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Spinal Afferent Tracts for Pain
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Lateral Spinothalamic Tract As indicated above, axons of secondary neurons that subserve pain sensation originate in laminae I, II, V, VII, and VIII of the spinal gray matter The principal bundle of these axons decussates in the anterior spinal commissure and ascends in the anterolateral fasciculus as the spinothalamic tract to terminate in several brainstem and thalamic structures (Fig 8-2) It is of clinical consequence that the axons carrying pain impulses from each dermatome decussate one to three segments above the level of root entry For this reason, a discrete lesion of the lateral spinal cord creates a loss of pain and thermal sensation of the contralateral trunk, the dermatomal level of which is two to three segments below that of the spinal cord lesion As the ascending bers cross the cord, they are added to the inner side of the spinothalamic tract (the principal afferent pathway of the anterolateral fasciculus), so that the longest bers from the sacral segments come to lie most super cially and bers from successively more rostral levels occupy progressively deeper positions (Fig 8-3) This somatotopic arrangement is of importance to the neurosurgeon insofar as the depth to which the funiculus is cut will govern the level of analgesia that is achieved; for the neurologist, it provides an explanation of the special pattern or sacral sparing of pain and thermal sensation created by centrally placed lesions of the spinal cord
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The Dorsal Horn
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The afferent pain bers, after traversing Lissauer s tract, terminate in the posterior gray matter or dorsal horn, predominantly in the marginal zone Most of the bers terminate within the segment of their entry into the cord; some extend ipsilaterally to one or two adjacent rostral and caudal segments; and some project, via the anterior commissure, to the contralateral dorsal horn The cytoarchitectonic studies of Rexed in the cat (the same organization pertains in primates and probably in humans) have shown that secondorder neurons, the sites of synapse of afferent sensory bers in the dorsal horn, are arranged in a series of six layers or laminae (Fig 8-1B) Fine, myelinated (A- ) bers terminate principally in lamina I of Rexed (marginal cell layer of Waldeyer) and also in the outermost part of lamina II; some A- pain bers penetrate the dorsal gray matter and terminate in the lateral part of lamina V Unmyelinated (C) bers terminate in lamina II (substantia gelatinosa) Yet other cells that respond to painful cutaneous stimulation are located in ventral horn laminae VII and VIII The latter neurons are responsive to descending impulses from brainstem nuclei as well as
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Dorsal root ganglion Columns of Goll & Burdach (Posterior columns) Dorsal root fibers
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Lateral corticospinal tract
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Rubrospinal tract Intermediolateral cell column Dorsal Spinocerebellar tract Ventral
Motor neurons SPINOTHALAMIC TRACT Ventral root fibers Ventral corticospinal tract
A- fiber C fiber A- fiber
I Marginal zone II Substantia gelatinosa III IV V VI Base of dorsal horn Nucleus proprius
Figure 8-1 A Spinal cord in transverse section, illustrating the course of the afferent bers and the major ascending pathways Fast-conducting pain bers are not con ned to the spinothalamic tract but are scattered diffusely in the anterolateral funiculus (see also Fig 8-3) B Transverse section through a cervical segment of the spinal cord, illustrating the subdivision of the gray matter into laminae according to Rexed and the entry and termination of the main sensory bers (Adapted from Martin, JH: Neuroanatomy: Text and Atlas New York, McGraw-Hill, 2003, with permission)
PAIN
Other Spinocerebral Afferent Tracts In addition Leg to the lateral spinothalamic tract the above deTrunk Post-central scribed fast-conducting pathway that projects directly cortex to the thalamus the anterolateral fasciculus of the Arm cord contains several more slowly conducting, mediInternal capsule ally placed systems of bers One such group of bers projects directly to the reticular core of the medulla Face and midbrain and then to the medial and intralaminar nuclei of the thalamus; this group of bers is referred Thalamus to as the spinoreticulothalamic or paleospinothalamic pathway At the level of the medulla, these bers synapse in the nucleus gigantocellularis; more rostrally, Ventral they connect with nuclei of the parabrachial region, posterolateral midbrain reticular formation, periaqueductal gray nucleus of thalamus matter, and hypothalamus A second, more medially placed pathway in the anterolateral cord ascends to MIDBRAIN the brainstem reticular core via a series of short interneuronal links It is not clear whether these spinore- Reticulothalamic pathway ticular bers are collaterals of the spinothalamic tracts, as Cajal originally stated, or whether they repPrincipal sensory nucleus of V resent an independent system, as more recent data PONS seem to indicate Probably both statements are correct There is also a third, direct spinohypothalamic pathMedial lemniscus way in the anterolateral fasciculus Nucleus of The conduction of diffuse, poorly localized pain funiculus gracilis arising from deep and visceral structures (gut, periNucleus of osteum) has been ascribed to these pathways Melzack funiculus cuneatus MEDULLA and Casey have proposed that this ber system (which Nucleus of they refer to as paramedian), with its diffuse projecspinal tract V Spinothalamic tract tion via brainstem and thalamus to the limbic and frontal lobes, subserves the affective aspects of pain, ie, the unpleasant feelings engendered by pain It is evident that these spinoreticulothalamic pathways continue to evoke the psychic experience of pain even SPINAL CORD when the direct spinothalamic pathways have been interrupted However, it is the direct spinothalamic pathway, which projects to the ventroposterolateral Spinothalamic tract (VPL) nucleus of the thalamus and thence to discrete areas of the sensory cortex, that subserves the sensory- Figure 8-2 The main somatosensory pathways The spinothalamic tract (pain, thermal discriminative aspects of pain, ie, the processes that sense) and the posterior column lemniscal system (touch, pressure, joint position) are underlie the localization, quality, and possibly the in- shown Offshoots from the ascending anterolateral fasciculus (spinothalamic tract) to nuclei tensity of the noxious stimulus Also, the pathways in the medulla, pons, and mesencephalon and nuclear terminations of the tract are indicated for visceral pain from the esophagus, stomach, small The cortical representation of sensation is shown grossly; it is shown more explicitly in Fig bowel, and proximal colon are carried largely in the 9-4 and discussed in Chap 9 vagus nerve and terminate in the nucleus of the solitary tract (nucleus tractus solitarius, NTS) before projecting to the ments below the lesion as noted earlier After a variable period of thalamus, as described below Other abdominal viscera still activate time, pain sensibility usually returns, probably being conducted by the NTS when the vagus is severed in animals, probably passing pathways that lie outside the anterolateral quadrants of the spinal through the splanchnic plexus cord and which gradually increase their capacity to conduct pain It should be emphasized that the foregoing data concerning impulses One of these is a longitudinal polysynaptic bundle of the cells of termination of cutaneous nociceptive stimuli and the small myelinated bers in the center of the dorsal horn (the dorsal cells of origin of ascending spinal afferent pathways have all been intracornual tract); another consists of axons of lamina I cells that obtained from studies in animals (including monkeys) In humans, travel in the dorsal part of the lateral funiculus the cells of origin of the long (direct) spinothalamic tract bers have not been fully identi ed Information about this pathway in Thalamic Terminus of Pain Fibers humans has been derived from the study of postmortem material and from the examination of patients subjected to anterolateral corThe direct spinothalamic bers separate into two bundles as they dotomy for intractable pain What can be stated of clinical releapproach the thalamus The lateral division terminates in the venvance is that unilateral section of the anterolateral funiculus protrobasal and posterior groups of nuclei, the most important of which duces a relatively complete loss of pain and thermal sense on the is the VPL nucleus The medial contingent terminates mainly in opposite side of the body, extending to a level two or three segthe intralaminar complex of nuclei and in the nucleus submedius
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