DISORDERS OF

AUTONOMIC NERVOUS
SYSTEM
BY

Dr. Puji Pinta O. Sinurat, Sp S.

Neurology Departement/ Medical Faculty
Sumatera Utara University

MEDAN

THE AUTONOMIC NERVOUS

SYSTEM

The Autonomic (visceral) Nervous System

(ANS)

Control the target tissue

involuntarily

- cardiac muscle
- visceral smooth muscle
- glands
- maintain a constant internal body
environment (homeostasis)

Contrasting the Somatic and

Autonomic Nervous System
Peripheral Nervous System:
1. Sensory neuron: act pot: periphery
CNS
2. Motor neuron: act pot: CNS periphery.
a.Somatic motor neuron innerv skeletal
m
b. Autonomic motor neuron
innvervate
smooth m, cardiac m and glands.

Somatic motor neuron

- cell bodies : in the CNS
- axon
: extend from CNS to
skeletal m.
- innerv
: skeletal muscle

Autonomic motor neuron has 2 neurons:

1. Preganglionic neuron
- cell body : in the CNS (within brainstem or
spinalcord) axon extend to autonomic
ganglia (located outside the CNS)
2. Postganglionic neuron
- cell body : in the autonomic ganglia axon
extend to effector organ
--- innerv : smooth m, cardiac muscle and
glands.

AUTONOMIC NERVOUS
SYSTEM

Anatomically : 2 major division:

1.Sympathetic (Thoracolumbar) division
2.Parasympathetic (Craniosacral)
division

Central & Peripheral

Component

Central component:
Hypothalamus
Cerebral Cortex
Hypophyse
Mesencephalon and Brain stem
Spinal cord
Peripheral component :
N III, VII, IX dan X
Preganglion, ganglion,postganglion S2
S4
Preganglion, ganglion,postganglion T1 L2

Neurotransmitter SSO

Cholinergic Neuron Acetylcholine

at all pregangl endings (Sympathetic &
Parasympathetic preganglionic neuron)

parasympathetic postganglionic neuron

Sympathetic postgagl that project to
sweat gld or mediate vasodilation

Adrenergic Neuron Norepinephrine

is the chemical transmitter at most
sympathetic postganglionic endings.

Sympathetic N S Pathway

The cell bodies of sympathetic preganglionic

neuron: in the lateral horns of sp cord
graymatter between T1-L2 segment
(Thoracolumbar division)
Axon pregl ventral root T1-L2 course
thrgh spinal nerve (white ramus
communicans autonomic ganglia
(sympathetic chain ganglia = paravertebral
gangl= sympathetic trunk gang)
postgangl (gray ramus communicans) -->
visceral organ

Sympathetic Nervous System

Pregang T1 Trunkus gang

Superior symp ganglion Postgang
Pupillary dilator m, Lacrimal gld &
nasal gld, Submaxill & subling gld,
Parotid gld.
Pregang T1-5 Trunkus gang post
gang Heart and Lungs
Pregang T5-9 Trunkus Gang
Celiac ganglion postgang innerv:
stomach,liver,pancreas,spleen
Pregang T9-10 postgang innerv
adrenal medulla.

Pregang T10-12 Trunkus gang

sup mesenteric gang Postgang
innerv small intestine, colon.
Pregang L1-2 Trunkus gang inf
mesenteric ganglion postgang,
innerv : colon,kidney and bladder
Pregang L2 Trunkus gang
postgang innerv sex organ

Peripheral Sympathetic Nervous

System Dysfunction

Horners Syndrome damage of:

Pregang T 1 nerve fibres
Superior cervicalis ganglion
sympathetic postgang fibres
Clinically:
Unilateral Enophthalmos
Ptosis
Myosis
Anhydrosis (loss of sweating) -----over the ipsilateral half of the face or
forehead.

Disturbances of sweat gld secretion

Hypo/anhydrosis perspiration test
Hyperhidrosis (excessive sweating) caused
by exagregated symph innerv of the sweat
gld
Orthostatic Hypotension is a drop in
BP from sitting/lying down suddenly stands
up. - failure of the vessels of lower
extremity to constrict venous return &
CO decreased BP CBF fainting

Causalgia : painful cond of the

hands or feet, caused by irritation
of median/ sciatic n thrgh injury
charact : severe burning pain,
glossi skin, swelling, redness,
sweating and tropic nail changes.
th/ sympathetic block or
sympathectomy

Parasympathetic Nervous
System

The cell bodies of parasympathetic

preganglionic neuron : within cranial
nerve nuclei (III, VII, IX, X) in the
brainstem or within the lateral part of
the graymatter of sp cord (region S2-4).
(Craniosacral division)

The Cranial Component

Pregang N III Ciliary Gangl Postgang

innervate: m.constrictor pupillae & m. ciliaris
Pregang N VII Sphenoplatine Gang &
submaxillar gang Postgang innervates:
lacrimal gld, nasal gld, submaxill & subling
gld.
Pregang N IX Otic Gang Postgang
innervate: parotis gld
Pregang N X Postgang innervate: cardiac
muscle, lung, stomach, liver, pancreas,
spleen, intestine and colon

The Sacral Component

Preganglion ; arises from Sacral cord

segment 2,3,4 Post Ganglion
innervate : descending colon
rectum
baldder
anal
prostat and sexual organ

Peripheral Parasympathetic
Nervous System dysfunction

Pupillary light reflex ( - ), mydriasis

Hirschprungs disease (megacolon) : is caused by a
functional obstruct in the lower colon & rectum.
Ineffective parasympathetic stimulation &
predominance sympathetic stimulation of the colon
inhibit peristaltic contraction feces accumulate
obove the inhibited area.
It is associated with congenital lack of parasymp gang
& the existence of abnormal nerve fibrils in an
apparently normal segment of large bowel
Incotinentia urin & alvii
Ejaculatio dysfunction

INFLUENCE OF HIGHER PARTS OF THE BRAIN

ON AUTONOMIC FUNCTION

Sudden BP initiates
parasympathetic reflex inhibits cardiac
muscle cells & HR BP normal.

Sudden BP sympathetic reflex

stimulates heart to increase HR & force
contraction BP to normal

Regulates body temperature

Thought & emotion
Regulating defecation,urination,
penile & clitoral erection, and
ejaculation

Central A N S disturbances

Cerebral Lesion
Respiration type :Cheyne stokes
Urinary & Alvii Incotinentia
hemiplegic region: edema,
Cyanosis,
Temp >> Temp<< , Vasodilation
vasoconstriction

Diencephalon Hypothalamic
disfunction: failure of body
temperature, respiratory &
Cardio Vascular regulation.
disorders of basal metabolic
GIT disorders, sleep disorder, etc
Mesencephalon
Central Neurogenic Hyperventilation
Horners Syndrome
disturbances of pupillary size & reflex

Pontine Lesion
Apneustic respiration
Horners Syndrome
disfunction of N VII
Medulla oblongata
Ataxic Respiration
disfunction of N IX dan X
disturbances of Cardiac center &
vasomotor center

Spinal Cord Lesion

TH 1 4 Lesion
Horners Syndrome (Th 1)
Sympathetic Dysfuntion Face &
Visceral organ thoracal visceral
organ
L 1 2 Lesion
disorders of micturition, defecation
erection & ejaculation dysfunction
Anhydrosis of Trunk & Leg

Innervation of the urinary

bladder
Parasympathetic innervation:
Control of bladder m is predominantly
parasympath.
The pelvic splanchnic n originating in the sacral
cord (S2-4) terminate at ganglia in the wall of
bladder & in internal spinchter m.
Bladder dilated sensory impulses by
parasympathetic neurons Excite detrusor m &
inhibit urinary spinchter Emptying the bladder.
Paralysis of the parasympathetic fibres Atonic
Bladder.

Sympathetic Innervation:
originate in the Intermediolat nucl of
lateral horn of Th 12, L1 and L2 pass
through caudal segment of the trunks
inf mesenteric gang by way of inf
splanchnic n.
Inf hypogastric plexus transmits the
impulses to internal spinchter m.
Stimulation of int spinch m relaxation
of the wall of bladder filling the bladder

Voluntary urinary bladder innervation

The external spinchter m is

striated musc. ( is under voluntary
control) but : the muscle opens
by reflex when urine passes
through internal spinchter and
stays open until the bladder is
empty.

External spinchter m, perinealis,

levator ani, penial corpus cavernosus,
urogenital diaphragm innervate by
n,pudendalis: S 2 4 voluntarily
supra segmental innervation of
bladder cerebral paracentral
lobe inisiative :urination or
suppression

Micturition mechanism
Full Bladder
detrusor m. dilation
Parasympathetic afferent
Ascending pathway (spinothal tract)
Cerebral cortex :
voluntary : urination or
Retard urination

AUTONOMIC BLADDER INNERVATION

Efferent innervation
PARA SYMPATHETIC

SYMPATHETIC
T 11
T 12
L1
L2

Detrusor muscel
Inferior hypogas
ganglion

Hypogastric plexus
BLADDER

S2
S3
S4

Function :
Detrusor mus contrac
Internal sphinc relax

Pudendal nerves
Function :
Detrusor mus relax
Internal sphinc contrac

SOMATIC EFFERENT
Origin : ant horn cell S 2,3,4

CORTICAL CONTROL

Micturition disturbances

Uninhibited neurogenic
bladder
Infant :
cerebral cortex inhibition (-),
control of volume (-), tone &
sensation normal emptying the
bladder
cerebral diffuse lesion
th/ : Atropin, tofranil

NEUROGENIC BLADDER Reflex

interrupt of ascendens &
descenden tract upper medulary
conus (arch reflex) cortical ( - )
initiation & suppression
micturition (-)

AUTONOMOUS NEUROGENIK
BLADDER
innervation of bladder (-)
bladder emptying (-) caused by
failure of detrusor m contraction
Bladder capacity <<, urinary residu
>>> - full bladder overflow
emptying abdominal pressure
etiology : lesion of medulary conus,
cauda equine, motor / sensory root
of S2-S4

SENSORIC PARALYTIC BLADDER

sensory impulses signaling that the
bladder is dilated (-)
inisiative for urination (-)
contraction ( - ) atonic neurogenic
bladder
bladder capacity & urinary residu : >>
urinary overflow
Emptying abdominal pressure
Lesion : dorsal root S2 S4, post column
of spinal cord

MOTOR PARALYTIC BLADDER

Bladder dilation & decompensation
detrusor m contraction (-)
Sensasion (normal) pain
sensation
(+) but urination (-)
cause : polio, polyradiculoneuritis,
trauma, neoplasm, congenital

Spastic neurogenic bladder :

caused by a more or less complete
transection of the spinal cord above
S2.
Flaccid Neurogenic bladder
caused by a lesion of either the sacral
portion of the spinal cord or the cauda
equina