NBSS CASE 2 - Spinal Cord Injury and PTSD

Case 2 / NBSS Bunga Diela
Spinal Cord Injury & PTSD 130110120114
VERTEBRAL BONE
Vertebral Column is composed by 33 vertebrae:

- 7 cervical
- 12 thoracic
- 5 lumbar
- 5 sacral (fused to form the sacrum)
- 4 coccygeal (the lower 3 are commonly fused).
Each column is segmented by intervertebral discs, consist of:

- The anulus fibrosus in peripheral part: composed of fibrocartilage, which is strongly attached to the
vertebral bodies and the anterior & posterior longitudinal ligaments of the vertebral column
- The nucleus pulposus in central part: an ovoid (but may change in shape) mass of gelatinous material,
which permits one vertebra to rock forward or backward on another.
Sometimes, an incident may cause rupture of the anulus fibrosus and allow the nucleus pulposus to
protrude into the vertebral canal and press the spinal nerve roots, the spinal nerve, or the spinal cord.
General Characteristics of a Vertebra:

- Anterior: a rounded body These enclose the vertebral foramen, a space
- Posterior: vertebral arch* which runs the spinal cord and its coverings.
* The vertebral arch, gives rise to seven processes:

- 1 spinous : directed posteriorly from the junction of the two lamina Receive attachment of
- 2 transverse : directed laterally from the junction of the lamina and the pedicle muscles and ligaments
- 4 articular (2 superior and 2 inferior) : arise from the junction of the lamina and the pedicles.
Synovial joints, formed by joining the superior articular processes of one vertebral arch with the inferior
articular processes of the arch above, which are innervated by branches from the posterior rami of the
spinal nerves.
On each side, the superior pedicle of one vertebra and the inferior pedicle of an adjacent vertebra
together form an intervertebral foramen, which serves to transmit the spinal nerves and blood vessels.
Joints in the cervical, thoracic, and lumbar regions of the vertebral column
ANATOMY OF SPINAL CORD
General view
- Cylindrical in shape, that is located :
* Superiorly, at the foramen magnum in the skull (continuous with the medulla oblongata).
* Inferiorly, in adult, at the level of the lower border of the first lumbar vertebra.
- It occupies the upper two-thirds of the vertebral canal of the vertebral column.
- It is surrounded by the three meninges: the dura mater, the arachnoid mater, and the pia mater.
- It is protected by the cerebrospinal fluid, which surrounds the spinal cord in the subarachnoid space.
Specific parts
- The cervical enlargements formed by the brachial plexus, originated from cervical region.
- The lumbar enlargements formed by the lumbosacral plexus, originated from lower thoracic & lumbar.
- Inferiorly, the spinal cord tapers off into the conus medullaris.
- The filum terminale (inferior to the conus medullaris) descends to be attached to the posterior surface
of the coccyx as a prolongation of the pia mater.
The spinal cord is composed of an inner core of gray matter and an outer covering of white matter.
Gray Matter
- Seen as an H-shaped pillar with anterior and posterior gray columns (or horns), and a small lateral gray
column (or horn) is present in the thoracic and upper lumbar segments of the cord
- United by a thin transverse gray commissure (posterior and interior gray commisure)
- In the center of gray commisure, there is a small central canal filled with cerebrospinal fluid and is
lined with the ependyma. Superiorly, it is opens into the fourth ventricle; inferiorly, it is closed and
terminates below within the root of the filum terminale.
- Consists of a mixture of multipolar nerve cells and their processes, neuroglia around the nerve cell
bodies, and blood vessels.
a. Nerve Cell Groups in the Anterior Gray Columns

- The axons of larger multipolar nerve cells pass out as alpha efferents, innervate skeletal muscles.
- The axons of smaller multipolar nerve cells pass out as gamma efferents, innervate the intrafusal
muscle fibers of neuromuscular spindles.
- It may be divided into three basic groups or columns:
* The medial group:
Innervates the skeletal muscles of the neck, trunk, intercostals and abdominal.
* The central group :
The phrenic nucleus : collective nerve cells at C3-C5, innervate the diaphragm.
The accessory nucleus : collective nerve cells at C1-C6, innervate sternocleidomastoid & trapezius.
The lumbosacral nucleus : collective at L2-S1, innervate an unknown distribution.
* The lateral group :
Innervates the skeletal muscles of the limbs.
b. Nerve Cell Groups in the Posterior Gray Columns

- The substantia gelatinosa group : Golgi type II neurons at the apex of posterior gray column, which
receives afferent fibers concerned with pain, temperature, and touch from the posterior root.
- The nucleus proprius : a group of large nerve cells at the anterior of substantia gelatinosa, which
receives fibers from the posterior white column that are associated with the senses of position and
movement (proprioception), two-point discrimination, and vibration.
- The nucleus dorsalis (Clarke's column) : a group of large nerve cells at the base of the posterior gray
column and extending at C8-L4, that are associated with proprioceptive endings (neuromuscular
spindles and tendon spindles).
- The visceral afferent nucleus : a group of nerve cells at lateral side of nucleus dorsalis and extending
at T1-L3, that are associated with receiving visceral afferent information.
c. Nerve Cell Groups in the Lateral Gray Columns

- Formed by the intermediolateral group of cells
* Extended at T1 - L3 : give rise to preganglionic sympathetic fibers.
* Extended at S2 - S4 : give rise to preganglionic parasympathetic fibers.
White Matter
- Consists of a mixture of nerve fibers, neuroglia, and blood vessels.
- Its white color is due to the high proportion of myelinated nerve fibers.
a. The anterior column: between midline and the emergence of anterior nerve roots.
b. The lateral column: between the emergence of anterior nerve roots and entry of posterior nerve roots
c. The posterior column: between the entry of the posterior nerve roots and the midline.
Comparison of Structural Details in Different Regions of the Spinal Cord

Gray Matter
White
Region Shape Lateral Gray
Matter Anterior Gray Column Posterior Gray Column
Column
Cervical Oval - Fasciculus - Medial group of cells for - Substantia gelatinosa Absent
cuneatus neck muscles present, continuous with
present - Central group of cells for cranial nerve V at level C2
- Fasciculus accessory nucleus (C1- - Nucleus proprius present
gracilis C5) and phrenic nucleus - Nucleus dorsalis (Clarke's
present (C3-C5) column) absent
- Lateral group of cells for
upper limb muscles
Thoracic Round - Fasciculus - Medial group of cells for - Substantia gelatinosa Present;
cuneatus trunk muscles - Nucleus proprius gives rise to
(T1-T6) - Nucleus dorsalis (Clarke's preganglionic
present column) sympathetic
- Fasciculus - Visceral afferent nucleus fibers
gracilis Those are present
present
Lumbar Round to - Fasciculus - Medial group of cells for - Substantia gelatinosa Present (L1-L2);
oval cuneatus lower limb muscles - Nucleus proprius gives rise to
absent - Central group of cells for - Nucleus dorsalis (Clarke's preganglionic
- Fasciculus lumbosacral nerve column) at level L1-S4 sympathetic
gracilis - Visceral afferent nucleus fibers
present Those are present
Sacral Round - Fasciculus - Medial group of cells for - Substantia gelatinosa Absent;
cuneatus lower limb and perineal present group of cells
absent muscles - Nucleus proprius present present at S2-S4,
- Fasciculus for para-
gracilis sympathetic
present outflow
EMBRYOLOGY OF SPINAL CORD
Originates from Neural Plate (an ectodermal thickening in the floor of the amniotic sac)
↓
3 weeks after fertilization, Neural Plate begins to folding toward to the Notochord
↓
Formation of two Neural Folds (with Neural Groove in between) starts
↓
The two Neural Folds fused and Neural Groove leaves the surface ectoderm to form Neural Tube
↓
The open ends of the tube, the neurophores are closed before the end of the fourth week.
↓
Cells at the edge of each neural fold escape from the line of union and form the neural crest,
and become to spinal and autonomic ganglion cells and the Schwann cells
HISTOLOGY OF SPINAL CORD
Spinal Cord
- From the cross-section seen the general shape of an H
- In the peripheral part: the white matter, which contains primarily oligodendrocytes and tracts of
myelinated axons running along the length of the cord.
- In the internal part: the gray matter, which surrounded by white matter and contains abundant
astrocytes and large neuronal cell bodies
* In the anterior column: contain motor neurons (large and multipolar) that travels to effector organs.
* In the posterior column: receive sensory fibers from neurons in the spinal ganglia (posterior roots).
→Both column joined by the gray commissure around the central canal
- In the center part: the central canal, which contains cerebrospinal fluids (CSF). It develops from the
lumen of the embryonic neural tube and is lined by ependymal cells.
Meninges
The membrane of connective tissue that is located between the bone and nervous tissue.
1. The outermost Dura Mater

- Consist of dense and fibroelastic connective tissue, continuous with the periosteum of the skull.
- Separated from the periosteum of the vertebrae by the Epidural Space, which contains a plexus of
thin-walled veins and areolar connective tissue.
- Separated from the Arachnoid Mater by the thin Subdural Space.
- The internal surface of all dura mater is covered by simple squamous epithelium of mesenchyme.
2. The middle Arachnoid Mater

- The thicker web-like meningeal layer, acts as a shock absorbing pad between the brain and skull.
- Has two components:
* A sheet of connective tissue in contact with the dura mater
* A trabeculae system containing fibroblasts and collagen, continuous with the deeper pia mater
- Contains the large Subarachnoid Space filled with CSF, which communicates with the brain ventricles.
- Blood vessels from the arachnoid mater branch into smaller arteries and veins that enter brain tissue
carrying oxygen and nutrients.
- Intimately associated with the Pia Mater (often referred as a pia-arachnoid or the leptomeninges)
- Arachnoid villi: the CSF-filled protrusions into blood-filled venous sinuses in the Dura Mater, covered
by vascular endothelial cells, to release the excess CSF into the blood.
3. The innermost Pia Mater

- The thin meningeal layer which is lined internally by flattened and mesenchymal-derived cells.
- Closely applied to the entire surface of the CNS tissue, but does not directly contact nerve cells.
- A thin limiting layer of astrocytic processes adheres firmly to the Pia Mater
- Together with the glial layer form a physical barrier at the CNS periphery to separates the CNS tissue
from the CSF in the subarachnoid space
- Blood vessels penetrate the CNS through the perivascular spaces, covered by Pia Mater – which will be
disappears when the blood vessels branch to the smallest capillaries. However, these capillaries
remain completely covered by expanded perivascular processes of astrocytes.
PHYSIOLOGY OF SPINAL CORD
Nerve Fiber Tracts
Ascending Tracts
From the peripheral nerve endings → enter to the spinal cord → then ascend to the higher center of the
central nervous system. Thus, it connects the spinal cord with the brain.
- Consist of three types of neurons:
* The first-order neuron has its cell body in the
posterior root ganglion of the spinal nerve.
- A peripheral process connects with a sensory
receptor ending.
- A central process enters the spinal cord to
synapse on the second-order neuron.
* The second-order neuron gives rise to an axon
that decussates (crosses to the opposite side) and
ascends to the higher center of CNS, where it
synapses with the third-order neuron.
* The third-order neuron (usually in the thalamus)
gives rise to a projection fiber that passes to a
sensory region of the cerebral cortex via the
reticular formation.
- It conducts afferent information:
* Exteroceptive information,
originates from outside the body (pain, temperature, touch)
* Proprioceptive information,
originates from inside the body (from muscles and joints)
Functions of the Ascending Tracts

Information Destination Pathway
Painful and thermal sensations Thalamus Lateral Spinothalamic Tract
Light touch and pressure Thalamus Anterior Spinothalamic Tract
Discriminative touch Thalamus Posterior White Column
Movement and position Thalamus Posterior White Column
Vibratory sensation Thalamus Posterior White Column
Unconscious information from Anterior and Posterior
muscles, joints, the skin, and Cerebellum Spinocerebellar Tracts, and
subcutaneous tissue Cuneocerebellar Tract
Pain, thermal, and tactile
information for the purpose of Superior colliculus of midbrain Spinotectal Tract
spinovisual reflexes
Information from the muscles,
Reticular formation Spinoreticular Tract
joints, and skin
Indirect pathways for further
Cerebellum The Spino-Olivary Tract
afferent information
(1) Pain and Temperature Pathways

- The pain and thermal receptors in the skin and other tissues are free nerve endings.
- The pain impulses are transmitted to the spinal cord in:
* Fast-conducting delta A-type fibers (for alert the individual to initial sharp pain)
* Slow-conducting C-type fibers (for prolonged burning, aching pain).
- The sensations of heat and cold also travel by delta A and C fibers.
The first-order neurons enter the posterior gray column

↓
Travel one / two segments of the spinal cord and form the Posterolateral Tract of Lissauer
↓
Synapsing with the second-order neurons (with the Substance P act as the neurotransmitter)
↓
Cross obliquely to the opposite side in the anterior gray and white commissures (the
Intersegmental Tract) within one spinal segment of the cord
↓
Ascend in the contralateral white column (Lateral Spinothalamic Tract)
↓
New fibers are added to the anteromedial aspect of the tract
↓
In the upper cervical segments: sacral fibers are lateral and cervical fibers are medial
↓
In the medulla oblongata: lies near the lateral surface and between the inferior olivary nucleus
and the nucleus of the spinal tract of the trigeminal nerve
↓
Together with the Anterior Spinothalamic Tract and the Spinotectal Tract, this lateral
spinothalamic tract form the Spinal Lemniscus
↓
Continues to ascend through the posterior part of the pons
↓
In the midbrain: it lies in the tegmentum lateral to the medial lemniscus
↓
Synapsing with the third-order neuron in the ventral posterolateral nucleus of thalamus
↓
In the thalamus: light pain and temperature sensations are appreciated
↓
Continues to ascend through the posterior limb of internal capsule and the corona radiata
↓
Reach the somesthetic area in the postcentral gyrus of the cerebral cortex
↓
The contralateral half of the body is represented as inverted, with the hand and mouth situated
inferiorly and the leg situated superiorly, and with the foot and anogenital region on the medial
surface of the hemisphere
↓
Here, the information is transmitted to other regions of the cerebral cortex to be used
by motor areas and the parietal association area
Pain and temperature

pathways
(2) Light Touch and Pressure Pathways

↓
Travel one / two segments of the spinal cord and form the Posterolateral Tract of Lissauer
↓
Synapsing with the second-order neurons in the substantia gelatinosa group in the posterior gray
column
↓
Cross obliquely to the opposite side in the anterior gray and white commissures (the
Intersegmental Tract) within several spinal segment of the cord
↓
Ascend in the opposite anteroalateral white column (Anterior Spinothalamic Tract)
↓
New fibers are added to the anteromedial aspect of the tract
↓
In the upper cervical segments: sacral fibers are lateral and cervical fibers are medial
↓
In the medulla oblongata: lies near the lateral surface and between the inferior olivary nucleus
and the nucleus of the spinal tract of the trigeminal nerve
↓
Together with the Lateral Spinothalamic Tract and the Spinotectal Tract, this anterior
spinothalamic tract form the Spinal Lemniscus
↓
Continues to ascend through the posterior part of the pons
↓
In the midbrain: it lies in the tegmentum lateral to the medial lemniscus
↓
Synapsing with the third-order neuron in the ventral posterolateral nucleus of thalamus
↓
In the thalamus: light touch and temperature sensations are appreciated
↓
Continues to ascend through the posterior limb of internal capsule and the corona radiata
↓
Reach the somesthetic area in the postcentral gyrus of the cerebral cortex
↓
↓
Here, the information is transmitted to other regions of the cerebral cortex to be used
by motor areas and the parietal association area
Light Touch and

Pressure Pathways
(3) Discriminative Touch, Vibratory Sense, and Conscious Muscle Joint Sense
The first-order neurons from the posterior root ganglion enter the spinal cord
and pass directly to the posterior white column of the same side
↓
Ascend ipsilaterally via fasciculus gracilis and fasciculus cuneatus:
- The Fasciculus Gracilis present in the sacral, lumbar, and lower six thoracic segments
- The Fasciculus Cuneatus present laterally in the upper thoracic and cervical segments
↓
Synapsing on the second-order neurons (called the internal arcuate fibers) in the nuclei gracilis
and cuneatus of the medulla oblongata
↓
Sweep anteromedially around the central gray matter and cross the median plane, decussating
with the corresponding fibers of the opposite side in the sensory decussation
↓
Ascend as the medial lemniscus through the medulla oblongata, pons, and midbrain
↓
Synapsing on the third-order neurons in the ventral posterolateral nucleus of thalamus.
↓
Ascend through the posterior limb of internal capsule and the corona radiate and reach the
somesthetic area in the postcentral gyrus of the cerebral cortex
↓
↓
Here, the impressions of touch with fine gradations of intensity, exact localization, and two-
point discrimination can be appreciated. Also, vibratory sense and the position of
the different parts of the body can be consciously recognized.
The Main Somatosensory Pathways to Consciousness

First- Second-
Third-Order
Sensation Receptor Order Order Pathways Destination
Neuron
Neuron Neuron
Ventral
Posterior Lateral
Pain and Free nerve Substantia posterolateral Posterior
root spinothalamic,
temperature endings gelatinosa nucleus of central gyrus
ganglion spinal lemniscus
thalamus
Ventral
Posterior Anterior
Light touch Free nerve Substantia posterolateral Posterior
root spinothalamic,
and pressure endings gelatinosa nucleus of central gyrus
ganglion spinal lemniscus
thalamus
Discriminative Meissner's
touch, and pacinian Ventral
Posterior Nuclei Fasciculi gracilis
vibratory, and corpuscles, posterolateral Posterior
root gracilis and and cuneatus,
conscious muscle nucleus of central gyrus
ganglion cuneatus medial lemniscus
muscle joint spindles, thalamus
sense tendon
(4) Muscle Joint Sense Pathways to the Cerebellum
a. Posterior Spinocerebellar Tract
The first-order neurons from the muscle spindles, tendon organs, and joint receptors
of the trunk and lower limbs enter the posterior gray column
↓
Synapsing on the second-order neurons (called nucleus dorsalis / Clarke's column) at the base of
the posterior gray column, which extends from the eighth cervical segment to the third or
fourth lumbar segment (so, axons entering the spinal cord at the lower lumbar and sacral
segments must ascend in the posterior white column until they reach it)
↓
Enter the posterolateral part of the lateral white column on the same side
↓
Ascend as the posterior spinocerebellar tract to the medulla oblongata.
↓
Joins the inferior cerebellar peduncle and terminates in the cerebellar cortex
↓
Here, the tension of muscle tendons and the movements of muscles and joints are concerned to
coordinate the limb movements and the maintenance of posture
b. Anterior Spinocerebellar Tract
The first-order neurons from the muscle spindles, tendon organs, and joint receptors of the
trunk and upper and lower limbs enter the posterior gray column
↓
Synapsing on the second-order neurons (called nucleus dorsalis / Clarke's column) at the base of
the posterior gray column, which extends from the eighth cervical segment to the third or
fourth lumbar segment (so, axons entering the spinal cord at the lower lumbar and sacral
segments must ascend in the posterior white column until they reach it)
↓
Cross to the opposite side and ascend as the anterior spinocerebellar tract in the contralateral
white column (majority) or in the lateral white column of the same side (minority)
↓
Continue to ascend through the medulla oblongata and pons
↓
Joins the superior cerebellar peduncle and terminate in the cerebellar cortex
↓
Here, those fibers that crossed over to the opposite side in the spinal cord cross back, and
concerning the information from the skin and superficial fascia
c. Cuneocerebellar Tract
The posterior external arcuate fibers in the fasciculus cuneatus from the cervical and upper
thoracic segments ascend through the inferior cerebellar peduncle of the same side
↓
Synapsing on the second-order neurons of the nucleus cuneatus
↓
Enter the cerebellum and concerning the information of muscle joint sense
Muscle Joint Sense Pathways to the Cerebellum

Sensation Receptor First-Order Second-Order Pathways Destination
Neuron Neuron
Unconscious Muscle spindles, Posterior Nucleus Anterior and Cerebellar
muscle tendon organs, root dorsalis posterior cortex
joint sense joint receptors ganglion spinocerebellar
Discriminative touch,
vibratory sense, and conscious
muscle joint sense pathways
(5) Spinotectal Tract

↓
Synapsing on unknown second-order neurons, which then cross the median plane
↓
Ascend as the Spinotectal Tract in the anterolateral white column (lying close to the lateral
spinothalamic tract), and pass through the medulla oblongata and pons
↓
Synapsing on the neurons in the superior colliculus of the midbrain
↓
Provides afferent information for spinovisual reflexes and brings about movements of the eyes
and head toward the source of the stimulation.
(6) Spinoreticular Tract

↓
↓
Ascend as the Spinoreticular Tract in the lateral white column, mixed with the lateral
spinothalamic tract (most of the fibers are uncrossed)
↓
Synapsing with neurons of the reticular formation in the medulla oblongata, pons, and midbrain
↓
Provides an afferent pathway for the reticular formation, which plays an important role in
influencing levels of consciousness
(7) Spino-olivary Tract

The first-order neurons from cutaneous and proprioceptive organs enter posterior gray column
↓
↓
Ascend as the Spino-olivary Tract in the white matter at anterior and lateral columns’ junction
↓
Synapsing on the third-order neurons in the inferior olivary nuclei in the medulla oblongata
↓
Cross the midline and through the inferior cerebellar peduncle to enter the cerebellum
(8) Visceral Sensory Tracts

The first-order neurons from pain and stretch receptor endings in the viscera (located in the
thorax and abdomen and may participate in reflex activity) enter the posterior gray column
↓
Synapsing with the second-order neurons in the gray matter (probably in the posterior or lateral
gray columns), which then join with the spinothalamic tracts to ascend
↓
Continue to ascend as the Visceral Sensory Tracts, synapsing with the third-order neurons in the
ventral posterolateral nucleus of thalamus, and reach the postcentral gyrus of cerebral cortex
Spinotectal,
Spinoreticular, and
Spino-olivary Tracts
Descending Tracts
The upper motor neurons from the medulla,

pons, midbrain, and cerebral cortex
↓
Descend in the white matter of the spinal cord
↓
Came out from the spinal cord as the lower
motor neurons through the anterior roots of
spinal nerves
↓
Innervates skeletal muscle
Made up of three neurons:

* The first-order neuron (upper motor
neuron) located in the cerebral cortex
* The second-order neuron (internuncial
neuron) located in the anterior gray
column of spinal cord
* The third-order neuron (lower motor
neuron) located in (and innervates) the
skeletal muscle through the anterior root
and spinal nerve
Pathways Functions
Concerned with voluntary, discrete, and skilled movements (especially those of the
Corticospinal Tracts
distal parts of the limbs)
Regulate the activity of the alpha and gamma motor neurons in the anterior gray
Reticulospinal Tracts
columns, and also regulate the voluntary movement or reflex activity
Concerned with reflex postural movements in response to visual stimuli
Tectospinal Tract
(e.g: the pupillodilation reflex in response to darkness)
Acts on the alpha and gamma motor neurons in the anterior gray columns. Also,
Rubrospinal Tract
facilitates the activity of flexor muscles and inhibits the activity of extensor muscles
Acts on the motor neurons in the anterior gray columns.
Vestibulospinal Tract Also, facilitates the activity of the extensor muscles and inhibits the activity of the
flexor muscles. Also, concerned with the postural activity associated with balance
Play a role in muscular activity. The descending autonomic fibers are concerned with
Olivospinal Tract
the control of visceral activity
(1) Corticospinal Tracts
The first-order neuron from the precentral gyrus (primary motor cortex /area 4 and the
secondary motor cortex / area 6) and the postcentral gyrus (the parietal lobe /areas 3, 1, and 2)
arise as the axons of pyramidal cells situated in the fifth layer of the cerebral cortex
↓
Converge in the corona radiata and then pass through the posterior limb of the internal capsule
↓
Here, they are organized: The cervical portions of the body are concerned in the anterior part
The lower extremity are concerned in the posterior part
↓
Continue to descend through the middle three-fifths of the basis pedunculi of the midbrain
↓
Here, position are changed: The cervical portions of the body are concerned in the medial part
The lower extremities are concerned in the lateral part
↓
Enter to the pons, and broken into many bundles by the transverse pontocerebellar fibers
↓
Enter to the medulla oblongata, and become grouped together along the anterior border to
form a pyramid (pyramidal tract)
↓
At the junction of the medulla oblongata and the spinal cord:
Most of the fibers: cross at the decussation of the pyramids and enter the lateral white column
of the spinal cord to descend and form the lateral corticospinal tract
Few of the fibers: do not cross in the decussation and enter the anterior white column of the
spinal cord to descend and form the anterior corticospinal tract
↓
Synapsing with the second order neurons (internuncial neuron) in the anterior gray column of
the spinal cord segments in the cervical and upper thoracic regions
↓
Synapsing with the third-order neurons (alpha motor neurons and some gamma motor neurons)
in the muscle spindle, and confers speed and agility to voluntary movements and performs
the rapid skilled movement
Corticospinal
Tract
(2) Reticulospinal Tracts
- Reticular formation is a collective form of the groups of scattered nerve fibers throughout the
midbrain, pons, and medulla oblongata
* Reticular formation from the pons: mostly uncrossed, they descend to the spinal cord
through the anterior white column as the pontine reticulospinal tract
* Reticular formation from the medulla: may be crossed or uncrossed, descend to the spinal
cord through the lateral white column as the medullary reticulospinal tract
- Both sets of fibers enter the anterior gray columns of the spinal cord, to:
* Facilitate or inhibit the activity of the alpha and gamma motor neurons (to influence the
voluntary movements and reflex activity)
* Act as the descending autonomic fibers (to provide a pathway by which the hypothalamus
can control the sympathetic outflow and the sacral parasympathetic outflow)
(3) Tectospinal Tract
Fibers from the superior colliculus of the midbrain, mostly cross the midline soon after their origin
↓
Descend within the brainstem close to the medial longitudinal fasciculus through the anterior white
column of the spinal cord close to the anterior median fissure.
↓
Synapsing with internuncial neurons in the anterior gray column in the upper cervical segments of
the spinal cord, to concerned with reflex postural movements in response to visual stimuli.
(4) Rubrospinal Tract
Neurons of the red nucleus in the tegmentum of the midbrain at the level of superior colliculus
receive afferent impulses through connections with the cerebral cortex and the cerebellum (as
the indirect pathway for the activity of the alpha and gamma motor neurons of the spinal cord)
↓
Cross the midline at the level of the nucleus and descend as the rubrospinal tract through
the pons and medulla oblongata
↓
Enter the lateral white column of the spinal cord
↓
Synapsing with internuncial neurons in the anterior gray column of the cord
↓
Facilitates the activity of the flexor muscles and inhibits the activity of the extensor muscles
(5) Vestibulospinal Tract
The vestibular nuclei in the pons and medulla oblongata (beneath the floor of the fourth ventricle)
receive afferent fibers from the inner ear through the vestibular nerve and from the cerebellum
↓
The lateral vestibular nucleus forms the vestibulospinal tract and descends uncrossed through
the medulla and the length of the spinal cord in the anterior white column
↓
Synapsing with internuncial neurons of the anterior gray column of the spinal cord
↓
Facilitate the activity of the extensor muscles and inhibit the activity of the flexor muscles in
association with the maintenance of balance.
(6) Olivospinal Tract
The inferior olivary nucleus descend in the lateral white column of the spinal cord, and influence
the activity of the motor neurons in the anterior gray column.
(7) Descending Autonomic Fibers (may probably form part of the reticulospinal tract)
The fibers arise from the neurons in the cerebral cortex, hypothalamus, amygdaloid complex,
and reticular formation
↓
Cross the midline in the brainstem and descend in the lateral white column of the spinal cord
↓
Synapsing on the autonomic motor cells in the lateral gray columns in the thoracic and upper
lumbar (sympathetic outflow) and midsacral (parasympathetic) levels of the spinal cord
↓
Associated with the control of autonomic activity
(8) Intersegmental Tracts
Short ascending and descending tracts that originate and end within the spinal cord exist in the
anterior, lateral, and posterior white columns, to interconnect the neurons of different
segmental levels and important in intersegmental spinal reflexes.
The Main Descending Pathways to the Spinal Cord

Site of Branches
Pathway Function Origin Destination
Crossover to
Rapid, skilled, - Primary motor - Most cross at Internuncial Cerebral
voluntary cortex (area 4) decussation of neurons or cortex,
movements - Secondary motor pyramids and alpha motor basal
(especially distal cortex (area 6) descend as lateral neurons nuclei, red
Cortico- ends of limbs) - Parietal lobe corticospinal tract nucleus,
spinal tracts (areas 3, 1, 2) - Some continue as olivary
anterior cortico- nuclei,
spinal tracts and reticular
cross over at level formation
of destination
Inhibit or facilitate Reticular Some cross at Alpha and Multiple
voluntary formation various levels gamma motor branches as
movement; and neurons they
Reticulo- hypothalamus descend
spinal tracts controls
sympathetic,
parsympathetic
outflows
Reflex postural Superior Soon after origin Alpha and
Tectospinal
movements colliculus gamma motor
tract concerning sight neurons
Facilitates activity Red nucleus Immediately Alpha and
of flexor muscles gamma motor
Rubrospinal
and inhibits activity neurons
tract of extensor
muscles
Facilitates activity Vestibular nuclei Uncrossed Alpha and
Vestibulo-
of extensor inhibits gamma motor
spinal tract flexor muscles neurons
Inferior olivary Cross in brainstem Alpha and
Olivospinal
nuclei gamma motor
tract neurons
Control Cerebral cortex, Sympathetic
Descending sympathetic and hypothalamus, and para-
autonomic para-sympathetic amygdaloid sympathetic
fibers systems complex, reticular outflows
formation
Autonomic Nervous System

Unconsciousness ontrol over the functions of many organs and tissues, including heart muscle, smooth
muscle, and the exocrine glands; distributed throughout the central and peripheral nervous systems.
The autonomic nervous system has:

1. Afferent neurons: from visceral receptors (chemoreceptors, baroreceptors, osmoreceptors) and
travel via afferent pathways to the CNS
2. Connector neurons: allow the impulses to be integrated in the CNS, and connect the afferent
neurons to the efferent neurons
3. Efferent neurons: Allow the impulses to reach the visceral effector organs, made up of:
* Preganglionic neurons: in the lateral gray column of the spinal cord and in the motor nuclei of the
3rd, 7th, 9th, and 10th cranial nerves
* Postganglionic neurons: synapsing with the axons of the preganglionic cells that are then collected
together to form ganglia outside the central nervous system.
a. Sympathetic Part of the Autonomic System

The function is to prepare the body for an emergency
Afferent Nerve Fibers
Afferent myelinated nerve fibers travel from the viscera → through the sympathetic ganglia without
synapsing → pass to the spinal nerve via white rami → communicantes and reach their cell bodies in
the posterior root ganglion → the central axons enter the spinal cord → form the afferent
component of a local reflex arc or ascend to higher centers.
Efferent Nerve Fibers
The lateral gray columns of the spinal cord T1-L2 → possess the cell bodies of the sympathetic
connector neurons → this myelinated axons leave the cord in the anterior nerve roots → pass via
the white rami communicantes → to the paravertebral ganglia of the sympathetic trunk.
Sympathetic Trunks: the two ganglionated nerve trunks that extend the whole length of the vertebral
- In the neck: each trunk has 3 ganglia, lie anterior to the transverse processes of the cervical
vertebrae
- In the thorax: each trunk has 11 or 12 ganglia, lie anterior to the heads of the ribs or lie on the
sides of the vertebral bodies
- In the lumbar region: each trunk has 4 or 5 ganglia, lie anterolateral to the sides of the bodies of
the lumbar vertebrae
- In the pelvis: each trunk has 4 or 5 ganglia, lie anterior to the sacrum.
b. Parasympathetic Part of the Autonomic System

The function is directed toward conserving and restoring energy
Efferent Nerve Fibers (Craniosacral Outflow)
The connector nerve cells are located:
- In the brainstem: form nuclei in the the oculomotor (parasympathetic or Edinger-Westphal
nucleus), the facial (superior salivatory nucleus and lacrimatory nucleus), the glossopharyngeal
(inferior salivatory nucleus), and the vagus nerves (dorsal nucleus of the vagus).
- In the gray matter of the S2-S4: not sufficiently numerous to form a lateral gray column, as do the
sympathetic connector neurons in the thoracolumbar region.
Afferent Nerve Fibers
Afferent myelinated fibers from the viscera → to their cell bodies located either in the sensory
ganglia of the cranial nerves or in the posterior root ganglia of the sacrospinal nerves → enter the
central nervous system → take part in the formation of local reflex arcs or pass to higher centers
Comparison of Anatomical, Physiologic, and Pharmacologic Characteristics of

the Sympathetic and Parasympathetic Parts of the Autonomic Nervous System
Sympathetic Parasympathetic
Action Prepares body for emergency Conserves and restores energy
Outflow T1-L2 (3) Cranial nerves III, VII, IX, and X; S2–4
Preganglionic fibers Myelinated Myelinated
Ganglia Paravertebral (sympathetic trunks), Small ganglia close to viscera
prevertebral (e.g., celiac, superior (e.g., otic, ciliary) or ganglion cells in
mesenteric, inferior mesenteric) plexuses (e.g., cardiac, pulmonary)
Neurotransmitter Acetylcholine Acetylcholine
within ganglia
Postganglionic Long, nonmyelinated Short, nonmyelinated
fibers
Characteristic Widespread due to many Discrete action with few
activity postganglionic fibers and liberation postganglionic fibers
of epinephrine and norepinephrine
from suprarenal medulla
Neurotransmitter at Norepinephrine at most endings and Acetylcholine at all endings
postganglionic acetylcholine at few endings (sweat
endings glands)
Higher control Hypothalamus Hypothalamus
Effects of Autonomic Nervous System on Organs of the Body

Organ
Sympathetic Action Parasympathetic Action
Eye Pupil Dilates Constricts
Ciliary muscle Relaxes Contracts
Glands Lacrimal, parotid, Reduce secretion by Increase secretion
submandibular, causing vasoconstriction
sublingual, nasal of blood vessels
Sweat Increases secretion
Heart Cardiac muscle Increases force of Decreases force of
contraction contraction
Coronary arteries Dilates (beta receptors),
constricts (alpha receptors)
Lung Bronchial muscle Relaxes (dilates bronchi) Contracts (constricts bronchi)
Bronchial secretion Increases secretion
Bronchial arteries Constricts Dilates
Gastro- Muscle in walls Decreases peristalsis Increases peristalsis
Intestinal Muscle in sphincters Contracts Relaxes
Tract Glands Reduces secretion by Increases secretion
vasoconstriction of blood
vessels
Liver Breaks down glycogen into
glucose
Gallbladder Relaxes Contracts
Kidney Decreases output due to
constriction of arteries
Urinary Bladder wall Relaxes Contracts
bladder (detrusor)
Sphincter vesicae Contracts Relaxes
Erectile Relaxes, causes erection
tissues
Ejaculation Contracts smooth muscle of
vas deferens, seminal
vesicles, and prostate
Systemic arteries
Skin Constrict
Abdominal Constrict
Muscle Constrict (alpha receptors),
dilate (beta receptors),
dilate (cholinergic)
Suprarenal
Cortex Stimulates
Medulla Liberates epinephrine
and norepinephrine
Topography of Sensoric Distribution in Peripheral Nerve

Dermatome is the area of skin that is supplied by a single spinal nerve.
- On the trunk, the dermatomes extend round the body from the posterior to the anterior median plane.
- The area of tactile loss is always greater than the area of loss of painful and thermal sensations, because the
degree of overlap of fibers carrying pain and thermal sensations is much more extensive than the overlap of
fibers carrying tactile sensations.
- In the limbs, the arrangement of the dermatomes is more complicated because of the embryologic rotation of
the limbs as they grow out from the trunk.
- In the face, the divisions of the trigeminal nerve (Cranial Nerve V) supply a precise area of skin, and there is little
or no overlap to the cutaneous area of another division.
Topography of Motoric Distribution in Peripheral Nerve
Myotome is the area of skeletal muscle that supplied by more than one spinal nerve
The segmental innervation of the following muscles should be known because it is possible to test them by eliciting
simple muscle reflexes in the patient :
- Biceps brachii tendon reflex C5-6 (flexion of the elbow joint by tapping the biceps tendon).
- Triceps tendon reflex C6-7 and C8 (extension of the elbow joint by tapping the triceps tendon).
- Brachioradialis tendon reflex C5-6 and C7 (supination of the radioulnar joints by tapping the insertion of the
brachioradialis tendon).
- Abdominal superficial reflexes (contraction of underlying abdominal muscles by stroking the skin). Upper
abdominal skin T6-7; middle abdominal skin T8-9; lower abdominal skin T10-12.
- Patellar tendon reflex (knee jerk) L2, L3, and L4 (extension of knee joint on tapping the patellar tendon).
- Achilles tendon reflex (ankle jerk) S1 and 2 (plantar flexion of ankle joint on tapping the Achilles tendon).
Reflex Arc
An involuntary pathway in response a stimulus
A reflex arc consists of:

- A receptor organ, situated in the skin, muscle, or tendon
- An afferent neuron, its cell body is situated in the posterior
root ganglion
- An effector neuron, is the termination of afferent neuron
- An effector organ, situated in the muscle spindle
Figure A: Multiple branching of afferent fibers entering

the spinal cord and the presence of many internuncial
neurons that synapse with the effector neuron
Figure B: The law of reciprocal innervation

- The flexor and extensor reflexes of the same limb
cannot be made to contract simultaneously.
- The afferent nerve fibers responsible for flexor
reflex muscle action must have branches that
synapse with the extensor motor neurons of the
same limb, causing them to be inhibited.
- A reflex on one side of the body causes opposite
effects on the limb of the other body side, this
crossed extensor reflex may be demonstrated.
- Afferent stimulation of the reflex arc that causes
the ipsilateral limb to flex results in the
contralateral limb being extended.
A monosynaptic reflex arc: a reflex arc involving only one synapse (and occur in very short time).
Criteria: - The afferent fibers has large diameter
- The afferent fibers are rapidly conducting
- The afferent fibers entering the spinal cord frequently branch
- The afferent fibers synapse with many internuncial neurons, which ultimately
synapse with the effector neuron.
The spinal segmental reflex arc involving motor activity is greatly influenced by higher centers
in the brain, which are mediated through the corticospinal, reticulospinal, tectospinal,
rubrospinal, and vestibulospinal tracts.
Lower motor neuron axons give off collateral branches as they pass through the white matter
to reach the anterior roots of the spinal nerve. These collaterals synapse on neurons described
by Renshaw, which, synapse on the lower motor neurons. These internuncial neurons are
believed to provide feedback on the lower motor neurons, inhibiting their activity.
A: A monosynaptic reflex arc.

B: Multiple neurons synapsing with the lower motor neuron.
SUMMARY
Cerebral cortex
↓
Thalamus
↓
Brainstem Corticonuclear tract Cranial Nerve
↓
Corticospinal tract Upper
Motor
Neuron
Anterior Lateral
↓ ↓
Tidak menyilang Menyilang di decussition of pyramid
↓ ↓
Postular muscle tone Gray matter of spinal cord
↓
Anterior gray horn
↓
Anterior root
↓
Spinal nerve
Reflex ↓ Lower
Arc Anterior rami Motor
↓ Neuron
Nerve plexus
↓
Neuromuscular junction
↓
Skeletal muscle
SPINAL CORD DISEASE
Definition
Diseases that result from diverse pathologic processes occur in the spinal cord, including neoplasm,
infection, inflammation, trauma, vascular disorder, and degenerative diseases, which can lead to
impairment of motor, sensory, or autonomic function.
Epidemiology
The incidence is estimated at 15-40 cases per million populations.
Classification (based on etiology)

- Tumors: epidural neoplasm
- Vascular: inflammatory transverse myelitis, arteriovenous malformation
- Infection: meningitis, polio, infection with HIV
- Inflammation: acute transverse myelitis
- Trauma: herniated disc, cervical spondylosis, hematoma
- Degenerative: amyotrophic lateral sclerosis, spinal muscular atrophy
Injury in Spinal Cord

1. Complete Spinal Cord Injury (transverse lesion in spinal cord)
Causes: fracture dislocation of the vertebral column or an expanding tumor
Cilinical features:
- Bilateral lower motor neuron paralysis and muscular atrophy in the segment of the lesion  caused
by damage to the neurons in the anterior gray column and damage in the nerve roots.
- Bilateral spastic paralysis below lesion caused by the cutting of the descending tracts other than
corticospinal tracts
- Bilateral loss of all sensation below the level of lesion loss of tactile discrimination and vibratory
caused by destruction of ascending tracts in posterior white column; loss of pain, temperature and
light touch is caused by section of the lateral and anterior spinothalamic tracts.
- Bladder and bowel functions are no longer under voluntary control due to destroyed of all
descending autonomic fibers.
2. Incomplete Spinal Cord Injury (hemi lesion in spinal cord)

Types and its Clinical features:
- Anterior cord syndrome: will cause bilateral lower motor neuron paralysis and muscular athropy,
bilateral spastic paralysis, bilateral loss of pain, temperature and light touch sensation. Tactile
discrimination and vibratory is preserved
- Central cord syndrome: will cause bilateral lower motor neuron paralysis and muscular athropy,
bilateral spastic paralysis, bilateral loss of all sensation.
- Posterior cord syndrome: results in good muscle power, pain and temperature sensation but
difficult in coordinating movements.
- Brown-sequard syndrome: will cause Ipsilateral lower motor neuron paralysis in the segment of the
lesion and muscular atrophy, Ipsilateral spastic paralysis, Ipsilateral band of cutaneous anesthesia,
Ipsilateral loss of tactile discrimination and of vibratory and proprioceptive sensations, Contralateral
loss of pain and temperature sensations, Contralateral but not complete loss of tactile sensation
Diagnostic Tools
Imaging modality Advantages Disadvantages
Spinal radiographs Readily available, inexpensive, non Doesn’t evaluate soft tissues of
invasive, useful for evaluating vertebral column
vertebrae
Myelography Available, inexpensive, identifies Invasive, doesn’t evaluate spinal cord
compressive lesion, evaluate dynamic parenchyma
lesion
CT Non invasive, excellent bone detail, Expensive, doesn’t evaluate spinal
sensitive for mineralized disc cord parenchyma, does not identify
herniation soft tissue compressive lesion
MRI Sensitive to all disease, non invasive Expensive, lack of experience at
interpretation
Complication
- Respiratory insufficiency
- Quadriplegia with upper and lower extremity areflexia
- Neurogenic shock (hypotension without compensatory tachycardia)
- Loss of rectal and bladder sphincter tone
- Autonomic hypereflexia that may cause severe spasticity
Principle Management
Prevention and management for complication of spinal cord injury
- Physiotherapy is the most traditional form of treatment, which usually accompanied by intervention
of drugs (e.g: corticosteroids) to decrease the sign and symptoms of complication occurs.
- Administration of oxygen, intubation, and mechanical ventilation when patient got respiratoryfailure.
But it can be prevented by training of ventilator muscle and use of bronchodilators.
- Hemodyalysis or peritoneal dialysis must be done in patient with renal failure.
Prognosis
- Life expectancy is greatly decreased, although major advances of medical management have markedly
prolonged survival.
- The most important predictor of improved outcome is retention of sacral sensation (S4-5) 72 hours to
1 week after injury.
- In general, most individuals regain one level of motor function, mostly within the first 6 months,
although further improvement can be observed years later.
- Transient or chronic reactive mild or severe depression is very common after SCI. The suicide rate
among individuals with SCI is nearly 5 times higher than in the general population.
PHARMACOLOGICAL PROPERTIES OF METHYLPREDNISOLONE
Class of Drugs
Corticosteroid
Mechanism of Action
Control the rate of protein synthesis, suppress migration of polymorphonuclear leukocytes (PMNs) and
fibroblasts, reverse capillary permeability, and stabilize lysosomes at cellular level
Effect
Controls or prevents inflammation by decreasing immune system's response to various diseases to
reduce symptoms such as swelling, pain, and allergic-type reactions.
Side Effect
Adrenal suppression Delayed wound healing Pseudotumor cerebri
Menstrual irregularity Ulcerative esophagitis Psychosis
Diabetes mellitus Hepatomegaly Seizure
Hypokalemic alkalosis Myopathy Vertigo
Pharmacokinetic
Absorption : - Onset: PO, 1-2 hr; IM, 4-8 days
- Duration: PO, 30-36 hr; IM, 1-4 weeks
- Peak plasma time: IV, 31 min
Distribution : - Vd: 0.7-1.5 L/kg
Metabolism : - Extensively metabolized in liver
Elimination : - Half-life: 3-3.5 hr
- Dialyzable: Hemodialysis, slightly
- Total body clearance: 16-21 L/hr
- Excretion: Urine (mainly, as metabolites), feces (minimally)
Indications Contraindications
Allergic conditions Untreated serious infections
Acute exacerbations of multiple sclerosis Receipt of live or attenuated live vaccine
Acute spinal cord injury Documented hypersensitivity
Severe Lupus Nephritis Traumatic brain injury (high doses)
Cautions
- Long-term treatment: Risk of osteoporosis, myopathy, delayed wound healing
- Patients receiving corticosteroids should avoid chickenpox persons if unvaccinated
- Prolonged corticosteroid use may result in elevated IOP, glaucoma, or cataracts
- Pregnancy category: C
- Lactation: Drug enters milk; use with caution
Dosage Regiment (for spinal cord injury)

1st hour: 30 mg/kg IV over 15 minutes
Next 23 hours: 5.4 mg/kg/hr IV by continuous infusion
ANXIETY
Definition
Unpleasant emotional state consisting of psychophysiological response to anticipation of unreal or
unimagined danger, resulting from unrecognized intrapsychic conflict.
Peripheral Manifestation of Anxiety

Diarrhea Hyperreflexia
Dizziness Tremors
Palpitations Tingling in the extremities
Tachychardia Restlessness
Distinction between Fear and Anxiety

- Fear :
* A primary emotion (recognizable and can be interpreted by an observer)
* An alerting signal that appears as a response to a known, external, or non-conflictual threat.
- Anxiety :
* A secondary emotion (considered as an internal and private experience)
* An alerting signal that warns of impending danger and enables person to take measures to deal with
a threat. Somehow, it becomes abnormal when it begins to interfere with a person’s functioning and
overall well-being.
Theories of the cause of anxiety

- Psychoanalytic theories:
Anxiety as a result of psychic conflict between unconscious sexual or aggressive wishes corresponding
threats from the superego/ external reality.
- Behavioral theories:
Anxiety as a response to specific environmental stimuli.
- Existential theories:
There is no specifically identifiable stimulus for a chronically anxious feeling. Persons become aware of
feelings of profound nothingness in their lives.
Differentiation of Normal and Abnormal Anxiety

Physiological Anxiety Pathological Anxiety
An emotion characterized of feelings of tension, Exaggerated fear state in which hyperexcitability
worried thought, and physical changes like of fear circuits that include the amygdala is
increased BP expressed as hypervigilance and increased
behavioral responsively to fearful stimuli.
Proportionate to the situation that elicited the Disproportionate
anxious response
Eustress from the anxiety Intensity, duration, frequency of anxiety
become distressful or chronic
Improve peoples’ functioning or well-being Condition that impairs people’s functioning and
interferes with their well-being
Classification of Anxiety Disorder (based on DSM-IV-TR)

a. Panic disorder with agoraphobia
b. Panic disorder without agoraphobia
c. Agoraphobia without history of panic disorders
d. Specific phobia
e. Social phobia
f. Obsessive-compulsive disorder
g. Post-traumatic stress disorder
h. Acute stress disorder
i. Generalized anxiety disorder
j. Anxiety disorder due to a general medical condition
k. Substance induced anxiety disorder
l. Anxiety disorder not otherwise specified
TRAUMA
Traumatic Event
A traumatic event involves a single experience, or repeating events, that completely overwhelm the
individual's ability to integrate the ideas and emotions involved with that experience. The sense of being
overwhelmed can be delayed by weeks, years or even decades, as the person struggles to cope with the
immediate circumstances.
Psychological trauma may accompany physical trauma or exist independently of it. However, different
people will react differently to similar events. One person may experience an event as traumatic while
another person might not. In other words, not all people who experience a potentially traumatic event
will actually become psychologically traumatized.
Trauma Type
Major disaster event occurred
- War or other mass violencecan
recently which potentially can
- Natural Disaster, such as earthquakes, volcanic eruptions, tsunami →
become precipitating factors for
- Serious road accidents, such as car or plane crashes
Post-Traumatic Stress Disorder
- Terrorist attacks or police brutality
- Sexual or physical abuse
- Childhood neglect Bullying
- Being the victim of an alcoholic parent
- Medication-induced trauma
- The threat of life-threatening medical conditions
Trauma Severity
Traumatic events are more likely to cause PTSD when they involve a severe threat to personal life or
safety: the more extreme and prolonged the threat, the greater the risk of developing PTSD in response.
So, the severity of the trauma itself is often the most important predictor of PTSD in general. The
frequency, duration and severity of trauma predicts either the probability of someone developing PTSD
or the number and severity of PTSD symptoms.
DIFFERENTIATION OF ACUTE STRESS DISORDER AND PTSD

Criteria ASD PTSD
Stressor Threatening event Threatening event
Fear, helplessness, or horror Fear, helplessness, or horror
Dissociation Min. 3 of:
Numbing
Reduced awareness
Depersonalization
Derealization
Amnesia
Reexperiencing Min. 1 of: Min. 1 of:
Recurrent images, thoughts or distress Recurrent images, thoughts or distress
Consequent distress not presented Consequent distress presented
Intrusive nature not prescribed Intrusive nature prescribed
Avoidance Marked avoidance of: Min. 3 of:
Thoughts, feeling, or places Avoid thought or conversations
Avoid people or places
Amnesia
Diminished interest
Estrangement from others
Restricted affect
Sense of shortened future
Arousal Marked arousal, including: Min. 2 of:
Restlessness, insomnia, irritability, Insomnia
hypervigilance, and concentration Irritability
difficulties Concentration deficits
Hypervigilance
Elevated startle response
Duration 2 days - < 1month post trauma At least 1 month post trauma
Dissociate symptoms may be present
only during trauma
Impairment Impairs functioning Impairs functioning
POST-TRAUMATIC STRESS DISORDER (PTSD)
Definition
A condition marked by the development of symptoms after exposure to traumatic life events, that the
person reacts to this experiences with fear and helplessness.
Epidemiology
- Lifetime incidence of PTSD is 9 to 15%; Lifetime prevalence is 8% of the general population.
- Among high-risk group who experienced traumatic events, lifetime prevalences rates is 5% to 75%.
- In woman the lifetime prevalence ranges from 10% to 12% and in men range from 5% to 6%.
- PTSD is more prevalent in young adults and is most likely to occur in those who are single, divorced,
widowed, socially withdrawn, or of low socioeconomic levels.
Etiology
Stressor (prime causative factor):
The stressor alone doesn’t suffice to cause the disorder. In order to cause PTSD, the response to the
traumatic event must involve intense fear or horror.
Risk factors:
* Previous traumatic experiences, especially in early life
* History of substance, physical, or sexual abuse
* History of depression, anxiety, or another mental illness
* Family history of PTSD or depression
* High level of stress in everyday life
* Lack of support after the trauma
* Lack of coping skills
Predisposing Vulnerability Factors:
* Childhood trauma
* Borderline, paranoid, dependent, antisocial personality
* Inadequate family or peer support system
* Genetic vulnerability to psychiatric illness
* Stressful life changes
* Perception of external cause (natural cause) rather than internal cause (human cause)
* Excessive alcohol intake
Psychopathogenesis and Psychopathology

* Psychodynamic factors: reactivated of previous quiescent yet unresolved psychological conflict.
→ Subjective meaning of a stressor may determine its traumatogenicity;
→ Traumatic events can resonate with childhood traumas
→ Inability to regulate affect can result from trauma
→ Somatization and alexithmya as the aftereffects of trauma
→ Defenses include denial, minimization, splitting, guilt, etc.
* Cognitive-behavioral factors: affected person can’t rationalize the trauma that precipitated disorder.
→ Phase 1: trauma produces a fear response is paired with a conditioned stimuli
→ Phase 2: persons develop a pattern of avoiding both conditioned and unconditioned stimuli
Biological factors
→ Noradrenergic / Norepinephrine (findings of sign and symptom of altered noradrenergic system)
→ Dopamine
→ Endogenous opioid (hyperregulation of opioid system)
→ Benzodiazepine receptors
→ Corticotrophin-releasing factor & HPA axis (HPA axis hyperregulation lead to cortisol suppression)
Clinical Feature
The principal features of PTSD are painful reexperiencing of the event, a pattern of avoidance and
emotional numbing, and fairly constant hyperarousal.
- Reliving the event: flashback, repeated nightmares of the events, etc.
- Avoidance: emotional numbing, detached feeling from the environment, unable to remember
important aspects of the trauma, etc.
- Arousal: difficulty concentrating, startling easily, hypervigilance, insomnia, etc.
Diagnostic Criteria
1. The person has been exposed to a traumatic event in which both of the following were present:
- The person experienced, witnessed, or was confronted with an event or events that involved actual
or threatened death or serious injury, or a threat to the physical integrity of self or others
- The person's response involved intense fear, helplessness, or horror. (or agitation in children)
2. The traumatic event is persistently reexperienced in one (or more) of the following ways:
- Recurrent distressing recollections of the event, including images, thoughts, or perceptions.
- Recurrent distressing dreams of the event.
- Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the
experience, illusions, hallucinations, and dissociative flashback episodes).
- Intense psychological distress at exposure to internal or external cues that symbolize or resemble an
aspect of the traumatic event
- Physiological reactivity on exposure to internal or external cues that symbolize or resemble an
aspect of the traumatic event
3. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness
(not present before the trauma), as indicated by three (or more) of the following:
- Efforts to avoid thoughts, feelings, or conversations associated with the trauma
- Efforts to avoid activities, places, or people that arouse recollections of the trauma
- Inability to recall an important aspect of the trauma
- Markedly diminished interest or participation in significant activities
- Feeling of detachment or estrangement from others
- Restricted range of affect (e.g., unable to have loving feelings)
- Sense of a foreshortened future (e.g., does not expect to have a normal life span)
4. Persistent symptoms of increased arousal (not present before the trauma), indicated by two (or more)
of the following:
- Difficulty falling or staying asleep
- Irritability or outbursts of anger
- Difficulty concentrating
- Exaggerated startle response
5. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month.
6. The disturbance causes clinically significant distress or impairment in social, occupational, or other
important areas of functioning.
Specify if: Acute: if duration of symptoms is less than 3 months

Chronic: if duration of symptoms is 3 months or more
Specify if: With delayed onset: if onset of symptoms is at least 6 months after the stressor
Comorbidity
- Depressive disorders
- Substance-related disorders
- Other anxiety disorders
- Bipolar disorders.
Course and Prognosis

- PTSD develops some time after the trauma. The delay can be between 1 week until 30 years.
Symptoms can fluctuate over time but the most intense may occur during stress.
- If leave untreated, 30% of patients will recover completely, 40% with mild symptoms, 20% with
moderate symptoms, and 10% unchanged or worse.
- Good prognosis if rapid onset of the symptoms, short duration of the symptoms, good premorbid
conditioning, strong social support, absence of other psychiatric, medical, or substance related
disorders or other risk factors.
- In general the effect of traumatic events can be difficult for the very young or very old person and as
well as person with preexisting psychiatric disability. This is related to their coping mechanism of
traumatic events which is inadequate or weak.
Principle Management
Pharmacotherapy:
- Selective serotonin reuptake inhibitors (SSRIs), such as sertraline (Zoloft) and paroxetine (Paxil), to
reduce symptoms from all PTSD symptom clusters and are effective in improving symptoms unique to
PTSD, not just symptoms similar to those of depression or other anxiety disorders.
- Buspirone (BuSpar) is serotonergic and may also be of use.
Psychotherapy:
Should follow a model of crisis intervention with support, education, and the development of coping
mechanism and acceptance of the event, such as:
- Behavioral therapy
- Cognitive therapy
- Psychotherapy.
There are 2 major psychotherapeutic approach that can be taken:
- Exposure therapy: patient reexperiences the traumatic events through imaging techniques
- Educate about stress management including relaxation techniques and cognitive approaches to coping
with stress.
PHARMACOLOGICAL PROPERTIES OF AMITRIPTYLINE

Class of Drugs
Tricyclic antidepressants
Mechanism of Action
Inhibit reuptake of neurotransmitter (especially norepinephrine and serotonin)
Effect
Affecting the balance of neurotransmitters in the brain to improve mood and feelings of well-being,
relieve anxiety and tension, and increase energy level.
Side Effect
Restlessness Agitation Fatigue
Anxiety Arrhythmia Headache
Hallucination Myocardial Infarction Ocular pressure increased
Insomnia Agranulocytosis Extrapyramidal symptoms (EPS)
Pharmacokinetic
Absorption : - Peak plasma time: 4 hr
Distribution : - Protein bound: 75-90%
- Vd: 1.5 L/kg (neonates); 1.9 L/kg (children); 0.59-2 L/kg (adults)
Metabolism : - Metabolized by hepatic CYP2C19, CYP3A4
- Metabolites: Nortriptyline
Elimination : - Half-life: 9-27 hr
- Excretion: Urine (18%), small amounts in feces
Depression Hypersensitivity
Postherpetic neuralgia Severe cardiovascular disorder
Migraine prophylaxis Narrow-angle glaucoma
Eating disorder Myocardial Infarction
Cautions
May cause sedation and impair mental, physical abilities, and orthostatic hypotension
Use caution in patients with cardiovascular disease, diabetes, mania, hepatic and renal impairment,
thyroid dysfunction, seizure, urinary retention, open-angle glaucoma, decreased gastrointestinal motility
Pregnancy category: C
Lactation: Distributed in breast milk
Dosage Regiment (for PTSD / Depressions)

- Adult:
* Outpatient: 25 mg PO qHS initially; increase by 25 mg every 5-7 days to 100-200 mg/day (may divide
doses throughout day or give at bedtime); if needed, may increase to 300 mg/day
* Inpatient: 100-300 mg PO qDay
- Adolescents:
* Initial: 25-50 mg/day PO in divided doses; increase gradually to 100 mg/day in divided doses
- Children:
* First 3 days: 1 mg/kg/day divided q8hr PO, then 1.5 mg/kg/day divided q8hr PO
PHARMACOLOGICAL PROPERTIES OF DIAZEPAM
Class of Drugs
Benzodiazepines
Mechanism of Action
Modulates postsynaptic effects of GABA-A transmission, resulting in an increase in presynaptic inhibition.
Effect
Act on part of the limbic system, as well as on the thalamus and hypothalamus, to induce a calming
effect to treat anxiety and muscle spasms.
Side Effect
1-10% : - Ataxia
- Euphoria (3%, rectal gel)
- Rash (3%, rectal gel)
- Diarrhea (4%, rectal gel)
Pharmacokinetic
Absorption : - Bioavailability: 90% (PR)
- Duration: 7-8 hr (PO [hypnotic action]); 15-60 min (IV [sedative action])
- Peak plasma time: 30-90 min (PO), 5-90 min (PR)
- Peak plasma concentration: 373 ng/mL (initial at 45 min)
447 ng/mL (second peak at 70 min)
Distribution : - Protein bound: 98%
- Vd: 0.8-1 L/kg
Metabolism : - hepatic P450 enzymes CYP2C19, CYP3A4
- Metabolites: N-desmethyldiazepam, 3-hydroxdiazepam, oxazepam
Elimination : - Half-life: 20-70 hr (active metabolite)
- Renal clearance: 20-30 mL/min
- Excretion: Urine
Anxiety Documented hypersensitivity
Alcohol withdrawal Myasthenia gravis
Muscle spams Narrow angle glaucoma
Seizure disorder Severe respiratory depression
Status epilipticus Depressed neuroses, psychotic reactions
Cautions
- Use caution in COPD, sleep apnea, renal/hepatic disease, open-angle glaucoma (questionable),
depression, suicide ideation
- Prenatal benzodiazepine exposure slightly increased oral cleft risk
- Pregnancy category: D
- Lactation: Enters breast milk; do not use in women who are breastfeeding
Dosage Regiment (for PTSD / Anxiety)

- Adult: 2-10 mg PO q6-12hr, OR 2-10 mg IV/IM q3-4hr; no more than 30 mg/8 hours
BHP
PHOP
CRP

NBSS CASE 2 - Spinal Cord Injury and PTSD

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NBSS CASE 2 - Spinal Cord Injury and PTSD

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Case 2 / NBSS Bunga Diela

Spinal Cord Injury & PTSD 130110120114

Vertebral Column is composed by 33 vertebrae:

Each column is segmented by intervertebral discs, consist of:

General Characteristics of a Vertebra:

* The vertebral arch, gives rise to seven processes:

ANATOMY OF SPINAL CORD

a. Nerve Cell Groups in the Anterior Gray Columns

b. Nerve Cell Groups in the Posterior Gray Columns

c. Nerve Cell Groups in the Lateral Gray Columns

Comparison of Structural Details in Different Regions of the Spinal Cord

EMBRYOLOGY OF SPINAL CORD

HISTOLOGY OF SPINAL CORD

1. The outermost Dura Mater

2. The middle Arachnoid Mater

3. The innermost Pia Mater

PHYSIOLOGY OF SPINAL CORD

Nerve Fiber Tracts

Functions of the Ascending Tracts

(1) Pain and Temperature Pathways

The first-order neurons enter the posterior gray column

Pain and temperature

(2) Light Touch and Pressure Pathways

The first-order neurons enter the posterior gray column

Light Touch and

The Main Somatosensory Pathways to Consciousness

(4) Muscle Joint Sense Pathways to the Cerebellum

a. Posterior Spinocerebellar Tract

b. Anterior Spinocerebellar Tract

Muscle Joint Sense Pathways to the Cerebellum

(5) Spinotectal Tract

(6) Spinoreticular Tract

(7) Spino-olivary Tract

(8) Visceral Sensory Tracts

The upper motor neurons from the medulla,

Made up of three neurons:

(1) Corticospinal Tracts

(2) Reticulospinal Tracts

(3) Tectospinal Tract

(4) Rubrospinal Tract

(5) Vestibulospinal Tract

(6) Olivospinal Tract

(8) Intersegmental Tracts

The Main Descending Pathways to the Spinal Cord

Autonomic Nervous System

The autonomic nervous system has:

a. Sympathetic Part of the Autonomic System

b. Parasympathetic Part of the Autonomic System

Comparison of Anatomical, Physiologic, and Pharmacologic Characteristics of

Effects of Autonomic Nervous System on Organs of the Body

Topography of Sensoric Distribution in Peripheral Nerve

Topography of Motoric Distribution in Peripheral Nerve

A reflex arc consists of:

Figure A: Multiple branching of afferent fibers entering

Figure B: The law of reciprocal innervation

A: A monosynaptic reflex arc.

SPINAL CORD DISEASE

Classification (based on etiology)

Injury in Spinal Cord

2. Incomplete Spinal Cord Injury (hemi lesion in spinal cord)

PHARMACOLOGICAL PROPERTIES OF METHYLPREDNISOLONE

Dosage Regiment (for spinal cord injury)

Peripheral Manifestation of Anxiety

Distinction between Fear and Anxiety