MINISTRY OF HEALTH OF UKRAINE

VINNYTSIA NATIONAL MEDICAL UNIVERSITY

CHAIR OF NEUROLOGY

MODULE 1

Lessons # 1-2

Elements of the Nervous System. Anatomy, physiology, morphology of the Nervous System.
Somatosensory System. Pathways. Aids to the examination of the Somatosensory System. Somatosensory
Deficits due to Lesions at Specific Sites along the Somatosensory Pathways.

Key points:
1. Elements of the Nervous System.
2. Peripheral Components of the Somatosensory System
3. Posterior Columns.
4. Spinothalamic Tracts.
5. Central Components of the Somatosensory System
7. Testing for somatosensory deficits.
8. Somatosensory Deficits due to Lesions at Specific Sites along the Somatosensory Pathways

Questions for students:

Define the following terms:

neuron, Nissl substance, axonal transport, Wallerian degeneration, chromatolysis, regeneration of nerve cells,
glial cells, pigments and inclusions, nerve fibers, receptor, peripheral nerve, nerve plexus, posterior root,
dorsal root ganglion, superficial sensation, deep sensation, posterior columns, spinothalamic pathway,
dermatome, conscious proprioception, stereognosis, graphesthesia, 2-point discrimination, anesthesia,
hypoesthesia, hyperpathia, allodynia, hyperesthesia, dysesthesia, paresthesia.

1. What are the steps involved in the sensory exam?

2. How is it possible to lose some types of sensations and not others?
3. What sensations are conveyed by the small-diameter sensory nerve fibers in a peripheral nerve?
4. What sensations are conveyed by large-diameter sensory nerve fibers in a peripheral nerve?
5. What sensations are conveyed by the dorsal columns?
6. What sensations are conveyed by the spinothalamic tract?
7. What is tested by double simultaneous stimulation?
8. Where would the lesion be if the patient was able to detect all modalities of sensation but could not
recognize an object placed in the right hand?
9. What is the common sensory loss from damage to the spinothalamic tract?
10. What is the common sensory loss from damage to the posterior columns?
11. What is the characteristic of sensory loss due to damage of dorsal roots?
12. What is the characteristic of sensory loss due to damage of peripheral nerves in a limb?

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 Elements of the Nervous System.
NEURONS are classified by the number of processes (Figure 1-1).
A. PSEUDOUNIPOLAR NEURONS are located in the spinal (dorsal root) ganglia and sensory ganglia
of cranial nerves (CN) V, VII, IX, and X.
B. BIPOLAR NEURONS are found in the cochlear and vestibular ganglia of CN VIII, in the olfactory
nerve (CN I), and in the retina.
C. MULTIPOLAR NEURONS are the largest population of nerve cells in the nervous system. This group
includes motor neurons, neurons of the autonomic nervous system, interneurons, pyramidal cells of the cerebral
cortex, and Purkinje cells of the cerebellar cortex.
D. There are approximately 1011 neurons in the brain and approximately 1010 neurons in the neocortex.

NISSL SUBSTANCE is characteristic of neurons. It consists of rosettes of polysomes and rough endoplasmic
reticulum; therefore, it has a role in protein synthesis. Nissl substance is found in the nerve cell body
(perikaryon) and dendrites, not in the axon hillock or axon.

AXONAL TRANSPORT mediates the intracellular distribution of secretory proteins, organelles, and
cytoskeletal elements. It is inhibited by colchicine, which depolymerizes microtubules.

A. FAST ANTEROGRADE AXONAL TRANSPORT is responsible for transporting all newly

synthesized membranous organelles (vesicles) and precursors of neurotransmitters. This process occurs at the
rate of 200 to 400 mm/day. It is mediated by neurotubules and kinesin. (Fast transport is neurotubule-
dependent.)
B. SLOW ANTEROGRADE TRANSPORT is responsible for transporting fibrillar cytoskeletal and
protoplasmic elements. This process occurs at the rate of 1 to 5 mm/day.

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C. FAST RETROGRADE TRANSPORT returns used materials from the axon terminal to the cell body
for degradation and recycling at a rate of 100 to 200 mm/day. It transports nerve growth factor, neurotropic
viruses, and toxins, such as herpes simplex, rabies, poliovirus, and tetanus toxin. It is mediated by
neurotubules and dynein.

WALLERIAN DEGENERATION is anterograde degeneration characterized by the disappearance of axons and

myelin sheaths and the secondary proliferation of Schwann cells. It occurs in the central nervous system (CNS)
and the peripheral nervous system (PNS).

CHROMATOLYSIS is the result of retrograde degeneration in the neurons of the CNS and PNS. There is a loss
of Nissl substance after axotomy.

REGENERATION OF NERVE CELLS

A. CNS. Effective regeneration does not occur in the CNS. For example, there is no regeneration of the
optic nerve, which is a tract of the diencephalon. There are no basement membranes or endoneural investments
surrounding the axons of the CNS.
B. PNS. Regeneration does occur in the PNS. The proximal tip of a severed axon grows into the
endoneural tube, which consists of Schwann cell basement membrane and endoneurium. The axon sprout grows
at the rate of 3 mm/day (Figure 1-2).

GLIAL CELLS are the nonneural cells of the nervous system.

A. MACROGLIA consist of astrocytes and oligodendrocytes.
1. Astrocytes perform the following functions:
a. They project foot processes that envelop the basement membrane of capillaries, neurons, and synapses.
b. They form the external and internal glial-limiting membranes of the CNS.
c. They play a role in the metabolism of certain neurotransmitters (e.g., ᵞ-aminobutyric acid (GABA),
serotonin, glutamate).
d. They buffer the potassium concentration of the extracellular space.
e. They form glial scars in damaged areas of the brain (i.e., astrogliosis).
f. They contain glial fibrillary acidic protein (GFAP), which is a marker for astrocytes.
g. They contain glutamine synthetase, another biochemical marker for astrocytes.
h. They may be identified with monoclonal antibodies (e.g., A2B5).
2. Oligodendrocytes are the myelin-forming cells of the CNS. One oligodendrocyte can myelinate as
many as 30 axons.
B. MICROGLIA arise from monocytes and function as the scavenger cells (phagocytes) of the CNS.
C. EPENDYMAL CELLS are ciliated cells that line the central canal and ventricles of the brain. They
also line the luminal surface of the choroid plexus. These cells produce cerebrospinal fluid (CSF).
D. TANYCYTES are modified ependymal cells that contact capillaries and neurons. They mediate cellular
transport between the ventricles and the neuropil. They project to hypothalamic nuclei that regulate the release
of gonadotropic hormone from the adenohypophysis.
E. SCHWANN CELLS are derived from the neural crest. They are the myelin-forming cells of the PNS.
One Schwann cell can myelinate only one internode. Schwann cells invest all myelinated and unmyelinated
axons of the PNS and are separated from each other by the nodes of Ranvier.

THE BLOOD - BRAIN BARRIER consists of the tight junctions of nonfenestrated endothelial cells; some
authorities include the astrocytic foot processes. Infarction of brain tissue destroys the tight junctions of
endothelial cells and results in vasogenic edema, which is an infiltrate of plasma into the extracellular space.

THE BLOOD - CSF BARRIER consists of the tight junctions between the cuboidal epithelial cells of the choroid
plexus. The barrier is permeable to some circulating peptides (e.g., insulin) and plasma proteins (e.g.,
prealbumin).

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PIGMENTS AND INCLUSIONS
A. LIPOFUSCIN GRANULES are pigmented cytoplasmic inclusions that commonly accumulate with
aging. They are considered residual bodies that are derived from lysosomes.
B. MELANIN (NEUROMELANIN) is blackish intracytoplasmic pigment found in the substantia nigra
and locus coeruleus. It disappears from nigral neurons in patients who have Parkinson’s disease.
C. LEWY BODIES are neuronal inclusions that are characteristic of Parkinson’s disease.
D. NEGRI BODIES are intracytoplasmic inclusions that are pathognomonic of rabies. They are found in
the pyramidal cells of the hippocampus and the Purkinje cells of the cerebellum.
E. HIRANO BODIES are intraneuronal, eosinophilic, rodlike inclusions that are found in the
hippocampus of patients with Alzheimer’s disease.
F. NEUROFIBRILLARY TANGLES consist of intracytoplasmic degenerated neurofilaments. They are
seen in patients with Alzheimer's disease.
G. COWDRY TYPE A INCLUSION BODIES are intranuclear inclusions that are found in neurons and
glia in herpes simplex encephalitis.

THE CLASSIFICATION OF NERVE FIBERS is shown in Table 1-1.

Somatosensory System

RECEPTORS are specialized sensory organs that register physical and chemical changes in the external
and internal environment of the organism and convert (transduce) them into the electrical impulses that are
processed by the nervous system.
Receptors are found at the peripheral end of afferent nerve fibers.
Some receptors inform the body about changes in the nearby external environment (exteroceptors) or in
the distant external environment (teleceptors, such as the eye and ear).
Proprioceptors, such as the labyrinth of the inner ear, convey information about the position and
movement of the head in space, tension in muscles and tendons, the position of the joints, the force needed to
carry out a particular movement, and so on.
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 Processes within the body are reported on by enteroceptors, also called visceroceptors (including
osmoceptors, chemoceptors, and baroceptors, among others). Each type of receptor responds to a stimulus of
the appropriate, specific kind, provided that the intensity of the stimulus is above threshold.
Most receptors in the skin are exteroceptors.

CUTANEOUS RECEPTORS (Figure 1-5) are divided into two large groups: free nerve endings and
encapsulated endings.

A. Free nerve endings are nociceptors (pain) and thermoreceptors (cold and heat).
B. Encapsulated endings are touch receptors (Meissner’s corpuscles) and pressure and vibration receptors
(Pacinian corpuscles).
C. Merkel disks are unencapsulated light touch receptors.

The further “way stations” through which an afferent impulse must travel as it makes its way to the CNS
are the peripheral nerve, the dorsal root ganglion, and the posterior nerve root, through which it enters the
spinal cord.

PERIPHERAL NERVE. Action potentials arising in a receptor organ of one of the types described above
are conducted centrally along an afferent fiber, which is the peripheral process of the first somatosensory
neuron, whose cell body is located in a dorsal root ganglion.

NERVE PLEXUS AND POSTERIOR ROOT. Once the peripheral nerve enters the spinal canal through
the intervertebral foramen, the afferent and efferent fibers go their separate ways: the peripheral nerve divides
into its two “sources,” the anterior and posterior spinal roots.

The anterior root contains the efferent nerve fibers exiting the spinal cord, while the posterior root
contains the afferent fibers entering it.
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 In total, there are 31 pairs of spinal nerves; each spinal nerve is formed by the junction of an anterior
and a posterior nerve root within the spinal canal. There are just as many pairs of nerves in each of these
regions as there are vertebrae (12 thoracic, 5 lumbar, and 5 sacral). Lastly, there is a single pair of coccygeal
nerves (or, occasionally, more than one pair).

DORSAL ROOT GANGLION. The dorsal root ganglion is macroscopically visible as a swelling of the
dorsal root, immediately proximal to its junction with the ventral root (Fig. 2.4). The neurons of the dorsal root
ganglion are pseudounipolar, i.e., they possess a single process that divides into two processes a short distance
from the cell, in a T-shaped configuration. There are no synapses within the dorsal root ganglion itself.

The fibers of individual nerve roots are redistributed into multiple peripheral nerves by way of the
plexuses, and each nerve contains fibers from multiple adjacent radicular segments. The fibers of each radicular
segment regroup in the periphery, however (Fig. 2.6), to innervate a particular segmental area of the skin
(DERMATOME). Each dermatome corresponds to a single radicular segment, which, in turn, corresponds to a
single “spinal cord segment.”

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 When a peripheral nerve is injured, the fibers within it, derived from multiple nerve roots, can no longer
rejoin in the periphery with fibers derived from the same nerve roots but belonging to other peripheral nerves—
in other words, the fibers in the injured nerve can no longer reach their assigned dermatomes. The sensory
deficit thus has a different distribution from that of the dermatomal deficit seen after a radicular injury (Fig.
2.8).

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POSTERIOR (DORSAL) COLUMN–MEDIAL LEMNISCUS PATHWAY (Figures 2.15, 2.16, 2.17)

A. FUNCTION. The posterior (dorsal) column—medial lemniscus pathway mediates tactile

discrimination, vibration sensation, form recognition, and joint and muscle sensation (conscious
proprioception).
B. RECEPTORS include Pacinian and Meissner’s tactile corpuscles, joint receptors, muscle spindles, and
Golgi tendon organs.
C. FIRST-ORDER NEURONS are located in the spinal (dorsal root) ganglia at all levels. They project
axons to the spinal cord through the medial root entry zone. First-order neurons give rise to
1. The gracile fasciculus (Goll) from the lower extremity.
2. The cuneate fasciculus (Burdach) from the upper extremity.
3. The collaterals for spinal reflexes (e.g., myotatic reflex).
4. The axons that ascend in the dorsal columns and terminate in the gracile and cuneate nuclei of the
caudal medulla.
D. SECOND-ORDER NEURONS are located in the gracile and cuneate nuclei of the caudal medulla.
They give rise to axons and internal arcuate fibers that decussate and form a compact fiber bundle (i.e., medial
lemniscus). The medial lemniscus ascends through the contralateral brain stem and terminates in the ventral
posterolateral (VPL) nucleus of the thalamus.
E. THIRD-ORDER NEURONS are located in the VPL nucleus of the thalamus. They project through the
posterior limb of the internal capsule to the postcentral gyrus, which is the primary somatosensory cortex
(Brodmann’s areas 3, 1, and 2). The somatotopic projection on the postcentral gyrus resembles a person
standing on his head—an inverted “homunculus” (Fig. 9.19).
F. TRANSECTION OF THE POSTERIOR (DORSAL) COLUMN-MEDIAL LEMNISCUS TRACT
1. Above the sensory decussation, transection results in contralateral loss of the posterior (dorsal) column
modalities.
2. In the spinal cord, transection results in ipsilateral loss of the posterior (dorsal) column modalities.

LATERAL SPINOTHALAMIC TRACT (Figures 2.15, 2.16, 2.17)

A. FUNCTION. The lateral spinothalamic tract mediates pain and temperature sensation.
B. RECEPTORS are free nerve endings. The lateral spinothalamic tract receives input from fast- and
slow-conducting pain fibers (i.e., A-8 and C, respectively).
C. FIRST-ORDER NEURONS are found in the spinal (dorsal root) ganglia at all levels. They project
axons to the spinal cord through the dorsolateral tract of Lissauer (lateral root entry zone) to second-order
neurons.
D. SECOND-ORDER NEURONS are found in the dorsal horn. They give rise to axons that decussate in
the ventral white commissure and ascend in the contralateral lateral funiculus. Their axons terminate in the VPL
nucleus of the thalamus.
E. THIRD-ORDER NEURONS are found in the VPL nucleus of the thalamus. They project through the
posterior limb of the internal capsule to the primary somatosensory cortex (Brodmann’s areas 3, 1, and 2).
F. TRANSECTION OF THE LATERAL SPINOTHALAMIC TRACT results in contralateral loss of
pain and temperature below the lesion.

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 Like the posterior columns, the lateral spinothalamic tract is somatotopically organized; here, however,
the fibers from the lower limb lie laterally, while those from the trunk and upper limb lie more medially (Fig.
2.20).

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 Anterior Spinothalamic Tract. The impulses arise in cutaneous receptors (peritrichial nerve endings,
tactile corpuscles) and are conducted along a moderately thickly myelinated peripheral fiber to the
pseudounipolar dorsal root ganglion cells, and thence by way of the posterior root into the spinal cord. Inside
the cord, the central processes of the dorsal root ganglion cells travel in the posterior columns some segments
upward, while collaterals travel 1 or 2 segments downward, making synaptic contact onto cells at various
segmental levels in the gray matter of the posterior horn (Fig. 2.16c). These cells (the second neurons) then give
rise to the anterior spinothalamic tract, whose fibers cross in the anterior spinal commissure, ascend in the
contralateral anterolateral funiculus, and terminate in the ventral posterolateral nucleus of the thalamus,
together with the fibers of the lateral spinothalamic tract and the medial lemniscus (Fig. 2.17). The third
neurons in this thalamic nucleus then project their axons to the postcentral gyrus in the thalamocortical tract.

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 TESTING FOR SOMATOSENSORY DEFICITS
Testing for pain
The best screening test for sensory loss uses a safety pin to lightly prick the face, torso, and 4 limbs; the
patient is asked whether the pinprick feels the same on both sides and whether the sensation is dull or sharp.
The pin is discarded after use to avoid potential transmission of bloodborne disorders (e.g., HIV infection,
hepatitis).
Testing for light touch
A cotton wisp can be used to test light touch.

Testing for temperature sense

Temperature sense can be tested with a cold tuning fork that has one prong rubbed warm by the
examiner's palm or with test tubes containing warm and cold water.

Testing for proprioception

Joint position sense is tested by moving the terminal phalanges of the patient's fingers, then the toes, up
or down a few degrees. If the patient cannot identify these tiny movements with eyes closed, larger up-and-
down movements are tried before testing the next most proximal joints (e.g., testing the ankles if toe movement
is not perceived).

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 Romberg test
Inability to stand with feet together and eyes closed (Romberg test) indicates impaired position sense in
the lower extremities. When cerebellar disease is present, the patient stands with the feet apart but as close
together as possible without falling and only then closes the eyes.

Testing for vibration sense

To test vibration sense, the examiner places a finger under the patient's distal interphalangeal joint and
presses a lightly tapped 128-cycle tuning fork on top of the joint. The patient should note the end of vibration
about the same time as the examiner, who feels it through the patient's joint.

Testing for stereognosis, graphesthesia and 2-point discrimination

Cortical sensory function is evaluated by asking the patient to identify a familiar object (e.g., coin, key)
placed in the palm of the hand (stereognosis) and numbers written on the palm (graphesthesia) and to
distinguish between 1 and 2 simultaneous, closely placed pinpricks on the fingertips (2-point discrimination).

LESIONS AFFECTING THE ASCENDING AND DESCENDING TRACTS

Posterior column lesions. The posterior columns mainly transmit impulses arising in the proprioceptors
and cutaneous receptors. If they are dysfunctional, the individual can no longer feel the position of his or her
limbs; nor can he or she recognize an object laid in the hand by the sense of touch alone or identify a number or
letter drawn by the examiner’s finger in the palm of the hand. Spatial discrimination between two stimuli
delivered simultaneously at different sites on the body is no longer possible. As the sense of pressure is also
disturbed, the floor is no longer securely felt under the feet; as a result, both stance and gait are impaired (gait
ataxia), particularly in the dark or with the eyes closed. These signs of posterior column disease are most
pronounced when the posterior columns themselves are affected, but they can also be seen in lesions of the
posterior column nuclei, the medial lemniscus, the thalamus, and the postcentral gyrus.
The clinical signs of a posterior column lesion are, therefore, the following:
- Loss of the sense of position and movement (kinesthetic sense): the patient cannot state the position of his or
her limbs without looking.

- Astereognosis: the patient cannot recognize and name objects by their shape and weight using the sense of
touch alone.

- Agraphesthesia: the patient cannot recognize by touch a number or letter drawn in the palm of the hand by
the examiner’s finger.

- Loss of two-point discrimination: the patient cannot distinguish between 1 and 2 simultaneous, closely
placed pinpricks on the fingertips.

- Loss of vibration sense: the patient cannot perceive the vibration of a tuning fork placed on a bone.

- Positive Romberg sign: The patient cannot stand for any length of time with feet together and eyes closed
without wobbling and perhaps falling over. The loss of proprioceptive sense can be compensated for, to a
considerable extent, by opening the eyes (which is not the case, for example, in a patient with a cerebellar
lesion).

Lesions of the lateral spinothalamic tract. The lateral spinothalamic tract is the main pathway for pain
and temperature sensation. If the lateral spinothalamic tract is transected in the ventral portion of the spinal
cord, pain and temperature sensation are deficient on the opposite side one or two segments below the level
of the lesion, while the sense of touch is preserved (dissociated sensory deficit).

A unilateral lesion of the somatosensory cortex produces a subtotal impairment of the perception of
noxious, thermal, and tactile stimuli on the opposite side of the body; contralateral discrimination and position
sense, however, are totally lost, as they depend on an intact cortex.
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 SOMATOSENSORY DEFICITS DUE TO LESIONS AT SPECIFIC SITES
ALONG THE SOMATOSENSORY PATHWAYS

Figure 2.21 shows some typical sites of lesions along the somatosensory pathways; the corresponding
sensory deficits are discussed below.
- A cortical or subcortical lesion in the sensorimotor area corresponding to the arm or leg (a and b,
respectively, in Fig. 2.21) causes paresthesia (tingling, etc.) and numbness in the contralateral limb, which are
more pronounced distally than proximally. An irritative lesion at this site can produce a sensory focal seizure;
because the motor cortex lies directly adjacent, there are often motor discharges as well (Jacksonian seizure).
- A lesion of all sensory pathways below the thalamus (c) eliminates all qualities of sensation on the opposite
side of the body.
- If all somatosensory pathways are affected except the pathway for pain and temperature (d), there is
hypesthesia on the opposite side of the body and face, but pain and temperature sensation are unimpaired.
- Conversely, a lesion of the trigeminal lemniscus and of the lateral spinothalamic tract (e) in the
brainstem impairs pain and temperature sensation on the opposite side of the body and face, but does not
impair other somatosensory modalities.
- If the medial lemniscus and anterior spinothalamic tract (f) are affected, all somatosensory modalities of
the contralateral half of the body are impaired, except pain and temperature.

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- Lesions of the spinal nucleus and tract of the trigeminal nerve and of the lateral spinothalamic tract (g)
impair pain and temperature sensation on the ipsilateral half of the face and the contralateral half of the body.
- Posterior column lesions (h) cause loss of position and vibration sense, discrimination, etc., combined with
ipsilateral ataxia.
- If the posterior horn of the spinal cord is affected by a lesion (i), ipsilateral pain and temperature sensation
are lost, but other modalities remain intact (dissociated sensory deficit).
- A lesion affecting multiple adjacent posterior roots (j) causes radicular pain and paresthesiae, as well as
impairment or loss of all sensory modalities in the affected area of the body, in addition to hypotonia or atonia,
areflexia, and ataxia if the roots supply the upper or lower limb.

QUESTIONS FOR SELF-EDUCATION

1. Which of the following symptoms is true about NEURONS (choose applicable):

1. Neurons are basic cells of the nervous system
2. Neurons receive information, integrate it, and pass it along
3. Neurons can be located in the skin, muscles or connective tissue
4. Neurons consist of several parts
5. Neurons can be different (by types of processes)
6. Neurons mostly have only one process - axon
7. Neurons can make several types of synaptic contacts
8. Neurons can have different function
9. Neurons use neurotransmitters to transmit signals across a synapse
10. Signals between neurons occur via synapses

2. Name the entire structure.

1. Cell body
2. Myelin sheath
3. Dendrites
4. Soma
5. Axon
6. Schwann cell
7. Node of Ranvier
8. Astrocyte
9. Axon hillock
10. Axon terminals
11. Oligodendrocyte
12. Neurilemma
13. Microglia

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