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Chapter 1_Terms and Technigues 13
nerve compression or injury in the segment of the limb under discussion. Only the most commonly affected peripheral nerves are described in each chapter. The reader should remember that peripheral sensory nerve anatomy is highly variable and that the exact boundaries of altered sensation vary considerably from one individ-ual to another.
The most common way to define peripheral nerve deficits is to map out the area of altered sensation using light touch or sharp/dull discrimination testing. To test light touch, the examincr may use specially designed fil-aments or everyday objects such as an artists paintbrush, wisp of cotton, or rolled-up tissue. Morę quantitative testing may be done using Semmes-Weiss filaments, which are available in measured degrees of stiffness. The patient is instructed to close his or her eyes and to notify the examiner when a touch is felt. The examiner can then begin touching the patient in the area of suspected hypoesthesia or anesthesia and move outward until the patient feels the touch normally. The border between altered or absent and normal sensation can be marked with a pen (Fig. 1-10). The examiner again starts touching in the abnormal area and proceeds outward in differ-ent directions, eventually mapping the entire anesthetic area. The area supplied by an injured peripheral nerve may be only hypoesthetic or even hyperesthetic, so the examiner should ask the patient to describe the ąuality of the sensation experienced, not just the presence or absence of tactile stimulation, in response to light touch.
Figurę 1-10. Delineating an area of altered sensation.
Because the distribution of peripheral nerves may over-lap, a transition zonę between normal and abnormal areas usually is appreciated.
Sharp/dull discrimination testing can also be used to confirm the findings of light touch examination. In this case, the patient is asked to close his or her eyes and tell the examiner whether the sharp or duli end of a specially designed tester or an ordinary safety pin is touched to the patients skin. In areas of peripheral nervc injury, the patient may still be able to feel the touch of a pinpoint but not be able to distinguish it as sharp.
The tactile ability of the fingertips is so refined that a specialized method of testing, two-point discrimination, is generally used for peripheral nerve injuries or radicu-lopathies that involve the fingertips. Although specialized calipers, called two-point discriminators, are available, the examiner can improvise a serviceable device by straightening out a paper clip and bending it over so that the two ends are separated by a defined distance (Fig. 1-11). Because an average individual should be able to distinguish between two points separated by 5 mm, the paper clip is usually configured so that the ends measure 5 mm apart. The patient is instructed to close his or her eyes and notify the examiner whether the finger in ques-tion is being touched by one or two points. The examiner then touches the fingertip with the device a number of times, sometimes with only one end of the paper clip and sometimes with both simultancously. If two-point discrimination is impaired, the patient perceives the simul-taneous touch of both ends of the paper clip as only one end. If this is the case, the examiner can gradually spread apart the ends of the paper clip until the distance between the points that is requircd for the patient to distinguish two separate points is determined.
Because of the intimate relationship between the spine, the spinał cord, and its nerve roots, the neurologie examination is an integral part of the physical examina-tion of the spine. For this rcason, the evaluation of motor, sensory, and reflex deficits by dermatome is included in
Figurę 1-11. Testing for two-point discrimination.
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