CNS PNS
Conclusion References
All living organisms are able to detect changes within themselves and in their environments
External environment Internal environment
By means of nerves, the pathways of the senses are distributed like the roots and fibers of a tree. - Alessandro Benedetti, 1497 Ancient medical practitioners understand that nerves served two functions: Movement & Sensation 4th century B. C., the Greek philosopher Aristotle believed firmly that the nerves were controlled by and originated in the heart Six centuries later, the Roman physician Galen, Brain was the most important organ of the body, with the nerves emanating from it.
In the human brain there are approximately 10 billion neurons The most significant specialized features of nerve cells their axons, dendrites and synapses Nerve cell processes are quite thin, often less than a micron (1m) in diameter
2.5 million neurons must be generated per minute during the entire prenatal life
EMBRYOLOGY
THREE ECTODERMAL SOURCES A. DORSAL NEURAL TUBE B. NEURAL CREST C. SURFACE EPITHELIUM PLACODES 7 WEEK IUL NEURAL TUBE FLEXES TELENCEPHALON DIENCEPHALON MESENCEPHALON METENCEPHALON MYELENCEPHALON
MOTORS NERVE C N V,VII,IX,X,XI,XII --FROM METENCEPHALON & MYELENCEPHALON SENSORY NERVES --- FROM DIENCEPHALON & MESENCEPHALON BY 5 & 6 WEEK IUL FULL COMPLEMENT OF TWELVE CRANIAL NERVES ARE FORMED MYELINATION 12 WEEK IUL TO 3-4 YRS AFTER BIRTH
Brain- control center of nervous system receives sensory input from spinal cord as well its own nerves. ex: olfactory, optic Spinal cord- conducts sensory information from PNS to brain. Conducts motor information from brain to our various effectors Serves as minor reflex center
BRAIN
FORE BRAIN Cerebrum diencephalon MID BRAIN HIND BRAIN Medulla oblongata Pons cerebellum
BRAIN STEM
Receives information from and controls activities of head and neck Cranial nerves pass through foramina of skull
SPINAL NERVES 31 pairs 8 Cervical 12 Thoraxic 5 Lumbar 5 Sacral 1 Coccygeal Receives information from and controls activities of trunk and limbs. Spinal nerves leave through intervertebral foramina
PARA SYMPATHETIC NERVOUS SYSTEM Restores or maintains energy. Ex: Slowing heart rate, Speeding up movement of intestines.
L1 L2 L3
NEUROGLIA
Neuroglia
Non excitable cells in which support neurons
TYPES OF NEUROGLIA
NON ENCAPSULATED RECEPTORS Free nerve endings Merkels discs Hair follicle receptors
Functional components
Functions performed by each type of fiber contained within given nerve, as a class the several specialized fiber types referred by the generic term Functional components
TYPES
A) GENERAL: refers to stimuli conducted throughout the entire body, common to both cranial and spinal nerves.
II.
A) SOMATIC: Refers to skin and muscles of body wall B) VISCERAL: Organs within the body cavities
III.
A) AFFERENT: or sensory means the direction of conduction is towards the CNS B) EFFERENT: or motor means the direction of conduction is away from CNS ( Brain to effector)
A) GENERAL AFFERENT: fibers carry sensations of pain, temperature, touch and pressure from widely distributed receptors to brain. B) GENERAL EFFERENT: Includes all motor fibers to skeletal muscles, smooth muscles, cardiac muscle or glands.
IV.
GVA: Fibers transmit pain from the viscera. Also conduct specialized afferent impulses such as those concerned with blood pressure and regulation of other visceral activities. GVE: fibers transmit outgoing impulses to smooth muscles, cardiac muscle and glands
SSA: Fibers related to sight and hearing SVA: Fibers to taste and smell.
SVE: Fibers convey outgoing impulses to muscles derived from mesoderm of branchial arches.
This include muscles of mastication and facial expression and the muscles of pharynx and larynx.
1. Olfactory nerve 2. Optic nerve 3. Occulomotor nerve 4. Trochear nerve 5. Trigeminal nerve 6. Abducent nerve 7. Facial nerve 8. Vestibulocochlear nerve 9. Glossopharyngeal nerve 10. Vagus nerve
Sensory
Motor
Mixed
Olfactory nerve
Function: smell Cells of origin: olfactory mucosa in the nasal cavity Component: Special Afferent Exit from skull: cribriform plate of ethmoid bone
Applied anatomy
Anosmia: loss of olfaction unilateral/ bilateral Unilateralfrontal lobe tumors Bilateral Common colds, other forms of rhinitis severe anterior cranial fossa injury Hyperosmia: hysterias Caprosmia :unpleasant odour due to decomposition of the tissues in the individual. CEREBROSPINAL RHINORRHOEA Clinical Testing Each nostril tested separately using common test odours. Nasal infections spread along the nerve - Meningitis Identification or awareness of odour precludes anosmia 50% pts anosmia temporary, peak recovery 10 weeks
Optic nerve
Nerve of sight
5mm intracanalicular
10mm intracranial
Optic N
intraorbital
25mm long sinus course Posteriorly: surrounded by 4 recti muscles Anteriorly: separated by fat in which ciliary vessels and nerves are embedded
Intra orbital
In optic canal
5mm long Superiomedial to ophthalmic artery Medially: from sphenoidal and posterior ethmoidal sinuses by osseous lamina Anterior to canal: nasociliary nerve and opthalmic artery cross above the optic nerve
Intracranial
10mm long runs posteriomedially from optic canal to optic chaisma Here fibers from nasal half of retina cross over & form optic tract Near the chaisma: Above: anterior cerebral artery Lateral: internal carotid artery
Optic N
Bilateral loss of vision generalized disorder ex: hypertension, diabetes, multiple sclerosis
Optic N
CLINICAL TESTING
Acuity of vision : counting of fingers snellens chart. Field of vision : confrontation test. Colour vision : holgrems color wool test, ishiharas chart,
Oculomotor nerve
Supplies all extraocular muscles (SO4 and LR6) Through ciliary ganglion : splinter pupillae and ciliaris
oculomotor
Functional component
oculomotor
Oculomotor nerve
Nucleus : ventromedial part central grey
oculomotor
Passes btw superior cerebral and posterior cerebral arteries Runs forwards on lateral side of posterior communicating artery to reach cavernous sinus
oculomotor
Enters cavernous sinus by piercing posterior part of its roof on lateral side In part of sinus nerve divides into superior and inferior branches
oculomotor
Two divisions enter into orbit through middle part superior orbital fissure In fissure nasociliary nerve lies btw them, abducent nerve inferolateral to them
oculomotor
In orbit Small upper division: superior rectus Larger division: three branches Medial rectus Inferior rectus Inferior oblique
Ciliary ganglion
Peripheral parasympathetic ganglion placed in course oculomotor nerve Lies btw optic nerve and tendon of lateral rectus muscle
Edinger- westphal nuclues Motor root Nasociliary N Sensory root Splinter pupillae Ciliaris Short ciliary N Eyeball
Sympathetic root
Webers syndrome: midbrain lesion causing contralateral hemiplegia and ipsilateral paralysis
Trochlear Nerve
Supplies only superior oblique muscles Functional components: GSE: lateral movements of eyeball GSA: proprioceptive impulses from superior oblique muscle
Trochlear N
Trochlear Nerve
Nuclues: ventromedial part central grey matter of mid brain at the level of superiorcollicus Emerges from below the inferior collicus
Trochlear N
Trochlear Nerve
Nerves decussate with each other & peirce the medullary velum on dorsal surface of midbrain. Passes btw posterior cerebral arteries and sup cerebellar arteries to appear ventrally Enters cavernous sinus runs forwards in the lateral wall btw oculomotor and ophthalmic nerve
Trochlear N
Trochlear N
In passes medially above levator palpebral superioris and ends by supplying superior oblique muscle.
Trochlear N
Applied anatomy
When Trochlear nerve is damaged: Diplopia occurs on looking downwards. Vision is single so long as the eyes look above the horizontal plane.
Trigeminal nerve
N. Trigeminus; Fifth Or Trifacial Nerve Largest cranial nerve Proprioceptive impulses:- deep pressure and kinethesis Exterioceptive impulses:- touch pain and temp
Nerve is attached to lateral part of pons by its two roots , MOTOR and SENSORY Motor Root: SUPERIOR NUCLEUS cells occupying the whole length of the lateral portion of the gray substance of the cerebral aqueduct. Inferior or chief nucleus is situated in the upper part of the pons Fibers from both nucleus unite in pons, and form the motor root moves forwards in pons to its point of emergence
Sensory root: Fibers of the sensory root arise from the cells of the semilunar ganglion which lies in apex of the petrous part of the temporal bone On entering the pons, divide into upper and lower roots The upper root ends in nucleus situated in the pons lateral to the lower motor nucleus The lower root descends through the pons and medulla oblongata Lower root is sometimes named the spinal root of the nerve
Mesencephalic root of trigeminal nerve Consists of afferent fibers that accompany motor root which ascend to reach mesencephalic nucleus Fibers concerned with perfect synchronization in
Trigeminal ganglion
Sensory ganglion of 5th CN Puedounipoloar nerve cells
Trigeminal N Ophthalmic
Ophthalmic nerve
Sensory nerve
Trigeminal N Ophthalmic
Lacrimal nerve
Trigeminal N Ophthalmic
Lacrimal nerve
Lacrimal
Supplies sensory fibres to lacrimal gland and adjacent conjunctiva Postganglionic secretary fibres from sphenopalatine ganglion travel along ..
Frontal nerve
Largest br. Enters orbit SOF Curves lateral border of superior rectus muscle
Reaches upper surface of levator of upper eyelid Middle of orbit divides into Supraorbital N Supratroclear N
Supra-orbital nerve
Largest br. of frontal nerve Leaves orbit supraorbit foramen Supply skin: Upper eyelid, Forehead and Anterior scalp region to vertex of skull
Supratrochlear nerve
Smallest branch of frontal nerve Passes toward upper medial angle of orbit Pierces the fascia of eyelid to supply skin of upper eylid Lower medial portion of eyelid
Nasociliary nerve
Branches In orbit In Nasal cavity Supply MM lining of cavity On Face Terminal br: skin medial parts of eyelids Lacrimal sac Bridge of nose
Trigeminal N Ophthalmic
Nasociliary nerve...
Nasociliary
In orbit 1.Long root of ciliary ganglion Sensory fibres pass through ganglion without synapse cont short ciliary nerves 2.Long ciliary nerves 2 to 3 iris and cornea Postganglionic fibres superior cervical ganglion
Nasociliary nervE...
3.Posterior ethmoidal nerve PE Canal MM lining of post ethmiodal and sphenoid sinus
4.Anterior ethmoidal nerve Continues medial wall of orbit Upper part of nasal cavity Internal nasal branches
Septal br: Lateral br: ant ends of superior and middle nasal conchae
OphthalmIc division
To be continued..
references
Grays anatomy The anatomical basis of clinical practice, 39th edition, Susan Standring B.D.Chaurasias human anatomy, Vol 3: 4th edition New atlas of human anatomy : Thomas Mc cracken
Maxillary Nerve
Trigeminal N Maxillary
Maxillary Nerve
Entirely sensory Origin: semilunar ganglion Course: Lower part of cavernous sinus
Trigeminal N Maxillary
During course- gives of In 4 regions 1. Middle cranial fossa Meningeal 2. Pterygopalatine fossa Ganglionic Zygomatic PSA 3. Infraorbital groove & canal MSA and ASA 4. On face Palpebral Nasal Superior labial
Trigeminal N Maxillary
In pterygopalatine fossa
Zygomatic N Lateral surface orbit Zygomaticofacial N Perforates orbicularis oculi skin prominence of face Zygomaticotemporal N Thro Zygomaticotemporal fossa pierces temporal fascia- skin of temple
Trigeminal N Maxillary
Pterygopalatine Nerves
Ganglionic brances: Orbital br: IOF- periosteum of orbit Nasal br: PS lateral nasal br: MM of nasal septum and posterior ethmiodal sinus Medial or septal br: nasopalatine - premaxilla
Trigeminal N Maxillary
Pterygopalatine Nerves
Palatine br Anterior palatine: Greater palatine foramen Middle palatine: lesser palatine foramen Posterior palatine: lesser palatine foramen Tonsil
Trigeminal N Maxillary
Pterygopalatine ganglion
Parasympathetic root: Sympathetic root Sensory root
Trigeminal N Maxillary
Trigeminal N Maxillary
- Interradicular branches
Trigeminal N Maxillary
In infra-orbital groove
Anterior superior alveolar nerve
just before its exit from the infraorbital foramen
Trigeminal N Maxillary
Maxillary division
Mandibular Nerve
Trigeminal N Mandibular
Trigeminal N Mandibular
Branches from main trunk Nervous spinosus: passes into middle cranial fossa-dura and mastoid cells
Trigeminal N Mandibular
Trigeminal N Mandibular
Anterior division
skin and MM buccinator Labial aspect of gums of premolar and molar teeth
Trigeminal N
1. Masseteric Anterior Emerges: upper border of lateral pterygoid In front TMJ enters the deep surface of the masseter Supplies TMJ
Motor br: 2. Deep temporal nerve 2 anterior and posterior Anterior : upwards and crosses the infratemporal crest of spheniod bone Posterior: deep part of temporal muscle and supplies it
Motor br: 3. Pterygoid nerve: Enters the medial side of external pterygoid
Trigeminal N Mandibular
Posterior division
Large division: Extends downwards and medially Auriculotemporal Lingual Inferior alveolar nerve
Trigeminal N Mandibular
Auriclotemporal nerve
the artery - United nerve passes posteriorly deep to the external pterygoid muscle and neck of the condyle
Auriculotemporal nerve
fascia and then crosses the posterior root of the zygomatic arch
Branches :
Articular
Trigeminal N Mandibular
Lingual nerve
Smaller to two terminal br of post. Division Posterior Contributes sensory fibers to the mm of the floor of mouth & gingiva on lingual surface of mandible
In mental foramen: Mental Nerve: skin of the chin and lower lip Incisive Nerve: Fine incisive plexus supplies cuspid and incisor teeth
Mandibular division
Applied anatomy
Trigeminal neuralgia: char by extremely severe shock like or lancinating pain limited to one or more branches of trigeminal nerve. Etiology: pathosis along course of nerve brain stem tumor or infarction C/F: persons > 40 yrs women > men right side > left Pain searing, stabbing or lancinating Initiated by touching trigger zone Spasmodic contractions of facial muscles- tic douloureux
Trigeminal neuralgia:
Treatment: Initial treatment topical capsaicin Anticonvulsant medn pain control Nuerosurgical procedures: a. b. c. d. glycerol rhizotomy decompression Microvascular decompression Neurectomy
Applied anatomy
Sensory distribution explains why headache is common symptoms involvement of nose, teeth and gums, eyes and meninges. Referred pain : cancer of tongue- pain radiates to the ear and to the temporal fossa Infra orbital nerve anesthesia: Tapping on unanesthetized tooth Inferior dental nerve and lingual nerve greater risk during removal of posterior teeth
MUSCLES OF MASTICATION : clench the teeth (tempo, messeter) One side paralyzed jaw deviates same side PARALYSIS OF MYLOHYOID AND ANTERIOR BELLY OF DIGASTRIC Palpation of flabbiness or flaccidity of the floor of mouth
PARALYSIS OF TENSOR TYMPANI Difficulty in hearing high tones..
Abducens nerve
6th cranial nerve Functional component: GSE: lateral movements of eyeball GSA: proprioceptive impulses from lateral
rectus
Nucleus : in the floor of 4th ventricle
Facial nerve
Seventh CN- mixed Nerve of second brachial arch
Facial N
Functional components:
SVE: GSA GVE SVA lacrimal, muscles &of Facial submandibular, Fibers from skin Taste sensation from sublingual glands, bone elevation of hyoid palate external ear anterior2/3 of tongue and pharynx
SVE
GVE
SVA
GSA
Facial N
Nucluei
Motor Nucleus Superior Salivatory nucleus Lacrimatory nucleus Nucleus of the Tractus Solitarius
Facial N
Facial N
Facial N
Facial N
Extracranial course
Crosses lateral surface of base of styloid process Enters posteromedial surface of parotid glands runs
Facial N
on back of auricle
ii.
Facial N
Facial N
Applied anatomy
Preservation of Facial nerve is an important step In Parotid surgery, it is found b/w mastoid process & bony part EAM At birth mastoid process is absent Facial nerve superficial & vulnerable Caution < 4yrs Damage to a facial nerve is common with the fracture of temporal bone
Damage to facial nerve incorrect deposition of LA during inferior alveolar nerve block
Facial N
Applied anatomy
Damage to nerve above its chordatympani branch---loss of taste sensation at ant 2/3rd of tongue and decrease in salivation. Damage above the stapedius branch hyperacusis Involvement of the nerve at the level of geniculate ganglion- decrease in lacrimation Damage of the nerve within IAMDeafness Facial nerve may be injured during fracture of the base of the skull, forceps delivery, middle ear infections, tumours, meningitis.
Facial N
Facial Paralysis
Facial N
Facial Paralysis
UPPER MOTOR NEURON Lesions is above the pons. LOWER MOTOR NEURON Lesions is in the pons or in the pathway from pons to its exit. Furrows are absent on looking upwards of the affected side of face.
Lower part of the face is involved The whole face and forehead on the opposite side of the involved on the same side of lesion. the lesion.
Isolated involment of this type is rare. It is invariably associated with hemiplegia . Isolated involment of this type is common. It may be associated with hemiplegia .
Facial N
BELLS PALSY
Coined in 1829 by William bell A syndrome that consisted of ipsilateral facial paralysis with intact facial sensation
Facial N
Infection of eyes
Facial N
Treatment
Corticosteroids
Adults: Prednisone 20 mg QID 5 days Children: Prednisone 1 mg/kg/day
Acyclovir
Adults: 2g per day, 7 days. With varicella zoster 4g per day Children: 80 mg/kg per day, 5 days
Protecting eyes:
-eye drops/artificial tears -ointment at bed time -goggles for dust protection
Facial N
Secretory functions Schirmers test: Amount of tear secreted evaluated by hanging a strip of litmus paper on eye lid and note moistening
Facial N
Motor ability Ability to frown Smile, show teeth Puff out checks whistle, close eyes
8 8th CN
8th CN
Vestubular nuclei
superior and inferior medial and lateral Partly in medulla and pons
Vestibular pathway
Impulses arising in labyrinth Influence the movements of eyes, head, neck and trunk
8th CN
8th CN
Rinnes test:
Vibrating tuning fork held opp the ear & then on mastoid process.
Webers test:
- Vibrating tuning fork placed on the centre of forehead
9th CN
Glossopharyngeal nerve
9th cranial- mixed Supplies tongue and pharynx
9th CN
SVE stylopharyngeal GVE - Secretomotor-parotid GVA - Sensory to pharynx, tonsil and post 1/3 of tongue
Functional components :
9th CN
Nuclei
Nucleus Ambiguus Inferior Salivatory Nucleus Tractus Solitarius
9th CN
9th CN
9th CN
IX
Pharyngeal branches
Posterior 1/3 including vallate pappilla General sensationsV3 Taste-VII General sensations
and taste-IX
9th CN
Isolated lesions of the nerve: loss of sensation over soft palate,pharynx & post. 1/3rd of tongue, Taste sensation lost over postsulcal portion & gag reflexes absent. Gag reflux: Stimulation of posterior pharyngeal wall excites glossopharyngeal sensory fibers & initiates gag reflex
9th CN
9th CN
Vagus N
Vagus nerve
Extensive course through head, neck, thorax & abdomen Bears 2 ganglia Superior ganglia : In Jugular foramen Inferior ganglion : Near base of the skull
Vagus N
Functional components
GVE fibers: originate from dorsal nucleus of vagus nerve short postganglionic fibers innervate cardiac muscles, smooth muscles and glands of viscera SVE fibers: originate from ambiguus, to muscles of pharynx and larynx GVA fibers: carry impulse from viscera in neck, thoracic and abdominal cavity to nucleus of solitary tract GSA fiber: sensation from auricle, external acoustic meatus and cerebral dura mater
Vagus N
Vagus N
Vagus N
Auricular branches
Crosses facial canal 4mm above the stylomastoid foramen Emerges thru tympanomastoid fissure ends by supplying
Concha and root of auricle Posterior half of external auditory meatus Outer surface of tympanic membrane
Vagus N
Vagus N
Vagus N
Vagus N
Clinical testing Compare the palatal arches on 2 sides when pt. say ah -On paralysed side, no elevate & uvula pulled to normal side
11th C N
Accessory nerve
2 roots, cranial and spinal Cranial root -accessory to vagus Spinal root --more independent course
11th C N
CRANIAL XI
11th C N
XI
11th C N
11th C N
Clinical Testing:
Ask the patient to shrug his shoulders against
resistance and comparing the power of 2 sides
12th C N
Hypoglossal nerve
12th cranial nerve - supplies the extrinsic & intrinsic
muscles of tongue Functional components:
GSA: Carries proprioceptive impulses from muscles of tongue to
brain GSE: Fibres arise from the hypoglossal nucleus which lies in
12th C N
origin
Origin: fibers arise from hypoglossal nucleus Exit from skull; hypoglossal canal
12th C N
Rootlets merge into a trunk,passes out from brain via hypoglossal canal. At level of mn foramen turns antly deep to angle of mandible
Deep to post. Belly of digastric & stylohyoid-- ramifies to supply muscles of tongue
12th C N
12th C N
12th C N
12th C N
Power of tongue musculature tested by asking to push each cheek out with tongue against resistance & comparing power on both sides
Cervical plexus
Formed by ventral rami of upper 4 cervical nerves. Supplies some neck muscles, diaphragm & areas of skin on head, neck & chest Situation: opp. a line drawn down the side of neck from root of auricle to level of upper border of thyroid cartilage.
Branches
Deep
Superficial
Ascending Descending
Medial Lateral
references
Grays anatomy The anatomical basis of clinical practice, 39th edition, Susan Standring B.D.Chaurasias human anatomy, Vol 3: 4th edition New atlas of human anatomy : Thomas Mc cracken