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UERM

COLLEGE OF MEDICINE CLASS 2021B


5.06 Organization of the Nervous System

Luis Emmanuel O. Esguerra, MD| March 15, 2018 LE 5
ANATOMY
TRANS 6

OUTLINE ® Exception: Pseudounipolar neurons don’t have dendrites


but contain axons that divide into two. One process goes
I. Organization of the Nervous System towards the cell body, the other goes away from the cell body
a. Neurological Terms • Synapses
b. Overview of the Nervous System ® Site of communication between neurons using chemical
c. Functional Components of the Peripheral Nerves neurotransmitters such as epinephrine, norepinephrine,
d. Autonomic Nervous System GABA, glutamate, acetylcholine, etc.
e. White Matter vs Gray Matter
• Myelin
II. Central Nervous System
® Lipoprotein produced by glial cells (oligodendrocytes in
a. Brain Subdivisions
CNS, Schwann cells in PNS) within the myelin sheath
b. Lobes, Sulci, Fissures, and Gyri
surrounding myelinated axons to increase axonal
c. Functional and Brodmann Areas
conduction velocity
d. Homunculus: Sensory and Motor
• Glial Cells
e. Thalamus
f. Hypothalamus ® Supporting cells of the nervous system
g. Basal Nuclei ® Produces myelin
h. Cerebellum
i. Brainstem
j. Spinal Cord
k. Rexed Laminae
III. Neuroanatomical Correlation
a. Clinical Neurologic Diagnosis
b. Recognition of Impaired Function
c. Neuroanatomy: The Key to Localization
IV. Review Questions
V. References

Objectives:
1. Describe the organization of the Nervous system.
a. Define the common neuroanatomical terms.
b. Name the principal divisions.
c. Identify the component parts of the: Central nervous system
Peripheral Nervous system, Autonomic Nervous system.
d. Describe the functional components of the peripheral
nervous system.
2. Describe the general topology of the Brain: subdivisions,
lobes, gyri and fissures/sulci, and functional/Brodmann
areas.
3. Describe the brainstem.
a. Enumerate the parts of the brainstem.
b. Describe the important external landmarks on the anterior
and posterior aspects of the brainstem.
4. Describe the external and internal features of the spinal cord.
a. Describe its gross features and developmental changes
with respect to its relationship to adjacent structures.
b. Describe its cross-sectional anatomy: a. gray and white Figure 1. (A to E) Neurons with cell bodies in the CNS. Neuron A is
matter; differences between specific cord segments; fasciculi, confined to the CNS and terminates on neuron B at a typical chemical
funiculi, and fiber tracts; rexed laminae. synapse (C). Neuron B is a motor neuron; its axon extends to a peripheral
5. Describe the principles of Neuroanatomical Localization. nerve & innervates a striated (voluntary) muscle at the neuromuscular
junction (motor end plate, D). In E, the arrows indicate the direction of flow
of the action current ( Manter & Gatz’s)
LEGEND
Remember Lecturer Book Previous Presentation
Trans B. OVERVIEW OF THE NERVOUS SYSTEM
Central Nervous System
• Comprised of the brain and spinal cord
• Involved in the integration of information to and from the
I. ORGANIZATION OF THE NERVOUS SYSTEM periphery
A. NEUROLOGICAL TERMS • Receive information from the peripheral nervous system and
• Neurons send out impulses to direct actions or hormonal changes
® Main excitable cells of the nervous system • Interactions with other neurons to modulate or modify impulses
® Made of nerve cell body, axons, and dendrites within it.
® As to location, “neuron” refers to the location of the nerve cell
body Peripheral Nervous System
• Dendrites • Composed of cranial nerves, spinal nerves, and associated
® Carry nerve impulses towards the body ganglia (everything outside brain and spinal cord )
• Axons • Conducts information to and from the CNS
® Carry impulses away from the body

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• 12 pairs of cranial nerves that come from the brain (Table 1.) ® The dorsal and ventral roots join together to form a single
spinal nerve that exits the vertebral column via the
intervertebral foramina
• Spinal nerves are named based on location
• Naming convention changes at C7/T1
® CN1-CN7: exits above the vertebra
® CN8: exits between C7 and T1
® T1 onwards: exits below the vertebra

Figure 2. Cranial Nerves. M- Motor Root, S- Sensory Root, C- Cranial, & S-


Spinal branches. ( Lansang Neuroanatomy)

Table 1. Cranial Nerves and fiber components.


Cranial
Name Nerve Fibers
Nerve (CN)
I Olfactory Sensory
II Optic Sensory
III Oculomotor Motor
IV Trochlear Motor
V Trigeminal Mixed/Both
VI Abducens Motor
VII Facial Mixed/Both
VIII Vestibulocochlear/Auditory Sensory
IX Glossopharyngeal Mixed/Both
X Vagal Mixed/Both Figure 3. Spinal Nerves and their points of exit. Cranial, Thoracic,
XI Spinal Accessory Motor Lumbar, Sacral and Coccygeal nerves. ( Netter)
XII Hypoglossal Motor
CNS vs. PNS: Differences Based on Contents
• 31 pairs of spinal nerves (Fig. 2) emerging from the spinal Table 2. Name Differences of CNS & PNS Content Structure.
cord with associated ganglia Within CNS Within PNS
® 8 Cervical Nucleus Ganglion
Collection of cell bodies
® 12 Thoracic (pl. nuclei) (pl. ganglia)
® 5 Lumbar Bundle of nerve fibers
Nerve tract/ Peripheral
® 5 Sacral with common origin &
Nerve fascicle Nerve
® 1 Coccygeal termination.
Note (2020C):
There are 8 Cervical NERVES C. FUNCTIONAL COMPONENTS OF PERIPHERAL
Only 7 Cervical VERTEBRAE NERVES
Only 1 Coccygeal NERVE • Nerves are composed of nerve fibers which are classified
and 4 Coccygeal VERTEBRAE according to functional components based on the following:
1. Direction of impulse ( SAME)
Question: How many CRANIAL NERVES are there in the
• Sensory/ Afferent – going towards CNS
human body? 24 NERVES = 12 PAIRS
(^Common medical board exam question) ® E.g. pseudounipolar neurons conducting impulses from
sensory organs (sight, touch, taste, hearing, and smell) to
the CNS
• Each spinal nerve is formed by roots coming off the spinal cord
• Motor/ Efferent– going away from CNS towards effector
organ

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® E.g. multipolar neurons conduct impulses to muscles (an Motor General Somatic General Visceral
effector organ) (Efferent) Efferent (GSE) – Efferent (GVE) –
® Effector organs – receiver of motor impulse from CNS Motor impulses to Control glandular
skeletal muscle secretion, movement of
Editor’s Note: Here’s another way to remember SAME groups smooth muscles
No Special Somatic Special Visceral
Efferent (SSE) Efferent (SVE) –
Muscles of
branchiomeric origin
(neck muscles, muscles
2. Embryologic origin of innervated tissue of mastication, muscles
• Somatic – body wall of facial expression)
• Visceral – organs
Note Question ( 2020C) :
Table 3. Classification of nerves based on embryologic origin of innervated What are the functional components of a specific nerve?
tissue. Remember: Nerve – w/ >1 functional component.
Attribute Somatic System Visceral System e.g. Radial nerve
Embryologic “Body Wall” “Organs” - GSA: w/ nerve fibers for the sensation of skin +
origin of Somatic (parietal) splanchnic (visceral) blood pressure & oxygen content detection of blood
tissue mesoderm mesoderm/endoderm vessels.
(dermatome – - GSE: w/ motor fibers for some muscles.
sensory, - GVE: w/ nerve fibers that affect sweat & sebaceous
myotome – motor) gland activity (ANS controlled)
Examples of Dermis of skin, Glands, cardiac -2021A Trans
adult tissue skeletal muscles, muscles, smooth
connective tissues muscles Note ( 2020C) :
Perception Conscious, Voluntary Unconscious, Some cranial nerves are purely sensory (contain PURELY
Involuntary sensory nerve fibers), others are considered purely motor
(contain PURELY motor fibers), and several are MIXED
3. Particular functions (General & Special functions) (contain both sensory and motor fibers)
• General Function -Moore
(Discussed in depth in Peripheral and Nervous System)
® ALL Nerve fibers of SPINAL NERVES and SOME cranial
nerves with similar functions
®
In the head, there are nerve fibers that have the same D. AUTONOMIC NERVOUS SYSTEM
fxn as o/ nerve fibers (NF) in the body.
® e.g. NF of sensation - pain, temperature & touch: felt by
the face just the same as o/ body parts.
• Special Function – specialized functions exemplified by
some cranial nerves
® Special sense organs of the eye and ear ( including
balance)
® Olfactory and gustatory receptors (eg. Mouth, tongue,
nose, nasal cavity, pharynx)
® Motor for muscles of branchiomeric origin ( pharyngeal
pouch) – special skeletal muscles derived from branchial
arteries and are related to the development of the head
(eg. Muscles of mastication, facial expression, pharynx
and larynx, Muscles of the neck: trapezius and SCM etc.)

“ 2020C It is possible to confuse any sensation from the eyes, ears,


nose & tongue to under special functions. Remember: SENSE
ORGANS only are what’s considered special functions (2018B
Trans)”

• GSA + GSE = Somatic Nervous System


• GVA + GVE = Visceral Nervous System
• GSA or SSA are functional components

Table 4. Overview of the Functional Components of the Cranial Nerves whit


the combined three bases for classification.
Somatic Visceral
Sensory General Somatic General Visceral
(Afferent) Afferent (GSA) – Afferent (GVA) –
General sensation General sensation from Figure 4. Ascending vs Descending Tracts
from body wall visceral organs
Special Somatic Special Visceral • Components arising from both central and peripheral nervous
Afferent (SSA) – Afferent (SVA) – systems
Vision, hearing, and Smell & taste; • Involved in the regulation of the internal environment outside the
balance associated w/ digestive individual’s conscious control
tract • 2 divisions: Sympathetic and Parasympathetic

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White Matter ® Cerebral Cortex – collection of nerve cell bodies in the


• Represented by predominantly myelinated axons or nerve periphery of the cerebral hemisphere
fibers, appearing white on unstained sections of the brain and ® Nuclei – collection of nerve cell bodies inside or deep
spinal column inside
• White matter is outside on the spinal cord § Basal Ganglia – deep within cerebrum; a misnomer,
Examples: should be called Basal Nuclei
• Tracts • In the brain, white matter is on the inside, while gray matter
® Bundle of nerve fibers with a common origin and termination is on the outside
§ Ascending tracts (2) – carry nerve impulses towards the • In special stained sections (myelin), white matter will appear
brain from the periphery dark and gray will be lighter
- Ex. Anterior spinothalamic tract and lateral
spinothalamic tract
§ Descending tracts (1) – carry nerve impulses away from
the brain towards the periphery.
- Ex. Lateral corticospinal tract
® A spinocerebellar tract is different from a cerebellospinal
tract; don’t interchange the terms since the tracts follow a
different course
• Peduncles
® Stem-like connection between 2 parts of the CNS
® Ex. 1 cerebral, 2 cerebellar
• Brachium/brachia
® Arm-like connection between 2 parts of the CNS
® 2 of the cerebellar peduncles are also classified as brachia:
Brachia conjunctivum and brachium pontis
• Lemniscus/lemnisci
® Ribbon-like connection specifically part of the sensory tracts
® Ex. Medial, lateral, & spinal
• Fasciculus/fasciculi
® Column of nerve fibers
® Ex. Cuneate & gracile
• Funiculus/funiculi
® Larger column, cord-like bundle of nerve fibers for the major
divisions of SC white matter
Figure 6. Gray matter vs White matter on the brain and spinal cord. Gray
Matter – Nervous tissue that primary contains cell bodies. White Matter –
Nervous tissue that primarily contains axons.

Figure 7. Cross section of the spinal cord

Figure 5. Representative of White Matter courses type, showing funiculus


on the top figure, and peduncle (green), fasciculus, and lemniscus labeled
and highlighted in yellow at lower figure *Brachium is not seen in these
images.
Figure 8. Cross section of the spinal cord with stain
Gray Matter
• Represents predominantly the nerve cell bodies III. CENTAL NERVOUS SYSTEM
(unmyelinated)
A. BRAIN SUBDIVISIONS
• Includes the nuclei and cortex
• There are 3 subdivisions which are determined by their
embryological origin

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® Forebrain
§ Cerebrum/Telencephalon – “brain” in layman’s terms
§ Diencephalon – thalamus, hypothalamus, epithalamus
® Midbrain
§ Connects forebrain and hindbrain
® Hindbrain
§ Composed of the pons, cerebellum, and medulla
oblongata

Figure 9. Brain divisions and subdivisions


Figure 11. Major lobes, sulci, and fissures and Insular/Central/ Island of
B. LOBES, SUCLI, FISSURES, AND GYRI Reli synthetic lobe shown above.
Cerebrum / Telencephalon
Major Lobes
• Divided into 6 lobes: 4 major and 2 minor or synthetic
• Frontal, Parietal, Occipital, and Temporal
® Frontal (major)
• Named after the skull bones closely related to them
® Parietal (major)
• Separated by sulcus, fissures, and gyri that are important in
® Occipital (major)
orienting oneself in the study of the brain
® Temporal (major)
® Sulci – shallow grooves
® Central/Insular (minor)
® Fissures – deeper grooves
® Limbic (minor)
® Gyri – in between sulci; folds of the brain
• The four lobes are named after the skull bone closely
associated to them: Frontal, Parietal, Temporal, Occipital bone.
• There are 2 synthetic (minor) lobes that can be seen when the
4 sulci that separate the major lobes
brain is cut in half. • Central Sulcus (of Rolando)
® Separates the frontal lobe from the parietal lobe
® Most prominent line from the vertex to the lateral surface of
the cerebrum
® Not always located centrally and must be seen to be
uninterrupted from the vertex to the sides
• Lateral Longitudinal Fissure (of Sylvius)
® Separates the temporal lobe from the frontal lobe and
anterior part of the parietal lobe
® With anterior, ascending and posterior rami.
• Parietooccipital Sulcus
® Separates the parietal lobe from the occipital lobe
® Seen more prominently in the medial view
® The boundaries of the occipital, temporal, and parietal lobes
are arbitrary and indistinct
§ Rostral border of the occipital lobe is generally considered
to be an imaginary line between the parietooccipital sulcus
to the preoccipital notch
§ Inferior border of the parietal lobe is continued as an
imaginary line continuing the lateral sulcus to the posterior
border
• Preoccipital Notch/Temporooccipital Fissure
® Separates the parietal and temporal lobes from the
occipital lobe
® Small extension and small indentation on the lateral inferior
margin of the cortex

Figure 10. Major and Minor Lobes, sulci, and fissures.

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® “Even though, strictly speaking, the structures of the


limbic system are part of the frontal, parietal, and temporal
lobes, as far as the function of the limbic system is
concerned, they are part of the limbic lobe” (Esguerra, 2018)

Figure 13. Insular and limbic lobe

Figure 14. Major and minor lobes of the brain

Structures on the cerebral surface

Figure 12. Central Sulcus (of Rolando), Lateral Fissure/ sulcus (of
Sylvius), Parietoocipital Sulcus, and the Precentral & Postcentral
Sulculs and the Preoccipital Notch in Left (Top figure) and Right (middle
and bottom fig.) cerebral hemispheres.

Minor Lobes
• Central Lobe / Insular Lobe / Island of Reil
® Not visible on the outside
® Revealed by separating the lateral sulcus
® Superomedial surface of the temporal lobe will also be seen
® Opercular portions – portions of the frontal, parietal, and
temporal lobes overlying the insula that form the lips of the
lateral sulcus
® Functions with regards to consciousness and control of
emotions
• Limbic Lobe

® Not really an identifiable lobe but more of structures that Figure 15. Sulci and Gyri
are functionally related and involved in the limbic system
® Consists of a dorsally cingulate gyrus, the ventrally located • Central Sulcus – separates the frontal and parietal lobe
parahippocampal gyrus and a narrow cortical area that • Precentral Sulcus – found anterior to the precentral gyrus
connects them, the isthmus • Postcentral Sulcus – found posterior to the postcentral gyrus
® The Hippocampus and dentate gyrus are also parts of the • Precentral Gyrus – found anterior to the Central Sulcus of
limbic lobe, but cannot be seen unless the temporal lobe is Rolando
further dissected

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• Postcentral Gyrus – found posterior to the Central Sulcus of • Hypothalamus


Rolando ® Below the Thalamus
• Lateral/Longitudinal (Sylvian) Fissure – separates the ® Produces hormones related to the endocrine system such as
temporal lobe from frontal and parietal lobe the pituitary gland
• Interhemispheric Fissure – divides the cerebrum into 2 ® Functions in conjunction with other parts of the nervous
hemispheres. Deep groove separating the 2 cerebral system such as those involved in emotion as well as the ANS
hemispheres is called the longitudinal cerebral fissure • Brainstem
® 3 Parts: Midbrain, pons, and medulla
Structures in the sagittal section of the brain • Cerebellum (posterior view)

rd
Thalamus in (3
Ventricle)

Hypothalamus

Brainstem
Cerebellum

Figure 16. Parts of the corpus callosum

• Corpus Callosum / Callosal Commissure


® Band of white matter that connects the right and the left
hemispheres
® Parts: Rostrum, Genu, Body, and Splenium Figure 17. Sagittal section of the brain showing the medial surface of the
® Composed of commissural nerve fibers (myelinated axons) diencephalon.
connecting either cerebral hemisphere
• Cingulate Cortex
® Situated in the medial aspect of the cerebral cortex
® Forms a major part of the limbic system
® Has functions in emotion and behavior
® Includes the entire cingulated gyrus, and cingulated sulcus
§ Cingulate Gyrus – found immediately above the corpus
callosum; begins beneath the anterior end of the corpus
callosum and continues above the corpus callosum until it
reaches its posterior end
§ Cingulate Sulcus – above cingulated gyrus; separates
the cingulate gyrus from the superior frontal gyrus
§ Callosal Sulcus – separates the cingulate gyrus from the
corpus callosum
• Parietooccipital Sulcus (already mentioned)
• Calcarine Fissure
® A deep fissure found at the medial aspect of the occipital
lobe
® Important landmark to identify the visual cortex
® It is in the area surrounding this fissure that we process what
we see (visual stimuli)
® Surrounding this is the visual association cortex

Structures inferior to the Corpus Callosum


• Diencephalon
• Thalamus
® The interthalamic connection / interthalamic adhesions Figure 18. Horizontal section of the brain that shows the third and lateral
connect the two thalamus just like how the corpus callosum ventricles
connects the two cerebral hemispheres
• Third ventricle Structures in the inferior surface of the brain
® Fluid-filled ventricle that is part of the ventricular system in • Median Longitudinal/Sagittal Fissure – separates the right
which cerebrospinal fluid is produced and left cerebral hemispheres
• Optic Chiasm – crossing of fibers of your optic nerve
• Uncus
® Curved part/ bump on the anterior part of the hippocampal
gyrus which is anatomically part of the temporal lobe, but is
considered to be a part of the limbic system

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® Clinically important: may be involved in cases of C. FUNCTIONAL AND BRODMANN AREAS


hemorrhage • German anatomist named Korbinian Brodmann (1898-1918)
® Supratentorial part of the brain. identified 47 different areas of the cerebral cortex associated
® In cases of hemorrhage, wherein the brain is pushed down with specific neurologic functions and distinguished by different
into the foramen magnum, there is an increased intracranial histological cellular components.
pressure causing the uncus to be pushed toward the • Numbered in the sequenced in which they were studied and
brainstem (uncal herniation). This may cause breathing and not according to area.
heart action to stop, thereby causing death • Areas with similar specific neurologic functions are referred to
• Olfactory bulb and Tract – pass through the cribriform plate of as single functional cortical area.
the nose
® the limbic system
Longitudinal
Fissure

Optic
Chiasma

Uncus

Figure 21. Brodmann areas of the brain

Some Important Functional Cortical Areas


• Primary Cortical Areas
® Primary Motor Complex
§ BA 4
§ Found at the Pre-central Gyrus (anterior to central sulcus)
® Primary Somatosensory Cortex
§ BA 3, 1, 2 (numbered as such because of how it is
arranged at the central sulcus)
§ Found at the Post-central Gyrus (posterior to the central
Figure 19. Inferior view of the brain sulcus)
§ Important for the GSA (General Somatic Afferent Fibers)
Longitudinal Cerebral § Also called the Primary Somesthetic Center
Fissure ® Primary Auditory Cortex
Olfactory Bulb § BA 41, 42
§ Found at the Anterior Transverse Temporal Gyrus (of
Olfactory Tract
Heschl)
Olfactory Chiasm ® Primary Visual Cortex
§ BA 17
§ Found at the Calcarine area (at the occipital pole)
§ Also called the Calcarine Cortex
• Association Areas – Process the work of primary cortical area.
Ex: The primary motor complex tells your body that you have to
move. The premotor area processes what type of movement
and how it will go; “plans the movement”.
® Premotor Area
§ BA 6
Uncus § At area anterior to the Precentral gyrus
§ Catalogs what you see
® Visual Association Area
§ BA 18, 19
§ At the area surrounding the Primary Visual Area
§ Processes and interprets what you see
® Motor Speech Area (of Broca)
§ BA 44, 45
§ At inferior Frontal Gyrus
§ Controls how you speak
§ Problem: you know what to say but you can’t express it
properly. (Ex. Mr. Bean)
® Auditory Association Area (of Wernicke)
§ BA 22
Figure 20. Inferior view of the brain (cerebellum and brainstem removed)
§ At posterior part of superior temporal gyrus
§ Where you interpret the meaning of what you have heard
§ Problem: you don’t understand what another person is
telling you. (Ex. Winnie the Pooh)

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Summary of Important Cortical Areas (in terms of • Schematic representation of human body on a specific area
location): of the CNS
Table 5. Frontal Lobe • e.g. the sensory/motor areas of the cerebral cortex, with
Gyrus Name Brodmann Function respect to its relative weight dedicated to each body region
Area • The size of each body part in the figure shows how much
Pre-central Primary 4 Movement area of the brain is devoted to it
Motor Cortex ® Ex: the lips and tongue are so large as compared to the
Parts of: Pre-Motor 6 Movement knee. This is because a person’s lips and tongue are
- Superior Frontal Area Planning specialized for making small and precisely controlled
- Middle Frontal movements as compared to your knee which makes larger
and less precise movements.
- Pre-central
Inferior Frontal Motor 44-45 Motor ® The bigger the representation of the organ, the richer the
Speech Area Aspect of innervation in its corresponding area in the cortex.
(of Broca) Speech
E. THALAMUS
Table 6. Parietal Lobe • Large ovoid mass of gray matter
Gyrus Name Brodmann Function • Dorsal and largest portion of the diencephalon (the thalamus
Area is its largest part)
Post- Primary Somatosensory 3, 1, 2 General • A pair on either side of the 3rd ventricle connected in the
central Cortex/ Primary Somatic midline by the interthalamic adhesions/connections at
Somesthetic Center Afferent midline
Fibers • Covered by white matter:
® superiorly by the stratum zonale
Table 7. Temporal Lobe ® laterally by the external medullary lamina :
Gyrus Name Brodmann Function • Divided into 3 parts (Anterior, Medial, and Lateral) by the
Area internal medullary lamina (y-shaped)
Anterior Primary 41-42 Auditory Input ® Within the internal medullary lamina, there are nuclear
Transverse Auditory Cortex groups (+ intralaminar group) that send to and receive
Temporal impulses from specific parts of the CNS.
Gyrus (of • Functions:
Heschl) ® Relay center for sensory impulses (EXCEPT SMELL)
Superior Auditory 22 Speech ® Modifies and integrates afferent impulses
Temporal Association Comprehension ® Adds emotional tone
Area (of § Receives impulses for sensation then sends this
Wernicke) information to the cortex and basal nuclei already modified
and integrated (tells the cortex and basal nuclei what the
Table 8. Occipital Lobe
sensation means)
Gyrus Name Brodmann Function
® Regulates cortical activity
Area
Parts of: Primary 17 Visual Input
- Cuneus Visual Area
- Lingual
Parts of: Visual 18-19 Interpretation
- Cuneus Association of Visual
- Lingual Area Input
- Middle occipital

D. HOMUNCULUS: SENSORY AND MOTOR

Figure 23. Position of thalamus in the brain

Figure 22. Motor and Sensory homunculus. Motor homunculus (L)


represents the pre-central gyrus and tells the muscles being
supplied/innervated by a certain area of the brain. Sensory homunculus
(R) represents the post-central gyrus and shows the relative amount of
innervation for sensation. Figure 24. Thalamus (from Netter)

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F. HYPOTHALAMUS
• Located above the midbrain and below the thalamus
• Makes up the ventral diencephalon
• Extends from the optic chiasm to the caudal border of the
mammillary bodies and lies below the hypothalamic sulcus on
the lateral wall of the 3rd ventricle
• Controls and integrates the ANS and endocrine system
• Plays a vital role in maintaining body homeostasis
® emotional states
® fat, carbohydrate, and water metabolism
® Body temperature, genital functions, sleep, & food intake
® Release of pituitary hormones (closely associated with the
pituitary gland)

Figure 27. Caudate Nucleus of the Basal Ganglia Caudate Nucleus, Globus
Pallidus, Putamen.

H. CEREBELLUM

Figure 25. Hypothalamus (from Netter)

G. BASAL NUCLEI (GANGLIA)

Figure 28. (top) Superior surface of the Cerebellum (bottom) inferior


surface of the Cerebellum

• Also known as the “little brain” and is responsible for


maintaining equilibrium
• Located at the base of the brain, behind the dorsal aspects of
the pons and medulla
• Part of the hindbrain, connected to the pons by means of 3
pairs of cerebellar peduncles

Figure 26. Horizontal sections through cerebrum: It was emphasized


during the lecture that it is important to be able to identify the different parts
of the Basal Ganglia in this view of the brain.

• Large collections of neurons deep in the cerebral


hemispheres
• It is comprised of the Corpus Striatum, Amygdaloid Nucleus,
and Claustrum Figure 29. Section in plane of superior cerebellar peduncle
• Involved in control of motor activity, closely associated with
the primary motor cortex • Has ridges and folds called folia (like the gyri of the
• The major nuclei (Corpus Striatum) is comprised of: cerebrum)
® Caudate Nucleus • Main anatomical features:
® Putamen (Part of Lentiform Nucleus) ® Anterior (red) and Posterior (green) Lobes
® Globus pallidus (Part of Lentiform Nucleus) ® Flocculonodular lobe seen in the inferior view
® Vermis (ridge between the hemispheres)

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® Hemispheres - Posterior or Dorsal Median Sulcus – separates the


• Like the cerebrum, the cerebellum has a cortex and deep two fasciculus gracilis
cerebellar nuclei - Posterior or Dorsal Intermediate Sulcus – separates
® Outer part (gray matter) = Cerebellar Cortex the gracilis from the cuneatus
® Collection of nuclei (4) in the middle (white matter) = deep § 4 Dorsal Column Tubercles – eminences at the
cerebellar cortex termination of the fascicles which represent the nuclei or
nerve cell bodies underneath
I. BRAINSTEM - Tuberculum gracilis – also called clava; gracile nuclei
• Serves as a connection between the brain and spinal cord is underneath
• Conduit for ascending and descending tracts - Tuberculum cuneatus – cuneate nuclei underneath
• Contains important reflex control centers related to the § 4th Ventricle – space between the brainstem and
respiratory system, cardiovascular system, and consciousness cerebellum (roof) forming the diamond-shape floor called
rhomboid fossa
• Contains the nuclei for cranial nerves III to XII
§ 4 Colliculi
• Located inferior to the cerebrum and anterior to the cerebellum
- Superior pair- associated with controlling eye
• In relation to the tentorium cerebelli, the brainstem is
movement
infratentorial
- Inferior pair- associated with sound processing
® Cerebrum is supratentorial
• Made up of 3 parts (from ROSTRAL to CAUDAL)
® Midbrain
® Pons
® Medulla Oblongata
• The pons and medulla oblongata together are referred to
as the Bulbar Region
Some authors consider the diencephalon (thalamus,
hypothalamus, and epithalamus) as part of the brainstem, but most
authors do not. For our purposes, the brainstem will NOT include
the diencephalon.

Figure 31. Dorsal view of brainstem

® 3 parts of Cerebellar Peduncles – connects cerebellum


§ Superior – brachium conjunctivum
§ Middle – brachium pontis
§ Inferior – restiform + juxtarestiform bodies
® Origin of the 4th Cranial Nerve
§ “Mustache” above the pons (posterior view)
§ Only CN that will arise from dorsal surface
§ Arises caudal to the inferior colliculus in the area of the
junction of the midbrain and pons, courses around the
brainstem then goes to the ventral surface to exit the skull
® Medullary Veli – completes the roof of the 4th ventricle
§ Superior and inferior (posterior) to form part of the roof of
the 4th ventricle
§ From the rostral end at midline, note the medial eminence
(floor of 4th ventricle) terminating at the middle of the 4th
ventricle with the Facial Colliculus (“bump” on the lower
end)
§ Sulcus limitans – the groove lateral to the medial
eminence and facial colliculi
® Striae medullares of the 4th Ventricle
§ Also a “mustache”
§ Ridges formed by fibers passing towards the cerebellum
§ Laterally: mark the location of the lateral recesses where
the Foramina of Luschka (openings of the 4th ventricle)
allow CSF to exit the subarachnoid space.
Figure 30. (top) Posterolateral view of the Brainstem (bottom) Anterior view ® Vestibular Area/ Area Vestibularis
of the Brainstem § Above striae medullares
§ Forms the lateral third of the floor of the 4th ventricle
External Features of the Brainstem (lateral to sulcus limitans)
§ Underneath is the vestibular nuclei of the
• Dorsal View
vestibulocochlear nerve (CN VIII)
® Four Major Landmarks
® Two other swellings: (Below Striae Medullares)
§ 4 Dorsal Columns- direct extensions of white matter from
§ Medial ridge or Hypoglossal Trigone – indicates
the dorsal funiculus of the spinal cord are the two pairs of
location of the hypoglossal nucleus
medial fasciculus gracilis and two pairs of the lateral
§ Lateral ridge or Vagal Trigone – indicates location of the
fasciculus cuneatus
dorsal motor nucleus of the CN X

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§ Both trigones are medial to sulcus limitans - CN XII – in between pyramid and olive
® Facial Colliculus
§ Underneath is the nucleus for the Abducens Nerve Cross-Sectional Anatomy (Handout of Dr. Esguerra)
§ Called the “facial” colliculus because the motor fibers of • Identify the important internal structures (appearance and
the facial nerve are the ones that pass on top of the location of specific nuclei and nerve tracts) at the representative
abducens nucleus and the colliculus sections of the brainstem.
® Obex • The cross-section of the brainstem is divided into 3 regions:
§ Caudal end of the 4th ventricle as it continues as the ® Tectum – the roof
central canal in the caudal medulla and spinal cord ® Tegmentum – the cover or floor
§ Foramen of Magendie - single dorsal midline opening of ® Basis – the base
the obex where CSF exits into the cisterna magna

Figure 33. Rostral midbrain

Figure 32. Ventral view of brainstem

• Ventral View
® Origins of the cranial nerves III to XII except CN IV which
arises from the dorsal surface.
® Four Major Landmarks:

§ 2 Pyramids
- Contain axons of the corticospinal tract of the motor
system carrying signals from the cerebral cortex to the
spinal cord Figure 34. Transverse section of the midbrain at the level of the superior
- Note the area in the caudal medulla where these axons colliculus
cross the middle (decussate) to the contralateral side
- Anterior or ventral median fissure – separates the
two pyramids
§ Olives
- Eminences lateral to the pyramids which indicate the
area of the inferior olivary nucleus
- Inferior olivary nucleus – receive and transmit
impulses towards the cerebellum
- Pre-olivary sulcus - groove medial to the inferior
olivary nucleus which separates it from the pyramids
- Post-olivary sulcus – groove lateral to the inferior
olivary nucleus
§ Basal surface of the pons
- Also called basis pontis
§ Cerebral peduncles
- Also called basis pedunculi Figure 35. Photomicrograph of a transverse section of the midbrain at the
- At the area of the midbrain level of the superior colliculus
- Carry axons of the corticospinal tract from the
cerebrum to the brainstem through the base of the • Rostral (Upper) Midbrain
pons to emerge on the medullary surface as the ® Cut at the level of the superior colliculus
pyramids ® 3 regions: tectum, tegmentum, and basis pedunculi
® Origins of CN III, V, VI, VII, VIII, IX, X, XI, XII ® Fluid cavity: Cerebral aqueduct (of Sylvius) or Iter
§ VI, VII, VIII (surrounded by periaqueductal gray matter)
- Corticomedullary Junction ® Tectum
- CN VII has 2 components § Superior colliculus
- CN VIII will become the vestibular and cochlear nerve § Mesencephalic nucleus of CN V
in the inner ear ® Tegmentum
§ IX, X, XI, XII § Edinger-Westphal + Oculomotor nuclei
- CN XI – has contribution from the spinal cord (spinal § Medial longitudinal fasciculus (MLF)
accessory nerve) § Red nucleus

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§ Medial lemniscus § Spinal lemniscus


§ Spinal lemniscus § Lateral lemniscus
® Basis Pedunculi ® Basis pontis
§ Substantia nigra § Pyramidal tract (Corticospinal and Corticobulbar)
§ Pyramidal (Corticospinal and Corticobulbar) tract § Pontine nuclei
§ Origin of CN III § Pontocerebellar fibers
§ Middle cerebellar peduncle
• Caudal (Lower) Midbrain
® Cut at the level of the inferior colliculus
® 3 regions: tectum, tegmentum and basis pedunculi
® Fluid cavity: Cerebral aqueduct (surrounded by
periaqueductal gray matter)
® Tectum
§ Inferior colliculus
§ Mesencephalic nucleus of CN V
® Tegmentum
§ Trochlear nucleus (of CN IV)
§ MLF
§ Superior cerebellar peduncle decussation
§ Reticular formation
§ Medial lemniscus
§ Spinal lemniscus
® Basis pedunculi
§ Substantia nigra
§ Pyramidal (Corticospinal and corticobulbar) tract Figure 38. Transverse section through the pons at the level of the
trigeminal nuclei

Figure 36. Transverse section of the midbrain at the level of the inferior Figure 39. Photomicrograph of a transverse section of the pons at the level
colliculus of the trigeminal nuclei

Figure 37. Photograph of a transverse section of the midbrain at the level of


the inferior colliculus
Figure 40. Photograph of a transverse section of the most rostral part of the
• Rostral (Upper) Pons pons
® Fluid cavity: 4th ventricle
• Caudal (Lower) Pons
® No tectum
® Cut at the level of the facial colliculus
® Roof formed by cerebellum, superior medullary velum, and
superior cerebellar peduncle ® Fluid cavity: 4th ventricle
® Tegmentum (Floor of 4th ventricle) ® Roof: Cerebellum
§ MLF ® Tegmentum (Floor of the 4th ventricle)
§ Reticular formation § MLF
§ Motor and main sensory nuclei of CN V and fibers § Tectospinal tract
§ Superior vestibular nucleus § Facial colliculus (Abducens nucleus of CN VI with nerve
§ Medial lemniscus fibers from the Facial motor nucleus (of CN VII))

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§ Sulcus limitans § Spinal nucleus and tract of CN V


§ Superior and lateral vestibular nuclei (CN VIII) § Inferior cerebellar peduncle
§ Spinal nucleus and tract of CN V ® Deep tegmentum:
§ Anterior spinocerebellar tract § Medial lemniscus
® Deep tegmentum § Pyramidal (Corticospinal) tract
§ Medial lemniscus § Origin of CN XII
§ Trigeminothalamic tract § Pre- and Post- Olivary sulci
§ Spinal lemniscus § Olivary nuclei (inferior- underneath the olives, dorsal
§ Lateral lemniscus and medial)
§ Facial motor nucleus of CN VII § Nucleus ambiguus (CN IX/X/XI-motor)
® Basis pontis § Reticular formation
§ Pyramidal tract § Spinal lemniscus
§ Pontine nuclei § Spinocerebellar and rubrospinal tracts
§ Pontocerebellar fibers
§ Middle cerebellar peduncle
® Medial pontine tegmentum
§ MLF & tectospinal tract
§ Facial colliculus
§ Abducens nucleus (CN VI) and facial motor fibers of CN
VII

Figure 43. Transverse section of the medulla oblongata at the level of the
middle of the olivary nuclei

Figure 41. Transverse section through the caudal part of the pons at the
level of the facial colliculus

Figure 44. Transverse section of the medulla oblongata at the level of the
superior part of the olivary nuclei just inferior to the pons

Figure 42. Caudal Pons

• Rostral (Upper) Medulla


® Called “Open” medulla at this level due to presence of 4th
ventricle
® Roof: Inferior medullary velum
® Tegmentum (Floor): Figure 45. Rostral medulla
§ MLF
§ Tectospinal tract • Middle Medulla
§ Hypoglossal nucleus (of CN XII) ® Called “Closed” medulla; 4th ventricle replaced by central
§ Dorsal motor nucleus of CN X canal
§ Sulcus limitans ® Medial tegmentum
§ Solitary nucleus (CN VII, IX, X for taste) § Dorsal motor nucleus of CN X
§ Medial and inferior vestibular nuclei § Hypoglossal nucleus (CN XII)

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§ MLF ® Pyramidal (motor) decussation


§ Tectospinal tract ® MLF and Tectospinal tract pushed laterally
§ Medial lemniscus ® (Spinal) accessory nucleus and fibers of CN XI
§ Pyramidal tract ® Dorsal columns and nuclei (gracilis and cuneatus)
® Lateral tegmentum ® Spinal nucleus and tract of CN V
§ Solitary nucleus ® Anterior + Posterior spinocerebellar tracts
§ Nucleus and fasciculus gracilis + nucleus and fasciculus ® Anterior + Lateral spinothalamic tracts
cuneatus ® Lateral vestibulospinal tract and rubrospinal tract
§ Lateral (accessory) cuneate nucleus
§ Spinal nucleus and tract of CN V
® Deep tegmentum
§ Reticular formation
§ Nucleus ambiguus
§ Internal arcuate fibers (sensory decussation)
§ Inferior and accessory olivary nuclei
§ Spinal lemniscus
§ Anterior spinocerebellar tract and rubrospinal tract

Figure 49. Caudal Medulla

Positions of Cranial Nerve Nuclei in the Developing


Neural Tube
• The mantle layer (when nerve cell bodies are found) of the
cross-section of the developing neural tube is divided into a pair
Figure 46. Transverse section of the medulla oblongata at the level of of dorsal alar plates and a pair of ventral basal plates separated
decussation of the medial lemnisci by the sulcus limitans
• Nuclei for sensory or afferent components
® Located in the alar plate
• Nuclei for motor or efferent components
® Located in the basal plate
• As the brainstem develops, the central canal enlarges to form
the 4th ventricle rotating the dorsal portion laterally
® Motor nuclei medial to the sulcus limitans
® Sensory nuclei lateral to the sulcus limitans
• Nuclei with special functions (motor muscle of the branchial
origin, special senses of taste, hearing and balance) also arise
and migrate to their designated areas
• These nuclei of similar functions are aligned in relatively the
same nerve column through the brainstem and follows through
to the spinal cord

Brainstem Rule of “4”


Figure 47. Middle Medulla • 4 medial structures starting with “M”
® Motor (corticospinal) pathway
® Medial lemniscus
® Medial longitudinal fasciculus
® Motor nuclei & nerves
• 4 side (lateral) structures starting with “S”
® Spinocerebellar pathway
® Spinothalamic pathway
® Sensory CN V nuclei
® Sympathetic pathway
• 4 CN in medulla, 4 CN in pons, 4 CN above pons
• 4 motor nuclei in medial brainstem divide equally into 12
(except 1 & 2): 3, 4 6, 12

J. SPINAL CORD
• Surrounded by the 3 meninges:
Figure 48. Transverse section of the medulla oblongata at the level of ® Dura mater
decussation of the pyramids ® Arachnoid mater
® Pia mater
• Caudal (Lower) Medulla • Subarachnoid space is surrounded by cerebrospinal fluid for
® At the spinal cord-medullary junction further protection

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• Composed of an inner core of gray matter, surrounded by an ® T1 is BELOW T1 vertebrae


outer covering of white matter ® L1 is BELOW L1 vertebrae
External Features of Spinal Cord • Lumbar and sacral nerve roots descend within lumbar and
• Elongated cylindrical structure in vertebral canal 35-40 cm long cistern before reaching respective IV foramina and form
• Extends from foramen magnum (continuous with medulla) to the cauda equina
lower border of L1 vertebra • Naming of spinal nerves
• Continuous with the medulla oblongata of the brain ® C1-C7: ABOVE the vertebra
• 2 enlargements: Cervical and Lumbar ® C8: between C7 and T1
® Cervical: due to brachial plexus which arises from this region ® T1 downwards: BELOW the vertebra
® Lumbar (Lower thoracic and lumbar): due to the lumbosacral
plexus from this region
• Conus Medullaris: conical termination where the spinal cord
tapers off
• Filum terminale: connective tissue that is a prolongation of pia
matter, penetrating dura mater at S1-S2 as coccygeal ligament
• Cauda Equina: formation of spinal nerve roots descending from
conus
• Has 31 pairs of spinal nerves, formed by dorsal and ventral
roots

Figure 51. Spinal Nerve

Spinal Cord Cross-section


• Spinal nerve roots
® Dorsal or posterior (sensory)
® Ventral or anterior (motor)
• Gray and white matter

Figure 50. Spinal Cord

Developmental Changes
• Occupies only upper 2/3 of adult vertebral canal
• 3rd month of fetal life: rate of growth is higher in vertebral
column than in spinal cord
• At birth: L2-L3 IV disc; Adult: L1-L2 IV disc
• Clinical significance: lumbar puncture (spinal taps)
® L3-L4: adults
® L4-L5: children

Spinal Nerves
• Has 31 pairs of spinal nerves, formed by dorsal and ventral Figure 52. Cross-section of the anatomy of the spinal cord
roots
® 8 cervical ® Gray Matter
® 12 thoracic § Centrally located H-shaped pillar with ventral (anterior)
® 5 lumbar and dorsal (posterior) gray columns/ enlargements
® 5 sacral called dorsal and ventral horns
® 1 coccygeal - These are united by a thin gray commissure
® Note that 31 pairs means there are a total of 62 spinal containing the small central canal
nerves § Contains groups of neurons/ unmyelinated nerve cell
• C1 spinal nerve exits between atlas and occipital bone bodies
® C1 spinal nerve is ABOVE C1 vertebrae § Small lateral horns are present in the thoracic and
upper lumbar (L1-L2/L3) segments where cell bodies of
® C7 is ABOVE C7 vertebrae
the preganglionic neurons of the sympathetic nervous
• C8 emerges between C7 and T1 vertebrae system are located
® C8 is BELOW C7 vertebrae o Note: Lateral horns of the thoracic segment are
• Spinal nerves starting from T1 going down emerge from the NOT found on any other vertebra
IV foramina below the vertebra of the same number

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§ The amount of gray matter and the amount of muscles § Neurons that innervate the skeletal muscles have
innervated at a vertebral level are related greater masses on the limbs as compared to the trunk
- Cervical and lumbar enlargements have the greatest ® Cervical regions have more white matter than
size of gray matter since they innervate the upper and lumbosacral regions because all fibers connecting the
lower limbs, respectively. entire cord to the brain are passing through this region

Table 9. Spinal cord segments


Spinal Cord Segments
Cervical • More amount of white matter
• Large ventral horns
Thoracic • Lateral horns are present
• Small ventral horns
Lumbar • Less relative amounts of white
matter
• Large ventral horns
Sacral • Large ventral horns

Figure 53. White and gray matter

® White Matter
§ Periphery
§ Carries the different fiber tracts to and from the spinal
cord which are arranged in specific regions in particular
funiculi
§ Myelinated axons either ascending and descending
§ Three funiculi:
- Anterior (Ventral)
- Lateral
- Posterior (Dorsal)
§ Sulci/ Fissures marking the surface:
- Anterior/ Ventral Median Fissure (Deep)
o Located between 2 ventral funiculi
- Antero-/ Ventro-Lateral Sulcus
o Located between ventral and lateral funiculi
o Where ventral root fiber arises
- Postero-/ Dorso-Lateral Sulcus
o Are between dorsal and lateral funiculi
o Where dorsal root fibers enter
- Posterior/ Dorsal Intermediate Sulcus
o Located in cervical and 5 thoracic segments
o Divides each dorsal funiculus into 2 white
columns: inner gracile & outer cuneate fascicles
- Posterior/ Dorsal Median Sulcus (Shallow)
o Located between 2 dorsal funiculi
§ There is a ventral white commissure deep in the
ventral median fissure beside the gray matter,
surrounding the central canal
§ Gracile and cuneate fascicles can only be found up to
T6 upwards, supplying the upper limbs. Below the 6th Figure 54. Spinal Cord Segments
thoracic, it is only the gracile fasciculus that would be
supplying the lower limbs K. REXED LAMINAE
• When the cord is cut along its length (longitudinally), nuclei in
Spinal Cord Segments the gray matter are arranged in cell columns or laminae
• By comparing the composition and proportion of the gray & • 10 laminae according to cell structure and have consistent
white matter, one can differentiate the segments of the SC: location
® Ventral horns in gray matter are larger in cervical and • Laminae I-VI: Dorsal horn
lumbar segments Lamina VII: Intermediate gray horn
Laminae VIII & IX: Ventral horn
Lamina X: Surrounding the central canal

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III. NEUROANATOMICAL CORRELATION


A. CLINICAL NEUROLOGIC DIAGNOSIS
• Steps in Clinical Neurologic diagnosis
1. Recognition of impaired neurologic function
2. Identification of the affected site of the nervous system, i.e.
localization
3. Definition of the most likely etiology (with list of differential
diagnoses)
4. Use of ancillary diagnostic procedures to determine/confirm
the diagnosis

B. RECOGNITION OF IMPAIRED FUNCTION


• Dependent on:
® Very good history and physical examination
® By experience, recognition of normal and abnormal neurologic
function
Figure 55. Rexed Laminae
• Questions to ask:
Table 10. Rexed Laminae
® Is the dysfunction real?
Dorsal Horn ® To what extent is the dysfunction pathologic, i.e. warranting
formal diagnostic evaluation?
Lamina I & II • High concentrations of substance P
® Is the dysfunction neurologic in origin?
and opiate receptors
• Cells to noxious & thermal stimuli
Lamina II & III • Form the substantia gelatinosa:
C. NEUROANATOMY: THE KEY TO LOCALIZATION
transmission of pain stimuli • Two broad aspects of Neuroanatomy:
Lamina IV • Neurons to low intensity stimuli ® Morphology of the structures
(light touch) ® Their functional representation (i.e. function mediated by
the structures)
Lamina VI • Present only in cord enlargements
- Cervical: nucleus centrobasalis is • Neuroanatomy provides the road map for localization:
important for the cerebellar pathways ® Injury is expressed through neurologic dysfunction; the
and coordination of movement dysfunction can lead towards identification of the source of the
• Balance injury
® Combination of dysfunctions which affect different systems
Lamina V • Contains wide dynamic range
can identify the site of the lesion, most likely at the
(WDR) tract neurons, which can
intersection where their pathways meet
accept stimuli from different
modalities • Injury or lesion involving lower levels of nervous system:
• Processing afferent stimuli from ® Localization tends to be more precise
cutaneous/muscle & visceral ® Tends to produce findings that change little over time, i.e.
nociceptors more consistent or easier to elicit.
• Site of viscerosomatic • Neurologic examination more important than history in
convergence (referred pain) anatomical localization; the history (or temporal evolution of
Intermediate Gray Horn identified deficits) important in defining precise etiology
• Neurologic disease can result in discrete or multiple lesions/
Lamina VII • Intermediolateral nucleus
systemic dysfunction
- T1-L2/L3 (lateral horn):
preganglionic sympathetic fibers ® Cerebrovascular disease
- S2-S4: preganglionic § Most common condition producing single or discrete
parasympathetic fibers lesions
• Intermediomedial nucleus ® Infection, trauma and tumors
- Receives some dorsal root fibers § Also can produce discrete but also multiple lesions
from visceral afferents ® Degenerative disorders
- Nucleus dorsalis (of Clarke): for § More complicated to localize
posterior spinocerebellar tract
(T1-L2) REVIEW QUESTIONS
Lamina X • Gray matter surrounding the central 1. Which of the following structures are made up of
canal predominantly white matter?
Ventral Horn a. Caudate nucleus
b. Corpus callosum
Lamina VIII • Motor neurons
c. Dorsal horn of the spinal cord
• Receives fibers from descending
d. Thalamus
tracts and sends commissural axons
2. Which of the following structures, by definition, is a bundle of
to opposite side
axons with a common origin and termination in the central
Lamina IX • Contents nervous system?
- α – motor neurons: striated a. Brachium b. Peduncle
muscles c. Plexus d. Tract
- Υ-motor neurons: intrafusal fiber of
muscle spindles 3. Which lobe would only be revealed when the opercular
• Medial nuclear group: long & short portions of the frontal and temporal lobes are spread apart on
axial muscles the lateral cerebral hemisphere?
• Lateral nuclear group: remaining a. Central b. Limbic
musculature at the body wall and c. Occipital d. Parietal
appendicular muscles at cord
enlargements

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4. Which of the following sulci/fissures is BEST found on the


lateral surface of the cerebrum?
a. Calcarine
b. Central
c. Cingulate
d. Parietooccipital

5. Which of the following structures forms part of the bulbar


region of the brainstem?
a. Cerebellum
b. Diencephalon
c. Midbrain
d. Medulla oblongata

6. From which of the following grooves of the spinal cord do the


ventral root fibers of spinal nerves emerge?
a. Anterior median fissure
b. Anterolateral sulcus
c. Posterior intermediate sulcus
d. Posterolateral sulcus

7. A medical student would like to attempt a lumbar puncture


(spinal tap) to obtain cerebrospinal fluid from an adult patient
with suspected meningitis. If he inserts the spinal needle
midline at the space between the L2 and L3 vertebrae, which
of the following structures could the needle hit or most
closely pass by?
a. Cauda equina from the cord
b. Coccygeal ligament
c. Insertion of the filum terminale at the dura mater
d. Tip of the conus medullaris

8. Which of the following Rexed laminae is the site of


viscerosomatic convergence responsible for the referred pain
phenomenon?
a. II
b. V
c. VII
d. IX

9. Which of the following functional component fibers elicits


bilateral contraction of pharyngeal muscles evoked by
touching the posterior pharyngeal wall?
a. General somatic efferent
b. General visceral efferent
c. Special somatic efferent
d. Special visceral efferent

Aswers: b,d,a,b,d,b,a,b,d

REFERENCES
[Anatomy] 2018/15/03. Nervous System Organization. Dr.
Esguerra

(1) Gilman, S. and Newman, S. W. Manter and Gatz’s Essentials


of Clinical Neuroanatomy and Neurophysiology, 10th ed., F. A.
Davis co., 2003.
(2) Snell, R. S. Clinical Neuroanatomy, 7th ed., Lippincott Williams
and Wilkins, 2010.
(3) Haines, D. E. Neuroanatomy: An Atlas of Structures,
Sections, and Systems, 8th ed., Lippincott Williams and Wilkins,
2012.
(4) Moore, K. L., et al. Clinically Oriented Anatomy, 6th ed.,
Lippincott Williams and Wilkins, 2010.
(5) Netter, F. et al., Atlas of Neuroanatomy and
Neurophysiology. ICON Custom Comm., 2002.
(6) 2020B Trans
(7) Handout from the lecture
(8) Lecture recordings

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