DISORDERS OF AUTONOMIC NERVOUS

SYSTEMBY

Dr. Puji Pinta O. Sinurat, Sp S.

Neurology Departement/ Medical Faculty Sumatera Utara University

MEDAN

THE AUTONOMIC NERVOUS SYSTEM

The Autonomic (visceral) Nervous System (ANS)

Control the target tissue involuntarily

- cardiac muscle - visceral smooth muscle - glands - maintain a constant internal body

environment (homeostasis)

Contrasting the Somatic and Autonomic Nervous System

Peripheral Nervous System: 1. Sensory neuron: act pot: periphery

CNS2. Motor neuron: act pot: CNS periphery. a.Somatic motor neuron innerv skeletal

m b. Autonomic motor neuron

innvervate smooth m, cardiac m and glands.

Somatic motor neuron - cell bodies : in the CNS - axon : extend from CNS to skeletal m.- innerv : skeletal muscle

Autonomic motor neuron has 2 neurons: 1. Preganglionic neuron - cell body : in the CNS (within brainstem or spinalcord) axon extend to autonomic ganglia (located outside the CNS)2. Postganglionic neuron - cell body : in the autonomic ganglia axon extend to effector organ--- innerv : smooth m, cardiac muscle and glands.

AUTONOMIC NERVOUS SYSTEM Anatomically : 2 major division:

1.Sympathetic (Thoracolumbar) division

2.Parasympathetic (Craniosacral) division

Central & Peripheral Component

Central component: Hypothalamus Cerebral Cortex Hypophyse Mesencephalon and Brain stem Spinal cord Peripheral component : N III, VII, IX dan X Preganglion, ganglion,postganglion S2 –

S4 Preganglion, ganglion,postganglion T1 –

L2

Neurotransmitter SSO Cholinergic Neuron Acetylcholine at all pregangl endings (Sympathetic &

Parasympathetic preganglionic neuron) parasympathetic postganglionic neuron Sympathetic postgagl that project to sweat

gld or mediate vasodilation Adrenergic Neuron Norepinephrine is the chemical transmitter at most

sympathetic postganglionic endings.

Sympathetic N S Pathway The cell bodies of sympathetic

preganglionic neuron: in the lateral horns of sp cord graymatter between T1-L2 segment (Thoracolumbar division)

Axon pregl ventral root T1-L2 course thrgh spinal nerve (white ramus communicans autonomic ganglia (sympathetic chain ganglia = paravertebral gangl= sympathetic trunk gang) postgangl (gray ramus communicans) --> visceral organ

Sympathetic Nervous System Pregang T1 Trunkus gang

Superior symp ganglion Postgang Pupillary dilator m, Lacrimal gld & nasal gld, Submaxill & subling gld, Parotid gld.

Pregang T1-5 Trunkus gang post gang Heart and Lungs

Pregang T5-9 Trunkus Gang Celiac ganglion postgang innerv: stomach,liver,pancreas,spleen

Pregang T9-10 postgang innerv adrenal medulla.

Pregang T10-12 Trunkus gang sup mesenteric gang Postgang innerv small intestine, colon.

Pregang L1-2 Trunkus gang inf mesenteric ganglion postgang, innerv : colon,kidney and bladder

Pregang L2 Trunkus gang postgang innerv sex organ

Peripheral Sympathetic Nervous System Dysfunction

Horner’s Syndrome damage of: Pregang T 1 nerve fibres Superior cervicalis ganglion sympathetic postgang fibres Clinically: Unilateral Enophthalmos Ptosis Myosis Anhydrosis (loss of sweating) ------

over the ipsilateral half of the face or forehead.

Disturbances of sweat gld secretion

Hypo/anhydrosis perspiration test Hyperhidrosis (excessive sweating) caused

by exagregated symph innerv of the sweat gld

Orthostatic Hypotension is a drop in BP from sitting/lying down suddenly stands up. - failure of the vessels of lower extremity to constrict venous return & CO decreased BP ↓ CBF ↓ fainting

Causalgia : painful cond of the hands or feet, caused by irritation of median/ sciatic n thrgh injurycharact : severe burning pain, glossi skin, swelling, redness, sweating and tropic nail changes.th/ sympathetic block or sympathectomy

Parasympathetic Nervous System The cell bodies of parasympathetic

preganglionic neuron : within cranial nerve nuclei (III, VII, IX, X) in the brainstem or within the lateral part of the graymatter of sp cord (region S2-4). (Craniosacral division)

The Cranial Component Pregang N III Ciliary Gangl Postgang

innervate: m.constrictor pupillae & m. ciliaris Pregang N VII Sphenoplatine Gang &

submaxillar gang Postgang innervates: lacrimal gld, nasal gld, submaxill & subling gld.

Pregang N IX Otic Gang Postgang innervate: parotis gld

Pregang N X Postgang innervate: cardiac muscle, lung, stomach, liver, pancreas, spleen, intestine and colon

The Sacral Component Preganglion ; arises from Sacral cord

segment 2,3,4 Post Ganglion innervate : descending colon

rectum baldder anal prostat and sexual organ

Peripheral Parasympathetic Nervous System dysfunction

Pupillary light reflex ( - ), mydriasis Hirschprung’s disease (megacolon) : is caused by a

functional obstruct in the lower colon & rectum.Ineffective parasympathetic stimulation & predominance sympathetic stimulation of the colon inhibit peristaltic contraction feces accumulate obove the inhibited area.It is associated with congenital lack of parasymp gang & the existence of abnormal nerve fibrils in an apparently normal segment of large bowel

Incotinentia urin & alvii Ejaculatio dysfunction

INFLUENCE OF HIGHER PARTS OF THE BRAIN ON AUTONOMIC FUNCTION

Sudden BP↑ initiates parasympathetic reflex inhibits cardiac muscle cells & HR ↓ BP normal.

Sudden BP ↓ sympathetic reflex stimulates heart to increase HR & force contraction BP to normal

Regulates body temperature Thought & emotion Regulating defecation,urination,

penile & clitoral erection, and ejaculation

Central A N S disturbances Cerebral Lesion Respiration type :Cheyne stokes Urinary & Alvii Incotinentia hemiplegic region: edema,

Cyanosis, Temp >> Temp<< , Vasodilation vasoconstriction

Diencephalon Hypothalamic disfunction: failure of body temperature, respiratory & Cardio Vascular regulation.

disorders of basal metabolic GIT disorders, sleep disorder, etc Mesencephalon Central Neurogenic Hyperventilation Horner’s Syndrome disturbances of pupillary size & reflex

Pontine Lesion Apneustic respiration Horner’s Syndrome disfunction of N VII Medulla oblongata Ataxic Respiration disfunction of N IX dan X disturbances of Cardiac center & vasomotor center

Spinal Cord Lesion TH 1 – 4 Lesion Horner’s Syndrome (Th 1) Sympathetic Dysfuntion Face &

Visceral organ thoracal visceral organ

L 1 – 2 Lesion disorders of micturition, defecation erection & ejaculation dysfunction Anhydrosis of Trunk & Leg

Innervation of the urinary bladderParasympathetic innervation: Control of bladder m is predominantly

parasympath. The pelvic splanchnic n originating in the sacral

cord (S2-4) terminate at ganglia in the wall of bladder & in internal spinchter m.

Bladder dilated sensory impulses by parasympathetic neurons Excite detrusor m & inhibit urinary spinchter Emptying the bladder.

Paralysis of the parasympathetic fibres Atonic Bladder.

Sympathetic Innervation: originate in the Intermediolat nucl of

lateral horn of Th 12, L1 and L2 pass through caudal segment of the trunks inf mesenteric gang by way of inf splanchnic n. Inf hypogastric plexus transmits the impulses to internal spinchter m.

Stimulation of int spinch m relaxation of the wall of bladder filling the bladder

Voluntary urinary bladder innervation

The external spinchter m is striated musc. ( is under voluntary control) but : the muscle opens by reflex when urine passes through internal spinchter and stays open until the bladder is empty.

External spinchter m, perinealis, levator ani, penial corpus cavernosus, urogenital diaphragm innervate by n,pudendalis: S 2 – 4 voluntarily

supra segmental innervation of bladder cerebral paracentral lobe inisiative :urination or suppression

Micturition mechanismFull Bladder

detrusor m. dilation

Parasympathetic afferent

Ascending pathway (spinothal tract)

Cerebral cortex :voluntary : urination or

Retard urination

Efferent innervationSYMPATHETIC PARA SYMPATHETIC

T 12T 11

L 1L 2

S 2

S 3

S 4

SOMATIC EFFERENTOrigin : ant horn cell S 2,3,4

CORTICAL CONTROL

BLADDER

Function :Detrusor mus relaxInternal sphinc contrac

Function :Detrusor mus contracInternal sphinc relax

Detrusor muscel

Pudendal nerves

Hypogastric plexus

Inferior hypogasganglion

AUTONOMIC BLADDER INNERVATIONAUTONOMIC BLADDER INNERVATION

Micturition disturbances Uninhibited neurogenic

bladder Infant :cerebral cortex inhibition (-), control of volume (-), tone & sensation normal emptying the bladder cerebral diffuse lesion

th/ : Atropin, tofranil

NEUROGENIC BLADDER Reflex interrupt of ascendens & descenden tract upper medulary conus (arch reflex) cortical ( - )

initiation & suppression micturition (-)

AUTONOMOUS NEUROGENIK BLADDER

innervation of bladder (-) bladder emptying (-) caused by

failure of detrusor m contraction Bladder capacity <<, urinary residu

>>> - full bladder overflow emptying abdominal pressure etiology : lesion of medulary conus,

cauda equine, motor / sensory root of S2-S4

SENSORIC PARALYTIC BLADDER

sensory impulses signaling that the bladder is dilated (-)

inisiative for urination (-) contraction ( - ) atonic neurogenic

bladder bladder capacity & urinary residu : >>

urinary overflow Emptying abdominal pressure Lesion : dorsal root S2 – S4, post column

of spinal cord

MOTOR PARALYTIC BLADDER

Bladder dilation & decompensation detrusor m contraction (-) Sensasion (normal) pain

sensation (+) but urination (-)

cause : polio, polyradiculoneuritis, trauma, neoplasm, congenital

Spastic neurogenic bladder : caused by a more or less complete

transection of the spinal cord above S2.

Flaccid Neurogenic bladdercaused by a lesion of either the sacral portion of the spinal cord or the cauda equina