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dorsal columns, medial lemniscus, and thalamus Vibration and position sense are usually lost together, although one of them (most often vibration sense) may be affected disproportionately With advancing age, vibration is the sensation most commonly diminished, especially at the toes and ankles (see further on) Vibration sense is tested by placing a tuning fork with a low rate and long duration of vibration (128 Hz) over the bony prominences, making sure that the patient responds to the vibration, not simply to the pressure of the fork, and that he is not trying to listen to it As with thermal and pain testing, there are mechanical devices that quantitate vibration sense, but it is suf cient for clinical purposes to compare the point tested with a normal part of the patient or the examiner The examiner may detect the vibration after it ceases for the patient by holding a nger under the distal interphalangeal joint, the handle of the tuning fork being placed on the dorsal aspect of the joint Or, the vibrating fork is allowed to run down until the moment that vibration is no longer perceived, at which point the fork is transferred quickly to the corresponding part of the examiner and the time to extinction is noted There is a small degree of accommodation to the vibration stimulus, so that slight asymmetries detected by rapid shifting from a body part on one side to the other should be interpreted accordingly The perception of vibration at the patella after it has disappeared at the ankle or at the anterior iliac spine after it has disappeared at the knee is indicative of a peripheral neuropathy The approximate level of a spinal cord lesion can be corroborated by testing vibratory sensation over the iliac crests and successive vertebral spines Testing of Discriminative Sensation Damage to the parietal lobe sensory cortex or to the thalamocortical projections results in a special type of disturbance namely, an inability to make sensory discriminations and to integrate spatial and temporal sensory information (see further under Sensory Loss Due to Lesions of the Parietal Lobe and Chap 22) Lesions in these structures usually disturb position sense but leave the so-called primary modalities (touch, pain, temperature, and vibration sense) relatively little affected The integrity of discriminative sensory functions can be assessed only if it is rst established that the primary sensory modalities on which they depend (mainly touch) are largely normal If a cerebral lesion is suspected, discriminative function should be tested further in the following ways Two-Point Discrimination The ability to distinguish two points from one is tested by using a compass, the points of which should be blunt and applied simultaneously and painlessly The distance at which such stimuli can be recognized as a distinct pair varies but is roughly 1 mm at the tip of the tongue, 2 to 3 mm on the lips, 3 to 5 mm at the ngertips, 8 to 15 mm on the palm, 20 to 30 mm on the dorsa of the hands and feet, and 4 to 7 cm on the body surface It is characteristic of the patient with a lesion of the sensory cortex to mistake two points for one, although occasionally the opposite occurs Cutaneous Localization and Figure Writing (Graphesthesia) Localization of cutaneous tactile or painful stimuli is tested by touching various points on the body and asking the patient to place the tip of his index nger on the point stimulated or on the corresponding point of the examiner s limb Recognition of numbers or letters traced on the skin (these should be larger than 4 cm on the palm) with a pencil or similar object or the direction of a line drawn across the skin also depends on localization of tactile stimuli Normally, traced numbers as small as 1 cm can be detected on the pulp of the nger if drawn with a sharp pencil According to Wall and
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Noordenbos, these are also the most useful and simple tests of posterior column function Appreciation of Texture, Size, and Shape Appreciation of texture depends mainly on cutaneous impressions, but recognition of the shapes and sizes of objects is based on impressions from deeper receptors as well Inability to recognize shape and form is frequently a manifestation of cortical disease, but a similar clinical defect will occur if tracts that transmit proprioceptive and tactile sensation are interrupted by lesions of the spinal cord and brainstem (and, of course, of the peripheral nerves) This type of sensory defect is called stereoanesthesia [see further on, under Posterior (Dorsal) Column Syndrome ] and is distinguished from astereognosis, which connotes an inability to identify an object by palpation, even though the primary sense data (touch, pain, temperature, and vibration) are intact In practice, a pure astereognosis is rarely encountered, and the term is employed when the impairment of super cial and vibratory sensation in the hands seems to be of insuf cient severity to account for the defect in tactile object identi cation De ned in this way, astereognosis is either right- or leftsided and, with the quali cations mentioned below, is the product of a lesion in the opposite hemisphere, involving the sensory cortex, particularly S2 or the thalamoparietal projections The classic doctrine that somatic sensation is represented only in the contralateral parietal lobe is not absolute Beginning with the report by Oppenheim in 1906, there have been sporadic patients who showed bilateral astereognosis or loss of tactile sensation as a result of an apparently unilateral cerebral lesion The correctness of these observations was corroborated by Semmes and colleagues, who tested a large series of patients with traumatic lesions involving either the right or left cerebral hemisphere They found that the impairment of sensation (particularly discriminative sensation) following right- and left-sided lesions was not strictly comparable; the left hand as well as the right tended to be impaired by injury to the left sensorimotor region, whereas only the left hand tended to be affected by injury to the right sensorimotor region These observations, with minor quali cations, were also con rmed by Carmon and by Corkin and associates, who investigated the sensory effects of cortical excisions in patients with focal epilepsy Caselli has described six patients with extensive right-sided cerebral infarctions, associated in each case with bilateral impairment of tactile object recognition but without impairment of the primary sense modalities in the right hand In each of these patients, there was also a profound hemineglect, which confounded the interpretation of left-sided sensory signs Thus it appears that certain somatosensory functions in some patients are mediated not only by the contralateral hemisphere but also by the ipsilateral one, although the contribution of the former is undoubtedly the more signi cant The traditional concept of left hemispheric dominance in respect to tactile perception has been questioned by Carmon and Benton, who found that the right hemisphere is particularly important in perceiving the direction of tactile stimuli Also, Corkin observed that patients with lesions of the right hemisphere show a consistently greater failure of tactile-maze learning than those with left-sided lesions, pointing to a relative dominance of the right hemisphere in the mediation of tactile performance involving a spatial component Certainly the phenomenon of sensory inattention or extinction is more prominent with lesions of the right as opposed to the left parietal lobe and is most informative if the primary and secondary sensory cortical areas are spared These matters are considered further on in this chapter and in Chap 22
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