Spinal cord (anatomy and internal composition), back, vertebrae Objectives: Describe the anatomy of the spinal cord,

d, spinal nerves, and relations to the vertebral column Describe the structure and function of the vertebrae, associated ligaments, and muscles that move the spine Describe the internal anatomy of the spinal cord Summarise the function and anatomy of muscle stretch and withdrawal reflexes

Vertebral column (backbone, spine) Part of axial skeleton 33 vertebrae: 7 cervical, 12 thoracic, 5 lumbar, 5 sacral (fused), 4 or so coccygeal Support head and trunk, transmit body weight to lower limbs through pelvic girdle Protects spinal cord and nerve roots (in vertebral canal)
Moore & Agur 11 Netter 18

 Thoracic and sacral - concave anteriorly (primary curvatures) Cervical and lumbar - convex anteriorly (secondary curvatures) Abnormal curvatures: Kyphosis Lordosis Scoliosis

Curvatures of spine

Moore & Agur 276; Rosse fig 12.35

medicine.ucsd.edu/Clinicalimg/ thorax-kyphosis.htm www.chirotips.com/ scoliosis_and_curvatures.htm

Vertebrae
In mini-exploration, revise structure of typical vertebrae, including Vertebral body, pedicles, lamina, spinous process, transverse processes, superior and inferior articular processes, vertebral foramen; intervertebral foramen between adjacent vertebrae for spinal nerves Unique features of cervical vertebrae: lateral mass, transverse foramen for vertebral artery Special structures of C1=atlas (arches), C2=axis (dens)
Netter 12, 142,143,144

Joints and movements of vertebral column

Between vertebral bodies: intervertebral disc (symphysis)
Annulus fibrosus - outer 1/3 innervated Nucleus pulposus - not innervated

Zygapophyseal: between superior and inferior articular facets (synovial) Cervical, lumbar regions: flexion/extension, lateral flexion (abduction/adduction) Thoracic region, atlantoaxial joint: rotation Joints innervated by dorsal rami of spinal nerves

Netter 13, 144, 172; Moore&Agur 5, 291

Ligaments of vertebral column

Bear some weight when spine flexed, prevent displacement, and limit movements Anterior and posterior longitudinal ligaments Ligamenta flava Interspinous ligament Supraspinous ligament Ligamentum nuchae Ligaments for atlantooccipital and atlantoaxial joints: cruciform (transverse) and alar
Netter 146, 14, 15

Extensors of spine
Erector spinae Iliocostalis, longissimus, spinalis Transversospinalis Semispinalis, multifidus, rotatores Splenius cervicis and capitis Suboccipital mm Act against gravity to maintain upright posture, extend spine, lateral flexion, control rate of flexion and lateral flexion Innervated by dorsal rami of spinal nerves Netter 161, 162

 Neck: longus colli, scalenes, SCM Lumbar flexion : rectus abdominis, external and internal obliques (also rotation) Lumbar lateral flexion: quadratus lumborum, psoas major

Flexors and lateral flexors of spine

Netter 25, 246

Spinal cord and spinal nerves

Spinal cord from foramen magnum to L1/2 IV disc C (tapered end = conus medullaris) 31 pairs (right and left) of anterior and posterior roots exit spinal cord, unite to form 31 pairs of spinal nerves in intervertebral foramina T
8 cervical, 12 thoracic, 5 lumbar, 5 sacral, 1 coccygeal

Spinal nerves exit below respective pedicle, except cervical, which exit above (C8 n between C7, T1 v) Nerve roots increase in length inferiorly, with cauda equina inferior to termination of cord L
Netter 149, 155

L S

Meninges of spinal cord and associated spaces

Pia innermost meningeal layer Subarachnoid space - filled with cerebrospinal fluid (CSF) Arachnoid middle meningeal layer Subdural space - potential space Dura outermost meningeal layer Epidural space - between dura and vertebrae, contains fat, veins All 3 layers blend with epineurium of spinal nerves at IV foramen

Netter 156

Limits of meninges and spaces

Epidural space from foramen magnum to sacral hiatus Dura, arachnoid, subarachnoid space with CSF from foramen magnum to S2 or S3 of sacrum Lumbar cistern CSF filled, between terminations of spinal cord (L1/2) and dural sac (S2/3) Internal and external filum terminale anchors cord to dura, dura to sacrum/coccyx
Netter 148

Lumbar puncture
Lumbar cistern with CSF and cauda equina between L1/2 to S2/3 Usually accessed between L3, L4 or L4, L5 spinous processes Sample CSF, measure CSF pressure, deliver drugs or radiological contrast (myelography) Layers traversed

 Formed by anterior (motor) and posterior (sensory) root Divide into posterior and anterior ramus Posterior rami to extensors and skin of back Anterior rami:
C1-C4 - cervical plexus C5-T1 - brachial plexus T1-L1 intercostal, etc nerves L2-S3 - lumbosacral plexus

Spinal nerves

Netter 155, 166

Dermatomes and myotomes

Dermatome: a region of skin supplied by a single spinal cord segment (pair of spinal nerves) Myotomes: groups of muscle fibres supplied by a single spinal cord segment
Lower limb: anterior posterior hip flexors: L2-3 extensors: L5-S1 knee extensors: L3-4 flexors: L5-S1 ankle etc dorsiflex/invert: L4-5 plantar/evert: L5-S2 toes extensors: L5-S1 flexors: S1-S2 Upper limb: shoulder C5-7 elbow: flex C5-6, extend C7-8 wrist: flex/extend C6-7 fingers: flex/extend C7-8, abduct/adduct C8-T1

Netter 150

Lumbar back pain: common complaint with many causes

Muscle strain, tendon tears, or reflex extensor mm contraction Arthritis of zygapophyseal joints Intervertebral disc degeneration pain from annulus fibrosus, secondary strain on zygapophyseal joints
IV disc herniation: nerve root compression: dermatome/myotome distribution

Occasionally an indicator of more serious disease: cancer, infection, referred pain from pelvis or abdomen, AAA, vertebral fracture

Netter 144, 149

Anatomy of the spinal cord

Right and left sides symmetrical; almost separated by anterior median fissure and posterior median sulcus Central canal with ependymal cells, CSF Segmentation apparent because of spinal nerves Gray matter - neuron cell bodies White matter - myelinated axons

Netter 155, Fix 18

Functions of the spinal cord

Initial sensory processing - afferents from primary sensory cell bodies in dorsal root (spinal) ganglia enter cord via posterior root; synapse in cord and/or ascend to medulla Motor control of skeletal muscles Control of smooth muscle, cardiac muscle, glands (via autonomic ganglia); all sympathetics (T1-L2), some parasympathetics (S2-4) Reflex processing - unconscious, stereotyped responses to sensory inputs, processed in spinal cord by sensory neurons, interneurons, and motor neurons

Fix 18

Gray matter: posterior (dorsal) horn

Lamina of Rexed (I-X): functional and cytological subdivision of gray matter of spinal cord Posterior horn (I-VI): mainly sensory processing neurons Substantia gelatinosa (II) - mostly pain and temperature

Fix 18

Gray matter: anterior, lateral horns and intermediate gray

Anterior horn: lower motor neurons (LMNs, alpha MNs, layerIX) to ipsilateral skeletal muscle; gamma MNs to muscle spindles Lateral horn (VII): to smooth, cardiac muscle, glands via ganglia
T1-L2: intermediolateral cell column - sympathetics to entire body S2-S4 - parasympathetics to pelvic and some abdominal viscera

T1-L2 Clarkes nucleus (VII) proprioceptive afferents, axons form the posterior spinocerebellar tract

Netter 151

White matter
Posterior, lateral, anterior funiculi (columns) of white matter Ascending tracts (to brainstem, thalamus, cerebellum) Descending tracts (from cerebral cortex, brainstem) Between segments of spinal cord (fasciculus proprius) surrounds gray matter All tracts on R and L sides of cord
Fix 18

White matter: descending tracts (UMN tracts)

Anterior column: anterior corticospinal tract, tectospinal tract, reticulospinal tracts, vestibulospinal tracts Lateral column: lateral corticospinal tract, rubrospinal tract, and info to lateral horn autonomics at T1-L2, S2-4

Fix 18

White matter: ascending tracts (sensory info)

Dorsal (posterior) columns: axons of primary sensory neurons to medulla (touch, vibration, joint position, pressure, some pain)
Fasciculus gracilis (medially) info from T6 and below Fasciculus cuneatus (laterally) info from T6 and above

Spinothalamic tract: anterolateral, axons from contralateral dorsal horn to thalamus (pain, temperature, coarse touch) Spinocerebellar tracts: afferents to cerebellum

Fix 18

Appearance of spinal cord at various levels

Cervical and lumbar enlargements of spinal cord: neurons in posterior and anterior horns for upper limb (C5-C8, T1) and lower limb (L2-L5, S1-S3) T1-L2 lateral horn, Clarkes nucleus Fasciculus cuneatus only above T6 Total amount of white matter increases superiorly

Netter 149, 151

 2 neuron reflex: primary sensory neuron, LMN Monosynaptic reflex - one synapse within CNS Sensory receptor, peripheral nerve, sensory neuron, spinal cord segment, motor neuron (LMN), peripheral nerve, NMJ, muscle Modulated by descending UMN input to LMNs Commonly tested muscle stretch reflexes: Calcaneal (Achilles) tendon: S1-2 Patellar ligament: L3-4 Biceps brachii and brachioradialis tendons: C5-6 Triceps brachii tendon: C7-8

Muscle stretch reflex

Nolte 226

 Several neurons:

Reflexes: withdrawal reflex

Primary sensory neurons Interneurons

may be excitatory, or inhibitory (to LMNs of antagonist muscle groups) ipsilateral and contralateral axon branches

LMNs

Polysynaptic, involves several spinal cord segments

Nolte 10-13

Arteries of spinal cord, nerve roots

Anterior spinal arterymost gray matter Posterior spinal arteries superficial Travel the length of the cord Arise from vertebral arteries, reinforced at irregular intervals by radicular arteries from vertebrals, posterior intercostals, lumbars, lateral sacrals
Netter 157, Rosse 13.17

Vertebral venous plexus

Anterior and posterior spinal veins (radicular veins have valves) Internal and external vertebral venous plexus (no valves) Drain to IVC via lumbar, internal iliac vv, SVC via azygous system, internal jugular, deep cervical veins Many cancers may spread via blood to spine (prostate, lung, breast)

Netter 159