
If only the lower extremities are involved, a CT scan or MRI of the lumbar or thoracic spine may be done. EMG and nerve conduction velocity studies of the lower extremities will complement the diagnostic evaluation.
If the upper and lower extremities both are involved, an MRI of the cervical spine would be the best procedure to perform. A CT scan of the cervical spine is not nearly as precise. EMG examination of the upper and possibly the lower extremities should be done in these cases. Nerve conduction velocity studies may need to be done also.
If the face is involved along with the extremities, a CT scan or MRI of the brain should be done. Skull x-rays are not very useful unless a fracture of the skull is suspected.
Carotid scans and four-vessel angiography are very useful in evaluating cerebral vascular disease. If peripheral neuropathy is suspected, a neuropathy workup
should be done. If multiple sclerosis is suspected, a spinal tap and SSEP or VEP studies will assist in the diagnosis. A spinal tap will also be useful in diagnosing central nervous system lues. If pernicious anemia is suspected, a serum B
12
and folic acid and possibly a Schilling test should be done. Guillain-Barré syndrome is diagnosed by a spinal fluid examination, which will show a markedly elevated spinal fluid protein in the face of a normal cell count.
Entrapment syndromes, such as carpal tunnel syndrome, ulnar nerve entrapment, or tarsal tunnel syndrome, are diagnosed by nerve conduction velocity studies.
A wake-and-sleep EEG may diagnose complex partial seizures or parietal lobe seizures. Sometimes, combined myelography and CT scan are better than MRI studies in selected cases.
Copyright Details: Algorithmic Diagnosis of Symptoms and Signs, Copyright © 2003 Lippincott Williams & Wilkins.
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