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By: C. Uruk, M.S., Ph.D.

Associate Professor, University of Vermont College of Medicine

The frontopontine fibers occupy the medial part of the crus back spasms 34 weeks pregnant buy generic skelaxin 400 mg,and the temporopontine fibers occupy the lateral part of the crus spasms in 8 month old order skelaxin 400 mg mastercard. These descending tracts connect the cerebral cortex to the anterior gray column cells of the spinal cord spasms pronunciation buy skelaxin 400 mg without prescription, the cranial nerve nuclei back spasms 38 weeks pregnant purchase 400 mg skelaxin, the pons, and the cerebellum (Table 5-4). Transverse Section of the Midbrain at the Level of the Superior Colliculi the superior colliculus. It receives afferent fibers from the optic nerve,the Internal Structure of the Midbrain 213 Trochlear nerve Inferior colliculus Cerebral aqueduct containing cerebrospinal fluid Central gray matter Mesencephalic nucleus of trigeminal nerve Lateral lemniscus Nucleus of trochlear nerve Trigeminal lemniscus Spinal lemniscus Medial lemniscus Crus cerebri Temporopontine fibers Medial longitudinal fasciculus Region of reticular formation Corticospinal and corticonuclear fibers Decussation of superior cerebellar peduncles Tectum Tegmentum Substantia nigra Interpeduncular fossa A Frontopontine fibers Superior colliculus Cerebral aqueduct Central gray matter Trigeminal lemniscus Spinal lemniscus Mesencephalic nucleus of trigeminal nerve Nucleus of oculomotor nerve Medial longitudinal fasciculus Reticular formation Red nucleus Medial lemniscus Temporopontine fibers Corticospinal and corticonuclear fibers Substantia nigra Decussation of rubrospinal tracts Oculomotor nerve Frontopontine fibers B Figure 5-25 Transverse sections of the midbrain. Note that trochlear nerves completely decussate within the superior medullary velum. Cerebral cortex Third ventricle Stria medullaris thalami Internal capsule Habenula Lentiform nucleus Caudate nucleus Striae terminalis Thalamus Pineal Superior colliculus Inferior colliculus Pulvinar of thalamus Trochlear nerve Superior cerebellar peduncle Sulcus limitans Middle cerebellar peduncle Facial colliculus Floor of fourth ventricle Cuneate tubercle Entrance into cerebral aqueduct Medial eminence Median sulcus Striae medullares Vestibular area Hypoglossal triangle Vagal triangle Entrance into central canal Gracile tubercle Posterior median sulcus Central canal Figure 5-26 Posterior view of the brainstem showing the two superior and the two inferior colliculi of the tectum. Inferior colliculus Mesencephalic nucleus of trigeminal nerve Lateral lemniscus Cerebral aqueduct Central gray matter Nucleus of trochlear nerve Medial longitudinal fasciculus Reticular formation Medial lemniscus Temporopontine fibers Fibers of superior cerebellar peduncle Decussation of superior cerebellar peduncles Substantia nigra Corticospinal and corticonuclear fibers Interpeduncular fossa Frontopontine fibers Figure 5-27 Photomicrograph of a transverse section of the midbrain at the level of the inferior colliculus. The efferent fibers form the tectospinal and tectobulbar tracts, which are probably responsible for the reflex movements of the eyes, head, and neck in response to visual stimuli. This is a small group of neurons situated close to the lateral part of the superior colliculus. After relaying in the pretectal nucleus, the fibers pass to the parasympathetic nucleus of the oculomotor nerve (Edinger-Westphal nucleus). The oculomotor nucleus is situated in the central gray matter close to the median plane, just posterior to the medial longitudinal fasciculus. The fibers of the oculomotor nucleus pass anteriorly through the red nucleus to emerge on the medial side of the crus cerebri in the interpeduncular fossa. The medial, spinal, and trigeminal lemnisci form a curved band posterior to the substantia nigra, but the lateral lemniscus does not extend superiorly to this level. Its reddish hue, seen in fresh specimens, is due to its vascularity and the presence of an ironcontaining pigment in the cytoplasm of many of its neurons. Table 5-4 Level Comparison of Two Levels of the Midbrain Showing the Major Structures at Each Levela Cavity Nuclei Motor Tract Sensory Tracts Inferior colliculi Cerebral aqueduct Inferior colliculus, substantia nigra, trochlear nucleus, mesencephalic nuclei of cranial nerve V Superior colliculus, substantia nigra, oculomotor nucleus, Edinger-Westphal nucleus, red nucleus, mesencephalic nucleus of cranial nerve V Superior colliculi Cerebral aqueduct Corticospinal and corticonuclear tracts, temporopontine, frontopontine, medial longitudinal fasciculus Corticospinal and corticonuclear tracts, temporopontine, frontopontine, medial longitudinal fasciculus, decussation of rubrospinal tract Lateral, trigeminal, spinal, and medial lemnisci; decussation of superior cerebellar peduncles Trigeminal, spinal, and medial lemnisci a Note that the reticular formation is present at all levels. Efferent fibers leave the red nucleus and pass to (1) the spinal cord through the rubrospinal tract (as this tract descends, it decussates), (2) the reticular formation through the rubroreticular tract, (3) the thalamus, and (4) the substantia nigra. The reticular formation is situated in the tegmentum lateral and posterior to the red nucleus. The crus cerebri contains the identical important descending tracts­­the corticospinal, corticonuclear, and corticopontine fibers­­that are present at the level of the inferior colliculus (see Table 5-4). The continuity of the various cranial nerve nuclei through the different regions of the brainstem is shown diagrammatically in Figure 5-29. Oculomotor Trochlear Mesencephalic nucleus of trigeminal Main sensory nucleus of trigeminal Motor nucleus of trigeminal Abducent Facial Dorsal cochlear and vestibular nuclei Nucleus ambiguus Dorsal vagal nucleus Hypoglossal Nucleus of tractus solitarius Spinal nucleus of trigeminal A B Figure 5-29 Position of some of the cranial nerve nuclei in the brainstem. These tracts may become involved in demyelinating diseases, neoplasms, and vascular disorders. Arnold-Chiari Phenomenon the Arnold-Chiari malformation is a congenital anomaly in which there is a herniation of the tonsils of the cerebellum and the medulla oblongata through the foramen magnum into the vertebral canal. This results in the blockage of the exits in the roof of the fourth ventricle to the cerebrospinal fluid, causing internal hydrocephalus. It is commonly associated with craniovertebral anomalies or various forms of spina bifida. Signs and symptoms related to pressure on the cerebellum and medulla oblongata and involvement of the last four cranial nerves are associated with this condition. Raised Pressure in the Posterior Cranial Fossa and Its Effect on the Medulla Oblongata the medulla oblongata is situated in the posterior cranial fossa, lying beneath the tentorium cerebelli and above the foramen magnum. It is related anteriorly to the basal portion of the occipital bone and the upper part of the odontoid process of the axis and posteriorly to the cerebellum. In patients with tumors of the posterior cranial fossa, the intracranial pressure is raised, and the brain­­that is, the cerebellum and the medulla oblongata­­tends to be pushed toward the area of least resistance; there is a downward herniation of the medulla and cerebellar tonsils through the foramen magnum. This will produce the symptoms of headache, neck stiffness,and paralysis of the glossopharyngeal,vagus,accessory, and hypoglossal nerves owing to traction. In these circumstances, it is extremely dangerous to perform a lumbar Vascular Disorders of the Medulla Oblongata Lateral Medullary Syndrome of Wallenberg the lateral part of the medulla oblongata is supplied by the posterior inferior cerebellar artery, which is usually a branch of the vertebral artery. This coronal section of the skull shows the herniation of the cerebellar tonsil and the medulla oblongata through the foramen magnum into the vertebral canal.

A 45-year-old woman was examined by her physician and found to have carcinoma of the thyroid gland muscle relaxant that starts with a t buy skelaxin 400 mg line. Apart from the swelling in the neck muscle relaxant pictures buy skelaxin 400mg line, the patient also complained of back pain in the lower thoracic region muscle relaxant hamstring buy 400mg skelaxin with visa, with a burning soreness radiating around the right side of her thorax over the 10th intercostal space muscle relaxant options purchase 400mg skelaxin mastercard. Although the back pain was often relieved by changing posture,it was worsened by coughing and sneezing. A lateral radiograph of the thoracic part of the vertebral column revealed a secondary carcinomatous deposit in the 10th thoracic vertebral body. Using your knowledge of neuroanatomy, explain the following: (a) the pain in the back,(b) the soreness over the right 10th intercostal space, (c) the muscular weakness of both legs,and (d) which segments of the spinal cord lie at the level of the 10th thoracic vertebral body. A 35-year-old coal miner was crouching down at the mine face to inspect a drilling machine. A large rock suddenly became dislodged from the roof of the mine shaft and struck the miner on the upper part of his back. Examination by a physician showed an obvious forward displacement of the upper thoracic spines on the eighth thoracic spine. What anatomical factors in the thoracic region determine the degree of injury that may occur to the spinal cord? A 20-year-old man with a long history of tuberculosis of the lungs was examined by an orthopedic surgeon because of the sudden development of a humpback (kyphosis). He also had symptoms of a stabbing pain radiating around both sides of his thorax intensified by coughing or sneezing. A diagnosis of tuberculous osteitis of the fifth thoracic vertebra was made, with the collapse of the vertebral body responsible for the kyphosis. Using your knowledge of neuroanatomy, explain why the collapse of the fifth thoracic vertebral body should produce pain in the distribution of the fifth thoracic segmental nerve on both sides. A 50-year-old man woke up one morning with a severe pain near the lower part of the back of the neck and left shoulder. Movement of the neck caused an increase in the intensity of the pain, which was also accentuated by coughing. A lateral radiograph of the neck showed a slight narrowing of the space between the fifth and sixth cervical vertebral bodies. A medical student offered to help a fellow student straighten out the bumper of his foreign sports car. Undaunted, he attempted to lift the end of the bumper while his friend stood on the other end. Suddenly, he felt an acute pain in the back that extended down the back and outer side of his right leg. Later, he was examined by an orthopedic surgeon, who found that the pain was accentuated by coughing. A diagnosis of herniation of the intervertebral disc between the fifth lumbar and first sacral vertebrae was made. A 5-year-old child was seen in the emergency department, and a diagnosis of acute meningitis was made. The resident decided to perform a lumbar puncture in order to confirm the diagnosis. Name, in order, the structures pierced when a lumbar puncture needle is introduced into the subarachnoid space. A pregnant young woman told her friends that she hated the idea of going through the pain of childbirth but that she equally detested the thought of having a general anesthetic. Is there a specialized local analgesic technique that will provide painless labor? While crossing the road, a pedestrian was struck on the right side of his head by a passing car. After resting for an hour and then getting up, he appeared to be confused and irritable. On questioning, he was seen to be drowsy, and twitching of the lower left half of his face and left arm was noted.

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