SPINAL CORD

A.k.a. Medulla Spinalis, myelon

42-45cm long in adults
2cm in diameter
extends to the superior border of L2
new born infants L3
3 mo. fetal life extends throughout
the vertebral Column

External Anatomy
Meninges
Dura mater
Arachnoid mater
Pia mater

 Conus medullaris
Cauda Equina
Filum Terminale
from the tip of the conus
medullaris and attaches to the
distal dural sac (S1)

5 Regions
Cervical
Thoracic
Lumbar
Sacral
Coccygeal
Cervical Enlargement
C4-T1

Lumbar Enlargement
T9-T12

INTERNAL ANATOMY
White matter
Gray matter

White matter
divided into funiculi
Consists of
mainlynerve fibers
that runs longitudinally through the
spinal cord
Grooves:
Dorsal median
sulcus
Dorsolateral sulcus
Ventral median fissure
Ventrolateral sulcus

Funiculus/Column
Dorsal
f. gracilis
f. cuneatus

Lateral
lies between DL sulcus
and VL sulcus

Ventral
between VL sulcus and
VM fissure

Tracts
fiber bundles with a
common function
oligodendrocytes lie
between the fibers
Sensory (ascending)
Motor (descending)

Gray Mater

divided into horns

Shaped like letter H or butterfly;
surrounded by white matter
Consists :
the cell bodies of neurons
Neuroglia
unmyelinated axons
dendrites of interneurons
motor neurons

HORNS
Dorsal/Posterior gray horn
contains somatic and autonomic sensory nuclei
Ventral/Anterior gray horn
contains cell bodies of somatic motor neurons &
motor nuclei

HORNS
Lateral gray horn
present only in T, lower L, &
S segments
Contains cell bodies of
autonomic motor neuron that
regulates activity of smooth
(m), cardiac (m) and glands

REXED LAMINAE:

Lamina I
the most dorsal part of dorsal horn
contains many neurons that respond to noxious stimuli
Lamina II
substantia gelatinosa, responds to noxious stimuli
Lamina III-IV
referred to as the
nucleus propius
main input is from fibers
that convey position sense

 Lamina V

contains cells that respond to both noxious and visceral afferent

stimuli
Lamina VI
the deepest layer of the dorsal horn
contains neurons, which respond to mechanical signal from
joints and skin.
Lamina VII
a large zone that contains the
cell of the Dorsal nucleus (Clarks
column)
receives afferent from ms.
spindles, cutaneous touch
receptors and joint receptors

Lamina VIII
located in the ventral horn, contains
neurons that send commissural axons
to the opposite side of the spinal cord

Lamina IX
represents motor Neuron group
contains alpha, beta and gamma motor neurons which sends
their axons into the ventral roots of the spinal nerves and
innervate skeletal muscles.
Lamina X
Around the central canal

Pathways in White Matter

The Spinal Cord is the
major "highway"
connecting the brain
and peripheral
nervous system

Ascending tracts
Spinothalamic
Lateral
Anterior
Dorsal column
Spinocerebellar
Anterior
Posterior

Spinothalamic tract (LSTT)

Conveys pain, temperature and crude touch

Receptors: free nerve endings, Krauses end bulb, Ruffinis
corpuscles
Afferent nerve: A (small myelinated) C (unmyelinated)
Chemical mediators:
- Histamine
- Bradykinins
- Serotonin
- Acetylcholine
- Substance P
- High concentration of K+

PATHWAY (LSTT)

1. Noxious stimuli A and C mediate stimuli in the

DRG
2. Axon divide into short ascending & descending
branches- Lissauers tr
3. Some fibers synapse neurons in SG of the IL
dorsal horn at the same level of entry
4. Other fibers synapse within 1 or 2 segment above the
level of entry
5. Decussate via the anterior white commissure, joins
the CL STT
6. VPL nucleus thalamus
7. Synapse Posterior limb of the internal capsule
8. Post central gyrus of the cortex area 3,1,2

VENTRAL SPINOTHALAMIC TRACT

1.
2.
3.
4.
5.
6.

Conveys light touch

(+) light touch skin receptors spinal cord
dorsal horn of the cord synapses
crosses the midline
enters the ventral white matter
ventral spinothalamic tract synapse thalamus
the tertiary sensory neuron cerebral cortex area 3, 1,
2

Dorsal Column

Tactile discrimination, vibration,

Joint position sense, Conscious proprioception

Receptors: (m) spindle, GTO position sense

Mechanoreceptors:
Pacinian corpuscles
vibration
Meissner corpuscles superficial
touch sensation for tactile
discrimination
Afferent fibers: Large
myelinated, fast
conducting nerve
fiber

Dorsal Column pathway

1.
2.
3.
4.
5.
6.
7.

Sensation on skin Afferent sensory nerve (large

myelinated)
Dorsal column on ipsilateral side (F. gracilis & F.
cuneatus)
Lower medulla Synapse n. gracilis & cuneatus
Arcuate fibers, Cross the CL side into the medial
lemniscus
VPL nucleus of the thalamus Synapse
Posterior limb of the internal capsule
Postcentarl gyrus of the area 3,1,2

Spinocerebellar Tract

Unconscious proprioception
Proprioception from the legs to the cerebellum
Receptors: (m) spindle, GTO
Afferent n.: Large myelinated n.

Lateral Spinocerebellar Tract

1. Sensation
2. Afferent nerve
3. Synapse at posterior horn (nucleus dorsalis) T1L2
4. Ascend on the ipsilateral side in the
spinocerebellar tract
5. Enters the cerebellum through the inferior
cerebellar peduncle

Descending tracts

Corticospinal
Reticulospinal
Rubrospinal
Vestibulospinal
Tectospinal

Corticospinal
Controls primarily skilled movements of the distal (m) of
the limb and facilitate the , & motor neurons
1/3 originates in primary motor area 4
10% originate in large pyramidal cells Betz cells
1/3 arise in premotor area 6
1/3 originates in parietal lobe, area 3,1,2 of the
postcentral gyrus

Pathway (LCST)
1. Precentral gyrus (area 4,6)
2. Posterior limb of internal capsule
3. Midbrain (crus cerebri)
4. Lower medulla
5. Decussate 90% of the fibers
6. Descend through the SC lateral
corticospinal tract
7. Synapse on , , motor neurons

Functions of LCST
Excitatory
result from direct connections
with motor neurons
Inhibitory
occurs through synaptic
connections with inhibitory
interneurons

Ventral CST
10% of the fibers descends
ipsilateral
anterior funiculus of the
cervical & upper thoracic cord
level
innervates trunk (m)

Reticulospinal tract
inhibitory effect on the
& motor neurons
Originates in the precentral gyrus synapse
reticular formation
spinal cord

Rubrospinal tract
Functions similar to CST
facilitate flexor & inhibit
extensor
Originate from red nucleus
(tegmentum of the
midbrain)

Vestibulospinal tract
Affects postural adjustments of
the body accompanying head
movements and maintenance of
postural tone
Regulates posture and coordinates
movements

Tectospinal tract
Modulates reflex
movements of the head
& neck in response to
visual and vestibular
stimuli

SPINAL NERVES
31 pairs
Cervical it exit above the
corresponding vertebra
T1- L1-S it exit below
the corresponding vertebra

SPINAL NERVES
Ventral root
Dorsal root

Parasympathetic
CN 3, 7, 9, 10
S2-S4

Sympathetic
T1 L2

What are Neurotransmitters?

chemical messengers produced by the
nervous systems in order to relay a
nerve impulse from one cell to
another cell.
formed in a presynaptic neuron and
stored in small membrane-bound
sacks, called vesicles, inside this
neuron.

Transmission of chemical synapse

1.AP synaptic end bulb

2.VG Ca channel open Ca
influx
3.Vesicle membrane merge
with the plasma membrane
4.Exocytosis of synaptic vesicle
5.Release of NT
6.NT bind to their receptors
ligand-gated channel open
7.Ions flow postsynaptic
potential

What is a reflex?

Reflex
A specific, stereotyped response to an
adequate stimulus

Monosynaptic vs. Polysynaptic

Types:
1. Monosynaptic
Mediated by 1 afferent & 1 efferent pathway
having only 1 synapse in the CNS
Eg. Stretch reflex (DTR)

What is Stretch Reflex?

1.
2.
3.
4.

A.k.a. myotatic, segmental reflex

The basic neural mechanism for maintaining m. tone
Stretching the muscle
(+) intrafusal fibers group Ia fibers
(+) motorneuron extrafusal fibers
Muscle contraction

Stretch reflex (DTR)

Ia

Reflex
2. Polysynaptic
Involves more than 2
types
Tendon reflex
Flexor withdrawal
Crossed extension reflex

What is Tendon reflex?

Control muscle tension by causing muscle relaxation when

muscle force is too extreme
Protects the tendon & muscle from damage due to excessive
tension
Receptor: GTO
Detect & respond to changes in m. tension caused by
passive stretch or m. contaction

Tendon reflex
1. Shortening of m. stretches the tendon
2. (+) Ib afferent
3. (-) motorneuron of agonist
Autogenic inhibition
4. (+) motorneuron of antagonist
Reciprocal innervation

Ib

GTO

What is Flexor Withdrawal Reflex?

A.k.a. withdrawal reflex, intersegmental reflex

Respond to painful stimulus
Ipsilateral reflex

Flexor Withdrawal Reflex

1. (+) pain sensitive neuron
2. Afferent nerve spinal cord
3. Activates interneurons that extends to several cord
segment
4. Interneurons activate motor neuron:
(+) mn innervating the ipsilateral flexor m.
(-) mn innervating the ipsilateral extensor m.

Flexor Withdrawal Reflex

What is Crossed Extensor Reflex?

Contralateral reflex arc

Balance maintaining reflex

Crossed Extensor Reflex

1.
2.
3.

(+) sensory receptor (noxious)

Afferent nerve SC
Sensory neuron activates several interneurons that synapse
motor neuron on the CL side of the SC in several SC segment
4. Interneurons activate motor neuron:
(+) mn innervating the CL extensor m.
(-) mn innervating the CL flexor m.

Spinal Cord Circulation

Arteries
Anterior spinal artery
Posterior spinal arteries
Radicular erteries T1 to L1
Great ventral radicular artery/ Arteria
radicularis magna/ Artery of
Adamkiewicz (T9-L1)
Veins

What is Spinal Cord Injury?

Spinal Cord Injury

Partial or complete disruption of spinal cord
resulting in paralysis, sensory loss, altered
autonomic and reflex activity.

ETIOLOGY
A. Traumatic (T/SCI)
B. Nontraumatic (NT/SCI)

Traumatic SCI
the most frequent cause in adult population
under 40 y/o
More severe than NT/SCI
What are the spinal areas of greatest frequency
of injury?
C5, C4, C6, T12, C7, & L1
Q: What is the most common cause of SCI among
adult >45 years of age?

Fall

What are the causes of Traumatic SCI?

MVCs 45.6%
Falls 19.6%
Acts of violence 17.8%
Recreational sports activities
10.7%
Other etiologies 6.3%

Motor vehicle crashes (MVCs)

The leading cause of SCI until age 45

Acts of violence (GSW)

Younger, non-high
school graduate from
lower socioeconomic
status
Paraplegia
Thoracic

3. Falls
The leading cause of SCI beginning with the 46
60 y/o age group

4. Recreational sports injuries

Diving
Snow skiing
Surfing
Wrestling
football

 Justin Bailey, a Durham, North

Carolina high school student,
suffered a spinal cord injury
during practice, and was
paralyzed from the chest
downward in February of 2002

Neurological level & extent of lesion

Traumatic SCI
Cervical
Thoracic
LS

C5 segment
the most common lesion level
C4, C6, T12, C7, & L1 at the time of d/c

ASIA A
Followed by ASIA D, C, B & E

 Tetraplegia
recreational sports-related injuries
Falls
50% of MVCs

Paraplegia
Acts of violence

Causes of Death

Pneumonia
Heart disease
Septicemia
Cancer
Lung, Bladder, Prostate, & Colon/rectum

Incomplete - ASIA D
Heart disease
pneumonia

Mechanisms of Injury
1. Flexion
2. Compression
3. Hyperextension
4. Flexion-rotation
5. Shearing
6. Distraction

Mechanisms of Injury
1.

Flexion
Head-on collision
The most common
mechanism of T/SCI
Wedge fx of anterior
VB
most common in
Lumbar injury

2. Flexion-rotation
Rear-end collision
Most common in cervical injury
Fracture of pedicles, facets & laminae

3. Compression
axial blow to the head
Diving
Surfing
Falling objects
Concave fx of CEP,
comminuted fx,
teardrop fx

Compression

4. hyperextension
rear-end collision
Falls
elderly
Fx of SP, laminae & facets;
avulsion fx of anterior
aspect of vertebrae

Nontraumatic SCI (NT/SCI)

More common in older, female, married and retired

More common than trauma in persons over 40 y/o
Usually have less severe neurological impairment
More often present with paraplegia with motor
incomplete lesion
Common in thoracic and lumbar regions

What are the causes of Non-traumatic

SCI?
Disease / Pathologic

vascular (AVM, thrombus, embolus, hge)

vertebral subluxation (RA/OA)
infections (syphilis/ transverse myelitis)
spinal neoplasm
Syringomyelia
abscesses of the SC
neurologic dse (MS,ALS)

Decompression sickness

A.k.a. Caissons disease

Obstruction of the venous
drainage of the cord by
bubble emboli, resulting in
SC infarction

Transverse myelitis
It was often described as spinal cord softening
is a group of disorders characterized by focal
inflammation of the spinal cord and resultant
neural injury.
associated with systemic disease
Common in thoracic cord

Classification of SCI
1.

Functional categories
Tetraplegia
Paraplegia

Tetraplegia
involves all four
extremities & trunk,
including the respiratory
m.
Result from lesions of
the cervical cord (C18)

Paraplegia
involves all or part of the
trunk & (B) LE
Result from lesions of the
thoracic or lumbar spinal
cord or sacral roots.
(T12-L1)

Designation of Lesion Level

Neurological
assessment

Steps in classifying patient with SCI

Perform sensory exam in 28 dermatomes bilaterally for
pinprick/light touch
Determine SL & total sensory score
Perform motor exam in the 10 key myotomes including AC on
rectal exam
Determine ML & motor index score
Determine NLI
Classify injury as complete or incomplete
Categorize ASIA impairment scale
Determine ZPP if ASIA A

Sensory Level
the lowest sensory area
that is intact on either
sides of the body.
28 dermatomes
(0
2)
Pin prick & light touch

Motor Level
the lowest key muscle that
is normal (3) on either
sides of the body provided
that the key muscles above
are grade 5/5.
10 myotomes
(0
5)

Key muscle groups

C5 elbow flexors
C6 wrist extensors
C7 elbow extensors
C8 long finger flexors
T1 small finger
abductors

L2 hip flexors
L3 knee extensors
L4 ankle DF
L5 long toe extensor
S1 ankle PF

Neurologic level of injury (NLI)

used to locate the level of cord
injury
refers to the most caudal segment
of cord with intact motor &
sensory function on (B) sides of
the body.

Degree of injury

Complete
absence of sensory & motor function in the
lowest sacral segments
Caused by complete transection, severe
compression or extensive vascular impairment
to the cord.
(-) VAC / (-) PAS

Degree of injury

Incomplete lesions
preservation of some sensory or motor function below
the NLI that includes the lower sacral segments (sacral
sparing).
Often result from contusions produced by pressure on
the cord from displaced bone or soft tissues, or
swelling within the spinal canal
(+) PAS, VAC, Deep Anal Sensation

What is Sacral Sparing?

(+)

VAC & DAS

Tested by light touch and pin sensation
at the anal musculocutaneous junction
(S4-S5 dermatome), on both sides.

What is Zone of Partial Preservation (ZPP)?

refers to those dermatomes & myotomes

below the neurologic level that remains
partially innervated at least 3 segments
below the neurologic level
applies to complete injury only

ASIA Impairment Scale

A - complete
B - (+) sensory, (-) motor
C - sensory & motor preserve(< 3)
D - sensory & motor preserve(>3)
E - normal / full recovery

ASIA C or D
Patient

must have either:

VAC
Sensory sacral sparing with sparing of
motor function more than three levels
below the motor level.

Incomplete
Clinical Syndrome

Incomplete Clinical Syndromes

Central cord syndrome

Brown-Sequard syndrome
Anterior cord syndrome
Posterior cord syndrome
Conus medullaris
Cauda equina injuries

What is Central Cord Syndrome (CCS)?

most common of the
incomplete syndromes
caused by hyperextension
injury in C spine
common among older age
group w/ spondylosis

What are the clinical manifestations of CCS?

More severe neurological
involvement of the UE

Sensory impairment less severe than

motor deficits
Complete preservation of sacral
tracts, normal sexual, bowel &
bladder function

What is Brown Sequard Syndrome (BSS)?

Involves a hemisection of the

spinal cord
Consisting of asymmetric
paresis with hyperalgesia more
marked on the less paretic side
commonly caused by stab
wounds
Rare syndrome

What are the clinical features of BSS?

Ipsilateral loss of :
sensation in the dermatome segment
corresponding to the level of the
lesion,
proprioception, kinesthesia &
vibratory sense
motor function below the level of
the lesion
Contralateral loss of pain & temperature
below the level of the injury

What is Brown-Sequard plus syndrome

(BSPS)?
More common than BSS
Refers to a relative ipsilateral hemiplegia with a
relative contralateral hemianalgesia
Result from closed spinal injuries with or
without vertebral fractures

Recovery of patients with BSS

Have the greatest prognosis for functional
outcome & potential for ambulation of the
incomplete syndromes
Functional gait recovery by 6 months
Favorable recovery of bowel & bladder
function

What is Anterior Cord syndrome?

Involves a lesion affecting the anterior 2/3 of the spinal cord

Related to flexion injuries of the cervical region with resultant
damage to the anterior portion of the cord or with lesion of the
ASA.

What are the clinical features of Anterior Cord syndrome?

loss of motor and sense of

pain & temp below the level
of the lesion.
Preservation of
proprioception, kinesthesia &
vibratory sense
worst prognosis
10-20% chance of muscle
recovery

What is Posterior Cord Syndrome?

rare syndrome, seen with tabes dorsalis

Loss of proprioception and epicritic sensations (2
pt discrimination, graphesthesia, stereognosis)
below the level of lesion
Preservation of motor & sense of pain & light
touch
Wide-based gait pattern is typical

 By contrast, nobody enjoys tabes dorsalis,

destruction of the sensory nerves in the dorsal
roots, with ataxia, loss of pain sensation and
deep tendon reflexes, and the characteristic
"lightning pains". Both axons and myelin are
lost in the dorsal roots (hard to see) and
posterior columns (easy to see).

Conus medullaris & Cauda

Equina Syndromes

What is Epiconus?
Segment above the conus medullaris
Consist of spinal cord segments L4-S1
Lesions will affect the lower lumbar roots
supplying muscles of the lower part of the leg
and foot

Symptoms of epiconus lesion

Sparing of reflex function of sacral segments
Preserved BCR & micturition reflex
Spasticity develop in sacral innervated segments (toe
flexors, ankle PF, hams muscles)
Recovery is similar to other UMNL SCIs

What is Conus Medullaris Syndrome?

Lesion affecting neural segments
S2 and below
present with LMN deficits of the
anal sphincter & bladder due to
damage of the AHC of S2-S4
injury to the sacral cord &
lumbar nerve roots

Conus Medullaris Syndrome

Clinical findings:
Motor strength in the legs & feet may
remain intact if the NR (L3-S2) are
not affected
flaccid paralysis of the LE
areflexive bladder & bowel (reflex
voiding center S2 - 4) may or may not
occur

What is Cauda Equina Syndrome?

injury to the LS nerve
roots (below L1)
LMNL
May represent as
neuropraxia or
axonotmesis

Better prognosis for

recovery

Cauda Equina Syndrome

Clinical findings:
flaccid paralysis/atrophy of LE (L2-S2)
Areflexia of the ankle and plantar reflexes
Autonomous or areflexive bladder & bowel
(-) BCR/ and anal reflex

(+) impotence

Full return of innervation may not common because:

Large distance between the lesion & point
of innervation
Axonal regeneration may not occur along
the original distribution of the nerve
Axonal regeneration may be blocked by
glial scarring
The end organ may no longer be
functioning once reinnervation occurs
Rate of regenarion slows & stops after
about 1 year