SENSORY IMPAIRMENT

By
Dr. Vonny Goenawan, Sp.S

FACULTY OF MEDICINE

NERVOUS SYSTEM

SENSORY SYSTEM

Transmits sensory information collected by

receptors to the CNS
(Brain)Interpretation

SENSORY RECEPTORS

Somatic

Chemoreceptors
(taste, smell)
Thermoreceptors
(temperature)
Photoreceptors
(vision)
Baroreceptors (sound,
balance)
Proprioreceptors
(muscle stretch)

Visceral

Chemoreceptors
(chemicals in blood,
osmoreceptors)
Baroreceptors (blood
pressure)

SENSORY PATHWAYS

The sensory
pathways convey the
type and location of
the sensory stimulus

The type type of

receptor activated
The location brain
has a map of the
location of each
receptor

PATHWAYS

PATHWAYS

PATHWAYS

HOMONCULUS

DERMATOME

Locate: correlate the region of sensory dysfunction to the

lesion/dysfunction in the nervous system
Lumbar radiculopathy

Carpal tunnel syndrome

Diabetic peripheral neuropathy

PERIPHERAL NEUROPATHY

Trauma or pressure on the nerve.

Diabetes.
Vitamin deficiencies. B vitamins B-1, B-6
and B-12
Alcoholism.
Infections. Lyme disease, shingles (varicellazoster), Epstein-Barr, hepatitis C and HIV/AIDS.
Autoimmune diseases. (Lupus, rheumatoid
arthritis and Guillain-Barre syndrome.)
Inherited disorders.
Tumors.
Exposure to poisons.

ANATOMY

PERIPHERAL NERVES

Endoneurium

Fascicles

Groups of axons

Perineurium

Surrounds axons of
peripheral nerves

Surrounds
individual fascicles

Epineurium

Intraneural
Outer
circumferential

PHYSIOLOGY

PERIPHERAL NERVES

Peripheral nerve signaling

Action potentials
Unmyelinated

Rate of conduction directly proportional to cross

section of axon

Myelinated

fibers

fibers

Impulse jumps from each site of interrupted myelin

sheath (Node of Ranvier)
SALTATORY CONDUCTION

SALTATORY CONDUCTION

NERVE INJURY

Two classification systems

Seddon
Neuropraxia,

axonotomesis, neurotmesis
Based on clinical evaluation and judgment of
injury
Preoperative assessment

Sunderland
1st

to 5th degree
Histology
Applicable after nerve exploration

NERVE INJURY

NERVE ENTRAPMENT

EPIDEMIOLOGY

10-20% of the practices cases

Risk factor:

Female gender
Pregnancy
Diabetes
Rheumatoid arthritis
Job?

Carpal Tunnel Syndrome (CTS) is the

most common

PATHOPHYSIOLOGY

Systemic conditions

Diabetes
Alcoholism
Hypothyroidism
Exposure to industrial solvents
Aging

Depression of nerve function

Lowers threshold for manifestation of
compression neuropathy

CARPAL TUNNEL SYNDROME (CTS)

WHAT IS CTS?

Carpal tunnel syndrome (CTS) is a

condition affecting the hand &
wrist

Pressure on the median

nerve can result in;
sensations of numbness,
tingling, pain and
clumsiness of the hand

The combination of
these symptoms is
called CTS

ANATOMY

EPIDEMIOLOGY

Incidence of 99 to 148 per 100,000

4th-5th decade (82% > 40yo)
Female : Male 3:1

Stevens, Neurology 2001

No causal relationship
Rates ~ general population

PATHOPHYSIOLOGY

Disturbed axoplasmic flow

Endoneural edema
Impaired neural circulation
Diminished nerve elasticity
Decreased gliding

SYMPTOMS

Pain and paresthesias palmar radial hand

Intermittent pain and paresthesias in the

median nerve distribution
Worse at nightnocturnal paresthesia
(CARDINAL sign!!)
Exacerbated with repetitive forceful use
Sensation of swelling
Normal sensation in area of palmar cutaneous
branch of median nerve

Motor function

Late sign

Clumsiness
Thenar atrophy
Weak thumb abduction

DIAGNOSIS
Tinels Test:
Doctor taps the median nerve at the wrist
producing a tingling feelinglike hitting your
funny bone)

DIAGNOSIS
Phalens Test:
Symptoms can be reproduced when
wrists are kept down in a bent position
for one minute

ELECTROMYOGRAPHY
(EMG)

Electrodes are placed on the forearm and a

mild electrical current is passed through the
arm.
Measurement of how fast & how well the
median nerve

TREATMENT

Splint (usually worn at

night) to prevent the
wrist from bending.
Relieves swelling
through rest.

Medications: Oral antiinflammatories. The

swollen membranes are
reduced

TREATMENT

Cortisone injection: Reduce the swollen

membranes & tendon (effective when
diagnosis is made early)
Surgery: Relieves pressure on the median
nerve.

CUBITAL TUNNEL
SYNDROME

ANATOMY

EPIDEMIOLOGY

Ulnar nerve compression at the elbow:

Second most common compression
neuropathy of the upper limb
Incidence: 25 per 100000 person years

USA: 75000 cases annually

World-wide: 1.5 million cases

SIGN & SYMPTOM

Sensory changes in ulnar nerve

distribution (little+ring finger)
Intrinsic weakness (not always!)
Tinels sign at medial elbow
Elbow flexion test (3 min @ 120 flexion
reproduces symptoms)
Wartenbergs sign
Fromments sign

ULNAR NERVE SENSORY DISTRIBUTION

DIAGNOSIS

Most sensitive: 30 sec of elbow flexion in

conjunction with direct pressure at ulnar
nerve

93% SENSITIVITY !!

TREATMENT

Nonsurgical measures

Nighttime pillow splints keep the elbow

extended
Anti-inflammatory medications

Surgical methods releasing the nerve

Most commonly, decompression, medial

epicondylectomy, anterior transposition
(subcutaneous vs submuscular), or a
combination

TARSAL TUNNEL
SYNDROME

ANATOMY

EPIDEMIOLOGY

The incidence of TTS has not been

determined.
Age 15-70 years
Female >>male

ETIOLOGY

INTRINSIC

Metabolic
Toxic
Crush
Stretch
Diabetes

EXTRINSIC

Mechanical
Space
occupying
massses
Trauma
Arthritis ridges
Static or Dynamic
Compressive
forces

SYMPTOMS

Pain
Burning
Paraesthesiae or numbness in the sole of
the foot
Severe compression pain radiating
proximally along the medial aspect of
the leg

DIAGNOSIS

The Tinel sign +

Palpation of involved nerve causes pain
to radiate proximally and distally
Reduced sensitivity to light touch,
pinprick, and temperature

TREATMENT

Local injection of STEROID into the tarsal

canal
Surgery RELEASE the compression

THANK YOU