ANATOMY,

NEUROANATOMY,
AND VASCULAR SUPPLY
• The vertebral column is composed of:
• 7 cervical vertebrae
• 12 thoracic vertebrae
• 5 lumbar vertebrae
• 5 sacral vertebrae
• 4 coccygeal vertebrae
• The spinal cord is protected within the vertebral foramen,
and initially occupies the entire length of the vertebral
canal
• By adulthood, the spinal cord occupies only the upper two
thirds of the vertebral column with its caudal end located
at the lower border of the first lumbar (L1) vertebra (level
of L1-2 intervertebral disc)
• The spinal cord segments, especially in the thoracic and
lumbar regions, do not line up with their corresponding
vertebral level
• At the caudal end, the spinal cord is conical in shape and
is known as the conus medullaris.
• The lumbar and sacral nerve roots descend some
distance within the vertebral canal in order to exit from
their respective intervertebral foramina
• These nerve roots resemble a horse’s tail, and are termed
the cauda equina (CE).
• The lumbar cistern extends from the caudal end of the
spinal cord (L2 vertebra) to the second sacral vertebra
• The subarachnoid space is widest at this site and is
therefore most suitable for the withdrawal of cerebrospinal
fluid (CSF) by lumbar puncture, usually performed
between the L3 and L4 lumbar vertebrae
•
• Thirty-one pairs of spinal nerves (8 cervical, 12 thoracic,
5 lumbar, 5 sacral, and 1 coccygeal pair) emerge from the
spinal cord
• At and below the thoracic level, the nerve roots exit just
caudal to the corresponding vertebra while in the cervical
region the nerve roots exit through the intervertebral
foramina just rostral to the corresponding vertebra
• The spinal cord has two enlargements: cervical and
lumbar
• The cervical enlargement includes the C5-T1 nerve roots to
form the brachial plexus which innervates the upper extremities
(UEs)
• The lumbar plexus (roots L1 to L4) and lumbosacral plexus (L4
to S2) emerge from the lumbar enlargement and innervate the
lower extremities (LEs)
• The sacral spinal nerves
emerge from the conus medullaris and contain PS and somatic
motor fibers innervating the muscles of the bladder wall and
external sphincter, respectively
• The sacral spinal nerves emerge from the conus medullaris
and contain PS and somatic motor fibers innervating the
muscles of the bladder wall and external sphincter, respectively
• The spinal cord receives its blood supply from one
anterior and two posterior spinal arteries (PSAs) as well
as anterior and posterior radicular arteries
• The anterior spinal artery (ASA) - arises in the upper
cervical region and is formed by the union of two
branches of the vertebral arteries
• supplies the anterior two thirds of the spinal cord including the
gray matter and anterior and anterolateral white matter
• The ASA varies in diameter according to its proximity to a major
radicular artery
• It usually is narrowest in the T4-8 region of the spinal cord
• The PSAs supply the posterior one third of the spinal cord
consisting of posterolateral and posterior white matter of
the spinal cord
• The blood supply from the anterior and posterior arteries
is sufficient for the upper cervical segments
• Segmental arteries that arise from the aorta supply the
ASA and PSAs in the thoracic and lumbar regions
• The radicular arteries arise from the vertebral, cervical,
Intercostal, lumbar, and sacral arteries and supply the
remaining segments of the spinal cord
• The major radicular artery that supplies the lumbosacral
enlargement of the spinal cord is known as the artery of
Adamkiewicz.
• Artery of Adamkiewicz - It usually arises from the left
intercostal or lumbar artery at the level of T6-L3 and
provides the main blood supply to the lower two thirds of
the spinal cord
• There are less radicular arteries that supply the
midthoracic region of the spinal cord and are smaller in
diameter and therefore create a “watershed zone” of the
spinal cord at this level
• The internal structure of the spinal cord is such that a
transverse section of the spinal cord reveals a butterfly
shaped central gray matter surrounded by white matter
• The gray matter of the spinal cord contains cell bodies
and primarily neurons, dendrites, and myelinated and
unmyelinated axons
• Autonomic neurons are located laterally and exit by the
ventral root and innervate smooth muscle.
• Lower motor neurons (LMN) are located ventrally, exit by
the ventral roots and innervate striated muscle
• The white matter consists of ascending and descending
bundles of myelinated and unmyelinated axons (tracts or
fasciculi)
• The ascending pathways relay sensory information to the brain
• The descending pathways relay motor information from the brain
• Sensory tracts or ascending pathways are composed of
axons from peripheral sensory nerves whose cell bodies
are located in the dorsal root ganglion (DRG) and ascend
toward the brainstem
• Receptors for pain and temperature enter the
spinal cord and synapse in the dorsal horn of the gray
matter
• The fibers cross over within one to two vertebral segments,
then travel in the lateral spinothalamic tract and ascend to the
ventral posterolateral (VPL) nucleus of the thalamus
• The fibers then ascend in the internal capsule to reach the
postcentral gyrus, which is the primary somatic sensory area of
the brain
• Pressure and light touch (LT) fibers enter the cord in the same
fashion, and pass into the ipsilateral dorsal white column and
bifurcate
• One branch immediately enters the dorsal horn gray matter,
synapses, and crosses over within one to two segments, while
the other branch remains ipsilateral, and ascends in the dorsal
column for as many as ten spinal segments
• The ipsilateral branch ultimately enters the dorsal horn,
synapses, and crosses over to join the other branch in the
ventral white column, forming the ventral spinothalamic
tract
• These axons travel in the same pathway as the lateral
tract to reach the postcentral gyrus, which interprets these
sensations
• The posterior columns transmit three different sensations:
• Proprioception, fine touch, and vibration sense
• Their nerve fibers reach the DRG and immediately pass into
the ipsilateral dorsal white columns and ascend to the medulla
• Axons that enter the cord at the sacral, lumbar, and lower
thoracic levels are situated in the medial part of the dorsal
column called the fasciculus gracilis
• Those axons that enter at the thoracic (above T6) and cervical
levels are situated in the lateral part of the column (from the
upper part of the body) and are termed the fasciculus
cuneatus
• Axons of each fasciculus synapse in the medulla and form a
bundle termed the medial lemniscus, which ascends to the
postcentral gyrus
• The cerebellum is the control center for the coordination
of voluntary muscle activity, equilibrium, and muscle tone
• The spinocerebellar tract is a set of axonal fibers
originating in the spinal cord and terminating in the
ipsilateral cerebellum that conveys information to the
cerebellum about limb and joint positions (proprioception)
• The lateral corticospinal tract is the main tract for
voluntary muscle activity
• Its origin is the precentral gyrus of the frontal lobe of the brain
• Their axons descend through the internal capsule to the medulla
oblongata
Neurological Assessment
• The most accurate way to document impairment in a
person with a SCI is by performing a standardized
neurological examination
• The examination is composed of sensory and motor
components, and is performed with the patient in the
supine position to be able to compare initial and follow-up
exams
• The information from this examination is recorded on a
standardized flow sheet and helps determine the sensory,
motor, and NLI, sensory and motor index scores, and to
classify the impairment
Sensory exam
• The sensory exam is performed separately for LT and pin
prick (PP) modalities
• Each of 28 dermatomes is tested and graded 0 for
absent, 1 for impaired, 2 for normal (or intact), or NT for
not testable
• The face is used as the reference point for testing
sensation in each dermatome
• To test for deep anal sensation (DAS), a rectal digital
exam is performed
• The patient is asked to report any sensory awareness,
touch, or pressure, with firm pressure of the examiners’
digit on the rectal wall
• DAS is recorded as either present (yes) or absent (no)
• The maximum sensory score is 112 (calculated by adding
the scores from the 28 dermatomes—maximum score of
56 for each side of the body) for LT and pin sensation
• The sensory level is defined as the most caudal level
where sensation for LT and PP are both graded as 2
(normal) for both sides of the body
Motor Exam
• The motor exam is conducted using conventional manual
muscle testing (MMT) technique (on a scale from 0 to 5)
in ten key muscle groups, five in the upper limb (C5-T1
myotomes) and five in the lower limb (L2-S1), on each
side of the body
• Key muscles were chosen based upon their myotomal
innervations and ability to be tested in the supine position
• Most muscles are innervated by two root levels
• When a key muscle tests initially as a grade 5, it is
presumed to be fully innervated by the contributions from
the two roots
• If a muscle initially grades a three fifth, it is presumed to
have full innervation of its more proximal segment
• The maximum motor index score is 100 (calculated by
adding the scores—maximum of 50 for each side of the
body)
• Voluntary anal contraction is tested by sensing contraction
of the external anal sphincter around the examiner’s
finger and graded as either present or absent
•
• When examining a patient with an acute injury below T8,
the hip should not be flexed passively or actively beyond
90 degrees as this may place too great a kyphotic stress
on the lumbar spine
• If a muscle’s range is limited by contracture that exceeds
50% of the normal ROM, the muscle is to be listed as NT
(no testable); if less than 50% loss of range—the MMT
scoring can be applied
• The motor level is defined as the most caudal motor level
with a score of ≥3, with the more cephalad key muscles
grading a 5
• For injuries with no corresponding motor level (i.e., above
C4, T2-L1), the last normal sensory level is used
• If there are non–SCI-related causes of weakness, this
should be documented and taken into account when
classifying the injury
AIS Classification
• The patient’s injury is classified utilizing the AIS,
separating the injury into a neurologically complete versus
incomplete injury
• A neurologically complete injury is defined as an injury
with the individual having no “sacral sparing”
• Sacral sparing refers to having one or more of the
following residual findings:
• LT or PP in the S4-5 dermatome (can be on either side, impaired
or intact);
• DAS or voluntary anal contraction preserved
• If any of these components are present, the individual has
sacral sparing and therefore has a neurologically
incomplete injury
• Patients who have an incomplete injury initially (i.e.,
sacral sparing) have a significantly better prognosis for
motor recovery than those without preservation of the
lower sacral segments
• A neurologically complete injury is classified as AIS A
• Persons with sensory sacral sparing are classified as an
AIS B
• To be classified with a motor incomplete injury (AIS C or
D), the subject must have either:
• voluntary anal sphincter contraction
• sensory sacral sparing with sparing of motor function more than
three levels below the motor level
• To differentiate an AIS C from D, the individual with a
motor incomplete injury AIS D has at least half of key
muscles below the NLI with a muscle grade of 3 or more
(AIS C would be less than half)
• It is important to recognize the distinction using the motor
level to determine if one with sensory sacral sparing has a
motor incomplete injury (AIS B vs. C), yet uses the NLI
when differentiating an AIS C from D