DPT (1st year)

Nervous System
The nervous system acts as a control center and has a
communication network
Three broad roles:
 It senses changes in the body and in the external
environment
 It interprets these changes
 Responds to this interpretation by initiating action in
the form of muscle contraction or gland secretion
Division of Nervous System
Central nervous system
Peripheral nervous system
12 pairs of cranial nerves
31 pairs of Spinal nerves
Posterior (dorsal) root and an Anterior root, which
unite to form the spinal nerve in inter-vertebral
foramen
Grey matter is distinguished from white matter in that it contains numerous
cell bodies and relatively few myelinated axons, while white matter contains
relatively few cell bodies and is composed chiefly of long-range myelinated
axons. The colour difference arises mainly from the whiteness of myelin.

After exit from foramine:
Dorsal rami, which innervate the muscle and skin
of the head, neck, and back.
Generally larger and more important Ventral rami,
innervate the ventral and lateral parts of structures
as well as the upper and lower extremities
Dorsal root ganglion
A dorsal root ganglion (or spinal ganglion; also
known as a posterior root ganglion) is a cluster of
neurons (a ganglion) in a dorsal root of a spinal
nerve. The cell bodies of sensory neurons known as
first-order neurons are located in the dorsal root
ganglia.
Function
Nociception
Mechanosensitive receptors (pressure sensitive high
Threshold and low T)
Anatomy and Physiology of
Peripheral Nerves
The peripheral nerves are complex structures
consisting of
nerve fibers,
connective tissue
blood vessels.
Each component responds differently to injuries and
traumas
Sensory neurons
Motor neurons
 Nerve fiber
The term nerve fiber refers to the elongated process (axon)
extending from the nerve cell body along with its myelin
sheath and Schwann cells
Axonal transport systems
Most axons of the peripheral nervous system are
surrounded by multilayered, segmented coverings known as
myelin sheaths
Schwann cells
Unmyelinated gaps called nodes of Ranvier
Schwann cells
Schwann cells are a type of glial cells of the
peripheral nervous system that help form the myelin
sheath around the nerve fibers. Myelin sheath of the
neuron. A schwann cell envelops and rotates around
the axon forming myelin sheath, now axon is
myelinated
Saltatory conduction
The conduction velocity of a myelinated nerve is

directly proportional to the diameter of the fiber, which

usually ranges from 2 to 20 µm
Larger motor fibers for skeletal muscles and large
sensory fibers carrying touch heat cold senses etc….
Smallest fibers for dull pain fibers
Nerve fibers are packed closely in fascicles which are
further arranged into bundles that make up the nerve
itself
The fascicles are the functional subunits of the nerve.
Intraneural Connective Tissue Of Peripheral
Nerves

Successive layers of connective tissue surround the

nerve fibers-called the endoneurium, perineurium ,
Epineurium to protect the fibers continuity
Nerves are extremely susceptible to stretching and
compression.
The outer most layer, the Epineurium, is located
between the fascicles and
superficially in the nerve.

This loose connective tissue layer acts as a cushion

during movements of the nerve, protecting from
external trauma and maintaining the oxygen supply
system via the epineural blood vessels.
The amount of epineural connective tissue varies
among nerves and at different levels within the same
nerve.
Where the nerves lie close to bone or pass joints, the
epineurium is often more abundant than elsewhere,
as the need for protection may be greater in these
locations.
The spinal nerve roots are devoid of both epineurium
and perineurium, and the nerve fibers in the nerve root
may therefore be more susceptible to trauma

The Perineurium is a lamellar sheath that

encompasses each fascicle.
This sheath has great mechanical strength as well as a
specific Biochemical Barrier.
Its strength is demonstrated by the fact that the
fascicles can be inflated by fluid to a pressure of
approximately 1000 mm of mercury (Hg) before the
perineurium ruptures.
The barrier function or the perineurium chemically
isolates the nerve fibers From their surroundings, thus
preserving an ionic environment of the interior of the
fascicles
The endoneurium, the connective tissue inside the
fascicles, is composed principally of fibroblasts and
collagen.
The Microvascular System Of Peripheral Nerves
The peripheral nerve is a well- vascularized structure
containing vascular networks in the epineurium, the
perineurium, and the endoneurium
The blood supply to the peripheral nerve as a whole is
provided by large vessels that approach the nerve
segmentally along its course.
Large vessels run longitudinally and frequently
anastomose with the vessels in the perineurium and
endoneurium constitute longitudinal vascular system.
When these local nutrient vessels reach the nerve, they
divide into ascending and descending branches.
Within the epineurium, constitute a longitudinal
vascular system
Oblique course through the perineurium vessels
follow oblique course

It is extremely difficult to induce complete ischemia

to a nerve by local surgical procedures.(microvascular)
 Anatomy and Physiology of
Spinal Nerve Roots
Embryological developmental stages….
Fully grown individual……….
Conus Medularis
Cauda Equina

Dorsal root
Ventral root motor axons in AHC grey matter
 during developmental stages spinal cord has same length as vertebral
column. But in fully grown individual spinal cord ends as conus medullaris
approximately at 1st lumbar vertebrae.
 Nerve root for sacral region exit from point just below thoracic region, the
nervous content of this spinal canal is only comprised of lumbosacral roots,
this lumbosacral nerve roots within the lumbar & sacral has been suggested to
resemble tail of horse called cauda equina. Motor axons of AHC lie in grey
matter in spinal cord as nerve roots leave the spinal cord from ventral side so
called ventral roots. The other type is sensory/dorsal roots(roots mainly
comprise of afferent axons & reach spinal cord at dorsal region of spinal cord.
cell bodies of sensory axons are located in swelling of caudal part of respective
nerve root called dorsal root ganglion which is located in/close proximity of
intervertebral foramin.
 
Membranous coverings of spinal nerve Roots
The axons in the endoneurium are separated from
the cerebrospinal fluid by a thin layer of connective
tissue called the Root Sheath…. Which acts as
Fluid barrier……..
2 to 5 cellular layers in the root sheath
Outer layers/proximal part of the root sheath are
similar to the Pia cells of the spinal cord
Distal part are more similar to the arachnoid cells
of the spinal cord.
The inner layers of the root sheath resemble to
perineurium of peripheral nerves.
The inner layers of the root sheath constitute a
diffusion barrier between the endoneurium of the
nerve roots and the cerebrospinal fluid, This barrier is
considered to be relatively weak and may only
prevent the passage of macromolecules.
Meninges
 The spinal cord (and brain) are protected by three layers of tissue,
called spinal meninges, that surround the canal. The dura mater is the
outermost layer, and it forms a tough protective coating. Between the
dura mater and the surrounding bone of the vertebrae is a space
called the epidural space. The epidural space is filled with 
adipose tissue, and it contains a network of blood vessels. The 
arachnoid mater is the middle protective layer. Its name comes from
the fact that the tissue has a spiderweb-like appearance. The space
between the arachnoid and the underlying pia materis called the 
subarachnoid space. The subarachnoid space contains 
cerebrospinal fluid (CSF).
The Microvascular system of
spinal nerve roots
Vascularization of the spinal cord
The segmental arteries generally divide into three
branches when approaching the Intervertebral
foramen
An anterior branch that supplies the posterior
abdominal wall and lumbar plexus.
A posterior branch that supplies the paraspinal
muscles and facet joints
An intermediate branch that supplies the
contents of the spinal canal
A branch of the intermediate branch joins the
nerve root at the level of the dorsal root ganglion
Three branches from this vessel:
one to the ventral root
One to the dorsal root
One to the vasa corona of the spinal cord
 The pia mater continues as an extension called the filum terminale,
which anchors the spinal cord to the coccyx. The cauda equina
 ("horse's tail") is the name for the collection of nerves in the vertebral
column that continue to travel through the vertebral column below
the conus medullaris. The cauda equina forms as a result of the fact
that the spinal cord stops growing in length at about age four, even
though the vertebral column continues to lengthen until adulthood.
This results in the fact that sacral spinal nerves actually originate in
the upper lumbar region.
Branches of Vasa corona of the spinal cord,
called medullary arteries
Medullary arteries run parallel to the nerve
roots………..no connection….
Medullary feeder arteries only occasionally supply
the nerve roots with blood, they have been
referred to as the extrinsic vascular system of
the Cauda Equina.
 vasa corona refers to any of the arterial anastomoses
between anterior and posterior spinal arteries
that penetrate the spinal cord. It encircles the cord and
supplies the peripheral and lateral aspect of the spinal
cord.
Medullary arteries remain 7-8 out of 128 embryological
branches & each supply more than one segment of the
spinal cord. Medullary arteries run parallel to the nerve
roots but no connections between these vessels and the
vascular network of the nerve roots exists.
The vasculature of the nerve roots is formed by
branches from the intermediate branch of the
segmental artery distally and by branches from
the vasa corona of the spinal cord proximally.
As opposed to the medullary arteries, this
vascular network has been named the intrinsic
vascular system of the Cauda Equina
Arteries of the intrinsic system send branches
down to the deeper parts of the nerve tissue in a T
like manner.
.The arterioles within the cauda equina may be referred to either the
extrinsic (1) or the intrinsic (2) vascular system. From the superficial
intrinsic arterioles are branches that continue almost at right angles down
between the fascicles. These vessels often run in a spiraling course, thus
forming vascular "coils" (3).
When reaching a specific fascicle they
branch in a T-like manner, with one
branch running cranially and one
caudally, forming interfascicular arterioles (2b).
From these interfascicular arterioles are
small branches that enter the fascicles,
where they supply the endoneurial
capillary networks (2c).
Arterioles of the extrinsic vascular
system run outside the spinal dura (4)
and have no connections with the intrinsic system by local vascular
branches. The superficial intrinsic arterioles (2a) are located within the
root sheath (5).
Barrier of the endoneurial capillaries in peripheral
nerves called the Blood-nerve barrier, which is
similar to the blood-brain barrier of the central
nervous system

but barrier is in still question if present then, why

is Edema formed more easily in nerve roots
 Blood supply of floor sheath
Blood supply► Anterior spinal► 2 Posterior spinal
arteries► Arteria vasa corona
15. ► Main source of blood is the Vertebral arteries……
cervical► Radicular arteries…….spinal br. of vertebral,
asc cervical, deep cervical, intercostal, lumbar and sacral
art► Arteria radicularis magna a.k.a (largest anterior
segmental medullary artery).
16. DISTRIBUTION OF BLOOD SUPPLY► Radicular
art : grey & white matter► Anterior spinal : ant two-
third ventral grey matter,part of dorsal grey matter,ant
and lat funiculi► Posterior spinal : post one-third
posterior horn and posterior funiculus
Biomechanical Behavior of Peripheral Nerves
External trauma to the extremities and nerve
entrapment
There may be changes in nerve structure and
function if mechanical trauma exceeds a certain
degree.
Common modes of nerve injury are stretching and
compression caused by rapid extension and crushing.
Stretching (Tensile) Injuries Of
Peripheral Nerves
The maximal load that can be Sustained by the
median and ulnar nerves is in the range of 70 to 220
Newton (N) and 60 to 150 N, respectively.
Initially: low load  significant elongation
Elastic/linear region
Disruption of endoneurial tubes & perineurium 
rupture
Elongation of the nerve under a very small load is
followed by an interval in which stress and elongation
show a linear relationship
As the limit of the linear region is approached, the
nerve fibers start to rupture inside the endoneurial
tubes and inside the intact perineurium.
The perineurial sheaths rupture at approximately 25 to
30% elongation
Stretching, or tensile, injuries of peripheral nerves are
usually associated with severe accidents
Partial or total functional loss of some or all of the
nerves in the upper extremity, and the consequent
functional deficits
The outcome depends on which tissue components of
the nerves are damaged as well as on the extent of the
tissue injury.
High-energy plexus injuries represent an extreme
type of stretching lesion caused by sudden violent
trauma

Suturing of the two ends under moderate

tension………………….. The moderate, gradual tension
applied to the nerve in these cases may stretch and
angulate local feeding vessels.
Complete cessation of all blood flow in the nerve
usually occurs at approximately 15% elongation
Schematic representation of a peripheral nerve and its blood supply at
three stages during stretching.
Stage III: 15% elongation
Compression Injuries Of
Peripheral Nerves
Compression of a nerve can induce symptoms such
as numbness, pain, and muscle weakness.
Pressure level and mode of compression
Critical Pressure Levels
At 30 mm Hg of local compression, functional changes
may occur in the nerve, and its viability may be
jeopardized during prolonged compression (4 to 6
hours) at this pressure level..(impaired blood flow.)
Corresponding pressure levels (approximately 32 mm
Hg) were recorded close to the median nerve in the
carpal tunnel in patients with carpal tunnel
syndrome
Axonal transport system
Axonal transport, also called axoplasmic
transport or axoplasmic flow, is a cellular process
responsible for movement of mitochondria, lipids,
synaptic vesicles, proteins, and other organelles to
and from a neuron's cell body, through the cytoplasm
of its axon called the axoplasm
Changes in the axonal transport systems, and long-
standing compression may thus lead to depletion of
axonally transported proteins distal to the compression
site
Such blockage cause axon More susceptible to
additional compression distally the so-called double
crush syndrome.
Slightly higher pressure (80 mm Hg, for example)
causes complete cessation of Intraneural blood flow; the
nerve in the locally compressed segment becomes
completely ischemic
Magnitude of the applied pressure and the severity
of the induced compression lesion appear to be
correlated.
Mode of Pressure Application
Mode of pressure application is also of major
significance
Direct compression of a nerve at 400 mm Hg by means
of a small inflatable cuff around the nerve induces a
more severe nerve injury than does indirect
compression of the nerve at 1000 mm Hg via a
tourniquet applied around the extremity.
Mechanical Aspects of Nerve Compression
Experiments on baboon's nerve by tourniqet
compression.
“Edge effect” that is a specific lesion was induced in the
nerve fibers at both edges of the compressed nerve
segment
Nodes of Ranvier were displaced toward the non
compressed parts of the nerve.
Nerve fibers in center not effected.
 Large diameter nerve fibers were usually affected, but
the thinner fibers were spared.(In center hydrostatic
pressure is high so that spares the nerve fibers.)
Compression lesion of a nerve first affects the large
fibers carrying motor function while the thin fibers
carrying pain sensation) are often preserved
Intraneural blood vessels have also been shown to be
injured at the edges of the compressed segment
Consequences of the pressure gradient= higher at the
edges

Effect of a given pressure depends on the way in which it is

applied, its magnitude and duration.
Two basic types of pressure applications
Uniform pressure applied around the entire circumference
of a longitudinal segment or a nerve or extremity.
Radial pressure that is applied by the common pneumatic
tourniquet. Example : carpal tunnel syndrome
2nd experiment= Nerve is compressed laterally
When a nerve or extremity is placed between two parallel
flat rigid surfaces that moved toward each other
squeezing the nerve or extremity
Example: sudden blow by a rigid object squeezes a nerve
against the surface of an underlying bone
Duration of Pressure Versus Pressure Level
Mechanical factors are relatively more important at
higher than at lower pressures.
Ischemia plays a dominant role in longer duration
compression.
Time factors most imp………………….
Compression at 400 mm Hg causes a much more severe
nerve injury after 2 hours than after 15 minutes.
Indicate-------------High pressure has to act for a
certain period of time for injury to occur.
Biomechanical Behavior of
Spinal Nerve Roots
The nerve roots in the thecal sac lack epineurium and
perineurium, but under tensile loading they exhibit
both elasticity and tensile strength. The thecal sac or dural sac is the
membranous sheath (theca) or tube of dura mater that surrounds the spinal cord and the
cauda equina. The thecal sac contains the cerebrospinal fluid which provides nutrients and
buoyancy to the spinal cord
Ultimate load for ventral spinal nerve roots from the
thecal sac is between 2 and 22 N
For dorsal root is 5-33 N
The values of ultimate load are approximately five
times higher for the foraminal segment of the spinal
nerve roots than for the intrathecal portion of the same
nerve roots under tensile loading.
Nerve roots in the spine are not static structures
Capacity to glide
Disc herniation and/or Foraminal stenosis. can
thus impair the gliding capacity of the nerve roots.
Repeated "microstretching" injuries of the nerve roots
even during normal spinal movements
Further tissue irritation in the nerve root components
Cadaver experiments=It was found that straight leg
raising moved the nerve roots at the level of the
Intervertebral foramina approximately 2 to 5 mm.
Symptoms induced by nerve root deformation in
association with disc herniation & spinal stenosis and
resulting in radiating pain.
Disc herniation, only one nerve root is usually compressed
Contact pressure of approximately 400 mm Hg
Sciatic pain is relieved after chemonucleolysis disc
degeneration progresses over time and the disc height
thereby decreases
Chemonucleolysis is a non-surgical treatment for
a bulging disc that involves the injection of an
enzyme into the vertebral disc with the goal of
dissolving the inner part of the disc, the nucleus
pulposus.
The procedure uses chymopapain, an enzyme
from the papaya fruit, to dissolve the displaced
disc material that is putting pressure on the spinal
nerve.
Central spinal stenosis, the mechanics or nerve root
compression are completely different.
The pressure is applied circumferentially
around the nerve roots in the Cauda Equina at a slow,
gradual rate
Nerve roots centrally within the Cauda Equina differ
completely from the nerve roots located more laterally,
close to the discs