Nervous System

The nervous system is an organ system that contains a network of specialized cells called neurons. This is the master controlling and communicating system of the body. It coordinates the action of an animal and transmits signals between the different parts of the body. Every thought, movement and emotions reflect the activity of the nervous system. Functions of the NERVOUS SYSTEM

1. To monitor changes that takes place inside and outside the body. The nervous system utilizes the million sensory receptors to carry out this function. Any changes or stimuli occurring are noted by the nervous system and the gathered data is now called a sensory input. 2. Another important function of the nervous system is to process and interpret the sensory input or gathered data. It is the working of this system to make decision about what should be done at each moment. This is the process known as INTEGRATION. 3. As the nervous system has reached a decision of what response and appropriate action to be done in response to the stimuli, it then effects a response by activating muscles or glands through motor output. The nervous system consists of two parts, shown in Figure 1:
The central nervous system (CNS) consists of the brain and spinal cord, which occupy

the cavity and act as the integrating and command centers of the nervous system. They interpret incoming sensory information and issue instructions based on past experience and current conditions.
The peripheral nervous system (PNS) consists of nerves outside the CNS.

Nerves of the PNS are classified in three ways. First, PNS nerves are classified by how they are connected to the CNS. Cranial nerves originate from or terminate in the brain, while spinal nerves originate from or terminate at the spinal cord. Second, nerves of the PNS are classified by the direction of nerve propagation. Sensory ( afferent) neurons transmit impulses from skin and other sensory organs or from various

places within the body to the CNS. Motor ( efferent) neurons transmit impulses from the CNS to effectors (muscles or glands). Third, motor neurons are further classified according to the effectors they target. The somatic nervous system (SNS) directs the contraction of skeletal muscles. The autonomic nervous system (ANS) controls the activities of organs, glands, and various involuntary muscles, such as cardiac and smooth muscles. The autonomic nervous system has two divisions:
The sympathetic nervous system is involved in the stimulation of activities that prepare

the body for action, such as increasing the heart rate, increasing the release of sugar from the liver into the blood, and other activities generally considered as fight-or-flight responses (responses that serve to fight off or retreat from danger).
The parasympathetic nervous system activates tranquil functions, such as stimulating

the secretion of saliva or digestive enzymes into the stomach and small intestine. Generally, both sympathetic and parasympathetic systems target the same organs, but often work antagonistically. For example, the sympathetic system accelerates the heartbeat, while the parasympathetic system slows the heartbeat. Each system is stimulated as is appropriate to maintain homeostasis.

Figure 1. Two parts of the nervous system.

Motor Neuron

Term

Function(s)

Structure(s)

Axon

A nerve fibre: a single process extending from the cell body of a neurone and carrying nerve impulses away from it.

Dendrite

Carries nerve impulses from adjacent neurons into the cell body.

One of the shorter branching processes of the cell body of a neurone. All dendrites have synaptic knobs at the ends, which are the "connections" to adjoining nerves.

Mixed Nerves

Contain both motor and sensory nerve fibres running to/from a particular region of the body. (Examples include most large

nerves such as the brachial nerves, and all the spinal nerves.)

Motor Neurone = "Efferent Neurone"

Transmitting impulses (electrical signals for communication within the body) from the Central Nervous System (which is sometimes referred to by the abreviation: CNS, and) which consists of the brain and spinal cord, to muscles & glands elsewhere in the body.

Myelin Sheath

Three key functions of Myelin Sheath are:

A complex material formed of protein and phospholipid (fat) that is laid down as a sheath around the

Protection of the nerve fibre. Insulation of the nerve fibre. Increases the rate of transmission of nerve impulses.

axons of certain neurons.

Nerve

A nerve is a bundle containing 100s to 1000s of axons (thread-like conductors) plus the associated connective tissue and blood vessels.

Neurilemma

The sheath of the axon of a nerve fibre. The neurilemma of a medullated fibre contains myelin laid down by Schwann cells.

Neurone

A cell specialized to transmit

Each neurone has an enlarged

electrical nerve impulses and so carry information from one part of the body to another. "Neurone" = "Nerve Cell"

portion the cell body (perikaryon), containing the nucleus; from the body extend several processes (dendrites) through which impulses enter from their branches. A longer process, the nerve fibre (axon), extends outwards and carries impulses away from the cell body. This is normally unbranched except at the nerve ending. The point of contact of one neurone with another is known as a synapse.

Nodes of Ranvier

Key functions of Nodes of Ranvier include:

Gaps that occur at regular intervals in the myelin sheath of medullated nerve fibres, between adjacent

Allowing nutrients and waste products to enter/leave the neurone. Allowing nerve impulses to move along the neurone through a process of de-polarisation and re-polarisation of the nerve membrane.

Schwann cells.

Relay Neurone

Located within the Central Nervous System (CNS), relay neurons transmit the electrical impulses generated by the stimuli to other nerves.

Schwann Cells

Schwann cells are the cells that lay down the protective myelin sheath around the axon of medullated nerve fibers.

Each Schwann cell protects one length of axon, around which it twists as it grows - enveloping the axon.

Sensory Neurone

Transmit impulses inwards from sense organs to the Central Nervous System (CNS).

Synapse

Reaching a synapse, an impulse causes the release of a neurotransmitter, which diffuses across the gap and triggers an electrical impulse in the next neurone. (Some brain cells have more than 15,000 synapses.)

The minute gap across which nerve impulses pass from one neurone to the next, at the end of a nerve fibre.

Classification:

Bipolar neurons: small neurons with two distinct processes; a dendritic process and an axon extending from the cell body. They are CNS neurons specific for transmitting information from specialized sensory systems: sight, smell and hearing.

Unipolar neurons: large neurons with the cell body lying to one side of the continuous dendritic process and axon.

Multipolar neurons: large neurons with several dendrites and a single axon extending from the cell body.

Grey and white matter: Grey matter consisting of unmyelinated neurons is the processing area of the CNS. White matter located in the inner cortex and surrounding grey matter in the spinal cord - provide pathways of communication between grey matter.

Glial Cells CNS Glial Cell Types: there are 4 types of glial cells 1. Astrocytes - Regulates the chemical microenvironment surrounding neurons, 2. Oligodendrocytes - Myelinate central nervous system axons, 3. Microglia - Migrating phagocytic cells resembling immune cells that remove waste, debris, and pathogens and 4. Ependymal cells - Columnar cells that line the ventricals of the brain and the spinal canal in the spinal cord. PNS supporting cells: 2 types 1. Schwann cells - myelin sheaths around nerve fibers, and 2. Satellite cells - act as protective and cushioning cells. PERIPHERAL NERVOUS SYSTEM The PNS is the communication network between the CNS and the rest of the body. Organization and function: The peripheral nervous system (PNS) includes all neural tissue excluding the brain and the spinal cord. Proprioception: involve sensors that keep track of where the body is in space.The five senses: The sensory nervous system includes sensory organs, which receive information from the environment, and sends it to the CNS.

Skin: detects temperature, touch, and painful stimuli. Three separate kinds of nerves detect sensation on the skin
o o

Mechanoreceptors: Detect pressure and tension on the skin Thermoreceptors: Detect the temperature of the stimulus

Nociceptors: Detect painful stimuli.

Nose: detects aromatic molecules. Thousands of chemicals can be detected by our olfactory and taste receptors and sorted into pleasant, toxic, etc.

Tongue: taste buds detect salty, bitter, sweet, and sour information.

Ears: detect sound waves with mechanical receptors. Fluctuations in air pressure move a membrane attached to hair cells in the Organ of Corti. These motions open ion channels in neurons, sending the signal to the CNS.

Eyes: detect photons or light. The retina is the neural portion of the eye. Photons (light) activate receptors on the retina and the signal is transported to the CNS via the optic nerve.

Motor nervous system

Spinal Nerve Anatomy: There are 31 nerves exiting the spinal cord, dorsal connections bring sensory information to the CNS, ventral motor connections send commands to the periphery.

Reflexes: For painful stimuli, involuntary withdrawal (like a hand from a flame) occurs without input from the brain. This very simple nervous pathway is called a reflex arc.

Autonomic nervous system: directly controls automatic body functions (involuntary movements). The autonomic system has two opposing parts: the sympathetic and parasympathetic nervous systems.

Transmission of Nerve Impulses The transmission of a nerve impulse along a neuron from one end to the other occurs as a result of electrical changes across the membrane of the neuron. The membrane of an unstimulated neuron is polarizedthat is, there is a difference in electrical charge between the outside and inside of the membrane. The inside is negative with respect to the outside. Polarization is established by maintaining an excess of sodium ions (Na+) on the outside and an excess of potassium ions (K+) on the inside. A certain amount of Na+ and K+ is always leaking across the membrane through leakage channels, but Na+/K+ pumps in the membrane actively restore the ions to the appropriate side. The main contribution to the resting membrane potential (a polarized nerve) is the difference in permeability of the resting membrane to potassium ions versus sodium ions. The resting membrane is much more permeable to potassium ions than to sodium ions resulting in slightly more net potassium ion diffusion (from the inside of the neuron to the outside) than sodium ion

diffusion (from the outside of the neuron to the inside) causing the slight difference in polarity right along the membrane of the axon. Other ions, such as large, negatively charged proteins and nucleic acids, reside within the cell. It is these large, negatively charged ions that contribute to the overall negative charge on the inside of the cell membrane as compared to the outside. In addition to crossing the membrane through leakage channels, ions may cross through gated channels. Gated channels open in response to neurotransmitters, changes in membrane potential, or other stimuli. The following events characterize the transmission of a nerve impulse (see Figure 1):
Resting potential. The resting potential describes the unstimulated, polarized state of a

neuron (at about 70 millivolts).

Graded potential. A graded potential is a change in the resting potential of the plasma

membrane in the response to a stimulus. A graded potential occurs when the stimulus causes Na+ or K+ gated channels to open. If Na+channels open, positive sodium ions enter, and the membrane depolarizes (becomes more positive). If the stimulus opens K+ channels, then positive potassium ions exit across the membrane and the membrane hyperpolarizes (becomes more negative). A graded potential is a local event that does not travel far from its origin. Graded potentials occur in cell bodies and dendrites. Light, heat, mechanical pressure, and chemicals, such as neurotransmitters, are examples of stimuli that may generate a graded potential (depending upon the neuron). Figure 1. Events that characterize the transmission of a nerve impulse.

The following four steps describe the initiation of an impulse to the resetting of a neuron to prepare for a second stimulation: 1. Action potential. Unlike a graded potential, an action potential is capable of traveling long distances. If a depolarizing graded potential is sufficiently large, Na+ channels in the trigger zone open. In response, Na+ on the outside of the membrane becomes depolarized (as in a graded potential). If the stimulus is strong enoughthat is, if it is above a certain threshold leveladditional Na+gates open, increasing the flow of Na+ even more, causing an action potential, or complete depolarization (from 70 to about +30 millivolts). This in turn stimulates neighboring Na+ gates, farther down the axon, to open. In this manner, the action potential travels down the length of the axon as opened Na+ gates stimulate neighboring Na+ gates to open. The action potential is an all-or-nothing event: When the stimulus fails to produce depolarization that exceeds the threshold value, no action potential results, but when threshold potential is exceeded, complete depolarization occurs. 2. Repolarization. In response to the inflow of Na+, K+ channels open, this time allowing K+ on the inside to rush out of the cell. The movement of K+ out of the cell causes repolarization by restoring the original membrane polarization. Unlike the resting potential, however, in repolarization the K+ are on the outside and the Na+ are on the inside. Soon after the K+ gates open, the Na+gates close. 3. Hyperpolarization. By the time the K+ channels close, more K+ have moved out of the cell than is actually necessary to establish the original polarized potential. Thus, the membrane becomes hyperpolarized (about 80 millivolts). 4. Refractory period. With the passage of the action potential, the cell membrane is in an unusual state of affairs. The membrane is polarized, but the Na+ and K+ are on the wrong sides of the membrane. During this refractory period, the axon will not respond to a new stimulus. To reestablish the original distribution of these ions, the Na+ and K+ are returned to their resting potential location by Na+/K+ pumps in the cell membrane. Once these ions are completely returned to their resting potential location, the neuron is ready for another stimulus.

CENTRAL NERVOUS SYSTEM The anatomy of the brain is complex due its intricate structure and function. This amazing organ acts as a control center by receiving, interpreting, and directing sensory information throughout the body. There are three major divisions of the brain. They are the forebrain, the midbrain, and the hindbrain.

Anatomy of the Brain: Brain Divisions

The forebrain ( Prosencephalon )is responsible for a variety of functions including receiving and processing sensory information, thinking, perceiving, producing and understanding language, and controlling motor function. There are two major divisions of forebrain: The diencephalon contains structures such as the thalamus and hypothalamus which are responsible for such functions as motor control, relaying sensory information, and controlling autonomic functions. The telencephalon contains the largest part of the brain, the cerebrum. Most of the actual information processing in the brain takes place in the cerebral cortex.

The midbrain (Mesencephalon) and the hindbrain together make up the brainstem. The midbrain is the portion of the brainstem that connects the hindbrain and the forebrain. This region of the brain is involved in auditory and visual responses as well as motor function. The hindbrain (Rhombencephalon )extends from the spinal cord and is composed of the metencephalon and myelencephalon. The metencephalon contains structures such as the pons and cerebellum. These regions assists in maintaining balance and equilibrium, movement coordination, and the conduction of sensory information. The myelencephalon is composed of the medulla oblongata which is responsible for controlling such autonomic functions as breathing, heart rate, and digestion.

Anatomy of the Brain: Structures The brain contains various structures that have a multitude of functions. Below is a list of major structures of the brain and some of their functions.

Basal Ganglia

Involved in cognition and voluntary movement Diseases related to damages of this area are Parkinson's and Huntington's
o

Parkinson's disease: Nerves in a central area of the brain degenerate slowly, causing problems with movement and coordination. A tremor of the hands is a common early sign.

Huntington's disease: An inherited nerve disorder that affects the brain. Dementia and difficulty controlling movements (chorea) are its symptoms.

Brainstem

Relays information between the peripheral nerves and spinal cord to the upper parts of the brain

Consists of the midbrain, medulla oblongata, and the pons.

Broca's Area

Speech production Understanding language

Central Sulcus (Fissure of Rolando)

Deep grove that separates the parietal and frontal lobes

Cerebellum

Controls movement coordination Maintains balance and equilibrium

Cerebral Cortex

Outer portion (1.5mm to 5mm) of the cerebrum Receives and processes sensory information Divided into cerebral cortex lobes

Cerebral Cortex Lobes Frontal Lobes is concerned with higher intellectual functions, such as abstract thought and reason, speech (Broca's area in the left hemisphere only), olfaction, and emotion. Voluntary movement is controlled in the precentral gyrus (the primary motor area); involved with decision-making, problem solving, and planning.

The primary motor cortex is the most posterior part of the precentral gyrus. The primary motor cortex on one side controls all moving parts on the contralateral side of the body (shown on a spatial map called a homunculus); 90% of motor fibers from each hemisphere cross the midline in the brain stem. Thus, damage to the motor cortex of one hemisphere causes weakness or paralysis mainly on the contralateral side of the body.

The medial frontal cortex (sometimes called the medial prefrontal area) is important in arousal and motivation. If lesions in this area are large and extend to the most anterior part

of the cortex (frontal pole), patients sometimes become abulic (apathetic, inattentive, and markedly slow to respond).

The orbital frontal cortex (sometimes called the orbital prefrontal area) helps modulate social behaviors. Patients with orbital frontal lesions can become emotionally labile, indifferent to the implications of their actions, or both. They may be alternately euphoric, facetious, vulgar, and indifferent to social nuances. Bilateral acute trauma to this area may make patients boisterously talkative, restless, and socially intrusive. With aging and in many types of dementia, disinhibition and abnormal behaviors can develop; these changes probably result from degeneration of the frontal lobe, particularly the orbital frontal cortex.

The left posteroinferior frontal cortex (sometimes called Broca's area or the posteroinferior prefrontal area) controls expressive language function. Lesions in this area cause expressive aphasia (impaired expression of words).

The dorsolateral frontal cortex (sometimes called the dorsolateral prefrontal area) manipulates very recently acquired informationa function called working memory. Lesions in this area can impair the ability to retain information and process it in real time (eg, to spell words backwards or to alternate between letters and numbers sequentially).

Occipital Lobes is responsible for interpretation and processing of visual stimuli from the optic nerves, and association of these stimuli with other nervous inputs and memories ;involved with vision and color recognition. The occipital lobes contain the primary visual cortex and visual association areas. Lesions in the primary visual cortex lead to a form of central blindness called Anton's syndrome; patients become unable to recognize objects by sight and are generally unaware of their deficits. Seizures in the occipital lobe can cause visual hallucinations, often consisting of lines or meshes of color superimposed on the contralateral visual field. Parietal Lobes is dedicated to sensory awareness, particularly in the postcentral gyrus (the primary sensory area). It is also concerns with abstract reasoning, language interpretation and

formation of a mental egocentric map of the surrounding area; receives and processes sensory information. Parts of the midparietal lobe of the dominant hemisphere are involved in abilities such as calculation, writing, left-right orientation, and finger recognition. Lesions in the angular gyrus can cause deficits in writing, calculating, left-right disorientation, and finger-naming (Gerstmann's syndrome). The nondominant parietal lobe integrates the contralateral side of the body with its environment, enabling people to be aware of this environmental space, and is important for abilities such as drawing. Acute injury to the nondominant parietal lobe may cause neglect of the contralateral side (usually the left), resulting in decreased awareness of that part of the body, its environment, and any associated injury to that side (anosognosia). For example, patients with large right parietal lesions may deny the existence of left-sided paralysis. Patients with smaller lesions may lose the ability to do learned motor tasks (eg, dressing, other well-learned activities)a spatial-manual deficit called apraxia.

Temporal Lobes

is concerned with emotional development and formation, and also contains the auditory area responsible for processing and discrimination of sound. It is also the area thought to be responsible for the formation and processing of memories.; involved with emotional responses, memory, and speech.

Patients with epileptogenic foci in the medial limbic-emotional parts of the temporal lobe commonly have complex partial seizures, characterized by uncontrollable feelings and autonomic, cognitive, or emotional dysfunction. Occasionally, such patients have personality changes, characterized by humorlessness, philosophic religiosity, and obsessiveness.

Cerebrum

Largest portion of the brain Consists of folded bulges called gyri that create deep furrows

Corpus Callosum

Thick band of fibers that connects the left and right brain hemispheres

Cranial Nerves

Twelve pairs of nerves that originate in the brain, exit the skull, and lead to the head, neck and torso

Fissure of Sylvius (Lateral Sulcus)

Deep grove that separates the parietal and temporal lobes Limbic System Structures

Amygdala - involved in emotional responses, hormonal secretions, and memory Cingulate Gyrus - a fold in the brain involved with sensory input concerning emotions and the regulation of aggressive behavior

Fornix - an arching, fibrous band of nerve fibers that connect the hippocampus to the hypothalamus

Hippocampus - sends memories out to the appropriate part of the cerebral hemisphere for long-term storage and retrievs them when necessary

Hypothalamus - directs a multitude of important functions such as body temperature, hunger, and homeostasis

Olfactory Cortex - receives sensory information from the olfactory bulb and is involved in the identification of odors

Thalamus - mass of grey matter cells that relay sensory signals to and from the spinal cord and the cerebrum

Medulla Oblongata - Lower part of the brainstem that helps to control autonomic functions

Meninges - membranes that cover and protect the brain and spinal cord

Olfactory Bulb - Bulb-shaped end of the olfactory lobe and involved in the sense of smell

Pineal Gland - Endocrine gland involved in biological rhythms and secretes the hormone melatonin

Pituitary Gland - endocrine gland involved in homeostasis and regulates other endocrine glands

Pons - Relays sensory information between the cerebrum and cerebellum

Reticular Formation - Nerve fibers located inside the brainstem and regulates awareness and sleep

Substantia Nigra - Helps to control voluntary movement and regualtes mood

Tectum -The dorsal region of the mesencephalon (mid brain)

Tegmentum - The ventral region of the mesencephalon (mid brain).

Ventricular System - connecting system of internal brain cavities filled with cerebrospinal fluid Aqueduct of Sylvius - canal that is located between the third ventricle and the fourth ventricle Choroid Plexus - produces cerebrospinal fluid Fourth Ventricle - canal that runs between the pons, medulla oblongata, and the cerebellum Lateral Ventricle - largest of the ventricles and located in both brain hemispheres Third Ventricle - provides a pathway for cerebrospinal fluid to flow

Wernicke's Area - Region of the brain where spoken language is understood

Cerebrospinal fluid

Cerebrospinal fluid (CSF), clear, colourless liquid that fills and surrounds the brain and the spinal cord and provides a mechanical barrier against shock. Formed primarily in the ventricles of the brain, the cerebrospinal fluid supports the brain and provides lubrication between surrounding bones and the brain and spinal cord. When an individual suffers a head injury, the fluid acts as a cushion, dulling the force by distributing its impact. The fluid helps to maintain pressure within the cranium at a constant level. An increase in the volume of blood or brain tissue results in a corresponding decrease in the fluid. Conversely, if there is a decrease in the volume of matter within the cranium, as occurs in atrophy of the brain, the CSF compensates with an increase in volume. The fluid also transports metabolic waste products, antibodies, chemicals, and pathological products of disease away from the brain and spinal-cord tissue into the bloodstream. CSF is slightly alkaline and is about 99 percent water. There are about 100 to 150 ml of CSF in the normal adult human body.

CSF CIRCULATION: CSF is produced in the brain by modified ependymal cells in the choroid plexus (approx. 50-70%) and the remainder is formed around blood vessels and along ventricular walls. CSF Circulation lateral ventricles--> foramen of Monro third ventricle --> aqueduct of Sylvius --> fourth ventricle --> foramina of Magendie and Luschka --> subarachnoid space over brain and spinal cord --> reabsorption into venous sinus blood via arachnoid granulations.

The fluid flows through the interventricular foramen (of Monro) into the third ventricle, is augmented by fluid formed by the choroid plexus of this ventricle, and passes through the cerebral aqueduct (of Sylvius) to the fourth ventricle, which also possesses a choroid plexus. The CSF from all theses sources , as well as any formed in the central canal of the spinal cord, escapes from the fourth ventricle into the subarachnoid space through the median aperture (of Magendie) and lateral aperture (of Luschka). The CSF then circulates through the freely communicating subaracchnoid cisterns at the base of the brain. From the cisterns, most of the CSF is directed upward over the cerebral hemispheres and smaller amounts pass downward around the spinal cord.

Normal values typically range as follows:

Pressure: 70 - 180 mm H20 Appearance: clear, colorless CSF total protein: 15 - 60 mg/100 mL Gamma globulin: 3 - 12% of the total protein CSF glucose: 50 - 80 mg/100 mL (or greater than 2/3 of blood sugar level) CSF cell count: 0 - 5 white blood cells (all mononuclear), and no red blood cells Chloride: 110 - 125 mEq/L

Note: mg/mL = milligrams per milliliter; mEq/L = milliequivalents per liter Note: Normal value ranges may vary slightly among different laboratories. Blood Brain Barrier Neurons of the brain and spinal cord are protected from many chemical damage and biological substances by "blood brain barrier", interposed between the blood and the CSF by the endothelial cells of the capillaries and the choroid plexus. This is clinically important because some drugs cannot penetrate the barrier. This protective device has many elements, ranging from junctions between endothelial cells in the capillaries of the brain, restricting permeability of larger molecules to neuroglia. Large blood vessels penetrating the brain tissue are lined with an inner layer of endothelium reinforced by fibromuscular tissue. ABNORMALITIES OF CSF

Leukemic cells in the CSF

Blood: Blood may be spilled into the CSF by accidental puncture of a leptomeningeal vein during entry of the LP needle. Such blood stains the fluid that is drawn initially and clears gradually. If it does not clear, blood indicates subarachnoid hemorrhage. Erythrocytes from subarachnoid hemorrhage are cleared in 3 to 7 days. A few neutrophils and mononuclear cells may also be present as a result of meningeal irritation. Xanthochromia (blonde color) of the CSF following subarachnoid hemorrhage is due to oxyhemoglobin which appears in 4 to 6 hours and bilirubin which appears in two days. Xanthochromia may also be seen with hemorrhagic infarcts, brain tumors, and jaundice. Increased inflammatory cells (pleocytosis) may be caused by infectious and noninfectious processes. Polymorphonuclear pleocytosis indicates acute suppurative meningitis. Mononuclear cells are seen in viral infections (meningoencephalitis, aseptic meningitis), syphilis, neuroborreliosis, tuberculous meningitis, multiple sclerosis, brain abscess and brain tumors. Tumor cells indicate dissemination of metastatic or primary brain tumors in the subarachnoid space. The most common among the latter is medulloblastoma. They can be best detected by cytological examination. A mononuclear inflammatory reaction is often seen in addition to the tumor cells. Increased protein: In bacterial meningitis, CSF protein may rise to 500 mg/dl. A more moderate increase (150-200 mg/dl) occurs in inflammatory diseases of meninges (meningitis, encephalitis), intracranial tumors, subarachnoid hemorrhage, and cerebral infarction. A more severe increase occurs in the Guillain-Barr syndrome and acoustic and spinal schwannoma. In multiple sclerosis, CSF protein is normal or mildly increased, but there is often an elevation of IgG in CSF, but not in serum, expressed as an elevation of the CSF IgG/albumin index (normally 10:1). In addition, 90% of MS patients have oligoclonal IgG bands in the CSF. Oligoclonal bands are also seen occasionally in some chronic CNS infections . The type of oligoclonal bands is constant for each MS patient throughout the course of the disease. Oligoclonal bands occur in the CSF only (not in the serum). These quantitative and qualitative CSF changes indicate that in MS, there is intrathecal immunoglobulin production. In addition, the CSF in MS often contains myelin fragments and myelin basic protein (MBP). MBP

can be detected by radioimmunoassay. MBP is not specific for MS. It can appear in any condition causing brain necrosis, including infarcts. Low glucose in CSF is seen in suppurative, tuberculous and fungal infections, sarcoidosis, and meningeal dissemination of tumors. Glucose is consumed by leukocytes and tumor cells. Spinal Cord Even though the brain controls the activities of the whole body, it only extends down to the top of the neck. Below that, the spinal cord carries messages between the brain and your body. Your face has a direct connection to the brainstem, so it is independent of your spinal cord. The spinal cord looks like a long rope about the width of your little finger. It runs from the base of your brain down to the lower part of your back, and it is fragile. Spinal cord injury [SCI] can lead to loss of movement and feeling. It can also affect how your brain controls your internal organs. When your spinal cord is injured, parts of your body below the level of the injury are affected.

The spinal cord is protected by your backbones. The backbones are 29 small bones stacked on top of each other. These bones are called vertebrae. To allow your back to bend and to lessen jarring, each vertebra is cushioned from the next by disks. Disks are made of a spongy material and act like shock absorbers. Ligaments hold the vertebrae together and allow your neck and back to twist and bend.

The Spinal Column Each vertebra has a hole in ita hard, bony tunnel through which the spinal cord passes. This is the spinal canal. It protects the spinal cord from damage. The vertebrae and disks, held together by ligaments, are called the spinal column Has four sections. The top is the cervical section, which is your neck. The next down is the thoracic section, which extends from your lower neck to your lower ribs. The lumbar section is your lower back, and the sacral section is your tailbone. Your sacral section is really only one bone, with five nerve pairs coming out through holes in it. T The cervical section contains eight pairs of nerves and seven vertebrae. The nerves numbered C1 through C7 exit from the spine above the corresponding numbered vertebrae, and the C8 nerve pair exits between the C7 and T1 bones on each side. For the thoracic and lumbar sections, each of the numbered nerves lies below the corresponding numbered vertebra. There are 12 thoracic nerves and 5 lumbar nerves on each side. At the lower end of spinal cord [below the second lumbar vertebra], the nerves travel long distances before they exit the spine. This is because the spinal cord itself ends much higher, at about the level of the L1 vertebra. The lower lumbar and sacral nerves look like a horses tail inside the spinal column. In fact, this area is known as the cauda equina, which means horses tail in Latin. How The Spinal Cord Functions The spinal cord is the communicating link between the spinal nerves and the brain. The long nerve fibers inside the spinal cord are called the upper motor neurons [UMNs]. They run between the brain and the spinal nerves. The spinal nerves branch out from the spinal cord into the tissues of your body. Spinal nerves are called lower motor neurons [LMNs]

In movement, the brain sends messages through the spinal cord [UMNs] to the spinal nerves [LMNs]. The LMNs then carry these messages to the muscles to coordinate movements, such as walking. In this way, the brain controls movement.

Spinal Nerves In sensation, nerves in your body collect information and send it up the spinal cord to the rain. This allows you to be aware of feelings, such as heat, cold, touch, or pain. You may wonder how the spinal cord keeps these messages from getting confused, with all the running back and forth between brain and body. The motor nerves and the sensory nerves carry messages in different nerve fibers. Within the spinal cord, the nerve fibers are combined into groups called spinal tracts. Each tract carries messages one way, either up for sensation or down for voluntary movement. They are similar to the lanes on a freeway. What Is a Spinal Nerve and What Does It Do? Each spinal nerve has two main parts. One part carries information related to movement from the spinal cord to the muscles. It is called a motor nerve. Each motor nerve connects to a specific muscle. Each level of the spinal cord causes movement in a certain group of muscles. Spinal Tracts for Nerves The other part of the spinal nerve carries messages of feeling, such as heat and cold, from the body to the spinal cord. It is called a sensory nerve. Different types of sensation or feeling are carried up the spinal cord to the brain. These include pain, touch, heat, cold, vibration, pressure, and knowing where a body part is located in space without looking at it. Each sensory nerve collects information about feelings from a given body part or area of skin. Each skin area is called a dermatome and matches a specific spinal cord level. Try to identify areas where you have normal sensation and where you do not.

Spinal Cord Injury Many types of injuries and diseases can cause spinal cord injury or dysfunction. If the space for the spinal cord [spinal canal] becomes narrowed, the spinal cord can become injured. This can happen when bones in your back or neck are broken, or when ligaments are torn and the vertebrae move in different directions. Gunshot wounds, stab wounds, or fragments from explosions can directly damage the cord without much breaking of the bones. Infections and tumors near the spine can compress the spinal cord. Sometimes, arthritis can affect the bones and slowly compress the cord. Finally, the blood supply to the spinal cord can be blocked, causing part of the spinal cord to die. [This is similar to how a stroke affects the brain.] Damage to your spinal cord can cause changes in your movement, feeling, bladder control, or other bodily functions. The changes depend on where and how badly your spinal cord was injured. The main problem is that the connection between your brain and your body below the injury is impaired or broken. A numbering system is used to name levels of injury. Its the same as the system used to name bone and nerve levels in your back. A spinal cord injury is named for the lowest level of the spinal cord that still functions the way it did before the injury. It is important to your rehabilitation that you know your level of injury and how it affects your body. The level of spinal cord injury is not always the same level as where the spine was injured. When the spinal cord injury is at a cervical level, it is called tetraplegia or quadriplegia. When it is at a lower level [thoracic, lumbar, or sacral], it is called paraplegia. Most of the nerve supply to the arm and hand comes from cervical nerve roots. This means that people with tetraplegia have some numbness or weakness in their arms or hands. Paraplegia does not affect the arms or hands. Complete and Incomplete SCI If there is no voluntary movement [spasms dont countthey are involuntary] and no feeling below your spinal cord injury level, you have a complete injury. If you have some feeling or voluntary movement below your injury, you have an incomplete injury. This happens when there is only partial damage to your spinal cord; that is, some nerve fibers are still working across your spinal cord injury site.

UMN and LMN Injuries Earlier in this section, we discussed the difference between upper motor neurons [UMNs] and lower motor neurons [LMNs]. A complete injury cuts or affects all the UMNs running down the spinal cord. This disrupts the connection between the brain and the parts of the body below the injury. However, the LMNs below your spinal cord injury are not damaged. Because LMNs carry reflex actions, the reflexes below the level of injury are still working. So the LMNs are still carrying out reflex actions below the level of injury, but this may cause a problem. In reflexes, the brain normally controls how much your nerves react. In a UMN injury, messages from the brain cant get past the point of injury, so the LMNs act by themselves, which may cause reflexes without limit. One example is spasticity, which is uncontrolled movement of your arms or legs. LMN injuries are a different story. This kind of injury is usually at the lower tip of the spinal cord [the cauda equina]. The cauda equina is made up entirely of LMNs, so damage to it impairs reflex actions, although other UMNs and LMNs above the injury are still working. Spasticity does not occur with LMN injuries because the muscles no longer have any nerve contact to stimulate them. Stated simply, a UMN injury is one in which the UMN pathway is broken, the LMNs below the injury are intact, and spasticity usually occurs.

Upper Motor Neuron Injury An LMN injury, usually at the cauda equina, blocks nerve activity in muscles controlled below the injury, and no spasticity develops. It is important to know which kind of injury you have because that will determine how it is managed.

Lower Motor Neuron Injury

Sensory, No. Name motor, or both Origin Nuclei Function

Transmits the sense of Anterior Telencephalon olfactory nucleus smell from the nasal cavity.[1] Located in olfactory foramina in thecribriform plate of ethmoid.

Olfactory

Purely sensory

II

Optic

Purely sensory

[Lateral Diencephalon geniculate nucleus][2]

Transmits visual signals from the retina of the eye to the brain.[3] Located in the optic canal.

Oculomotor III Oculomot or Mainly motor Anterior aspect of Midbrain

Innervates the levator

nucleus,Edinge palpebrae superioris, superior r-Westphal nucleus rectus, medial rectus, inferior rectus,

and inferior oblique, which collectively perform most eye movements. Also innervates thesphincter pupillae and the muscles of the ciliary body. Located in the superior orbital fissure.

Innervates the superior oblique muscle, which IV Trochlear Mainly motor Dorsal aspect of Trochlear Midbrain nucleus depresses, rotates laterally, and intorts the eyeball. Located in the superior orbital fissure.

Principal sensory trigeminal nucleus,Spinal Trigemina Both sensory l and motor trigeminal Pons nucleus,Mesen cephalic trigeminal nucleus,Trigemi nal motor nucleus

Receives sensation from the face and innervates the muscles of mastication. Located in thesuperior orbital fissure (ophthalmic nerve - V1), foramen rotundum (maxillary nerve V2), andforamen ovale (mandibular nerve V3).

Nuclei lying VI Abducens Mainly motor under the floor of the fourth ventricle Pons Abducens nucleus

Innervates the lateral rectus, which abducts the eye. Located in the superior orbital fissure.

Provides motor innervation to the muscles of facial expression, posterior belly of the digastric muscle, and stapedius muscle. Also receives the special sense Facial Both sensory and motor of taste from the anterior

Pons(cerebellop nucleus,Solitary 2/3 of the tongue and ontine angle) above olive nucleus,Superi provides secretomotor inne or salivary nucleus rvation to the salivary glands (except parotid) and the lacrimal gland. Located in and runs through the internal acoustic canal to the facial canal and exits at the stylomastoid foramen.

VII

Facial

Acoustic or Vestibuloc ochlear(or VIII auditoryvestibular nerve ora coustic nerve) Mostly sensory Lateral to CN VII Vestibular (cerebellopontin nuclei,Cochlear e angle) nuclei

Senses sound, rotation, and gravity (essential for balance and movement). More specifically, the vestibular branch carries impulses for equilibrium and the cochlear branch carries impulses for hearing. Located in the internal acoustic canal.

IX

Glossoph Both sensory aryngeal and motor

Medulla

Nucleus

Receives taste from the

ambiguus,Inferi posterior 1/3 of the tongue,

or salivary

provides secretomotor

nucleus, Solitar innervation to theparotid y nucleus gland, and provides motor innervation to the stylopharyngeus. Some sensation is also relayed to the brain from the palatine tonsils. Located in the jugular foramen.

Supplies branchiomotor inn ervation to most laryngeal and pharyngeal muscles (except thestylopharyngeus, which is innervated by the glossopharyngeal). Also providesparasympathetic fi Nucleus Both sensory and motor Posterolateral sulcus of Medulla ambiguus,Dors al motor vagal nucleus, Solitar y nucleus bers to nearly all thoracic and abdominal viscera down to the splenic flexure. Receives the special sense of taste from the epiglottis. A major function: controls muscles for voice and resonance and the soft palate. Symptoms of damage: dysphagia(swallo wing problems), velopharyngeal insufficiency. Located in the jugular foramen.

Vagus

Accessory or spinalaccessory (or cranial XI accessory Mainly motor nerveor s pinal accessory nerve) Cranial and Spinal Roots Nucleus ambiguus,Spin al accessory nucleus

Controls the sternocleidomastoid and trapezius muscles, and overlaps with functions of the vagus nerve (CN X). Symptoms of damage: inability to shrug, weak head movement. Located in the jugular foramen.

Provides motor innervation to the muscles of the tongue (except for the palatoglossus, which is Hypoglos sal Hypoglossal nucleus innervated by the vagus nerve) and other glossal muscles. Important for swallowing (bolus formation) and speech articulation. Located in the hypoglossal canal.

XII

Mainly motor Medulla