A 47-year-old man presents to the emergency room with complaints of progressively worsening shoulder pain and weakness over the past 3 weeks. He works as a grocery store stocker and reports that lifting heavy objects and breathing in seem to exacerbate the pain. On physical examination, the patient's right eyelid appears slightly lower compared to the left. Further inspection of the eyes reveals a smaller right pupil, in addition to flushed, dry skin on the right half of his face. Lungs bases are clear to auscultation, but the right apex is dull to percussion. S1 and S2 hearts sounds are normal. Chest X-ray reveals a unilateral consolidation at the apex of the right lung.
If this patient’s lesion is in the cervical spinal cord, at which of the following levels would the lesion be expected?
A) C2-C5
B) C4-C7
C) C8-T1
D) T2-T4
E) T4-T5
C) C8-T1
This patient has Horner syndrome which manifests with ipsilateral facial flushing, ptosis (superior tarsal muscle), miosis (pupil constriction), and anhidrosis (absence of facial sweating). It may also cause shoulder weakness if it affects the brachial plexus. Horner syndrome can be produced by a lesion anywhere along the three-neuron sympathetic pathway that originates in the hypothalamus and that supplies the head, eye, and neck. The first-order neuron descends caudally from the hypothalamus to the first synapse, which is located in the cervical spinal cord at levels C8-T2. A Pancoast tumor, which this patient likely has, is a lung cancer occurring at the lung apex, which may affect the cervical sympathetic plexus.
Key Learning Point
Horner syndrome manifests with ipsilateral facial flushing, ptosis, miosis, and anhidrosis and can be produced by a lesion anywhere along the sympathetic pathway that supplies the head, eye, and neck. This pathway passes through cervical spinal cord levels C8-T2.
