Spinal Cord and Spinal Nerves Lecture Notes PDF

The Spinal Cord and Spinal Nerves Lecture slides prepared by Curtis DeFriez, Weber State University Copyright © John Wiley & Sons, Inc. All rights reserved. Copyright © John Wiley & Sons, Inc. All rig...

The Spinal Cord and Spinal Nerves Lecture slides prepared by Curtis DeFriez, Weber State University Copyright © John Wiley & Sons, Inc. All rights reserved. Copyright © John Wiley & Sons, Inc. All rights reserved.  Introduction to the Spinal Cord ❖ About 100 million neurons and even more neuroglia comprise the spinal cord, the part of the central nervous system that extends from the brain. ▪ The spinal cord and its associated spinal nerves contain reflex circuits that control some of your most rapid reactions to environmental changes. ▪ The gray matter of the cord is a site for integration of postsynaptic potentials (IPSPs and EPSPs). ▪ The white matter of the cord contains major sensory and motor tracts to and from the brain. Copyright © John Wiley & Sons, Inc. All rights reserved.  External Cord Anatomy ❖ The spinal cord begins as a continuation of the medulla oblongata (the most inferior portion of the brain stem) extending from the foramen magnum of the occipital bone to its termination as the conus medullaris between L1 - L2. Copyright © John Wiley & Sons, Inc. All rights reserved.  External Cord Anatomy ❖ The spinal cord is oval in shape and slightly flattened anteriorly and posteriorly. ❖ Two types of connective tissue coverings protect the cord and provide physical stability: ▪The bony vertebral column provides the backbone. ▪The spinal meninges surround the cord as a continuation of the cranial meninges that encircle the brain. Copyright © John Wiley & Sons, Inc. All rights reserved.  External Cord Anatomy ❖ These three membranes (each called a meninx) are labeled from superficial to deep as follows: ▪The outermost dura mater (tough mother) forms a sac that encloses the entire cord. ▪The middle meninx is a delicate avascular covering called the arachnoid mater. It is attached to the inside of the dura and forms the roof of the subarachnoid space (SAS) in which cerebral spinal fluid (CSF) circulates. ▪The transparent pia mater is pressed-up against the cord and is filled with blood vessels that supply nutrients to it. Copyright © John Wiley & Sons, Inc. All rights reserved.  External Cord Anatomy ❖ The epidural space runs between the dura mater and the more superficial ligamentum flavum (which lines the underside of the bony vertebral lamina). ❖ The subdural space lies between the dura and the arachnoid. In the spinal column, the dura and arachnoid membranes are held firmly together so that the subdural space is often no more than a potential space. Copyright © John Wiley & Sons, Inc. All rights reserved.  External Cord Anatomy ❖ The pia mater has 21 pairs of denticulate ligaments which attach it to the arachnoid and dura maters. Named for their tooth-like appearance, the denticulate ligaments are traditionally believed to provide stability for the spinal cord against sudden shock and displacement within the vertebral column. Copyright © John Wiley & Sons, Inc. All rights reserved.  External Cord Anatomy ❖ Arising from the conus medullaris is the filum terminale, an extension of the pia mater that extends inferiorly and blends with the arachnoid and dura to anchor the spinal cord to the coccyx. ❖ The cauda equina or “horses tail” are the roots of the lower spinal nerves that angle down alongside the filum terminale. Copyright © John Wiley & Sons, Inc. All rights reserved.  External Cord Anatomy ❖ The spinal cord has two enlargements, one in the cervical area from C4–T1, and another in the lumbar area between T9–T12. ▪ The cervical enlargement correlates with the sensory input and motor output to the upper extremities. ▪ The lumbar enlargement handles motor output and sensory input to and from the legs. Copyright © John Wiley & Sons, Inc. All rights reserved.  External Cord Anatomy ❖ From superior to inferior, the spinal cord becomes progressively smaller. ▪ There is less and less white matter as we descend because there are fewer sensory tracts going up (they haven’t “jumped on” yet), and there are fewer motor tracts going down (they’ve “jumped off ” already.) Copyright © John Wiley & Sons, Inc. All rights reserved.  External Cord Anatomy ❖ Two bundles of axons, called roots, connect each spinal nerve to a segment of the cord by even smaller bundles of axons called rootlets. ▪ The posterior (dorsal) root and rootlets contain only sensory axons, which conduct nerve impulses from sensory receptors in the skin, muscles, and internal organs into the central nervous system. Copyright © John Wiley & Sons, Inc. All rights reserved.  External Cord Anatomy ❖ Each posterior root has a swelling, the posterior (dorsal) root ganglion, which contains the cell bodies of sensory neurons. The anterior (ventral) root and rootlets contain axons of motor neurons, which conduct nerve impulses from the CNS to effectors (muscles and glands). Copyright © John Wiley & Sons, Inc. All rights reserved.  Epidural Anesthesia ❖ Epidural anesthesia is commonly administered to women about to go into labor. In this procedure, a needle is placed between the bones of the posterior spine until it just penetrates the ligamentum flavum yet remains superficial to the dura mater. ❖ Local anesthetic is used to provide pain relief – even complete anesthesia if a cesarean section is required. Copyright © John Wiley & Sons, Inc. All rights reserved.  Lumbar Puncture ❖ A needle inserted into the subarachnoid space for the purpose of withdrawing CSF (for diagnosis or to reduce pressure) or to introduce a drug or contrast agent is called a lumbar puncture. ▪ CSF is often collected to diagnose meningitis or some other disease of the CNS. ▪ Agents injected into the SAS include drugs such as antibiotics, chemotherapeutic agents, or analgesics, or contrast media for radiographic procedures. The pressure of CSF in the SAS can also be measured during a lumbar puncture. Copyright © John Wiley & Sons, Inc. All rights reserved.  Lumbar Puncture ❖ The site used for most lumbar punctures is between the 3rd and 4th (or 4th and 5th) lumbar vertebrae - below the termination of the actual cord in the region of the cauda equina. With the needle in the SAS, CSF can be sampled. ▪ Anesthetics can also be given in this way, but using 1/10 the dose required for epidural anesthesia. Copyright © John Wiley & Sons, Inc. All rights reserved.  Internal Cord Anatomy ❖ In the spinal cord, the white matter is on the outside, and the gray matter is on the inside. In the brain the white matter is on the inside, and the gray matter is on the outside. Copyright © John Wiley & Sons, Inc. All rights reserved.  Internal Cord Anatomy ❖ The white matter of the cord consists of millions of nerve fibers which transmit electrical information between the limbs, trunk and organs of the body, and the brain. ❖ Internal to this peripheral region, and surrounding the central canal, is the butterfly-shaped central region made up of nerve cell bodies (gray matter – here stained brown). Copyright © John Wiley & Sons, Inc. All rights reserved.  Internal Cord Anatomy ❖ Anterior (ventral) gray horns consist of somatic motor neurons. ❖ Posterior (dorsal) gray horns consist of somatic and autonomic sensory nuclei. ▪ The posterior gray horn is the site of synapse between first-order sensory neurons coming in from the periphery, and second-order neurons which either ascend in the cord or exit back out as parts of reflex arcs. ▪ PS. AM. Copyright © John Wiley & Sons, Inc. All rights reserved.  Internal Cord Anatomy ❖ The lateral gray horns are found only in the thoracic, upper lumbar, and sacral segments of the cord. ▪ They contain cell bodies of autonomic motor neurons Some of these fibers ascend outside the dura but close to the cord to supply sympathetic innervation to the head. Others travel in sympathetic trunks to the organs and glands of the thorax, abdomen, and pelvis. Copyright © John Wiley & Sons, Inc. All rights reserved. Internal Cord Anatomy Copyright © John Wiley & Sons, Inc. All rights reserved.  Internal Cord Anatomy ❖ A tract is a bundle of neuronal axons that are all located in a specific area of the cord and all traveling to the same place (higher or lower in the brain or cord). Copyright © John Wiley & Sons, Inc. All rights reserved.  Internal Cord Anatomy ❖ The white matter of the cord is divided into anterior, posterior, and lateral columns in which ascending sensory tracts are traveling to someplace in the brain and descending motor tracts (red) are traveling to a location in the cord. The afferent tracts are noted here in blue, while the efferent tracts are shown in red. Copyright © John Wiley & Sons, Inc. All rights reserved.  Internal Cord Anatomy ❖ Names of tracts are formed by using compound words that denote the origin of the tract, and the place where it ends. ▪ The spinothalamic tract goes from the spinal cord to the brain – it is an afferent tract. SA ME ▪ The corticospinal tract goes from the cortex of the brain to the spinal cord – it is an efferent tract. ▪ The vestibulospinal tract originates from an area in the brain which you probably don’t recognize; however, you can recognize the destination in the spine, and therefore deduce that it is a motor tract. Copyright © John Wiley & Sons, Inc. All rights reserved.  Internal Cord Anatomy ❖ The posterior columns are afferent tracts that convey nerve impulses for discriminative touch, light pressure, vibration, and conscious proprioception (awareness of tendon and joint position in space and their relative movements). ❖ The spinothalamic tract is an afferent tract that transmits sensations of pain, warmth, coolness, itching, tickling, deep pressure, and crude touch. Copyright © John Wiley & Sons, Inc. All rights reserved.  Internal Cord Anatomy ❖ The lateral and anterior corticospinal tracts are major pathways for carrying signals from the cerebral cortex that result in voluntary movement of skeletal muscles. ❖ Other motor tracts convey nerve impulses from the brain stem that coordinate visual stimuli with body movements, maintain posture and regulate skeletal muscle tone. Copyright © John Wiley & Sons, Inc. All rights reserved. Copyright © John Wiley & Sons, Inc. All rights reserved. Copyright © John Wiley & Sons, Inc. All rights reserved.  Dermatomes ❖ A dermatome is an area of skin that is innervated by a single spinal nerve, indicated by the letters and number of a particular segmental nerve. ❖ Important dermatomes include: ▪ C6/C7 - thumb and index finger (“six-shooter”) ▪ T4 - nipple line ▪ T10 - umbilicus ▪ L1-L5 - lower extremities “L for legs”) Copyright © John Wiley & Sons, Inc. All rights reserved. Copyright © John Wiley & Sons, Inc. All rights reserved.  Damage to the Cord ❖ “Transection” of the spinal cord means that ascending and descending tracts are partially or completely severed. ❖ If transection occurs, say in a motor vehicle or diving accident, paralysis will occur depending on the level of the injury. Transection: ▪ at the base of skull results in death by asphyxiation ▪ in the upper cervical area results in quadriplegia ▪ between the cord enlargements results in some form of paraplegia Copyright © John Wiley & Sons, Inc. All rights reserved. Peripheral Nerves Copyright © John Wiley & Sons, Inc. All rights reserved.  Peripheral Nerves ❖ Spinal nerves are the paths of communication between the spinal cord and specific regions of the body. ▪ Nerves are arranged in fascicles surrounded by a perineurium, with the entire nerve sheathed by a CT epineurium. Copyright © John Wiley & Sons, Inc. All rights reserved.  Peripheral Nerves ❖ 31 left-right pairs of spinal nerves emerge from the cord at regular intervals (called segments). Except for the first cervical pair the spinal nerves leave the vertebral column from the intervertebral foramen between adjoining vertebrae – the first pair leaves between the skull and the first cervical vertebrae. ▪Cervical – 8 pairs, C1-C8 ▪Thoracic – 12 pairs, T1-T12 ▪Lumbar – 5 pairs, L1-L5 ▪Sacral - 5 pairs, S1-S5 ▪Coccygeal – 1 nerve pair Copyright © John Wiley & Sons, Inc. All rights reserved.  Peripheral Nerves ❖ Piercing the dura, the segmental (spinal) nerves exit the central nervous system into the peripheral nervous system and almost immediately split into 3 major branches: An anterior ramus, posterior ramus, and rami communicantes (connections to sympathetic ganglia). Copyright © John Wiley & Sons, Inc. All rights reserved.  Peripheral Nerves ❖ The anterior rami of the segmental nerves may travel alone (such as the intercostal nerves which run underneath each of the 12 ribs), or they can join together to form large “braided ropes” – a plexus of nerves. ▪ There are a number of major nerve plexuses, all formed from anterior rami of spinal nerves, and all located anterior to the spine: The cervical plexus, brachial plexus, celiac (solar) plexus, lumbar plexus, sacral plexus, and coccygeal plexus Copyright © John Wiley & Sons, Inc. All rights reserved.  Nerve Plexuses ❖ The cervical plexus, formed by the anterior rami of C1- C5, serves the head, neck, and diaphragm. ▪ The phrenic nerves arise from the cervical plexus to supply the major muscle of respiration (“C3,4,5 keep the diaphragm alive”). Copyright © John Wiley & Sons, Inc. All rights reserved. Copyright © John Wiley & Sons, Inc. All rights reserved.  Nerve Plexuses ❖ The brachial plexus is formed by the anterior rami of C5-C8 and T1. It is divided into roots → trunks → divisions → cords → nerves. ▪ The nerves from the brachial plexus supply the shoulders and upper limbs. Copyright © John Wiley & Sons, Inc. All rights reserved. Copyright © John Wiley & Sons, Inc. All rights reserved. Copyright © John Wiley & Sons, Inc. All rights reserved. Copyright © John Wiley & Sons, Inc. All rights reserved. Copyright © John Wiley & Sons, Inc. All rights reserved. Copyright © John Wiley & Sons, Inc. All rights reserved.  Nerve Plexuses ❖ Injuries to the brachial plexus are not uncommon: ▪ Erb’s palsy is a paralysis of the arm that most often occurs as an infant's head and neck are pulled toward the side at the same time as the shoulders pass through the birth canal. A similar injury may be observed at any age, including adults, following a traumatic fall or other trauma whereby the nerves of the plexus a violently stretched. Copyright © John Wiley & Sons, Inc. All rights reserved.  Nerve Plexuses ❖ Injuries to the brachial plexus or peripheral nerves: ▪ Median nerve injury, either at the plexus or occurring more distally, results in numbness, tingling and pain in the palm and fingers. Carpal tunnel syndrome is a common type of median nerve injury that is seen in people who perform repetitive motions of the hand and wrist like typing on a computer keyboard. Copyright © John Wiley & Sons, Inc. All rights reserved.  Nerve Plexuses ❖ The ulnar nerve is the largest unprotected (by muscle or bone) nerve in the human body. It emerges from the medial and lateral cords of the brachial plexus to supply the medial half of the hand. Striking the medial epicondyle of the humerus where the nerve is exposed is referred to as bumping one’s “funny bone”. ▪ Damage to the nerve leads to abnormal sensations in the 4–5th fingers and an inability to abduct or adduct the little and ring fingers. Copyright © John Wiley & Sons, Inc. All rights reserved.  Nerve Plexuses ❖ The long thoracic nerve emerges from the cords of the brachial plexus to supply the serratus anterior muscle. ▪ Because of its long, relatively superficial course, it is susceptible to injury either through direct trauma or stretch of the plexus. Injury (resulting in a “winged scapula” in which the arm cannot be abducted beyond the horizontal position) has been reported in almost all sports. Copyright © John Wiley & Sons, Inc. All rights reserved.  Nerve Plexuses ❖ The lumbar plexus is formed by the anterior rami of L1- L4 to supply the anterolateral abdominal wall, external genitalia, and part of the lower limbs. ▪ The femoral and obturator nerves come from the lumbar plexus. Copyright © John Wiley & Sons, Inc. All rights reserved.  Nerve Plexuses ❖ The sacral plexus is formed by the anterior rami of L4-L5 and S1-S4. It supplies the buttocks, perineum, and part of the lower limbs. ▪ It gives rise to the largest nerve in the body, the sciatic nerve. Copyright © John Wiley & Sons, Inc. All rights reserved.  Nerve Plexuses ❖ The coccygeal plexus is formed by the anterior rami of S4-S5 and the coccygeal nerves. It is a small plexus from which the anococcygeal nerve exits to supply a small area of skin in the coccygeal region. Copyright © John Wiley & Sons, Inc. All rights reserved. Copyright © John Wiley & Sons, Inc. All rights reserved. Copyright © John Wiley & Sons, Inc. All rights reserved. Copyright © John Wiley & Sons, Inc. All rights reserved. Copyright © John Wiley & Sons, Inc. All rights reserved. Copyright © John Wiley & Sons, Inc. All rights reserved.  Nerve Terminology Summary ❖ Rootlets  roots (ant. and post.)  segmental nerves  anterior ramus  form large nerve plexuses posterior ramus rami communicantes Copyright © John Wiley & Sons, Inc. All rights reserved.  Reflexes ❖ A reflex is a fast, involuntary response to a stimulus. In a spinal reflex the integration takes place in the spinal cord, not the brain. ▪ Spinal reflexes can be monosynaptic (sensory neuron with motor neuron) or polysynaptic (involving interneurons), and they can go in and out on the same, or on the opposite side of the cord. Copyright © John Wiley & Sons, Inc. All rights reserved.  Reflexes ❖ A reflex arc is a pathway that a nerve impulse follows to produce a reflex. Components of a reflex arc include a sensory receptor and a sensory neuron, an integrating center inside the cord, an exiting motor neuron, and an effector (which is usually some sort of muscle or a gland which makes some- thing move or secrete “involuntarily”). Copyright © John Wiley & Sons, Inc. All rights reserved.  Reflexes ❖ Sensory receptors involved in reflex arcs are specifically adapted to perceive the stimulus and initiate an impulse. ❖ The motor neuron becomes stimulated without any processing in the brain (that comes later)… first you kick the person examining you (patellar reflex), then you feel the tap of the hammer! Copyright © John Wiley & Sons, Inc. All rights reserved.  Reflexes ❖ Reflex arcs can be ipsilateral (all neurons and effectors on the same side of the body) or contralateral (the receptors and afferent neurons are on the opposite side of the body as the efferent neurons and effectors.) ▪The flexor (withdrawal) reflex is a good example of a contralateral reflex (stepping on a tack). Copyright © John Wiley & Sons, Inc. All rights reserved.  Reflexes ❖ In addition to initiating the flexor reflex that causes you to withdraw the limb, the pain impulses from stepping on the tack also initiate a crossed- extensor reflex to help you maintain your balance. Copyright © John Wiley & Sons, Inc. All rights reserved.  Reflexes ❖ Some important spinal reflexes include: ▪ The patellar reflex in which the leg extends in response to stretch of the patellar tendon. This reflex can be blocked by damage in the corticospinal tracts from diabetes, neurosyphilis, or damage to the lumbar region of the spinal cord. ▪ The Achilles reflex causes contraction of the calf when a force is applied to the Achilles tendon. It is absent after damage to the lower cord or lumbosacral plexus. Copyright © John Wiley & Sons, Inc. All rights reserved.  Reflexes ❖ Some important spinal reflexes include: ▪ The Babinski, or plantar flexion reflex is considered normal in adults if they flex (curl) the big toe when the sole of the foot is stimulated. If the sole of the foot is stimulated and the patient extends the big toe, it would indicate damage in the corticospinal tract. ▪ Infants normally extend their toes when stimulated in this way; so an “abnormal Babinski” does not indicate any disease or damage in this age group. Copyright © John Wiley & Sons, Inc. All rights reserved. Copyright © John Wiley & Sons, Inc. All rights reserved.