Do not just think of spinal cord disease?

There is a sensory disturbance level in the trunk.
If it is not a spinal cord disease, how many possibilities can you think of? Can the only sensory plane be Guillain Barre syndrome? There are at least three possible locations for the sensory plane: medulla oblongata, parietal lobe, and peripheral nerves.

This article is going to describe your ~ Author: phase from the heart of this paper is authorized to release NMT Medical, please do not reprint without authorization.

Case 1: A 58-year-old male patient located in the medulla oblongata.
Sudden numbness in the left trunk and legs.
Physical examination: normal cranial nerves.
The sensation of pain and temperature in the left trunk below the T4 dermatome and legs decreased by 80%.

The muscle strength of the limbs is normal.

Vibration, position, two-point discrimination, and pattern perception are normal.

Thoracic MRI and somatosensory evoked potential are normal [1].

The head MRI is as follows: Figure 1 The lateral medulla oblongata infarction on the right side, and the sensory level below the trunk T4.
Example 2: An 86-year-old female patient with numbness in her right leg.

Physical examination: trunk and legs below T8 have pain, hypothermia, and normal muscle strength.

The MRI of the spine was normal [2].

The head MRI is as follows: Fig.
2 a sensory plane and b, c left lateral medullary infarction area Fig.
3 d left vertebral artery local stenosis; e the shaded area is the infarct area of ​​this patient, involving the pain and temperature sensation of the chest, lumbar, and sacrum It is not uncommon to report the appearance of sensory planes in small lateral medullary infarcts of the conduction beam.

The lateral fascicle of the spinothalamus conducts the pain and temperature sensation on the opposite side of the body.
It runs in a certain arrangement in the medulla oblongata.
The outer part is composed of sacral afferent fibers, and the inner part is neck afferent fibers.
If the patient’s disease is small, it is limited to The spinothalamic tract in the lateral medulla affects the afferent sensation of the sacrum, lumbar, and superficial thoracic sensations, and the trunk sensory plane appears.

 Early manifestation of Guillain-Barre syndrome.
The early appearance of sensory level in GBS may be that individual patients have obvious involvement of the thoracic and lumbar nerve roots in the early stage, and the trunk sensory level and lower limb sensory disturbances appear first.

Example 1: A 26-year-old female patient complained of numbness in both feet after waking up, and progressed to the waist 2 hours later without other neurological symptoms.

The patient had a history of upper respiratory tract infection 1 week ago.

Physical examination: cranial nerves are normal, muscle strength is normal, deep reflexes are normal, and plantar reflexes are flexed.

Before and after T7, the torso has decreased pain and temperature sensation, and there are patchy areas of loss of sensation in both lower limbs.

Vibration, position, two-point discrimination, and cortical sensation are intact.

Laboratory inspection is normal.

Head CT and cervical and thoracic spine MRI examinations showed no obvious abnormalities.

Five days later, the patient developed peripheral facial paralysis on the left side, with weakness in both lower limbs, and the proximal end was heavier than the distal end.

The bilateral ankle reflexes disappeared, the knee reflexes were weak, and the upper limb tendon reflexes decreased.

Cerebrospinal fluid examination showed mild lymphocytosis, 15/mm3, and protein increased 114mg/dL.

Related tests such as oligoclonal bands were negative.

Nerve conduction examination F wave disappeared, and the distal incubation period was prolonged with conduction block and waveform dispersion.

Diagnosis of Guillain-Barre syndrome, intravenous immunoglobulin treatment for more than 5 days, the effect is good [3].

Example 2: A 41-year-old male with progressive lower limb weakness and urinary retention for 3 days.

She had fever and upper respiratory tract infection before going to the doctor.

Physical examination: light touch and acupuncture at the T6 dermal area and below were weakened, muscle strength of the lower limbs was 0, knee and ankle reflexes disappeared, and no pathological reflexes.

Urinary retention in the bladder.

The rest were negative.

The patient's symptoms progressed to respiratory failure.

The MRI of the whole spine showed no abnormalities, the nerve conduction examination of the bilateral common peroneal nerve F waves disappeared, and the bilateral tibial nerve H reflex disappeared.
GBS was diagnosed.

Cerebrospinal fluid examination on the 7th day after the onset of the disease showed separation of protein cells.

Plasma exchange treatment, the effect is significant [4].

   Example 3: A 57-year-old man with lumbar spinal stenosis has improved postoperative symptoms.

On the 9th day, he went to see the doctor again due to abnormal paresthesia and weakness of the lower limbs.

Physical examination: There is a sensory plane in the T12 dermatome area, the acupuncture sensation of both legs is decreased, the proximal and distal muscle strength of the left leg is 3/4, the muscle strength of the right leg is 4/5, and the limb reflexes are present.

Subsequently, the patient's leg weakness became worse and the reflex disappeared.

Spine imaging did not reveal any acute changes.
Nerve conduction examination showed prolonged distal motor latency, conduction block, and sural nerve exemption.
GBS was diagnosed.

Give intravenous immunoglobulin therapy [5].

 Located in the parietal cortex.
Case 1: A 43-year-old female with 8 hours of progressive numbness and tingling in her left lower extremity.

Check the left side T8 or less hyperalgesia, feeling excessive.

The skin light touch, acupuncture sensation, and temperature sensation in the L2-L5 nerve distribution area of ​​the left lower limb were decreased, the position of the left toe was abnormal, the vibration sensation of the left knee and ankle joint was decreased, and the tendon reflex of the left lower limb was slightly increased.

MRI of the head revealed an extraaxial space (meningioma) on the right side of the parietal lobe, and no lesions were found in the spinal cord.

Meningioma is located in the central posterior gyrus and oppresses the anterior and medial parts of the central posterior gyrus.
These areas mainly represent the lower limbs and lower trunk sensory areas [6].

Figure 4 A schematic diagram of the right parietal meningioma and the parietal lobe sensory area on the opposite side of the B.
Example 2: A 59-year-old male patient had decreased sensation and tingling on his right thigh and buttocks for 5 days.

Physical examination: all the main sensory forms below T10 on the right side, touch, pain, temperature, vibration, and position are significantly weakened, and the proximal right leg is mildly weak.

The patient’s sensory disturbance gradually developed to the upper part of the body.
The sensory level reached T4 level on the second day, progressed to T4 level on the third day, reached the neck (C3) on the fourth day, and finally extended to the face on the fifth day, and then proceeded on the right side.
Sexual limbs and facial paralysis.

Magnetic resonance examination of the head showed that the central posterior lesion was involved, and the bacterial culture was confirmed to be a brain abscess caused by Klebsiella pneumoniae [7].

Figure 5 T1 enhancement shows the lesion involving the posterior gyrus of the left parietal lobe, pathologically confirmed as a brain abscess.
Diabetic Trunk Nerve Case 1: A 71-year-old man with a history of diabetes and oral hypoglycemic drugs.

Pain in the upper part of the left chest, acupuncture and knife cut-like sensation, aggravated when touched.

Tenderness appeared in the back afterwards.

Physical examination: T4-T6 hyperesthesia on the left side, T3-T8 cold, heat, and acupuncture sensation decreased.

The vibration threshold of the fingers and toes increased significantly.

MRI of the thoracic spine was normal.

Nerve conduction examination showed sensory polyneuropathy, and skin biopsy showed significant reduction of epidermal and dermal nerve fibers [8].

Example 2: A 58-year-old male with pain in the left waist.
The pain progressed rapidly and affected the upper chest, showing acupuncture and knife cutting.

Five months later, the patient was diagnosed with diabetes and started taking oral hypoglycemic drugs.
After that, the same symptoms appeared on the right side.

Physical examination: the skin dominated by T3-T6 on the left and T3-T8 on the right had decreased sensation of cold and heat and acupuncture.

The toe vibration threshold increased slightly.

Nerve conduction examination showed mild sensory polyneuropathy [8].

Diabetic trunk neuropathy, also called diabetic thoracic-abdominal neuropathy, can be acutely onset, usually involving the middle and lower parts of the chest, with unilateral or bilateral segmental sensory disturbances and pain, often accompanied by other forms and locations of diabetic neuropathy.

When diabetic peripheral neuropathy of the lower extremities, it may behave more like myelopathy.

 Summary Physicians usually consider the trunk sensory plane to be located in the spinal cord disease first, but pay attention to parietal lobe, medulla oblongata, GBS and diabetic trunk neuropathy, etc.
, can also produce sensory plane symptoms, understanding them will help us make a rapid differential diagnosis.

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[7] Song YM, Kim JI, Lee GH, et al.
Teaching NeuroImage: Sensory level in parietal lobe lesion[J].
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ae［8］Lauria G, McArthur JC, Hauer PE, et al.
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Journal of Neurology, Neurosurgery & Psychiatry, 1998, 65(5): 762-766.
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65.
5.
762A misleading sensory level[J].
Journal of neurology, 2009, 256(10): 1769-1770.
DOI 10.
1007/s00415-009-5199-y.
[7] Song YM, Kim JI, Lee GH, et al.
Teaching NeuroImage: Sensory level in parietal lobe lesion[J].
Neurology, 2007, 68(24): E38-E39.
10.
1212/01.
wnl.
0000264934.
56336.
ae［8]Lauria G, McArthur JC, Hauer PE, et al.
Neuropathological alterations in diabetic truncal neuropathy: evaluation by skin biopsy[J].
Journal of Neurology, Neurosurgery & Psychiatry, 1998, 65(5): 762-766.
DOI: 10.
1136/jnnp.
65.
5.
762A misleading sensory level[J].
Journal of neurology, 2009, 256(10): 1769-1770.
DOI 10.
1007/s00415-009-5199-y.
[7] Song YM, Kim JI, Lee GH, et al.
Teaching NeuroImage: Sensory level in parietal lobe lesion[J].
Neurology, 2007, 68(24): E38-E39.
10.
1212/01.
wnl.
0000264934.
56336.
ae［8]Lauria G, McArthur JC, Hauer PE, et al.
Neuropathological alterations in diabetic truncal neuropathy: evaluation by skin biopsy[J].
Journal of Neurology, Neurosurgery & Psychiatry, 1998, 65(5): 762-766.
DOI: 10.
1136/jnnp.
65.
5.
762Neuropathological alterations in diabetic truncal neuropathy: evaluation by skin biopsy[J].
Journal of Neurology, Neurosurgery & Psychiatry, 1998, 65(5): 762-766.
DOI: 10.
1136/jnnp.
65.
5.
762Neuropathological alterations in diabetic truncal neuropathy: evaluation by skin biopsy[J].
Journal of Neurology, Neurosurgery & Psychiatry, 1998, 65(5): 762-766.
DOI: 10.
1136/jnnp.
65.
5.
762