Chapter 60 Assessment of Neurologic Function 1827
rons of the CNS because of the bloodbrain barrier. This barrier
is formed by the endothelial cells of the brains capillaries,
which form continuous tight junctions, creating a barrier to
macromol- ecules and many compounds. All substances
entering the CSF must lter through the capillary endothelial
cells and astrocytes (Hickey, 2003). Often altered by trauma,
cerebral edema, and cerebral hypoxemia, the blood brain
barrier has implications in the treatment and selection of
medication for CNS disorders as well as serving a protective
function.
ANATOMY OF THE SPINAL CORD
The spinal cord and medulla form a continuous structure
extending from the cerebral hemispheres and serving as the
con- nection between the brain and the periphery.
Approximately 45 cm (18 in) long and about the thickness of
a nger, it extends from the foramen magnum at the base of
the skull to the lower border of the rst lumbar vertebra,
where it tapers to a brous band called the conus medullaris.
Continuing below the second lumbar space are the nerve roots
that extend beyond the conus, which are called the cauda
equina because they resemble a horses tail. Similar to the brain,
the spinal cord consists of gray and white matter. Gray matter in
the brain is external and white matter is internal; in the spinal
cord, gray matter is in the center and is surrounded on all sides
by white matter (Fig. 60-8).
The spinal cord is surrounded by the meninges, dura,
arachnoid, and pia layers. Between the dura mater and the
vertebral canal is the epidural space. The spinal cord is an H-
shaped struc- ture with nerve cell bodies (gray matter)
surrounded by ascending and descending tracts (white
matter) (see Fig. 60-8). The lower portion of the H is broader
than the upper portion and corresponds to the anterior horns.
The anterior horns contain cells with bers that form the
anterior (motor) root end and are essential for the voluntary
and reex activity of the muscles they innervate. The thinner
posterior (upper horns) portion contains cells with bers that
enter over the posterior (sensory) root end and thus serve as a
relay station in the sensory/reex pathway.
The thoracic region of the spinal cord has a projection
from each side at the crossbar of the H of gray matter called the
lateral horn. It contains the cells that give rise to the autonomic
bers of the sympathetic division. The bers leave the spinal
cord through the anterior roots in the thoracic and upper
lumbar segments.
Rubrospinal
Lateral spinothalamic
Anterior corticospinal
FIGURE 60-8 Cross-sectional dia-
gram of the spinal cord showing
major spinal tracts.
Sensory and Motor Pathways: The Spinal Tracts. The
white matter of the cord is composed of myelinated and
unmyelinated nerve fibers. The fast-conducting myelinated
fibers form bundles that also contain glial cells. Fiber bundles
with a common function are called tracts. There are six
ascending tracts. Two conduct sensation, principally the
perception of touch, pressure, vibration, position, and passive
motion from the same side of the body. Before reaching the
cerebral cortex, these fibers cross to the opposite side in the
medulla. The two spinocerebellar tracts conduct sensory
impulses from muscle spindles, providing necessary input
for coordinated muscle contraction. They ascend essentially
uncrossed and terminate in the cerebellum. The last two
spinothalamic tracts are responsible for conduction of pain,
temperature, proprioception, fine touch, and vibratory sense
from the upper body to the brain. They ascend, cross to the
opposite side of the brain, and terminate in the thalamus
(Hickey, 2003).
There are eight descending tracts, seven of which are
engaged in motor function. The two corticospinal tracts
conduct motor impulses to the anterior horn cells from the
opposite side of the brain and control voluntary muscle
activity. The three vestibulospinal tracts descend uncrossed
and are involved in some autonomic functions (sweating,
pupil dilation, and circulation) and involuntary muscle control.
The corticobulbar tract conducts impulses responsible for
voluntary head and facial muscle movement and crosses at the
level of the brain stem. The rubrospinal and reticulospinal
tracts conduct impulses involved with invol- untary muscle
movement.
Vertebral Column. The bones of the vertebral column surround
and protect the spinal cord and normally consist of 7
cervical,
12 thoracic, and 5 lumber vertebrae, as well as the sacrum
(a fused mass of ve vertebrae), and terminate in the coccyx.
Nerve roots exit from the vertebral column through the
intervertebral foramina (openings). The vertebrae are
separated by disks, except for the rst and second cervical, the
sacral, and the coccygeal vertebrae. Each vertebra has a ventral
solid body and a dorsal seg- ment or arch, which is posterior
to the body. The arch is composed of two pedicles and
two laminae supporting seven processes. The vertebral body,
arch, pedicles, and laminae all en- case the vertebral canal.
Fasciculus gracilis
White matter
Fasciculus cuneatus
Posterior spinocerebellar
Lateral corticospinal
Anterior spinocerebellar
Tectospinal
Anterior spinothalamic Vestibulospinal
Descending fibers Ascending fibers Gray matter
1828 Unit 14 NEUROLOGIC FUNCTION

The Peripheral Nervous System

The peripheral nervous system includes the cranial nerves, the Table 60-2 Cranial Nerves
spinal nerves, and the autonomic nervous system.
CRANIAL NERVE TYPE FUNCTION

CRANIAL NERVES I (olfactory) Sensory Sense of smell

There II (optic) Sensory Visual acuity
surfaceare 12 pairs
of the brainofand
cranial
pass nerves
throughthat
theemerge from
foramina in the
the lower
skull. III (oculomotor) Motor Muscles that move the
Three are entirely sensory (I, II, VIII), ve are motor (III, IV, eye and lid,
VI, XI, and XII), and four are mixed (V, VII, IX, and X) as they pupillary
have both sensory and motor functions (Downey & Leigh, constriction, lens
1998; Hickey, 2003). The cranial nerves are numbered in the IV (trochlear) Motor accommodation
V Mixed Muscles that move the eye
order in which they arise from the brain. For example, cranial
(trigeminal) Facial sensation, corneal
nerves I and II attach in the cerebral hemispheres, whereas Motor reex, mastication
cranial nerves IX, X, XI, and XII attach at the medulla (Fig. VI (abducens) Mixed Muscles that move the eye
60-9). Most cranial nerves innervate the head, neck, and VII (facial) Facial expression and muscle
special sense structures. Table 60-2 lists the names and movement, salivation and
primary functions of the cranial nerves. tearing, taste, sensation in
Sensory the ear
SPINAL NERVES VIII (acoustic) Mixed Hearing and equilibrium
IX (glossopharyngeal) Taste, sensation in pharynx
The spinal cord is composed of 31 pairs of spinal nerves: 8 muscles
and tongue, pharyngeal
cervi
cal, 12 thoracic, 5 lumbar, 5 sacral, and 1 coccygeal. Each X (vagus) Mixed Muscles of pharynx,
spinal nerve has a ventral root and a dorsal root (Fig. 60-10). larynx, and soft palate;
- The dorsal roots are sensory and transmit sensory impulses sensation in external ear,
from specic areas of the body known as dermatomes (Fig. 60-11) pharynx,
larynx, thoracic and
to the dorsal ganglia. The sensory ber may be somatic, carrying abdominal viscera;
information about pain, temperature, touch, and position sense parasympathetic inner-

(proprioception) from the tendons, joints, and body surfaces; vation of thoracic and
or visceral, carrying information from the internal organs. abdominal organs
The ventral roots are motor and transmit impulses from the XI (spinal accessory) Motor Sternocleidomastoid and
spinal cord to the body. These bers are also either somatic or trapezius muscles
vis- ceral. The visceral bers include autonomic bers that XII (hypoglossal) Motor Movement of the tongue
control the cardiac muscles and glandular secretions.

AUTONOMIC NERVOUS SYSTEM
The autonomic nervous system regulates the activities of inter-
nal organs such as the heart, lungs, blood vessels, digestive
organs, and glands. Maintenance and restoration of internal
homeostasis is largely the responsibility of the autonomic
nervous system. There are two major divisions: the
sympathetic nervous system,
with predominantly excitatory responses, most notably the ght
or ight response, and the parasympathetic nervous
system, which controls mostly visceral functions.
The autonomic nervous system innervates most body
organs. Although usually considered part of the peripheral
nervous system, it is regulated by centers in the spinal cord,
brain stem, and

Name Location
Optic II
Cerebral hemisphere
Olfactory I

Oculomotor III
Midbrain
Trochlear IV
Trigeminal V
Abducens VI
Facial VII Pons
Acoustic VIII
Glossopharyngeal IX
Vagus X
Hypoglossal XII Medulla
FIGURE 60-9 Diagram of the base of the
Spinal accessory XI brain showing entrance or exit of the cranial
nerves. The right column shows the anatomic
location of the connection of each cranial nerve
to the central ner- vous system.