Section: USMLE

49) During a fight, a 32-year-old man is hit on the back of the neck with a chair. A CT scan reveals a bony fragment that penetrated the lateral portion of the dorsal columns. Which of the following functions would most likely be affected by a lesion at this site?

1. Fine motor control of the ipsilateral fingers
2. Motor control of the contralateral foot
3. Proprioception from the ipsilateral leg
4. Sweating of the ipsilateral face
5. Vibratory sense from the ipsilateral arm

At this level, the lateral portion of the dorsal columns (funiculus) is composed of the fasciculus cuneatus. Axons carrying tactile, proprioceptive, and vibratory information from the ipsilateral arm enter the spinal cord via the dorsal root, ascend the cord in the fasciculus cuneatus, and synapse in the nucleus cuneatus of the caudal medulla. Secondary neurons from this nucleus give rise to internal arcuate fibers, which decussate and ascend to the thalamus (ventral posterolateral nucleus, VPL) as the medial lemniscus. Tertiary neurons from the VPL project to the ipsilateral somatosensory cortex. Therefore, damage to the fasciculus cuneatus would result in a deficit in tactile, proprioceptive, and vibratory sense in the ipsilateral arm, because the fibers that carry this information do not cross until they reach the medulla.

Fine motor control of the fingers would be carried principally by the ipsilateral lateral corticospinal tract in the lateral funiculus of the cord.

Motor control of the contralateral foot is carried by the ipsilateral corticospinal tract in the lateral funiculus of the cord.

Proprioception from the ipsilateral leg is carried by the fasciculus gracilis in the medial part of the dorsal columns.

Hemianhidrosis (lack of sweating) of the face could be produced by interruption of sympathetic innervation to the face. The hypothalamospinal tract projects from the hypothalamus to the intermediolateral cell column at levels T-1 to T-2. It descends the cord in the lateral funiculus of the cord. Interruption of this tract results in Horner syndrome (miosis, ptosis, hemianhidrosis).