Download - Regulation1 Spine
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MÍCHAMÍCHA
David Kachlíkand
Petr Zach
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Spinal cord = Spinal cord = Medulla spinalisMedulla spinalisSpinal cord = Spinal cord = Medulla spinalisMedulla spinalis
• myelon
• Inside canalis vertebralis
• 1st level of CNS
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Development of neural tube in the spinal Development of neural tube in the spinal cord regioncord region
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Spinal cord growthSpinal cord growth
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Spinal cordSpinal cord
• Segmental organization derived from Segmental organization derived from neural tube and somitesneural tube and somites
• Spinal segments - 31
• Spinal nerves: C8, T12, L5, S5, CC8, T12, L5, S5, Coo11
• Comparable to Comparable to „„iinput-nput-ooutpututput„ „ systemof computer
• Seat of reflexesSeat of reflexes
• Origin of ascending and descending Origin of ascending and descending projectionsprojections
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Spinal segmentsSpinal segments
C8, T12, L5, S5, CC8, T12, L5, S5, Coo11
• Fila radiculariaFila radicularia
• Radix anteriorRadix anterior• Radix posteriorRadix posterior
•Ganglion spinaleGanglion spinale
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• arbitrary border between spinal cord and brain arbitrary border between spinal cord and brain stemstem– fforamen oramen mmagnumagnum– deccussatio pyramidumdeccussatio pyramidum– Exit of nervus spinalis Exit of nervus spinalis C1C1 ( (n. cervicalis primusn. cervicalis primus))
• intumescentia (plexus origin)intumescentia (plexus origin)– cervicalcervicalisis (C (C33-T1)-T1)– llumbosacralumbosacralisis ( (T12T12-L4)-L4)
• Longitudinal sulcusLongitudinal sulcus– fissura mediana fissura mediana anterior anterior (deep,contains pia mater)(deep,contains pia mater)– sulcus medianus posteriorsulcus medianus posterior
• septum medianum posterius (from pia mater)septum medianum posterius (from pia mater)– sulcus anterolateralis (ventral root)sulcus anterolateralis (ventral root)– sulcus posterolateralis (dorsal root)sulcus posterolateralis (dorsal root)– sulcus intermedius posteriorsulcus intermedius posterior
Spinal cordSpinal cord – external surface – external surface
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• Conus Conus mmedullarisedullaris• vertebras vertebras L1-L1-LL22• segments S3-S5segments S3-S5
• epiconusepiconus• vertebras T12-vertebras T12-L1L1• segments L5-S2segments L5-S2
• horse tail = cauda equina cauda equina ((nerv fibersnerv fibers))
• pars spinalis fili terminalispars spinalis fili terminalis
Spinal cordSpinal cordExternal surfaceExternal surface
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Spinal cord – ventral viewSpinal cord – ventral view
• fissura fissura mediana mediana anterioranterior
• sulcus sulcus anterolateralisanterolateralis
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• sulcus medianus posterior
• fasciculus gracilisfasciculus gracilis GolliGolli
• sulcus intermedius posterior
• fasciculusfasciculus cuneatuscuneatus BurdachiBurdachi
• sulcus posterolateralis
Spinal cordSpinal corddorsal viewdorsal view
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Vertebromedullar topography Vertebromedullar topography Chipault ruleChipault rule
● spinous proc. of upper C column = same spinal segments
● spinous proc. of caudal C column = spinal segment + 1
● spinous proc. of upper T column = m.s. + 2● spinous proc. of caudal T column = m.s. + 3● vertebras T10-12 = lumbar segments● transition T12-L1= epiconus● vertebra L1= conus
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Layers inside Layers inside vertebral canalvertebral canal
• periosteum = endorhachis• spatium epidurale• dura mater spinalis • arachnoidea mater spinales • spatium subarachnoideum
– cisterna lumbalis
• pia mater spinalis – lig. denticulatum
• medulla spinalis
• Epidural anesthesia
• Lumbal puncture / spinal anesthesia / aplication of medicaments
• Electrical stimulation / (chordotomy)
Clinical useClinical use
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Lumbal puntureLumbal punture
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• subarachnoid anesthesia
= „spinal“
•„lumbal“ – CSF sample !
• epidural anesthesia
= „epidural“
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Content of vertebral canalContent of vertebral canal
http://anatomie.lf3.cuni.cz/prezentace_topografie.htm
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Content of vertebral canalContent of vertebral canal
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Ligamentum denticulatumLigamentum denticulatum
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Canalis vertebralisCanalis vertebralis• ventrally: lig. longitudinale posterius • dorzally: arcus vertebrarum, ligg. flava • laterally: pediculi arcus vertebrae, foramina
intervertebraliaConten:• medulla spinalis + fila radicularia • dura mater spinalis, arachnoidea mater spinales,
pia mater spinalis, lig. denticulatum • a. spinalis ant., aa. spinales post.• plexus venosi vertebrales interni (ant. et post.),
vv. spinales ant. et post.
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Sond Rosette (2004)
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67P Churyumov-Gerasimenko
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Arterial supplyArterial supply
• Longitudinal vessels• a. spinalis anterior
• Non-paired ventrally• Originates from connection of short paired branches of a.
vertebralis• ventral 2/3 of spinal cord• aa. sulcocommissurales → grey matter
• aa. spinales posteriores • Paired posteriorly (sometimes doubled)• Branch from a. basilaris → a. inf. post. cerebelli
• Transversal vessels (segmental)• rr. spinales → a. radicularis anterior et posterior →
connects with longitudinal vessels → vasocoronae (around spinal cord)
• aa. periphericae → white matter
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Origins of rr. spinalesOrigins of rr. spinales• a. vertebralis • a. cervicalis ascendens• a. cervicalis profunda• aa. intercostales
posteriores• aa. lumbales• a. iliolumbalis• aa. sacrales laterales
aa. radiculares • irregular• 5-9• a. radicularis magna
Adamkiewiczi
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Arteria radicularis magnaArteria radicularis magna
• T9–T11• more often left
(65 %)• supplies
intumescentia lumbosacralis and caudal 2/3 of spinal cord
Albert Wojciech Adamkiewicz (1850 - 1921)
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Arteria radicularis magnaArteria radicularis magna
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Venous drainageVenous drainage
• Longitudinal veins• Transversal veins
– vv. basivertebrales• Run via vertebrate bodies• Connects internal and external veinous plexus
Spinal cord → plexus venosus vertebralis internus anterior + posterior (in spatium epidurale)
→ vv. radiculares
→ vv. intervertebrales
→ plexus venosus vertebralis externus anterior
→ closest regional veins (correspond to arteries)
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Spinal cord – internal Spinal cord – internal compositioncomposition
• White matter (substantia alba) = funiculi– funiculus anterior– funiculus lateralis– funiculus posterior
• Grey mattter (substantia grisea) = columns– columna anterior - motor– columna intermedia - autonomous– columna posterior - senzitive
• canalis centralis– CSF
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Mícha – řezMícha – řez• canalis centralis• cornu anterius• cornu laterale• cornu posterius• commissura grisea ant.+
post.• funiculus anterior• funiculus lateralis• funiculus posterior
– septum medianum posterius
• commissura alba ant.+ post.
• tractus posterolateralis Lissaueri
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T8T8
S1S1
C8C8
L3L3
TT88
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Spinal cord – internal Spinal cord – internal composition, general rulescomposition, general rules
• Longitudinal organization– fibers = funiculi = white matter– Nerve cells aggregates = nuclei = grey matter
• Horizontal organization– afferent & efferent fibers– crossing
• commissural (different side)• decussation (crossed)
• somatotopic organization
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Laminae spinales Rexedi I-XLaminae spinales Rexedi I-XI = nucleus marginalis (apex cornus posterioris)II = substantia gelatinosa Rolandi (caput c.p.)III+IV = nucleus proprius (cervix c.p.)V = cervix c.p.VI = basis c.pVII = cornu laterale
– ncl. thoracicus posterior Stilling-Clarke– ncl. intermediolateralis– ncl. intermediomedialis
VIII+IX = cornu anterius – ncl. anterolateralis, anteromedialis, posteromedialis,
posterolateralis, centralisX = commissura grisea ant. + post.
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Somatotopic organizationSomatotopic organization
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Regional differences in spinal Regional differences in spinal cordcord
• Cervical spinal cord– ncl. nervi phrenici (C3-5)– ncl. nervi accessorii (C1-6)– ncl. spinalis nervi trigemini (C1-2)– RF replaces for ncl. intermediolateralis
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Spinal cord tractsSpinal cord tracts
• ascending (afferent, upward)– Somatosensory and viscerosensory
konverging in spinal nerves
• descending (efferent, downward)– somatomotor– visceromotor (autonomous)
• Tracts crossing !!!
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Ascnding tractsAscnding tracts
• modality: touch, pain, heat-cold, tactile (proprioception, kinesthesia)
• receptor: exteroceptors, interoceptors, proprioceptors
• 1. neuron: ganglion spinale• 2. neuron: spinal cord / brain stem• 3. neuron: talamus (nuclei ventrobasales)• termination: cortex, cerebellar cortex, brain
stem
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Ascending tractsAscending tracts
• tractus spino-bulbo-thalamo-corticalis= posterior fascicle tract = lemniskal system =
fasciculus gracilis + cuneatus– tactile, subtle skin sensitivity, discrimination system,
pressure, vibration
• tractus spinothalamicus ant.+lat. = anterolateral system– Fast pain, heat-cold, rough skin sensitivity
• tractus spinoreticularis– Slow pain
• tractus spinocerebellares ant.+post.• And other…
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Descending tractsDescending tracts
• tractus corticospinalis = pyramidal tract– Principal motor tract – voluntary motoric– 1. neuron – cortex (pyramidal cell)– 2. neuron – alfa-motoneuron → spinal nerve
• Extrapyramidal systems– Non-voluntary motoric– tr. vestibulospinalis – postural muscles
• tr. reticulospinalis – gama moto-neurons– tr. rubrospinalis (rudimentary)– And other
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Paresis – palsy (non complete lesion)plegia– complete palsy
kvadruparesis – 4 limbs hemiparesis – half of the body longitudinally (1UL
and 1LL) paraparéza – postižení obou DK
central paresis – lesion of 1. motoneuron = SPASTIC palsy
periferal paresis – lesion of 2. motoneuron = WEAK palsy
Brain –1. neuron
Spinal cord – 2. neuron
In corresponding segment
Muscle
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A. transversal spinal cord lesionB. Brown-Séquard syndrom (spinal cord hemisection)C. syndrom a. spinalis anteriorD. hemisferic syndrom
Examples of spinal cord lesionsExamples of spinal cord lesions
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Cauda equina – roots L3-S5Cauda equina – roots L3-S5• palsy asymmetrical (according to lesioned
roots), periferal = weak (muscular atrophy, areflexia, hypotonia)
• Perception problems • radicular – asymmetrical hypesthesia + pain
– Perianal, perigenital (also hemi-, smaller extent) • Problems with sphincters • Acute urine retention • Stool retention, sexuál dysfunctions • cause: caudally from L2 vertebra, most often
discopathia (L4/5, L5/S1…)
• More on www.lf3.cuni.cz/cs/pracoviste/neurologie/vyuka/studijni-materialy/CMCP0334/studijni-materialy/Misni_poruchy.doc
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Medullary conus – segments S3-Medullary conus – segments S3-S5S5
• Is not LL palsy !!– Only short flexors of foot fingers and muscles of pevlic
diaphragm
• Perception problems – perianal, perigenital, on internal and posterior side of thigh (also S2)
• Pain into perineum and gluteal region• Sphincter problems:
– Autonomous urinary bladder (urine retention) – Stool incontinency
• Sexual problems (erection and ejaculation) • visualization – at the level of L1 vertebra • Highly suspect expansion process
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Spinal epiconus, segments L5-S2Spinal epiconus, segments L5-S2
• Paresis as in radicular lesion L5 + S1 – mistakes !! paresis of extensors of foot, muscles on the ventral and
dorsal side of crus = problems with foot flexion and crus flexion
• Perception problem (posterior side of LL and distally from knees)
• Autonomous urinary bladder • Sexual problems (erection and ejaculation) • Visualization is necessary at the level of vertebras T12/L1! • It is not discus prolapsus, but suspect expansion process!
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Casuistic 1Casuistic 1
• 33-year old female patient comes with great back pain, radiculopathy (lesion of radices) on the left LL and worsening urine incontinency
• Which part of the vertebral column would you examine using visualization techniques (X-ray, CT, MR)?
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Examination resultsExamination results
CT myelogramArrow points to intramedullar thing, that was identified
as tumor from adipous tissue – lipoma.
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Casuistic 2Casuistic 2
• 60-year female patient with fastly growing paraplegia and complete anesthesia of lower half of the body
• In personal anamnesis there is operation for abdominal aorta aneurysm
Which tracts are impaired?
How big is spinal cord lesion on „horizontal section“ ?
What could be the cause of sudden paraplegia?
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Examination resultsExamination results
MR T-L páteřeischemia by T5
+ konus
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A: abdominal CT – arrow points to
aortal aneurysma
B: Abdominal CT – arrow points to
left atrophic kidney