 Nama : dr. Nuke Ariyanie, Sp.

S
 Lahir : 05-12-1976
 Pendidikan :
 SMA Negeri 3, Bandung

 Dixie Heights High School, Kentucky, USA

 S1 Fakultas Kedokteran UNPAD, Bandung

 Spesialis Penyakit Saraf FK UNPAD, Bandung

 Pekerjaan :
 Manager Website FK UNPAD (formerly)

 RSUD Gunung Jati

 RS Mitra Plumbon

 RSIA Sumber Kasih

 FK UNSWAGATI
 THE SPINE,
SPINAL CORD,
& SPINAL NERVES

dr. Nuke Ariyanie, Sp.S

The Spine
 Vertebral column
 Vertebrae
Vertebral Column
 = spinal column.
 26 individual bones = vertebrae.
 Divided into 5 different areas, grouped as follows:
7 cervical vertebrae in neck (C1-C7)
 12 thoracic vertebrae in upper back (T1-T12)

 5 lumbar vertebrae in lower back (L1-L5)

 5 sacral vertebrae fused together to form 1 bone

sacrum.
 4 coccygeal vertebrae fused together to form coccyx
 Vertebrae consists of 2 essential parts:
 Anterior segment (the body/ corpus)
 Posterior part (neural arch)  encloses vertebral
foramen, concists of pair of pedicles, pair of laminar, 4
articular processes, 2 transverse processes, 1 spinous
processes.
 Sagittal section of
Thoracic vertebrae lumbar vertebrae
 Vertebral body
 Largestpart of vertebrae. Covered with strong cortical
bone, with cancellous bone within.
 Pedicles
2 short processes, made of strong cortical bone,
protude from the back of vertebral body.
 Laminae
2 relatively flat plates of bone, extend from the
pedicles on either side and join in midline.
 Processes
3 types : articular, transverse, spinous. The processes
serve as connection points for ligaments and tendons. 4
articular processes link with articular processes of
adjacent vertebrae to form the facet joints. Facet joints
combined with intervertebral discs allows for spine
motion.
 Intervertebral foramen
 Nerve roots exit from spinal cord through this area to
rest of body.
 Cervical vs Thoracic vs Lumbar

 Cervical vertebrae

 Smallest

 Foramen in each
transverse process
What is this?

 C1 –Atlas

 Forms the joint

connecting the skull and
spine

 Has no body
 AXIS (Second cervical vertebra)

 (C2) of the spine is

named the axis.
 It forms the pivot upon
which the Atlas- rotates
 strong odontoid process
which rises
perpendicularly from the
upper surface of the
body.
 Thoracic Vertebra

 Intermediate in size
 Increase in size as one
proceeds down the spine
 They are distinguished by
the presence of facets on
the sides of the bodies
 Facets on the transverse
processes of all, except the
eleventh and twelfth,
Lumbar Vertebra

 The lumbar vertebrae

are the largest
segments of the
movable part of the
vertebral column
 Absence of a foramen
in the transverse
process,
 Absence of facets on
the sides of the body.
 The cervical curve, convex forward,
C1/2 – T7

 The thoracic curve, is concave

T2 – T12

 The lumbar T12 – L4, It is convex

anteriorly.

 The pelvic curve L4/5 - Coccyx

 Intervertebral Disk
 Each disc forms a cartilaginous joint
to allow slight movement of the
vertebrae, and acts as a ligament to
hold the vertebrae together.

 The annulus fibrosus consists of

several layers of fibrocartilage. The
strong annular fibers distribute
pressure evenly across the disc.

 The nucleus pulposus contains loose

fibers- like JELLY. The nucleus of the
disc acts as a shock absorber,
absorbing the impact of the body's
daily activities and keeping the two
vertebrae separated.
From Course Guide…

Flexion/extension Lateral flexion Rotation

C1-C7 ++ ++ ++

T1-T6 0 + +

T7-T12 + ++ ++

L1-sacrum ++ + 0
Abnormalities in curvature
The following abnormal curvatures may occur in some people:
 Kyphosis is an exaggerated posterior curvature in the thoracic
region. This produces the so-called "humpback".

 Lordosis is an exaggerated anterior curvature of the lumbar

region, "swayback". Temporary lordosis is common among
pregnant women.

 Scoliosis, lateral curvature, is the most common abnormal

curvature, occurring in 0.5% of the population. It is more
common among females and may result from unequal growth
of the two sides of one or more vertebrae.
 The spinal cord

 Gross anatomy
 3 layers of meninges

 Epidural space (fat & vessels)

 CSF – subarachnoid space

 Terminates at L1/2 vertebral level (conus medullaris)

 Dura extends to S2 vertebral level

 Connects via filum terminale & denticulate ligaments (pia)

 31 pairs of spinal nerves (mixed)

 cauda equina
 Cervical & lumbar enlargements
 Spinal Cord Anatomy

 Conus medullaris – terminal portion of the spinal cord

 Filum terminale – fibrous extension of the pia mater; anchors
the spinal cord to the coccyx
 Denticulate ligaments – delicate shelves of pia mater; attach
the spinal cord to the vertebrae
 Spinal nerves – 31 pairs attach to the cord by paired roots
 Cervical nerves are named for inferior vertebra
 All other nerves are named for superior vertebra
 Cervical and lumbar enlargements – sites where nerves serving
the upper and lower limbs emerge
 Cauda equina – collection of nerve roots at the inferior end of
the vertebral canal
Cross-Sectional Anatomy of the Spinal Cord

 Anterior median fissure – separates anterior funiculi

 Posterior median sulcus – divides posterior funiculi
 The 3 Meningeal Layers

• Dura mater:
– outer layer of spinal cord
– subdural space:
• between arachnoid mater and dura mater
• Arachnoid mater:
– middle meningeal layer
– subarachnoid space:
• between arachnoid mater and pia mater
• filled with cerebrospinal fluid (CSF)
• Pia mater:
– inner meningeal layer
 Structures of the Spinal Cord

 Paired denticulate
ligaments:
 extend from pia mater to
dura mater
 stabilize side-to-side
movement
 Blood vessels:
 along surface of spinal
pia mater
 within subarachnoid
space
 Cross-sectional anatomy

 Gray matter (cell

bodies, neuroglia, &
unmyelinated processes)
 Posterior horns (sensory,
all interneurons)
 Lateral horns (autonomic,
T1-L2)
 Anterior horns (motor, cell
bodies of somatic motor
neurons)
 Spinal roots
 Ventral (somatic &
autonomic motor)
 Dorsal (DRG)
 Cross-sectional anatomy

 White matter
 3 funiculi (posterior, lateral,
anterior)
 Ascending, descending,
transverse
 Consist of “tracts” containing
similarly functional axons
 All tracts are paired
 Most cross over (decussate) at
some point
 Most exhibit somatotopy
(superior part of the tracts are
more lateral that inferior body
regions)
 Most consist of a chain of 2 or
3 successive neurons
 Gray Matter: Organization

 Dorsal half – sensory roots and ganglia

 Ventral half – motor roots
 Dorsal and ventral roots fuse laterally to form spinal nerves
 Four zones are evident within the gray matter – somatic sensory
(SS), visceral sensory (VS), visceral motor (VM), and somatic motor
(SM)
 White Matter in the Spinal Cord

 Fibers run in three directions – ascending, descending,

and transversely
 Divided into three funiculi (columns) – posterior, lateral,
and anterior
 Each funiculus contains several fiber tracts
 Fiber tract names reveal their origin and destination
 Fiber tracts are composed of axons with similar functions

 Pathways decussate (cross-over)

 Most consist of two or three neurons
 Most exhibit somatotopy (precise spatial relationships)
 Pathways are paired (one on each side of the spinal
cord or brain)
White Matter: Pathway Generalizations
Spinal Cord Tracts
Tracts of the Spinal Cord

1. Fasciculus Gracilis
2. Fasciculus Cuneatus
3. Tractus spinocerebellaris dorsalis
4. Tractus corticospinalis lateralis
16 5. Tractus spinothalamicus lateralis
6. Tractus spinocerebellaris ventralis
7. Tractus rubrospinalis
8. Tractus spinotectalis
9. Tractus corticospinalis anterior
10. Tractus olivospinalis
11. Tractus spinoolivaris
12. Tractus tectospinalis
13. Tractus reticulospinalis
14. Tractus vestibulospinalis
15. Tractus spinothalamicus anterior
16. Raphe-spinal & Hypothalamospinal fibers
 Spinal Cord Tracts

Ascending Tracts

Modality: Touch, Pain, Temperature, Kinesthesia

Receptor: Exteroceptor, Interoceptor, Proprioceptor
Primary Neuron: Dorsal Root Ganglion (Spinal Ganglion)
Secondary Neuron: Spinal Cord or Brain Stem
Tertiary Neuron: Thalamus (Ventrobasal Nuclear Complex)
Termination: Cerebral Cortex, Cerebellar Cortex, or
Brain Stem
Spinal Cord Tracts

Ascending Tracts

Posterior White Column-Medial Lemniscal Pathway

Spinothalamic Tract
Spinoreticular or Spinoreticulothalamic Tract
Spinocerebellar Tract
Spinomedullothalamic Tract
Cervicothalamic or Spinocervicothalamic Tract
Spino-olivary Tract
Spinotectal Tract
 Spinal Cord Ascending Tracts

Posterior White Column-Medial Lemniscal Pathway

Modality: Discriminative Touch Sensation (include Vibration) and

Conscious Proprioception (Position Sensation, Kinesthesia)
Receptor: Most receptors except free nerve endings

Ist Neuron: Dorsal Root Ganglion (Spinal Ganglion)

Posterior Root - Posterior White Column
2nd Neuron: Dorsal Column Nuclei (Nucleus Gracilis et Cuneatus)
Internal Arcuate Fiber - Lemniscal Decussation
- Medial Lemniscus
3rd Neuron: Thalamus (VPLc)
Internal Capsule ----- Corona Radiata
Termination: Primary Somesthetic Area (S I)
 medial lemniscus

lemniscal decussation

internal arcuate fiber

posterior white column

posterior root

Posterior White Column -

Medial Lemniscal Pathway

- ipsilateral loss of discriminative touch

sensation and conscious proprioception
below the level of lesion
Spinal Cord Ascending Tracts

Spinothalamic Tract

Modality: Pain & Temperature Sensation, Light Touch

Receptor: Free Nerve Ending

Ist Neuron: Dorsal Root Ganglion (Spinal Ganglion)

Posterior Root
2nd Neuron: Dorsal Horn (Lamina IV, V, VI)
Spinothalamic Tract - (Spinal Lemniscus)
3rd Neuron: Thalamus (VPLc, CL & POm)
Internal Capsule ----- Corona Radiata
Termination: Primary Somesthetic Area (S I) &
Diffuse Widespread Cortical Region
 spinothalamic
tract

anterior white
decussation
commissure

posterior root

Spinothalamic Tract

- contralateral loss of pain and temperature

sensation below the level of lesion
Spinal Cord Ascending Tracts

Spinocerebellar Tract

Modality: Unconscious Proprioception

Receptor: Muscle spindle, Golgi tendon organ

Ist Neuron: Dorsal Root Ganglion (Spinal Ganglion)

Posterior Root , [Posterior Column]
2nd Neuron: 1. Clarke’s column (Lamina VII)
Posterior Spinocerebellar Tract
2. Accessory Cuneate Nucleus
Cuneocerebellar Tract
3. Posterior Horn
Anterior Spinocerebellar Tract
Termination: Cerebellar Cortex
Spinocerebellar Tract
Spinal Cord Descending Tracts
Corticospinal Tract

Origin: Cerebral Cortex

Brodmann Area 4 (Primary Motor Area, M I)
Brodmann Area 6 (Premotor Area, PM )
Brodmann Area 3,1,2 (Primary Somesthetic Area, S I)
Brodmann Area 5 (Anterior Portion of Sup. Parietal Lobule)
Corona Radiata
lnternal Capsule, Posterior Limb
Crus Cerebri, Middle Portion
Longitudinal Pontine Fiber
Pyramid - pyramidal decussation
Corticospinal Tracts:
- Lateral (crossed) - 85%
- Anterior (Not crossed) - 15%
Termination: Spinal Gray (Rexed IV-IX)
 Corona Radiata
lnternal Capsule, Posterior Limb
Crus Cerebri, Middle Portion
Longitudinal Pontine Fiber
Pyramid CR
Pyramidal Decussation
Corticospinal Tract
IC
- Lateral and Anterior

LPF

Corticospinal Tract
Pyr
PD LCST

- ipsilateral UMN syndrome ACST

at the level of lesion
Spinal Cord Descending Tracts

Descending Tracts from Brain Stem

Dorsolateral (Motor) Pathway

Rubrospinal Tract
Ventromedial (Motor) Pathway
Tectospinal Tract
Vestibulospinal Tract
MLF (Medial Longitudinal Fasciculus)
- interstitiospinal tract
Sensory Modulation pathways
Raphespinal & Cerulospinal Pathways
Descending Autonomic Pathways
Spinal Cord
Tracts

ventromedial dorsolateral
Descending pathway pathway
Tracts
from
Brain Stem
 SOMATIC MOTOR SYSTEM

upper motor neuron

UMN Brain Stem
Descending
Pathway

VOLUNTARY Final Common Pathway Rubrospinal Tract

CONTROL Tectospinal Tract
lower motor neuron Vestibulospinal Tract
MLF
LMN
Reticulospinal Tract
Pyramidal Tract AUTOMATIC CONTROL

REFLEX
EFFECTORS
skeletal muscle
3 Connective Tissue Layers

 Epineurium:
 outer layer
 dense network of collagen
fibers
 Perineurium:
 middle layer
 divides nerve into fascicles
(axon bundles)
 Endoneurium:
 inner layer
 surrounds individual axons
Peripheral Distribution of Spinal Nerves

 Each spinal nerve connects

to the spinal cord via two
medial roots
 Each root forms a series of
rootlets that attach to the
spinal cord
 Ventral roots arise from the
anterior horn and contain
motor (efferent) fibers
 Dorsal roots arise from
sensory neurons in the
dorsal root ganglion and
contain sensory (afferent)
fibers
Figure 13–7a
 Spinal Nerves: Rami

 The short spinal nerves branch into three or four

mixed, distal rami
 Small dorsal ramus – to back
 Larger ventral ramus – to plexuses/intercostals

 Tiny meningeal branch – to meninges

 Rami communicantes at the base of the ventral rami in the

thoracic region – to/from ANS
 Nerve Plexuses

 All ventral rami except T2-T12 form interlacing nerve

networks called plexuses
 Plexuses are found in the cervical, brachial, lumbar, and
sacral regions
 Each resulting branch of a plexus contains fibers from
several spinal nerves
 Fibers travel to the periphery via several different routes
 Each muscle receives a nerve supply from more than one
spinal nerve
 Damage to one spinal segment cannot completely paralyze
a muscle
Spinal Nerve Innervation: Back,
Anterolateral Thorax, and Abdominal Wall

 The back is innervated by

dorsal rami via several
branches
 The thorax is innervated
by ventral rami T1-T12 as
intercostal nerves
 Intercostal nerves supply
muscles of the ribs,
anterolateral thorax, and
abdominal wall
The 4 Major Plexuses of Ventral Rami

1. Cervical plexus
2. Brachial plexus
3. Lumbar plexus
4. Sacral plexus
 Cervical Plexus

 The cervical plexus is formed

by ventral rami of
C1-C4 (C5)
 Most branches are cutaneous
nerves of the neck, ear, back
of head, and shoulders
 The most important nerve of
this plexus is the phrenic nerve
 The phrenic nerve is the major
motor and sensory nerve of
the diaphragm
 Brachial Plexus

 Formed by C5-C8 and T1

(C4 and T2 may also
contribute to this plexus)
 It gives rise to the nerves
that innervate the upper
limb
 Trunks and Cords of Brachial Plexus

• Nerves that form brachial plexus originate from:

– superior, middle, and inferior trunks
– large bundles of axons from several spinal nerves
– lateral, medial, and posterior cords
– smaller branches that originate at trunks
 Brachial Plexus: Nerves

 Axillary – innervates the

deltoid and teres minor
 Musculocutaneous – sends
fibers to the biceps brachii
and brachialis
 Median – branches to most
of the flexor muscles of
forearm
 Ulnar – supplies the flexor
carpi ulnaris and part of the
flexor digitorum profundus
 Radial – innervates
essentially all extensor
muscles
Lumbar Plexus

 Arises from (T12) L1-L4

and innervates the thigh,
abdominal wall, and
psoas muscle
 The major nerves are the
femoral and the obturator
 Sacral Plexus

 Arises from L4-S4 and

serves the buttock, lower
limb, pelvic structures, and
the perineum
 The major nerve is the
sciatic, the longest and
thickest nerve of the body
 The sciatic is actually
composed of two nerves:
the tibial and the common
fibular (peroneal) nerves
 Nerve plexuses - Summary

 Cervical – C1-C4
 Phrenic nerve
 Brachial – C5 – T1 (roots/trunks/divisions/cords)
 Axillary, MC, median, ulnar, radial
 Lumbar – L1-L4
 Femoral, obturator
 Sacral – L4-S4
 Sciatic (common peroneal/tibial), pudendal
Dermatomes

 Area of skin innervated by the

cutaneous branches of a single
spinal nerve.
 All segments except C1 have
dermotomal distribution
 UE typically from C5-T1
 LE typically from L1-S1

Figure 13–8
5 Patterns of Neural Circuits in Neuronal Pools

1. Divergence:
 spreads
stimulation to
many neurons or
neuronal pools
in CNS
2. Convergence:
 brings input
from many
sources to single
neuron
Figure 13–13a
5 Patterns of Neural Circuits in Neuronal Pools

3. Serial processing:
 moves information
in single line
4. Parallel processing:
 moves same
information along
several paths
simultaneously

Figure 13–13c
5 Patterns of Neural Circuits in Neuronal Pools

5. Reverberation:
 positive feedback mechanism
 functions until inhibited

Figure 13–13e
 Reflex activity

 5 components of a
reflex arc
 Receptor
 Sensory neuron

 Integration center
(CNS)
 Motor neuron

 Effector
4 Classifications of Reflexes
1. By early development
 Innate or Acquired
2. By type of motor response
 Somatic or Visceral
3. By complexity of neural circuit
 Monosynaptic or Polysynaptic
4. By site of information processing
 Spinal or Cranial
Spinal Reflexes
 Range in increasing order of complexity:
 monosynaptic reflexes
 polysynaptic reflexes

 intersegmental reflex arcs:

 many segments interact
 produce highly variable motor response
Monosynaptic Reflexes
 Have least delay
between sensory
input and motor
output:
 e.g.,stretch
reflex (such as
patellar reflex)
 Completed in
20–40 msec
Muscle Spindles

 The receptors in stretch

reflexes
 Bundles of small,
specialized intrafusal
muscle fibers:
 innervatedby sensory
and motor neurons
 Surrounded by extrafusal
muscle fibers:
 which maintain tone and
contract muscle
Postural Reflexes
 Postural reflexes:
 stretchreflexes
 maintain normal upright posture

 Stretched muscle responds by contracting:

 automatically maintain balance
Polysynaptic Reflexes
 More complicated than monosynaptic reflexes
 Interneurons control more than 1 muscle group
 Produce either EPSPs or IPSPs
The Tendon Reflex
 Prevents skeletal muscles from:
 developing too much tension
 tearing or breaking tendons

 Sensory receptors unlike muscle spindles or

proprioceptors
 Withdrawal Reflexes
 Move body part away
from stimulus (pain or
pressure):
 e.g., flexor reflex:
 pulls hand away from
hot stove
 Strength and extent of
response:
 depends on intensity
and location of stimulus
Reciprocal Inhibition
 For flexor reflex to work:
 the stretch reflex of antagonistic (extensor) muscle must
be inhibited (reciprocal inhibition) by interneurons in
spinal cord
 Crossed Extensor Reflexes

 Occur simultaneously,
coordinated with flexor
reflex
 e.g., flexor reflex causes
leg to pull up:
 crossed extensor reflex
straightens other leg
 to receive body weight

 maintained by
reverberating circuits
Integration and Control
of Spinal Reflexes
 Though reflex behaviors are automatic:
 processing centers in brain can facilitate or inhibit
reflex motor patterns based in spinal cord
 Higher centers of brain incorporate lower, reflexive
motor patterns
 Automatic reflexes:
 can be activated by brain as needed
 use few nerve impulses to control complex motor
functions
 walking, running, jumping
 Superficial reflexes

 Stroking of the skin elicits muscle contraction

 Involves functional upper motor pathways as well as cord level
reflex arcs
 Plantar reflex (L4-S2)…Babinski is normal in infants
 Usually indicative of CNS damage in adults
 Abdominal reflex (T8-T12)
 Absent with corticospinal lesion
 Spinal Cord Vascular Supply

Arterial Supply
- Spinal Arteries
Anterior (1) & Posterior (2) Spinal Artery
from Vertebral artery
- Radicular Arteries ----- Segmental arteries
from Vertebral, Ascending Cervical, Intercostal and
Lumbar Artery
Venous Drainage
- Longitudinal & Radicular Veins
to Intervertebral veins ---- to Internal Vertebral Venous Plexus
to external vertebral venous plexus ---- to segmental veins
 5. Adamkiwicz artery

anterior spinal artery segmental arteries

Blood Supply
Blood Supply