2. The Spinothalamic System Learning Module Click to Begin

3. Used with permission of the Academy of Neurologic Physical Therapy of the APTA Do not duplicate without acknowledging Learning Activity author Michael McKeough, PT, EdD

4. Contents Overview Introduction Learning Objectives Instructions Legend Read these Instructions ! Review of the Lateral Spinothalamic Tract Lesion lessons Lateral spinothalamic tract lesion Internal capsule lesion Lateral medulla lesion Patient Cases Case 1 Case 2 Case 3 Case 4 ContentsContents LSTTLesionsPatient Cases ExitLSTTLesionsPatient Cases Exit

5. Overview Introduction Learning Objectives Instructions Legend ContentsContents LSTTLesionsPatient Cases ExitLSTTLesionsPatient Cases Exit

6. Introduction This module reviews the Spinothalamic System. Module organization consists of three components. Review of the lateral spinothalamic tract, lesion lessons (3 interactive lesions with feedback), and patient cases (4 interactive cases with feedback). At the bottom of each screen a navigation bar contains options to move throughout the module. Material is presented at both the behavioral level and the neuroanatomical level. The behavioral level is presented first and depicts a patient’s clinical presentation. The neuroanatomical level depicts the detailed anatomy of first- order, second-order and third-order neurons. The neuroanatomical level accounts for the patient’s behavioral presentation on examination under normal and lesioned conditions. ContentsContents LSTTLesionsPatient Cases ExitLSTTLesionsPatient Cases Exit

7. Learning Objectives After completing this module you should be able to: 1.describe, in detail, the structure and function of the lateral spinothalamic system. 2.given a lesion, identify the signs and symptoms that would be expected. 3.given a patient case (examination results and chief complaint), identify the location of the lesion causing the signs and symptoms. 4.correlate neurology information between the behavioral and neuroanatomical levels. ContentsContents LSTTLesionsPatient Cases ExitLSTTLesionsPatient Cases Exit

8. Instructions This module contains 3 interactive lesion lessons with animation. Lesson lessons begin with a question about the symptoms produced by that particular lesion. Clicking the answer button will reveal the answer to the question. Clicking the explanation button will lead to both behavioral and neuroanatomical explanations of the lesion. Each presentation is launched by clicking the animation button. The same button serves to replay the animation if desired. Any of the lessons may be accessed by simply clicking on the lesion title on the Contents page. Please refer to the Legend that defines the symbols used throughout the module. ContentsContents LSTTLesionsPatient Cases ExitLSTTLesionsPatient Cases Exit

9. First-order neuron Second-order neuron Third-order neuron Pain stimulus Mechanism of injury Lesion Sensory impairment Legend Function intact Function lost Sensory stimulus ContentsContents LSTTLesionsPatient Cases ExitLSTTLesionsPatient Cases Exit

10. Thalamus Primary sensory cortex Lateral spinothalamic tract The Lateral Spinothalamic Tract: Behavioral Description Information about pain and temperature from the body is conveyed via several spinal tracts collectively known as the anterolateral system. The lateral spinothalamic tract (LSTT) is the most prominent among these. The LSTT is a crossed system. It originates from nociceptors (free nerve endings and chemo-receptors) and projects to the opposite (contralateral) cerebral hemisphere via a three neuron projection system. Click to animate Neuroanatomical Explanation First-order neuron Second-order neuron Third-order neuron Stimulus ContentsContents LSTTLesionsPatient Cases ExitLSTTLesionsPatient Cases Exit

11. The Lateral Spinothalamic Tract: Neuroanatomical Description First-order neurons Cell body: dorsal root ganglion (DRG) Distal axon: innervates nociceptors via peripheral nerves Proximal axon: enter the spinal cord, diverge 1-3 levels and terminate on second-order neurons in the dorsal horn Second-order neurons Cell body: dorsal horn Axon: decussates at or about the level of entry and projects to the contralateral thalamus (ventral posterior lateral nucleus, VPL) via the lateral spinothalamic tract Third-order neurons Cell body: VPL of thalamus Axon: ascends via the posterior limb of the internal capsule and terminates in the primary somatosensory cortex DRG Click to animate Behavioral Explanation Lateral spinothalamic tract ContentsContents LSTTLesionsPatient Cases ExitLSTTLesionsPatient Cases Exit

12. Lesion Lessons Lateral spinothalamic tract lesion Internal capsule lesion Lateral medulla lesion ContentsContents LSTTLesionsPatient Cases ExitLSTTLesionsPatient Cases Exit

13. Lesion of the right lateral spinothalamic tract at T7 would produce what impairment? Click for answer Absence of pain and temperature sensation on the left side of the body generalized below T7. Click for explanation ContentsContents LSTTLesionsPatient Cases ExitLSTTLesionsPatient Cases Exit

14. Thalamus Primary sensory cortex Lateral spinothalamic tract Sensory impairment: absence of pain and temperature sensation on the left side of the body, below the lesion level. Lesions of the lateral spinothalamic tract on the right : Behavioral explanation T7 Sensory impairment: left body, below the lesion level. Click to animate Neuroanatomical Explanation First-order neuron Second-order neuron Third-order neuron Stimulus ContentsContents LSTTLesionsPatient Cases ExitLSTTLesionsPatient Cases Exit

15. Lesions of the lateral spinothalamic tract on the right: Neuroanatomical explanation Because the lesion involves second-order neurons that have already decussated, impairment is contralateral to the lesion. Interruption of the right LSTT causes absence of pain and temperature sensation on the left side of the body, below the lesion level. Click to animate Behavioral Explanation ContentsContents LSTTLesionsPatient Cases ExitLSTTLesionsPatient Cases Exit

16. Lesion of the right internal capsule or primary somatosensory cortex would produce what impairment? Click for answer Absence of pain and temp. sensation on the entire left body, including the face. Click for explanation ContentsContents LSTTLesionsPatient Cases ExitLSTTLesionsPatient Cases Exit

17. Thalamus Primary sensory cortex Lateral spinothalamic tract Sensory impairment: the entire left side of the body, including the face. Lesion of the internal capsule or primary somatosensory cortex on the right: Behavioral explanation Sensory impairment: absence of pain and temperature sensation on the entire left body, including the face. Click to animate Neuroanatomical Explanation Lesion Lost function Impairment ContentsContents LSTTLesionsPatient Cases ExitLSTTLesionsPatient Cases Exit

18. Lesion of the internal capsule or primary somatosensory cortex on the right: Neuroanatomical explanation Because the lesion involves third-order neurons that have decussated, impairment is contralateral to the lesion. Lesion of the right internal capsule or primary sensory cortex causes absence of pain and temperature sensation on the entire left body, including the face. Click to animate Behavioral Explanation ContentsContents LSTTLesionsPatient Cases ExitLSTTLesionsPatient Cases Exit

19. Lesion of the right lateral medulla would produce what impairment? Click for answer Absence of pain and temperature sensation on the ipsilateral face and contralateral body. Click for explanation ContentsContents LSTTLesionsPatient Cases ExitLSTTLesionsPatient Cases Exit

20. Thalamus Primary sensory cortex Lateral spinothalamic tract Sensory impairment: ipsilateral face and contralateral body. Lesion of the lateral medulla on the right (Wallenberg syndrome): Behavioral explanation Sensory impairment: absence of pain and temp. sensation on the ipsilateral face and contralateral body. Click to animate Neuroanatomical Explanation Lesion Lost function Impairment ContentsContents LSTTLesionsPatient Cases ExitLSTTLesionsPatient Cases Exit

21. Lateral Medullary (Wallenberg) Syndrome Click to animate Because the lesion involves first-order neurons in the trigeminal system before decussation, facial impairment is ipsilateral to the lesion. Because the lesion involves second-order neurons in the LSTT after decussation, body impairment is contralateral to the lesion. The lesion impairs the sensation of pain and temperature. Behavioral Explanation ContentsContents LSTTLesionsPatient Cases ExitLSTTLesionsPatient Cases Exit

22. Patient Cases Read these instructions! Patient Case 1 Patient Case 2 Patient Case 3 Patient Case 4 ContentsContents LSTTLesionsPatient Cases ExitLSTTLesionsPatient Cases Exit

23. Case Instructions These patient cases are intended to facilitate the integration and clinical application of information about the spinothalamic tract by coupling the findings on examination and patient interview with their neuroanatomical correlates. Each case begins with the patient’s chief complaint and significant examination findings. Then, the question is asked, Damage to what system(s) is causing this patient’s problems? Clicking the Answer button will reveal the answer and clicking the Show lesion button will reveal the neuroanatomic lesion along with the patient’s behavioral impairments. Cases are presented from two perspectives. What lesion would account for a given set of examination results and patient history? For a given lesion, what signs and symptoms would be expected on examination? Click on a Case number to begin the exercise. ContentsContents LSTTLesionsPatient Cases ExitLSTTLesionsPatient Cases Exit

24. Review Questions: Case 1 The 73 year old African-American woman complains of a sudden onset left sided weakness, loss of balance, and left sided numbness. Her face is asymmetric with drooping of the mouth and loss of the nasal-labial fold on the left. Her left arm is flaccid with no voluntary movement. Her left leg is weak and she requires assistance to stand. Deep tendon reflexes are hyperactive on the left. Sensation of light touch and sharp/dull are absent in the left arm and impaired in the left face and leg. Strength and sensation are WNL in the right trunk, arm and leg. Damage to what system(s) is causing this patient’s problems? Lesion of the right internal capsule or cerebral cortex. Corticospinal tracts are impaired on the right and intact on the left: her left arm is flaccid with no voluntary movement. Her left leg is weak and she requires assistance to stand. Deep tendon reflexes are hyperactive on the left. Strength is WNL in the right trunk, arm and leg. Corticobulbar tract impaired on the right: her face is asymmetric with drooping of the mouth and loss of the nasal-labial fold on the left. Lateral spinothalamic tracts are impaired on the right and intact on the left. Sensation of light touch and sharp/dull are absent in the left arm and impaired in the left face and leg. Sensation is WNL in the right trunk, arm and leg. Dorsal columns are impaired on the right and intact on the left: sensation of light touch is absent in the left arm and impaired in the left face and leg. But intact on the right trunk, arm and leg. Lesion type: stroke, distribution of signs and symptoms are hemi (left) body. Lesion location: the right middle cerebral artery supplies the internal capsule and primary cortical areas for the motor and sensory systems. Answer Show lesion ContentsContents LSTTLesionsPatient Cases ExitLSTTLesionsPatient Cases Exit

25. Thalamus Primary sensory cortex Lateral spinothalamic tract Sensory impairment: the entire left side of the body, including the face. Lesion of the internal capsule or primary somatosensory cortex on the right: Behavioral explanation Sensory impairment: absence of pain and temperature sensation on the entire left body, including the face. Click to animate Neuroanatomical Explanation Lesion Lost function Impairment ContentsContents LSTTLesionsPatient Cases ExitLSTTLesionsPatient Cases Exit

26. Lesion of the internal capsule or primary somatosensory cortex on the right: Neuroanatomical explanation Because the lesion involves third-order neurons that have decussated, impairment is contralateral to the lesion. Lesion of the right internal capsule or primary sensory cortex causes absence of pain and temperature sensation on the entire left body, including the face. Click to animate Behavioral Explanation ContentsContents LSTTLesionsPatient Cases ExitLSTTLesionsPatient Cases Exit

27. Review Questions: Case 2 Following a gun shot wound to the abdomen, the patient complains of inability to feel or move the right leg. Light touch, position, and vibration sensation are intact in the left lower extremity but absent in the right below the L1 dermatome. Strength is 5/5 for all motions at the hip, knee and ankle of the left lower extremity, 0/5 for the right. Sharp/dull and temperature sensation are intact in the right lower extremity but absent in the left below the L1 dermatome. Damage to what system(s) is causing this patient’s problems? Right hemicord lesion (Brown-Sequard Syndrome) at L1 Dorsal column (fasciculus gracilis) is intact on the left but absent on the right: light touch, position, and vibration sensation are intact in the left lower extremity but absent in the right below L1. Lateral corticospinal tract is intact on the left but absent on the right : strength is 5/5 for all motions at the hip, knee and ankle of the left lower extremity, 0/5 for the right. Lateral spinothalamic tract is intact on the left but absent on the right : sharp/ dull and temperature sensation are intact in the right lower extremity but absent in the left below L1. Lesion level: L1. Answer Show lesion ContentsContents LSTTLesionsPatient Cases ExitLSTTLesionsPatient Cases Exit

28. Hemicord Lesion (Brown-Sequard Syndrome) Dorsal column lesion Ipsilateral loss of light touch, vibration, and position sense Lateral corticospinal tract lesion Ipsilateral upper motor neurons signs Lateral spinothalamic tract lesion Contralateral loss of pain and temperature sense UMN Hemicord lesion RL DRG L1 Click to animate ContentsContents LSTTLesionsPatient Cases ExitLSTTLesionsPatient Cases Exit

29. Review Questions: Case 3 A 24 year-old cocaine addict has reported to the emergency room complaining of headache, vertigo, nausea, and vomiting. Cerebral angiogram reveals spontaneous dissection and hemorrhaging of the right posterior inferior cerebellar artery. What signs and symptoms would be expected from this lesion? Lesion of the posterior inferior cerebellar artery (PICA) produces lateral medullary (Wallenberg) syndrome. Common signs and symptoms include: 1.Ipsilateral facial hypalgasia (diminished sensation of pain) and thermoanaesthesia (diminished sensation of temperature) (due to involvement of the trigeminal system). 2.Contralateral trunk and extremity hypalgasia and thermoanaesthesia (due to involvement of the spinothalamic tract). 3.Dysarthria (hoarse speech) and dysphagia (difficulty swallowing) due to ipsilateral palatal, pharyngeal and vocal cord paralysis (due to involvement of the nucleus ambiguous). 4.Ipsilateral ptosis (eyelid drooping), miosis (excessive constriction of the pupil) and anhidrosis (absence of sweating) Horner’s syndrome (due to sympathetic denervation). 5.Ipsilateral cerebellar signs, vertigo, nausea, and vomiting (due to involvement of the cerebellum). Answer Show lesion ContentsContents LSTTLesionsPatient Cases ExitLSTTLesionsPatient Cases Exit

30. Thalamus Primary sensory cortex Lateral spinothalamic tract Sensory impairment: ipsilateral face and contralateral body. Lesion of the lateral medulla on the right (Wallenberg syndrome): Behavioral explanation Sensory impairment: absence of pain and temp. sensation on the ipsilateral face and contralateral body. Click to animate Neuroanatomical Explanation Lesion Lost function Impairment ContentsContents LSTTLesionsPatient Cases ExitLSTTLesionsPatient Cases Exit

31. Lateral Medullary (Wallenberg) Syndrome Click to animate Because the lesion involves first-order neurons in the trigeminal system before decussation, facial impairment is ipsilateral to the lesion. Because the lesion involves second-order neurons in the LSTT after decussation, body impairment is contralateral to the lesion. The lesion impairs the sensation of pain and temperature. Behavioral Explanation ContentsContents LSTTLesionsPatient Cases ExitLSTTLesionsPatient Cases Exit

32. Review Questions: Case 4 The patient complains of a progressive loss of the ability to sense hot or cold or pain in both arms and hands. The condition started in the shoulders and progressed down both arms. The sensation of pain and temperature in the trunk and legs is intact. The sensation of light touch, position, and vibration is intact throughout including the affected dermatomes. Strength is 5/5 throughout including the affected dermatomes. Damage to what system(s) is causing this patient’s problems? The anterior gray and white commissures, in the cervical region of the spinal cord. Lateral spinothalamic tracts are intact bilaterally: the sensation of pain and temperature in the trunk and legs is intact, bilaterally. Dorsal columns are intact bilaterally: the sensation of light touch, position, and vibration is intact throughout including the affected dermatomes. Lateral corticospinal tracts are intact bilaterally: strength is 5/5 throughout including the affected dermatomes. Lesion level: cervical region of the spinal cord. Answer Show lesion ContentsContents LSTTLesionsPatient Cases ExitLSTTLesionsPatient Cases Exit

33. R L Syringomyelia DRG Loss of pain and temperature sensation Click to animate Syrinx Second-order neuron lesion ContentsContents LSTTLesionsPatient Cases ExitLSTTLesionsPatient Cases Exit

34. The End D. Michael McKeough, PT, EdD  2015