Anatomy:

The spinal cord is part of the autonomic nervous system in the human body.It is comprised of 31 pairs of
nerve roots that branch off to different areas of the body and transmit signals from the brain that enable
sensory and motor functions.

The autonomic nerves are broken into two system classifications:

1). Sympathetic.

2). Parasympathetic.
1). Sympathetic is responsible for how your body responds to stress ad and prepares you to take action.

2). Parasympathetic works while the body is at rest.

The spinal cord is located inside three thin sheaths or membranes,which are situated with in the
protective bony casing of the vertebral spinal column.

The five spinal cord regions are:

1).The Cervical spinal cord:

This is the highest region of the spinal cord(where the neck connects to the upper back).Where the
brain connects to the spinal cord.The sections of the cervical spine are commonly referred to as C1-
C8,ranking top- down from highest to lowest ,because there are eight vertebrae in this region of the
spinal column.

2). Thoracic spinal cord:

This is the next lowest section of the spinal cord and consists of vertebrae labeled T1- T12.

3).The lumbar spinal cord:

 This is a lower region of the spinal cord,where your spinal cord begins to bend.If your put your hand in
your lower back,where your back bends inward,you're feeling your lumbar region.There are five lumbar
vertebrae,numbered L1-L5.

4).The Sacral spine:

This is the lower,triangle-shaped region of the spine,also with five vertebrae.While the lumbar cord
bends inward,the vertebrae of the Sacral region bend slightly outward.There is no actual spinal cord in
this section,it is made up of nerve roots which exit the spine at their respective vertebral levels.

5).The Coccygeal region:

Sometimes known as the

Coccyx or
tailbone,consists of a single
vertebrae at the very base of
the spinal cord.

Spinal cord injuries typically are divided into two broad functional categories: Tetraplegia and paraplegia.

Tetraplegia refers to partial or complete paralysis of all four extremities and trunk including the
respiratory muscles,and results from lesions of the cervical cord.
Paraplegia refers to partial or complete paralysis of all or part of the trunk and both lower
extremities,resulting from lesions of the thoracic or lumbar spinal cord or Sacral roots.

There are 31 pairs of spinal nerves:

8 cervical,12 thoracic,5 lumbar,5 Sacral,1coccygeal.

1).Complete lesions:

In a complete lesion there is no sensory or motor function below the level of the lesion.It is caused by
a complete transection,severe compression or extensive vascular impairment to the cord.

2). Incomplete lesions:

Incomplete lesions are characterized by preservation of some sensory or motor function below the
level of injury.This preservation of function indicates that some viable neural tissue is crossing the area of
injury to more distal segments.

Incomplete lesions often result from contusions

produced by pressure on the cord from displaced
bone and/or soft tissues or from swelling with in
the spinal canal.

Some or even complete recovery from

contusion is possible when the source of pressure is
relieved . Incomplete lesions also may result from
partial transection of the cord.
1).Brown-sequard syndrome occurs from hemisection of the spinal cord(damage to one side) and is

typically caused by stab wounds.The clinical features of this syndrome are asymmetrical on the ipsilateral

side as the lesion,there is loss of sensation in the dermatome segment corresponding to the level of the

lesion.Owing to lateral column damage there are decreased reflexes,lack of superficial reflexes,clonus

and a positive Babinski sign.As a result of dorsal column damage,there is loss of

proprioception,kinesthesia and vibratory sense on the side contra lateral to the lesion,damage to the

spinothalamic tracts results in loss of sense of pain and temperature.This loss begins several dermatome

segments below the level of injury.This discrepancy in levels occurs because the lateral spinothalamic

tracts ascend two to four segments on the same side before crossing.

2).Anterior-cord syndrome:

It is frequently related to flexion injuries of the cervical region with resultant damage to the anterior
portions of the cord and/or its vascular supply from the anterior spinal artery.

There is typically compression of the anterior cord from fracture ,dislocation or cervical disc protrusion.

This syndrome is characterized by loss of motor function(corticospinal tract damage)and loss of the
sense of pain and temperature(spinothalamic tract damage)below the level of the
lesion,proprioception,kinesthesia and vibratory sensory are generally preserved,because they are
mediated by the posterior columns with a separate vascular supply from the posterior spinal arteries.

3).Central cord syndrome:

It is most commonly occurs from hyper extension injuries to the cervical region.It also has been
associated with congenital or degenerative narrowing of the spinal canal.The resultant compressive
forces give rise to hemorrhage and edema,producing damage to the most central aspects of the
cord.There is characteristically more severe neurological involvement of the upper extremities ( Cervical
tracts are more centrally located)than of the lower extremities.

Varying degrees of sensory impairment occur but tend to be less severe than motor deficits with
complete preservation of Sacral tracts,normal sexual,bowel and bladder function will be retained.
Patients with central cord syndrome typically recover the ability to ambulate with some remaining distal
arm weakness.

Surgical intervention to relieve the source of compression has produced significant improvement in
some patients.

4). Posterior cord syndrome: It is an extremely rare syndrome resulting in deficits of function served by the
posterior columns.

The clinical picture includes preservation of motor function,sense of pain and light touch.There is loss of
proprioception and epicritic sensations.(Eg:Two-point discrimination,graphesthesia,stereognosis) below
the level of lesion.In the past ,this syndrome was seen with tabes dorsalis a condition found with late
stage syphilis.

5).Sacral sparing:

It refers to an incomplete lesion in which the most centrally located Sacral tracts are spared.

Varying levels of innervation from Sacral segments remain intact.

Clinical signs include peri anal sensation,rectal sphincter contraction,cutaneous sensation in the
"Saddle area"and active contraction of the sacrally innervated the flexors.These are important
neurological findings and often the first signs that a cervical lesion is incomplete.

6).Cauda equina injuries:

The spinal cord tapers distally to form the conus medullaris at the lower border of the first lumbar
vertebrae.

Although some anatomical variations exist,this is the typical termination point the spinal cord.

Below this level is the collection of long nerve roots known as the "Cauda equina".

Complete transections in this area may occur.

However Cauda equina lesions are frequently Incomplete owing to the great number of nerve roots
involved and the comparatively large surface area they encompass(i.e. it would be unlikely that an injury
to this region would involve the entire surface area and all the nerve roots).

Cauda equina lesions are peripheral nerve(lower motor neuron)lesion.As such,they have the same
potential to regenerate as peripheral nerves else where in the body.

The spinal cord is elongated,almost cylindrical part of CNS,which is suspended in the vertebral canal
surrounded by meninges and CSF.It is continues above with medulla oblongata and extends form upper
border of Atlas to the lower border of first lumbar vertebrae and ends in a cone shaped structure known
as "Conus medullaris".
It is approximately 45cm long in an adult male and is about the thickness of little finger.

The spinal cord includes The outer white matter nd the inner grey matter.

Spinal cord is incompletely divided into 2 equal parts anteriorly by a short ,shallow median fissure and
posteriorly by a deep narrow septum the posterior media septum.

A cross section of the spinal cord shows that is composed of grey matter in the center surrounded by
white matter supported by neuralgia.

Grey matter:

The arrangement of grey matter in the spinal cord resembles the shape of letter H,having 2 posterior,2
anterior and 2 lateral columns.

The area of grey matter lying transversely is the transverse commissure and it is pierced by central
canal,an extension from 4 ventricle containing CSF.

The cell bodies may be:

Sensory cells-which receive impulses from the periphery of the body.

Lower motor neurons-which transmit to the skeletal muscles,connector neurons,linking sensory and
motor neurons,at the same or different levels which form spinal reflex arcs.

At each point where nerve impulses are passed from one neuron to another their is synaptic cleft and a
chemical transmitter.

Posterior columns of grey matter:

These are composed of cell bodies which are stimulated by sensory impulses form the periphery of the
body.The nerve fibers of these cells contribute to the formation of white matter of the cord and transmit
the sensory impulses to the brain.

Anterior -columns of grey matter:

These are composed of cell bodies of LMN which are stimulated by the axons of UMN or by cell bodies of
connector neurons linking the anterior and posterior columns to form reflex arcs.

The posterior root ganglia are composed of cell bodies which lie just outside the spinal cord on the
pathway of sensory nervous systems.

All sensory nervous fibers pass through these ganglia.The function of cells is to promote the onward
movement of nerve impulses.

White matter:
 The white
matter of
the spinal cord
is arranged in
3 columns or

tracts,anterior,posterior and lateral.

The white matter of the spinal cord contains nerve fibers and neuralgia is divided into 3 columns.

Posterior Column:

It includes fasciculus(laterally)and fasciculus gracilis(medially)mediating proprioceptive,vibratory and

tactile sensations.

Lateral column:

Contains descending motor lateral corticospinal and lateral spinothalamic fasciculi.

Anterior column:

Contains the ascending anterior spino thalamic tract and other descending tracts -conveys crude touch
sensation.These tracts are formed by sensory nerve fibers ascending to brain,motor nerve fibers
descending from the brain and fibers of connector fibers.

Spinal nervous tracts(Ascending or afferent)of spinal cord:

Two main sources of sensation transmitted to the brain via Spinal cord.

1.Skin: Sensory nervous ending in the skin called receptors are stimulate by pains,heat,cold and touch
including pressure.The nervous impulses are passed three neurons to the sensory area in opposite
hemisphere of cerebrum where sensation and it's locations are perceived.

2.Tendons,muscles and joints: Sensory nervous ending in these structures called proprioceptors are
stimulated by stretch . Together impulses form eyes and ears they are associated with the maintenance
of balance and posture and with perception of the position of the body in space.

3.These nervous impulses have 2 destination:

By three nervous systems ,the impulses reach sensory area of opposite hemisphere of cerebrum.
By two neurons systems ,the nervous impulses reach cerebellar hemisphere on the same side.

Motor nerve tracts (Efferent or Descending)in spinal cord.Neurons which transmit nervous impulses
away from the brain are motor neurons.

Motor neuron stimulation results in

Contraction of voluntary (striated skeletal muscles)

Contraction of smooth muscle and the secretion by glands controlled by nerves of system.

Spinal reflexes:

Reflex arch:

A reflex arch is an immediate motor response to a sensory stimulus.

Many connector and motor neurons may be stimulated by afferent impulses from a small area of skin.

Example:The pain impulses initiated by touching a very hot surface with finger are transmitted to spinal
cord by sensory nerves.These stimulate connectors and LMN in the cord which results in contraction of
many skeletal muscles of hand,arm and shoulder and the removal of finger.Reflex action takes place very
quickly,infact motor responses may have occurred simultaneously with perception of the pains in the
cerebrum.

Stretch reflex:

Only two neurons are involved.The cell of LMN is stimulated by sensory neuron.There is no connector
neuron involved.

Example:

Knee jerk.By tapping the tendon just below the knee.When it is bent,the sensory nervous endings in the
tendon and in the thigh muscles are stretched.This initiates a nerve impulses which passes into the
Spinal cord to cell.

Blood supply:

The vessels supplying the spinal cord are derived from the branches of the vertebral,deep cervical,inter
costal and lumbar axons.

The axon of spinal cord include the anterior spinal axon lying in the anterior median fissure and two
posterior spinal axon running along the posterior lateral sulci.

These vessels are reinforced by segmental or radicular arteries which originates from Subclavian
artery.The vertebral arteries join together to form the basilar artery beyond the foramen Magnum.In
foramen Magnum region,the vertebral arteries give branches anteriorly that join together to form the
"Single anterior spinal artery."
The anterior and posterior spinal arteries are the major blood supply to the spinal cord.

The anterior spinal artery supplies majority of spinal cord except the posterior columns.The posterior
spinal artery and it's branches supply the posterior funiculus,most of the posterior grey columns and
superficial lateral cuniculus.

The spinal cord also receives blood supply from the radicular arteries from vertebral ascending cervical
posterior intercostal , lumbar and lateral Sacral artery.

The radicular arteries enter the vertebral canal and through intervertebral foramen and divide into
anterior and posterior radicular arteries.

The anterior radicular arteries supplies anterior spinal arteries and posterior arteries contribute blood to
the spinal arteries.

Cells of lower motor neuron and anterior columns of grey matter in the same side .As result the thigh
muscle suddenly contract and the foot kicks forward.This is used as the test of the integrity of the reflex
arc,this type
of reflex has a
protective
reflex.

Venous drainage:
The veins draining the spinal cord are arranged in the form of six longitudinal channels,these are anterio-
median and posterior -median channels.

These lie in the midline and anterior lateral and posterior lateral channels that are paired.These channels
are inter connected by plexus of veins that form a venous vasocorona.

The blood supply from these veins is drained into radicular veins that open into a venous plexus lying
between the duramater and bony vertebral canal and through it into various segmental veins.

Spinal nerves:

These are 31pairs of spinal nerves that leave the vertebral canal by passing through the inter vertebral
foramina formed by the adjacent vertebrae.They are named and grouped according to the vertebra with
which they are associated

8 cervical,12 thoracic,5 lumbar,5 sacral,1coccygeal.

Although there are only 7 vertebra and their are 8 nerves because the first pair leaves the vertebral canal
between the occipital bone and atlas and 8th pair leave below the last cervical vertebrae.There after the
nerves are given the name and number of vertebra immediately above.

The lumbar,sacral,coccygeal nerves leave the spinal cord near its termination at the level 1st lumbar
vertebrae and extends downwards inside the vertebral canal in the sub-arachnoid space forming sheath
of nerves which resembles a horse tail called"Cauda equina".

These leave the vertebral canal at appropriate lumbar,sacral,Coccygeal level.

The spinal nerves arise from both sides of spinal cord and emerge through inter-vertebral foramina.A
mixed nerve formed by the union of a motor and sensory nerve root.

Nerve roots:

The anterior nerve root consists of motor nerve fibres which are the axons of the nerve cells in the
anterior column of grey matter.In the spinal cord and the thoracic and lumbar regions the sympathetic
nerve fibers which are the axons of the cells in the lateral columns of grey matter.

The posterior nerve root consists of Sensory nerve fibres.Just outside the spinal cord,there is spinal
ganglion or posterior root ganglion consisting of little cluster of nerve cells.Sensory nerve cells pass
through this ganglion before entering the spinal cord.The area of the skin supplied by each nerve is called
a "dermatomes".

Immediately after emerging from the inter vertebral foramina each spinal nerve divides into a ramus of
communicans,a posterior ramus and anterior ramus.
The rami communicans are a part of pre-ganglionic sympathetic neurones of the

"autonomic nervous system".

The posterior rami pass backwards and divides into medial lateral branches to supply skin and muscles of
relatively small areas of the posterior aspect of head,neck,trunk.

The anterior rami supply the anterior and lateral aspects of neck,trunk and upper and lower limb.
cervical , lumbar and sacral regions,the anterior rami unite near their origine to form a large masses of
nerve plexuses,where nerve fibers are regrouped and rearranged before proceeding to supply
skin,bones,muscles and joints of a particular area.In thoracic region,the anterior rami do not form
plexuses.There are 5 large plexuses of mixed nerve formed on the each side of the vertebral column.

They are:

Cervical
plexus,Brachial
plexus,Lumbar
plexus,Sacral
plexus,Coccygeal
plexus.

Physiology:

Any injury to spinal cord

means at level of
lower thoracic and upper
lumbar regions,
several segments of
spinal cord can be damaged,which will affect the Grey matter in these segments and tracts passing up and
down the cord.
Initially there is a period spinal shock with a flaccid paralysis below the level of lesion and there is a tendency
for flexor spasm developed as reflex activity below the lesion.

The

descending tracts carrying impulses relating to motor activity and if here interrupted release the LMN from
central control and so all activity is reflexes.

The paralysis muscles below the level of lesion will be permanent.Sensory information is carried to the brain
in the ascending tracts and so all the sensation will be lost.

Loss of anterior horn cell will results in a flaccid paralysis of the muscles supplied by the nerves, sometimes
only few of the fibers of nerve affected and they may give muscle weakness rather than a paralysis

There may be loss of sensation in areas supplied by the peripheral nerves because of destruction of cell in
the posterior root ganglion.

In thoracic region there are cells of the sympathetic system in the lateral horn and loss of these may affect the
Bp,temperature control and other visceral activities.

The lower lumbar and several segments have cells of parasympathetic system with nerves passing to pelvic
viscera.Interruption of these nerves will lead to bladder and bowel problem.