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Anatomy of Spinal Cord

EXTERNAL FEATURES

It is the lower elongated cylindrical part of the CNS and connect with the brain above
It occupies upper 2/3rd of the vertebral canal
It extends from the foraman magnum to the lower border of the L1 or upper border of the L 2
In neonates, the spinal cord extends approximately to vertebra LIII, but can reach as low as vertebra LIV.
It is about 45 cm in length
The lower end is called the conus medullaris
From here a prolongation of pia mater, the filum terminale descends to be attached to the back of the coccyx.


It has six external longitudinal fissures and sulci. They are a deep anterior median fissure, a shallow posterior median sulcus, a pair of anterolateral sulcus and a pair of posterolateral sulcus lying lateral to them.

The anterolateral sulcus and posterolateral sulcus marks the sites of attachment for the anterior and posterior roots of each pair of spinal nerves.

It also has two enlargement called cervical and lumbosacral enlargement which represent the aggregations of cell bodies that supply the muscles and skin of upper limbs and lower limbs.



The spinal cord gives off 31 pairs of spinal nerves. 8 cervical,12 thoracic, 5 lumbar, 5 sacral, & 1 coccygeal, each nerve is attached to the spinal cord by 2 roots, ventral ( motor) , & dorsal ( sensory ), each dorsal root bears a ganglion, the ventral & dorsal nerve unites to form the nerve trunk, which soon divides into ventral & dorsal rami

The part of spinal cord that gives off one pair of spinal nerve we call it a segment of spinal cord

Below the lower end of the spinal cord the roots of spinal nerves form a bundle known as the cauda equina (because of resemblance to the tail of a horse)



In transverse section of the cord is seen the central canal around which is the H-shaped grey matter, surrounded in turn by the white matter which contains the long ascending and descending tracts.
Gray matter

When seen in transverse section the grey matter of the spinal cord forms an “ H “ shaped mass and is surrounded by white matter.
It is divisible into 1) Ventral Horn(column ) 2) Dorsal Horn (column ) 3) intermediate zone .In some parts of spinal cord it presents as a lateral horn (column ) 4)The right & left halves of spinal cord are connected across the midline by the grey commisure, which is traversed by the central canal


The Ventral horn contains several nuclei with large motor neurons to control the movement of skeleton muscles of trunk and limbs

The dorsal horn is dominated by neurons that respond to sensory stimulation.
All incoming sensory fibers in spinal nerves enter the dorsolateral part of the cord adjacent to the dorsal horn in a dorsal root. Neurons in the dorsal horn project to higher levels of the CNS to carry sensations to them
Sympathetic and parasympathetic neurons locate in the intermediate zone espacially in the thoracic and sacral part of spinal cord.

White matter

The white matter of the sp cord is divisible into right & left halves in front by the anterior median fissure & behind by the posterior median sulcus

Each half of the white matter is divided into 1) post funiculus 2)lateral funiculus 3)anterior funiculus

The white matter of the rt & lft sides is continuous across the midline through the anterior white commisure which lies ant to the grey commisure

The nerve fibers in the white matter are of two general types:
1. long , ascending fibers projecting to the upper parts of the brain
2. long, descending fibers projecting from the upper parts of the brain to the spinal gray matter

ASCENDING TRACTS

1.Fasiculus gracilis and Fasiculus cuneatus
They convey sensory fibres subserving fine
touch and proprioception (position sense), mostly
uncrossed, to the gracile and cuneate nuclei in the
medulla oblongata.

2 . The lateral and anterior spinothalamic tracts
They transmit information to the thalamus about pain, temperature and crude touch




DESCENDING TRACTS

Corticospinal tracts – descends from the cerebral cortex to the sp cord. It consists of 2 parts 1) the lat corticospinal tract, which lies in the lateral funiculus. 2) the ant corticospinal tract which lies in the ant funiculus
The corticospinal tracts are responsible for voluntary movements control.

2 . Rubrospinal tracts
3 . Olivospinal tracts

Migraine and its types


it has been estimated that 18 million women and 6 million men in the United states suffer from sever Migraine headaches.

Migraine can usually be distinguished clinically from the two other common types of headaches :

Migraine: present as a pulsatile,throbbing pain

a. Cluster headaches : as excruciating,sharp and steady pain.

b. Tension-type headaches: as dull pain,with a persistent,tightening feeling in the head.

Patients with severe migraine headaches report one to five attacks per month of moderate to severe pain, usually unilateral. The headaches affect patient for a major part of their lives and result in considerable health losts.

Types of Migraine

There are two main types of migraine headaches.

The first, migraine without aura(previously called common migraine), is a severe,unilateral,pulsating headaches that typically lasts from 2 to 72 hours. These headaches are often aggravated by physical activity and are accompained by nausea, Vomiting , Photophobia (hypersensitivity to light), and Phonophobia (hypersensitivity to sound).

Approximately 85 percent of patients with migraine do not have aura.

In the Second type, Migraine with aura (previously called classic migraine),
the headache is preceded by neurologic symptoms called auras,which can be visual,sensory,and/or cause speech or motor disturbances.Most commonly,these prodromal symptoms are visual, occuring approximately 20 to 40 minutes before headache pain begins. In the 15 percent of Migraine patients whose headaches is preceded by an aura, the aura itself allows similar.

For both types of Migraine, women are three-fold more likely than men to experience either type of Migraine.

BIOLOGIC BASIS OF MIGRAINE HEADACHES:

The first manifestation of migraine with aura is a spreading depression of neuronal activity accompanied by reduced blood flow in the most posterior part of the cerebral hemisphere. This hypoperfusion gradually spreads forward over the surface of the cortex to other contiguous areas of the brain. The vascular alteration is accompanied by functional changes; for example, the hypoperfused regions show an abnormal response to changes in arterial partial pressure of CO2. The hypoperfusion persists throughout the aura and well into the headache phase, after which hyperperfusion occurs. Patients who have Migraine without aura do not show hypoperfusion. However the pain of both types of Migraine may be due to Extracranial and Intracranial arterial dilation. This stretching leads to release of neuroactive molecules, such as Substance P.

Antepartum Hemorrhage


Any Bleeding from genital tract after 24 to 28 weeks of pregnancy and Before delivery of the fetus

4% of all pregnancy

Causes:

Placental causes ( 50-70%) (obstetric causes)

_Placental previa
-Placental abruption
-Velamentous insertion of cord
-Marginal sinus rupture
-Circumvellate placenta
-Rarely rupture uterus

Excessive show

Non Obstetric Causes

_Cervical polyp
-Cervical ectopy (erosion)
_Carcinoma cervix
_Vaginal/ vulval Varicositis
_Cervicitis/vaginitis

Indeterminate Bleeding

Abruptio Placentae / accidental hemorrhage

Types:

Revealed / External hemorrhage

Concealed hemorrhage- carries worse risk , increased risk of consumptive coagulopathy / extent of hemorrhage not appreciated

Mixed

Total / partial
Incidence : 0.5%

Etiology

Advancing Maternal age

Race- more common among african american as compared to asians

main etiology is Hypertension such as chronic HTN : pre eclampsia

Uterine over distention e.g multiple pregnancy

Trauma

Cigarette smoking / cocaine

acquired thrombophilias

previous abruption

Pathophysiology:

Vascular injury

Rise in Uterine venous pressure
also separation of placenta

Clinical feature

Symptoms:

Bleeding (may be altered / fresh blood
Abdominal pain- Continuos pain
Too frequent contraction
Back pain