Clinical case discussion

30 yrs old female with Hx of headache occipital region for 10 yrs gradual progressive weakness of all four limbs and numbness below neck region for 4 yrs
O/E
General - WNL
CNS
HMF : normal
Cranial Nerves : lower cranial nerves ( IX, X, XI, XII ) intact
Motor : Bulk grossly maintained
Tone : Increased; spasticity
upper limbs : weakness all the way starting from shoulder abbdction ( C5)
weakness of flexors and extensors of elbow and wrist joints
small muscles of hand (T1)
boths sides involved
power 3 on MRC scale

lower limbs : similarly weakness of lower limbs Power 3 on MRC scale
weakness limited to knee joint
Reflexes : brisk Biceps
Triceps
Supinator
Knee
flexor plantar bilateral
Sensory :
Sensory level C4
bilateral Loss of Pain and temperature sensations from C4
dorsal column sensation intact
sacral sparing
Cerrebellar signs absent
Patient wheel chair bound

From history and clinical examination :
Quadriparesis with dissociative suspended sensory loss lesion at C4 cord segment due to Syrinx
MRI cervical spine with focus on craniocervical junction done

Discussion :
Clinically Syrinx is associated with typical dissociative suspended sensory loss
Detecting site of lesion is tricky but there are key points
In these case quadriparesis means lesion in cervical cord T1( small muscles of hand ) and above but can be lower brain stem medullary lesion .
So lower Cranial nerves examination is important and shouldnt be missed
Lower cranial nerves intact means lesion in the cervical cord clinically
Now this patient has weakness of shoulder abdduction so definitely deltoid is involved so
C5 cord is involved . Above C5 generally we use dermatome to localise lesion since testing of muscles above C5 is clinically insignificant.
Here sensory level is C4
Now the lower limit easy way is to check scral sensation first if it is spared it is called suspended sensory loss .
Lets review our knowledge og spinal cord and the arrangement of fibres which are topographivally arranged.
The fibres of spinothalamic tract are arranged with cervical fibres medially towards central canal and then thoracic then lumbar and most lateral are the sacral fibres .