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Spinal cord anatomy
• A thin tubular extension of CNS within the bony spinal
• from the level of cranial border of Atlas (continuous
with medulla) lower border of the L1 vertebrae
• Average length-45cm.
• 31 pairs of nerves originate from it (8 cervical, 12
thoracic, 5 lumbar, 5 sacral, 1coccygeal) 2
Relationship of spinal cord to vertebral

• Growth rate of the spinal cord lags behind that of the

vertebral column
• The lower spinal nerves take a longer downward course
to exit via the respective interverte. Foramina. 3
Vertebrae Spinal cord segments
Upper Cervical Corresponds
Lower Cervical Add 1
Thoracic vertebrae 1 – Add 2
Thoracic vertebrae 7 – Add 3
Thoracic vertebrae 11 Overlies L3
Thoracic vertebrae 12 Overlies S1
1st lumbar arch Overlies sacral &
coccygeal segments 4
Cross-sectional Anatomy of the spinal cord

(1) Pia Mater

(2) Arachnoid
(3) Dura Mater
(4) Subarachnoid Space Containing CSF
(5) Subdural Space
(6) Epidural Space (Contains Adipose Tissue) 5 6 7
Lateral spinothalamic tract:

 Pain & temperature

 cross midline at a few segments higher

Anterior spinothalamic tract

 Pressure & crude touch

Dorsal column system

 Proprioception, light touch & vibratory senses 8
. 9 10
Descending Tracts
• 5 descending systems:
1 Corticospinal tract (Pyramidal tract).
2. Medial reticulospinal tract
3 Vestibulospinal tract
4. Corticorubrospinal tract
5. Lateral reticulospinal tracts 11
. 12
Corticospinal Tract
 Distal limb movements

Primary motor cortex, lateral premotor cortex

Corona radiata

Posterior limb of internal capsule

Ventral portion of midbrain & pons

Ventral portion of medulla

At caudal portion of medulla

Lateral corticospinal tract

Anterior (Ventral)
corticospinal tract
Decussate & terminate in lamina VIII in
cervical & upper thoracic region 13
Spinal cord
Spinal Cord – Functional Anatomy
Out of 10 or more Long Fibre Spinal Tracts coursing longitudinally in the
spinal cord, only 3 (shown below in Red, Blue and Green) are of prime
importance in clinical neurology practice:

Courtesy of Medical College, University of Florida.

1. Spinothalamic Tracts (Red) = Pain, Temperature, Crude Touch. 2.

Posterior Column Tracts (Green) = Position, Vibration, Discriminative
Touch. 3. Corticospinal Tracts (Blue) = Motor efferent (Descending) Fibres. 14
Spinal Cord – Vital Functions
• Respiration (mainly C4).
• Autonomic functions (Blood Pressure
and Heart rate).
• Brachial plexus = Upper limbs.
• Thoracic segments = Inter-costal nerves.
• Lumbosacral plexus = Lower limbs.
• Segmental sensations.
• Segmental autonomic nervous supply
(e.g. Sweating).
• Reflex control (e.g. withdrawal).
• Gait control (Walking).
• Bowel (regulation).
• Bladder (control).
• Sexual functions (Sympathetic and
Parasympathetic neurovascular inputs). Courtesy of MD Images. 15
Spinal Cord – Autonomic Nervous System 16
Courtesy of MD Images.
Spinal Cord – Key Symptoms
• Paralysis:
- Onset = Acute, Sub-Acute, Gradual, Chronic,
- Progress = Rapid, Slow, None, Improvement, Recovery,
- Proximal (Myelopathy), Distal, Global weakness,
- Fluctuation = Syringomyelia, Lipoma, Disc disease,
- Unilateral (Brown-Sequard) or Bilateral.

• Increased Tone & Reflexes (signs of UMN lesion) versus diminished

or absent reflexes, normal or decreased tone and presence of
Fasiculations (signs of LMN lesions). 17
• Pattern of Sensory Loss:
– Descending or Ascending
– Sensory level (localising value). Spinothalamic, Dorsal
Column, Dissociated or Segmental
– Brown-Sequard syndrome.
• Sphincter Involvement:
– Early incontinence occurring with relatively late
corticospinal weakness (Intramedullary lesion).
• Fluctuation of (motor & sensory) symptoms suggest:
1. Syringomyelia
2. Foramen Magnum pathology
3. Spinal Cord Lipoma (commonly Lumbo-Sacral in location). 18
Spinal Cord – Patterns of LMN Diseases
Four anatomic stations underlying lower motor neuron (LMN) weakness:

1. Anterior (ventral) Horn Cell,

2. Peripheral Nerve (Ventral & Dorsal Roots = Radiculopathy or Nerve = Neuropathy),

3. Neuromuscular Junction,

4. Muscle (Myopathy), * LMN = Lower Motor Neruon.

Arterial supply
• Anterior spinal artery
supply ant 2/3 the spinal cord &ventral
surface of medulla
• Two posterior spinal arteries
supply the posterior one-third of the
spinal cord.
• Radiculomedullary arteries
6 to 10 join the ASA
10 to 20 join the PSA 20
Arterial supply to the spinal cord 21
Spinal Cord – Disease Classification
• Vascular – Infarction, AV Malformations, Haemorrhage, Fibro-
cartilaginous embolism..

• Infectious (Abscess) – Viral, Bacterial, Fungal, TB, Brucella,


• Immune-Mediated – Mixed Connective Tissue Disease, Anti-

Phospholipid & Anti-Ro (SSA) causing Recurrent Transverse
Myelitis, as well as SLE & Rheumatoid Arthritis..

• Demyelinating – Primary (Multiple Sclerosis, Devic’s Disease),

Secondary (ADEM)..

• Granulomatous – Sarcoidosis 22
• Neoplastic (Tumours) – Primary or Metastatic – Extradural, Extra or
• Genetic – Hereditary & Familial Spastic Paraplegias, Friedreich
• Developmental – Meningomyelocele, Tethered Cord, Lumbosacral
• Metabolic – Deficiency (B12) and Toxic (Cassava)..
• Traumatic (Injury) – e.g. Fracture dislocation: RTA, Sports, Domestic
falls, Violence..
• Degenerative – Prolapsed inter-vertebral Disc, Osteophyte
• Miscellaneous – Iatrogenic, Paraneoplastic, 23
Lesions of .
the spinal cord 24
Complete SC transection (transverse myelopathy)

• All ascending & descending tracts are interrupted

• Sensory
– loss of all sensation below the level of lesion
– sensory level
– radicular pain
– vertebral tenderness 25
Complete SC transection (transverse myelopathy)

• Motor
– weakness below the lesion
– LMN at the level
– UMN below the level
• In spinal shock LMN weakness is seen
• Autonomic
– Bladder, bowel and sexual dysfunction
– Anhidrosis, trophic skin, impaired T0 control 26
Hemisection of the Spinal Cord /Unilateral Lesions/
(Brown- sequard syndrome) 27
Brown- sequard syndrome
• Ipsilateral spastic weakness(
• Segmental LMNS and sensory signs.(ant.horn
cell damage)
• Loss of pain and temp. Sensation contra lateral
to hemi section
• Ipsilateral propioceptive fn loss
• Eg. Extramedullary lesions 28
common causes are syringomyelia, intramedullary cord
• damage starts centrally and extend centrifugally
• Initially
• decussating spinothalamic tract
– touch, position and vibration intact
– dissociation of sensory loss. 29
• Forward extension -anterior horn cell with segmental sign .
• Lateral extension:
– ipsilateral Horner syndrome
– spastic paralysis below the level of the lesion.
• Dorsal extension
– position and vibration loss
• With extreme ventrolateral extension
– pain and temperature loss below the level of the lesion
with sacral sparing 30
Posterolateral Column Syndrome

causes of posterolateral column damage:

• SCDS(Vit B12 Def.)
• Vacuolar myelopathy associated with AIDS
• Tropical spastic paraparesis
• Extrinsic cord compression e.g. cervical spondylosis
 Dorsal column dysfn,sensory ataxia with positive Romberg sign&spasticity
 Pain &temperature remain intact 31
Posterior Cord Lesions /syndrome

• The posterior columns are selectively damaged by tabes dorsalis

(tabetic neurosyphilis).
• impaired vibration and position sense and decreased tactile
localization below that level
• disturbances in the knowledge of extremity movement and
position (temporal and spatial disturbances) 32
Posterior Cord Lesions /syndrome
• sensory ataxia, noted first at night or in the dark, and a
positive Romberg sign.
• The gait is ataxic – it is more pronounced in darkness or
with eye closure
• Often pt fall forward immediately following eye closure
(+ve Sink sign)
• Affected limb is hypotonic but not weak.
• Absent ankle & patellar reflexes
• In cervical region  neck flexion may elicit a sudden
“electriclike” sensation down the back or into the arms
(Lherrmitie’s sign or “barber’s chair” syndrome).
• Other Causes , compressive cervical ds, MS 33
Anterior Horn cell syndrome

• Diffuse anterior horn cell damage  diffuse muscle

weakness, atrophy, and fasciculations –in muscles of the
trunk & extremities
• Muscle tone usually reduced & DTR may be depressed or
• Sensory changes are absent b/se the sensory tracts remain
unaffected 34
Anterior Horn cell syndrome

•E.g. of spinal muscle atrophies

- infantile progressive spinal muscular atrophy of
- intermediate spinal muscular atrophy or type II
spinal muscular atrophy
- juvenile progressive spinal muscular atrophy or
Kugelberg-Welander disease
- progressive spinal muscular atrophy in motor
neuron disease 35
Combined ant. Horn cell &pyramidal tract disease

• Diffuse LMN signs superimposed on UMN
• Sensory changes are absent
• Bulbar and pseudo bulbar impairment
• Urinary and rectal sphincters unaffected 36
Vascular syndrome of the spinal cord

• Spinal cord infarction very rare compared to

cerebral infarction
• Most spinal cord infarction –from inv’t of the
territory of ASA 37
Anterior spinal artery syndrome:

• Abrupt onset & often associated with radicular or

“girdle” pain
• Deficit in pin prick, light touch, temperature sensations
–starting one or 2 segments below the level of the
lesion  lateral spinothalamic tracts bilaterally
• Deficit in light touch below the level of the lesion 
ventral spinothalamic tracts bilaterally
• Loss of motor function (flaccid tetraplegia or
paraplegia) –within minutes to hrs below the lesion 
bilateral corticospinal tract
• Impaired bladder & bowel control
 T1 to T4 segments & The L1 segment; common sites 38
Extamedullary vs. intramedullary

Symptoms & signs Intramedullary Extramedullary

Radicular pain Unusual Common, early
Vertebral pain Unusual Common
Funicular (central) pain Common Less Common

UMN signs late Yes, early

LMN signs e.g. anterior horn Prominent & diffuse Unusual, if present
cells segmental
Parasthesias progression Descending progression Ascending progression
Sphincter abnormalities e.g. Early with caudal Late
bladder inv’t lesions (conus –cauda
equina) 39
II/ Localization SC lesions at
different levels
A) Foramen magnum syndrome
– tumors, syringobulbia, joint subluxation
– Hemiplegia cruciata
– Sub occipital pain , neck stiffness 40
B) Cervical cord
C1- C4:
– may also involve CN XI
– weakness of sternocleidomastoid and trapezium
– Spastic quadriparesis with diaphragmatic
– LMN at segmental level and UMN below the lesion
– LMN sign at deltoid, biceps, brachioradialis
– spastic paraparesis of the lower extremity
– Biceps and brachioradialis reflex absent or
– triceps and finger flexors reflex exaggerated 41
– paresis involve flexors and extensors of the wrists and fingers
– Biceps and brachioradialis reflex preserved (C5- C6)
– Finger flexor reflex (C8- T1) - exaggerated.
C8 and T1:
– weakness of the small hand muscles
– spastic Paraparesis
– C8 lesion -triceps and fingers flexor reflex decreased
– T1 lesion -triceps reflex preserved
– Horner syndrome 42
C) Thoracic cord
 Root pain and paraesthesia
 Paraplegia
 sensory loss below a thoracic level
 segmental LMN sign is difficult to detect clinically.
D) Lumbar cord
L2- L4:
 paralyze flexion and adduction of the thigh &
extension of the knee
 absent knee reflex
 exaggerated ankle jerk.
 paralyze movement of foot and ankle, flexion at the knee ,
and extension of the thigh
 Absent ankle jerk (S1). 43
E) Sacral cord/conus medullaris
– Bilateral saddle anesthesia (S3- S5)
– Prominent bladder and bowel dysfunction
– Impotence
– Bulbocavernosus(S2 – S4) and anal ( S4- S5)
reflexes are absent
– Muscle strength largely preserved
F) Caudal equina syndrome
– Early radicular pain
– Asymmetric flaccid paralysis and sensory finding
– Ankle reflex absent
– Sphincter abnormality late 44