Spinal Cord

● The spinal cord, or medulla spinalis, is a vital component of the vertebral canal.
● In adults, it occupies the upper two-thirds of the vertebral canal.
● Originating from the medulla oblongata, it extends from the upper border of the first
cervical vertebra (C1) to the lower border of the first lumbar vertebra (L1).

Dimensions of the Cord:

● The spinal cord is approximately 45 cm long and exhibits a flattened cylindrical shape.
● Two enlargements are present at the cervical and lumbar levels, corresponding to the
spinal segments innervating the upper and lower limbs.

Conus Medullaris and Filum Terminale:

● The lowest part of the spinal cord is conical and termed the conus medullaris.
● The conus is continuous with the filum terminale, a fibrous cord attached to the first
coccyx piece, extending from the pia mater.

Age-wise Changes:

● In early fetal life, the spinal cord matches the length of the vertebral canal.
● Subsequent development results in the spinal cord ascending less than the vertebral
column, leading to its upward migration.
● At birth, the cord reaches level of L3, and in adults, it extends to the lower border of L1.
● As a result of this upward migration of the cord, the roots of spinal nerves have to follow
an oblique downward course to reach the appropriate intervertebral foramen, forming
the cauda equina.

External Features of Spinal Cord:

● Anterior Surface:
○ Marked by a deep anterior median fissure.
○ Contains the anterior spinal artery.
● Posterior Surface:
○ Characterized by a shallow posterior median sulcus.
● Surface Division:
○ The anterior median fissure and posterior median sulcus divide the cord into
symmetrical halves.
○ Each half further subdivided into posterior, lateral, and anterior regions by
anterolateral and posterolateral sulci.
● Rootlets of Spinal Nerves:
○ Dorsal (sensory) rootlets enter the cord at the posterolateral sulcus.
○ Ventral (motor) rootlets emerge through the anterolateral sulcus on either side.
Spinal Segments:

Definition: The part of the spinal cord giving origin to the rootlets for one pair of spinal nerves
constitutes one spinal segment.

Number of Segments: The spinal cord is composed of 31 segments: 8 cervical, 12 thoracic, 5

lumbar, 5 sacral, and 1 coccygeal.

Vertebral Levels: Due to the shorter length of the spinal cord (45 cm) compared to the vertebral
column (65 cm), spinal segments are thinner and crowded, particularly in the lower part. Spinal
segments do not align precisely with vertebral bodies; they are generally located above their
numerically corresponding vertebral bodies.
Vertebral Level Differences:

○ In the cervical region, there is typically a difference of one segment (e.g., the
fifth cervical spine overlies the sixth cervical segment).
○ In the thoracic region, the difference ranges from two to three segments (e.g., the
fourth thoracic spine overlies the sixth thoracic segment, and so on).

SEGMENTAL INNERVATION Any condition that leads to pressure on the spinal cord, or on
spinal nerve roots, can give rise to symptoms in the region supplied by nerves. For this purpose,
it is necessary to know which areas of skin and which muscles are innervated by each segment.
● Dermatomes of Clinical Significance:
○ C1: No dermatome (no skin supply).
○ C4: Supplies the tip of the shoulder.
○ C6, C7, C8: Supplies the skin of the hand.
○ T4: Supplies the skin over the nipple.
○ T10: Supplies the skin over the umbilicus.
○ L5, S1: Supplies the skin of the sole.

Spinal Meninges:

Dura Mater:

○ Forms a loose tubular covering for the spinal cord.

○ Does not fuse with the vertebral canal's endosteum, creating a well-developed
epidural space.
○ Epidural space contains Batson's plexus (internal vertebral venous plexus) and
fat.
○ Dorsal and ventral roots of spinal nerves pass through the dura mater separately.
○ Dura-arachnoid partially enclose the dorsal nerve root ganglion.
○ Extends to the level of the second sacral vertebra, covering the filum terminale
beyond that level.
 ○ Distally attaches to the dorsal surface of the first coccygeal vertebra.

Arachnoid Mater:

○ Lies deep to the dura mater and extends up to the level of the second sacral
vertebra.
○ Subarachnoid space, containing cerebrospinal fluid (CSF), extends to this level
(lumbar cistern).
○ Lumbar cistern is broadest between L2 and L4 levels, making it the preferred site
for lumbar puncture (L3-L4 or L2-L3 space).

Pia Mater:

○ A thin membrane closely applied to the spinal cord.

○ Specialized areas include:
■ Linea splendens: Thickening along the anteromedian fissure; pierced by
branches from the anterior spinal artery.
■ Ligamenta denticulata: Triangular thickenings along the lateral aspect
between dorsal and ventral roots; pierce the arachnoid and attach to the
dura. There are 21 pairs.
■ Filum terminale: Thin filament extending from the lower end of the spinal
cord; surrounded by cauda equina. Passes through the sacral hiatus and
attaches to the dorsal surface of the first coccygeal vertebra.

Blood Supply of the Spinal Cord:

The spinal cord is supplied by three main arteries: two posterior spinal arteries and one anterior
spinal artery. Segmentally arranged arteries from outside the vertebral column reinforce the
main arteries.

● Posterior Spinal Arteries:

 ○ Arise directly from vertebral arteries inside the skull or indirectly from posterior
inferior cerebellar arteries.
○ Descend on the posterior surface of the spinal cord close to posterior nerve roots.
○ Supply the posterior one-third of the spinal cord.
○ Vulnerability in the upper thoracic region, with the first three thoracic segments
being particularly susceptible to ischemia if segmental or radicular arteries are
occluded.
● Anterior Spinal Artery:
○ Formed by the union of two arteries, each arising from the vertebral artery inside
the skull.
○ Descends on the anterior surface within the anterior median fissure.
○ Supplies the anterior two-thirds of the spinal cord.
○ May be extremely small in the upper and lower thoracic segments, making the
fourth thoracic and first lumbar segments susceptible to ischemic necrosis if
segmental or radicular arteries are occluded.
● Segmental Spinal Arteries:
○ Reinforce the longitudinally running arteries at each intervertebral foramen.
○ Branches of arteries outside the vertebral column (deep cervical, intercostal, and
lumbar arteries).
○ Enter the vertebral canal and give rise to anterior and posterior radicular arteries
accompanying nerve roots to the spinal cord.
● Great Anterior Medullary Artery of Adamkiewicz:
○ Arises from the aorta in the lower thoracic or upper lumbar vertebral levels.
○ Unilateral and often enters the spinal cord from the left side.
○ Significant as it may be a major source of blood to the lower two-thirds of the
spinal cord.
Clinical Syndromes Affecting the Spinal Cord:

Spinal Shock Syndrome:

● Description:
○ Follows acute severe spinal cord damage.
○ Results in depressed or lost functions below the lesion level.
○ Causes sensory impairment and flaccid paralysis.
○ Depresses segmental spinal reflexes due to higher center influence removal.
○ May lead to severe hypotension from loss of sympathetic vasomotor tone,
especially in high cord lesions.
● Duration:
○ Persists for less than 24 hours in most cases.
○ May last up to 1 to 4 weeks.
● Recovery:
○ Neurons regain excitability as shock diminishes.
○ Upper motor neuron effects, like spasticity and exaggerated reflexes, appear as
shock resolves.
● Testing for Spinal Shock:
○ Anal sphincter reflex activity can indicate the presence of spinal shock.
○ Absent anal reflex suggests the existence of spinal shock.

Destructive Spinal Cord Syndromes:

1. Complete Cord Transection Syndrome:

○ Cause: Fracture dislocation, trauma, or tumor.
○ Features:
■ Complete loss of sensibility and voluntary movement below the lesion.
■ Bilateral lower motor neuron paralysis with muscular atrophy.
■ Bilateral spastic paralysis, Babinski sign, loss of superficial abdominal and
cremaster reflexes.
■ Bilateral loss of all sensations below the lesion.
■ Loss of voluntary control over bladder and bowel functions.
○ Note: If the injury is below L2-3 vertebral level, neural damage is confined to the
cauda equina.
2. Anterior Cord Syndrome:
○ Cause: Cord contusion, injury to anterior spinal artery, herniated disc.
○ Features:
■ Bilateral lower motor neuron paralysis and muscular atrophy in the lesion
segment.
■ Bilateral spastic paralysis below the lesion.
■ Bilateral loss of pain, temperature, and light touch sensations.
■ Preservation of tactile discrimination, vibratory, and proprioceptive
sensations.
3. Central Cord Syndrome:
 ○ Cause: Often due to hyperextension injury in elderly individuals.
○ Features:
■ Motor weakness and sensory loss more pronounced in the upper limbs
than lower limbs.
■ Often affects the cervical region.
■ Variable bladder dysfunction.
4. Brown-Séquard Syndrome:
○ Cause: Hemisection or unilateral damage to the spinal cord.

Cause:

○ Hemisection can result from fracture dislocation, trauma, bullet or stab wound, or
an expanding tumor.
○ Complete hemisection is rare; incomplete hemisection is common.

Clinical Features (Complete Hemisection):

○ Ipsilateral Lower Motor Neuron Paralysis:

■ In the segment of the lesion with muscular atrophy.
■ Caused by damage to neurons in the anterior gray column and possibly to
anterior nerve roots.
○ Ipsilateral Spastic Paralysis:
■ Below the level of the lesion.
■ Ipsilateral Babinski sign present.
■ Ipsilateral loss of superficial abdominal reflexes and cremasteric reflex.
■ Due to loss of corticospinal tracts on the side of the lesion.
○ Ipsilateral Cutaneous Anesthesia:
■ In a band in the segment of the lesion.
■ Results from destruction of the posterior root and its entrance into the
spinal cord at the lesion level.
○ Ipsilateral Loss of Tactile Discrimination and Vibratory/Proprioceptive
Sensations:
■ Below the level of the lesion.
■ Caused by destruction of ascending tracts in the posterior white column
on the same side.
○ Contralateral Loss of Pain and Temperature Sensations:
■ Below the level of the lesion.
■ Due to destruction of crossed lateral spinothalamic tracts on the same
side of the lesion.
■ Sensory loss occurs two or three segments below the lesion distally.
○ Contralateral Incomplete Loss of Tactile Sensation:
■ Below the level of the lesion.
■ Incomplete due to preservation of discriminative touch in ascending
tracts in the contralateral posterior white column.
Syringomyelia:

● Cause:
1. Due to developmental abnormality in the formation of the central canal.
2. Often affects the brainstem and cervical region of the spinal cord.
● Signs and Symptoms:
1. Loss of Pain and Temperature Sensations:
■ Dermatomes on both sides related to affected cord segments.
■ Shawl-like distribution due to interruption of lateral spinothalamic tracts.
2. Preservation of Tactile Discrimination, Vibratory Sense, and Proprioceptive
Sense:
■ Ascending tracts in the posterior white column remain unaffected.
3. Lower Motor Neuron Weakness:
■ In small hand muscles; may be bilateral or unilateral initially.
■ Later, expansion of the lesion results in atrophy of other arm and shoulder
girdle muscles.
4. Bilateral Spastic Paralysis of Legs:
■ Exaggerated deep tendon reflexes.
■ Presence of a positive Babinski response.
■ Due to lateral expansion of the lesion involving descending tracts.

5. Horner syndrome may be present.

Anterior spinal artery syndrome: Thrombosis in the anterior spinal artery produces a
characteristic syndrome. The territory of supply includes the corticospinal tracts. This leads to an
upper motor neuron paralysis below the level of lesion. The spinothalamic tracts are also
involved. This leads to loss of sensations of pain and temperature below the level of lesion.
Touch and conscious proprioceptive sensations are not affected as the posterior column tracts
are not involved.
Poliomyelitis:

○ Acute viral infection affecting neurons in the anterior gray columns of the spinal
cord and motor nuclei of cranial nerves, results in the death of motor nerve cells.
○ Manifests as paralysis and muscle wasting.
○ Predominantly affects muscles of the lower limb over the upper limb.
○ Respiratory function may be compromised due to paralysis of intercostal muscles
and diaphragm. Paralysis extend to muscles of face, pharynx, larynx, tongue.

Multiple Sclerosis: Common disease confined to the central nervous system (CNS).

Causes demyelination of ascending and descending tracts. Typically occurs in young adults.

Amyotrophic Lateral Sclerosis (ALS or Lou Gehrig's Disease):

Disease confined to corticospinal tracts and motor neurons of the anterior gray columns.

○ Features:
■ Lower motor neuron signs: Progressive muscular atrophy, paresis,
fasciculations.
■ Upper motor neuron signs: Paresis, spasticity, Babinski response.
○ Motor nuclei of some cranial nerves may also be involved.

Tabes Dorsalis: Syphilis leading to the destruction of the posterior root of the spinal cord.

● Clinical Features:
1. Stabbing pains in the lower limbs.
2. Paresthesia in the lower limbs.
3. Hypersensitivity of the skin to touch, heat, and cold.
4. Loss of sensation in the skin of parts of the trunk and lower limbs.
5. Loss of awareness of a full urinary bladder.
6. Loss of appreciation of posture.
7. Loss of deep pain sensation.
8. Loss of pain sensation in the skin.
9. Ataxia of the lower limbs due to the loss of proprioceptive sensibility.
10. Hypotonia due to the loss of proprioceptive information from muscles and joints.
11. Loss of tendon reflexes due to the degeneration of the afferent fiber component.

Types of Plegia:

● Hemiplegia: Paralysis of one side of the body, including the upper limb, one side of the
trunk, and the lower limb.
● Monoplegia: Paralysis of one limb only.
● Diplegia: Paralysis of two corresponding limbs (arms or legs).
● Paraplegia: Paralysis of the two lower limbs.
● Quadriplegia: Paralysis of all four limbs.