L4- spinal tracts and associated disease states

gray matter

• located in cortex of cerebrum, cerebellum, and brain stem

  • forms cerebral cortx (outermost layer)

  • overlies sulci and gyri

    • folds and groves increase surface area

    • allows for more efficient processing of information

• central aspect of spinal cord

components of grey matter

• neural cell bodies

• axon terminals

• dendrites

• nerve synapses

grey matter function

• recieves infor from white matter

• process info for motor and sensation in spinal cord

• processing center for personality, intelligence, motor funciton, planning, organization,language processing and processing sensory info

white matter

• located in more central aspect of brain

• peripheral aspect of spinal cord

  • ascending and desceding pathways

white matter components and function

• primary axons and coated with myelin

• conducts, processes, and send nerve signals up and down spinal cord

spinal cord tracts

• spinothalamic tract

  • pain/temp

• spinocerebellar tract

  • light tough

  • unconscious proprioceptiom

• posterior column

  • proprioception

  • vibration

spinal cord

• ascending pathways relay sensory infp to the brain

  • first order neuron (primary afferent); extremity → into brain

  • second order neuron

  • third order neuron

first order neuron

• extends from skin adn runs to dorsal root ganglion into posterior horn of gray matter in sponal cord until point of decussation

second order neuron

• carries sensory impulses to subcortical areas in thalamus

third order neurons

• carries impulses to cerebral cortex

spinothalamic tract

• pain, temp, contralateral

• cross over to opposite side of spinal cord occurs within 1-2 vertebral segments

• injury causes loss of pain and temperature sensation contralaterally

• L sided brain injury→ R sided loss of pain and temp

components of spinothalamic tract

• dorsal root ganglion

• substantia gelatinosa

  • dorsal horn of spinal cord

• brain stem

• thalamus

• primary somatosensory cortex

• nerve root injury= sam eside sx

• injury to spinal cord or brain= contralateral sx

spinothalamic tract injury- syringomyelia

• loss of normal flow of CSF (decreased nutrients→ spinal cord starts to die)

• trauma

• birth defect

spinothalamic tract injury- anterior spinal artery syndrome

• infarction

  • loss of pain and temperature sensation bilaterally BELOW injury

  • opposite side

• vibration ad proception are preserved (posterior column)

• bilateral paralysis below level injury

spinothalamic tract injury- thalamic pain syndrome

• initial loss of ALL sensation to contralateral side

• then pain to contralateral side (body doesnt know how to turn it off)

• may seem to be psychological rather than physiologic

posterior column

• extends to thamus and to cerebral cortex

• cross over at brainstem

effect of injury at spinal cord of posterior column

• causes ipsilateral sx

• loss of fine touch

• proprioception

• vibration

posterior column effect with brain injury

• contralateral loss of vibration and proprioception

conditions associated with posterior column injury

• tabes dorsalis (untreated tertiary syphalis)

• pernicious anemia

• brown sequard syndrome

severe B12 deficiency

• affects posterior column and lateral (motor)column

  • compromised nerve transmission

  • paresthesias

  • loss of vibratory sense (posterior column)

  • loss of proprioception (posterior column)

  • spastic paresis and hyperreflexia (lateral- UMN)

brown sequard syndrome

• C spine injury due to trauma, stabbing, abscess, or tumors

  • involves only one side of spinal cord

• loss of spinothlamic tract, corticospinal (motor) tract, and posterior column

classic clinical features for brown sequard syndrome

• contralateral loss of pain and temperature

• ipsilateral hemiparesis

• ipsilateral loss of vibration and proprioception

spinocerebellar tract

• controls UNCONSCIOUS proprioception

• primarily lower limbs and trunk

• walking

• ipsilateral

how to eval proprioception for spinocerebellar tract

• use finger/toe up/down in space

sx of spinocerebellar tract injury

• ataxia

• dysmetria

• paresthesias

• impaired coordination

  • dont know where hand is going in space

conditions associated with spinocerebellar tract inury

• brown seqruard syndrome

• tabes dorsalis

• B12 deficiency

• vitmain e def

  • similar sx to B12 def + hemolytic anemia

• friedreich ataxia

friedreich’s ataxia

• autosomal recessive d/o that effects chormosome 9

  • degeneration of spinocerebellar tract, dorsal root ganglia, dorsal column, lateral corticospinal tracts

sx of friedreich’s ataxia

• ataxia

• loss of proprioception (dorsal)

• spastic paralysis (corticospinal tract-UMN)

• loss of DTR (afferent pathway

descending pathway

• relay motor instruction from the brain

  • pyramidal tracts

    • corticobulbar tract

    • corticalspinal tract

  • extrapyramidal tracts

  • 2 interconnecting neuron

interconnnecting neurons of descending pathway

• 1st order neuron

  • UMN

    • cerebral cortex and brain stem

    • soinal cord to anterior gray horn

• 2nd order neuron

  • LMN

    • spinal cord to skeletal muscles

corticospinal tract

• control limb and trunk mvmt

• motor cortex to medulla

  • crossover of lateral corticospinal tract at medulla

  • crossover of anterior corticospinal tract occurs in spinal cord

• ends at junction of UMN and LMN

  • voluntary motor control

corticobulbar tract

• motor response for cranial nerves V, VII, IX, X, XI, and XII

• control head, neck, amd face mvmt

extrapyramidal tract

• located in brainstem

• involuntary motor mvmt

  • muscle tone

  • balance

  • posture

  • modulator of motor response

sx of injury to extrapyramidal tract

• hypokinetic

  • bradykinetic mvmt

  • loss of pendulaiton with walking

• hyperkinetic

  • athetosis- writhing/twisting motion of the arm

• chorea- invol constant small to large mvmts througout the body

• myoclonus

• tremors and tics

• dystonia

UMN injury

• spastic apralysis

• limited muscle atrophy

• NO fasiculations/fibrilations

• hyperrefelxia

• babinski reflex mya be present- big toe up

LMN injury

• flaccid paralysis

• sig atrophy

• fasiculations ad fibrilations

• hyporeflexia

• babinski not present

spinal cord disease

• amyotrophic lateral sclerosis

• tertiary syphilis

• guillan barre syndrome

• pernicious anemia

• poliomyelitis

amyotrophic lateral sclerosis (ALS)

• mixed upper and lower motor neuron sx

  • UMN- corticospinal tracts

  • LMN- anterior horns and grey matter

• progressive neuro sx

• medial survival 3-5years for most cases

  • pulm infections mcc of death

• + CN involvement

ALS s/sx

• bulbar involvement (CN IX, X, XI, XII); sometimes V and VII

  • swallowing

  • chewing (CN V)

  • coughing

  • breathing

  • talking

• vauge sensory complaints

• progressice weakness

• cognitive complaints

ALS physical exam

• drooping of the palate (CN IX and X)\

• depressed gag reflex (CN IX asn X)

• poolig of saliva in pharynx (CN IX)

• weka cough

• tongue wasting with contraction and fasiculations

• sensation typically preserved

• sphincter function usually intact

• UMN- spasticty

• LMN- weakness, atrophy, and fasiculations

ALS testing

• electromyogrphy

  • acute and chrinic partial denervation with reinnervation

  • changes in cervical, thoracic, and lumbar region

  • two spinal regions and bulbar musculature

ALS drooling control

• OTC decongestants

• aticholinergics

  • trihexyphenidyl

  • amitriptyline

  • atropine

• dextiropmorphan/quinidine

• tracheostomy

• gastrostomy tube

• advanced care directives/palliative care consult

tertiary syphilis

• can occur anytime after secondary syphilis

• 2 types of rxn

  • hyperproliferative gummatous reaction

    • rapid onset

    • prompt response to therapy

  • diffuse inflammation that involves CNS, large arteries

    • fatal of not treated

s/sx of tertiary syphilis

• skin

  • cutaneous lesions

    • multinodular lesions

    • solitary gummas (painless)

  • mucous memebranes

    • nodular gummas

    • leukoplakia

  • skeletal

    • destructive boen lesions

      • periostits

      • osteitis

      • arthritis

tertiary syphilis eye sx

• gummatous iritis

• optic atropy

• cranial nerve palsy

tertiary syphilis cardiovascular s/sx

• arteritis of large vessel

  • leads to MI

  • aortic regurgitation

  • CHF

  • aortic aneurysm

asx tertiary syphilis

• abnormal CSF findings

  • + spinal fluid serology

  • lymphocutic pleocytosis

  • increased protein

meningovascular syphilis

• headache

• irritability

• cranial nerve palsies

• unequal reflexes

• irregular pupil

  • accomodation intact with poor/absent light reflexes

• CVA

• CSF similar to asx findings

tertiary syphilis neuro s/sx

• sx can occue in any stage of dz

• may br preogressive, disabling, and life threatening

tertiary syphilis s/sx general paresis

involvement of cerebral cortex

• loss of concentration

• memory loss

• dysarthria

• tremors fingers/lips

• irritability

• headaches

• personality change

  • slovenly, irresponsible, confused, and psychotic

tertiary syphilis labs

• lumbar puncture

  • indicared if signs of neurosyphilis or ocular involvementn

  • evidenc eof tx failure

• VDRL

• RPR

• repeat serology testing q3-6months post treatment

tertiary syphylis tx

• aqueous PCN

• ceftriaxone if PCN allergy

tabes dorsalis

• chronic progressive demyelination of posterior columns to posterior roots/ganglia

  • proprioception

  • virbration

• posterior sensory ganglia

• nerve roots

tabes dorsalis s/sx

• agryll robertson pupil

  • poor light reaction

  • accommodation intact

• muscle hypotonia

• hyporeflexia

• progressive ataxia

  • wide based gait/inability to wlak in dark

tabes dorsalis PE findings

• paresthesias

• analgesia

• radicular type pain

• charcot joints

  • painless, destructive arthritis with progressive deformity

tabes dorsalis labs

• CSF

  • normal to increased lypmphcytic cell count

  • elevated protein

guillain barre syndrome causes

• can follow illness

• a/w camplyobacter jejuni enteritis

  • undercooked or raw poultry MCC

• inoculations

• surgery

guillain barre syndrome s/sx

• weakness

  • proximal emphasis

  • starts in lefs can extend to arms and face

  • muscles of respiration/deglutition

• sensory

  • distal paresthesias

  • neuropathic and radicular pain

• autonomic sx

  • tachy

  • hypo vs hypertension

  • cardiac irregularities

  • abnormal sweating

  • pulm dysfunction → vent + ICu

guillain barre syndrome labs

• CSF

  • increased protein

  • normal cell count

  • WBC greater than 50

guillain barre syndrome tx

• hospitalization

• plasmapheresis

• IVIG

• respiratory toileting

  • airway suctioning, chest PT, incentive spirometry, nasotracheal, suctioning

• chest pt

• DVT prophylaxis bc laying in bed fro long recovery

• ICU admission if decreasing forced vital capacity

• LONG RECOVERY

pernicious anemia findings

• proprioceptive loss

• weakness and spaciticy ( UMN sx)

• posterior column and corticospinal tract involvement

  • subacute combine degnereation

• impaired B12 absorption due to lack of intrinsic factor

pernicious anemia s/sx

• glossitis→ check VitD

• anorexia

• diarrhea

• peripheral nuropathy

• balance/proprioception issues (posterior problem)

• dementai sx

• pale to icteric

• loss of vibration

pernicious anemia labs

• CBC

  • moderate to severe megaloblastic anemia

  • decreased retic count

• decreased Vit B12

  • <200

• elevated methylmalonic acid

• elevated homocysteine levels

pernicious anemia tx

• parental B12

  • IM vs SubQ

• methylcobalamin

  • oral vs SL

• neuro sx

  • parenteral B12 preferred

poliomyelitis

• anterior horn involvement

• LMN

  • weakness

  • atrophy severe

  • fasciculation/fibrilations

  • hyporeflexia

• highly contagious

  • fecal oral route

  • enterovirus affects anterior horn

polio abortive s/sx

• fever

• HA

• vomiting

• diarrhea vs constipation

• sore throat

polio nonparalytic s/sx

• abortive sx +

• meningeal irritaiton

• muscle spasms

• absence of paraluysis

polio paralytic s/sx

• flaccid asymmetric paralysis

  • proximal muscles lower extremities

• febriel period

• sensory loss rare

• spinal variant

  • spinal nerve involvement

• bulbar involvement

  • CN IX and X

polio tx

• hospilatizaiton

  • skin precautions

• ICU admin if resp sx

• PT- long term

decorticate posturing

• pathologic response to noxious stimuli

• assault or injury to brain and or brainstem

• abnormal flexion of the arms with extension of the lower extremities

• sx of neuro injury not a dx

decerebrate posturing positioning

• adduction and internal rotation at the shoulder

• extension of elbows with flexedwrist/fingers

• extension at the knees with plantar flexion of the ankle ad extension of toes

• sx of neuro injury, NOT a dx

decorticate posturing

• pointe dand turned intoes

• arms bent toward center body

• curled wrists nd balled hands against chest

decerebrate positioning

• flexed wrists

• curled fingers

• straight tense arms prallel to body

decorticate and decererbrate posturing- what to check

• CT vs MRI

  • tumor, trauma, hydrocephalus

• CBC

• CMP

  • hepatic encephalopathy

• lead testing

• infectious causes

  • malaria

  • encephalitis

• CSF

frontal loeb funitons

• motor cortex

• sensory cortex

• brocas area

• personality

temporal lobe functions

• -hearing

• language- wernickes area

pariteal lobe functions

• senses

  • taste

  • touh

  • smell

  • hearing

  • sight

occipital lobe functions

vision center

causes of cerebral injury

traumatic brain injury

stroke

• ischemic

• hemorrhagic

tumors

• malignant vs benign

intracranialhemorrhage

• aneurysms

• ateriovenous malformations

encephalitis

neurodegenerativedz

• alheimers

• parkinsons

• huntingtons

cerebral injury s/sx

• memory loss

  • temporal lobe

• impaired judegment

• personality changes

• sensory changes

  • visual

  • auditory

• language changes

cerebral injury tx

• surgery

• meds

  • anticoags for CVA (not for hemorrhagic)

  • abx fro infections

• PT

• OT

• speech therapy

• cognitive therapy

cerebral injury pronosis

• highly variable

  • permanent deficit vs partial vs full recovery

  • extent of injury

  • TIME to recognition and tx

  • access to care

cerebellar injury ddx

• trauma

• stroke

• tumors

  • benign vs malignant

• infections

• hereditary ataxia

  • friedreichs ataxia

  • spinocerebellar ataxia

• hemorrhgae

  • nauerysm

  • AVM

• MS

• etoh

• vestribular disorders

cerebellar injury s/sx

• ataxia

• balance issurs

• weakness

• coordination issues

• tremor

cerebellar dz tx

• treat undelryign cond

  • sugery

  • meds

  • stop etoh

• PT

  • balance

  • coordination

  • motor skills

cerebellar injury prognosis

• typically, better tha cerebra

• early recognition still very important

• sccess to care

• commitment to care