Spinal Cord - syringomyelia

 

Thank you for asking for asking me to see Harry - please examine the upper limbs.

 

The salient features on examination were dissociative sensory loss with impaired pain and temperature in the upper limbs, with intact vibration and proprioception. This was associated with atrophy and areflexia. Collectively, this consistent with syringomyelia.

 

In further detail..

 

On general inspection, there was kyphoscoliosis. There were surgical scars over the shoulders and a midline cervical scar (for shoulder replacement, cervical laminectomy or decompression).

 

On inspection of the upper limbs, there were fasciculations. There was a swollen, deformed elbow joint, consistent with Charcot joints. There were painless scars and ulcers over the digits (loss of pain sensation). There was distal wasting of the arms and small joints of the hand.

 

Tone was normal.

 

Power was normal/reduced (syrinx may extend in to the anterior horns and cause weakness beginning in the hands and extending proximally).

 

Reflexes were absent (of upper arms, apparently UMN signs in lower limbs).

 

Coordination was normal.

 

There was symmetrical dissociative sensory loss with impaired pain and temperature in the upper limbs in a dermatomal distribution to ___ (examine chest as well for thoracic nerves to determine the lowest point of the syrinx), with intact vibration and proprioception.

 

On examination of the legs, there were upper motor neuron signs.

 

The presence of:

• Impaired sensation to T __, suggest it extends inferiorly to ___

• Horner’s syndrome suggests it extends superiorly to at least C8-T1

• Internuclear ophthalmoplegia suggests it extends superiorly to at least C5 (MLF extends down this far apparently)

• Palatal, tongue wasting and weakness, and weakness of sternomastoid (bulbar palsy) suggest it extends into the medulla

• Normally between C2 - T9

 

In summary, my findings are consistent with a syringomyelia, which extends from T__ inferiorly to at least C___.

 

My differentials include:

• Anterior spinal artery thrombosis

• Small fibre neuropathy

​

Disassociated sensory loss:

• Spinothalamic loss only

  • Syringomyelia​

  • Brown-Sequard syndrome (contralateral)

  • Anterior spinal artery thrombosis

  • Lateral medullary syndrome

  • Small fibre peripheral neuropathy

• Dorsal column loss only

  • Subacute combined degeneration​

  • Brown Sequard (ipsilateral)

​