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Basic Spinal Cord Anatomy:
Through The Eyes Of Brown-
Séquard
Why a good knowledge of
spinal tracts is important?
10 yrs post op 10 yrs post op with
stem cell therapy
Stem cells in the...
A brief history of Brown-Séquard
Syndrome
• Charles-Edouard Brown-Séquard (1817-1896) first
described the syndrome in 1850...
Brown-Séquard syndrome
Motor: 1. Ipsilateral spastic paralysis below the level of the lesion.
2. Ipsilateral flaccid paral...
Motor Symptoms
1. Motor loss - spastic paralysis on the same side of lesion
Let’s review the corticospinal tract
Decussation
Contralatera...
1. Motor loss - spastic paralysis on the same side of lesion
Red – Ipsilateral loss of somatosensation
Green – Contralater...
1. Motor loss - spastic paralysis on the same side of lesion
Upper vs Lower motor neuron lesions
Upper motor neuron lesion...
1. Motor loss - spastic paralysis on the same side of lesion
Upper vs Lower motor neuron lesions
Lower motor neuron lesion...
1. Motor loss - spastic paralysis on the same side of lesion
Upper vs Lower motor neuron lesions
Difference UMNL LMNL
S – ...
1. Motor loss - spastic paralysis on the same side of lesion
Red – Ipsilateral loss of somatosensation
Green – Contralater...
2. Motor loss - flaccid paralysis at the level of the lesion
Red – Ipsilateral loss of somatosensation
Green – Contralater...
2. Motor loss - flaccid paralysis at the level of the lesion
Why is the paralysis flaccid?
Because at the level of the les...
2. Motor loss - flaccid paralysis at the level of the lesion
A word on dermatomes…
Increasingsteepness
Somatosensory Symptoms
Let’s review the dorsal column medial
lemnsiscus pathway
• Primary sensory afferents originate in
the periphery and ascend...
3. Somatosensory loss - ipsilateral loss of touch and vibration sensation
Red – Ipsilateral loss of somatosensation
Green ...
Let’s review the nociceptive pathway
• Primary sensory afferents originate in
the periphery and synapse in the dorsal
horn...
Red – Ipsilateral loss of somatosensation
Green – Contralateral loss of nociception
Blue – Ipsilateral spastic paralysis
B...
4. Somatosensory loss - ipsilateral loss of touch and vibration sensation
Let’s review Lissauer’s tract
• When primary pai...
4. Somatosensory loss - ipsilateral loss of touch and vibration sensation
Lissauer’s tract preserves innervation
“spinotha...
Red – Ipsilateral loss of somatosensation
Green – Contralateral loss of nociception
Blue – Ipsilateral spastic paralysis
B...
Clinical summary of Brown-
Séquard syndrome
Brown-Séquard syndrome
Aetiology:
• Full Brown-Séquard syndrome is rarely seen – as are machete wounds
• Trauma e.g. gunsh...
Brown-Séquard syndrome
Presentation:
• You should know this by now!
• Additionally there may be ipsilateral Horner’s syndr...
Brown-Séquard syndrome
Investigations:
• Spinal plain radiograph (for bony injury in penetrating or blunt trauma)
• MRI to...
Brown-Séquard syndrome
Management:
• Investigation of aetiology
• Immobilisation of cervical/dorsal spine
• No movement of...
Spinal cord injuries
What else can we learn from Spinal Cord Injuries?
Other CNS injuries include:
• Anterior cord syndrome
• Posterior cord sy...
Let’s review the position of descending motor tracts
Anterior
Posterior
Pyramidal tracts
• Lateral Corticospinal
tract (1a...
Let’s review the position of the ascending sensory tracts
Anterior
Posterior
DCML
• Gracile fasciculus (3a)
• Cuneate fasc...
Anterior Cord syndrome
• Complete bilateral motor paralysis below the level of the lesion due to
interruption of the corti...
Anterior Cord syndrome
Cause: Anterior spinal artery occlusion
Anterior Cord syndrome
Artery of adamkeiwicz
• Tabes dorsalis – degeneration due to a
syphilis infection.
Cause: • Posterior spinal artery occlusion?
Posterior cord sy...
Symptoms:
Posterior cord syndrome
• Bilateral paresthesia, hypoesthesias due to disruption of the posterior
columns
• Dimi...
Syringomyelia
Cause: • a cyst or cavity forms within the spinal cord
• Associated with the Chiara malformation in infants
...
Syringomyelia
Symptoms: • Bilateral paresthesia, hypoesthesias due to disruption of the posterior
columns.
• May disrupt s...
• The history of BSS.
• The symptoms of BSS.
• The ascending and descending tracts.
• The difference between UMNL and LMNL...
Thank you for listening
Good luck!
All images are taken from Google Commons, Wikipedia Commons or
www.weblearn.ox.ac.uk un...
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  1. 1. Basic Spinal Cord Anatomy: Through The Eyes Of Brown- Séquard
  2. 2. Why a good knowledge of spinal tracts is important? 10 yrs post op 10 yrs post op with stem cell therapy Stem cells in the injured spinal cord: reducing the pain and increasing the gain – Nature Neuroscience -Klen and Svendsen 2005
  3. 3. A brief history of Brown-Séquard Syndrome • Charles-Edouard Brown-Séquard (1817-1896) first described the syndrome in 1850. • His observations were based on observing machete injuries seen in the sugar cane farmers of Mauritius. • Paul Loye (1861 – 1890) later confirmed Séquard’s findings through the decapitation of hundreds of dogs in his laboratory in Paris! • If you understand Brown-Séquard syndrome you are well on your way to understanding the anatomy of the spinal cord.
  4. 4. Brown-Séquard syndrome Motor: 1. Ipsilateral spastic paralysis below the level of the lesion. 2. Ipsilateral flaccid paralysis at the level of the lesion. Sensory: 1. Ipsilateral loss of touch and vibration sensation 2. Contralateral loss of pain one or two levels below lesion Red – Loss of somatosensation Green – Loss of nociception Blue – Spastic paralysis Black – flaccid paralysis in muscles supplied by nerve originating from this level So what side is the lesion?
  5. 5. Motor Symptoms
  6. 6. 1. Motor loss - spastic paralysis on the same side of lesion Let’s review the corticospinal tract Decussation Contralateral Ipsilateral
  7. 7. 1. Motor loss - spastic paralysis on the same side of lesion Red – Ipsilateral loss of somatosensation Green – Contralateral loss of nociception Blue – Ipsilateral spastic paralysis Black – flaccid paralysis in muscles supplied by ipsilateral nerves originating from this level • Lesion disrupts descending corticospinal tract on one half of the spinal cord. • Tract has already crossed over so it is on the same side as the muscles it innervates • Thus the motor loss is ipsilateral
  8. 8. 1. Motor loss - spastic paralysis on the same side of lesion Upper vs Lower motor neuron lesions Upper motor neuron lesions: • Caused by a lesion to a neuron above the anterior horn cell (or cranial nerve nuclei) • Exaggeration of the stretch reflex • Spasticity • Slight loss of muscle tone • Clasp-knife response • Babinski sign (only abnormal in adults)
  9. 9. 1. Motor loss - spastic paralysis on the same side of lesion Upper vs Lower motor neuron lesions Lower motor neuron lesions: • Caused by a lesion to a neuron below the anterior horn cell (or cranial nerve nuclei) • Exaggeration of the stretch reflex due to • Causes flaccid paralysis • Larger loss of muscle tone • Fibrillations and fasciculations • Hypotonia • Babinski sign usually absent (on abnormal in adults)
  10. 10. 1. Motor loss - spastic paralysis on the same side of lesion Upper vs Lower motor neuron lesions Difference UMNL LMNL S – strength Lowered Lowered T – Tone Increases Decreases O – Others Clonus Fasciculations/fibrillations R-Reflexes Increased Decreases M-Muscles mass Slight loss Atropy Baby – Babinski Positive Negative STORM BABY
  11. 11. 1. Motor loss - spastic paralysis on the same side of lesion Red – Ipsilateral loss of somatosensation Green – Contralateral loss of nociception Blue – Ipsilateral spastic paralysis Black – flaccid paralysis in muscles supplied by ipsilateral nerves originating from this level • Why is the paralysis spastic? Because the lesion is in an upper motor neuron.
  12. 12. 2. Motor loss - flaccid paralysis at the level of the lesion Red – Ipsilateral loss of somatosensation Green – Contralateral loss of nociception Blue – Ipsilateral spastic paralysis Black – flaccid paralysis in muscles supplied by ipsilateral nerves originating from this level • Why is the paralysis flaccid? Because at the level of the lesion the lower motor neuron is involved.
  13. 13. 2. Motor loss - flaccid paralysis at the level of the lesion Why is the paralysis flaccid? Because at the level of the lesion the lower motor neuron is involved…. Can often damage LMNs at the level of the lesion But LMN lower down are unaffected
  14. 14. 2. Motor loss - flaccid paralysis at the level of the lesion A word on dermatomes… Increasingsteepness
  15. 15. Somatosensory Symptoms
  16. 16. Let’s review the dorsal column medial lemnsiscus pathway • Primary sensory afferents originate in the periphery and ascend ipsilaterally. • Synapse in the gracile and cuneate nuclei in the medulla. • Second order neurons decussate in the medial lemeniscus. • Ascend contralaterally, synapsing in the thalamus. • Third order neurons synapse in S1. 1st 2nd 3rd 3. Somatosensory loss - ipsilateral loss of touch and vibration sensation
  17. 17. 3. Somatosensory loss - ipsilateral loss of touch and vibration sensation Red – Ipsilateral loss of somatosensation Green – Contralateral loss of nociception Blue – Ipsilateral spastic paralysis Black – flaccid paralysis in muscles supplied by ipsilateral nerves originating from this level • Lesion disrupts ascending somatosensory fibres • Tract has not crossed over so it is on the same side as the tissue it innervates. • Thus the sensory loss is ipsilateral • Why is nociceptive loss contralateral?
  18. 18. Let’s review the nociceptive pathway • Primary sensory afferents originate in the periphery and synapse in the dorsal horn. • Second order neurons decussate in the anterior white commissure and ascend contralaterally to synapse in the thalamus • Third order neurons synapse in S1. 1st 2nd 3rd 4. Somatosensory loss - ipsilateral loss of touch and vibration sensation
  19. 19. Red – Ipsilateral loss of somatosensation Green – Contralateral loss of nociception Blue – Ipsilateral spastic paralysis Black – flaccid paralysis in muscles supplied by ipsilateral nerves originating from this level • Lesion disrupts ascending pain fibres. • Tract has crossed over so it is on the opposite side as the tissue it innervates. • Thus the sensory loss is contralateral. • Why does the loss start below the lesion? 4. Somatosensory loss - ipsilateral loss of touch and vibration sensation
  20. 20. 4. Somatosensory loss - ipsilateral loss of touch and vibration sensation Let’s review Lissauer’s tract • When primary pain afferents enter the spinal cord some ascend or descend one or two spinal levels. • This is the dorsolateral tract of Lissauer. • The fibres then synapse in the dorsal horn at the new level. Taken from Painmed.com
  21. 21. 4. Somatosensory loss - ipsilateral loss of touch and vibration sensation Lissauer’s tract preserves innervation “spinothalamic tract disrupted
  22. 22. Red – Ipsilateral loss of somatosensation Green – Contralateral loss of nociception Blue – Ipsilateral spastic paralysis Black – flaccid paralysis in muscles supplied by ipsilateral nerves originating from this level Summary • Ascending and descending tracts • The difference between the ascending tracts • UMNL vs LMNL • Lissauer’s tract
  23. 23. Clinical summary of Brown- Séquard syndrome
  24. 24. Brown-Séquard syndrome Aetiology: • Full Brown-Séquard syndrome is rarely seen – as are machete wounds • Trauma e.g. gunshot • Neoplasia • Multiple Sclerosis • Degenerative e.g. herniation of disc • Cysts • Vascular Causes • Infectious Causes
  25. 25. Brown-Séquard syndrome Presentation: • You should know this by now! • Additionally there may be ipsilateral Horner’s syndrome is sympathetic fibres are damaged, ptosis, anhydrois, miosis • Sphincter disturbances.
  26. 26. Brown-Séquard syndrome Investigations: • Spinal plain radiograph (for bony injury in penetrating or blunt trauma) • MRI to define extent of spinal cord injury – useful in non traumatic cases • CT myelography (useful if MRI is contra-indicated).
  27. 27. Brown-Séquard syndrome Management: • Investigation of aetiology • Immobilisation of cervical/dorsal spine • No movement of the neck should be permitted • Poor prognosis
  28. 28. Spinal cord injuries
  29. 29. What else can we learn from Spinal Cord Injuries? Other CNS injuries include: • Anterior cord syndrome • Posterior cord syndrome • Syringomyelia Before we consider them we need to look a bit closer at the spinal cord.
  30. 30. Let’s review the position of descending motor tracts Anterior Posterior Pyramidal tracts • Lateral Corticospinal tract (1a) • Anterior Corticospinal tract (1b) Extrapyramidal tracts • Rubrospinal (2a) • Reticulospinal (2b) • Vestibulospinal (2c) • Olivospinal (2d) What else can we learn from Spinal Cord Injuries?
  31. 31. Let’s review the position of the ascending sensory tracts Anterior Posterior DCML • Gracile fasciculus (3a) • Cuneate fasciculus (3b) Spinocerebellar tracts • Posterior (4a) • Anterior (4b) What else can we learn from Spinal Cord Injuries? Anterolateral system • Lateral (5a) • Anterior (5b) Spinoolivary fibres (6)
  32. 32. Anterior Cord syndrome • Complete bilateral motor paralysis below the level of the lesion due to interruption of the corticospinal tract. • Bilateral loss of pain and temperature sensation at and below the level of the lesion due to interruption of the spinothalamic tract • Bilateral retained discriminative touch, proprioception and vibratory sensation due to intact dorsal columns. Symptoms:
  33. 33. Anterior Cord syndrome Cause: Anterior spinal artery occlusion
  34. 34. Anterior Cord syndrome Artery of adamkeiwicz
  35. 35. • Tabes dorsalis – degeneration due to a syphilis infection. Cause: • Posterior spinal artery occlusion? Posterior cord syndrome • Very rare
  36. 36. Symptoms: Posterior cord syndrome • Bilateral paresthesia, hypoesthesias due to disruption of the posterior columns • Diminished reflexes • Loss of coordination • Episodes of intense pain
  37. 37. Syringomyelia Cause: • a cyst or cavity forms within the spinal cord • Associated with the Chiara malformation in infants (cerebellar herniation).
  38. 38. Syringomyelia Symptoms: • Bilateral paresthesia, hypoesthesias due to disruption of the posterior columns. • May disrupt sympathetic system • If high up it may affect the brainstem causing trigeminal nerve sensory loss.
  39. 39. • The history of BSS. • The symptoms of BSS. • The ascending and descending tracts. • The difference between UMNL and LMNL. • The importance of Lissauer’s tract. • Disruption of the spinal cord tracts. • Anterior cord syndrome. • Spinal blood supply. • The importance of the artery of Adamkiewicz. • Posterior cord syndrome. • Syringomyelia. What have we covered:
  40. 40. Thank you for listening Good luck! All images are taken from Google Commons, Wikipedia Commons or www.weblearn.ox.ac.uk unless otherwise stated Manuscript - http://www.mediafire.com/?tjqwdf26d6f382b

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