A SEMINAR ON
BEDSIDE SUPERFICIAL, DEEP AND COMBINED
CORTICAL SENSORY TESTING
PRESENTED BY JAHIR ABBAS
MODERATED BY MR K.VIJAYA KUMAR
Contents:
• Introduction
• Anatomical and physiological basis of sensory
system
• Bedside sensory examination
• Abnormal sensory patterns
• References
INTRODUCTION
Motor control – relies heavily on the sensory
information to regulate and maintain the
movements.
Sensory information tells us about
- State of the environment
- State of our own body
- State of our body in respect to the environment
Vision
Audition
Proprioception
PROBLEM AREA
• Acutely ill patient ( inadequate information)
• Brought by some one!
• The Four “Cs”
1. Consciousness
2. Cognition
3. Co operation due to behavioral problem
4. Communication
• Patient with symptoms but no signs
NEUROLOGICAL EVALUATION
MISCONCEPTION/ SKEPTCISM
• Complex !
• Lacks precision !
• Time consuming !
• Do we need to examine patients in the era of
modern technology ?
!!!!!!!!!!!!!!!!!!!
What is the need ?
• To treat a patient need a diagnosis
• Ascertain the diseases
• Localize the lesion
• Establish the pathology
• Select appropriate investigation
• Quantitative documentation for management
and treatment
What do we need?
• Desire to make correct diagnosis!
• Organized brain
• Problem solving skills
• Specific questions
1. Is there a neurological problem?
2. What is the site of the lesion
3. What is the etiology?
4. What are the potential differential diagnosis?
Examination of sensory function has
three components:
• Patient history.
• A review of relevant systems.
• Specific tests and measures
History is the “Cornerstone”
History consists of:
• Present illness
• Past illness
• Family history
• Personal history
• Treatment details
• Impact in quality of living
• Specific issues ( birth, growth, development,
immunization, travel details, etc.)
Neurological examination
• Mental function/ status
• Cranial nerves
• Sensory examination
• Motor examination
• Reflexes
• Autonomic function
Bedside examination
• A quick /abbreviated examination
• Formal evaluation
• Specific diseases oriented approach
Positive phenomenon
• Represents heightened activity in sensory
pathways.
• Not associated with any demonstrable sensory
deficits.
• Produced due to ectopic generation of volleys
of impulses at some site of lowered neural
threshold.
• Tingling, pins and needles, prickling, band like
sensations.
Negative phenomenon
• Results from loss of sensory function.
• Characterized by diminution or absence of
sensation in particular area.
• Definite sensory loss on examination.
• At least 50 % of the innervating fibers get
damaged.
Important notes :
• Explain each test before you proceed.
• Unless otherwise specified the patient’s eyes
should be closed.
• Compare symmetrical areas on the two sides of
the body.
• Compare distal to proximal areas ( specailly in
peripheral neuropathy).
• When you detect an area of sensory loss map
out its boundary.
• Follow dermatome.
Sensory landmarks
• C 3 - nape of the neck
• C 4 – shoulder/ shawl area
• C 6 – thumb
• C 8 – little finger
• T4 – nipple area
• T 10 – umbilicus
• L 1 - inguinal ligament/ groin area
• L2 - front of both thighs
• L 4,5 – medial and lateral aspect of calves
• S1 – little toe
Dermatomal pattern
Sensory examinations
Superficial sensations
• Light touch
• Pin prick
• Temperature
Deep sensations
• Vibration sense ( pallesthesia)
• Joint position sense
Combined cortical sensations
• Precise/ point/ tactile localisation
• Two – point discrimination
• Stereognosis
• Graphesthesia
• Double simultaneous stimulation
Combined cortical sensation
• Desctribes the perception that involves
integration of information from more than one of
the primary modalities for the recognition of the
stimulus.
• Parietal lobe is the primary area.
Streognosis
• Is the perception of understanding , recognition
and identification of the form and nature of
objects by touch.
Graphesthesia
• Is the ability to recognise letters or numbers
written on skin with pencil, dull pin, or similar
object.
Two point, or spatial discrimination
• Is the ability to differentiate, eyes closed,
cutaneous stimulation by one point from
stimulation of two points.
Double simultaneous stimulation
• Double simultaneous light touch stimuli at
homologous sites on the two sides of the body.
Demonstrations
Abnormal sensory patterns
Abnormal sensations (contd.)
a) Total hemianaesthesia
b) Lateral medullary syndrome
c) Transverse cord lesion
d) Brown sequard syndrome
e) Central cord lesion
f) Sacral sparing
g) Saddle anaesthesia
h) Peripheral neuropathy
Errors in bedside examinations
• Insufficient time
• Inadequate history
• Incomplete examination
• Assumptions
• Poor diagnostic reasoning (anchoring,
premature closing)
• Over reliance on investigations
Summary
REFERENCES:
• William W. Campbell; The Motor System;Dejong’s The
Neurologic Examination; Fifth Edition;2005;Lippincott
Williams and Wilkins;281.
• Susan B. O’Sullivan,Thomas J. Schmitz; Assessment of
Motor Function; Physical Rehabilitation assessment and
Treatment; Fourth Edition;2001;Jaypee Brothers;177.
• Goetz.G.C, pappert.J.E, Propioception, touch and
vibratory sensation in the book of clinical neurology; W.B.
Saunders, 1999, p.315-30.
• Members of department of neurology,mayo clinic and
mayo foundation for medical education and research.
Sensory examination in neurology. Mosby year
book;1991.p.225-75.
• Algappan.R. nervous system in the manual of practical
medicine. Jaypee brothers;2007p.395-25
Thank you
