MED(Neuro): Neuroanatomy

The Motor System (Pyramidal, Extrapyramidal and Cerebellum)

1. Lower motor neurone
 Motor neurons in the spinal cord/brain stem that supply skeletal muscles directly
 Receive information from pyramidal tract, extra-pyramidal tract, spinal cord inter-neurones,
peripheral sensory organs (muscle spindles)
 Clinical features
- Flaccid paralysis/hypotonia
- Muscle atrophy (anterior horn cells produce nourishing factor that is conveyed to the muscles
by axonal transport)
- Fasciculations
- Hyporeflexia/areflexia
2. Upper motor neurone
 Motor neurons in the cerebral cortex (primary motor cortex) and other motor nuclei in other
parts of the brain/brainstem
 Ultimately influence LMN
 Types of descending motor pathways
(a) Conscious voluntary pathways (pyramidal tract)
 Corticospinal tract
 Corticobulbar (brainstem) tract
(b) Postural pathways (extrapyramidal tract)
 Rubrospinal tract (red nucleus in midbrain)
 Vestibulospinal tract (vestibular nuclei in pons)
 Tectospinal tract (superior colliculus in midbrain)
 Reticulospinal tract (reticular formation in pons and medulla)
 Basal ganglia
 Clinical features
- Initial flaccid paralysis and hyporeflexia
- Clasp-knife spasticity (increased tone in UL flexors and LL extensors due to destruction of
corticoreticulospinal tract stretch reflex hyperactivity)
- Muscle weakness (UL extensors/abductors and LL flexors/abductors)
- Little muscle atrophy (unless severe disuse atrophy)
- Clonus
- Hyper-reflexia but absent superficial reflexes (abdominal)
- Up-going plantar response (Babinski’s positive)
3. Corticospinal tract
 Function = voluntary control of discrete/skilled
movements
 UMN originate from cerebral cortex (pre-central
gyrus – 1 motor cortex supplementary motor area –
2 motor cortex post-central gyrus – sensory cortex
[modulate afferent inputs])
- Axons of UMN pass through corona radiate 
internal capsule  midbrain (crus cerebri) 
pons  medulla (90% decussate in the pyramids
to form lateral corticospinal tract; 10% do not
decussate and form anterior corticospinal tract
which eventually decussate at the spinal cord) 
synapse with anterior horn cells (spinal grey
matter) just prior to leaving the cord
4. Corticobulbar (corticonuclear) tract
 Function
- Controls muscles of the face, head and neck
- Influences CN 3-12 except vestibulocochlear nerve (no motor function)
 UMN originate from cerebral cortex  crosses midline just above motor nuclei  terminate in
brainstem motor nuclei
 Innervates cranial nerve nuclei bilaterally except lower facial nucleus (contralateral innervation)
- Unilateral damage to the corticobulbar tract does not cause massive dysfunction
- Bilateral lesions of the corticobulbar tracts result in pseudobulbar palsy
5. Extra-pyramidal system
 Descending pathways that influence muscle tone, posture and movement
 Affects LMN by modifying and adjusting influence of pyramidal system
 Basal ganglia disorders are characterised by meaningless unintentional movements that occur
unexpectedly
 Clinical features
- Increased tone that is continuous throughout the range of movement (rigidity)
- Involuntary movement (tremor, tics, dystonia, chorea, athetosis, hemiballismus, myoclonus)
- Cogwheel rigidity (tremor + rigidity)
- Bradykinesia
- Postural instability
6. Cerebellum
 Function = balance, muscle tone, coordination of voluntary movements on ipsilateral side
 Located in posterior cranial fossa between temporal lobe, occipital lobe and brainstem
 Lesion in a cerebellar hemisphere causes lack of coordination on the ipsilateral side
 Clinical features
- Dysdiadochokinesia
- Ataxia (truncal)
- Slurred speech
- Hypotonia
- Intention tremor (initial part of movement is
normal until target is approached)
- Nystagmus
 Gait (ataxic = broad-based, tendency to veer to
the side of the lesion)
 Central vermis of the cerebellum is concerned
with coordination of gait and posture
- lesions affecting here produces
characteristic ataxic gait
7. Summary
(a) monoplegia (paralysis affecting only 1 limb)
- partial internal capsule lesion
- motor cortex
(b) hemiplegia
- corona radiata
- internal capsule
- crus cerebri of midbrain, pons, medulla oblongata
- high cervical cord (ipsilateral hemiplegia)
(c) paraplegia (paralysis affecting both lower limbs)
- cortical paraplegia
- thoracic cord leison
(d) quadriplegia (paralysis affecting all 4 limbs)
- high cervical cord lesion
- brainstem lesion (basilar artery thrombosis)
The Sensory System
1. General sensory modalities
(a) crude touch and pressure
(b) pain and temperature
(c) fine touch and pressure
(d) vibration
(e) proprioception (conscious / subconscious)
2. General pathway
 peripheral processes of 1 sensory neurones synapse with receptors
 central processes enter dorsal root of spinal cord
 2 sensory neurones located either in spinal cord or brain stem
 axons cross midline and ascend in CNS
 synapse with 3 sensory neurones in thalamus
 eventually reaches sensory cortex (post-central gyrus of parietal lobe)
3. Main somatosensory systems
(a) spinothalamic (anterior → crude touch and pressure; lateral → pain and temperature)
- 1st-order neurone = dorsal root ganglion
- 2nd-order neurone = dorsal horn neurone, axons cross midline in front of the central canal
- 3rd-order neurone = thalamus
- sensory cortex
(b) dorsal column medial lemniscus
- 1st-order neurone = dorsal root ganglion, ascend in dorsal column (fasciculus gracilis and
fasciculus cuneatus)
- 2nd-order neurone = medulla oblongata (gracile and cuneate nuclei), axons cross midline to
form medial lemniscus
- 3rd-order neurone = thalamus
- sensory cortex
(c) spinocerebellar
- 1st-order neurone = dorsal root ganglion
- 2nd-order neurone = dorsal root neurone, axons do not cross midline
- terminates in vermis of cerebellum via superior and inferior peduncles
(d) trigeminothalamic
4. Thalamus
 Location
- large mass of grey matter in lateral wall of 3rd ventricle and floor of lateral ventricles
- Lies between midbrain and cerebral hemisphere, hypothalamus lies just inferiorly
 Function
- sensory (receives all contralateral general sensory fibres from spinal cord and brain stem;
receives visual and auditory input)
- motor (receives afferents from cerebellum, basal nuclei and motor cortex)
- cognitive
 Sensory fibres ascend through the brain stem → synapse in the thalamus → relayed to the
sensory cortex via internal capsule (motor fibres are relayed to the brainstem via internal
capsule without passing through the thalamus)
 Lesions to VPL (ventral posterior lateral) and VPM (ventral posterior medial) nuclei can cause
loss of all sensation on contralateral side of body
 Thalamic strokes are not known for motor manifestations
 Issues to discuss
 Positive Romberg can occur in proprioceptive or vestibular defects
- Maintaining balance requires at least 2 out of the 3 senses = vision, vestibular sense and
proprioception
- Patient with a pure cerebellar lesion will not have a positive Romberg = will sway with or
without eyes closed
Brainstem

1. Structure
 Made up of the midbrain, pons and medulla oblongata
 Location
- Extends between the thalamus and spinal cord
- Begins at the foramen magnum
- Anterior to the cerebellum and connected to it by 3 cerebellar peduncles (superior, middle,
inferior)
 Contains
- 10 cranial nerve nuclei (except CN 1,2) inc apparatus for controlling eye movements (CN
3,4,6)
- Ascending and descending pathways
- Reticular formation
2. Ascending pathways
 Spinothalamic tract
 Dorsal column medial lemniscus
- 1st-order neurones synapse in the ipsilateral dorsal column nuclei (gracile and cuneate nuclei)
- 2nd-order neurones decussate in the medial lemniscus and ascend on the contralateral side to
synapse in the thalamus
3. Descending pathways
 Corticospinal tract
4. Midbrain

 Cerebral aqueduct = continuation of the central canal in the spinal cord

 Superior colliculus = afferent fibres for pupillary light reflex synapse here before terminating in
the EW nucleus
- Perinaud’s syndrome = lesions affecting the area of the midbrain just below the superior
 colliculus
 Produce difficulty with upward gaze, nystagmus on attempted convergence and poor
pupillary reaction to light but not to accommodation
 Red nucleus = involved in motor control; lesions here produce contralateral ataxia and tremor
 Substantia nigra = synthesizes dopamine; degeneration associated with Parkinson’s disease
 Crus cerebri = contains descending corticospinal tract
5. Pons
 Medial longitudinal fasciculus = lesions here result in internuclear ophthalmoplegia
 Lateral gaze centre = lesions here result in ipsilateral gaze palsy
 Trigeminal nerve nucleus = exits at the level of mid-pons
- High pontine lesions = contralateral pain and sensory loss both in the face and extremities
- Medulla/lower pontine lesions = ipsilateral pain and sensory loss in the face and contralateral
pain and sensory loss in the extremities
6. Medulla
 Medial structures = pyramidal tract, dorsal column and 12th nerve nucleus
- Medial medullary syndrome
 Ipsilateral tongue paralysis
 Contralateral hemiplegia
 Contralateral loss of touch, vibration and proprioception
 Lateral structures = sympathetics, vestibular + CN 9 + CN 10 nuclei, spinothalamic tract, spinal
trigeminal nucleus, spinocerebellar tract
- Lateral medullary syndrome (Wallenberg’s syndrome)
 Contralateral pain and sensory loss in extremities
 Ipsilateral pain and sensory loss in the face
 Ipsilateral Horner’s syndrome
 Ipsilateral cerebellar signs
 Vertigo, nausea, nystagmus
 Dysphagia, impaired gag reflex, dysarthria
 Vocal cord paralysis, hoarseness
 Descending sympathetics
- Horner’s syndrome
 Ptosis, miosis, facial anhidrosis
7. Blood supply
 Arterial supply by the vertebro-basilar system
- Midbrain (cerebral peduncles)
 Central arteries from the circle of Willis
 Anterior choroidal artery
- Midbrain (tectum)
 Posterior cerebral artery
 Posterior choroidal artery
 Superior cerebellar artery
- Pons = pontine arteries
- Medulla (medial) = medullary branches of verterbral arteries
- Medulla (lateral) = posterior inferior cerebellar artery
 Drains into 2 internal cerebral veins → great cerebral vein → straight sinuses
8. Summary
 Cerebral lesion = entire contralateral side of body
 Brainstem lesion = crossed symptoms (ipsilateral face and contralateral extremities)
 Spinal cord lesion = sparing of cranial nerves, paraparesis (LL), quadriparesis (UL+LL),
sensory dissociation
The Spinal Cord
1. Structure
 caudal extension of the brain that is located in the vertebral column
 31 pairs of spinal nerves attached to it via dorsal and ventral nerve roots
- exit vertebral column through intervertebral foramina
 ends at L1/L2 level in adults
 forms cauda equina below termination
 pia mater ends as filum terminale which anchors spinal cord to the coccyx
- dura and arachnoid mater end at S2/S3 level
 spinal segment does not correlate with vertebral segment due to differential growth (latter grows
faster than former)
 central grey matter contains neuronal cell bodies and synapses
 peripheral white matter contains ascending and descending nerve fibres

dorsal horn (sensory)

lateral horn (autonomic)

ventral horn (motor)

2. Arterial supply
(a) anterior and posterior spinal arteries
- given off by vertebral arteries before they merge to form the basilar artery
- anterior spinal artery supplies the entire cord except for the dorsal columns
 anterior spinal artery thrombosis
 paralysis and loss of pain and temperature sensation
 intact vibration and proprioception
(b) segmental arteries
- enter vertebral column through intervertebral foramina

 Issues to discuss
 Hemisection of the spinal cord at the level of T1 actually produces contralateral loss of pain and
temperature of T3 dermatome and below as the fibres usually ascend 1-2 segments before
crossing over