Motor, sensory and autonomic pathways The vertebral column consists of seven cervical, 12 thoracic, five lumbar, five

sacral and four coccygeal vertebrae, although the sacral and coccygeal vertebrae are fused.Emerging from the spinal cord are 31 pairs of anterior and posterior nerve roots:eight cervical, 12 thoracic, five lumbar, five sacral and one coccygeal. At each level an anterior (ventral) pair of nerve roots carries motor nerves and a posterior (dorsal)pair of nerve roots carries sensory nerves. The anterior and posterior roots join to form two spinal nerves, one on either side of the spine, which then exit the vertebral canal through the intervertebral foramina. Once outside the intervertebral foramina they form peripheral nerves.While there are eight pairs of cervical spinal nerves there are only seven cervical vertebrae. This disparity occurs because the first pair of cervical spinal nerves exits above the first cervical vertebra just below the skull. However, the eighth pair of cervical spinal nerves exits below the last cervical vertebra (see Figure 1.2).17 Motor pathways Upper and lower motor neurons connect the motor cortex and muscles. The upper motor neurons originate within the motor cortex and then travel down the spinal cord within the corticospinal tracts. These tracts are also called pyramidal tracts. Approximately 85% of upper motor neurons cross over to the contralateral side in the brainstem and then travel within the lateral corticospinal tract. The other 15% cross within the spinal cord at the level they terminate and are carried within the medial corticospinal tract. The cervical upper motor neurons are centrally located within the corticospinal tract and the lumbar and sacral neurons are peripherally located (see Figure 1.3). This explains patterns of neurological loss seen with certain types of incomplete spinal cord injuries where the peripheral rim of the spinal cord There are also other complex motor pathways contained within the extrapyramidal system.The upper motor neurons synapse in the spinal cord with anterior horn cells of lower motor neurons, usually via interneurons. The anterior horn cells are the cell bodies of the lower motor neurons and are located in the grey matter of the spinal cord. Axons project from the cell bodies of lower motor neurons to form the anterior nerve roots before mixing with the posterior sensory nerve roots to form spinal nerves. In the cervical region the spinal nerves are short and exit the vertebral canal almost immediately after forming. However, this is not the case further down the spine where the spinal nerves travel progressively longer distances within the vertebral canal before exiting. This is particularly apparent in the cauda equina which consists solely of lumbar, sacral and coccygeal spinal nerves. That is, it consists solely of lower motor neurons. The cell bodies of the lower motor neurons of the cauda equina are positioned within the conus, located at approximately the L1 vertebral body. However, even above the conus, spinal nerves travel down within the vertebral canal before exiting. Consequently, the anterior horn cells of lower motor neurons are often positioned at a higher level in the vertebral canal than where they exit. Sensory pathways There are many sensory tracts and pathways carrying different types of sensory information from the periphery to the cerebral cortex. The key ones are the lateral and anterior spinothalamic tracts and the gracile and cuneate tracts within the posterior columns. The spinothalamic tracts sit within the dorsal horn of the spinal cord. Most of the fibres cross at or near the level they enter the spinal cord. The lateral spinothalamic tract carries information about pain and temperature, and the anterior

spinothalamic tract carries information about crude touch. The gracile and cuneate tracts carry information about proprioception and light touch. The gracile tract is positioned medially and predominantly carries sensory fibres from the lower body while the cuneate tract is positioned laterally and predominantly carries fibres from the upper body. The fibres within the gracile and cuneate tracts cross in the brainstem. Autonomic pathways The spinal cord not only carries motor and sensory nerves but also autonomic nerves (see Figure 1.4). Sympathetic nerves exit the vertebral canal via thoraco-lumbar spinal nerves, and parasympathetic nerves exit via sacral spinal nerves. Consequently,patients with cervical lesions lose supraspinal control of the entire sympathetic nervous system18 and of the sacral part of the parasympathetic nervous system. Patients with thoracic, lumbar or sacral lesions lose varying amounts of supraspinal control of the sympathetic and parasympathetic nervous system as determined by the level of the lesion. Some parasympathetic fibres are carried within cranial nerves and are unaffected by spinal cord injury. The ASIA assessment of neurological deficit Spinal cord injuries are classified according to The American Spinal Injury Association (ASIA) classification system.19 The classification is based on a standardized motor and sensory assessment (see Figure 1.5). It is used to define two motor, two sensory and one neurological level. It is also used to classify injuries as either complete (ASIA A) or incomplete (ASIA B, C, D or E).