A patient has loss of pain and temperature sensation in a cape-like distribution over the shoulders and arms, with preservation of touch, vibration, and proprioception, and wasting of small hand muscles. Which condition is most likely?

• A. Brown-Séquard syndrome
• B. Syringomyelia
• C. Tabes dorsalis
• D. Central cord syndrome

Answer: (B)

This pattern is classic for syringomyelia. An expanding syrinx in the cervical spinal cord damages the crossing fibers of the spinothalamic tract right at the anterior white commissure. Since these fibers carry pain and temperature, their interception produces bilateral loss of these modalities in a cape-like distribution over the shoulders and arms. The dorsal columns—which carry touch, vibration, and proprioception—are spared early, so those senses remain intact. As the syrinx grows, it can extend into the ventral horn cells at the cervical level, producing lower motor neuron signs in the intrinsic hand muscles and causing wasting.

This presentation helps distinguish it from Brown-Séquard syndrome, which would show a combination of ipsilateral motor and position sense loss with contralateral pain and temperature loss below the lesion. Tabes dorsalis mainly disrupts the dorsal columns and dorsal roots, leading to sensory ataxia and lancinating pains, not a cape pattern. Central cord syndrome from trauma typically presents with greater weakness in the upper limbs and variable sensory loss, not the characteristic cape distribution of pain and temperature loss.