The Spinal Cord and Peripheral Nerves

Mina N. Astejada, MD, FPNA Clinical Associate Professor Department of Neurosciences UP-PGH

The Spinal Cord

Extent: From Foramen Magnum to lower border of L1 vertebra or upper border of L2 vertebra Length of human spinal cord 45 cm (male) 43 cm (female) Length of human vertebral column
70 cm

Weight of human spinal cord

35 g

DEVELOPMENT OF SPINAL CORD

4 cell columns of spinal cord 2 dorsal (alar) plates form dorsal horns 2 ventral (basal) plates form ventral and lateral horns dorsal & ventral plates are separated by sulcus limitans

Compare the Development of Spinal Cord & Vertebral Column

Vertebral body level:

3rd fetal month - cord occupies entire canal Birth - L3 vertebral body Adult - L1-L2 vertebral body

SPINAL CORD ANATOMY

spinal cord is protected by:
vertebral column meninges cerebrospinal fluid

The Spinal Cord Segments and Nerves

Gives rise to 31 pairs of spinal nerves

8 12 5 5 1

Cervical Thoracic Lumbar Sacral Coccygeal

Spinal Cord Segments

Cervical level - Wide flat cord, lots of white matter, ventral horn enlargements. Thoracic level - An extra cell column between the small dorsal and ventral horns is called the intermediate horn. It is the source of all of the sympathetics in the body & occurs only in the Thoracic sections T1 - L 2. Lumbar level - Round cord, ventral horn enlargements.

Sacral level - Small round cord, lateral Horn.

Gross Anatomy of the Spinal Cord

It contains 2 enlargements 1.Cervical Maximal Circumference is 38 mm C5-T1 segments Give rise to nerve roots forming the brachial plexus that innervates the upper extremities 2. Lumbar or lumbosacral Maximal Circumference is 35 mm Give rise to fibers forming lumbar plexus (L1-L4) and sacral plexus (L4-S2)that innervates the lower extremities

External Anatomy of Spinal Cord

Conus medullaris: - conical termination of the spinal cord - S2-S4 cord segments - Located between L1 & L2 vertebrae
Conus medullaris

Spinal Cord External Anatomy

Cauda equina (Horses tail): - contain L2 to S5 nerve roots - distal to L2 vertebra Filum terminale: - fibrous strand at inferior end of conus medullaris - inserts at dorsum of coccyx Denticulate ligament: - delicate shelves of pia mater that attach the spinal cord to the vertebrae laterally

Anatomy of the Spinal Cord sulcus & fissures

Posterolateral sulcus Posterior median sulcus Posterior intermediate sulcus

Antrolateral sulcus

Anterior median fissure

Cross-Sectional Anatomy of the Spinal Cord

Central area of gray matter shaped like a butterfly and surrounded by white matter in 3 columns Number of neurons in human spinal cord = 1 billion

Cross-Sectional Anatomy of the Spinal Cord Gray Matter

Gray matter consists of soma, unmyelinated processes, & neuroglia Pair of Posterior (dorsal) horns interneurons Pair of Anterior (ventral) horns interneurons & somatic motor neurons Pair of lateral horn contain intermediolateral cell column which give rise to sympathetic preganglionic fibers Connected by gray commissure punctured by a central canal continuous above with 4th ventricle

Grey commissure
Central canal

Lamina of 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

Cross-Sectional Anatomy of the Spinal Cord White Matter

Posterior columns

Lateral columns

Antrolateral column

Central area of gray matter shaped like a butterfly and surrounded by white matter in 3 columns

Spinal Tracts

Somatotopical Arrangement of Spinal Tracts

Dorsal Column

Corticospinal

spinothalamic

Spinothalamic Pathway
Modality: Pain & Temperature Sensation, Light Touch

1st order Neuron: Dorsal Root Ganglion 2nd order Neuron: Dorsal Horn (Lamina I, II, V,) 3rd order Neuron:

Thalamus (Ventral posterolateral)

Termination: Primary Somesthetic Area (S 1)

Dorsal Column-Medial Lemniscal Pathway

Modality: Discriminative Touch Sensation (include Vibration) and Conscious Proprioception (Position Sensation, Kinesthesia)

1st order Neuron: Dorsal Root Ganglion (Spinal Ganglion) 2nd order Neuron: Dorsal Column Nuclei in the medulla

(Nucleus Gracilis & Cuneatus)

3rd order Neuron: Thalamus (VPLc) Termination: Primary Somesthetic Area (S I)

The Corticospinal (Pyramidal) System

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

Corona Radiata lnternal Capsule, Posterior Limb Crus Cerebri, Middle Portion Longitudinal Pontine Fiber Pyramid decussation at the medulla

Corticospinal Tracts:
Termination: Spinal Gray (Rexed IV-IX)

Spinal Cord Arterial Blood Supply

1. Vertebral arteries a. Anterior spinal artery - supplies anterior 2/3 of spinal cord b. Posterior spinal arteries - supplies posterior 1/3 of spinal cord

There is 1 anterior & 2 posterior spinal artery

Spinal Cord Arterial Blood Supply

2.Radicular arteries from segmental arteries (Vertebral, Ascending Cervical, Intercostal, Lumbar & sacral artery) Anterior radicular (2-17) & posterior radicular (10-23) vulnerable (watershed) areas of the spinal cord (T1-T4) Artery of Adamkiewics: - artery of the lumbar enlargement - anterior radicular artery - originates at T9-T12 in 75% of the cases - Left side in 2/3 of cases

Spinal Cord Venous Drainage

1.Three (3) anterior and three (3) posterior spinal sinuses/veins that are drain by 6-11 anterior and 5-10 posterior radicular veins 2. Internal vertebral plexus (epidural) Batsons plexus - valveless - pathway for metastatic spread e.g. prostatic CA 3. All of them drain into vertebral veins in the neck, azygos veins in the thorax, lumbar veins in the lumbar region, lateral sacral veins in the sacral region through intervertebral foramina

Spinal nerves
31 pairs arise from spinal cord each contains thousands of nerve fibers All are mixed nerves (have both sensory and motor neurons)
5 groups correspond to regions of origins from spinal cord Cervical 8 pr. Thoracic 12 pr. Lumbar 5 pr. Sacral 5 pr. Coccygeal 1 pr.
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Spinal Nerves: Roots

Ventral roots arise from the ventral horn and contain motor (efferent) fibers Dorsal roots arise from sensory neurons in the dorsal root ganglion and contain sensory (afferent) fibers

Dermatomal Regions
Topographical region of the body surface innervated by one dorsal nerve root Collar region: C-3 middle finger: C-7 Nipple line: T-4 Umbilicus: T-10 Big toe: L-5 Small toe: S-1

Formation of Rami
Rami are lateral branches of a spinal nerve It contain both sensory and motor components Two major groups Dorsal ramus: Innervate the dorsal regions of the body Ventral ramus Larger Innervate the ventral regions of the body fused together to form plexuses (plexi) Rami communicantes to sympathetic chain ganglion (ANS)

Spinal Nerve Plexuses

network of ventral rami that branch and join with one another
Cervical plexus Brachial plexus Lumbar plexus Sacral plexus
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T2 T12 do not form plexuses

Cervical plexus
Buried deep in the neck under the sternocleidomastoid muscle C1 C4 (+ C5) cutaneous nerves, mostly sensory from skin of neck & back of head Phrenic nerve (C3-5) to diaphragm Motor stimulation for breathing!
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Brachial Plexus

Posterior Cord: Axillary Nerve (C5-6)

Motor component stimulate Deltoid, teres minor Abducts arm- deltoid Laterally rotate armteres minor Sensory component Skin: inferior lateral shoulder

Posterior Cord: Radial Nerve (C5-8)

Motor components stimulate - Posterior muscles of arm, forearm, and hand Triceps, supinator, brachioradialis, ECR, ECU, extensor digitorum Cause extension movements at elbow and wrist, thumb movements Sensory components: Skin on posterior surface of arm and forearm, hand Compression results in crutch paralysis Major symptom is wrist drop Failure of extensors of wrist and fingers to function Elbow, wrist, and fingers constantly flexed

Lateral cord: Musculocutaneous Nerve (C5-7)

Motor components stimulate Flexors in anterior upper arm: (biceps brachii, brachialis) Cause flexion movements at shoulder and elbow Sensory: Skin along lateral surface of forearm

Medial Cord: Ulnar Nerve (C7-T1)

Motor components stimulate
Flexor muscles in anterior forearm (FCU, FDP, most intrinsic muscles of hand) Results in wrist and finger flexion

Sensory: Skin on medial part of hand Most easily damaged

Hitting the funny bone excites it

Med & Lat Cord: Median Nerve (C5-T1)

Motor components stimulate All but one of the flexors of the wrist and fingers, and thenar muscles at base of thumb (Palmaris longus, FCR, FDS, FPL, pronator) Causes flexion of the wrist and fingers and thumb Sensory components Stimulate skin on lateral part of hand Damaged in carpal tunnel and suicide attempts

Lumbar plexus
L1 L4 (+ L5) Ilioinguinal nerve (L1) mostly sensory from skin of thigh & genitals Abdominal & pubic muscles Genitofemoral nerve (L1-2) mostly sensory from scrotum, labia majora, ant. Thigh Inferior abdominal muscles Femoral Nerve (L2-4) to quadriceps, sartorius Obturator (L2-4) Adductors of thigh and gracilis
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Lumbar Plexus:Obturator Nerve (L2-4)

Motor components
Innervate adductor group and gracilis in thigh Causes adduction of the thigh and knee (gracilis)

Sensory: Skin of the superior middle side of thigh

Femoral Nerve (L2-4)

Motor components Innervates flexors of hip Iliopsoas (Iliacus and psoas), rectus femoris Cause flexion of the hip Innervates extensors of knee Quadriceps group-Vastus and rectus femoris Cause extension of the knee Sensory: Skin- anterior and lateral thigh; medial leg and foot

Sacral plexus
L4 S4 Superior & inferior gluteal nerves (L4-S2) To gluteus muscles Sciatic nerve (L4-S3) To hamstrings & other posterior thigh & leg muscles Pudendal nerve (S1-4) Sensory from penis, clitoris, labia minora, anus (ext. anal sphincter) Voluntary micturation
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Sciatic Nerve (L4-S3)

Thickest and longest nerve of the body Composed of 2 nerves in one sheath Tibial nerve Common fibular nerve Leaves pelvis via greater sciatic notch Courses deep to gluteus and enters posterior thigh just medial to the hip joint The 2 divisions diverge just above the knee. Innervates posterior thigh and entire lower leg

Sciatic Branches: Tibial Nerve

Tibial nerve (L4-S3) Innervates Hamstring muscles knee flexors, hip extensors Posterior leg muscles gastrocnemius, soleus plantar flexors FDL, FHL toe flexors Branches in foot to form medial plantar nerve lateral plantar nerve If injured, paralyzed calf muscles cannot plantar flex foot; shuffling gait develops

Common Fibular (Peroneal) Nerve

Common fibular (L4-S2) Branches: deep & superficial fibular (peroneal) nerves Innervates anterior and lateral muscles of the leg and foot: (extensors that dorsiflex the foot- Tibialis anterior, EDL, EHL) sensory: lateral and anterior leg and dorsum of the foot susceptible to injury because of its superficial location at the head & neck of the fibula - Foot drop (unable to hold foot horizontal) - Toes drag while walking

ank

Sensory territory of nerves

Brachial plexus serves to re-direct spinal routes into named nerves covering certain territory

Cutaneous branches of medial cord/ulnar nerve

Nerve anatomy of lower leg

Spinal Tap (Lumbar Puncture)

Withdrawing CSF from the subarachnoid space

Figure 22.4