VOLUNTARY MOVEMENTSVOLUNTARY MOVEMENTS

Pyramidal tract.Pyramidal tract.Syndromes of disorders.Syndromes of disorders.

The chair of neurologyThe chair of neurology

HrybHryb Viktoriya AnatiliivnaViktoriya Anatiliivna

Movements which are the results of Movements which are the results of cortical innervation, made by life cortical innervation, made by life experiences are conditioned reflexes - experiences are conditioned reflexes - they are called "voluntary" movements.they are called "voluntary" movements.

Automatic reflex movements are called Automatic reflex movements are called "involuntary.""involuntary."

To implement voluntary motion impulse is To implement voluntary motion impulse is carried by the cortico-muscular tract:carried by the cortico-muscular tract:

11 neuron - central motive: neuron - central motive:

– – coricobulbar tractcoricobulbar tract ((for musclesfor muscles of cranial of cranial

nervesnerves))

– – coricospinal tract coricospinal tract = = pyramidal tractpyramidal tract

((forfor muscles of trunkmuscles of trunk, , limbslimbs))

- lateral lateral inin spinalspinal- anterioranterior cordcord

2 2 neuronneuron – – peripheralperipheral motivemotive

Precentral gyrus - Corona radiata -

Capsula interna (knee) – PARTIAL CROSSINGNucleus (peripheral

motoneuron) in brain stem -Peripheral nerves

Precentral gyrus - Corona radiata -

Capsula interna (back leg) –

CROSSINGNucleus (peripheral

motoneuron) in anterior horn

of spinal cord –Roots

Peripheral nerves

Features of theFeatures of the coricobulbarcoricobulbar tracttract Realizes partialRealizes partial supranuclearsupranuclear crossing – that is why the crossing – that is why the innervation of facial muscles isinnervation of facial muscles is bilateralbilateral (pathology does not (pathology does not occur in case of unilateral occur in case of unilateral lesion), except:lesion), except:

- The lower part of the nucleus - The lower part of the nucleus

n. facalis (VII)n. facalis (VII)

- Nucleus n. hypoglossus (XII)- Nucleus n. hypoglossus (XII)

V

IV

III

II

I

IX

VIII

VII

VI

XI

X

XII

Features of the pyramidal pathway crossed Features of the pyramidal pathway crossed and non-crossed fibers location in the spinal and non-crossed fibers location in the spinal

cordcord

––coricospinalcoricospinal tract tract – – pyramidal pyramidal tracttract::

- LateralLateral – – ends in the anterior ends in the anterior horns of spinal cord segmentshorns of spinal cord segments

- AnteriorAnterior – – ends in the anterior ends in the anterior horns segments Ci-Civ, Thiii-Thxi, horns segments Ci-Civ, Thiii-Thxi, Siii-Sv (except cervical - Cv-Thii Siii-Sv (except cervical - Cv-Thii and lumbar - Thxii-Siiand lumbar - Thxii-Sii enlargementsenlargements).).

In case of the voluntary movements In case of the voluntary movements pathway damage (both central and pathway damage (both central and peripheral neurons) the following occurs:peripheral neurons) the following occurs:

Paralysis = plegia - complete loss of Paralysis = plegia - complete loss of movementmovement

Paresis - reduction of motion range and Paresis - reduction of motion range and muscle strengthmuscle strength

Signs of paralysis-Signs of paralysis-plegia (paresis)plegia (paresis)

CentralCentral, ,

spasticspastic

PeripheralPeripheral,,

flaccidflaccid

ReflexesReflexes hyperhyperreflexiareflexia аа- / - / hyporeflexiahyporeflexia

Muscular tonusMuscular tonus hyperhypertoniatonia аа- / - / hypotoniahypotonia

AtrophyAtrophy -- аа- /- /hypotrophiahypotrophia

Patological signsPatological signs ++ --

FibrillationsFibrillations, , fasciculationsfasciculations ((in in case of the anterior case of the anterior horn lesionshorn lesions))

-- ++

Hyperreflexia Hyperreflexia and hypertoniaand hypertonia are the result of are the result of loss of cortex loss of cortex control on the control on the activity of the activity of the spinal cord spinal cord segmental segmental apparatus apparatus

Pathological signsPathological signs

Pathological reflexes Pathological reflexes

((in new-borns - the norm,until the nerve in new-borns - the norm,until the nerve fibers myelination of in the CNS is fibers myelination of in the CNS is endedended))

The defenceThe defence reflex reflexeses

SynkineSynkinesissis

Pathological reflexesPathological reflexes

1. 1. Symptoms of oralSymptoms of oral

automatism:automatism:

- - palmomental reflexpalmomental reflex

- - lip reflexlip reflex

- - nasolabial reflexnasolabial reflex

- distance-oral- distance-oral

2. 2. PatologicalPatological plantar reflexesplantar reflexes

- ExtensorExtensor

- - Babinski’s symptomBabinski’s symptom

- - Oppenheim’s symptomOppenheim’s symptom

- - Gordon sypmtomGordon sypmtom

- - Schaffer reflexSchaffer reflex

- - FlexorFlexor

- - Rossolimo symptomRossolimo symptom

- - Bechterew symptomBechterew symptom

- - Zhukovski symptomZhukovski symptom

- - Hirschberg signHirschberg sign

2. 2. PatologicalPatological plantar reflexesplantar reflexes

DefenseDefense reflexes - spinal automatismreflexes - spinal automatism reflexes reflexes

Marie-FuaMarie-Fua reflex reflex - in the supine position - in the supine position of the patient, involuntary flexion of feet in of the patient, involuntary flexion of feet in all joints is caused by the tactile irritation all joints is caused by the tactile irritation of foot, the opposite leg extends. That is of foot, the opposite leg extends. That is automatism motions. automatism motions.

Remak’s femoral reflex Remak’s femoral reflex – flexion of the – flexion of the plantar and toes occurs in case of tactile plantar and toes occurs in case of tactile irritation of femur anterior surface irritation of femur anterior surface

Synkinesis - concordant movement in Synkinesis - concordant movement in paralyzed limbs, that accompany the voluntary paralyzed limbs, that accompany the voluntary

movement by non-paralyzed limbmovement by non-paralyzed limb

GlobalGlobal – – occurs in paralyzed limb ,when the occurs in paralyzed limb ,when the patient tries to perform active movement by patient tries to perform active movement by non-paralyzed limb (pressing a fist causes the non-paralyzed limb (pressing a fist causes the elbow flection). elbow flection).

ІІmitationalmitational – – unvoluntary movements by unvoluntary movements by paralized limb imitate voluntary movements of paralized limb imitate voluntary movements of the healthy limbthe healthy limb

CoordinationCoordination – – may be different. may be different.

monoplegiamonoplegia ((monoparesismonoparesis))

upperupperparaplegiaparaplegia ((paraparesisparaparesis))

lowerlowerрараraplegiaraplegia (ра(раraparesisraparesis))

rightrighthemiplegiahemiplegia ((hemiparesishemiparesis))

tetraplegiatetraplegia ((tetraparesistetraparesis))

There are following types of paralysis (paresis) There are following types of paralysis (paresis) prevalenceprevalence

Syndromes of the motor pathway defeat at the Syndromes of the motor pathway defeat at the

different levels:different levels:

1. 1. peripheral nerveperipheral nerve - peripheral paresis of - peripheral paresis of muscles innervated by it + pain + anesthesiamuscles innervated by it + pain + anesthesia2. 2. plexusplexus - peripheral paresis of muscles + - peripheral paresis of muscles + pain + anesthesiapain + anesthesia3. 3. anterior roots and anterior hornanterior roots and anterior horn - peripheral - peripheral paresis of the muscles (with fibrillations)paresis of the muscles (with fibrillations)4. 4. lateral ropelateral rope - homolateral central paresis of - homolateral central paresis of muscles (below the affected area) + muscles (below the affected area) + contralateral anesthesia of the superficial contralateral anesthesia of the superficial sensitivity)sensitivity)5. 5. diameter of the spinal cord diameter of the spinal cord - the central - the central para- or tetraparesis + para- / tetraanesthesia, para- or tetraparesis + para- / tetraanesthesia, sensitivity ataxiasensitivity ataxia

Syndromes of the motor pathway defeat at the Syndromes of the motor pathway defeat at the different levels:different levels:

6. 6. half of the brainstemhalf of the brainstem - central - central contralateral hemiparesis, peripheral contralateral hemiparesis, peripheral paresis of muscles innervated by paresis of muscles innervated by nucleus of cranial nerves (alternating nucleus of cranial nerves (alternating syndrome) + contrlateral syndrome) + contrlateral hemihypesthesia and hemiataxiahemihypesthesia and hemiataxia7. 7. internal capsuleinternal capsule - central contralateral - central contralateral hemiparesis (pose of Wernicke-Mann), hemiparesis (pose of Wernicke-Mann), paresis of the lower face and tongue + paresis of the lower face and tongue + contralateral hemihypesthesia, contralateral hemihypesthesia, hemiataxia, hemianopsiahemiataxia, hemianopsia

Pose of Wernicke-MannPose of Wernicke-Mann – –

Syndromes of the motor pathway defeat at the Syndromes of the motor pathway defeat at the different levels:different levels:

8. 8. precentralprecentral gyrusgyrus – – centralcentral monoparesismonoparesis ( (more oftenmore often) / ) / hemiparesishemiparesis

IrritationIrritation of the cortex motor of the cortex motor zone – zone – Jackson’s motor Jackson’s motor epilepsyepilepsy

Regulation of urinationRegulation of urination Periodic incontinentio - Periodic incontinentio - incontinentio intermittensincontinentio intermittens - - urine is excreted periodically by portions. In mild urine is excreted periodically by portions. In mild lesions - imperative call on urination with the inability lesions - imperative call on urination with the inability to hold urine for a long time.to hold urine for a long time.It’s normal for children untill the myelination of fibers It’s normal for children untill the myelination of fibers and until the formation of neatness and until the formation of neatness - it occurs when bilateral central neurons are - it occurs when bilateral central neurons are damaged (from cortex up to Siii)damaged (from cortex up to Siii) True incontinentio - True incontinentio - incontinentio veraincontinentio vera - occurs when the peripheral neuron - occurs when the peripheral neuron centrum vesico-spinale is damaged (Siii – Sv).centrum vesico-spinale is damaged (Siii – Sv). Retention urineRetention urine – – - occurs in lesions of the central or peripheral - occurs in lesions of the central or peripheral neuronsneurons

Symptoms of the spinal cord defeat Symptoms of the spinal cord defeat at the different levelsat the different levels

- - the upper cervical partthe upper cervical part ((ССi-i-ССiv)iv)

- CentralCentral tetraparesistetraparesis- Tetrahipesthesia by theTetrahipesthesia by the explore typeexplore type- ІІncontinentio intermittensncontinentio intermittens- Violation of breath- Violation of breath (peripheral(peripheral paralysis of the diaphragm -paralysis of the diaphragm - CII-Siv segments)CII-Siv segments)

Symptoms of the spinal cord defeat at Symptoms of the spinal cord defeat at the different levelsthe different levels

- - cervical enlargementcervical enlargement (С (Сvv--Thi)Thi)

- TetraparesisTetraparesis : : - - flaccid upperflaccid upper paraparesisparaparesis - - centralcentral lowerlower paraparesisparaparesis- Tetrahypesthesia byTetrahypesthesia by exploreexplore typetype- ІІncontinentio intermittensncontinentio intermittens- Horner’s syndromHorner’s syndrom::((centrum cilio-spinalecentrum cilio-spinalelesion Cvii-Thii)lesion Cvii-Thii) - - ptosptos - - myosmyos - - enophtalmenophtalm

Symptoms of the spinal cord defeat Symptoms of the spinal cord defeat at the different levelsat the different levels

- - thoracic thoracic level level ((ThiThiіі- іі- Thxii)Thxii)

- Central lowerCentral lower

paraparesisparaparesis- Tetrahypesthesia byTetrahypesthesia by

explore typeexplore type- ІІncontinentio intermittensncontinentio intermittens

Symptoms of the spinal cord defeat Symptoms of the spinal cord defeat at the different levelsat the different levels

- - lumber enlargement lumber enlargement ((LLіі - - Sii)Sii)

- Peripheral lowerPeripheral lower

paraparesisparaparesis- ParahypesthesiaParahypesthesia byby

explore typeexplore type- ІІncontinentio intermittensncontinentio intermittens

Symptoms of the spinal cord defeat Symptoms of the spinal cord defeat at the different levelsat the different levels

- - conus medullarisconus medullaris ( (Si-Sii)Si-Sii)

- Hypesthesia inHypesthesia in perineumperineum- ІІncontinentio verancontinentio vera

Symptoms of the spinal cord defeat at Symptoms of the spinal cord defeat at the different levelsthe different levels

- - cauda equina cauda equina

((LLіі – – Sv roots)Sv roots)

- PeripheralPeripheral lowerlower

paraparesisparaparesis- ParahypesthesiaParahypesthesia byby

the segmental typethe segmental type- SevierSevier root’s painroot’s pain

in legsin legs- ІІncontinentio verancontinentio vera

Calculation of correspondence of spinal cord Calculation of correspondence of spinal cord segment with certain vertebra segment with certain vertebra

Upper cervical partUpper cervical part (Сі-С (Сі-Сiv) iv) - segment- segment = = vertebravertebra

Lower cervical part Lower cervical part (С(Сv-Cviiiv-Cviii)) - - segmentsegment = = vertebravertebra - 1- 1

Upper thoracic part Upper thoracic part ((Thi-ThviiThi-Thvii)) - - segmentsegment = = vertebravertebra - 2- 2

Lower thoracic partLower thoracic part ( (Thviii-ThxiiThviii-Thxii)) - segment- segment = = vertebravertebra - 3- 3

Lumbar and sacral partsLumbar and sacral parts ( (Li-Sv)Li-Sv) - on the level of- on the level of Thx-Li vertebriThx-Li vertebri

RememberRemember – the spinothalamic truct – the spinothalamic truct crossingcrossing occurs notoccurs not in horizontal areain horizontal area, , but vertically but vertically aslope position for aslope position for 1-2 1-2 segmentssegments

CalculationCalculation of the defeat levelof the defeat level according to theaccording to the neurological neurological status datastatus data

((where the CT scan must be donewhere the CT scan must be done?)?)

- - Central tetraparesisCentral tetraparesis- Tetrahypesthesia byTetrahypesthesia by exploreexplore typetype- 2-3 2-3 smsm belowbelow clavicleclavicle - - CviCvi - ІІncontinentio intermittensncontinentio intermittens- Violation of breath- Violation of breath (peripheral(peripheral paralysis of the diaphragm -paralysis of the diaphragm - CII-Siv segments)CII-Siv segments) ССvi segmentvi segment – – on the on the ССvv vertebra levelvertebra level – – taking into the account the crossing,taking into the account the crossing, the defeat levelthe defeat level – С – Сiiiiii segmentsegment CCТ – СТ – Сiiii-С-Сiviv vertebrivertebri

CalculationCalculation of the defeat levelof the defeat level according to theaccording to the neurological neurological status datastatus data

((where the CT scan must be donewhere the CT scan must be done?)?)- - Central lower Central lower paraparesisparaparesis- TetrahypesthesiaTetrahypesthesia byby explore typeexplore type below nipples’ levelbelow nipples’ level - - ThvThv - ІІncontinentio intermittensncontinentio intermittens

Thv segmentThv segment – – Th Thііі ііі vertebra levelvertebra level – –

taking into the account the crossing,taking into the account the crossing, the defeat levelthe defeat level – – Thi segmentThi segment CCТ – СТ – Сvvіі - іі - ThThііii vertebrivertebri

CalculationCalculation of the defeat levelof the defeat level according to theaccording to the neurological status dataneurological status data

((where the CT scan must be donewhere the CT scan must be done?)?)- Central lowerCentral lower

paraparesisparaparesis- Tetrahypesthesia byTetrahypesthesia by

the explore typethe explore type

below navel's’ levelbelow navel's’ level - - ThxThx- ІІncontinentio intermittensncontinentio intermittens

Thx segmentThx segment – –ThvThvіі іі vertebra levelvertebra level – –

taking into the account the crossing,taking into the account the crossing,

the defeat levelthe defeat level – – Thv segmentThv segment

CCТ – Т – Thiv - ThviThiv - Thvi vertebrivertebri

CalculationCalculation of the defeat levelof the defeat level according to theaccording to the neurological status dataneurological status data

((where the CT scan must be donewhere the CT scan must be done?)?)- PeripheralPeripheral lowerlower

paraparesisparaparesis- Parahypesthesia byParahypesthesia by

the explore typethe explore type

below inguinal ligament below inguinal ligament - - ThxiiThxii- ІІncontinentio intermittensncontinentio intermittens

Thxii segmentThxii segment – – ThixThix vertebra levelvertebra level – –

taking into the account the crossing,taking into the account the crossing,

the defeat levelthe defeat level – – ThviiThvii segmentsegment

CCТ – Т – ThviThvi – – Thviii vertebriThviii vertebri

CalculationCalculation of the defeat levelof the defeat level according to theaccording to the neurological status dataneurological status data

((where the CT scan must be donewhere the CT scan must be done?)?)

- - conus medullarisconus medullaris ( (Si-Sii)Si-Sii)

- Paresis is absentParesis is absent- Hypesthesia Hypesthesia inin perineum perineum – – Siii-SvSiii-Sv- - ІІncontinentio verancontinentio vera

Siii - Sv segmentsSiii - Sv segments – – LiLi vertebra levelvertebra level – – taking into the account the small sizetaking into the account the small size these segmentsthese segments, , the crossing is ignoredthe crossing is ignored CCТ – Т – ThxThxіі - іі - LiiLii vertebrivertebri