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Used with permission of the Academy of
Neurologic Physical Therapy
of the APTA
Do not duplicate without acknowledging
Learning Activity author
Michael McKeough, PT, EdD
Contents
Overview
Introduction
Learning Objectives
Instructions
Legend
Read these Instructions!
Review of functional systems in the spinal cord
Lateral corticospinal tract
Dorsal column-medial lemniscal system
Lateral spinothalamic tract
Lesion lessons
Dorsal column lesion
Transverse cord lesion
Fasciculus gracilis lesion
Hemicord lesion
Fasciculus cuneatus lesion
Central cord syndrome
Lateral corticospinal tract lesion
Lateral spinothalamic tract lesion Anterior cord syndrome
Posterior cord syndrome
Patient Cases
Case 1
Case 2
Case 3
Fasciculus gracilis
gracilis: light touch,
vibration, and position sense
from the contralateral leg and
lower trunk
Fasciculus Gracilis
Consists of a 3-neuron
projection system extending
from receptors in the periphery
to the primary somatosensory
cortex (Click neuroanatomical
explanation)
Click to animate
Fasciculus cuneatus
Contents Functional Systems Lesions Patient Cases Exit
Fasciculus Gracilis:
Neuroanatomical Description
First-order neurons
Cell body: dorsal root ganglion (DRG)
Distal axon: innervates mechanoreceptors in
leg and lower trunk via peripheral nerves
Proximal axon: enter dorsal column (fasciculus
gracilis), ascend ipsilaterally and terminate in
the nucleus gracilis
Second-order neurons
Cell body: nucleus gracilis
Axon: decussates in the medulla and projects
to the contralateral thalamus (ventral
posterior lateral nucleus, VPL) via the medial
lemniscus
Third-order neurons
Cell body: VPL of thalamus
Axon: ascends via the posterior limb of the
internal capsule and terminates in the
primary somatosensory cortex
Fasciculus Cuneatus
Fasciculus cuneatus: light
touch, vibration, and position
sense from the contralateral
arm and upper trunk
Consists of a 3-neuron
projection system extending
from receptors in the
periphery to the primary
somatosensory cortex (Click
neuroanatomical explanation)
Click to animate
First-order neurons
Cell body: dorsal root ganglion (DRG)
Distal axon: innervates mechanoreceptors in
arm and upper trunk via peripheral nerves
Proximal axon: enter dorsal column (fasciculus
cuneatus), ascend ipsilaterally and terminate
in the nucleus cuneatus
Second-order neurons
Cell body: nucleus cuneatus
Axon: decussates in the medulla and projects
to the contralateral thalamus (ventral
posterior lateral nucleus, VPL) via the medial
lemniscus
Third-order neurons
Cell body: VPL of thalamus
Axon: ascends via the posterior limb of the
internal capsule and terminates in the
primary somatosensory cortex
Click to animate DRG
Behavioral Explanation
Behavioral Description
Information about pain and
temperature from the body is
conveyed via several spinal
tracts collectively known as the Lateral spinothalamic
tract
anterolateral system. The
lateral spinothalamic tract
(LSTT) is the most prominent
among these. The LSTT is a
crossed system. It originates
from nociceptors (free nerve
endings and chemo-receptors)
and projects to the opposite
(contralateral) cerebral
hemisphere via a three neuron
projection system. Click to animate
Stimulus
Second-order neurons
Cell body: dorsal horn
Axon: decussates at or about the
level of entry and projects to the
contralateral thalamus (ventral
posterior lateral nucleus, VPL) via
the lateral spinothalamic tract
Behavioral Explanation
Third-order neurons
Cell body: VPL of thalamus
DRG
Axon: ascends via the posterior limb
of the internal capsule and
terminates in the primary Click to animate
somatosensory cortex Lateral spinothalamic tract
Contents Functional Systems Lesions Patient Cases Exit
Lesion Lessons
Dorsal column lesion
Fasciculus gracilis lesion
Fasciculus cuneatus lesion
Lateral corticospinal tract lesion
Lateral spinothalamic tract lesion
Transverse cord lesion
Hemicord lesion
Central cord syndrome
Anterior cord syndrome
Posterior cord syndrome
DRG
R L
L1
Fasciculus Gracilis
Sensory impairment:
absence of light touch,
vibration, and position
sensation in the left
leg and lower left
trunk.
Sensory impairment:
Click to animate
left leg and lower
left trunk.
Neuroanatomical Explanation
Lesion
Lost function
Impairment
Contents Functional Systems Lesions Patient Cases Exit
Lesion of the fasciculus gracilis
on the left: Neuroanatomical
Explanation
Click to animate
Behavioral Explanation
DRG
R L
C3
R L
L1
DRG
R L
L1
C5-C6 DRG
R L DRG
Lateral
Spinothalamic
Tract
Common causes
include posttraumatic Impaired pain and temperature
contusion and sensation, C5-C6 dermatomes,
syringomyelia, and
bilaterally
intrinsic spinal cord
tumors.
Click to animate
R L
L1
Hemicord lesion
Common causes
Dorsal column lesion
include penetrating
Ipsilateral loss of light touch,
injuries, lateral
vibration, and position sense
compression from
tumors, and MS. Lateral corticospinal tract lesion
Ipsilateral upper motor neurons signs
Build the lesion Lateral spinothalamic tract lesion
Contralateral loss of pain
and temperature sense
Hemicord Lesion (Brown-Sequard Syndrome)
UMN
Click to animate
DRG
DRG
R L
L1
R L
Click to animate
DRG
DRG
R L
DRG
DRG
R L
Click to animate
DRG
DRG
R L
Patient Case 1
Patient Case 2
Patient Case 3
Lateral corticospinal tracts are intact, bilaterally: AROM and strength are WNL
Lateral spinothalamic tracts are intact, bilaterally: sharp/dull is WNL
Dorsal column is intact on the right: light touch, two-point discrimination,
proprioception, and vibration are WNL
Dorsal column is absent on the left: light touch, two-point discrimination,
proprioception (limb position in space), and vibration are absent in all
dermatomes below the umbilicus
Lesion level, T10: the umbilicus is located in the T10 dermatome
DRG
R L
T10
Lateral corticospinal tracts absent, bilaterally, below C3: unable to move any
body part except head and shoulder shrug (C3-5)
Dorsal columns absent , bilaterally, below C3: unable to sense light touch below
neck
Lateral spinothalamic tracts absent, bilaterally, below C3: unable to sense pain
below neck
Lesion level, C3: patient was alert and oriented (cortex and reticular activating
system intact), he could turn his head (spinal accessory nerve), shoulder shrug
and respiration were weak (shoulder elevator and respiratory muscles C3-5)
Click to animate
DRG
DRG
R L
C3
Dorsal column is intact on the left but absent on the right: light touch, position
and vibration sense are WNL in the left lower extremity but absent in the right
Lateral corticospinal tract is intact on the left but absent on the right: active
range of motion and strength are normal in the left lower extremity but absent in
the right
Lateral spinothalamic tract is intact on the left but absent on the right: pain and
temperature sensation are intact in the right lower extremity but absent in the
left
Lesion level, approximately L1: hip flexion absent on right (L2), pain and
temperature sense absent below T12
Contents Functional Systems Lesions Patient Cases Exit Show lesion
Hemicord Lesion (Brown-Sequard Syndrome)
UMN
Click to animate
DRG
DRG
R L
T12