The Brainstem

and Spinal cord

Dr. G. Kawishe
2022
Parts of the Brainstem
–Medulla oblongata
–Pons
–Midbrain
• Cerebellum is not part of BS (but part
of Hindbrain)
• Hindbrain=MO+ Pons + Cerebellum
 Parts of Brainstem

Midbrain

Pons

Medulla
Oblongata
Brainstem: Anatomical Overview

• Part of the brain which fills the

posterior cranial fossa
• Lies btn the cerebral hemispheres
above and the spinal cord below
• Provides the main motor and sensory
innervations to head and neck region
through cranial nerves.
Four Major Functions of BS:
• It provides passage to various ascending
and descending tracts that connect the
spinal cord to the different parts of the
forebrain.
• It contains important autonomic reflex
centres (vital centres) associated with the
control of respiration heart rate and blood
pressure.
• It contains reticular activating system which
controls consciousness.
• It contains important nuclei of the last ten
cranial nerves (i.e. IIIrd to XIIth).
Brainstem: Clinical Correllation
• The bilateral destructive lesions of the
brainstem are fatal because of damage to
‘vital centres’.
• The impairment of reticular activating system
leads to progressive loss of consciousness,
followed by stupor and coma.

NB: BS is virtually the center for life. BS

death means the death of a person.
Coma & Persistent Vegetative State
• A patient is unconscious with the eyes closed and unable to be
aroused by even vigorous or painful stimulation.
• Higher brain centres are affected with the vital lower centres
remaining intact
• Cause: Stroke, physical trauma, tumor, etc

Coma PVS
 Medulla oblongata:
• It forms the lowest part of the brainstem and extends
down as spinal cord at foramen magnum. It
measures about 3 cm in length and 2 cm in breadth
(at the widest part).
• It is shaped like a truncated cone (bulb-like) hence
its alternative name ‘bulb’.
• It contains vital centres which are essential for life:
cardiac centre, vasomotor centre, and
respiratory centre.
• It provides attachment to last four cranial nerves.
• The medulla is divided into a lower closed part and
an upper open part.
External features:
• The medulla is divided into right and left symmetrical
halves by anterior median fissure and posterior
median sulcus.
Anterior surface:
 Pyramids: Lie btn anterior median and anterolateral sulci
on each side.
• Pyramids contain the fibers of the corticospinal tracts
(pyramidal tracts) and tend to narrow inferiorly
• The tracts cross at the base of the pyramids to form pyramidal
decussation (great motor decussation)
 Olive: Oval swelling btn anterolateral & posterolateral sulci.
• Contain large mass of gray matter called inferior olivary nucleus
• The anterolateral sulcus separate the pyramids from olives.
CNXII emerges from this sulcus
Decussation of pyramidal (corticospinal) tracts in the lower part of medulla oblongata
External features
The posterior part of medulla contains:
Fasciculus gracilis medially ending in rounded
elevation (gracile tubercle),containing nucleus
gracilis.
Fasciculus cuneatus laterally ending in rounded
elevation (cuneate tubercle),containing nucleus
cuneatus.
 A posterior median sulcus.
Tuberculum cinereum, longitudinal elevation in the
lower part of medulla lateral to fasciculus cuneatus.
Posterior part of the medulla forms the floor of the
fourth ventricle
Refer cranial nerves lecture
Medula oblongata: Clinical Notes
• Since the medulla contains vital centres, an
injury to it is usually fatal.
• The bulbar paralysis is characterised by the
paralysis of muscles supplied by last four cranial
nerves arising from the medulla.
 Pons – (bridge)
• About 2.5 cm and lie anterior to the cerebellum.
• Connects the medulla oblongata to the midbrain.
• Relay motor information between cerebral cortex
& cerebellum
• Basilar artery lie in the basilar groove of the
pons.
• CN III & CN IV emerge at the upper border
• CN V emerges on anterolateral aspect.
• CN VI, CN VII, CN VIII emerge from the
pontomedullary groove.
 PONS
External features ..
1.Ventral surface PONS

• convex in all directions-transveresly

striated
2.Vertical basilar sulcus/groove
• lodges Basilar Artery.
MCP
3. Dorsal surface is hidden by
cerebellum.
4. Dorsal surface forms upper part of
BASILAR GROOVE
floor of 4th Ventricle.
5. Laterally .. Continuous with Middle
Cerebellar Peduncle- trigeminal
nerve
 PONS

MID BRAIN
PONS 5th C.N.

6th C.N.

7th C.N.

4th ventricle 8th C.N.

Posterior surface Anterior surface

 PONS: Internal Features
• Pons is divisible into:
• Ventral (Basilar) Part & Dorsal Part (Tegmentum).
• Ventral (Basilar) Part:
• Has a uniform structure throughout the length of pons.
• Contains transverse and vertical fibres & pontine nuclei.
• Transverse fibres:
• Pontocerebellar fibres- cross the midline to enter the
opposite middle cerebellar peduncle.
• The vertical fibres:
• Corticopontine fibres: descend from cerebral cortex
to end in the pontine nuclei.
• Corticospinal fibres: descend from cortex through
the pons in to the medulla.
• Corticonuclear fibres: descend from cortex and end
in the motor nuclei of cranial nerves mainly of
opposite side.
Pons - Internal features

Sections of Pons.

Upper part

Lower part

• The basilar (ventral) part has a uniform structure

throughout its length.
• The structure of tegmentum (dorsal) part differs in the
upper & lower parts of pons.
PONS

(Dorsal)

(ventral)
C.S. of Upper Part of Pons.
C.S. of Lower Part of Pons
 Ventral (Basilar) Part of Pons
GREY MATTER
• Pontine nuclei:
• Scattered groups of cells separated by nerve fibres.
• Afferents - Corticopontine fibres of the same side.
• Efferents - Pontocerebellar fibres that cross the
midline & pass through the MCP to enter the
cerebellum. (Cortico-ponto-cerebellar pathway)
WHITE MATTER:
• Longitudinal fibres:
• Corticospinal and corticonuclear (pyramidal) tracts.
• Corticopontine fibres ends in pontine nuclei.
• Transverse fibres: are pontocerebellar fibres begning in
the pontine nuclei and going to opposite half of
cerebellum through inferior cerebellar peduncle.
Tegmentum of Pons: Nuclei & Tracts
Ventral & dorsal cochler nuclei:
• Receive (afferents) fibres of the cochlear nerve.
• Efferents of the ventral cochlear nuclei cross the
midline in the ventral part of tegmentum & end in
the superior olivary nucleus & dorsal nucleus of
trapezoid body of opposite side.
• These crossing & decussating fibres form the
trapezoid body (bundle of secondary auditory fibres)
• Most of the fibres of the dorsal cochlear nuclei also
end in the superior olivary nucleus & dorsal nucleus
of trapezoid body of opposite side. Some fibres of
cochlear nuclei are uncrossed.
Tegmentum of Pons: Nuclei & Tracts
 Superior olivary nucleus & Dorsal nucleus of
trapezoid body:
• Present in the ventral part of tegmentum.
• Receive (Afferents) from cochlear nuclei & give
fibres (efferents) to lateral lemniscus.

 Vestibular nuclei:
• Lie deep to vestibular area of floor of 4th ventricle
• There are Superior, inferior, lateral & medial.
• Afferents: Fibres of vestibular nerve from
cerebellum
• Efferents: Vestibulocerebellar, Vestibulospinal.
• Concerned with balance
Tegmentum of Pons: Nuclei & Tracts
Abducent nucleus:
• Is a motor nucleus (lies deep to facial colliculus).
• Facial nerve fibres curve round the abducent nucleus forming
facial colliculus (Neurobiotaxis)
• It receives corticonuclear fibres of the opposite side.
• Its efferents form the abducent nerve fibres.
Motor Facial nucleus:
• Lies in the ventral part of tegmentum.
• Dorsal part of nucleus controls the muscles of upper part of face
& under the control of corticonuclear fibres of both sides.
• Ventral part of nucleus controls the muscles of lower part of
face & under the control of corticonuclear fibres of opposite
side only.
• In upper motor neuron lesion, muscles of upper face are not
affected. Muscles of lower face are affected on the opposite
side.
• In lower motor neuron lesion, all the muscles of the same side of
face are affected.
Lesion of UMN
Facial nerve

Facial Nucleus

LMN
Trigeminal Nuclei
• 1st order sensory neurons from the head and neck are
carried by CNs V, VII, IX, and X. Their cell bodies are located
in peripheral ganglia
Principal trigeminal nucleus:
• 1st order sensory neurons of trigeminal nerve carrying touch,
pressure & vibration, synapse in the main/principal trigeminal
nucleus.
Spinal trigeminal nucleus:
• 1st order sensory neuron of trigeminal nerve carrying
temperature & pain sensation synapse in the spinal trigeminal
nucleus via spinal trigeminal tract.
• 1st order GSA nerve fibers carried by CNs VII, IX & X, also
synapse in the spinal trigeminal nucleus
Mesencephalic trigeminal nucleus:
• 1st order sensory neurons of trigeminal nerve carrying
proprioceptive information synapse in the mesencephalic
trigeminal nuleus.
 Tegmentum of Pons: Nuclei & Tracts
Trigeminal Nuclei:
• Efferent (2nd order sensory neurons) from the
principal & spinal trigeminal nuclei decussate and
ascend as the trigeminal lemniscus to the
thalamus (VPM nucleus)
• 3rd order neurons from VPM nucleus of thalamus
project to somatosensory cortex.

• Motor nucleus of trigeminal nerve: Gives motor fibres of

trigeminal nerve and forms the motor root.
Tegmentum of Pons: Nuclei & Tracts
Corpus trapezium: .
• Is a compact mass of secondary auditory fibres from
Cochlear nucleus.
• it later becomes Lateral lemniscus.
Medial lemniscus:
• Contains Posterior column tract fibres.
• Carries conscious proprioceptive sensation.
Spinal lemniscus:
• Contains fibres of Lateral & Anterior Spino-thalamic tracts.
Medial longitudinal bundle:
• Lies immediately deep to floor of 4th Ventricle.
Trigeminal lemniscus:
• carries the fibers from the spinal and main sensory
trigeminal nucleus and relays on the ventral posteromedial
nucleus(VPM) of the thalamus
Structurally, pons consists of grey and white matter
containing number of nuclei and fibre tracts respectively.
The Spinal Cord (SC)
Terminologies:
• CNS- Brain and spinal cord
• PNS- Peripheral Nerves and ganglia
outside the cranial and spinal nerves
• Spinal cord-Neural tissue
• Spine/ vertebral column- entire bony
housing
• Vertebral canal—Opening in vertebral
column that house spinal cord
• Spinal canal- opening in spinal cord filled
with CSF
Terminologies:
• Funiculus/column- a large group of nerve
fibers located in one area of the SC.
• Fasciculus- a smaller bundle of nerve fibers
within a funiculus with one course, but may
have a diverse functions.
• Tract- a bundle of nerve fibers carrying
specific modalities btn nuclei in the CNS.
• Lemniscus- a bundle of secondary sensory
fibers in the brainstem.
• Pathway- general term for impulse course
 Spinal Cord and its meninges
• Surrounded by meninges: dura mater,
arachnoid and pia mater
• Closely invested in the pia mater
• CSF fills the space between arachnoid
and pia mater
• SC is attached to dura mater by
denticulate ligaments between the
anterior and posterior nerve roots
• SC terminate in a cone shaped Conus
Medularis at lower L1 or upper L2
Termination of the SC
Cross section of SC
• Grossly SC has inner gray matter and an
outer white matter (opposite to brain)
• GM is butterfly-shaped and surrounds central
canal
• GM has anterior and posterior horns
throughout
• T1-L2 has lateral horn made of preganglionic
sympathetic cell bodies (intermediolateral
column)
• SC has an anterior median fissure and
posterior median septum 29
Polio virus affect the anterior horn neurons leading
to LMN signs
Organization of spinal nerves
• Each ramus is mixed-motor and
senesory fibers.
• In the thoracic region rami
communicantes are joined to the base of
the ventral rami of spinal nerves. These
carry sympathetic fibers
• Posterior rami supply the posterior body
trunk whereas the thicker ventral rami
supply the rest of the body trunk and the
limbs.
Spinal Roots & Nerves

• Each segment of the spinal cord has four

roots: anterior and posterior roots pairs
• The first cervical segment lacks posterior
roots.
• Each root is made up of 1 to 8 rootlets.
• The posterior root has a posterior root
ganglion, a swelling that contains nerve
cell bodies.
• The nerve roots exit from the vertebral
column through intervertebral foramina.
CLINICAL NOTES:
 Lumbar puncture/lumbar tap
• A procedure to withdraw CSF from the
spinal subarachnoid space
• Intrathecal injection of anaethetics etc
(lumbar block in CS)
• Must be performed well clear of the
termination of the SC.
• A line joining the iliac crests passes
through L4 vertebra
• Intervertebral spaces immediately
above the line (L3/4) or below (L4/5)
are safe.
Lumbar puncture position
  Spinal Disc Prolapse (Herniation)
and Radiculopathies
Risk factors:
• Smoking; Familial genetics; Age; Weight lifting; Sedentary life
style.

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Compression and inflammation
 Vertebral Canal Stenosis:
fibrous constriction of the vertebral canal e.g in
Cauda Equina Syndrome
 Cauda Equina Syndrome, CES
• Compression of cauda equina nerves
• Leads to LL paralysis, perianal anesthesia, urine
incontinence and retention.
Dermatomes
• The sensory component of each spinal nerve
is distributed to an area of skin called
dermatome
• C1 dermatome is normally absent but may
exist in the central part of the neck
• C5, C6, C7, C8, and T1 are confined to the UL
• The thumb, middle finger, and fifth digit are
within the C6, C7, and C8 dermatomes,
respectively.
• The nipple is at the level of T4.
• The umbilicus is at the level of T10
• Dermatomes tend to overlap hence difficult to
localize the lesions in the SC.
CLINICAL NOTES:
T3 Dermatome Herpes Zoster

38
 Dermatomes and Referred Pain

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Neural Tracts and Pathways
• The spinal cord contains ascending
and descending fibers, which are
organized into groups
• The descending fibers are motor in
function and consists of pyramidal
and extra-pyramidal fibers.
• The ascending fibers are sensory in
function
 Somatosensory systems
• Involve receptors, sensory neurons, and brain
centers (for integration & action).
• Pathways for conscious somatic sensation, at their
simplest, require three neurons and two relay sites.
• First-order neurons: carry signals from receptors
to the spinal cord.
• Second-order neurons: carry signals from the
spinal cord to the thalamus. They are generally
located in the spinal cord or brainstem.
• Third-order neurons: carry signals from the
thalamus to the primary sensory cortex.
 Somatosensory systems
• Pathways for unconscious sensation transmit
proprioceptive information (for maintenance of
normal muscle tone and posture, as well as for
coordination) and primarily terminating in the
ipsilateral cerebellum.
• Some of these pathways, such as the dorsal
spinocerebellar tract and the cuneocerebellar
tract, require only 2 neurons (1st & 2nd order).
Ascending (sensory) pathways
 Ascending (Sensory) Pathways
 Functional Classification: based on modalities they
carry
1. General Somatic Afferent (GSA) system:
• Transmit sensory information like touch,
pressure,vibration, pain, temperature, stretch and
position sense from somatic structures.
2. General Visceral Afferent (GVA) system:
• Transmits sensory information like pressure, pain, and
other sensation from visceral structures.
 Ascending (Sensory) Pathways…
 Anatomical Classification: based on their
anatomical organization.
1. Anterolateral System (ALS):
• Include: Spinothalamic, spinoreticular, spinomesencephalic,
spinotectal & spinohypothalamic tracts
• Relays pain & temperature (predominantly), as well as
nondiscriminative(crude) touch, pressure & some proprioceptions.
2. Dorsal Column-Medial Lemniscal (DCML) pathway:
• Include: Fasciculus gracilis, fasciculus cuneatus & medial lemniscus
• Relays discriminative (fine) touch, vibratory sense & position
sense.
3. Somatosensory pathways to Cerebellum:
• Include: Anterior, posterior & rostral spinocerebellar, as well as
cuneocerebellar tracts.
• Relay primarily proprioceptive information; but also some pain and
pressure.
 The End
Thank You For Listening

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