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INTRODUCTION TO NERVOUS SYSTEM I. CNS (brain & spinal cord) II.

PNS contains: - Nerves cranial & spinal - Plexus - Ganglia Functional Divisions I. Somatic NS II. Autonomic NS a. Sympathetic b. Parasympathetic Anatomical Levels of Nervous System 1. SUPRATENTORIAL level a. Located above tentorium cerebelli 2. INFRATENTORTIAL/ Posterior Fossa level a. Located below tentorium cerebelli BUT above foramen magnum 3. SPINAL level a. Located below foramen magnum BUT contained within the vertebral column 4. PERIPHERAL level a. Located outside the skull & vertebral column SUPRATENTORIAL 1. CNs 1 & 2 2. Basal ganglia 3. Cerebrum 4. Hypothalamus 5. Thalamus INFRATENTORIAL 1. CNs 3-7 2. Brainstem 3. Cerebellum 4. Midbrain 5. Pons & Medulla of Oblangata SPINAL - - compression is inside 1. Spinal Cord 2. Spinal nerves within vertebral column PERIPHERAL - - compression is outside

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Neuromuscular structures located outside skull & cerebral column including Cranial nerves & Spinal nerves and their peripheral branches

Lesions of the Nervous Systems A. TOPOGRAPHY of the Lesions - Anatomical location of the pathologic process and a judgment as to whether the abnormality is: o FOCAL strictly confined to a single circumscribed anatomical area Localized o DIFFUSE distributed over a wide areas; may involve only a single level or it may be distributed over multiple levels; bilateral Ex: meningitis, Alzheimers dse. B. MORPHOLOGY of the Lesions - The gross & histologic appearance of the abnormal area & the judgment whether the pathologic is: o NON MASS altering cellular function in the area of the lesion but is not significantly interfering w/ neighboring function; NOT compressing/destroying or damaging nearby structures o MASS lesion is of sufficient size & volume to interfere with neighboring cell structure Ex: tumor, blood clot, abscess formation C. DEVELOPMENT of SYMPTOMS - ACUTE within minutes - SUBACUTE within days - CHRONIC within weeks, months or years o Ex. Tumor D. EVOLUTION of SYMPTOMS 1. TRANSIENT when symptoms have resolved completely after onset 2. IMPROVING when symptoms have decreased from the maximum but have not completely resolved 3. PROGRESSIVE when symptoms continue to increase in severity; addition of new symptoms 4. STATIONARY when symptoms remain unchanged after reaching maximum severity

E. ETIOLOGY OF LESIONS 1. Degenerative chronic, progressive, diffuse (alzheimers & parkinsons) 2. Neoplastic chronic, progressive, focal (tumors) 3. Vascular 4. Inflammatory 5. Toxic metabolic 6. Traumatic 7. Immunologic SPINAL CORD ANATOMY & LESIONS spinal cord terminates at lower border of L1 & upper border of L2 - vertebral column i. cervical 8 ii. thoracic 12 iii. lumbar 5 - VERTEBRA HAS i. ANTERIOR segment ii. POSTERIOR segment iii. INTERVERTEBRAL disc SPINAL CORD - Lies within the vertebral canal & protected by 3 surrounding fibrous membranes called MENINGES - Held in position by the DENTICULATE ligaments on each side & FILUM TERMINALE inferiorly - Segmented & paired posteriorly/sensory and anterior/motor roots corresponsing to each segment of the cord. - Leave the vertebral canal through the INTERVERTEBRAL FORAMINA - Shorter than the vertebral column & terminates in the adult at the level of the lower L1 and upper border of L2 - Composed of: o Gray & White matter o Central Canal Parts of Gray Matter - Anterior horn - Posterior horn - Lateral horn - Gray commisure/ central canal Columns in the White Matter - POSTERIOR funiculus - LATERAL funiculus
NOTE: >Spinal nerve = all MIXED NERVE

>Cranial nerve = SENSORY NERVE

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ANTERIOR funiculus

Each Column is subdivided into tracts: - Ascending tracts - Descending tracts - Intersegmentral tracts Laminae of nerve groupings Location Laminae 1-6 - Posterior horn Laminae 7 - Lateral horn Laminae 8-9 - Anterior horn Laminae 10 - Gray substance surrounding the central canal 3 Principal Fibers Tracts I. Dorsal Tracts 1. Fasciculus gracilis (medial/ more upper) a. provides proprioception of the lower limbs and trunk to the brain stem b. Additional functions of the fasciculus gracilis include carrying deep touch, vibrational, and visceral pain information to the brain stem. 2. Fasciculus cuneatus (lateral/ more lower) a. The cuneate fasiculus carries information from vertebral level T6 and up, while the fasiculus gracilis carries information from vertebral levels below T6. NOTE: The fasciculus gracilis and the cuneate fasiculus offer the same functions but can be differentiated by the vertebral level at which information is provided. The 2 fasciculus is divided by POSTEROINTERMEDIATE SULCUS The fibre tracts within the white matter of the spinal cord are named to indicate whether they are ascending (sensory) or descending (motor) tracts. Ascending tracts usually start with the prefix spino- and end with the name of the brain region where the spinal cord fibres first synapse. The anterior spinothalamic tract, for example, carries impulses conveying the sense of touch and pressure, and synapses in the thalamus. From there it is relayed to the cerebral cortex. Descending motor tracts, conversely, begin with a prefix denoting the brain region that gives rise to the fibres and end with the suffix -spinal. The lateral corticospinal tracts, for
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example, begin in the cerebral cortex and descend the spinal cord. Ascending - convey sensory information from cutaneous receptors, proprioceptors (muscle and joint senses), and visceral receptors. Most of the sensory information that originates in the right side of the body crosses over and eventually reach the region on the left side of the brain, which analyses this information. (vice vesa) Information arising in the left side of the body is ultimately analyzed by the right side of the brain. Descending Two major groups of descending tracts from the brain: o corticospinal, or pyramidal tracts, and o extrapyramidal tracts. corticospinal fibres decussate in the pyramids of the medulla oblongata (hence the name "pyramidal tracts") and descend in the lateral corticospinal tracts, which decussate in the spinal cord. Because of the crossing of fibres, the right cerebral hemisphere controls the musculature on the left side of the body, where the left hemisphere controls the right musculature. The corticospinal tracts are primarily concerned with the control of fine movement that requires dexterity. extrapyramidal motor tracts, which originate in the midbrain and brain stem regions. o Reticulospinal tracts are the major descending pathways of the extrapyramidal system.

3. Touch 4. Pain 5. Temperature DERMATOMES to localize levels of lesions C2 Back of head C5 Tip of the shoulder C6 Thumb C7 Middle finger C8 Small finger T4-T5 Nipple T10 Umbilicus L1 Inguinal L4-L5 Big toe S1 Small toe S5 Perineum

DESCENDING TRACTS MOTOR pathway only


Composed of: 1. Lateral Corticospinal 2. Rubrospinal 3. Lateral & Medial Reticulospinal 4. Vesibulospinal 5. Tectospinal 6. Anterior Corticogninal Injury in the following affects (motor/sensory) o Posterior horn SENSORY o Anterior horn MOTOR o Corticospinal tract MOTOR o Lateral Spinothalamic tract SNESORY

ASCENDING TRACTS SENSORY pathway only


Functions of DORSAL/ POSTERIOR column: o Position sense o 2 point discrimination o Fine, discriminative o Vibration sense o Stereognosis Functions of SPINOTHALAMIC TRACT o ANTERIOR stt for pressure & touch o LATERAL stt for pain & temperature (5) PROPRIOCEPTION: 1. Functions of Dorsal/Posterior column 2. Pressure

PYRAMIDAL SYSTEM Provides voluntary control of skeletal muscles Owes its name tot eh pyramidal cells of the primary motor cortex Sometimes called the direct activation systems because of its straight pathway from the cortex to the cranial & spinal nerves Its fibers are divided into: o Corticospinal & Corticobulbar tracts Corticospinal tracts o Made up of axons that descend down from the cortex, through the internal capsule, the brainstem, and into the spinal cord. The axons terminate in the

spinal cord, where many of them synapse with spinal nerves. Corticobulbar tracts o Also made up of axons descending from cortex, but its axons terminate in brainstem, where synapse eventually with the cranial nerves Originates: primary motor cortex Axons of pyramidal cells descend in the internal capsule & extend into the brainstem & spinal cord to synapse on lower motor neurons Descending pathways referred to as upper motor neuron In order to have PARALYSIS, it must have injury in: o CORTICOSPINAL TRACT Leading to upper motor neuron lesion o ANTERIOR HORN cells Leading to lower motor neuron lesion Ex: POLIO POLIO Acute viral infection of the neurons of anterior gray columns of spinal cord The muscles of lower limb are more affected Note: Injury in CORTICOSPINAL TRACT o Contra lateral o Injury in RIGHT side = LEFT side paralysis Traumatic injury in SPINAL CORD o Ipsilateral o Injury in RIGHT spinal cord = RIGHT side para. Lower motor neuron lesions Flaccid + + decresed

CLINICAL SIGNS of spinal cord disorders 1. Motor findings 2. sensory level 3. DTR 4. _

AMYOTROPHIC LATERAL SCLEROSIS (ALS) MOTOR


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Pure motor disease involving the degeneration of anterior horn cells (Lower motor neuron lesion) & coticospinal tract (upper motor neuron lesion)

SPINAL SHOCK
Follows acute damage to the spinal cord; temporary interruption of the function of spinal cord following injury All cord functions below the level of lesions & become depressed or lost Persists for less than 24 hours or may persist for as long as 14 weeks Can be determined by testing for the activity of anal sphincter reflex

SUBACUTE COMBINED DEGENERATION - BOTH


Caused by vitamin B12 deficiency Degenerations of posterior & lateral column Loss of position sense & vibration in legs associated with UMNL Spinal cord hemisection Features o Contralateral loss of pain & temperature o Ipsilateral loss of proprioception o Ipsilateral manifestations of upper & lower motor neuron lesions L2-L3 level with nerve root compression

BROWN-SEQUARDs SYNDROME BOTH


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Manifestations of Spinal Shock Flaccid, areflexic paralysis Complete loss of sensation Loss of autonomic function Loss of reflex activity paralysis of bladder & rectum Destructive spinal cord syndromes Complete core transaction Anterior cord Central cord Brown Sequards = hemisection (R&L side paralysis SPINAL CORD LESIONS SYRINGOMYELIA - SENSORY - Progressive cavitation around central canal - Loss of pain & temperature sensations in hands & forearm - Common in cervical - Sensory loss dissociated

HERNIATED LUMBAR DISC


LEMNISCAL PATHWAY The sensory pathway responsible for transmitting touch, vibration and conscious proprioceptive information from the body to the cerebral cortex. Clinical signs of injury to the Lemniscal pathway (Dorsal/posterior column lemniscus pathway) 1. Inability to recognize limb position 2. Astereognosis - inability to identify an object by touch without visual input. 3. Loss of 2-point discrimination 4. Loss of vibration sense 5. (+) Romberg sign a. Test for drunken driving b. The exam is based on the premise that a person requires at least two of the three following senses to maintain balance while standing: proprioception (the ability to know one's body in space), sensation (the ability to feel touch, pressure, or vibration -- e.g., to feel one's feet against the ground), and vision (which can be used to monitor changes in balance).

SIGNS OF MOTOR NEURON LESIONS Upper motor neuron lesions Paralysis Spastic Atropy Fasciculations Clonus + Pathologic reflexes + Muscle tone Increased LESIONS OF CORTICOSPINAL TRACT

POLIOMYELITIS - MOTOR
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Attacks the anterior horn cells leading to lower motor neuron loss Caused by neurosyphilis Dorsal root involvement with secondary degeneration of dorsal columns sensory loss Loss of vibrations & position sense

TABES DORSALIS - SENSORY


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Used to investigate the cause of loss of motor coordination (ataxia). A positive Romberg test suggests that the ataxia is sensory in nature, which is, depending on loss of proprioception.

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