AUTONOMIC NERVOUS SYSTEM

ANATOMY PHYSIOLOGY AND DYSFUNCTION

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RICHA GUPTA MPT II YR

8/6/2011

Introduction
y Involuntary AND automatic nervous system y Primarily concerned with regulation of visceral or

vegetative functions

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Autonomic Nervous System

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ppt 8/6/2011 .DIVISIONS OF ANS Sympathetic ANS Parasympathetic 5 ANS.

THIRD DIVISION OF ANS ENTERIC NERVOUS SYSTEM 6 ANS.ppt 8/6/2011 .

SYMPATHETIC DIVISION y Thoracolumbar outflow y Preganglionic neurons: LGH of 12 thoracic & 2 lumbar segments of SC y Preganglionic fibers 7 ANS.ppt 8/6/2011 .

Sympathetic ganglia Paravertebral Prevertebral Terminal or Peripheral Heart. bladder cervical Thoracic Lumbar & sacral Sup. mesenteric Celiac 8 ANS. mesenteric Inf.ppt 8/6/2011 . pancreas. Bronchi.

PARASYMPATHETIC DIVISION y CRANIOSACRAL OUTFLOW 9 ANS.ppt 8/6/2011 .

IX & X CN fibers 2.ppt 8/6/2011 . 3 & 4th sacral segment 10 ANS.PARASYMPATHETIC DIVISION Tectal or midbrain level Bulbar level or bulbar outflow Sacral outflow Edinger Westphal Nucleus of CN III VII.

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ppt 8/6/2011 .Functions of ANS y Regulation of functions which are beyond voluntary control y Maintain homeostasis y SNS & PNS antagonistic effect 13 ANS.

digestion. circulation.ppt 8/6/2011 .y Governs activities of cardiac & smooth muscles including smooth muscles of blood vessels & glandular function y Regulates respiration. temp adjustment & metabolism 14 ANS.

ppt 8/6/2011 .Sympathetic Division y Stress responses y Increased pulse & respiratory rate y Vasoconstriction to skin & viscera y Sweating (cold sweat) y Release of "adrenalinµ (epinephrine) y Inhibition of digestive activity y Loss of appetite 15 ANS.

Parasympathetic Division y Relaxation responses y y y y Slower pulse & respiratory rate Increased blood flow to skin & viscera Increased digestive activity SLUD y Salivation. receptiveness y Penile erection. Lacrimation. Digestion/Defecation y Increased reproductive interest. engorgement of vulva 16 ANS. Urination.ppt 8/6/2011 .

Detrusor Internal sphincter Sweat glands Heart.rate & Force of contraction Blood vessels. 4. 9.No. 3. 2. 6.skin coronary ANS. 1.Motility Secretion Sphincters Gall bladder Urinary bladder. 7. Effector organ Eye ² Ciliary muscle Pupil Lacrimal glands Salivary secretion GIT.ppt skeletal msl Sympathetic Relaxation Dilatation Decrease in secretion Decrease Inhibition Decrease Constriction Relaxation Relaxation Constriction Increase secretion Increase Increase Constriction Dilalatation Constriction Parasympathetic Contraction Constriction Increase Increase Acceleration Increase Relaxation Contraction Contraction Relaxation Decrease Decrease No effect No effect No effect No effect 8/6/2011 5. 17 . 8.

Decreased mucous secretion No action dialatation No action 12.NO. 10. EFFECTOR ORGAN LUNGS: Bronchiole Gland secretion SYMPETHETIC PARASYMPETHETIC Dilatation Decrease Constriction Increase 11. Reproductive system: Male sex organs External genitalia Mucous membrane Ejaculation No action on BVs Capillaries constricted.ppt 8/6/2011 . 18 ANS.

ppt 8/6/2011 .DETAILED ANATOMY 19 ANS.

myelinated) 20 ANS.Autonomic Nervous System: Anatomy y Two kinds of efferent neurons y Preganglionic neuron/axon y Cell body in CNS.ppt 8/6/2011 . axon to autonomic ganglion (usu.

ppt 8/6/2011 . postganglionic axon to effector y (unmyelinated) 21 ANS.y Ganglionic neuron y Cell body in ganglion.

Parasympathetic: Anatomy y Ganglia y Terminal. close to effector cells y Preganglionic axons relatively long 22 ANS. = intramural ganglia y in walls of viscera.ppt 8/6/2011 .

. And partly in the 2nd. Hence called craniosacral outflow.3rd & 4th sacral segment of spinal cord.PARASYMPATHETIC NERVOUS SYSTEM y PREGANGLIONIC NEURONS: ‡ ‡ ‡ ‡ ‡ Located partly in the brain stem in connection with: 3rd(occulomotor) 7th(facial) 9th(glossophyrangeal) and 10th(vagus) .

Parasympathetic: Anatomy y Parasympathetic pathway y Hypothalamus & brain stem y Cranial or sacral outflow y Long preganglionic axon to intramural ganglion y Short ganglionic neuron (postganglionic axon) 24 ANS.ppt 8/6/2011 .

y POST GANGLIONIC NEURONS:  Occulomotor nerve are situated in the ciliary ganglion.  Vagus and sacral component are loacated in the walls of target organs.ppt 8/6/2011 .  Glossopharyngeal nerve in the otic ganglia. 25 ANS.  Facial nerve in pterygopalantine and submandibular ganlion.

ppt 8/6/2011 .26 ANS.

mesenteric ganglion y Aortico-renal y Superior hypogastric 3.Terminal or peripheral ganglia Suprarenal medulla as chromaffin cells 27 ANS.Sympathetic: Anatomy y Sympathetic Ganglia 1.Prevertebral = collateral ganglia unpaired among abdominal viscera y Celiac ganglion y Superior mesenteric ganglion y Inf.ppt 8/6/2011 .Sympathetic trunk = sympathetic chain ganglia paired on either side of vertebrae 2.

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Sympathetic Trunk Ganglia

Figure 15.8

y The trunk presents:  3 ganglia in cervical part ie superior. middle and inferior  11 ganglia in thoracic part  4 ganglia in lumbar part  4 ganglia in sacral part .

.y some time inferior cervical and first thoracic ganglia are fused to form a cervicothoracic or stellate ganglia. 5th and 6th unite to form middle cervical ganglion y 7th and 8th cervical ganglion join to form inf. Cervical ganglion. y Upper 4 cervical ganglia are fused to form the sup. Cervical ganglion.

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ppt 8/6/2011 . white rami lying lateral to the gray rami. White rami: convey preganglionic fibers from lateral horn cells of T1-L2 segment of spinal cord through all thoracic and upper two lumbar spinal nerves.y Each of thoracic and upper two lumbar sympathetic ganglion is connected to the corresponding spinal nerves by both white and gray rami communicants. upper and lower limb and and vasodilator fibers to the skeletal muscle. 35 ANS. Grey rami: convey post ganglionic fibers from the lateral ganglia through all 31 pairs of spinal nerves and their limb plexuses to supply sudomotor. pilomotor and vasoconstrictor fibers to segmental skin viscera of body wall.

Subsidiary ganglia: consist of collateral and terminal ganglia. Collateral ganglia: are represented by coeliac. aortico renal ganglia and neurons in the sup. 36 ANS. inferior mesenteric.ppt 8/6/2011 . Hypogastric plexus. Terminal ganglia: are formed only in the suprarenal medulla as the chromaffin cells which liberate more adrenalin than non adrenaline.superior mesenteric.

ppt 8/6/2011 .Sympathetic: Anatomy y Adrenal medulla y One in each adrenal gland y Develops as ´misplacedµ sympathetic ganglion y Neuron-like cells without axons y Secrete epinephrine. norepinephrine 37 ANS.

S2. Ganglia 3. IX.Ach Postsynaptic. Postganglionic fibers Long Short 5. Neurotransmitters Presynaptic. Preganglionic fibres 4. Origin T1 to L2-L3 Thoracolumbar outflow Situated away from the organ it supply Short Cr ns.ppt 8/6/2011 . S4 Craniosacral outflow Situated near or at the organ it supply Long 2. S3.s. X Sacral. characterestic SNS PNS 1. III.no.VII.nor adrenaline Both Ach 38 ANS.

ppt 8/6/2011 .AUTONOMIC DYSFUNCTION 39 ANS.

ppt 8/6/2011 .y Acute autonomic paralysis ( dysautonomic polyneuropathy. pure pandysautonomia) y Primary autonomic failure ( idiopathic orthostatic hypotension ) y Peripheral neuropathy with secondary orthostatic hypotension 40 ANS.

y Autonomic neuropathy in infants & children (Riley-Day Syndrome) y Autonomic failure in elderly y Horner (oculosympathetic) & stellate ganglion syndromes 41 ANS.ppt 8/6/2011 .

ppt 8/6/2011 .y Sympathetic & Para sympathetic paralysis in Tetraplegia & Paraplegia y Acute autonomic crisis ( Sympathetic Storm ) y Disorders of sweating y Disturbances of bladder & bowel function 42 ANS.

ppt 8/6/2011 .ANS dysfunction following SCI 43 ANS.

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45 ANS.ppt 8/6/2011 . temperature dysregulation. and hyperhidrosis.Journal of Rehabilitation Research & Development. 2007 y Assessment of autonomic dysfunction following spinal cord injury: Rationale for additions to International Standards for Neurological Assessment joint committee of the American Spinal Injury Association (ASIA) and the International Spinal Cord Society The committee recommends The recognition and assessment of the following conditions: neurogenic shock. cardiac dysrhythmias. autonomic dysreflexia. orthostatic hypotension.

Neurogenic shock y Severe hypotension and bradycardia y An effect of the imbalance in autonomic control.ppt 8/6/2011 . with an intact parasympathetic influence via the vagal nerve and a loss of sympathetic tone because of disruption in supraspinal control 46 ANS.

y Can last upto 5 weeks post injury y ´Spinal shockµ 47 ANS.ppt 8/6/2011 .

‡ Usually temporary 48 ANS.ppt 8/6/2011 .Cardiac Dysrhythmias y Depends on level & completeness of SCI y Above T6: reduction in sympathetic cardiovascular control hypotension & bradycardia.

Consensus Committee of the American Autonomic Society and the American Academy of Neurology 49 ANS.Orthostatic Hypotension y A decrease in systolic blood pressure of •20 mmHg or a decrease in diastolic blood pressure of •10 mmHg when the subject moves from an supine to upright posture.ppt 8/6/2011 . regardless of whether symptoms occur.

y Loss of supraspinal control of the sympathetic nervous system below the lesion level frequently results in orthostatic hypotension y 2 grades of severity: Asymptomatic Symptomatic 50 ANS.ppt 8/6/2011 .

light-headedness. or faintness y Physical signs : pallor.ppt 8/6/2011 . nausea. or loss of consciousness y Common problem after acute cervical and high thoracic SCI 51 ANS. diaphoresis.y Symptoms : dizziness.

ppt Pooling of blood in the viscera and dependent vasculature 8/6/2011 .Mechanism Interruption of efferent pathways from the brain stem vasomotor center to the sympathetic nerves involved in vasoconstriction Failure of short-term blood pressure regulation 52 ANS.

paresthesias & flushing above the lesion level.ppt 8/6/2011 . chills or shivering. pounding headache.Autonomic Dysreflexia y Sudden bouts of hypertension (triggered by afferent stimuli below the lesion level) y Accompanied by piloerection. anxiety. malaise. and nausea 53 ANS. as well as nasal congestion.

y In both acute & later stages y Occurs as a result of noxious or nonnoxious peripheral or visceral stimulation below the lesion level y Primarily affects subjects with lesions above the outflow to the splanchnic and renal vascular beds (T5²T6) 54 ANS.ppt 8/6/2011 .

y Found in subjects with both complete and incomplete lesions (C>I) y Irritation of the urinary bladder and GIT are among the most common causes 55 ANS.ppt 8/6/2011 .

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ppt 8/6/2011 .Temperature Dysregulation y Occurs in the acute phase of SCI and can potentially last a lifetime y 3 categories  Poikilothermia. or ´environmental fever.µ from prolonged cold exposure  ´Quad feverµ without an infectious source  Exercise-induced fever 57 ANS.

Sweating Disturbances y Hyperhidrosis y Most common pattern: profuse sweating above the lesion level with minimal or no sweating (hypohidrosis. anhidrosis) below the lesion level 58 ANS.ppt 8/6/2011 .

ppt 8/6/2011 .59 ANS.

31:538±542 The International Standards for Neurological Classification of Spinal Cord Injury: Intra-Rater Agreement of Total Motor and Sensory Scores in the Pediatric Population J Spinal Cord Med. 2008.ppt 8/6/2011 . Apr 2009.32(2):157±161 60 ANS.International Standards for Neurological Classification of Spinal Cord Injury: Training Effect on Accurate Classification J Spinal Cord Med.

ppt 8/6/2011 .Autonomic Peripheral Neuropathy Roy Freeman Neurol Clin 25 (2007) 277±301 61 ANS.

y Small or Unmyelinated fibers are selectively involved.ppt 8/6/2011 . S/S y Cardiovascular y Thermoregulatory y Gastrointestinal y Urogenital y Pseudomotor y Pupillomotor 62 ANS.

63 ANS.ppt 8/6/2011 .

Diabetic autonomic neuropathy y Manifests initially as an increased resting heart rate caused by a cardiac vagal neuropathy y Later on. causing reduced vasoconstriction of the splanchnic and other peripheral vascular beds 64 ANS. sympathetic involvement y Orthostatic hypotension occurs in diabetes as a consequence of efferent sympathetic vasomotor denervation.ppt 8/6/2011 .

ppt 8/6/2011 .y Bladder dysfunction: threshold for micturition reflex is increased y GI Dysfn: diabetic gastroperesis y Constipation y Diabetic diarrhoea y Loss of thermoregulatory sweating in a glove and stocking distribution: SNS dysfn y Hyperhydrosis 65 ANS.

Guillain-Barre syndrome y Orthostatic hypotension y Thermoregulatory problems 66 ANS.ppt 8/6/2011 .

flutter) ECG changes (elevated or depressed ST segment changes.Cardiovascular manifestation of autonomic involvement Sinus tachycardia Bradycardia Asystole Tachyarrhythmias( fibrillation. QT interval prolongation) y Postural hypotension y Hypertension y y y y y y .

.Riley-Day-Syndrome (familial dysautonomia) y This syndrome has an autosomal recessive mode of inheritance and occurs primarily in Ashkenazic jews y Pathological studies show reduction in number of preganglionic neurons in intermediolateral columns and also small myelinated fibers in the ventral roots.

y Clinical features: y Diminished lacrimation y Hyperhydrosis y Transient blotching of skin y Postural hypotension y Poor temperature control .

Autonomic Dysfunction in PD 70 ANS.ppt 8/6/2011 .

the aging process itself.y Occur in 90% patients during disease course y May be the result of other conditions (such as multiple system atrophy [MSA]). or pharmacotherapy for PD 71 ANS.ppt 8/6/2011 .

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. autonomic. pyramidal or cerebellar symptoms and signs.  Clinically characterised by any combination of Parkinsonian.Multiple System Atrophy y It is a degenerative disease with onset in middle of life.

y Autonomic featuresy Postural faintness y Recurrent syncope y Urinary incontinence y Faecal incontinence y Impotence in males .

Clinical features: y Ptosis y Miosis y Anhidrosis y Enophthalmos 1.Localised Dysautonomic Disorder Horner·s syndrome Lesion affecting pre ganglionic fibres from T1 and T2 at the inferior cervical gangion is manifested by horner·s syndrome. .

y Pre ganglionic lesion :  Thoracic surgical trauma  Trauma to brachial plexus  Aneurysm of aorta or subclavian artery Post ganglionic lesion :  Ischemia or compression of paracarotid sympathetic pathways as a result of vasospasm .

Holmes Adie Syndrome y Pupil has decreased or absent light reflex y A slow or delayed contraction to near vision y And slow or delayed dilatation to dark Causes y Degeneration of the ciliary ganglion and the post ganglionic parasympathetic fibers of constrictor pupillae muscle .

Hirschsprung·s disease y Congenital y Absence of myentric plexus y Segment of colon remain in constriction 78 ANS.ppt 8/6/2011 .

Raynaud·s Disease y Raynaud·s disease ² characterized by constriction of blood vessels y Provoked by exposure to cold or by emotional stress .

Hypertension y Hypertension ² high blood pressure y Can result from overactive sympathetic vasoconstriction .

ppt 8/6/2011 .AUTONOMIC DYSFUNCTION AFTER TBI??? 81 ANS.

PATHOGENESIS: ‡Epileptogenic etiology ‡Disconnection theory ‡Excitation. decorticate or decerebrate posturing. temperature.inhibition ratio model 82 ANS.Dysautonomia after severe traumatic brain injury European Journal of Neurology 2010.ppt 8/6/2011 . respiratory rate.8% Dysautonomia after traumatic brain injury (TBI) is characterized by episodes of increased heart rate. blood pressure. and profuse sweating. 17: 1172-1177 INCIDENCE: 11. muscle tone.

THANK YOU 83 ANS.ppt 8/6/2011 .

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