The Spinal Cord

 Structure of the spinal cord

 Tracts of the spinal cord

 Spinal cord syndromes

Nabeel Kouka, MD, DO, MBA

www.brain101.info
 Spinal Cord

- Comparable to
Input-Output (IO) System of the Computer

- Spinal Nerve (C8, T12, L5, S5, Cx1)

- Segmental Structure of Neural Tube Origin

Spinal segment
C8, T12, L5, S5, Cx1

Anterior (Ventral) Root

Posterior (Dorsal) Root
Dorsal Root (Spinal) Ganglion
Root - Rootlets
Conus Medullaris (L1-2)
Cauda Equina
Anterior median fissure
Anterolateral fissure
 Posterior
median sulcus
Posterolateral
sulcus
Posterior
intermediate
sulcus
Fasciculus
cuneatus
Fasciculus
gracilis

Posterior surface of the spinal cord

Spinal Cord Meninges

Periosteum of Vertebra
- Epidural Space ----------------- epidural anesthesia
Dura Mater Spinalis
Arachnoid Membrane
- Subarachnoid Space -------- Lumbar Puncture
Spinal Anesthesia
Pia Mater Spinalis
- Denticulate Ligament --------- Cordotomy
- Filum Terminale
 Meninges of
the spinal cord
• Dura mater
• Arachnoid membrane
• Pia mater

Denticulate ligament
- specialization of the pia mater
- landmark for cordotomy
Meninges of the spinal cord
Meninges of the spinal cord
Lumbar Puncture – lumbar (terminal) cistern
 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

Spinal Cord External Figure
Spinal Cord External Figure

Conus Medullaris (L1-2)

Spinomedullary Junction
- Foramen Magnum, Pyramidal decussation, C1 ventral root
Enlargements
- Cervical (C4-T1) & Lumbosacral (L1-L4)
Longitudinal Fissures
- anterior median fissure
- anterolateral fissure
- posterior median sulcus
- posterolateral sulcus
cervical enlargement (C8) thoracic cord (T8)

lumbar enlargement (L3) sacral cord (S1)

• Cervical level
- Wide flat cord, lots of white matter,
ventral horn enlargements.

• Lumbar level
- Round cord, ventral horn enlargements.

• Sacral level
- Small round cord, lateral Horn.

• Tthoracic level
- Notice the pointed tips which stick out
between the small dorsal and ventral horns.
This extra cell column is called the
intermediate horn (AKA: Intermediolateral
Cell Column).
Column It is the source of all of the
sympathetics in the body & occurs only in
the Thoracic sections T 1 - L 2
Spinal Cord Internal Structure

White Matter
Anterior Funiculus (Anterior White Column)
Posterior Funiculus (Posterior White Column)
Fasciculus Gracilis & Fasciculus Cuneatus
Lateral Funiculus (Lateral White Column)
Gray Matter
Anterior Horn --------------- motor
Posterior Horn -------------- sensory
Lateral Horn ----------------- autonomic (sympathetic)
Gray Commissure -------- anterior and posterior
1. posterior horn
9. anterior median
2. anterior horn fissure

3. intermediate zone 10. posterior median

sulcus
(intermediate gray)
11. anterolateral
4. lateral horn
sulcus
5. posterior funiculus
12. posterolateral
6. anterior funiculus sulcus
13. Posterior
7. lateral funiculus
intermediate
8. Lissauer's tract sulcus
Spinal Cord Internal Structure

Principles of Cord Organization

1) Longitudinal Arrangement
Fibers (White Matter) ------------- White Column
Cell Groups (Gray Matter) ------- Gray Column

2) Transverse Arrangement
Afferent & Efferent Fibers
Crossing (Commissural and Decussating) Fibers
3) Somatotopical Arrangement
Columnar arrangement Somatotopical arrangement
Lamina of Rexed
Lamina of Rexed

Lamina I Posteromarginal Nucleus

Lamina II Substantia Gelatinosa of Rolando
Lamina III
Lamina IV, V, VI ----- Nucleus Proprius
Lamina VII
- Intermediate Gray
- Intermediolateral cell column (ILM)
- Clarke’s column (Nucleus dorsalis)
- Intermediomedial cell column (IMM)
Lamina VIII
Lamina IX ---------- Anterior Horn (Motor) Cell
Lamina X ----------- Gray Commissure
Lamina I

• AKA: lamina marginalis

or the layer of Waldeyer

• Receives incoming dorsal root fibers

and collateral branches as well

• Larger neurons contribute axons

to Contralateral Spinothalamic Tract
Lamina II
• AKA: Substantia Gelatinosa

• Involved in Pain interpretation

• Receives incoming input from dorsal
root axons & descending input from
reticular formation of the medulla

• Efferent axons travel up & down

several segments to make contact
with other areas of the dorsal horn
Lamina III

• Contains larger, less densely packed

cells than lamina II

• Receives primary afferents from

dorsal root fibers
• Neurons considered as a part of
nucleus proprius
Lamina IV
• Contains a variety of cell types that have
more myelin than any other lamina

• Some tract cells originate here, axons cross

the midline and enter the contralateral
Spinothalamic Tract,
Tract also sends contacts to
layers II and III

• Receives afferents from dorsal roots via

the dorsal funiculus

• At rostral end of spinal cord, laminas I-IV

become continuous with the spinal
trigeminal nucleus
Lamina V - VI

• Origination of tract cells,

cells similar
to lamina IV, these tracts cells are
also known as the Nucleus Proprius
(e.g. spinal thalamic tract or
anterolateral system;
system pain and
temperature, some tactile)

• Receives afferent input from

dorsal roots and descending fibers,
most importantly Corticospinal
 Lamina V - VI
C7

reticular formation ---------------->

Laterally, gray matter at base of dorsal horn mixes with

white matter from lateral funiculus, this region is called
reticular formation.
formation It is noticeable in the cervical region
Lamina VII

• The largest region, occupies most of

ventral horn &intermediate zone

• Projects long axons that connect to other

gray matter segments of the cord

• Some columns do not fit into the lamina

scheme, and have individual designations:
a. Nucleus dorsalis (Clarke)
Clarke
b. Intermediolateral cell column
c. Intermediomedial cell column
d. Sacral autonomic nucleus
 Lamina VII

• Nucleus dorsalis of Clark

T5
AKA nucleus thoracicus
is located medial & ventral
to the dorsal horn in T1-L3

• Composed of large neurons

& axons that form the
dorsal spinocerebellar tract
on the ipsilateral side
 Lamina VII

• Intermediolateral cell column

is located at the lateral portion T5
of the intermediate zone.

• Responsible for the formation

of the lateral horn in T1 - L2

• Consists of cell bodies of

sympathetic preganglionic
neurons
 Lamina VII

• Intermediomedial cell column T5

is located lateral to lamina X.
Not seen in all cord sections.

• Receives primary afferent

fibers from dorsal root and
has been implicated in
visceral reflexes
 Lamina VII

S2

• Sacral autonomic nucleus

is located in the lateral part of
lamina VII in S2-S4 segments

• Consists of preganglionic para-

sympathetic neurons
Lamina VIII

• Located on the medial aspect of

the ventral horn

• Efferent projections both ipsilaterally

and contralaterally to the same and
nearby segmental levels to lamina
VII & IX

• Site of termination for descending

fibers, including the vestibulospinal
and reticulospinal tracts
Lamina IX
• Consists of columns of neurons
embedded in either lamina VII or VIII
• Cells include alpha and gamma motor
neurons, which axons exit via the
ventral roots and innervate striated
muscle.
muscle Smaller neurons contribute
axons to the ventral fasciculus proprius
• Four columns of motor neurons can
be identified within this lamina;
ventromedial,
ventromedial ventrolateral,
ventrolateral dorsolateral
& central each has characteristic
dendritic features
Lamina IX

Ventral gray columns in lamina IX

have somatotopic arrangement:
- Medial areas innervate the
axial musculature
- Lateral areas innervate the
limbs muscles
 PHRENIC NUCLEUS
The phrenic nucleus is located in the ventromedial area of the
ventral horn in C2-C5 segments. It receives bilateral innervation
from the solitary nucleus of the medullary region, via solitary tract.
This nucleus is responsible for the innervation of the diaphragm

SPINAL ACCESSORY NUCLEUS

The spinal accessory nucleus (cranial nerve XI) is located in the
lateral area of vental horn in C1-C5 segments. Corticospinal tract
innervates this nucleus bilaterally. This nucleus is also responsible
for the innervation of the trapezius & sternocleidomastoid muscles
(ipsilaterally)
 Lamina IX

Nucleus of Onuf S2

• Located ventrolaterally in
S1-S2 spinal segments

• Supplies muscles of the

pelvic floor, including striated
muscle sphincters for urinary
and fecal continence
Lamina X

• Surrounds the central canal,

canal and
includes the ventral gray commissure

• Contains relatively small neurons,

neurons
radial neuroglia cells & decussating
axons

• Some dorsal root afferents terminate

here
 Fasiculus Proprius

• Ascending and descending association fiber systems of the

spinal cord which lie deep in the anterior, lateral & posterior
funiculi adjacent to the gray matter.
• Fasciculi proprii aka Flechsig's fasciculi or Ground bundles
consist of: anterior, lateralis & intersegmental fasciculi
 Dorsal Roots

• Each dorsal root divides

into 6 - 8 rootlets
• Each rootlet can be divided into
lateral & medial division
• Lateral division carries
information related to pain
& temperature
• Medial division carries
information related to tactile
discrimination & vibration
 Dorsal Roots

• Lateral division axons enter

dorsolateral tract of Lissauer,
Lissauer
and then divide into ascending
& descending branches, each
terminate in the dorsal horn
• Most terminate at same
level & some fibers may
travel up or down the cord
up to four levels
 Dorsal Roots

• Medial division axons enter the

white matter & then divide into
ascending & descending branches

• Descending branches are

organized into two bundles,
the Septomarginalis Fasiculus
and the Interfascicular Fasiculus

• All descending branches terminate

in the dorsal horn
 Dorsal Roots

• Ascending branches of the

medial division enter the
dorsal funiculus & terminate
in gracile & cuneate nuclei
in the medulla
 Ventral Horn

• Lamina IX contains two types

of motor neurons, alpha and
gamma
• Alpha motor neurons innervate
extrafusal fibers of striated
skeletal muscles
• Gamma motor neurons innervate
intrafusal fibers of neuromuscular
spindles
• Both types receive inputs from
interneurons, including the
inhibitory Renshaw cell
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
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
 NeoSTT PaleoSTT
Primary Motor Widespread
Area (M I) cortical region

VPLc (ventrobasal CL (intralaminar

thalamus
nuclear complex) thalamic nuclei)

(spinal lemniscus) reticulothalamic

pathways

spinothalamic spinoreticular
tract tract reticular
formation

Spinothalamic Tract
& Spinoreticular Tract
Comparison of Fast and Slow Pain ------ Spinothalamic Tract

Fast Pain Slow Pain

Sharp, pricking Dull, burning

Group III (Aδ) fiber Group IV (C) fiber
Short latency Slower onset
Well localized Diffuse
Short duration Long duration
Less emotional Emotional, autonomic response
Not blocked by morphine Blocked by morphine
Neospinothalamic Tract Paleospinothalamic Tract
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
Anterior SCbllT Posterior SCbllT
Inferior cerebellar
peduncle
(superior Inferior
cerebellar cerebellar
peduncle) peduncle

anterior cuneocerebellar posterior

spinocerebellar tract spinocerebellar
tract (upper body) tract

anterior white posterior Clarke’s

commissure white column column

posterior root posterior root posterior

white column

Spinocerebellar Tract posterior root

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
Spinal Cord Syndrome

Location of
Symptoms in
Spinal Disease

ipsilateral to lesion contralateral to lesion

Upper Motor Neuron (UMN) vs. Lower Motor Neuron (LMN) Syndrome

UMN syndrome LMN Syndrome

Type of Paralysis Spastic Paresis Flaccid Paralysis

Atrophy No (Disuse) Atrophy Severe Atrophy

Deep Tendon Reflex Increase Absent DTR

Pathological Reflex Positive Babinski Sign Absent

Superficial Reflex Absent Present

Fasciculation and Absent Could be

Fibrillation Present
Spinal Cord Syndrome

Predominantly Motor Syndromes

• Poliomyelitis (Infantile Paralysis)

- viral infection of lower motor neuron
- LMN syndrome at the level of lesion

• Amyotrophic Lateral Sclerosis (ALS)

- combined LMN and UMN lesion
- LMN syndrome at the level of lesion
- UMN syndrome below the level of lesion
- Lou Gehrig’s disease
 Spinal Cord Syndrome

1. corticospinal 2. lower motor

tract neuron (LMN)

Amyotrophic Lateral Sclerosis

 Spinal Cord
Syndrome

Amyotrophic
Lateral Sclerosis
(ALS)

Lou Gherig’s
Disease
Lou "The Iron Horse" Gehrig (1903-41)
3.40, 2131(1925-39), 23 GSH, 147 RBI avg.
 Spinal Cord
Syndrome

Amyotrophic
Lateral Sclerosis
(ALS)

Lou Gherig’s
Disease Stephen Haking (1946- )
British Physicist, A Brief History of Time
Spinal Cord Syndrome

Predominantly Sensory Syndromes

• Herpes Zoster
- inflammatory reactions of spinal ganglion
- severe pain on the dermatomes of affected ganglion
• Tabes Dorsalis
- common variety of neurosyphilis
- posterior column and spinal posterior root lesion
- loss of discriminative touch sensation and conscious
proprioception below the level of lesion
- posterior column ataxia
- lancinating pain (a stabbing or piercing sensation)
- loss of deep tendon reflex (DTR)
Herpes Zoster (Shingles)
• varicella-zoster virus
reactivation from
the dorsal root ganglia
• unilateral vesicular
eruption within
a dermatome
• T3 to L3 dermatome
lesions are frequent
• zoster ophtahalmicus
(ophthalmic division
of trigeminal n., V1)
• Ramsey-Hunt syndrome
(sensory br. of VII)
• acyclovir, antiviral agent
Spinal Cord Syndrome

Sub-Acute Combined Degeneration

(Combined System Disease)

Lesion
- posterior white column
- corticospinal tract (UMN)

Symptom
- loss of discriminative touch sensation and conscious
proprioception below the level of lesion
- ipsilateral UMN syndrome below the level of lesion
 Spinal Cord Syndrome

1. corticospinal 2. posterior
tract white column

Sub-Acute Combined Degeneration

Spinal Cord Syndrome

Syringomyelia, Hematomyelia
Lesion
- central canal of spinal cord
- gradually extended to peripheral part of the cord

Symptom
- initial symptom is bilateral loss of pain
(compression of anterior white commissure)
- variety of symptoms appear
according to the lesion extended from central canal
Spinal Cord Syndrome

Syringomyelia - Initial Symptoms

Spinal Cord Syndrome

Brown-Sequard syndrome
(spinal cord hemisection)
Major Symptoms
1. ipsilateral UMN syndrome below the level of lesion
2. ipsilateral LMN syndrome at the level of lesion
3. ipsilateral loss of discriminative touch sensation and
conscious proprioception below the level of lesion
(posterior white column lesion)
4. contralateral loss of pain and temperature sensation
below the level of lesion (spinothalamic tract lesion)
Spinal Cord Syndrome

3' 3
1 1

3' 3
1' 1
4' 4
2' 2

5' 5
4 1
1' 3 3

Brown-Sequard Syndrome (Spinal Cord Hemisection)