Spinal cord and spinal nerves

Beka Aroshidze
2017
Normal functional spinal unit
 Metastasis to CNS and bone
 A Route of Metastasis for breast, lung, and prostate cancer
(carcinoma) to the brain and bone exists because the internal
vertebral venous plexus, basivertebral veins, and external vertebral
venous plexus surrounding the vertebral column communicate with the
cranial dural sinuses and veins of the thorax, abdomen, and pelvis.
 Meninges of the Spinal Cord
 The spinal meninges are membranes that surround the spinal
cord and nerve roots and that contain the cerebrospinal fluid
(a fluid that cushions and nourishes the brain and spinal cord)
 The three layers of spinal meninges are continuous with the
meninges that surround the brain:
◦ 1. Dura mater, a tough outer layer that forms the dural sac
enclosing the spinal cord and extending along the nerve roots to
the intervertebral foramina.The dural sac begins at the foramen
magnum of the skull and ends at the level of S2.
◦ 2. Arachnoid mater, a delicate middle layer that is connected to
the underlying membrane by arachnoid trabeculae (strands of
connective tissue).
◦ 3. Pia mater, a thin layer that adheres to the surface of the spinal
cord. Denticulate ligaments, transverse extensions of the pia mater,
attach to the dura mater and suspend the spinal cord within the
dural sac.
 The filum terminale, a thin cord of pia mater, extends from the conus
medullaris to the apex of the dural sac. There it is surrounded by spinal
dura mater and extends to the end of the vertebral canal, where it anchors
both membranes to the coccyx.
 Features Related to Meninges
 1. Epidural space
◦ a. Lies between dural sac and walls of vertebral canal
◦ b. Contains epidural fat and internal vertebral
venous plexus
 2. Subdural space
◦ a. Artifact of pathology and not a true space
◦ b. Formed by physical separation of dura mater from
arachnoid mater by hemorrhage (subdural hematoma)
or CSF collection (subdural hygroma)
 3. Subarachnoid space
◦ a. Lies between arachnoid mater and pia mater and
extends inferiorly to S2 vertebra
◦ b. Contains cerebrospinal fluid that protects spinal cord
and removes catabolites from neuronal activity
◦ c. Below spinal cord forms lumbar cistern, which
contains cauda equina
 The spinal cord is the part of the
central nervous system that relays
information between the brain and
the body. The spinal cord, along with
its spinal nerves, surrounding
membranes (the meninges), and
associated vasculature, is enclosed
within the vertebral canal.
◦ 1. Continuous above with medulla
oblongata of brainstem and ends below
near superior border of vertebra L2 in
adults, but range is T12-L3
◦ 2. Tapers at inferior end to conus
medullaris
◦ 3. Cervical enlargement is related to
brachial plexus and innervation of upper
extremity, and lumbosacral enlargement
is related to lumbosacral plexus and
innervation of lower extremity
 The spinal cord, continuous with the medulla oblongata of the
brain superiorly, exits the skull base through the foramen
magnum of the occipital bone. It descends within the
vertebral canal and terminates as the conus medullaris
adjacent to the L1 vertebra
 During development the longitudinal growth of the vertebral
column exceeds that of the spinal cord. At birth the conus
medullaris is at the level of the L3 vertebra, but in the adult it lies
adjacent to the L1/L2 intervertebral disk.
 Because the adult spinal cord is considerably shorter than the
vertebral column, occupying only the superior two thirds of the
vertebral canal, most spinal cord segments do NOT lie adjacent to
the vertebral level of the same number.
 The spinal cord consists of 31 segments, each of which innervates
a specific area of the trunk or limbs.
 Each spinal cord segment has paired spinal nerves that contain
both sensory and motor neurons.
◦ ALL SPINAL NERVES ARE “MIXED”!
 Two swellings occur in the regions of the
spinal cord that innervate the limbs:
◦ The cervical enlargement at C4–T1 is
related to the brachial plexus, a plexus of
nerves that innervate the upper limb.
◦ The lumbosacral enlargement at T11–S1
is related to the lumbar and sacral
plexuses, nerve plexuses that innervate the
abdominal wall and lower limb.
 Blood Supply to the Spinal Cord
 Longitudinal spinal arteries supply the superior part of
the spinal cord.
◦ A single anterior spinal artery arises from the two
vertebral arteries (branches of the subclavian arteries)
and supplies the anterior two thirds of the spinal cord.
◦ Paired posterior spinal arteries arise from the
vertebral arteries (or one of their branches, the
posterior cerebellar artery) and supply the posterior
third of the spinal cord.
 Anterior and posterior segmental medullary
arteries are large, irregularly spaced vessels that
communicate with the spinal arteries.
◦ They arise from branches of the subclavian artery and
segmental arteries in the thoracic and lumbar region.
◦ The medullary arteries enter the vertebral canal through
the intervertebral foramina and are found mainly at the
cervical and lumbar enlargements.
 The largest anterior segmental medullary artery is also known as
the artery of Adamkiewicz.
 The great anterior segmental medullary
artery (of Adam-kiewicz), a single large,
usually left-sided vessel, can provide an
important contribution to the circulation of the
lower two thirds of the spinal cord.
◦ It arises as a branch of a lower thoracic or lumbar
segmental artery.
◦ It enters the vertebral canal through an intervertebral
foramen in the lower thorax or upper lumbar region.
 The anterior and posterior radicular
arteries are small arteries that supply the roots
of the spinal nerves and the superficial gray
matter of the spinal cord. They do not
communicate with the spinal arteries.
 Spinal cord is held in place by two pial
specializations: A pair of toothed denticulate
ligaments and the filum terminale
Lumbar puncture, spinal anesthesia,
and epidural anesthesia
 A lumbar puncture, used to extract cerebrospinal fluid
from the spinal subarachnoid space, is administered by
inserting a needle between the spinous process of L3
and L4 (sometimes between L4 and L5). The
needle pierces the ligamentum flavum and wall of
the dural sac before entering the lumbar cistern.
 The injection of a local anesthetic for spinal anesthesia
is also administered in this manner.
 A similar approach may be used for epidural
anesthesia, to anesthetize emerging spinal nerves, but
the anesthetic is injected into the epidural space
without entering the dural sac.
 A caudal approach through the sacral hiatus also
allows access to the epidural space
 Spinal Nerves
 A. 31 pairs: 8 cervical, 12 thoracic, 5 lumbar, 5 sacral, 1 coccygeal
 B. Contain preganglionic general visceral efferent (between T1 and L2
sympathetic and between S2 and S4 parasympathetic), general visceral afferent,
general somatic efferent, and general somatic afferent fibers
 C. Formed by the junction of anterior (motor) and posterior (sensory) roots,
the posterior root is the site of the spinal ganglion (dorsal or posterior root
ganglion), which contain all afferent cell bodies for the body (somatic and
visceral)
 The Cauda Equina: Anterior and posterior roots that are found in the
subarachnoid space below the conus medullaris form the cauda equina.
Herniation of intervertebral disks
 As elasticity of the anulus fibrosus declines with age,
compressive forces can cause the nucleus pulposus to
protrude through weakened areas.
 Rupture of the nucleus pulposus through the anulus
fibrosus causes a herniated intervertebral disc.
◦  Herniations may follow degenerative changes in the anulus fibrosus
or be caused by sudden compression of the nucleus pulposus.
 Posterolateral herniations that compress spinal nerves are
MC, particularly at the L4–L5 or L5–S1 level.
◦ In the lumbar region, where spinal nerves exit the vertebral canal
above the IV disk, the hernia is likely to compress the spinal nerve
inferior to that level (e.g., a herniation of the L4–L5 disk will impact the
L5 spinal nerve), and pain is felt along the corresponding dermatome.
  Because its presence reinforces the intervertebral disc in the posterior midline, the
posterior longitudinal ligament reduces the incidence of disc herniations that
may compress the spinal cord and cauda equina.
An intervertebral disc usually herniates
posterolaterally just lateral to posterior longitudinal
ligament.
 Herniated discs usually occur in lumbar (L4/L5 or
L5/S1) or cervical regions (C5/C6 or C6/C7) of
individuals younger than age 50 and may impinge on
spinal nerves or their roots.
 Herniated lumbar discs usually involve the nerve root
descending to exit the intervertebral foramen inferior
to the vertebra below (traversing root) rather than
the nerve root leaving the vertebral canal at the level
of the disc (exiting root).
 LUMBAR SPINAL STENOSIS
 Degenerative changes in the lumbar spine and
ligamenta flava may cause narrowing of the spinal canal
(lumbar spinal stenosis). The resulting compression of
neural structures produces pain on walking or standing
that is relieved by bending forward or sitting
(neurogenic claudication).
◦  This differs from vascular claudication of the lower
extremities that is relieved by standing still.
 Conus Medullaris
 The tapering inferior end of the spinal cord, occurs in the
newborn at the level of the body of the third lumbar
vertebra (L3). In the adult, it occurs at the level of the
inferior border of the first lumbar vertebra (L1). This is
clinically relevant in determining the appropriate position for
performing lumbar puncture in children and adults.
 Cauda Equina Syndrome
(Spinal Roots L3 to C0)
 May result from a nerve root tumor, an
ependymoma, a dermoid tumor, or from a
lipoma of the terminal spinal cord. It is
characterized by:
 A. Severe radicular unilateral pain.
 B. Sensory distribution in a unilateral saddle-
shaped area.
 C. Unilateral muscle atrophy and absent
quadriceps (L3) and ankle jerk (S1) reflex
activity.
 D. Unremarkable incontinence and sexual
function.
 E. Gradual and unilateral onset.
 Conus Medullaris Syndrome
(Cord Segments S3 to C0)
 usually results from an intramedullary tumor
(e.g., ependymoma). It is characterized by:
 A. Pain, usually bilateral and not severe.
 B. Sensory distribution in a bilateral saddle-
shaped area.
 C. Unremarkable muscle changes; normal
quadriceps and ankle jerk reflexes.
 D. Severely impaired incontinence and sexual
function.
 E. Sudden and bilateral onset.
  DO YOU REMEMBER?
 A. Gray rami communicans contain unmyelinated postganglionic
sympathetic fibers. They are found at all levels of the spinal cord.
 B. White rami communicans contain myelinated preganglionic
sympathetic fibers. They are found from T1 to L2 (the extent of the
lateral horn and the intermediolateral cell column which forms it).
 Location of the Major Motor and Sensory
Nuclei of the Spinal Cord
 A.The ciliospinal center of Budge, from C8 to T2, contains the
preganglionic sympathetic neurons that innervate the superior
cervical ganglion to provide sympathetic innervation of the eye.
 B.The intermediolateral cell column, of the lateral horn,
from T1 to L2, contains all of the preganglionic sympathetic cell
bodies in the body.
 C.The sacral parasympathetic nucleus, from S2 to S4
 Location of the Major Motor and Sensory
Nuclei of the Spinal Cord
 D.The posterior thoracic nucleus (nucleus dorsalis of
Clarke), from C8 to L2, gives rise to the posterior spinocerebellar
tract.
 E. Substantia gelatinosa and nucleus proprius, found at all spinal cord
levels, contain neurons that mediate light touch, pain, and
temperature.
 F.The phrenic nucleus, from C3 to C5
 G.The spinal accessory nucleus, from C1 to C6