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2020_ME
The Nervous System
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The Nervous System
BASIC SCIENCE AND CLINICAL CONDITIONS
third edition
Adina T. Michael- Titus
Professor of Neuroscience
Centre for Neuroscience, Surgery and Trauma
Blizard Institute
Barts and The London School of Medicine and Dentistry
Queen Mary University of London
London, UK
Peter J. Shortland
Discipline Lead for Medical Science
Associate Professor of Human Anatomy
Western Sydney University
School of Science,
Penrith, New South Wales, Australia
Series Editor
Stephen Hughes BSc,
MSc, MBBS, FRCSEd,
FRCEM, FHEA
Consultant in Emergency Medicine, Broomfield Hospital
Senior Lecturer in Medicine, School of Medicine,
Anglia Ruskin University
Chelmsford, UK
For additional online content visit ExpertConsult.com
© 2023, Elsevier Limited. All rights reserved.
First edition 2003
Second edition 2010
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s
permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the
Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions
This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).
Notices
Practitioners and researchers must always rely on their own experience and knowledge in evaluating
and using any information, methods, compounds or experiments described herein. Because of rapid
advances in the medical sciences, in particular, independent verication of diagnoses and drug dosages
should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or contributors for any injury and/or damage to persons or property as a matter of products liability,
negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas
contained in the material herein.
ISBN: 978-0-7020-8340-2
Publisher: Jeremy Bowes
Content Project Manager: Fariha Nadeem
Design: Margaret Reid
Illustration Manager: Anitha Rajarathnam
Marketing Manager: Deborah Watkins
Copyedited by Editage, a unit of Cactus Communications Services Pte. Ltd.
Typeset by TNQ Technologies Pvt. Ltd.
Printed in Poland
Last digit is the print number: 9 8 7 6 5 4 3 2 1
ACKNOWLEDGEMENTS
We would like to express our thanks to the various people who have supported us throughout the writing of
this book, in particular during the production of the third
edition.
Michael Parkinson encouraged us to write this vol-
ume. Very special thanks go to Fariha Nadeem and
Jeremy Bowes who helped us, cajoled us and kept us
on track, so that the work could be completed. Special
thanks are due to our clinical colleague, Dr Stephen
Hughes, who reviewed all the updated material and provided important comments on each chapter.
SERIES EDITOR FOREWORD
Most students now study medicine through a form of
inte grated curriculum. These courses blend basic science
with exposure to clinical medicine from an early stage.
These students have the good fortune to be left in no
doubt, from the outset, why they are studying medicine.
I teach in a medical school that delivers a fully integrated
curriculum and I can compare it with the traditional
model according to which I received my early medical
education. That com parison is very favourable.
Unlike many other texts, the Systems of the Body series
has been designed very specifically to sup port an integrated approach to learning medicine. Our carefully
selected panel of authors drawn from across the Englishspeaking world have combined basic sci ence with
clinical application. Links to clinical skills, clinical investigation and therapeutics are made clear throughout.
The aim is to offer highly accessible guidance for all
student types and stages. It will be invaluable to those
who are approaching the subject for the first time or
who may have found a topic challenging when using
other more traditionally configured resources – as well as
greatly assist all students wishing to excel as their course
progresses. The clear layout and writing style, together
with detail that informs without overwhelming, go a
long way to supporting students. It may also provide
welcome reminders to postgraduates facing their own
examinations.
Whatever curriculum you follow, wherever you
are in the world, and whichever stage you are at, we
know that the Systems of the Body volumes will serve as
great places to start when learning something new and
enable you to effectively piece together the essential
components of each major body system, in a modern
clinical context.
Good luck!
Stephen Hughes, MSc MBBS FRCSEd FRCEM FHEA
Senior Lecturer in Medicine
Anglia Ruskin University
Chelmsford, UK
and
Consultant, Emergency Medicine
Broomfield Hospital
Chelmsford, UK
PREFACE
The diseases of the nervous system represent one of the
most important challenges in modern medicine. Medical
schools worldwide have adopted various strategies in
the teaching of neuroscience. One of the more recent
approaches combines anatomy, physiology and pharmacology in order to achieve an integrated view of the
various pathologies, through the integrated analysis of
clinical cases. The problem- based learning method in
medicine is based on this concept of integration.
This book is part of the Systems of the Body series,
which has been designed to provide a teaching tool for
medical curricula that use problem- based learning. The
aim of our book is to cover the basic science required to
understand the structure and function of the nervous
system, and its major pathologies, at a level appropriate to medical students in the first years of training. The
volume comprises two parts. The early chapters offer an
introduction to the general organization of the nervous
system and the cellular and molecular mechanisms that
govern its function. A separate chapter is devoted to the
clinical examination of the nervous system. The later
chapters, which form the main body of the book, are built
around clinical cases. The chapters start with clinical scenarios, which prompt an exploration of specific issues,
thus allowing us to introduce and discuss the knowledge
that is required for the diagnosis and treatment of the
conditions presented. To reflect the rapid pace of research
in neuroscience, the information in the third edition has
been updated throughout the text, and figures modified
as appropriate, compared to the second edition.
Our experience of teaching medical students guided
us throughout the writing of this text and we tried to
present complex concepts in an accessible and clear manner. Our wish was not only to present the facts but also
to increase the students’ awareness of the many unresolved issues in neuroscience. It is our hope, therefore,
that this book will not only assist students in the learning
process, but also stimulate their interest and enthusiasm
for the fascinating field of neuroscience.
Since the second edition of this book, we have lost
our dear colleague and co- author, Dr Patricia Revest. We
would like to dedicate this third edition to her memory.
CONTENTS
1
ORGANIZATION OF THE NERVOUS SYSTEM 1
Introduction 2
Overview of brain anatomy 3
Internal anatomy of the brain 7
Forebrain 12
Hemisphere specialization 14
Limbic system 16
Orbitofrontal cortex 18
Basal ganglia 18
Diencephalon 18
Thalamus 18
Hypothalamus 19
Peripheral nervous system 22
Putting it all together: from anatomy to behaviour 30
2
ELEMENTS OF CELLULAR AND MOLECULAR
NEUROSCIENCE 33
Introduction 34
Neurons 34
Glial cells 36
Neuron excitability 39
Postsynaptic events and postsynaptic receptors 46
Neurotransmitter synthesis 51
Neurotransmitter inactivation 51
Summation and neuronal integration 51
3
CLINICAL ASSESSMENT 53
Introduction 54
Component parts of the clinical examination 55
Other investigations 62
General comments 65
4
THE SPINAL CORD 67
Introduction 68
Gross anatomy of the spinal cord and vertebral
column 68
Functional organization of the spinal cord 69
Spinal cord cell types 72
Receptive fields 73
Somatosensory pathways 73
Blood supply to the spinal cord 80
Damage to the spinal cord 80
Comments on the case history 86
Self- assessment case study 86
5
PAIN AND ANALGESIA 89
Introduction 90
Nociceptors 92
Pain pathways 93
Visceral and muscular pain pathways 94
How does the central nervous system interpret a
stimulus as painful? 95
Physiology of pain modulation 96
Counter- stimulation analgesia 97
Supraspinal (descending) analgesia 97
Acupuncture analgesia 99
Arousal analgesia 99
Psychology of pain 100
Measuring pain 100
Pain mechanisms after tissue damage: peripheral and
central sensitization 101
Neuropathic pain mechanisms 102
Glial cells and neuropathic pain 104
Pharmacology of pain 104
Opioid receptors and ligands 107
Opioid analgesic drugs 108
Opioid antagonists 108
Pain sensitivity to opioids 110
Non- opioid analgesics 110
Other approaches to pain management 111
Neuropathic pain 111
Migraine 111
Treatment of migraine attacks 113
Preventive treatment of migraine 115
Trigeminal neuralgia 116
Pain in children and in the elderly 116
General comments on pain management 117
Self- assessment case study 118
6
CRANIAL NERVES AND THE BRAINSTEM 119
Introduction 120
Anatomical organization of cranial nerves and their
nuclei 120
Internal organization of the brainstem 121
Reticular formation 123
Blood supply to the brainstem 126
Brainstem reflexes 126
Brainstem lesions 130
Comments on the case history 132
Self- assessment case study 133