Neuroanatomy untangled

Dr. Martin Turner MA MB BS MRCP PGCAP PhD turnermr@doctors.org.uk Specialist Registrar in Neurology (Oxford Deanery) 5th Year Undergraduate Medical Students

Localisation
Brain (stroke, MS, tumour) Brain-stem (stroke, MS)

Cerebellum (stroke,MS, alcohol) Spinal cord (tumour, MS) Anterior horn (MND) Peripheral nerve (GBS,
vasculitis)

Neuromuscular junction (MG)

NB always ask why not?

Muscle (dystrophy, myositis)

NB muscle wasting think nerve first

Autonomic nervous system

Big clues
Brain (hemi-body, cognitive involvement) Brain-stem (CN involvement) Cerebellum (ataxia, NB remember dorsal columns) Spinal cord (legs not arms, sensory level) Anterior horn (upper and lower motor neurone) Peripheral nerve (asymmetrical, patchy) Neuromuscular junction (non-specific, fatiguable) Muscle (symmetry, family history) Autonomic nervous system (postural hypotension, diarrheoa, sweating)

Upper vs. Lower Motor Neuron

Brain Brain-stem Spinal cord Peripheral nerves (including some CNs)

UMN*

LMN

* Pyramidal (corticospinal) tract

Common UMN/LMN conditions

UMN (central) conditions LMN (peripheral) conditions

Stroke
MS (demyelination) Head injury Cerebral palsy

Entrapment neuropathies
Guillain-Barr Diabetes Vasculitis

UMN and LMN = anterior horn = MND

Much rarer, but dont forget

Neuromuscular junction
Myasthenia Gravis Lambert-Eaton myasthenic syndrome (LEMS) Clues:

1 Muscle disease
Dystrophies: Duchenne, FSH Inflammatory Clues: Symmetrical wasting Retained reflexes

Generalised, fatiguable weakness

Unexplained ptosis, bulbar problems

The Examination elements

The central nervous system The peripheral nervous system
cranial nerve testing (brain-stem and brain) (cognitive testing cortex: grey matter) limb function (spinal cord, neuromuscular junction, muscle)

The autonomic nervous system

control of heart rate, BP, blood flow

Cranial nerves
Twelve pairs

The origins of the CNs

I II

III, IV V, VI, VII, VIII IX, X, XI, XII

The course of the CNs

I back of nose (trauma), frontal lobe (tumour) II visual fields III, IV, VI,II, VI cavernous sinus V, VII, VIII cerebellopontine angle (CPA) VI long, easily trapped under brain (false-localising)

IX, X, XI, XII base of skull (jugular/hypoglossal foramina)

II - Optic

Optic chiasm bitemporal hemianopia e.g. pituitary tumour Optic radiation homonymous hemianopia or quadrantanopia (lower parietal, upper temporal) e.g. stroke

Pupillary response to light

Inbound (afferent): II to midbrain Outbound (efferent): Parasympathetic on surface of III to both eyes So, testing the left pupil: Direct (left II and III working) Consensual (right II and left III working) Pupil-sparing III lesion: localises origin of pathology

Eye movements III, IV and VI

VI (Abducens) Lateral rectus: abducts eye IV (Trochlear) Superior oblique: depresses abducted eye III (Oculomotor) everything else and eyelid retraction So, III palsy: down and out and ptosis:

Left complete IIIrd nerve palsy

V - Trigeminal
Sensation to face and muscles of mastication

Corneal reflex, Jaw jerk (UMN sign)

VII - Facial
Muscles of facial expression (Taste to front 2/3 tongue) UMN e.g. stroke: only lower part of face affected (opposite side to stroke) as back-up supply from other side LMN e.g. Bells palsy: whole of face as lesion beyond point of back-up supply NB remember the close association to the ear (Ramsay-Hunt syndrome)
Right LMN facial nerve palsy

The Cavernous Sinus

Uncal herniation

VI Right abducens palsy

Cerebello-pontine angle
V VI VIII VII

Right acoustic neuroma

IX - Glossopharyngeal, X - Vagus

XI - taste to back 1/3 tongue, pharyngeal sensation, afferent pathway for gag reflex, some palatal elevation X efferent pathway for gag reflex,vocal cords, and main parasympathetic supply

XI - Accessory

Motor to trapezius and sternocleidomastoid muscles

Right trapezius weakness

XII - Hypoglossal
Tongue movements

Right tongue wasting LMN sign

The Peripheral Nervous System

Spinal cord anatomy

Terminates at L1 bone (LP below here)
Everything below is LMN (cauda equina)

Peripheral nerves enter like Christmas tree to centre (LL lateral to UL fibres)