MBBS2 Tutorial Pain: ascending and descending pathways of the spinal

cord
You will find an on-line version of this tutorial at the following URL:
http://ehealth.kcl.ac.uk/tel/pain/spinal_cord_pathways/

CASE REPORT
Case History:
A woman aged 56 presented with interscapular pain which had been increasing for two weeks
and was keeping her awake at night. Her left leg had begun to give way. When she took a bath
the previous night she could not feel the temperature of the bath water with her right foot. Two
years earlier she had had a carcinoma excised from her left breast.
Examination:
The patient was lying, still distressed by pain centred on the spine of the 6th thoracic vertebra,
which was slightly tender. There was no wasting or fasciculation of her leg muscles. The left
leg was slightly spastic. There was slight weakness of the left hip, knee and ankle. The left
knee and ankle reflexes were increased and the left plantar response was extensor (positive
Babinski sign). Pain and temperature sensation were impaired on the right in all regions below
the 8th thoracic dermatome. Vibration sensation was absent at the left ankle. She could stand
and walk only with difficulty because of pain, and dragged her left foot.
Management:
Radiographs showed a collapse of the 6th thoracic vertebra. An urgent magnetic resonance
scan showed a mass compressing the anterolateral aspect of the spinal cord on the left side at
that level. A neurosurgeon advised against surgery. A radiotherapist started urgent
radiotherapy to the 6th thoracic vertebra and oral steroid treatment. Within 2 days her pain was
relieved and within a week she was able to walk more easily.
Questions:
1. On the outline diagrams (below) of the central nervous system draw a) the two major
pathways of somatosensation from the spinal cord to the somatosensory cortex and b) the
corticospinal motor pathways, showing the decussations. Mark the position of the potential
spinal lesion in this patient.

Right

Left

Right

Left

2. Using the schematic transverse spinal cord section drawn below indicate the location of the
main sensory and motor tracts. Which of the tracts (on left or right side) are affected in this
patient?

Right

Left

3. Why is the area of altered sensation lower than the level of vertebral damage?

4. Is the motor weakness a sign of an upper or a lower motor neurone lesion? State your
reasons.

5. Given the previous history of mammary carcinoma, what is the likely pathology?

6. Why did the surgeon advise against surgery? What special surgical interventions might give
pain relief.

7. What was the purpose of the oral steroid treatment?

8. What are the main classes of analgesics? How and where do they act and what are the
advantages of each class?

9. What is meant by the term 'gating' in connection with afferent input to the spinal cord? Draw
a diagram showing the main elements of the gate hypothesis. How is this related to TENS?

10. What are the likely outcomes of the measures taken to treat the patient and what other
steps could be taken?