Sensory and motor pathways



Sensory and motor pathways


The central nervous system contains a large number of ascending and descending tracts that pass between the brain and spinal cord. However, in this chapter discussion will be restricted to the three most clinically important pathways that are routinely assessed in the neurological examination. The concept of upper and lower motor neurons will also be introduced, together with the anatomical basis of muscle tone and tendon reflexes.



Spinal segments


The spinal cord is divided into 31 segments (Fig. 4.1A), each with a pair of dorsal (sensory) roots and a pair of ventral (motor) roots. The dorsal and ventral roots unite on each side to form a mixed spinal nerve (spinal nerve root) (Fig. 4.1B). Each nerve root divides into a small dorsal ramus, which supplies the paravertebral muscles and provides cutaneous sensation to the back, and a large ventral ramus which innervates the limbs and trunk. The dorsal root ganglia at each spinal level contain the cell bodies of sensory neurons that innervate an area of skin called a dermatome (Fig. 4.2). They also contain the cell bodies of sensory neurons innervating muscles, tendons, ligaments and joints.





Internal anatomy of the spinal cord


The spinal cord has an H-shaped inner core of grey matter, with dorsal and ventral horns, surrounded by a thick layer of white matter. The ventral (anterior) horns contain longitudinal columns of motor neurons that innervate the skeletal musculature via the ventral roots; and each column supplies a functionally related group of muscles. The dorsal (posterior) horns contain sensory neurons that receive afferent projections from the dorsal root ganglia. The white matter of the spinal cord includes connections between segmental levels, together with long tracts passing to and from the brain.




Somatic sensory pathways


Two major spinal cord pathways carry sensory information to the cerebral cortex where it can be consciously perceived. The dorsal column pathway is concerned with precisely localized touch and joint position sense. The spinothalamic tract is primarily responsible for pain and temperature sensation. Each pathway is composed of a three-neuron chain with a similar arrangement (Fig. 4.3):




The axons of the somatic sensory pathways are arranged in a precise point-to-point or somatotopic fashion (Greek: soma, body; topos, place). This means that fibres innervating adjacent parts of the body surface remain side-by-side along the full length of the pathway to the brain.



Dorsal column pathway


The dorsal column pathway is mainly responsible for precisely localized touch and proprioception (awareness of one’s own body; Latin: proprius, one’s own) including joint position sense. It contains large myelinated axons (A-alpha fibres) which transmit impulses at speeds of up to 120 metres per second. Integrity of the dorsal columns is best assessed clinically using a tuning fork (Clinical Box 4.1).





Pathway to the cerebral cortex (Fig. 4.4)


The first-order neurons of the dorsal column pathway have their cell bodies in the dorsal root ganglia. A central axonal process enters the dorsal column and, without crossing the midline, ascends uninterrupted to the medulla. These fibres terminate on second-order neurons in the dorsal column nuclei (the gracile and cuneate nuclei).



Axons emerge from the dorsal column nuclei and arch anteriorly and medially through the substance of the medulla as the internal arcuate fibres (Latin: arcuate, shaped like a bow). These axons cross the midline as the great sensory decussation. It is important to appreciate that in the dorsal column pathway all the second-order axons cross the midline together (in the great sensory decussation of the medulla).


Having crossed the midline, the second-order fibres turn sharply upwards and ascend to the thalamus as the medial lemniscus. This is a strap-like bundle which twists like a ribbon as it passes through the brain stem (Latin: lemniscus, ribbon). The medial lemniscus terminates on third-order neurons in the thalamus, which project to the primary somatosensory cortex in the parietal lobe.



Spinothalamic tract


The spinothalamic tract mediates pain and temperature sensations. Impulses are transmitted by small-diameter unmyelinated c-fibres and thinly-myelinated A-delta fibres which conduct impulses at relatively slow speeds of 0.5–15 metres per second. This pathway can be tested clinically using a sterile pin (Clinical Box 4.2).





Pathway to the cerebral cortex (Fig. 4.5)


The first-order neurons of the spinothalamic tract have their cell bodies in the dorsal root ganglia. The central processes enter the spinal cord where they synapse on second-order neurons in the dorsal horn.



Axons of the second-order neurons then cross the midline in the ventral white commissure (in the anterior spinal cord) to reach the opposite side. Having crossed over, the second-order fibres ascend in the anterolateral spinal cord as the spinothalamic tract and pass through the brain stem as the spinal lemniscus. This fibre system runs in close proximity to the medial lemniscus and also terminates on third-order neurons in the thalamus.


Finally, third-order thalamocortical fibres project to the primary somatosensory cortex. It is important to note that in the spinothalamic tract (in contrast to the dorsal column pathway) axons of second-order neurons can be found crossing the midline at all levels of the cord, rather than in a single sensory decussation.



The spinoreticulothalamic pathway


Some spinothalamic axons contribute to a spinoreticular pathway which synapses in the reticular formation of the brain stem. From here, reticulothalamic fibres ascend to the intralaminar nuclei of the thalamus before projecting on to the limbic lobe and insula, which have visceral and emotional roles including pain perception (Clinical Box 4.3).






Pain arising from the internal organs


The internal organs (or viscera) are insensitive to cutting and burning, but respond to stretching, twisting, inflammation and vascular compromise. Pain-related afferents from the internal organs reach the central nervous system via visceral afferent fibres which travel with autonomic nerves. Visceral pathology can generate three types of pain: visceral, viscerosomatic and referred.



Visceral and viscerosomatic pain


Visceral pain is diffuse, poorly localized and centred on the midline. It is often associated with autonomic features such as sweating, nausea, vomiting and pallor. In contrast, viscerosomatic pain is sharp and well-localized. It occurs when inflammatory exudate from a diseased organ makes contact with a somatic (body-wall) structure such as the parietal peritoneum. Abdominal pathology (e.g. appendicitis) may therefore present with diffuse visceral pain, before progressing to sharp viscerosomatic pain (Fig. 4.6).


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Jun 19, 2016 | Posted by in NEUROLOGY | Comments Off on Sensory and motor pathways

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