Anatomic Basis of Neurologic Diagnosis 1st Edition
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Library of Congress Cataloging-in-Publication Data
Anatomic basis of neurologic diagnosis / Cary D. Alberstone … [et al.].
p.; cm.
Includes bibliographical references and index.
ISBN 978-0-86-577976-1 (alk. paper)
1. Neurologic examination. 2. Neuroanatomy. I. Alberstone, Cary D.
[DNLM: 1. Diagnostic Techniques, Neurological. 2. Central Nervous
System—anatomy & histology. WL 141 A535 2009]
RC348.A53 2009
616.8′0475—dc22
2008035366
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Printed in China
54321
ISBN 978-0-86-577976-1
To my wife, Lisa: Thank you for your patience and your friendship.
And to my children, Lauren and Adam: The nervous system is an
extraordinary asset; use yours to the utmost.
— Cary Alberstone
I dedicate this book to Mrs. Benzel (Mary, my wife) for her unending love
and support of my craziness and to our children (Morgan, Jason, Brian, and
Matthew) for their tolerance and their commitment to the team we call
family.
— Ed Benzel
To my wife, Tania, whose continuous support allowed me to work on this
book, and to my children, Elias, Joseph and Maya, who make our efforts all
worthwhile.
— Imad Najm
I dedicate this book to my wife, Bettina, and my children, Cameron and
Marcus, for their unending love and support. My family continuously
reminds me why we undertake such endeavors.
— Michael Steinmetz
Contents
Foreword
Preface
Section I Development and Developmental Disorders
1 Neuroembryology
Section II Regional Anatomy and Related Syndromes
2 Peripheral Nerves
3 Plexuses
4 Nerve Roots and Spinal Nerves
5 Spinal Cord
6 Brainstem
7 Cranial Nerves
8 Cerebellum
9 Thalamus
10 Hypothalamus
11 Basal Ganglia
12 Limbic System
13 Cerebral Cortex
Section III System-Based Anatomy and Differential Diagnosis
14 Somatosensory System
15 Visual System
16 Auditory System
17 Vestibular System
18 Ocular Motor System
19 Motor System
20 Autonomic Nervous System
21 Consciousness
Section IV Fluid-System Anatomy and Function
22 Vascular System
23 Cerebrospinal Fluid
Index
Foreword
The authors of this volume are a world-class group of clinical
neuroscientists from one of the world's greatest medical centers. They have
done a masterful job of integrating basic anatomy and neurologic diagnosis
based on the patient's signs and symptoms. This is the best book I have seen
on the correlation between neuroanatomy and clinical findings during my
more than 40 years of clinical practice. In 23 chapters, beginning with
neuroembryology and ending with cerebrospinal fluid, they have covered
the full spectrum of regional and system-based neuroanatomy, related
syndromes, and differential diagnosis. The presentation of each topic is
concise, but it is comprehensive in its overall coverage of neurologic
diagnosis. The text in each chapter is supplemented with color illustrations
showing the anatomic basis of the patient's signs and symptoms. Students
and trainees will benefit from studying this book from cover to cover, and
clinicians with advanced knowledge and experience will use it frequently
for quick reference.
Albert L. Rhoton Jr., MD
R.D. Keene Family Professor
Professor and Chairman Emeritus
Department of Neurosurgery
University of Florida
Preface
This book is intended for medical students, residents, and practicing
clinicians who wish to understand or review the basic anatomic concepts
that underlie neurologic diagnosis. The book explains the fundamentals of
neuroanatomy and illustrates their clinical application. In keeping with this
philosophy, this book emphasizes principles and clinically relevant facts:
anatomic details with little or no clinical import are discussed briefly or
omitted so as to concentrate on the essentials of neurologic diagnosis.
This fund of knowledge is organized as the clinical neurologist would
organize it: by regions and functional systems. Thus, after an introductory
chapter on neuroembryology (Part I), Part II of the book comprises a series
of chapters on the anatomy of regional parts of the nervous system,
including peripheral nerves, plexuses, nerve roots and spinal nerves, spinal
cord, brainstem, cranial nerves, cerebellum, thalamus, hypothalamus, basal
ganglia, limbic system, and cerebral cortex. These chapters are divided into
two sections: the first section describes the basic anatomy of the region, the
second section discusses the region's cardinal manifestations in disease.
Part III comprises a series of chapters on functional systems. These
include the somatosensory system, visual system, auditory system,
vestibular system, ocular motor system, motor system, autonomic system,
and consciousness. These chapters are divided into two sections: the first
section describes the basic anatomy of the system, the second section
describes a practical approach to the patient with a system disorder. Part IV
comprises a chapter on the vascular system and a chapter on the
cerebrospinal fluid.
To complement and amplify the text we have illustrated the book lavishly
with original drawings that convey anatomic and clinical concepts. These
unique drawings are rendered so as to illustrate structure, function, and
dysfunction in a single view. Thus each drawing illustrates the clinical
deficit associated with a described structure, or, conversely, a structure that
produces a described clinical deficit.
In introducing clinical material we have eschewed the fashionable
"clinical notes" and "clinical correlates" frequently found in neuroanatomy
textbooks. The inclusion of such corollaries, which primarily comprise
descriptions of randomly selected syndromes, diseases, and diagnostic tests,
in our view fails to meet the needs of those who actually require a logical,
patient-oriented approach. Discussions of the pathology and clinical
presentation of specific disease states are also assiduously avoided so as to
put the proper emphasis where it belongs: on patients and their neurologic
symptoms.
To that end, this book offers the following features:
The cardinal manifestations of regional nervous system disturbances
facilitate rapid anatomic localization.
Approaches to common neurologic complaints demonstrate the
systematic method of neurologic diagnosis.
Abundant original drawings summarize key anatomic and clinical
concepts.
Ample tables summarize key points.
In this era of advanced diagnostic technology, the relevance of clinical
diagnosis in neurology has not diminished. Indeed, despite recent
technological advances made in our approach to the nervous system,
particularly in neuroimaging, the signs and symptoms elicited by the
clinician at bedside remain paramount in the process of neurologic
diagnosis. With no working hypothesis—formulated by history taking and
tested by physical examination—to guide ancillary studies, no rational
decision can be made regarding which studies to undertake.
In whatever field of medicine or surgery one eventually practices, patients
will present with nervous disorders. These patients deserve caring and
knowledgeable physicians to accurately diagnose their complaints. The
present book provides a rational and practical approach to this humbling
task.
Acknowledgments
We wish to thank Christine Moore for her outstanding organizational
contributions and Joseph Kanasz and Michael Norviel for their creativity
and artistic skills.
Cary D. Alberstone
Edward C. Benzel
Imad M. Najm
Michael P. Steinmetz
I
Development
and
Developmental
Disorders
1 Neuroembryology
Knowledge of nervous system development can provide the foundation for
understanding nervous system structure and function. This chapter
describes early development of the nervous system and then discusses
development of the spinal cord and brain. The main malformations due to
abnormal nervous system development are also discussed. Table 1.1
summarizes the embryonic elements of the nervous system and their
derivatives in the adult.
Early Neural Development
See Fig. 1.1.
Formation of the nervous system begins during the third week of
gestation, when the neural plate develops from a thickening of the
embryonic ectoderm. A longitudinal neural groove, bounded by two neural
folds, forms along the midline of the plate. Fusion of the neural folds,
which meet along the midline, proceeds in both cranial and caudal
directions, gradually converting the grooved plate into the neural tube,
which comes to lie below the surface ectoderm.
The process of neural tube formation (neurulation) occurs simultaneously
with the separation of the neu-roectoderm from the surface ectoderm, a
process termed disjunction. Disjunction results in a separation of the future
nervous system from the future skin. Failure to complete the process of
disjunction (nondisjunction) and completion of disjunction prior to neural
tube closure (premature disjunction) are two sources of spinal dysraphism.
Before the neural tube closes completely during the fourth week of
embryonic development, it remains in communication with the amniotic
cavity through the anterior and posterior neuropores. The anterior neuropore
closes between gestational days 23 and 25; the posterior neuropore closes
between gestational days 25 and 27.
Along the lateral margins on either side of the neu-roepithelial cells of the
neural plate are two strips of cells that pinch off from the neural groove as it
forms the neural tube. These neural crest cells eventually occupy a
dorsolateral position between the surface ectoderm and the neural tube.
Most of the peripheral nervous system is derived from the neural crest,
including sensory ganglion cells of the cranial and spinal nerves, autonomic
ganglia, and Schwann cells. Neural crest cells give origin to the adrenal
medulla and melanocytes as well (Table 1.2).
Thickening of the neural tube walls gives form to the brain and the spinal
cord, whereas the lumen of the tube becomes the ventricular system and the
central canal. The neuroepithelial cells that form the walls of the neural tube
give origin to neurons and macroglia (i.e., astrocytes, oligodendrocytes, and
ependymal cells). The microglia are derived from cells of mesodermal
origin that enter the central nervous system (CNS) from the vasculature
during development (Table 1.2).
Fig. 1.1 Early neural development.
Table 1.2 Comparison of Neural Tube and Neural Crest Derivatives
Neural Tube Derivatives Neural Crest Derivatives
Ventral horn cells Cranial ganglia
Preganglionic autonomic neurons Dorsal root ganglia
