Mdula espinal

Estructura Tractos

anatmica

de la mdula espinal de la mdula espinal

Prof. Federico Batiz

Sndromes

Mdula espinal
- Comparable al sistema de Input-Output (IO) de un computador - Nervios espinales (C8, T12, L5, S5, Cx1) - Estructura segmentaria

Segmentos espinales C8, T12, L5, S5, Cx1 - Raz Anterior (Ventral) - Raz Posterior (Dorsal) Ganglio de la raz dorsal

Cara o superficie anterior Surco o fisura media anterior Surco lateral antero Cono Medular (L1-2) Cauda Equina

Surco medio posterior Surco lateral posterior Surco intermedio posterior Fasciculus cuneatus Fasciculus gracilis

Superficie posterior de la mdula espinal

Mdula espinal

Meninges

Periosteo de la vrtebra
- Espacio epidural ----------------- Anestesia epidural

Duramadre Membrana aracnoidea

- Espacio Subaracnoideo -------- Puncin lumbar Anestesia Espinal

Piamadre
- Ligamento Denticulado
- Filum Terminale

Meninges de la mdula espinal

Duramadre Aracnoides Piamadre

Ligamento Denticulado
- especializacion de la piamadre

Meninges of the spinal cord

Lumbar Puncture lumbar (terminal) cistern

Mdula espinal

Irrigacin

Arterial
- Arterias Espinales Arteria espinal anterior (1) & posterior (2) ramas de la arteria vertebral - Arterias Radicular es ----- Arterias Segmentarias ramas de la Vertebral, Cervical Ascendente, Intercostal y Lumbar

Venosos
- Venas Longitudinales & Radiculares hacia venas Intervertebrales ---- plexo venoso vertebral interno hacia plexo venoso vertebral externo ---- venas segmentarias

5. Adamkiwicz artery

Arteria espinal anterior

Arterias segmentarias

Mdula espinal

Configuracin externa

Mdula espinal

Configuracin externa

Cono Medular (L1-2) Unin Espinomedular

- Foramen Magnum, Decusacin piramidal, raz ventral C1

Engrosamientos
- Cervical (C4-T1) & Lumbosacro (L1-L4)

Fisuras y surcos longitudinales

- Fisura media anterior - Surco lateral anterior - Surco medio posterior - Surco lateral posterior

cervical enlargement (C8)

thoracic cord (T8)

lumbar enlargement (L3)

sacral cord (S1)

 Cervical level
- Wide flat cord, lots of white matter, ventral horn enlargements. Lumbar level - Round cord, ventral horn enlargements. Sacral level - Small round cord, lateral Horn. Thoracic level - Notice the pointed tips which stick out between the small dorsal and ventral horns. This extra cell column is called the intermediate horn (Intermediolateral Cell Column). It is the source of all of the sympathetics in the body & occurs only in the thoracic sections T 1 - L 2

Mdula espinal Sustancia blanca

Configuracin interna

Cordn Anterior (Columna blanca anterior) Cordn Posterior (Columna blanca posterior)
Fasciculus Gracilis & Fasciculus Cuneatus

Cordn Lateral (Columna blanca lateral)

Sustancia gris
Asta Anterior ----------------- motora Asta Posterior --------------- sensitiva Asta intermediolateral --- autonmica (simptico) Comisura gris --------------- anterior y posterior

Mdula espinal

Configuracin interna

1. posterior horn 2. anterior horn 3. intermediate zone (intermediate gray) 4. lateral horn 5. posterior funiculus 6. anterior funiculus 7. lateral funiculus 8. Lissauer's tract

9. anterior median fissure 10. posterior median sulcus 11. anterolateral sulcus 12. posterolateral sulcus 13. Posterior intermediate sulcus

Mdula espinal

Configuracin interna

Organizacin medular
1) Longitudinal (columnar)
Fibras (Sustancia blanca) --------------- Columna blanca Grupos celulares (Sustancia gris) --- Columna gris

2) Transversal
Fibras aferentes & eferentes Fibras que cruzan la lnea media (comisurales, decusando)

3) Somatotpica

Columnar arrangement

Somatotopical arrangement

Laminas de Rexed
Lamina I Posteromarginal Nucleus Lamina II Substantia Gelatinosa of Rolando Lamina III Lamina IV, V, VI ----- Nucleus Propius Lamina VII - Intermediate Gray - Intermediolateral cell column (ILM) - Clarkes column (Nucleus dorsalis) - Intermediomedial cell column (IMM) Lamina VIII Lamina IX ---------- Anterior Horn (Motor) Cell Lamina X ----------- Gray Commissure

Laminas de Rexed

Lamina I
lamina marginalis or lamina de Waldeyer Receives incoming input from dorsal root axons Larger neurons contribute axons to Contralateral Spinothalamic Tract

Lamina II
Substantia Gelatinosa Receives incoming input from dorsal root axons & descending input from reticular formation of the medulla. Involved in Pain interpretation Efferent axons travel up & down several segments to make contact with other areas of the dorsal horn

Lamina III
Contains larger, less densely packed cells than lamina II Receives primary afferents from dorsal root fibers Neurons considered as a part of nucleus proprius

Lamina IV
Contains a variety of cell types that have more myelin than any other lamina Some tract cells originate here, axons cross the midline and enter the contralateral Spinothalamic Tract, also sends contacts to layers II and III Receives afferents from dorsal roots via the dorsal funiculus At rostral end of spinal cord, laminas I-IV become continuous with the spinal trigeminal nucleus

Lamina V - VI
Origination of tract cells, similar to lamina IV, these tracts cells are also known as the Nucleus Proprius (e.g. spinothalamic tract or anterolateral system; pain and temperature, some tactile) Receives afferent input from dorsal roots and descending fibers, most importantly Corticospinal

Lamina V - VI
C7

reticular formation ---------------->

Laterally, gray matter at base of dorsal horn mixes with white matter from lateral funiculus, this region is called reticular formation. It is noticeable in the cervical region

Lamina VII
The largest region, occupies most of ventral horn &intermediate zone Projects long axons that connect to other gray matter segments of the cord Some columns do not fit into the lamina scheme, and have individual designations: a. Nucleus dorsalis (Clarke) b. Intermediolateral cell column c. Intermediomedial cell column d. Sacral autonomic nucleus

Lamina VII
Nucleus dorsalis of Clark or nucleus thoracicus is located medial & ventral to the dorsal horn in T1-L3 Composed of large neurons & axons that form the dorsal spinocerebellar tract on the ipsilateral side

T5

Lamina VII
Intermediolateral cell column is located at the lateral portion of the intermediate zone. Responsible for the formation of the lateral horn in T1 - L2 Consists of cell bodies of sympathetic preganglionic neurons

T5

Lamina VII

Intermediomedial cell column is located lateral to lamina X. Not seen in all cord sections. Receives primary afferent fibers from dorsal root and has been implicated in visceral reflexes

T5

Lamina VII
S2

Sacral autonomic nucleus is located in the lateral part of lamina VII in S2-S4 segments Consists of preganglionic parasympathetic neurons

Lamina VIII
Located on the medial aspect of the ventral horn Efferent projections both ipsilaterally and contralaterally to the same and nearby segmental levels to lamina VII & IX Site of termination for descending fibers, including the vestibulospinal and reticulospinal tracts

Lamina IX
Consists of columns of neurons embedded in either lamina VII or VIII Cells include alpha and gamma motor neurons, which axons exit via the ventral roots and innervate striated muscle. Smaller neurons contribute axons to the ventral fasciculus proprius Four columns of motor neurons can be identified within this lamina; ventromedial, ventrolateral, dorsolateral & central each has characteristic dendritic features

Lamina IX

Ventral gray columns in lamina IX have somatotopic arrangement: - Medial areas innervate the axial musculature - Lateral areas innervate the limbs muscles

PHRENIC NUCLEUS
The phrenic nucleus is located in the ventromedial area of the ventral horn in C2-C5 segments. It receives bilateral innervation from the solitary nucleus of the medullary region, via solitary tract. This nucleus is responsible for the innervation of the diaphragm

SPINAL ACCESSORY NUCLEUS

The spinal accessory nucleus (cranial nerve XI) is located in the lateral area of vental horn in C1-C5 segments. Corticospinal tract innervates this nucleus bilaterally. This nucleus is also responsible for the innervation of the trapezius & sternocleidomastoid muscles (ipsilaterally)

Lamina IX
Nucleus of Onuf
Located ventrolaterally in S1-S2 spinal segments Supplies muscles of the pelvic floor, including striated muscle sphincters for urinary and fecal continence
S2

Lamina X
Surrounds the central canal, and includes the ventral gray commissure Contains relatively small neurons, radial neuroglia cells & decussating axons Some dorsal root afferents terminate here

Fasiculus Proprius

Ascending and descending association fiber systems of the spinal cord which lie deep in the anterior, lateral & posterior funiculi adjacent to the gray matter.

Dorsal Roots
Each dorsal root divides into 6 - 8 rootlets Each rootlet can be divided into lateral & medial division Lateral division carries information related to pain & temperature Medial division carries information related to tactile discrimination & vibration

Dorsal Roots

Lateral division axons enter dorsolateral tract of Lissauer, and then divide into ascending & descending branches, each terminate in the dorsal horn Most terminate at same level & some fibers may travel up or down the cord up to four levels

Dorsal Roots
Medial division axons enter the white matter & then divide into ascending & descending branches Descending branches are organized into two bundles, the Septomarginalis Fasiculus and the Interfascicular Fasiculus All descending branches terminate in the dorsal horn

Dorsal Roots

Ascending branches of the

medial division enter the dorsal funiculus & terminate in gracile & cuneate nuclei in the medulla

Ventral Horn
Lamina IX contains two types

of motor neurons, alpha and gamma Alpha motor neurons innervate extrafusal fibers of striated skeletal muscles Gamma motor neurons innervate intrafusal fibers of neuromuscular spindles Both types receive inputs from interneurons, including the inhibitory Renshaw cell

Tractos ascendentes y descendentes

Tractos ascendentes y descendentes

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. Fasciculus Gracilis Fasciculus Cuneatus Tractus spinocerebellaris dorsalis Tractus corticospinalis lateralis Tractus spinothalamicus lateralis Tractus spinocerebellaris ventralis Tractus rubrospinalis Tractus spinotectalis Tractus corticospinalis anterior Tractus olivospinalis Tractus spinoolivaris Tractus tectospinalis Tractus reticulospinalis Tractus vestibulospinalis Tractus spinothalamicus anterior Raphe-spinal & Hypothalamospinal fibers

16

Tractos ascendentes
Modality: Touch, Pain, Temperature, Kinesthesia Receptor: Exteroceptor, Interoceptor, Proprioceptor Primary Neuron: Dorsal Root Ganglion (Spinal Ganglion) Secondary Neuron: Spinal Cord or Brain Stem Tertiary Neuron: Thalamus (Ventrobasal Nuclear Complex) Termination: Cerebral Cortex, Cerebellar Cortex, or Brain Stem

Tractos ascendentes

Posterior White Column-Medial Lemniscal Pathway Spinothalamic Tract Spinoreticular or Spinoreticulothalamic Tract Spinocerebellar Tract Spinomedullothalamic Tract Cervicothalamic or Spinocervicothalamic Tract Spino-olivary Tract Spinotectal Tract

Posterior White Column-Medial Lemniscal Pathway Modality: Discriminative Touch Sensation (include Vibration) and Conscious Proprioception (Position Sensation, Kinesthesia) Receptor: Most receptors except free nerve endings Ist Neuron: Dorsal Root Ganglion (Spinal Ganglion) Posterior Root - Posterior White Column 2nd Neuron: Dorsal Column Nuclei (Nucleus Gracilis et Cuneatus) Internal Arcuate Fiber - Lemniscal Decussation - Medial Lemniscus 3rd Neuron: Thalamus (VPLc) Internal Capsule ----- Corona Radiata Termination: Primary Somesthetic Area (S I)

Spinothalamic Tract Modality: Pain & Temperature Sensation, Light Touch Receptor: Free Nerve Ending

Ist Neuron: Dorsal Root Ganglion (Spinal Ganglion) Posterior Root 2nd Neuron: Dorsal Horn (Lamina IV, V, VI) Spinothalamic Tract - (Spinal Lemniscus) 3rd Neuron: Thalamus (VPLc, CL & POm) Internal Capsule ----- Corona Radiata Termination: Primary Somesthetic Area (S I) & Diffuse Widespread Cortical Region

NeoSTT
Primary Motor Area (M I)

PaleoSTT
Widespread cortical region thalamus

VPLc (ventrobasal CL (intralaminar nuclear complex) thalamic nuclei) (spinal lemniscus) reticulothalamic pathways spinothalamic tract spinoreticular tract

reticular formation

Spinothalamic Tract & Spinoreticular Tract

medial lemniscus lemniscal decussation internal arcuate fiber posterior white column posterior root

Posterior White Column Medial Lemniscal Pathway

- ipsilateral loss of discriminative touch sensation and conscious proprioception below the level of lesion

spinothalamic tract

decussation

anterior white commissure

posterior root

Spinothalamic Tract

- contralateral loss of pain and temperature sensation below the level of lesion

Tractos descendentes Corticospinal Tract

Origin: Cerebral Cortex
Brodmann Area 4 (Primary Motor Area, M I) Brodmann Area 6 (Premotor Area, PM ) Brodmann Area 3,1,2 (Primary Somesthetic Area, S I) Brodmann Area 5 (Anterior Portion of Sup. Parietal Lobule)

Corona Radiata lnternal Capsule, Posterior Limb Longitudinal Pontine Fiber Pyramid - pyramidal decussation Corticospinal Tracts: - Lateral (crossed) - 85% - Anterior (Not crossed) - 15%

Termination: Spinal Gray (Rexed IV-IX)

Descending Tracts from Brain Stem Dorsolateral (Motor) Pathway Rubrospinal Tract Ventromedial (Motor) Pathway Tectospinal Tract Vestibulospinal Tract MLF (Medial Longitudinal Fasciculus) - interstitiospinal tract Sensory Modulation pathways Raphespinal & Cerulospinal Pathways Descending Autonomic Pathways

Descending Tracts from Brain Stem Dorsolateral (Motor) Pathway Rubrospinal Tract Ventromedial (Motor) Pathway Tectospinal Tract Vestibulospinal Tract MLF (Medial Longitudinal Fasciculus) - interstitiospinal tract Sensory Modulation pathways Raphespinal & Cerulospinal Pathways Descending Autonomic Pathways

ventromedial pathway

dorsolateral pathway

SOMATIC MOTOR SYSTEM

upper motor neuron UMN

Brain Stem Descending Pathway Final Common Pathway lower motor neuron
Rubrospinal Tract Tectospinal Tract Vestibulospinal Tract MLF Reticulospinal Tract AUTOMATIC CONTROL

VOLUNTARY CONTROL

LMN
Pyramidal Tract

REFLEX

EFFECTORS skeletal muscle

Comparison of Fast and Slow Pain ------ Spinothalamic Tract

Fast Pain
Sharp, pricking Group III (A) fiber Short latency Well localized Short duration Less emotional Not blocked by morphine Neospinothalamic Tract

Slow Pain
Dull, burning Group IV (C) fiber Slower onset Diffuse Long duration Emotional, autonomic response Blocked by morphine Paleospinothalamic Tract

Spinal Cord

Ascending Tracts

Spinocerebellar Tract
Modality: Unconscious Proprioception Receptor: Muscle spindle, Golgi tendon organ

Ist Neuron: Dorsal Root Ganglion (Spinal Ganglion)

Posterior Root , [Posterior Column]

2nd Neuron: 1. Clarkes column (Lamina VII)

Posterior Spinocerebellar Tract

2. Accessory Cuneate Nucleus

Cuneocerebellar Tract

3. Posterior Horn
Anterior Spinocerebellar Tract

Termination: Cerebellar Cortex

Anterior SCbllT (superior cerebellar peduncle) anterior spinocerebellar tract anterior white commissure posterior root

Posterior SCbllT Inferior cerebellar peduncle cuneocerebellar tract (upper body) posterior white column posterior root

Inferior cerebellar peduncle

posterior spinocerebellar tract Clarkes column posterior white column posterior root

Spinocerebellar Tract

Spinocerebellar Tract

Corona Radiata lnternal Capsule, Posterior Limb Crus Cerebri, Middle Portion Longitudinal Pontine Fiber Pyramid Pyramidal Decussation Corticospinal Tract
IC CR

- Lateral and Anterior

LPF

Corticospinal Tract
Pyr PD LCST

- ipsilateral UMN syndrome at the level of lesion

ACST

Spinal Cord

Syndrome

Location of Symptoms in Spinal Disease

ipsilateral to lesion

contralateral to lesion

Upper Motor Neuron (UMN) vs. Lower Motor Neuron (LMN) Syndrome UMN syndrome Type of Paralysis Atrophy Deep Tendon Reflex Pathological Reflex Superficial Reflex Fasciculation and Fibrillation Spastic Paresis No (Disuse) Atrophy Increase Positive Babinski Sign Absent Absent LMN Syndrome Flaccid Paralysis Severe Atrophy Absent DTR Absent Present Could be Present

Spinal Cord

Syndrome

Predominantly Motor Syndromes Poliomyelitis (Infantile Paralysis)

- viral infection of lower motor neuron - LMN syndrome at the level of lesion

Amyotrophic Lateral Sclerosis (ALS)

- combined LMN and UMN lesion - LMN syndrome at the level of lesion - UMN syndrome below the level of lesion - Lou Gehrigs disease

Spinal Cord

Syndrome

1. corticospinal tract

2. lower motor neuron (LMN)

Amyotrophic Lateral Sclerosis

Spinal Cord Syndrome

Amyotrophic Lateral Sclerosis (ALS)

Lou Gherigs Disease

Lou "The Iron Horse" Gehrig (1903-41)
3.40, 2131(1925-39), 23 GSH, 147 RBI avg.

Spinal Cord Syndrome

Amyotrophic Lateral Sclerosis (ALS)

Lou Gherigs Disease

Stephen Haking (1946- )

British Physicist, A Brief History of Time

Spinal Cord

Syndrome

Predominantly Sensory Syndromes Herpes Zoster

- inflammatory reactions of spinal ganglion - severe pain on the dermatomes of affected ganglion

Tabes Dorsalis
- common variety of neurosyphilis - posterior column and spinal posterior root lesion - loss of discriminative touch sensation and conscious proprioception below the level of lesion - posterior column ataxia - lancinating pain (a stabbing or piercing sensation) - loss of deep tendon reflex (DTR)

Herpes Zoster (Shingles)

varicella-zoster virus reactivation from the dorsal root ganglia unilateral vesicular eruption within a dermatome T3 to L3 dermatome lesions are frequent zoster ophtahalmicus (ophthalmic division of trigeminal n., V1) Ramsey-Hunt syndrome (sensory br. of VII) acyclovir, antiviral agent

Spinal Cord

Syndrome

Sub-Acute Combined Degeneration (Combined System Disease)

Lesion - posterior white column - corticospinal tract (UMN) Symptom - loss of discriminative touch sensation and conscious proprioception below the level of lesion - ipsilateral UMN syndrome below the level of lesion

Spinal Cord

Syndrome

1. corticospinal tract

2. posterior white column

Sub-Acute Combined Degeneration

Spinal Cord

Syndrome

Syringomyelia, Hematomyelia
Lesion - central canal of spinal cord - gradually extended to peripheral part of the cord Symptom - initial symptom is bilateral loss of pain (compression of anterior white commissure) - variety of symptoms appear according to the lesion extended from central canal

Spinal Cord

Syndrome

Syringomyelia - Initial Symptoms

Spinal Cord

Syndrome

Brown-Sequard syndrome
(spinal cord hemisection)
Major Symptoms 1. ipsilateral UMN syndrome below the level of lesion 2. ipsilateral LMN syndrome at the level of lesion 3. ipsilateral loss of discriminative touch sensation and conscious proprioception below the level of lesion (posterior white column lesion) 4. contralateral loss of pain and temperature sensation below the level of lesion (spinothalamic tract lesion)

Spinal Cord

Syndrome

3'

3' 1' 4' 2'

3 1 2 4

5'

5 1' 3 3 1

Brown-Sequard Syndrome (Spinal Cord Hemisection)