Day 31 – Limb Bud

Day 33 – Hand Paddle

Day 36 – Chondrification

Day 54 – Finger separated

Day 54 – Ossification begin

http://discovery.lifemapsc.com/library/review-of-medical-embryology/chapter-164-the-autonomic-
nervous-system-the-sympathetic-system

Damage to upper motor neuron axons in the spinal cord results in a characteristic pattern of
ipsilateral deficits. These include hyperreflexia, hypertonia and muscle weakness. Lower
motor neuronal damage results in its own characteristic pattern of deficits. Rather than an
entire side of deficits, there is a pattern relating to the myotome affected by the damage.
Additionally, lower motor neurons are characterized by muscle weakness, hypotonia,
hyporeflexia and muscle atrophy.

Spinal shock and neurogenic shock can occur from a spinal injury. Spinal shock is usually
temporary, lasting only for 24–48 hours, and is a temporary absence of sensory and motor
functions. Neurogenic shock lasts for weeks and can lead to a loss of muscle tone due to
disuse of the muscles below the injured site.

Nerve irritation in the cervical spine

 Neck pain, or tingling, numbness

 Shoulder pain, or tingling, numbness
 Arm pain, or tingling, numbness

Nerve irritation in the thoracic spine

  Upper back pain
 Pain along the ribs to the chest wall
 Pain in the abdomen (rarely)

Nerve irritation in the lumbar spine

 Low back pain

 Hip pain
 Buttock pain
 Leg pain, or numbness, tingling
Paraplegia is an impairment in motor or sensory function of the lower extremities

Tetraplegia, also known as quadriplegia, is paralysis caused by illness or injury to a human that
results in the partial or total loss of use of all their limbs and torso; paraplegia is similar but does not
affect the arms

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Herniated nucleus pulposus is prolapse of an intervertebral disk through a tear in the

surrounding annulus fibrosus. The tear causes pain; when the disk impinges on an adjacent
nerve root, a segmental radiculopathy with paresthesias and weakness in the distribution of
the affected root results. Diagnosis is usually by MRI or CT. Treatment of mild cases is with
analgesics as needed. Bed rest is rarely indicated. Patients with progressive or severe
neurologic deficits, intractable pain, or sphincter dysfunction may require immediate or
elective surgery (eg, diskectomy, laminectomy).

Spinal vertebrae are separated by cartilaginous disks consisting of an outer annulus fibrosus
and an inner nucleus pulposus. When degenerative changes (with or without trauma) result in
protrusion or rupture of the nucleus through the annulus fibrosus in the lumbosacral or
cervical area, the nucleus is displaced posterolaterally or posteriorly into the extradural space.
Radiculopathy (see Nerve Root Disorders) occurs when the herniated nucleus compresses or
irritates the nerve root. Posterior protrusion may compress the cord or cauda equina,
especially in a congenitally narrow spinal canal (spinal stenosis). In the lumbar area, > 80%
of disk ruptures affect L5 or S1 nerve roots; in the cervical area, C6 and C7 are most
commonly affected. Herniated disks are common.

Symptoms and Signs

Herniated disks often cause no symptoms, or they may cause symptoms and signs in the
distribution of affected nerve roots. Pain usually develops suddenly, and back pain is
typically relieved by bed rest. In contrast, nerve root pain caused by an epidural tumor or
abscess begins more insidiously, and back pain is worsened by bed rest.

In patients with lumbosacral herniation, straight-leg raises stretch the lower lumbar roots and
exacerbate back or leg pain (bilateral if disk herniation is central); straightening the knee
while sitting also causes pain.

Cervical herniation causes pain during neck flexion or tilting. Cervical cord compression, if
chronic, manifests with spastic paresis of the lower limbs and, if acute, causes quadriparesis.

Cauda equina compression often results in urine retention or incontinence due to loss of
sphincter function.

Diagnosis

 MRI or CT

MRI or CT can identify the cause and precise level of the lesion. Rarely (ie, when MRI is
contraindicated and CT is inconclusive), CT myelography is necessary. Electrodiagnostic
testing may help identify the involved root. Because an asymptomatic herniated disk is
common, the clinician must carefully correlate symptoms with MRI abnormalities before
invasive procedures are considered.

Repeated eccentric and torsional loading and recurrent microtrauma result in circumferential and
radial tears in the annular fibers. Some annular tears may cause endplate separation, which results
in additional loss of nuclear nutrition and hydration. The coalescence of circumferential tears into
radial tears may allow nuclear material to migrate out of the annular containment into the epidural
space and cause nerve root compression or irritation.

PATOFISIOLOGI
Suatu HNP pada umumnya didahului dengan terjdinya proses degenarasi pada diskus. Robekan
sirkumferensial dapat meluas menjadi robekan radial pada annulus dan hal ini merupakan penyebab
dari gangguan pada annulus secara internal untuk menjadi suatu herniasi. Dalam wadah protrusi
 diskus yang masih utuh serabut annulus masih intak. Pada herniasi diskus yang sudah tidak utuh
serabut annulus terpecah, material dari diskus dapat terpecah menjadi fragmen yang bebas.

Suatu tekanan yang mengenai diskus intervertebralis memungkinkan akan mengakibatkan terjadinya
dislokasi atau rupture. Penonjolan diskus pada daerah lumbal sering terjadi pada bagian posterior-
lateral, hal ini disebabkan karena :
a. Tekanan pada annulus fobrosus yang mengalami degenarasi dapat menyebabkan keluarnya
nucleus dipicu dengan mengangkat barang beat dalam posisi punggung fleksi dimana tekanan
terbesar mengenai aspek postero-lateral dari annulus fibrosus.
b. Annulus bagian posterior bentuknya lebih kecil. Ligamentum longitudinalis posterior, semaakin
menyempit pada daerah lumbosakral sehingga pertahanan lebih lemah.

Dislokasi atau rupture dari diskus tersebut paling sering terjadi pada daerah vertebra lumbalis L5-S1,
berikutnya L4-L5 disusul berikutnya cervikalis C5-C6. Pada vertebra cervikalis daerah vertebra
Cervikalis C4-C5 adalah paling mobil dan aktif. Gerakan fleksi terbesar dilakukan oleh vertebra
cervikalis C4-C5 dan C5-C6 sehingga pada daerah ini sering terjadi robekan dan proses degenaratif.

PATOFISIOLOGI

Protrusi atau ruptur nukleus pulposus biasanya didahului dengan

perubahan degeneratif yang terjadi pada proses penuaan. Kehilangan protein
polisakarida dalam diskus menurunkan kandungan air nukleus pulposus.
Perkembangan pecahan yang menyebar di anulus melemahkan pertahanan pada
herniasi nukleus. Setelah trauma (jatuh, kecelakaan, dan stress minor berulang
seperti mengangkat) kartilago dapat cedera.
Pada kebanyakan pasien, gejala trauma segera bersifat khas dan singkat,
dan gejala ini disebabkan oleh cedera pada diskus yang tidak terlihat selama
beberapa bulan maupun tahun. Kemudian pada degenerasi pada diskus, kapsulnya
mendorong ke arah medula spinalis atau mungkin ruptur dan memungkinkan
nukleus pulposus terdorong terhadap sakus dural atau terhadap saraf spinal saat
muncul dari kolumna spinal.
Hernia nukleus pulposus ke kanalis vertebralis berarti bahwa nukleus
pulposus menekan pada radiks yang bersama-sama dengan arteria radikularis
berada dalam bungkusan dura. Hal ini terjadi kalau tempat herniasi di sisi lateral.
Bilamana tempat herniasinya ditengah-tengah tidak ada radiks yang terkena.
Lagipula pada tingkat L2 dan terus kebawah sudah tidak terdapat medula spinalis
lagi, maka herniasi di garis tengah tidak akan menimbulkan kompresi pada kolumna
anterior.
Setelah terjadi hernia nukleus pulposus sisa duktus intervertebralis
mengalami lisis sehingga dua korpora vertebra bertumpang tindih tanpa ganjalan.
Patofisiologi HNP