NEUROANATOMY OF THE

MUSCULO-SKELETAL DISORDERS
ERIAL BAHAR
2016
Learning objectives:
After completing the course, students should:
Know the basic anatomical structures of the
somatosensory system.
Know the basic anatomical structures of the
somatic motor system.
Understand mechanisms of pains and movement
disorders
 Musculoskeletal complaints:
1. Pain
2. Movement disorders
3. Deformity
 HUMAN NERVOUS SYSTEM
A. Central Nervous
System
1. Brain
2. Spinal cord

B. Peripheral Nervous
System
1. Somatic
2. Autonomic
1. Sympathetic
2. Parasympathetic
 Functional Areas of Cerebral Cortex
There are three types of functional areas of cerebral cortex:
1. Sensory areas which receive and interpret somatic
sensory impulses including cutaneous sensations, the five
special senses, and some aspects of proprioception
(however, little visceral sensory information is routed to
the cortex),
2. Association areas which integrate sensory information
with emotional states, memories, learning and rational
thought processes.
3. Motor areas which generate impulses which innervate
voluntary skeletal muscles.
FUNCTIONAL AREAS OF CEREBRAL CORTEX
1. Sensory areas
2. Motor area
3. Association area
 Left cerebral
hemisphere
Gyri

Sulci
CEREBRUM
Conscious thought processes,
intellectual functions Fissures
Memory storage and processing
Conscious and subconscious regulation
of skeletal muscle contractions

DIENCEPHALON
THALAMUS
Relay and processing
centers for sensory
information

HYPOTHALAMUS
Centers controlling
emotions, autonomic
functions, and hormone CEREBELLUM
production Coordinates complex
Spinal
somatic motor
cord
patterns
MESENCEPHALON Adjusts output of
Brain other somatic motor
Processing of visual stem centers in brain and
and auditory data spinal cord
Generation of reflexive
somatic motor
responses
Maintenance of
consciousness

PONS
Relays sensory MEDULLA OBLONGATA
information to
cerebellum and Relays sensory information to thalamus and
thalamus to other portions of the brain stem
Subconscious Autonomic centers for regulation of visceral
somatic and visceral function (cardiovascular, respiratory, and
motor centers digestive system activities)
Physiologic Classification of the human nervous system

1. Sensory System
1. Somatosensory
2. Viscerosensory
3. Special senses
2. Motor System
1. Voluntary motor system
2. Autonomic motor system
3. Integrative system = the higher function of the
brain
1. Association system (cognitive and intelligence)
2. Limbic system
Introduction

Millions of sensory neurons are delivering

information to the CNS all the time
Millions of motor neurons are causing the
body to respond in a variety of ways
Sensory and motor neurons travel by different
tracts within the spinal cord
Sensory and Motor Tracts

Communication to and from the brain involves

tracts
Ascending tracts are sensory
Deliver information to the brain
Descending tracts are motor
Deliver information to the periphery
Sensory and Motor Tracts

Naming the tracts

If the tract name begins with spino
(as in spinocerebellar), the tract is a sensory tract
delivering information from the spinal cord to the
cerebellum (in this case)
If the tract name ends with spinal (as in
vestibulospinal), the tract is a motor tract that
delivers information from the vestibular apparatus
(in this case) to the spinal cord
Sensory and Motor Tracts

Sensory pathways
The posterior column pathway
The spinothalamic pathway
The spinocerebellar pathway
Sensory pathways usually contain three neurons:
First-order neuron to the CNS
Second-order neuron an interneuron located in either
the spinal cord or the brain stem
Third-order neuron carries information from the
thalamus to the cerebral cortex
Figure 15.1 Anatomical Principles for the Organization of the Sensory Tracts and LowerMotor Neurons in the
Spinal Cord
MEDIAL LATERAL

Leg Hip Trunk Arm

Sensory fibers
carrying fine
touch, pressure,
and vibration

Sensory fibers
carrying pain
and temperature

Flexors

Extensors
Sensory fibers
carrying crude
touch

Trunk Shoulder Arm Forearm Hand

Table 15.1 Principal Ascending (Sensory) Tracts and the Sensory Information They Provide
Sensory and Motor Tracts

Posterior Column tract consists of:

Fasciculus gracilis
Transmits information coming from areas inferior to T6
Fasciculus cuneatus
Transmits information coming from areas superior to
T6
Figure 15.2 A Crosssectional View Indicating the Locations of the Major Ascending (Sensory) Tracts in the
Spinal Cord

Fasciculus gracilis
Posterior
Fasciculus cuneatus columns
Dorsal root

Dorsal root
ganglion
Posterior spinocerebellar tract
Anterior spinocerebellar tract

Ventral root
Lateral spinothalamic tract
Anterior spinothalamic tract
Figure 15.3a The Posterior Column, Spinothalamic, and Spinocerebellar Sensory Tracts
Posterior Columns

Ventral nuclei
in thalamus

Midbrain

Medial
lemniscus
Nucleus gracilis and
nucleus cuneatus
Medulla
oblongata

Fasciculus cuneatus
and fasciculus gracilis

Dorsal root
ganglion

Fine-touch, vibration, pressure, and proprioception

sensations from right side of body

The posterior columns deliver fine-touch, vibration, and proprioception

information to the primary sensory cortex of the cerebral hemisphere
on the opposite side of the body. The crossover occurs in the medulla,
after a synapse in the nucleus gracilis or nucleus cuneatus.
Sensory and Motor Tracts

Spinothalamic tract
Transmits pain and temperature sensations to the
thalamus and then to the cerebrum
Spinocerebellar tract
Transmits proprioception sensations to the
cerebellum
Figure 15.2 A Crosssectional View Indicating the Locations of the Major Ascending (Sensory) Tracts in the
Spinal Cord

Fasciculus gracilis
Posterior
Fasciculus cuneatus columns
Dorsal root

Dorsal root
ganglion
Posterior spinocerebellar tract
Anterior spinocerebellar tract

Ventral root
Lateral spinothalamic tract
Anterior spinothalamic tract
Figure 15.3b The Posterior Column, Spinothalamic, and Spinocerebellar Sensory Tracts
Anterior Spinothalamic Tract

A Sensory Homunculus

A sensory homunculus
(little human) is a
functional map of the
primary sensory cortex.
The proportions are very
different from those of
the individual because
the area of sensory
cortex devoted to a
particular body region is
proportional to the
number of sensory
receptors it contains.

Midbrain

Medulla
oblongata

Anterior
spinothalamic
tract

Crude touch and pressure sensations

from right side of body

The anterior spinothalamic tract carries crude touch and pressure

sensations to the primary sensory cortex on the opposite side of the
body. The crossover occurs in the spinal cord at the level of entry.
Figure 15.3c The Posterior Column, Spinothalamic, and Spinocerebellar Sensory Tracts
Lateral Spinothalamic Tract

Midbrain

Medulla
oblongata

Lateral
spinothalamic
Spinal tract
cord

KEY
Axon of first-
order neuron
Second-order
neuron
Pain and temperature sensations Third-order
from right side of body neuron

The lateral spinothalamic tract carries sensations of pain and

temperature to the primary sensory cortex on the opposite side of the
body. The crossover occurs in the spinal cord, at the level of entry.
Figure 15.3d The Posterior Column, Spinothalamic, and Spinocerebellar Sensory Tracts
Spinocerebellar Tracts

PONS

Cerebellum

Medulla
oblongata
Spinocerebellar
tracts

Anterior Spinal Posterior

spinocerebellar cord spinocerebellar
tract tract

Proprioceptive input from Golgi tendon organs,

muscle spindles, and joint capsules

The spinocerebellar tracts carry proprioceptive

information to the cerebellum. (Only one tract is detailed
on each side, although each side has both tracts.)
Sensory and Motor Tracts

Motor tracts
CNS transmits motor commands in response to
sensory information
Motor commands are delivered by the:
Somatic nervous system (SNS): directs contraction of
skeletal muscles
Autonomic nervous system (ANS): directs the activity of
glands, smooth muscles, and cardiac muscle
Figure 15.4a Motor Pathways in the CNS and PNS
Upper motor
neurons in
primary motor
BRAIN
cortex

Somatic motor
nuclei of brain
stem

Skeletal
muscle

SPINAL
Lower
CORD
motor
neurons

Somatic motor
nuclei of
spinal cord
Skeletal
muscle

In the somatic nervous system (SNS), an

upper motor neuron in the CNS controls a
lower-motor neuron in the brain stem or
spinal cord. The axon of the lower-motor
neuron has direct control over skeletal
muscle fibers. Stimulation of the lower-
motor neuron always has an excitatory effect
on the skeletal muscle fibers.
Figure 15.4b Motor Pathways in the CNS and PNS
Visceral motor
nuclei in
hypothalamus
BRAIN

Preganglionic
neuron

Visceral Effectors

Smooth
muscle Autonomic
Autonomic nuclei in
Glands ganglia brain stem
Ganglionic
Cardiac SPINAL
neurons
muscle CORD

Adipocytes
Autonomic
nuclei in
spinal cord
Preganglionic
neuron

In the autonomic nervous system (ANS),

the axon of a preganglionic neuron in the
CNS controls ganglionic neurons in the
periphery. Stimulation of the ganglionic
neurons may lead to excitation or
inhibition of the visceral effector
innervated.
Sensory and Motor Tracts

Motor tracts
These are descending tracts
There are two major descending tracts
Corticospinal tract: Conscious control of skeletal
muscles
Subconscious tract: Subconscious regulation of
balance, muscle tone, eye, hand, and upper limb
position
Sensory and Motor Tracts

The Corticospinal Tracts

Consists of three pairs of descending tracts
Corticobulbar tracts: conscious control over eye, jaw,
and face muscles
Lateral corticospinal tracts: conscious control over
skeletal muscles
Anterior corticospinal tracts: conscious control over
skeletal muscles
 Figure 15.5 The Corticospinal Tracts and Other Descending Motor Tracts in the Spinal Cord

Motor homunculus on primary motor

cortex of left cerebral
KEY hemisphere
Axon of upper-
motor neuron

Lower-motor
neuron

To
skeletal Corticobulbar
muscles tract

Motor nuclei
of cranial
nerves Dorsal root Lateral corticospinal tract
Cerebral peduncle
To MESENCEPHALON Dorsal root
skeletal ganglion
muscles
Motor nuclei
of cranial
nerves
MEDULLA
OBLONGATA
Rubrospinal
Decussation
Pyramids tract
of pyramids

Lateral
corticospinal
Ventral root
tract Anterior Vestibulospinal tract
To corticospinal
tract Anterior Reticulospinal tract
skeletal
corticospinal
muscles SPINAL CORD tract Tectospinal tract
Sensory and Motor Tracts

The Subconscious Motor Tracts

Consists of four tracts involved in monitoring the
subconscious motor control
Vestibulospinal tracts
Tectospinal tracts
Reticulospinal tracts
Rubrospinal tracts
Sensory and Motor Tracts

The Subconscious Motor Tracts

Vestibulospinal tracts
Send information from the inner ear to monitor
position of the head
Vestibular nuclei respond by altering muscle tone, neck
muscle contraction, and limbs for posture and balance
Sensory and Motor Tracts

The Subconscious Motor Tracts

Tectospinal tracts
Send information to the head, neck, and upper limbs in
response to bright and sudden movements and loud
noises
The tectum area consists of superior and inferior
colliculi
Superior colliculi: receives visual information
Inferior colliculi: receives auditory information
Sensory and Motor Tracts

The Subconscious Motor Tracts

Reticulospinal tracts
Send information to cause eye movements and activate
respiratory muscles
Rubrospinal tracts
Send information to the flexor and extensor muscles
 Figure 15.6 Nuclei of Subconscious Motor Pathways

Motor cortex

Caudate nucleus

Basal Thalamus
Putamen
nuclei
Globus pallidus Superior colliculus
Inferior colliculus

Red nucleus
Cerebellar nuclei
Tectum
Reticular formation
Pons
Vestibular nucleus
Medulla oblongata
Figure 15.7b Somatic Motor Control

Motor
association
areas
Cerebral
cortex
Decision
in
frontal
lobes Basal
nuclei

Cerebellum

The planning stage: When a conscious decision is made to

perform a specific movement, information is relayed from the
frontal lobes to motor association areas. These areas in turn
relay the information to the cerebellum and basal nuclei.
Figure 15.7c Somatic Motor Control
Primary
motor
Motor cortex
association
areas
Cerebral
cortex

Basal
nuclei

Cerebellum

Other nuclei of
the medial and
lateral pathways
Corticospinal
pathway

Lower
Motor activity motor
neurons

Movement: As the movement begins, the motor association areas send instructions
to the primary motor cortex. Feedback from the basal nuclei and cerebellum
modifies those commands, and output along the conscious and subconscious
pathways directs involuntary adjustments in position and muscle tone.
 The Somatosensory system
1. Receptors
2. Sensory pathways
3. Perceptions
RECEPTORS
Types of receptors
- Mechanoreceptors:
-- Proprioreceptors in tendons, ligaments
and muscles body position
-- Touch receptors in the skin: free nerve endings, Merkels
disks and Meissners corpuscles (superficial touch), hair
follicles, Pacinian corpuscles and Ruffinis ending

- Thermoreceptors: Warm receptors (30-45oC) and cold

receptors (20-35oC)

- Nociceptors: respond to noxious stimuli

Figure 10.6
 Proprioceptors

Skeletal muscles, joints, tendons, ligaments

Degree of stretch, therefore information on body
movement:
to cerebrum,
cerebellum and
spinal reflex arcs
Include: -Muscle spindles
-Golgi tendon organs
-Joint kinesthetic receptors

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 Proprioceptors continued

Muscle spindles:
Intrafusal fibers rate &
degree of stretch
Golgi tendon organs
Near muscle-tendon
junction: monitor tension
within tendons
Joint kinesthetic receptors
Monitor stretch in
synovial joints
Send info to cerebellum
and spinal reflex arcs

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Skin touch receptors
Sensory receptors
Somatic Visceral

-- Nociceptors (pain) -- Chemoreceptors (chemicals

Chemoreceptors (taste, in blood, osmoreceptors)
smell, smell)
-- Baroreceptors (blood
-- Thermoreceptors pressure)
(temperature)
-- Photoreceptors (vision)
-- Baroreceptors (sound,
balance)
-- Proprioreceptors (muscle
stretch)
Sensory transduction
Receptors transform an
external signal into a
membrane potential

Two types of receptor

cells:
- a nerve cell
- a specialized epithelial
cell
Two types of sensory receptors
Sensory
pathways

The sensory pathways

convey the type and
location of the sensory
stimulus

The type: because of the

type of receptor activated

The location: because the

brain has a map of the
location of each receptor
 Pain perception

Fast pain: sharp and well localized, transmitted by

myelinated axons

Slow pain: dull aching sensation, not well localized,

transmitted by unmyelinated axons

Visceral pain: not as well localized as pain originating

from the skin pain impulses travel on secondary
axons dedicated to the somatic afferents referred
pain
Homunculus - Motor and Sensory
Referred pain
 Peripheral motor endings

Innervation of skeletal muscle

Innervation of visceral muscles and glands

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 Motor axons innervate skeletal muscle fibers at
neuromuscular junctions = motor end plates
Resemble nerve synapses between neurons, except for
acetylcholinesterase:
breaks down acetylcholine so one twitch only

53
All muscles in Motor unit: motor neuron & all the
motor unit
contract muscle fibers it innervates
together
when neuron
fires
Stimulation of
single motor
unit causes
weak
contraction of
entire muscle
(spread out)
Those with fine
control
fewer fibers
per motor
neuron (avg.
150: range is
4-100s)
54
 Innervation of visceral muscles & glands

Near end organ visceral motor axon swells =

presynaptic terminals (vesicles with
neurotransmitters): action slow (NT diffuses)

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 Spinal nerves
Part of the peripheral nervous system
31 pairs attach through dorsal and ventral nerve roots
Lie in intervertebral foramina

56
 Spinal cord segments are
superior to where their
corresponding spinal nerves
emerge through
intervetebral foramina

Spinal nerves are named

according to the spinal cord
segment from which they
originate
8 cervical
12 thoracic
5 lumbar
5 sacral
1 coccygeal

Cauda equina (horses

tail): collection of nerve
roots at inferior end of
vertebral canal 57
http://www.apparelyzed.com/spinalcord.html
 Spinal nerves
Dorsal roots sensory fibers arising from cell bodies in dorsal root ganglia
Ventral roots motor fibers arising from anterior gray column of spinal cord

58
 Spinal nerves
Note: cervical spinal nerves exit from above the
respective vertebra
Spinal nerve root 1 from above C1
Spinal nerve root 2 from between C1 and C2, etc.
The remaining spinal nerve pairs emerge from the
spinal cord below the same-numbered vertebra
Clinically, for example when referring to disc
impingement, both levels of vertebra mentioned,
e.g. C6-7 disc impinging on root 7
Symptoms usually indicate which level

59
 Spinal nerves

Dorsal roots
sensory fibers arising
from cell bodies in
dorsal root ganglia
Ventral roots motor
fibers arising from
anterior gray column
of spinal cord

(not labeled on drawing)

60
 Dorsal and ventral roots join in an intervertebral foramen
forming spinal nerve
Outside foramen, re-branch as rami (sing., ramus):
Dorsal and ventral rami (somatic)
Rami communicantes (visceral)

61
 Dorsal rami serve the muscles and skin of the
posterior trunk
Back, from neck to sacrum, innervated in a neatly
segmented pattern: horizontal strip at same level
as emergence from spinal cord

Ventral rami serve the muscles and skin of the

lateral and anterior trunk
In thorax only, a simple segmented pattern as
intercostal nerves
Also serve the limbs
62
Cross section of thorax showing main roots and branches
of a spinal nerve
Note dorsal and ventral roots and rami, and rami
communicantes
In the thorax, each ventral ramus continues as an intercostal
nerve

63
 Nerve plexuses
Networks of successive
ventral rami that exchange
fibers (crisscross &
redistribute)
Why would this be
protective?
Mainly innervate the limbs
Thoracic ventral rami do
not form nerve plexuses

64
 Plexuses

Cervical
Brachial
Lumbar
Sacral

65
 Nerve plexuses

Cervical plexus (C1-C4)

innervates the muscles and
skin of the neck and shoulder

most important:
Its phrenic nerve* (C3-C5) is
the sole motor supply of
diaphragm: one reason why
neck injuries are so dangerous
can be lethal (respiratory *
arrest = stop breathing)

66
67
 Serves upper limbs and Brachial plexus
shoulder girdle
Arises primarily from C5-
T1
Main nerves (be able to
label):
Musculocutaneous to
arm flexors
Median anterior
forearm muscles and
lateral palm
Ulnar anteromedial
muscles of forearm and
medial hand
Axillary to deltoid and
teres minor
Radial to posterior part
of limb
68
69
70
71
72
 Musculo-
cutaneous

Median

Ulnar

Axillary

Radial

73
Brachial plexus

74
Note distribution of cutaneous nerves

75
Sensory innervation, palm
1. Ulnar nerve
2. Median
nerve
3. Radial nerve

76
 Lumbar plexus
L1-L4
Lies within the psoas major muscle
Innervates anterior and medial muscles of
thigh through femoral and obturator nerves
respectively
Femoral nerve also innervates skin on anterior
thigh (including quads) and medial leg

77
78
 Lumbar plexus
(be able to label femoral, obturator and saphenous nerves)

79
 Sacral plexus
L4-S4
Supplies muscles and skin
of posterior thigh and
almost all of the leg
Main branch is the large
sciatic nerve, which
consists of:
Tibial nerve to most of
hamstrings, calf and sole
Common fibular nerve
to muscles of anterior and
lateral leg and skin
Other branches supply
pelvic girdle (gluteus
muscles) and perineum
(pudental nerve)

80
 Sacral plexus
nerves:

(Be able to label

sciatic, tibial and
common fibular
nerves)

81
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83
Nerve plexuses (very) simplified.
Diaphragm? Cervical plexus C1-5
Phrenic nerve C3-5

Arm and forearm extensors? Brachial plexus C5-T1

Radial nerve
Medial hand?
Ulnar nerve
Lateral palm?
Median nerve

Quad?
Femoral nerve
Lumbar plexus L1-4
Footdrop?
Common fibular/peroneal nerve
(branch of Sciatic nerve)
Sacral plexus L4-S4

84
 Dermatomes
Dermatomes (innervation of skin)
(area of skin innervated by the cutaneous
branches from a single spinal nerve is called a
dermatome)

Reveal sites of
damage to spinal
nerves or spinal cord

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