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Loss of muscle power may result from central disease involving the upper or lower motor neurons; from peripheral disease involving the roots, plexus, or peripheral nerves; from disorders of neuromuscular transmission; or from primary disorders of muscle. The clinical findings help localize the lesion and thus reduce the number of diagnostic possibilities.

Weakness due to upper motor neuron lesions is characterized by selective involvement of certain muscle groups and is associated with spasticity, increased tendon reflexes, and extensor plantar responses. The site of upper motor neuron (pyramidal) involvement may be indicated by the presence of other clinical signs or by the distribution of the motor deficit (eFigure 24–2). Lower motor neuron lesions lead to muscle wasting as well as weakness, with flaccidity and loss of tendon reflexes, but no change in the plantar responses unless the neurons subserving them are directly involved. Fasciculations may be evident over affected muscles. In distinguishing between a root, plexus, or peripheral nerve lesion, the distribution of the motor deficit and of any sensory changes is of particular importance. In patients with disturbances of neuromuscular transmission, weakness is patchy in distribution, often fluctuates over short periods of time, and is not associated with sensory changes. In myopathic disorders, weakness is usually most marked proximally in the limbs, is not associated with sensory loss or sphincter disturbance, and is not accompanied by muscle wasting or loss of tendon reflexes—at least not until an advanced stage.

eFigure 24–2.

Schematic illustration of upper motor neuron pathways. (Reproduced, with permission, from Adams M, Victor RD. Principles of Neurology, 5th ed. McGraw-Hill, 1993.)

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