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CHAPTER 6 The Nervous System
161
forehead is spared, as evidenced by wrinkling caused by
the action of frontalis. Also, a patient with a unilateral
supranuclear lesion will be able to close the eye on that
side.
VIII Vestibulocochlear (Auditory) Nerve
• Consists of two sets of bres: cochlear and vestibular.
• e nerve emerges from the brain at the cerebellopontine angle and leaves the cranium via the internal auditory meatus with the facial nerve.
• Enters internal auditory meatus with the facial nerve.
• Cochlear bres subserve hearing.
• Vestibular bres subserve equilibrium.
• Cochlear:
• cerebral processes of bipolar spiral ganglion cells of
cochlea
• pass through internal auditory meatus to reach lat-
eral aspect of medulla (at cerebellopontine angle
with cranial nerve VII)
• terminate in dorsal and ventral cochlear nuclei.
• Vestibular:
• to utricle, saccule and semicircular canals
• cells originate in the vestibular ganglion
• bres enter the medulla just medial to the cochlear
division, and terminate in the vestibular nuclei in the
oor of the fourth ventricle
• vestibular connections with cranial nerves III, IV, V
and XI, and upper cervical cord via vestibulospinal
tract bring eye and neck muscles under reex vestibular control.
Clinical Points
• Temporal lobe tumours may give rise to auditory hallucinations if they encroach upon the auditory gyrus.
• Unilateral lesions of the auditory pathway do not greatly
aect hearing because of the bilateral nature of the auditory projections (unless the cochlea itself is damaged).
• Lesions of the cochlear division result in deafness,
which may or may not be accompanied by tinnitus.
• e dierential diagnosis between middle ear and inner
ear deafness (cochlear or auditory nerve lesions) may
be made clinically by using a tuning fork. Air conduction with the fork being held next to the ear is normally
louder than bone conduction (the fork being held on
the mastoid process). If the middle ear is damaged, then
the reverse will be true.
IX Glossopharyngeal Nerve
e glossopharyngeal nerve:
• has sensory bres, including taste from the posterior
third of the tongue and the oropharynx (tonsillar fossa)
• supplies stylopharyngeus
• has parasympathetic bres supplying the parotid gland
• innervates the carotid sinus and carotid body.
e glossopharyngeal nerve has the following nuclei in the
medulla:
• nucleus ambiguus: bres to stylopharyngeus; also innervates the muscles of the pharynx, larynx and so palate
via the vagus nerve
• inferior salivatory nucleus, supplying the parotid gland
• nucleus of tractus solitarius, which receives taste bres
via the glossopharyngeal nerve
• dorsal motor nucleus of vagus (shared with vagus) for
general sensation from the posterior third of the tongue
and oropharynx.
e course of the glossopharyngeal nerve is as follows:
• emerges on brainstem between olive and inferior cerebellar peduncle
• passes forwards and laterally to leave skull through jugular foramen
• emerges from foramen, giving o tympanic branch
(supplying middle ear), which continues as lesser supercial petrosal nerve carrying parasympathetic bres to
the otic ganglion to supply parotid gland
• in upper part of neck accompanies stylopharyngeus
(which it supplies) to enter pharynx, passing between
the middle and superior constrictor muscles of the
pharynx
• terminal branches supply the posterior third of the
tongue and oropharynx.
Clinical Points
• Complete section of the nerve results in sensory loss in
the pharynx, loss of taste and common sensation over
the posterior third of the tongue, and loss of salivation
from the parotid gland.
• Isolated lesions of the glossopharyngeal nerve are rare.
X Vagus Nerve
• Contains sensory bres:
• mucosa of pharynx and larynx
• those transmitting visceral sensation from organs in
the thorax and abdomen
• bres carrying general sensation from dura, part of
external auditory meatus, external surface of tympanic membrane; taste bres from epiglottis.
• Contains preganglionic parasympathetic bres to all
thoracic and abdominal viscera (up to splenic exure of
colon).
• Cranial part of accessory nerve is also distributed with
vagus.
• Nuclei associated with vagus in brainstem:
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SECTION I Anatomy
• dorsal nucleus of vagus in oor of fourth ventricle
in medulla; receives general visceral sensation from
various organs supplied by vagus; its motor component gives rise to preganglionic parasympathetic
bres in vagus
• nucleus of tractus solitarius, shared with facial nerve
and glossopharyngeal nerve for taste bres
• nucleus ambiguus: origins of bres of cranial part
of accessory nerve which are distributed along with
vagus.
• Emerges on brainstem in groove between olive and inferior cerebellar peduncle, below roots of glossopharyngeal nerve.
• Passes through jugular foramen.
• Bears two ganglia: in foramen (superior) and just below
foramen (inferior).
• Joined by cranial part of accessory nerve.
• Branches and distribution:
• meningeal: supplies dura of posterior cranial fossa
• auricular: supplies medial aspect of auricle (small
area), external auditory meatus and outer surface of
tympanic membrane
• pharyngeal: supplies muscles of so palate and pharynx
• superior laryngeal: divides into external laryn-
geal branch to cricothyroid, and internal laryngeal
branch supplying sensation to the laryngeal pharynx
and the laryngeal mucosa above the level of the vocal
cord
• recurrent laryngeal nerve
• cardiac branches
• pulmonary branches
• branches to abdominal viscera.
Clinical Points
• Isolated lesions of the vagus nerve are uncommon.
• Injuries to the recurrent laryngeal nerve are discussed
under the section on larynx.
XI Accessory Nerve
• Small cranial root and larger spinal root.
• Cranial part arises from the nucleus ambiguus and
emerges with bres of vagus from brainstem.
• Joins spinal root for short distance and then branches
o to rejoin vagus to be distributed to muscles of so
palate, pharynx and larynx.
• Spinal root arises from upper ve segments of cervical
spinal cord.
• Enters skull through foramen magnum.
• Joins cranial root.
• Leaves skull through jugular foramen.
• Immediately below jugular foramen, spinal root passes
backwards to supply sternocleidomastoid and trapezius.
Clinical Points
• Isolated lesions of the cranial root are rare.
• May be involved jointly with lesions of vagus, giving rise
to paralysis of the laryngeal and pharyngeal muscles,
resulting in dysphonia and dysphagia.
• Damage to the spinal root may occur in block dissection
of the neck and operations on the posterior triangle.
• Damage in the posterior triangle will result in inability
to shrug the shoulder and wasting of trapezius (loss of
contour of side of neck).
XII Hypoglossal Nerve
• Supplies all extrinsic and intrinsic muscles of tongue
(except palatoglossus).
• Nucleus lies in medulla in oor of fourth ventricle.
• Emerges as rootlets between pyramid and olive, which
unite to form nerve.
• Leaves skull through hypoglossal canal.
• Lies initially between internal jugular vein and internal
carotid artery.
• Crosses supercial to internal carotid artery and external carotid artery.
• Passes forwards deep to mylohyoid to supply muscles of
the tongue.
Clinical Points
• Division of the hypoglossal nerve results in ipsilateral
paralysis and wasting of the muscles of the tongue.
• On protrusion, the tongue deviates to the aected side.
• Supranuclear paralysis (owing to an upper motor neuron lesion involving the corticobulbar pathways) leads
to paralysis but not atrophy of the muscles on the contralateral side.
Relationships of the nerves emerging from the brain are
shown in Fig. 6.15.
PERIPHERAL NERVOUS SYSTEM
e peripheral nervous system is formed by the cranial and
spinal nerves carrying somatic and autonomic nerve bres.
e cranial nerves have already been described above.
e sympathetic nervous system is described later in this
chapter.
Spinal Nerves and Their Distribution (Fig. 6.7)
• Each spinal nerve is formed by the union of a dorsal and
ventral root.
• e ventral root contains motor bres with cell bodies
in the ventral horn of the spinal cord.
• e dorsal root contains sensory bres with cells of origin in the dorsal root ganglion.
CHAPTER 6 The Nervous System
Optic chiasma
Posterior perforated substance
Trigeminal nerve (sensory root)
Middle cerebellar peduncle
163
Fig. 6.15 The brainstem and cerebellum, ventral view.
• e ventral and dorsal roots lie in the vertebral canal
within the dural sac.
• Ventral and dorsal roots join together to form the spinal
nerve in the intervertebral foramen (mixed motor and
sensory and sympathetic).
• Immediately beyond the intervertebral foramen the
nerve divides into a dorsal and ventral ramus.
• e dorsal ramus passes backwards to innervate the
muscles of the back and the ligaments and joints of the
vertebral column. ey also supply cutaneous branches
to the skin of the posterior aspect of the head, trunk and
gluteal region (dorsal rami of C1, L4, L5 have no cutaneous branches).
• Ventral rami in the thoracic region form the intercostal
nerves.
• e lower six intercostal nerves extend onto the anterior
abdominal wall to innervate the muscles and overlying
skin in segmental fashion.
Spinal Nerves
ere are 31 pairs of spinal nerves:
• eight cervical
• twelve thoracic
• ve lumbar
• ve sacral
• one coccygeal.
Oculomotor nerve
Trochlear nerve
Pons
Nervus intermedius
Facial nerve
Vagus nerve
Accessory nerve
Cerebellum
Optic tract
Optic nerve
Anterior perforated substance
Mamillary body
Trigeminal nerve (motor root)
Abducens nerve
Vestibulocochlear nerve
Hypoglossal nerve
Olive
Pyramid
e rst cervical nerve lies above the rst cervical vertebra,
but since there are eight nerves and only seven cervical
vertebra, the eighth nerve lies below the seventh cervical
vertebra, and from here down each nerve lies below the
vertebra of the corresponding number.
• e remaining spinal nerves supply the head and neck
and limbs, and are dealt with in detail in the appropriate
sections.
• At cervical, lumbar and sacral levels the ventral rami
form a plexus:
• cervical plexus: C1–4
• brachial plexus: C5–8, T1
• lumbar plexus L1–4, with contribution from T12
• sacral plexus S1–5, with contribution from L4, 5.
Cervical Plexus
• C1–4 ventral rami.
• Motor to:
• prevertebral muscles
• levator scapulae
• scalene muscles
• sternocleidomastoid and trapezius via accessory nerve
• diaphragm.
• Sensory to:
• skin of anterior and lateral neck
• shoulder
164
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SECTION I Anatomy
• lower jaw
• external ear.
Brachial Plexus
• C5–8 ventral rami, T1 (part).
• Motor to muscles and joints of upper limb.
• Sensory to skin of upper limb.
Lumbar Plexus
• L1–4 ventral rami plus T12 (part).
• Supplies muscles and skin of thigh through obturator
and femoral nerve.
• Small nerves from plexus innervate muscles of lower
part of abdominal wall, skin of foot, lateral part of hip
and external genitalia.
Sacral Plexus
• Ventral rami S1–5 and contribution of ventral rami L4–5.
• Innervate muscles and skin of lower limb, pelvic oor
and perineum.
UPPER AND LOWER MOTOR NEURONS
• Upper motor neuron commences in the motor cortex.
• Groups of cells control movements rather than individual muscles.
• Upper motor neurons synapse with anterior horn cells
in the spinal cord.
• Lower motor neurons are from the anterior horn cells
and end in voluntary muscle.
• Peripheral nerves contain motor and sensory bres.
• Lesions of anterior horn cells and ventral nerve roots
will be entirely motor. Lesions of peripheral nerves will
be mixed motor and sensory.
• Lower motor neuron is inuenced by upper motor neuron and by extrapyramidal system; modications of
muscle tone and reexes result when correct balance
between these neurons is lost.
• e clinical distinction between upper and lower motor
neuron lesions is shown in Box 6.2.
Dermatomes
• The skin of the trunk is supplied segmentally by the
intercostal nerves. In the limbs a similar segmental
supply is furnished by the cutaneous nerves. The
area of skin supplied by one spinal nerve is called a
dermatome. Dermatomes of the body are shown in
Fig. 6.16.
Motor Root Values and Peripheral Nerve Supply
of Important Muscle Groups
ese are shown in Table 6.1.
BOX 6.2 Distinction Between Upper and
Lower Motor Neuron Lesion
Upper Lower
Paralysis affects movements
rather than muscle
Wasting slight Wasting pronounced
Muscles hypertonic (clasp-
knife rigidity)
Tendon reflexes increased Tendon reflexes
No trophic skin changes Skin often cold, blue
Superficial reflexes
diminished:
• absent abdominal
reflexes
• Babinski sign present
(both are corticospinal
reflexes in which the
afferent arc is via a small
number of ascending fibres
in the corticospinal tracts)
Individual or groups of
muscles affected
Muscles hypotonic
(flaccidity)
absent or diminished
and shiny
Superficial reflexes
unaltered unless
sensation also lost
Tendon and Abdominal Reflexes
ese are shown in Table 6.2.
AUTONOMIC NERVOUS SYSTEM
• e autonomic nervous system consists of two separate
parts:
• sympathetic nervous system
• parasympathetic nervous system.
Sympathetic Nervous System
The patterns of distribution of the sympathetic nerve
fibres are shown in Fig. 6.17. The sympathetic nervous
system:
• plays a major role in regulating the internal environment of the body
• is concerned with stress reactions of the body
• when stimulated, the following occur:
• sweating
• pupillary dilatation
• vasoconstriction
• bronchial dilatation
• diminished peristalsis
• increased heart rate.
CHAPTER 6 The Nervous System
C8
C7
L5
S3
C2
C3
165
C3
C4
T2
T3
C5
T2
T1
C6
L5
Fig. 6.16 The dermatomes of the body.
C5
T2
T4
T9
L1
L2
L3
L4
S1
S5
S4
S3
C4
T12
L1
L2
S2
L3
L4
L5
S1
Origin of Sympathetic Outflow
• Preganglionic eerent bres lie in the lateral horn of
grey matter of T1–L2.
• The pattern of sympathetic outflow is shown in
Table 6.3.
• end by synapsing in the corresponding ganglion of
the sympathetic chain
• enter the chain and travel various distances up and
down before synapsing at a ganglion
• enter the chain and leave without synapsing as
splanchnic nerves to synapse in coeliac, aortic or
Sympathetic Trunk
• Ganglionated chain.
• Lies on either side of vertebral bodies about 2.5 cm from
the midline.
• Extends from base of skull to coccyx.
• Ganglia are associated with each spinal segment except
in the neck, where there are only three ganglia.
pelvic ganglia, associated with the corresponding
autonomic plexuses in the abdomen.
• Synapses in the ganglionic neurons provide amplication and facilitate widespread reaction on stimulation.
• Unmyelinated postganglionic axons may also take one
of a number of routes:
• some leave in the grey rami communicantes, which
join the spinal nerve for distribution to skin and
Distribution of Preganglionic and Postganglionic Fibres
• Myelinated preganglionic bres from T1–L2 segments
of the spinal cord, which leave the corresponding spinal nerves through white rami communicantes, have a
number of possible destinations:
blood vessels
• some leave to form plexuses around arteries
• cardiac nerves are postganglionic bres from the cervical
and upper thoracic ganglia, which innervate the thoracic
viscera through the cardiac and pulmonary plexuses.
166
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SECTION I Anatomy
TABLE 6.1 Motor Root Values and Peripheral Nerve Supply of Important Muscle Groups
Joint Movement Muscle Root Value Peripheral Nerve
Shoulder
Abduction Deltoid C4, 5 Axillary
External rotation Infraspinatus C4, 5 Suprascapular
Adduction Pectoralis/latissimus dorsi C6–8 Medial and lateral pectoral
Elbow
Flexion Biceps C5, 6 Musculocutaneous
Extension Triceps C7, 8 Radial
Pronation C6, 7
Supination Biceps/ C5, 6 Musculocutaneous
brachioradialis C6 Radial
Wrist
Flexion Flexor muscles of forearm C7, 8 Median and ulnar
Dorsiflexion Extensor muscles of forearm C7 Radial
Finger
Flexion Long finger flexors C8 Median and ulnar
Extension Long finger extensors C7 Radial
Opposition of thumb or
splaying of fingers
Small hand muscles T1 Ulnar
Hips
Flexion Iliopsoas L1–3 –
Extension Glutei L5, S1 Sciatic
Adduction Adductors L2, 3 Obturator
Abduction Glutei and tensor fasciae latae L4, 5, S1 Sciatic
Knee
Flexion Hamstrings L5, S1, 2 Sciatic
Extension Quadriceps L3, 4 Femoral
Ankle
Dorsiflexion Anterior tibial L4, 5 Sciatic (common peroneal)
Plantarflexion Calf (gastrocnemius and soleus) S1, 2 Sciatic (tibial)
Eversion Peronei L5, S1 Sciatic (common peroneal)
Inversion Anterior tibial and posterior tibial L4 Sciatic (common peroneal)
L4, 5 Sciatic (tibial)
Toes
Flexion Flexor hallucis longus S2, 3 Sciatic (tibial)
Extension Extensor hallucis longus L5, S1 Sciatic (common peroneal)
Note: All muscles on back of upper limb (triceps, wrist and finger extensors) are innervated by C7.
From Easterbrook P Basic Medical Sciences for MRCP Part 1, 2nd edn Churchill Livingstone 1999, with permission.
CHAPTER 6 The Nervous System
Collateral ganglion
Sweat gland
Sympathetic fibres
167
TABLE 6.2 Tendon and Abdominal
Reflexes
Reflex Muscle Root Value
Knee Quadriceps L3, 4
Ankle Gastrocnemius S1
Biceps Biceps C5, 6
Triceps Triceps C7
Supinator Brachioradialis C6
Abdominal Abdominal muscle T8–12
Cremasteric Cremaster L1, 2
Anal Anal sphincter S3, 4
Head and Neck
• Superior cervical ganglion (C2–4).
• Middle cervical ganglion (C5–6).
• Inferior cervical ganglion (fused with rst thoracic ganglion) to form stellate ganglion (C7, 8, T1).
• Preganglionic bres arise from T1–2 segments of cord
and relay in superior cervical ganglion.
• Supply head and neck, ciliary muscle, iris, blood vessels
and sweat glands.
• Division of head and neck supply results in Horner’s
syndrome, i.e. miosis, ptosis, anhidrosis, on side of
lesion.
Sympathetic afferent fibres
Preganglionic
fibres
Ganglia of
sympathetic chain
Gut
Cutaneous
blood vessel
Fig. 6.17 The patterns of distribution of the sympathetic fibres.
on large blood
vessels
Skin
168
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SECTION I Anatomy
TABLE 6.3 Sympathetic Outflow (T1–L2)
Spinal
Segments
T1–2 Via internal carotid
T1–4 Via cardiac and
T2–7 Upper limb
T4–L2 Via coeliac,
T11–L2 Lower limb
T1–4: relay in sympathetic ganglion.
T4–L2: do not relay in sympathetic ganglion.
From Easterbrook P Basic Medical Sciences for MRCP Part 1,
2nd edn Churchill Livingstone 1999, with permission.
Sympathetic
Innervation Destination
Head and neck
and vertebral
arteries
pulmonary plexuses
mesenteric,
hypogastric and
pelvic plexuses
Ciliary muscle
and iris
Blood vessels
Sweat glands
Heart and
bronchi
Adrenal
medulla
Alimentary
tract
Colon and
rectum
Bladder and
genitalia
Upper Limb
• Preganglionic bres arise from T2–7 segments.
• Postganglionic bres from middle cervical and stellate
ganglion are distributed to limb mainly through the brachial plexus.
• Control of palmar hyperhidrosis and vasospastic disorders can be achieved by removing second and third
thoracic ganglia (the rst is not removed as this would
cause Horner’s syndrome).
Lower Limb
• Preganglionic bres from T12–L2 spinal segments synapse in lumbar and sacral ganglia.
• Postganglionic bres are distributed to the limb via
lumbosacral plexus.
• Lumbar sympathectomy (for plantar hyperhidrosis or
vasospastic diseases) removes third and fourth lumbar
ganglia and intervening chain.
• First lumbar ganglion is preserved to avoid compromising ejaculation.
Abdominal and Pelvic Viscera
• ese receive sympathetic innervation via:
• coeliac plexus
• aortic plexus
• hypogastric plexus.
• Coeliac plexus lies around coeliac axis.
• Continues downwards over abdominal aorta as aortic
plexus.
• Hypogastric plexus lies in front of h lumbar vertebra
as continuation of aortic plexus.
• Plexuses supply gastrointestinal tract, bladder and genitalia.
• Hypogastric and aortic plexuses may be damaged in
aortic aneurysm surgery and extensive pelvic surgery,
e.g. anterior resection of the rectum: ejaculation may be
compromised.
Parasympathetic Nervous System
• Craniosacral outow.
• Oen antagonizes sympathetic nervous system.
• Supply limited to viscera and glands; no distribution to
skin and skeletal muscle.
• e distribution of the parasympathetic nervous system
may be summarized as follows:
• oculomotor nerve supplying sphincter pupillae and
ciliary muscles in the eye
• facial nerve supplying the lacrimal, submandibular
and sublingual glands as well as glands in the nasal
cavity and mucosa of the palate
• glossopharyngeal nerve supplying the parotid gland
• vagus nerve supplying thoracic and abdominal vis-
cera up to the le colic exure
• S2–4 sacral nerves supplying the pelvic viscera and
descending and sigmoid colon.
ere are four ganglia associated with the parasympathetic
nervous system in the head and neck. ese are:
• Ciliary ganglion in orbit:
• site of synapse of preganglionic bres accompanying
oculomotor nerve
• postganglionic bres supply ciliary muscles and constrictor pupillae.
• e sphenopalatine ganglion in the pterygopalatine fossa:
• site of synapse of preganglionic bres accompanying
facial nerve
• postganglionic bres supply lacrimal glands and
glands in nasal cavity and palate.
• Submandibular ganglion attached to lingual nerve:
• site where preganglionic bres accompanying facial
nerve and chorda tympani synapse
• postganglionic bres supply submandibular and
sublingual glands, and glands in tongue and oor of
mouth.
• Otic ganglion attached to trunk of mandibular nerve in
infratemporal fossa:
• site of synapse of preganglionic bres accompanying
the glossopharyngeal nerve
• postganglionic bres supply parotid gland.
OSCE SCENARIOS
CHAPTER 6 The Nervous System
169
OSCE Scenario 6.1
An 18-year-old male is assaulted at a party. He is struck on
the le temporal region with a bottle. He briey loses consciousness. He is taken to hospital where on examination
his GCS (Glasgow Coma Scale) is 15. Four hours following
admission, he suddenly deteriorates with a GCS of 8 and
his le pupil dilates.
1. What is the most likely diagnosis?
2. What is the explanation for the ‘lucid’ interval?
3. What is the anatomical basis for the le pupillary
dilatation?
4. Where would you locate the middle meningeal artery
for the purpose of making a burr hole?
5. What layers of the scalp would you encounter in your
incision?
OSCE Scenario 6.2
A 55-year-old male presents with low back pain, bilateral
sciatica, numbness over the buttock area and weakness in
the lower limbs. He has also developed diculty in passing
urine. Examination reveals reduced lower limb reexes and
loss of anal tone and sensation.
1. What is the most likely diagnosis?
2. At what level does the spinal cord end in the adult?
3. Describe the level and type of disc lesion that is likely to
cause the symptoms.
4. Describe the anatomy of an intervertebral disc.
5. Explain the anatomical basis of bladder and bowel
dysfunction.
6. What investigation would you carry out to conrm the
diagnosis and what action would you take if the diagnosis was conrmed?
3. Describe the characteristic clinical picture of cavernous
sinus thrombosis.
OSCE 6.4
A 75-year-old male has been referred to you by the Accident
and Emergency department for a possible stroke. His main
symptom is le arm and leg weakness.
1. Which hemisphere has suered a stroke?
2. If the patient had suered le-sided amaurosis fugax,
which hemisphere would have been aected?
3. e patient is right-handed and has had dysphasia
only. Which hemisphere is the most likely to have been
aected and why?
OSCE 6.5
A 70-year-old non-smoking female presents with a hoarse
voice. A CT angiogram is shown below (Figs. 6.5Q).
1. What is the diagnosis?
2. What are the treatment options?
3. What is the anatomical explanation for the hoarse voice?
OSCE Scenario 6.3
A 55-year-old insulin-dependent diabetic develops a boil
on the right upper lip. She does not seek treatment. A few
days later she develops a severe headache and redness and
swelling around the right orbit. A diagnosis of cavernous
sinus thrombosis is made.
1. Describe the anatomy of the cavernous sinus.
Fig. 6.5Q CT angiogram of the thoracic aorta.
2. Why does cavernous sinus thrombosis develop follow-
ing an infection on the upper lip?
Answers in Appendix pages 442–444
Please check your eBook at https://studentconsult.inkling.com/ for more self-assessment questions. See inside cover for
registration details.
SECTION II
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Physiology
7. General Physiology, 171
8. Respiratory System, 186
9. Cardiovascular System, 204
10. Gastrointestinal System, 214
11. Urinary System, 232
12. Endocrine System, 240
13. Nervous and Locomotor Systems, 259
170
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