SENSORY LOSS

SENSORY LOSS: Excerpt from Differential Diagnosis in Primary Care

Anatomy is the key to developing a list of possible causes of sensory loss. Tracing the nerve endings in the face or extremities to the brain we have the peripheral nerves, nerve plexus, nerve roots, spinal cord, brainstem, and cerebrum. Now cross-index these structures with the various etiologies (Vascular, inflammatory, neoplastic, etc.), and you have an excellent list of possibilities.

1. Peripheral nerve—This structure should prompt the recall of carpal tunnel syndrome, ulnar entrapment in the hand or elbow, and diffuse peripheral neuropathy (diabetes, nutritional disorders, etc.).
2. Nerve plexus—This structure should suggest brachial plexus neuritis, sciatic neuritis, brachial plexus neuritis, sciatic neuritis, brachial plexus compression by a pancoast tumor or thoracic outlet syndrome, or lumbosacral plexus compression by a pelvic tumor.
3. Nerve roots—This would facilitate the recall of space-occupying lesions of the spinal cord (tumor, abscess, e.g.) and fractures of the spine compressing the root. It would also help to recall tabes dorsalis, herniated disc disease, osteoarthritis, cervical spondylosis, spinal stenosis, and spondylolisthesis. Guillain–Barré syndrome affects the nerve causing sensory loss.
4. Spinal cord—Lesions in the spinal cord that cause sensory loss include space-occupying lesions, syringomyelia, pernicious anemia, multiple sclerosis, and Friedreich ataxia, acute traumatic or viral transverse myelitis, and anterior spinal artery occlusion may also cause sensory loss.
5. Brainstem—This should prompt the recall of brainstem tumors, abscess and hematomas, multiple sclerosis, syringobulbia, encephalomyelitis, basilar artery, thrombosis, posterior inferior cerebellar artery occlusion, and neurosyphilis. Do not forget the thalamic syndrome.
6. Cerebrum—Space-occupying lesions of the cerebrum, cerebral hemorrhage, thrombosis, or embolism should be considered here. Encephalitis, toxic encephalopathy, and multiple sclerosis are less likely to cause significant sensory loss if the lesions are confined to the cerebral cortex.

Approach to the Diagnosis

The neurologic examination will help to determine the location of the lesion. Peripheral neuropathy presents with diffuse distal loss of sensation to all modalities. Nerve root involvement will present with sensory loss in a radicular distribution; spinal cord involvement will be associated with a sensory level. Sensory loss to pain and temperature on one side of the face and the opposite side of the body is typical of posterior inferior cerebellar artery occlusion. If there is only loss of vibratory and position sense, look for pernicious anemia or a cerebral tumor. The workup for peripheral neuropathy and entrapment syndromes will include nerve conduction velocity (NCV) tests and EMGs. An MRI and CT scan can be done if brain and spinal cord pathology is suspected, but a neurologist should be consulted first. If a cerebrovascular disease is suspected, Doppler ultrasound and an MRA (magnetic resonance angiography) may be necessary as well. Ultimately, four-vessel cerebral angiography may be indicated.

Other Useful Tests

1. CBC (pernicious anemia)
2. Chemistry panel (diabetic neuropathy, e.g.)
3. Fluorescent treponemal antibody absorption (FTA–ABS) test (neurosyphilis)
4. Serum B12 (pernicious anemia)
5. Blood lead level (lead neuropathy)
6. Spinal tap (neurosyphilis, multiple sclerosis, Guillain–Barré syndrome)
7. Urine porphobilinogen (porphyria)
8. Antinuclear antibody (ANA) (collagen disorders)

Book Source Details

• Book Title: Differential Diagnosis in Primary Care
• Author(s): R. Douglas Collins MD, FACP
• Year of Publication: 2007
• Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Differential Diagnosis in Primary Care Authors: R. Douglas Collins MD, FACP Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-7817-6812-8

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