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NSx Neuroanatomy > Spinal Anatomy > Flashcards

Spinal Anatomy Flashcards

1
Q

Number of SC segments

A

31

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2
Q

Number of cervical nerves

A

8

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3
Q

Origin of C1

A

Between occipital bone and atlas

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4
Q

Number of thoracic nerves

A

12, the first emerges below the first thoracic vertebra

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5
Q

Number of lumbar nerves

A

5

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6
Q

Number of sacral nerves

A

5

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7
Q

Number of coccygeal nerves

A

1

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8
Q

Borders of the anterior spinal column

A

Anterior median fissure

Anterolateral sulcus

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9
Q

Borders of the lateral spinal column

A

Anterolateral sulcus

Posterolateral suclus

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10
Q

What do the anterolateral and posterolateral sulci represent?

A

Point of entry for the ventrally located (motor) and dorsal (sensory) nerve roots

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11
Q

Borders of the posterior spinal column

A

Posterolateral sulcus

Posterior median fissure

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12
Q

What happens to the posterior spinal column above the level of T6?

A

Further divided into two tracts by the posterior intermediate sulcus

The medial fasciculus gracile and the more lateral fasciculus cuneatus

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13
Q

What structures fix the SC in place

A

Rostrally it is continuous with the brainstem

Laterally the spinal nerves exiting the vertebral foramina

Two attachments of dura mater

Dentate ligaments which are located between ventral and dorsal spinal roots and are extensions of the pia and arachnoid mater

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14
Q

What are the two attachments of the spinal dura mater?

A

Caudally as the filum terminalis with the coccyx and sacrum

Rostrally with the periosteum of the skull.

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15
Q

Rexed lamina I

A

Posteriomarginal nucleus

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16
Q

Rexed lamina II

A

Substantia gelatinosa

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17
Q

Rexed III + IV

A

Nucleus proprius

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18
Q

Function of Rexed lamina I-IV

A

Exteroreceptive sensations

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19
Q

Rexed lamina V

A

Neck of posterior horn

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20
Q

Rexed lamina VI

A

Base of posterior horn

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21
Q

Function of Rexed lamina V+VI

A

Proprioceptive sensations

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22
Q

Divisions of Rexed lamina VII

A

Medial

Two lateral

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23
Q

Medial division of Rexed lamina VII

A

Thoracic nucleus

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24
Q

Lateral divisions of Rexed lamina VII

A

Intermediomedial zone

Intermediolateral zone

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25
Q

Function of medial nucleus of Rexed VII

A

From C8-L3 receive information from muscle spindles and golgi tendon organ

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26
Q

Function of intermediomedial zone?

A

Gamma motor neurones involved in motor reflexes

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27
Q

Function of intermediolateral zone

A

Motor visceral function

Thoracolumbar sympathetic outflow

Caudal parasympathetic outflow

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28
Q

Rexed VIII

A

Commissural nucleus

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29
Q

Function of Rexed VIII

A

Regulates skeletal muscle contraction

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30
Q

Rexed IX

A

Ventral horn

Main motor area composed of alpha neurones

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31
Q

Rexed X

A

Grisea centralis

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32
Q

Function of Rexed X

A

Contains nuclei from autonomic system

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33
Q
A
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34
Q

Def: myotome

A

A group of muscles that is innervated by a single spinal nerve

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35
Q

Def: dermatome

A

Area of skin that receives sensory innervation from a single spinal nerve

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36
Q

Formation of spinal nerve

A

Dorsal nerve root (afferent), cell body in the DRG, fibres enter through dorsal suclus

Ventral nerve root (efferent) originate in cell bodies of ventral gray horn.

Unite to forma. spinal nerve and exit through corresponding intervertebral foramen.

After exiting from foramen, it divides into dorsal and ventral rami.

Dorsal rami-> skin on dorsal aspect of trunk and longitudinal muscles

VEntral rami_> motor and sesnory innervation to limbs and nonaxial skeleton.

Ventral ramus also communicates with sympathetic chain via white and gray rami communicantes

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37
Q

C1-4 nerve roots

A

Supply innervation to muscles and skin of neck and head

Contribute to diaphragm

Difficult to evaluate muscles so sensory distribution is the most effective

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38
Q

C2 landmarks

A

1cm lateral to the occipital protruberance or a point at least 3cm behind the ear

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39
Q

C3 landmark

A

Supraclavicular fossa MCL

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40
Q

C4 landmark

A

ACJ

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41
Q

C5 nerve root

A

Motor:

Deltoid (C5- axillary)- abduction

Biceps (C5,6- musculocutaneous nerve)- elbow flexion

Sensory:

Lateral aspect of arm (axillary nerve)

Reflex:

Biceps (C5.6)

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42
Q

How to assess integrity of C5

A

Motor:

Shoulder abduction

Elbow flexion

Sensory:

Regimental patch

Reflex:

Biceps

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43
Q

Motor:

Shoulder abduction

Elbow flexion

Sensory:

Regimental patch

Reflex:

Biceps

A

C5

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44
Q

How to assess integrity of C6

A

Motor:

Biceps (C5,6- musculocutaenous)

Wrist extension (C6,7- ulnar). Weakness in wrist extension due to isolated C6 compromise results in ulnar deviation

Sesnory:

Lateral forearm, thumb, index finger and one half of middle finger

Reflex:

Biceps (C5,6)

Brachioradials C6

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45
Q

Motor:

Biceps

Wrist extension

Sensory:

Lateral forearm, thumb, index finger and one half of middle finger

Reflex:

Biceps

Brachioradialis

A

C6

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46
Q

What is the best reflex to test C6 nerve root?

A

Brachioradialis

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47
Q

How to assess the integrity of C76 lesions

A

Motor:

Elbow extensors (radial)

Wrist flexors (median, ulnar), with C7 lesion wrist flexion results in ulnar deviation

Finger extensors

Sensory:

Middle finger, though it can also receive supply from C6 or 8

Reflex:

Triceps

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48
Q

Motor:

Elbow extensors (radial)

Wrist flexors (median, ulnar)

Finger extensors

Sensory:

Middle finger

Reflex:

Triceps

A

C7

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49
Q

How to assess the integrity of C8

A

Motor:

Finger flexion

Sensory:

Little finger

Reflex:

None

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50
Q

Motor:

Finger flexion

Sensory:

Little finger

Reflex:

None

A

C8

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51
Q

How to assess integrity of T1

A

Motor:

Finger abduction (T1, ulnar)

Finger adduction (C8,T1, ulnar)

Sensory:

Upper half of medial forearm and medial portion of arm

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52
Q

Motor:

Finger abduction

Finger adduction

Sensory:

Upper half of medial forearm and medial portion of arm

A

T1

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53
Q

Beevor’s sign

A

Present when the umbilicus of a patient is drawn up or down or to one side or the other when the patient is quarter way through a sit up

Indicates asymmetric weakness of the abdominal muscles

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54
Q

T4

A

Nipples

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55
Q

T6

A

Xiphoid process

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56
Q

T10

A

Umbilicus

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57
Q

T12

A

Inguinal ligament

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58
Q

How to assess the integrity of L1-3

A

Motor:

No specific muscle groups

Ilipsoas (L1-3)

Quadriceps (L-4)

Adductor L2-4

Sensory:

L1- oblique band just below the IL

L3- oblique band just above knee

L2- oblique band between L1 and L3

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59
Q

Motor:

No specific muscle groups

Ilipsoas

Quadriceps

Adductor

Sensory:

Oblique band just below the IL

Oblique band just above knee

Oblique band between L1 and L3

A

L1-3

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60
Q

How to assess integrity of L4

A

Motor:

Dorsiflexion and foot inversion (tibialis anterior, deep peroneal nerve)

Sensory:

Medial side of leg below the knee

Reflex:

Patellar (L2,3,4)

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61
Q

Motor:

Dorsiflexion and foot inversion (tibialis anterior, deep peroneal nerve)

Sensory:

Medial side of leg below the knee

Reflex:

Patellar

A

L4

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62
Q

Explain how to differentiate between L4 radiculopathy and peroneal nerve lesion

A

In peroneal nerve lesion, foot inversion is preserved as the peroneal nerve does not supply the foot inverter (tibialis posterior, tibial nerve) which is supplied by L4

https://www.youtube.com/watch?v=fJo0rERyBJM&feature=emb_title

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63
Q

How to assess for the integrity of L5

A

Motor:

EHL and extensor digitorum (deep peroneal nerve)- toe extension

Gluteus medius (SGN)- abduction of the hip

Reflex:

None

Sensory;

First dorsal webspace

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64
Q

How to differentiate between an L5 and deep peroneal nerve lesion

A

In an L5 lesion there will may also be loss of hip abduction (gluteus medius, SGN)

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65
Q

Motor:

Toe extension

Hip abduction

Reflex:

None

Sensory;

First dorsal webspace

A

L5 nerve root

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66
Q

How to assess integrity of S1

A

Motor:

Peroneus longus and brevis (superficial peroneal nerve)- ankle eversion

Gastrocnemius (S1/2, tibial nerve)- Ankle plantarflexors

Gluteus maximus (S1, IGN)- hip extensor

Reflex:

Achilles

Sensory:

Lateral aspect and part of plantar aspect of foot

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67
Q

Motor:

Peroneus longus and brevis (superficial peroneal nerve)- ankle eversion

Gastrocnemius (S1/2, tibial nerve)- Ankle plantarflexors

Gluteus maximus (S1, IGN)- hip extensor

Reflex:

Achilles

Sensory:

Lateral aspect and part of plantar aspect of foot

A

How to assess integrity of S1

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68
Q

How to assess integrity of S2-4

A

Motor;

Intrinsic muscles of foot- not testable

Anal sphincter

Sensory:

Skin surrounding anus

Reflex:

Anal wink

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69
Q

Unilateral

Neck and arm pain in distribution of single nerve root

Paraesthesia

Weakness may develop with association atrophy and fasciculations.

Hyporeflexia

A

?Cervical disk causing radiculopathy

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70
Q

Relationship between cervical disc and nerve roots

A

Typically impingement occurs in the spinal canal at the level of the disk space proximal to the the nerve’s exit point from the spinal canal

First exits between occiput and C1, second between C1 and 2

Eighth between C7 and T1

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71
Q

Herniated C3-4 disc impinges on

A

C4 nerve

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72
Q

Posterior neck and suboccipital pain sometimes affecting the ear

No motor deficit

A

?C3 radiculopathy

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73
Q

Paraspinous pain extending from root of the neck to mid-shoulder and posteriorly to level of scapula

May be aggravated by neck extension

Rarely, numbness

No motor deficit

A

?C4 radiculopathy

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74
Q

Shoulder pain to midpoint of lateral upper arm

No pain on manual rotation of shoulder

Deltoid weakness

+/- biceps hypreflexia

A

C5 radiculopathy

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75
Q

Most common cervical disc herniation

A

C6/7

Then C5/6

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76
Q

Pain and paraesthesia radiating from neck to lateral aspect of forearm and hand

Weakness of wrist extension and elbow flexion

Numbness involving lateral forearm and first and second digits

Brachioradialis reflex and biceps reduced

A

C6 radiculopathy

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77
Q

Pain and paraesthesia radiating across back of shoulder through triceps and posterolateral forearm into middle finger

Weakness in elbow extension, wrist flexion and finger extension

Reduced or absent triceps reflex

A

C7 radiculopathy

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78
Q

Pain involving little and ring finger, medial aspect of forearm

Weakness in finger flexion causing loss of grip strength or other fine motor activities

A

C8 radiculopathy

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79
Q

Uncinate process

A

Ridge of bone extending from superior lateral aspect of each cervical vertebra

Stabilises the spine and forms inferior medial wall of neural formanina

Enlargement can cause radiculopathy

Symptoms may be aggravated by neck extension

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80
Q

What clinical features differentiate cervical disc disease from spondylosis?

A

More than one cervical segment may be affected

Chronic and episodic in spondylosis rather than acute in cervical disc disease, thus more commonly associated with muscle atrophy and fasciculations

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81
Q

Features of thoracic disc disease

A

No typical clinical syndrome

Radicular pain may predominate in cases where there is lateral disc protrusion

Can cause cardiac like pain across the chest wall which does not cross the midline.

Can be confused for cardiac or GI disease

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82
Q

Acute persistent unilateral monoradiculopathy

Aggravated by sitting, sneezing or coughing, relieved by standing or bed rest

SLR positive

Motor/sensory deficit

L5/S1 distribution typically

A

?Lumbar disc disease

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83
Q

Paracentral disk herniation involves which nerve root

A

To the vertebra below the herniated disc

L4-5 paracentral disc contacts the L5 nerve root

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84
Q

Far lateral lumbar disc herniation affects which nerve root

A

Affects the exiting nerve root

i.e. L4/5 disc affects the L4 nerve

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85
Q

Chronic intermittent bilatearl posterior leg pain

Typically beginning in the buttocks and radiating downward in a non-radicular distribution, often burning, cramping or heavy feeling

Frequently associated with numbness or paraesrthesias

Pain precipitated by prolonged standing or walking (spinal extension) and relieved by forward bending, stiting or bed rest (flexion)

Reduced walking distances

Minimal or no back pain and motor or sphincteric dysfunction are late and inconsistent findings.

Negative SLR

A

Lumbar canal stenosis

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86
Q

Borders of lumbar lateral recess

A

Ventrally by posterior vertebral body

Laterally by pedicle

Dorsally by superior articular facet

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87
Q

Bilateral radicular pain associated with numbness and paraesthesias with mild or no low back pain

Tends to be worse on standing or walking

SLR negative

Neurologic findings are usually minimal though patients tend to have weakness or atrophy more often than those with central stenosis

A

Lateral recess stenosis

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88
Q

Mechanical low back pain aggravated by activity and improved with rest

May also produce radicular symptoms by traction or compression

Uncommon neurologic findings

A

Spondylolisthesis

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89
Q

Causes of spondylolisthesis

A

Degenerative

Isthmic

Traumatic

Dysplastic

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90
Q

Degenerative sponylolisthesis most commonly occrus

A

At L4/5

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91
Q

Traumatic and dysplastic spondylolisthesis most commonly involves which level

A

L5/S1

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92
Q

Def: Arachnoiditis

A

Chronic inflammatory condition affecting the meninges which occurs commonly at the lumbar spine

Can be secondary to surgery, myelography or introduction of other agents

Usually present with back pain and radicular leg pain

Aggravated by activity and not relieved by rest. Can be unilateral or bilateral symptoms.

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93
Q

Trauma

Radicular type pain with severe upper limb motor and sensory loss in a radicular distribution

Can be masked by associated brachial plexus injury

A

Cervical nerve root avulsion

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94
Q

Characteristic electrophysiological findings of nerve root avulsion

A

EMG and NCV used to differentiate from brachial plexus injury

Severe reduction or absence in compound motor action potentions, increase in pathological fibrillation potentials, completely normal sensory nerve action potentials

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95
Q

Why are there preserved SNAPs in cervical nerve root avulsion

A

Sensory root avulsion occurs proximal to DRG

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96
Q

Acute viral infection involving anterior horn cells

Presenting with myotomal weakness

Variable patterns of weakness- young children commonly have lower limb weakness, adults quadrapaaresis

A

?Polio

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97
Q

Why is isolated foot drop a relatively common finding in polio patients

A

Presence and extent of redundant innervation of a partiacular muscle e.g. quadriceps L2-4 is relatively spared whereas tibialis anterior L4 which is a single nerve root may present with more severe form of weakness

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98
Q

Why is complete resection of neurofibroma more difficult than Schwannoma

A

Nerve fibres are typically transversing the tumour whereas an schwannoma they are splayed over the fcapsule

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99
Q

Ascending weakness with lower extremities involved earlier.

Proximal and distal limb muscles equaly involved

Pain and myalgia

Progress to respiratory failiure

Autonomic dysregulation

A

GBS

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100
Q

T2DM

Painful paraesthesia of feet

Weakness atrophy typically of femoral or sciatic nervesS

Skin ulcers and loss of achilles reflex

Autonomic symptoms e.g. bladder dysfunction and hypotension

A

?Diabetic radiculopathy

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101
Q

Filum terminale

A

Caudal prolongation of the spinal pia mater that terminates on the dorsal surface of the coccyx

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102
Q

What are the main cell group of the dorsal horn

A

4:

Posteromarginal nucleus

Substantia gelatinosa

Nucleus proprious

Nucleus dosralis

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103
Q

Posteromarginal nucleus

A

Forms the cap of the dorsal horn

Many of the axons of the cells in this nucleus contribute to the spinothalamic tract

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104
Q

Substantia gelatinosa

A

Occupies most of the apex of the dorsal horn

Contains neurones and their processes as well as afferent fibres from te dirsal nerve eoot and descending fibres from supraspinal levels

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105
Q

Nucleus proprios

A

Anterior to substantia gelatinosa

Axons carried in the spinothalamic, spinocerebellar and propriospinal system

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106
Q

Nucleus dorsalis

A

Clark’es colum

Present in the base of the dorsal horn in segments C8-L3

Contains cell bodes whose axons form the dorsal spinocerebellar tract

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107
Q

Two cell groups of the intermediate gray

A

Intermediolateral cell group

Intermediomedial cell group

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108
Q

Intermediolateral cell group

A

Forms the lateral horn in segments T1-L2, gives rise to preganglionic sympathetic fibres

In segments S2-4 an equivalent column of cells projects preganglionic parasympathetic fibres

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109
Q

Intermediomedial cell group

A

Lies lateral to central canal throughout the length of the spinal cord

Receives visceral afferent fibres from the dorsal roots

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110
Q

Arrangement of fibres in the ventral horn

A

Somatotopically orientated in two ways

Neurones that innervate flexors are dorsal to extensors

Those that innervate te hand are lateral to the trunk

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111
Q

What are the two groups of neurones in the ventral horn

A

Medial group- axial musculature

Lateral- present only in cervical and lumbosacral enlargements- limb muscles

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112
Q

Lamina I II and V

A

Important in transmisison of information about pain

113
Q

Lamina VII

A

Contains nucleus odrsalis, intermediolateral cell columna nd sacral autonomic nucleus

114
Q

Lamina IX

A

Contains motor neurones that innervate extremities

In addition the phrenic nucleus, spinal accessory nucleus and Onuf’s nucleus (spincteric control)

115
Q

Divisions of white matter in spinal cord

A

Ventral, lateral and dorsal funiculi

Which contain ascending and descending fibre bundles that transmit signals within the SC and brain

116
Q

What are the asending tracts of the dorsal funiculi?

A

Fasciculus gracilisi

Fasciculus cuneatus

Mediate proprioception, vibration and discriminative touch

117
Q

At what level does the fasciculus cuneatus begin?

A

T6, below this there is only gracilis

118
Q

Somatotopic arrangement of the dorsal column

A

Legs are medial (gracilis), arms laterally (cuneatus)

GC

119
Q

What are the ascending tracts of the lateral funiculi

A

Posterior spinocerebellar tract

Anterior spinocerebellar tract

Lateral spinothalamic tract

Spinotectal tract

Posterolateral tract

Spinoreticular tract

Spino-olivary tract

120
Q

Anterior spinothalamic tract

A

Located anteromedial to the lateral spinothalamic tract, involved in light touch and pressure sensation

121
Q

Posterior spinocerebellar tract

A

Lateral funiculi

Occupies posterior part of the periphery

Conveys position, sense, touch and pressure to the cerebellum.

It ascends uncrossed in the spinal cord

122
Q

Anterior spinocerebellar tract

A

Lateral funiculi

Anterior part of the periphery

Majority of fibres are crossed

123
Q

Lateral spinothalmic stract

A

Lateral funiculi

Main ascending nerve mediating pain and temperature organisation

Somatotopically organised- arms central, legs laterally

Crossed in the spinal cord

124
Q

Spinotectal tract

A

Closely associated with the lateral and anterior spinothalamic tract

Conveys information to the superior colliculus

Unknown functional significance

125
Q

Posterolateral tract

A

Lateral funiculus

AKA Lissaue’rs tract

Caps the dorsal gray horn

Carries fibres from the dorsal nerve root and getaltinosa cells that interconnect different levels of the substantia gelatinosa.

126
Q

Spinoreticular tract

A

Lateral funiculus

Travels in association with lateral spinothalamic tract

Conveys information related to behavioural awareness

127
Q

Spino-olivary tract

A

Lateral funiculus

Lies anterior to the anterior spinocerebellar tract, conveys sesnosry information to the cerebellum

128
Q

What are the descending tracts of the ventral funciuli

A

Anterior corticospinal tract

Vestibulospinal tract

Tectospinal tract

Scattered reticulospinal fibres

129
Q

What are the descending tracts in the lateral funiculi

A

Lateral corticospinal tract

Rubrospinal tract

Descending autonomic fibres

Reticulospinal fibres

130
Q

Anterior corticospinal tract

A

Ventral funiculi

Present only in cervical and upper thoracic segments

Lies adjacent to the median fissure

Voluntary movement

131
Q

Vestibulospinal tract

A

Descending tract, ventral funiculi

Occupies periphery of anterior funiculi

Descends uncrossed in the spinal cord

Facilitates extensor tone of muscles and maintains tone in antigravity muscles

132
Q

Tectospinal tract

A

Between anterior corticospinal tract and vestibulospinal tract

Cross in the dorsal segmentation and are only present in the cervical levlels.

Thought to be involved in reflex postural movements in response to visual/auditory stimuli

133
Q

Lateral corticospinal tract

A

Lateral funiculi

Lateral to dorsal gray horn and medial to spinocerebellar tract

Mediates impulses concerned with voluntary movement, particularly fine motore movement

Somatotopic orientation, medial arms, lateral legs.

134
Q

Rubrospinal tract

A

Lateral funiculi

Anterior to lateral corticospinal tract

Facilitates flexor muscle tone

135
Q

Descending autonomic fibres

A

Lateral funiculi

Carry impulses associated with control of smooth muscle, cardiac muscle, glands and body visecera

136
Q

Which regions of the spinal cord are distinguished by relative richness of arterial supply

A

Cervicothoracic C1-T2

Thoracolumbar T9-conus which receives radicular artery of Adamkiewicz

137
Q

Most common location of entry for great radicular atery of Adamkiewicz

A

75% enters the SC at T9-L2 segment from the left

138
Q

Quadriplegia

IMpaired bowel and bladder control

Loss of pain and temperature sensation

Sparing of proprioception

A

Anterior spinal artery syndrome

139
Q

Anterior spinl artery syndrome

A

Quadriplegia (corticospinal tract)

IMpaired bowel and bladder control (corticospinal)

Loss of pain and temperature sensation (lateral spinothalamic)

Sparing of proprioception (preservation of dorsal column

140
Q

What is the most common vascular syndrome of the SC/

A

Anterior spinal artery occlusion

141
Q

Posterior spinal artery syndrome

A

Loss of poisition, vibratory and light touch sensation below level of lesion

Preservation of motor, pain and temperature modalities

142
Q

Loss of poisition, vibratory and light touch sensation below level of lesion

Preservation of motor, pain and temperature modalities

A

Posterior spinal artery syndrome

143
Q

Categorisation of spinal tumours

A

Extradural extramedullary tumours

Intradural extramedullary tumours

Intramedullary tumours

144
Q

Clinical features of extramedullary tumours

A

Radicular pain

Tender to palpation

Loss of pain and temperature sensation

Spastic paraparesis

Little or no muscle atrophy

Muscle fasciculations common

Trophic skin disturbance absent

Bowel and bladder distrubance late

145
Q

Spinal tumour- intra or extramedullary

Radicular pain

Tender to palpation

Loss of pain and temperature sensation

Spastic paraparesis

Little or no muscle atrophy

Muscle fasciculations common

Trophic skin disturbance absent

Bowel and bladder distrubance late

A

Extramedullary

146
Q

Clinical features of intramedullary tumours

A

Dysesthesia and paraesthesia common

Dissociated sensory loss with sacral sparing

Paraparesis is only spastic in 50%

Muscle atrophy common

Muscle fasciculations rare

Trophic skin disturbance common

Bowel and bladder distrubance early

147
Q

Respiratory disturbance and spinal cord

A

C3-5 lesions may involve phrenic nucleus resulting in diaphragmatic paralysis-> respiratory compromise

148
Q

Cardiovascular disturbance and spinal cord

A

Upper cervial SC lesions may be associated with bradycardia due to nterruprtion of ascendin fibres to the medulla with hypotension 2o to descending sympathetic disruption

149
Q

Describe passage of sympathetic fibres

A

Originate in hypothalamus-> intermediolateral gray matter of the C8-T2 spinal segments (1o)

Subsequent fibres are projected to the superior cervical ganglion (2o)

Finally from superior cervical ganglion to the superior tarsal, dilator pupillae and swet glands of face

150
Q

Horner’s

A

Partial ptosis (denervation of superior tarsal muscle)

Enophthalmos

Miosis (denervation of dilator pupillae)

Anhydrosis (denervation of sweat glands of face)

151
Q

What are the muscle groups mediating bladder function

A

Detrusor muscle

External sphincter

152
Q

Detrusor muscle

A

Spiral, longitudinal and circular smooth musle bundles that surround the body of the bladder wall.

Contraction results in micturition

153
Q

EUS

A

Skeletal muscle bundle that occurs on the distal segment of the urethra

Reflexive relaxation is coordinated with contraction of detrusor muscle during icturition.

VOluntary contaction stops micturition

154
Q

IUS

A

Extnesion of detrusor that consists of longitudinal muscles which incompletely surround the proximal urethra

Limited role in micturition, primary function is to prevent retrograde ejaculation

155
Q

Main innervation of bladder

A

PNS

Cerebrospinopudendal pathway (voluntary control of EUS)

Sensory afferents carried in pelvic splanchnic and pudendal nerves which ascend in the lateral spinothalamic and dosral column tracts, relay in the reticular formation and terminate in the paracetntral lobule of the frontal lobe

Paracentral lobule in turn exerts voluntary control on the EUS via corticospinal efferents

SNS

156
Q

What are the 5 syndromes of bladder disturbance

A

Uninhibited bladder

Reflex bladder

Autonomous bladder

Motor paralytic bladder

Sensory paralytic bladder

157
Q

Uninhibited bladder

A

Interruption of supraspinal control

Disorder charactersised by susdden uncontrollable evaucation of urine due to a lack of supraspinal inhibition

Normal bladder tone

Normal bladder capacity

Micturition occurs precipitously at low bladder volumes (detrusor hyperreflexia)

Usually complete micturition with no residual

Intact bladder sensation

Frontal lobe tumours, parasagittal meningiomas, ACA aneurysms, NPH

158
Q

Normal bladder tone

Normal bladder capacity

Micturition occurs precipitously at low bladder volumes (detrusor hyperreflexia)

Usually complete micturition with no residual

Intact bladder sensation

A

Uninhibited bladder

Distruption of suprapsinal control e.g. NPH

159
Q

Reflex bladder

A

In spinal cord lesions above the S1 segment, bladder function is mediated solely by a reflex arc

Increased bladder tone

Reduced bladder capacity

If incomplete lesion, there is urgency with little filling though urgency absence if lesion complete, in which case a rise in intravesical pressure may be manifest by pallor, flexor spasms, hypertension (autonomic dysreflexia)

Retention-> overflow incontinence-> Automaticity

Small post-void residual

Interrupted bladder sensation

e.g. MS, SCI, tumour

160
Q

Increased bladder tone

Reduced bladder capacity

Retention-> overflow incontinence-> Automaticity

Small post-void residual

Interrupted bladder sensation

A

Reflex bladder

Lesion above S1

e.g. SCI

161
Q

Autonomous bladder

A

In lesions involving sacral level there is denervation of both afferent and efferent supply to bladder

Overflow incontinence

Flaccid tone

Absen t urgency

Increased capacity

Increaesd PVR

Absent sensation

High risk of infection

e.g. CES

162
Q

Overflow incontinence

Flaccid tone

Absen t urgency

Increased capacity

Increased PVR

Absent sensation

High risk of infection

e.g. CES

A

Autonomous bladder

In lesions involving sacral level there is denervation of both afferent and efferent supply to bladder

163
Q

Motor paralytic bladder

A

Lesions involving efferent motor fibres to detrusor in the sacral spinal cord

Produce a paralysed bladder with intact sensation

Flaccid bladder tone

Urgency present

Painful urinary retention or impaired emptying

Increased bladder capacity and PVR

Infection risk high

164
Q

Produce a paralysed bladder with intact sensation

Flaccid bladder tone

Urgency present

Painful urinary retention or impaired emptying

Increased bladder capacity and PVR

Infection risk high

A

Motor paralytic bladder

165
Q

Sensory paralytic bladder

A

With lesions involving afferent pathways, voluntary micturition is possible but bladder sensation is impaired.

Urinary retention or overflow incontinence results.

Infection risk is high

E.g. tabes dosralis, DM

166
Q

Innervation of rectum

A

PNS- S3-5 responsible for reciprocal contaction of rectal muscles and relaxation of IAS.

Afferent fibres also carried in PNS

SNS inhibits rectal emptying

Voluntary control is via somatic efferents from the paracetnral lobule which descend in the corticospinal tract. Synapse on ventral horn cells in segments T6-12 which in turn innervate abdominal muscles used in emptying rectum

167
Q

Anatomical disturbances of rectal function

A

Lesions above sacral level

Conus and cauda lesions

168
Q

Rectal dysfunction

Lesions above sacral level

A

Loss of voluntary control and loss of sensation of rectal fullness

Faecal retention

Reflexive contraction of the sphincter usually persists causing sphincter spasticity.

High spinal lesions tend to produce less severe sphincter dysfunction compared with lower level lesions

169
Q

Rectal dysfunction

Conus and cauda lesions

A

Lesions involving S3-4 produce sphincter muscle paralysis-> incontinence

170
Q

Describe the innervation of erection

A

PNS

Supplies corpus cavernosum via pelvic splanchnic nerves

171
Q

Consequence of complete lesion of S2-4 on erection

A

Complete lesion resultsin loss of reflex erection though psychogenic erection may still be possible.

This is due to hypothalamic impulses that are partially sympathetically mediated.

Psychogenic erections are abolished by lesions above T12

172
Q

Consequence of spinal lesion above T12 on erection

A

Loss of psychogenic erection (sympathetically mediated)

Refelex erection preserved

173
Q

Describe the biomechanics of erection

A

PNS facilitates erections by causing relaxation of the muscular cushions within the lumina of the cavernosus arteries, which nor ally obstruct the inflow of blood

174
Q

How do spinal cord lesions cause pripaism

A

Abnormal persistent erection thought to be due to PNS induced vasodilation and is seen in lesions that occur above the lower thoracic levels.

Tonic contraction of the transverse perineal, bulbocavernousus and ischiocavernosus muscles probably also contribute by preventing escape of venous blood

175
Q

Describe the reflex arc of ejaculation

A

Two part process- propulsion of semen into urethra (emission) and ejaculation proper

Afferent limb- dorsal nerve of penis to the S3-4 segments via pudendal nerve

Efferent from S3-4 -> 2 spinal centres, the sympathetic centre (T6-L3) which projects efferenet fibres in the pelvic plexus and the superior hypogastric plexus. Sympathetic ganglion at L2 is particularly important in this.

The second is the somatomotor centre that projects its efferent fibres in the pudendal nerve.

176
Q

Impact of spinal lesions on ejaculation

A

Lesions abve T6 may abolish normal ejaculation though ejaculatory reflex activity may be preserved

In lesions involving S3-5, ejaculation does not occur

177
Q

Pattern of weaknss with foramen magnum lesions

A

Suboccipital neck pain

Dysaesthesia of the extremities (UE>LE)

Gait disturbance

Weakness (UE>LE)

Weakness may involve arm, then the ipsilateral leg, then contralateral leg “around the clock” pattern

Other early symptoms- clumsiness of the hands, bladder disturbance, dysphagia, nausea and vomiting, drop attacks, dizziness.

Wasting of intrinsic hand muscles

Downbeat nystagmus

178
Q

Suboccipital neck pain

Dysaesthesia of the extremities (UE>LE)

Gait disturbance

Weakness (UE>LE)

Weakness may involve arm, then the ipsilateral leg, then contralateral leg “around the clock” pattern

Other early symptoms- clumsiness of the hands, bladder disturbance, dysphagia, nausea and vomiting, drop attacks, dizziness.

Wasting of intrinsic hand muscles

Downbeat nystagmus

A

Foramen magnum lesion

179
Q

Round the clock weakness

A

Foramen magnum

180
Q

What may cause wasting of intrinsic hand mucles in foramen magnum lesions

A

?Venous obstruction in upper SC that leads to venous infarction in lower cervical gray matter

181
Q

C3 lesion

A

Motor-

Quadriplegia

Sensory:

Abolished below base of neck

Reflexes:

In acute phase all absent then they may return and become hyperreflexic

Respiratory failure

182
Q

Motor-

Quadriplegia

Sensory:

Abolished below the base of neck

Reflexes:

In acute phase all absent then they may return and become hyperreflexic

Respiratory failure

A

C3 lesion

183
Q

C4 lesion

A

Motor-

Quadriplegia

Sensory:

Present in upper anterior chest wall

Reflexes:

In acute phase all absent then they may return and become hyperreflexic

Respiratory function may be partially preserved, though paralysis of the intercostal muscles and abdominal muscles hampers spontaneous respiration

184
Q

Motor-

Quadriplegia

Sensory:

Present in upper anterior chest wall

Reflexes:

In acute phase all absent then they may return and become hyperreflexic

Respiratory function may be partially preserved, though paralysis of the intercostal muscles and abdominal muscles hampers spontaneous respiration

A

C4 lesion

185
Q

C5 lesion

A

Motor:
Preserved shoulder abduction, may be some flexion of elbow

Sensory:

Preserved in upper anterior chest and lateral aspect of arm above the elbow

Reflexes:

Biceps is normal or slightly decreased

Repsiratory reserve is compromised

186
Q

Motor:
Preserved shoulder abduction, may be some flexion of elbow

Sensory:

Preserved in upper anterior chest and lateral aspect of arm above the elbow

Reflexes:

Biceps is normal or slightly decreased

Repsiratory reserve is compromised

A

C5 lesion

187
Q

C6 lesion

A

Motor:

Shoulder abduction, elbow flexion, wrist extension present

Sensory:

Normal in the lateral UE including thumb, index finger and half of middle finger

Reflexes:

Biceps and brachioradialis normal

Respiratory reserve is low

188
Q

Motor:

Shoulder abduciton, elbow flexion, wrist extension present

Sensory:

Normal in the lateral UE including thumb, index finger and half of middle finger

Reflexes:

Biceps and brachioradialis normal

Respiratory reserve is low

A

C6 lesion

189
Q

C7 lesion

A

Motor:

Triceps, wrist flexors, long finger extensors functional

Sensation:
Preserved in lateral aspect of UE

Reflexes:

Biceps, BR, triceps are normal

Respiratory reserve is low

190
Q

Motor:

Triceps, wrist flexors, long finger extensors functional

Sensation:
Preserved in lateral aspect of UE

Reflexes:

Biceps, BR, triceps are normal

Respiratory reserve is low

A

C7 lesion

191
Q

C8 lesion

A

Motor:

UE motor function normal except finger abduction

Sensory:

Preserved up to medial forearm

Reflexes:

Normal in UE

192
Q

Motor:

UE motor function normal except finger abduction

Sensory:

Preserved up to medial forearm

Reflexes:

Normal in UE

A

C8 (C8 spared)

193
Q

T1 lesion

A

Motor:

UE normal, patient paraplegic

Reflexes:

Normal in UE

Sensory:

Normal in the upper anterior chest and entire upper extremity except for the medial aspect of the most proximal part of the arm

194
Q

Motor:

UE normal, patient paraplegic

Reflexes:

Normal in UE

Sensory:

Normal in the upper anterior chest and entire upper extremity except for the medial aspect of the most proximal part of the arm

A

T1 lesion (T1 spared)

195
Q

T2-T12 spinal levels

A

Motor:

Paraplegic, Beevor’s sign which is present when the umbilicus is pulled away from its normal location as te patient sits up

Sensory:

Level of the lesion determines the level of intact sensation

Reflex:

UE refelexes normal, LE may be absent or hyper-reflexic

196
Q

Motor:

Paraplegic, Beevor’s sign which is present when the umbilicus is pulled away from its normal location as te patient sits up

Sensory:

Level of the lesion determines the level of intact sensation

Reflex:

UE refelexes normal, LE may be absent or hyper-reflexic

A

T12 lesion

197
Q

L1 lesion

A

Motor:

Paraplegic excpet for some hip flexion due to partial innervation of ilipsoas

Sensation:

Present on the most proximal portion of anterior thigh

Reflex:

Patella and ankle reflexes absent initially, later they may become increased

Bowel and bladder:

Bladder function absent

Anal sphincter tone decreased with absence of superifical anal reflex

With time anal tone returns

198
Q

Motor:

Paraplegic excpet for some hip flexion due to partial innervation of ilipsoas

Sensation:

Present on the most proximal portion of anterior thigh

Reflex:

Patella and ankle reflexes absent initially, later they may become increased

Bowel and bladder:

Bladder function absent

Anal sphincter tone decreased with absence of superifical anal reflex

With time anal tone returns

A

L1 lesion

199
Q

L2 lesions

A

Motor:

Hip flexion present though diminished

Adductors partially funcional

Flexion and adduction deformity may be present

Sensory:

Absent from point halfway between hip and knee

Reflexes:

None

Bowel and bladder:

Voluntary control is absent

200
Q

Motor:

Hip flexion present though diminished

Adductors partially funcional

Flexion and adduction deformity may be present

Sensory:

Absent from point halfway between hip and knee

Reflexes:

None

Bowel and bladder:

Voluntary control is absent

A

L2

201
Q

L3 lesion

A

Motor:

Iliopsoas, adductors and quadriceps all show signficiant power

Reflexes:

Patellar present, Achilles absent

Sensory:

Absent below the knee

Bladder/bowel:

No voluntary control

202
Q

Motor:

Iliopsoas, adductors and quadriceps all show signficiant power

Reflexes:

Patellar present, ahilles absent

Sensory:

Absent below the knee

Bladder/bowel:

No voliuntary contorl

A

L3 lesions

203
Q

L4 lesion

A

Motor:

Quadriceps normal, ankle dorsiflexion is the only functional muscle below the knee

Sensory:

Normal along the medial aspect of lower limb

Reflex:

Patellar present, achilles absent

Bowel and bladder:

Voluntary control still absent

204
Q

L5 lesion

A

Motor:

Hip assumes flexed posture as gluteus maximus not functional, adduction resisted by partial innervation of the gluteus medius

Foot inversion and dorsiflexion present

EHL present

Sensation:

Normal except plantar aspects of foot

Reflexes:

Patellar normal, Achilles absent

Voluntary control of bowel and bladder is absent

205
Q

Motor:

Hip assumes flexed posture as gluteus maximus not functional, adduction resisted by partial innervation of the gluteus medius

Foot inversion and dorsiflexion present

EHL present

Sensation:

Normal except plantar aspects of foot

Reflexes:

Patellar normal, Achilles absent

Voluntary control of bowel and bladder is absent

A

L5

206
Q

Motor:

Quadriceps normal, ankle dorsiflexion is the only functional muscle below the knee

Sensory:

Normal along the medial aspect of lower limb

Reflex:

Patellar present, achilles absent

Bowel and bladder:

Voluntary control still absent

A

L4 lesion

207
Q

S1 lesion

A

Motor:

Normal except intrinsic muscles of foot- toe defomrity

Reflexes

Normal in lower limb

Sensation in LE normal but saddle anaesthesia persists

Loss of normal bowel and bladder function

208
Q

Motor:

Normal except intrinsic muscles of foot- toe defomrity

Reflexes

Normal in lower limb

Sensation in LE normal but saddle anaesthesia persists

Loss of normal bowel and bladder function

A

S1 lesion

209
Q

Difference between conus and cauda lesions

A

Conus pain tends to occur late

Sphincter disturbance early

Saddle anaesthesia is symmetrical and motor disturbacnes in LE are absent

210
Q

Conus medullaris syndrome

A

Autonomous bladder

Faecal incontinence

Impotence

Saddle anaesthesia

Absence of corticospinal tract or LE weakness

211
Q

Autonomous bladder

Faecal incontinence

Impotence

Saddle anaesthesia

Absence of corticospinal tract or LE weakness

A

Conus medullaris

212
Q

Radicular pain

Autonomous bladder

Impotence

Asymmetric saddle anaesthesia

Flaccid paraplegia

Absent deep tendon reflexes

A

CES

213
Q

CES

A

Radicular pain

Autonomous bladder

Impotence

Asymmetric saddle anaesthesia

Flaccid paraplegia

Absent deep tendon reflexes

214
Q

Four cardinal manifestations of SC lesiosn

A

Spastic para/quadriparesis

Bowel and bladder dysfunction

Sensory level

Features of UMN lesion

215
Q

Def: sensory level

A

Dermatome below which no sensation is felt

216
Q

What are the signs of sacral sparing

A

Flexion of S1 intact

Anal sphincter intact

Intact perianal sensation

217
Q

Transverse myelopathy

A

Motor- LMN at level of lesion, UMN below

Sensory: sensory level

218
Q

Why might the sensory level appear lower than the actual level of the lesion

A

In the lateral spinothalamic tract, lower spinal segments are represented more superficially

Clinical evidence of segmental pain or paraesthesias may identify lesion more precisely.

219
Q

Autonomic signs seen in transverse myelopathy

A

Dependent on level;

Respiratory compromise

Hypotension, bradycardia

Horner syndrome

Bowerl or bladder impairment

Sexual dysfunction

220
Q

Brown-Sequard Syndreome

A

Due to hemisection of the SC usually due to penetrating spinal injury

Ipsilateral loss of position and vibration sense below level of inury

Contralateral loss of temperature/pain sensation

Ipsilateral spastic parapareiss

+/- UMN signs at level of lesion

221
Q

Ipsilateral loss of position and vibration sense below the level of injury

Contralateral loss of temperature/pain sensation

Ipsilateral spastic paraparesis

A

Brown-Sequard

222
Q

Anterior SCI syndrome

A

Spastic quadraparesis

Loss of pain and temperature sensation below level of lesion

Preservation of position and vibration sense

223
Q

Spastic quadraparesis

Loss of pain and temperature sensation below level of lesion

Preservation of position and vibration sense

A

Anterior SCI syndrome

224
Q

Central cord syndrome

A

Weakness in UE>LE which is more severe distally than proximally

Explained by somatotopy of the CTS

Semsory loss is variable but tends to disproprotionally involve the UE.

225
Q

Weakness in UE>LE which is more severe distally than proximally

Explained by somatotopy of the CTS

Semsory loss is variable but tends to disproprotionally involve the UE.

A

Central cord syndrome

226
Q

Anterior horn cell syndrome

A

Selective destruction of anterior horn cells e.g. poliomyositis or progressive spinal muscular atrophy

Flaccid paralysis of muscles at the level with LMN signs

Intact sensation

227
Q

Flaccid paralysis of muscles at the level with LMN signs

Intact sensation

A

Anterior horn cell syndrome

228
Q

Central cord lesions

A

Suspended sensory level- decussating fibres of the spinothalamic tract which in cervical levels results in shawl distribution

Asymmetric involvement of centrally located fibres in the corticospinal tract may result in ipsilateral spastic monoparesis.

Flaccid paralysis at the level of the lesion may occur due to involvement of anterior horn cells.

Dorsal columns frequently spared

229
Q

Suspended sensory level- decussating fibres of the spinothalamic tract which in cervical levels results in shawl distribution

Asymmetric involvement of centrally located fibres in the corticospinal tract may result in ipsilateral spastic monoparesis.

Flaccid paralysis at level of lesion may occur due to involvement of anterior horn cels.

Dorsal columns frequently spared

A

Central cord lesions

230
Q

Amyotrophic lateral sclerosis

A

Degenration of lateral corticospinal tracts and anterior horn cells

Flaccid paralysis at level of lesion

Spastic paralysis below level of lesion

Tongue atrophy and weakness

Initially may be focal or unilateral but spreads to involve both sides +/- bulbar musculature

231
Q

Flaccid paralysis at level of lesion

Spastic paralysis below level of lesion

Tongue atrophy and weakness

Initially may be focal or unilateral but spreads to involve both sides +/- bulbar musculature

A

ALS

232
Q

What differentiates between ALS and cervical spondylotic myelopathy?

A

Cervical spondylotic myelopath may also have mixture of UMN and LMN signs but in ALS there is no sensory component

233
Q

Tabes dorsalis

A

Neurological sequelae of neurosyphilis, typically developing 10-20y post infection

Selective destruction of dorsal columns

Loss of proprioception and vibration sensation below level- gait ataxia, Rombeg’s and reduced patellar and achilles tendon reflexes

Urinary incontinence

Lancinating pain in the LE

234
Q

Clinical features of Friedreich’s ataxia

A

Degeneration in 3 tracts

Corticospinal, dorsal column and spinocerebellar

Loss of position and vibration sensation, Romberg’s sign

Ataxia

Spastic paraparesis

Pes cavus and spinal kyphosis may also be found

235
Q

B12 deficiency

Loss of position and vibration sense

Spastic paraparesis

A

SACD

236
Q
A
237
Q

Lesion of the anterior horn of SC

A

Purely LMN

238
Q

Purely LMN affecting ventral horn of SC, found in infants

A

Progressive infantile muscular atrophy (Werdnig-Hoffman disorder)

239
Q

Juvenile hereditary LMN disease

A

Disease affecting ventral horns of SC

(Kugelburg Wilender disease)

240
Q

Hereditary spastic paraplegia/diplegia

A

Hereditary lesion of UMN causing bilateral spastic paresis with UMN signs.

241
Q

Where do pain and temperature first order afferents synapse in the spinal cord?

A

Ascend through dorsolateral tract of Lissauer to ascend or decsend one to three spinal levels from their level of entry and synapse in either:

substantia gelatinosa

posteromarginal nucleus

nucleus proprius

242
Q

Spinal lemniscus

A

Lateral spinothalamic tract in the brainstem

Gives off collateral branches to the reticular formation at several levels of the brainstem

243
Q

Somatotopy of lateral spinothalamic tract

A

Hand medial to legs and sacrum

244
Q

Through which portion of the internal capsule do ascending thalamocortical fibres from VPL pass?

A

Posterior limb

245
Q

What is unique about trigeminal proprioceptive fibres?

A

Cell bodies of axons carrying proprioceptive information are located within the brainstem (mesencephalic nucleus) rather than in a peripheral ganglion

246
Q

Ventral trigeminothalamic tract

A

Carries crossed second-order spinothalamic input from spinal trigeminal nucleus to VPM of thalamus

247
Q

Dorsal trigeminothalamic tract

A

Second-order crossed and uncrossed fibres from the main sensory nucleus ascend to the VPM of the thalamus

248
Q

Astereognosis

A

Inability to identify common object when held in hand while eyes are closed

249
Q

Agraphaesthesia

A

Inability to recognise letters or numbers drawn on the hand

250
Q
A
251
Q
A
252
Q
A
253
Q

What are the three tubercles on the TP of the lumbar spine

A

Lateral cosiform process

Superior mamillary process

Accessory process

254
Q

Which muscle attaches to the mammillary process?

A

Multifidus

255
Q
A
256
Q

Intrinisc ligaments of the CCJ

A

Odontoid ligmaents:

Apical- dens to basion

Alar- dens to occipital condyls and bone bilaterally

Cruciform ligament:

Transverse ligament

Superior crus

INferior crus

Tectorial membrane

257
Q

Tectorial ligament is a continuation of what/

A

PLL

Runs from C2 to anterior margin of FM

258
Q

Extrinsic ligaments of the CCJ

A

Anterior atlanto-occipital ligament (continuation of ALL)

Posterior atlanto-occipital ligament (continuation of flavum)

Ligamentum nuchae (continuation of supraspinous)

Interspinous ligaments

259
Q
A
260
Q
A
261
Q
A
262
Q
A
263
Q

Function of tectorial membrane

A

Stabilises Atlanto-axial joint

Restricts extension, flexion and vertical translation

264
Q

Function of alar ligaments

A

Stabilises atlanto-axial joint

Limits excessive rotation, lateral flexion

265
Q

Function of the transverse ligament

A

Stabilises atlantoaxial joint, limits anterior atlas motion

Allows axial rotation

266
Q

Attachment point of transverse ligament

A

Colliculus atlantis

267
Q
A

Rectus capitis anterior

268
Q
A
269
Q
A

Longus capitis

270
Q

Borders of lateral recess

A

Anterior: Posterolateral suraface of vertebral body and PLL

Posteriorly: Superior articular facet and overlying ligamentum flavum

Laterally: Pedicle

271
Q
A
272
Q

What attaches to anterior tubercle of C1?

A

Longus coli

273
Q

What attaches to the posterior tubercle of C1?

A

Posterior atlanto-occipital membrane

274
Q

Where does the dens articulate on C1?

A

In the fovea dentis

275
Q

Where does the vertebral artery run on C1?

A

Sulcus arteriae vertebralis

276
Q

What muscles attach to the transverse process of C1?

A

Superior obliques to occipit
Levator scapulae
Splenius cervicis
Scalenus medius
Inferior oblique

277
Q

What is the main stabiliser at C1/2

A

Transverse ligament

278
Q

Artery of von Haller

A

Upper thoracic anterior radiculomedullary artery
Seen in up to 85% of patients
left sided around T5

279
Q

Desproges-Gotteron artery

A

The cone artery, also known as the artery of Desproges-Gotteron, is a rare anatomical variant which commonly arises from the internal iliac artery.

NSx Neuroanatomy (25 decks)

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