ANATOMY AND PHYSIOLOGY

THE SPINAL CORD

The spinal cord is a fundamental component of the central nervous

system. It is an elongated, cylindrical structure extending from the level of the
foramen magnum, through the vertebral canal, to the upper border of the
second lumbar vertebra. Up to the third month of embryonic development
however, the spinal cord extends the full length of the vertebral column, with
paired spinal nerves emanating from either side and passing through the
intervertebral foramina of adjacent vertebrae. After the third month the
vertebral column lengthens faster than the spinal cord, which results in the
cord appearing to 'travel up' the vertebral column with spinal nerves having to
stretch downwards to reach their formerly adjacent exits.
 At its uppermost point, the spinal cord is contiguous with the medulla
oblongata. At this point, the meningeal coverings of the brain proceed
downwards in the form of spinal meninges but, whereas the dural meninx
surrounding the brain comprises two layers, the meningeal and the periosteal,
the spinal dura has a single meningeal layer separated from vertebrae by the
epidural space (Snell 2001). This space contains fatty connective tissue and
venous plexuses. The spinal dura meninx extends to the level of the second
sacral vertebra, where it tapers to a fine filament of dura and pia mater called
the filium terminale externum, or coccygeal ligament. This filament secures the
cord caudally to the second segment of the coccyx (Haines 2004, Hickey 2003,
Sapru 2002). The arachnoid meninx is inferior to the dura mater and
connected to it by connective tissue called traceculae. It continues inferiorly
from the foramen magnum and ends at the level of the second sacral vertebra.
The third meninx, the pia mater, is a highly vascular membrane that is in
intimate contact with the cord surface, following vessels as they pierce it.
Thickened protractions of pia mater project laterally between nerve roots,
piercing the arachnoid and adhering to the dural sheath. These dentate
ligaments provide lateral anchoring and shock absorption for the suspended
cord. The pia mater continues caudally beyond the cord, along the filium
terminale, which anchors the cord to the dura at the second sacral vertebra,
and inferiorly to the coccyx (Fitzgerald and Curran 2002, Haines 2004, Sapru
2002).
EXTERNAL ANATOMY

The spinal cord is described as having 31 'segments', which is somewhat

misleading because the cord is not segmented. In fact, it has a relatively
smooth surface with longitudinal fissures on the anterior and posterior
aspects. The concept of segmentation derives from the regular lateral
emanation of paired spinal nerves on both sides of the spinal cord. Although
the presence of these nerves describes 31 cord 'segments', the vertebral column
only presents with 30 interforaminated vertebrae, the coccygeal bones
representing one.This has led to an inconsistency in the numbering of cord
segments when compared with the spinal vertebrae: there are equal vertebrae
and cord segments at the thoracic, lumbar, sacral and coccygeal levels but
eight, rather than the expected seven, segments in the cervical spinal cord (Fig.
3). There are two regions of the spinal cord that are fusiformly enlarged: the
cervical and the lumbar enlargements. These regions contain more grey matter
than any other in the spinal cord due to greater number of nerves needed to
innervate muscles.
INTERNAL ANATOMY

The external structure of the spinal cord is not particularly exciting,

comprising a few bumps and grooves. The internal anatomy, however, is
altogether different with a complexity that is beyond the scope of this article A
typical cross-section view of the spinal cord demonstrates a grey 'H' or
'butterfly' shape surrounded by white matter (Fig. 5). The grey 'H' matter
consists of nerve cells, axons and dendrites, while the white matter consists of
longitudinally running myelinated and unmyelinated axonal tracts. There are
six columns, or funiculi, each containing ascending, sensory and descending,
motor tracts. These columns--the anterior, lateral and posterior funiculi--are
separated laterally by the posterolateral and anterolateral furrows, or sulci,
anteriorly by the anterior median sulcus and posteriorly by the posterior
median sulcus. There is proportionately more grey matter in the lumbosacral
sections because the greater muscle mass in the lower extremities requires
greater innervation. In contrast, there is much more white matter seen in
cervical sections due to the presence there of connecting fibres that span the
entire cord, linking all regions of the body with the brain. The white matter of
the lumbosacral region contains only fibres serving the caudal end of the cord.
Close examination of the grey matter shows that it is divided into ten sections
called laminae of Rexed (Hickey 2003, Sapru 2002). The posterior laminae play
an integral role in sensory reception and modulation while the anterior laminae
help to innervate muscles
SPINAL NERVES

The spinal nerves, which link the spinal cord and the periphery of the body,
comprise, along with the cranial and peripheral nerves, the peripheral nervous
system. Understanding their paths and fibres is essential to making sense of
the theory that underpins the American Spinal Injury Association scoring
system. This internationally accepted standard diagnostic tool for assessing
neurological function involves the testing of the sensory input to, and motor
output from, the spinal cord on a level-by-level basis. It is therefore possible,
through examining sensory input, to trace the viability of nerve pathways from
specific regions of the skin to specific segments of the spinal cord. Similarly, it
is possible to examine the intactness of nerve pathways from specific segments
of the spinal cord to specific muscles of the limbs and axial skeleton. The value
of this is inestimable. Despite the tendency of some anatomy textbooks to
depict spinal nerves as structures that extend from the spinal cord to the
periphery of the body, the reality is that these nerves are very short: about 1cm
long. Each spinal nerve is formed by the union of dorsal, sensory and ventral,
motor nerve roots, which arise from the posterolateral and anterolateral sulci
respectively (Fig. 6). The dorsal nerve root contains a ganglion where the cell
bodies of the first order, unipolar sensory neurones are found. These neurones
carry information about pain, touch, vibration, temperature and proprioception
from the body wall, tendons and joints, as well as sensory impulses from
organs within the body. The ventral root meanwhile consists of nerve fibres
that transmit impulses to voluntary striated muscles as well as smooth and
cardiac muscle, and to glands to regulate secretion (Hickey 2003).

SPINAL PATHWAYS

Knowing the location and path of the tracts that link spinal nerve fibres with
the brain can help to understand the pattern of neurologic loss that can
present if particular regions of the spinal cord are damaged.

These patterns make up the anterior, posterior, central cord and Brown-
Sequard spinal cord syndromes.

The spinal cord contains many ascending and descending neural pathways,
which transmit sensory and motor information to and from the brain
respectively.

As the reflex centre for the body, the spinal cord also acts as an integrating
centre, controlling both somatic and autonomic reflexes.

The reflex is the simplest form of neuronal pathway. A single sensory neurone
brings information from the receptor to the spinal cord and links, through an
interneurone, with the motor neurone that carries impulses out to the effector,
namely a muscle or gland (Fig. 7).
BLOOD SUPPLY

The spinal cord's blood supply is complex, with different regions receiving
blood from distinct sources. For example, the superior region, from C1 to T2,
receives its supply from branches of the vertebral and ascending cerebral
arteries, the anterior spinal arteries and the radicular arteries. The
intermediate region, from T3 to T8, is supplied by paired segmental intercostals
and lumbar branches of the aorta, posterior spinal arteries and the posterior
radicular arteries. The inferior region, from T9 through the lumbosacral
sections, is served by the artery of Adamkiewicz. The distinctive nature of blood
supply to specific levels carries with it a significant problem; if the vessels are
damaged, local ischaemia results. This is particularly relevant in the T1-to-T4
and L1 regions. Venous drainage is provided by the six spinal veins, which are
located longitudinally on the ventral and dorsal aspects of the cord (Sapru
2002). These drain into the epidural venous plexuses.
PATHOPHYSIOLOGY

SPINAL CORD INJURY

A SPINAL CORD INJURY (SCI) IS DAMAGE TO THE SPINAL CORD THAT
RESULTS IN A LOSS OF FUNCTION, SUCH AS MOBILITY AND/OR FEELING.
FREQUENT CAUSES OF SPINAL CORD INJURIES ARE TRAUMA (CAR
ACCIDENT, GUNSHOT, FALLS, ETC.) OR DISEASE (POLIO, SPINA BIFIDA,
FRIEDREICH'S ATAXIA, ETC.). THE HIGHER THE INJURY THE MORE THE
PERSON WILL FUNCTION LESS. CERVICAL SEGMENT INJURY=
TETRAPLEGIA THORACIC BELOW= PARAPLEGIA.