NEUROANATOMY

UNIT OBJECTIVES
Demonstrate knowledge of anatomy that is pertinent to the diagnosis of diseases of the nervous system and the practice of neurological surgery.

COMPETENCY-BASED KNOWLEDGE OBJECTIVES:

Junior Level:

General

1. Review the embryological development of the brain, cerebellum, brain stem, glial elements, spinal cord, conus medullaris, cauda equina, sympathetic and parasympathetic systems and the peripheral nervous system.
2. Discuss the embryologic development of the skull, craniovertebral junction, and spine.
3. Describe and differentiate the different types of neurons.
4. Discuss the microanatomy of the neuron including the:
   1. cell body
   2. dendritic process
   3. axonal process
5. Diagram and describe the microanatomy of the synapse.
6. List the microglial elements and review their microanatomy:
   1. astrocytes
   2. oligodendrocytes
   3. microglia
   4. ependyma
   5. choroid epithelium
7. Diagram and describe in detail the carotid and vertebral arteries and their branches which provide blood supply to the face, scalp, skull, meninges, brain, brain stem, cerebellum, and rostral spinal cord.
8. Discuss in detail the arterial blood supply to the spinal cord. Include in the discussion the spinal and radicular arteries and the concept of watershed ischemia.
9. Identify and review the venous drainage of the central nervous system.
10. List and identify the bones of the skull.
11. Describe each of the sutures of the skull.
12. Identify each named foramen of the skull and list its contents.
13. Describe the anatomy of the meninges including the:
    1. dura mater
    2. arachnoid mater
    3. pia mater
14. Describe the anatomy of the dura including the falx cerebri and tentorium.
15. Review the layers of the scalp and discuss its innervation.
16. Diagram the cerebral ventricles.
17. Discuss the major arachnoid cisterns.
18. Review the anatomy of the arachnoid villi.
19. Discuss the anatomic correlates pertinent to the production, flow, and reabsorption of cerebrospinal fluid.
20. Identify and describe the gross anatomy of the spine including:
    1. atlas
    2. axis
    3. subaxial cervical vertebrae
    4. thoracic vertebrae
    5. lumbar vertebrae
    6. sacrum
    7. coccyx
    8. intervertebral disc complex
    9. supporting ligaments of the spine
21. List the muscles related to the skull and spine.
22. Describe the gross anatomy of the neck.
23. Discuss the anatomical basis for the blood-brain barrier in detail.

Central Nervous System

1. Describe the gross anatomy of the brain, brain stem, cerebellum, cranial nerves, and spinal cord in detail.
2. Describe the anatomy of the cerebral cortex in detail including:
   1. cortical layers
   2. sensory areas
   3. motor areas
   4. prefrontal cortex
   5. fiber tracts
   6. calcarine cortex
3. Describe the anatomy of the olfactory pathways, hippocampal formation and amygdala in detail including:
   1. rhinencephalon
   2. olfactory pathways
   3. anterior commissure
   4. hippocampal formation (including cytoarchitecture)
   5. amygdala
   6. limbic system
4. Describe the anatomy of the corpus striatum in detail including:
   1. striatum
   2. globus pallidus
   3. claustrum
   4. subthalamic region
   5. striatal afferent and efferent connections
   6. pallidal afferent and efferent connections
   7. pallidofugal fiber systems
5. Describe the anatomy of the hypothalmus and pituitary in detail including:
   1. cytoarchitecture of the hypothalmus
   2. afferent and efferent connections of the hypothalmus
   3. supraoptic nuclei and tracts
   4. hypophysial portal system
   5. anatomy of the pituitary stalk
   6. anterior and posterior pituitary
   7. cellular organization of the anterior pituitary
   8. hormonally active cells of the hypothalmus and pituitary
6. Describe the anatomy of the diencephalon in detail including:
   1. midbrain-dienencephalon junction
   2. caudal diencephalon
   3. epithalamus
   4. thalamus (including nuclei)
   5. thalamic radiations
   6. internal capsule
   7. visual pathways
7. Describe the anatomy of the cerebellum in detail including:
   1. cerebellar cortex including organization
   2. deep cerebellar nuclei
   3. cerebellar connections
   4. cerebellar peduncles
8. Describe the anatomy of the mesencephalon in detail including:
   1. superior colliculus
   2. inferior colliculus
   3. pretectal region
   4. posterior commissure
   5. mesencephalic nuclei
   6. oculomotor nerve
   7. tegmentum
   8. mesencephalic reticular formation
   9. substantia nigra
   10. crus cerebri
   11. ascending and descending tracts
9. Describe the anatomy of the pons in detail including:
   1. vestibulocochlear nerve
   2. facial nerve
   3. abducens nerve
   4. trigeminal nerve
   5. ascending and descending tracts
10. Describe the anatomy of the medulla in detail including:
    1. olivary nucleus
    2. medullary reticular formation
    3. cranial nerves of the medulla
    4. ascending and descending tracts
11. Review the location and connections of each cranial nerve nuclei. Trace the course of each cranial nerve from nucleus to end organ termination.
12. Describe the external topography and landmarks of the fourth ventricle.
13. Describe the anatomy of the spinal cord in detail including:
    1. nuclei and cell groups
    2. cytoacrchitectural lamination (Rexed laminae)
    3. somatic and visceral efferent neurons
    4. posterior horn neurons
    5. descending tracts
    6. ascending tracts
    7. upper and lower motor neurons
    8. somatotopic organization

Autonomic Nervous System

1. Distinguish pre- and postganglionic neurons.
2. Describe the sympathetic nervous system.
3. Describe the parasympathitic nervous system.
4. Review the visceral afferent fibers.
5. Describe the structure of the autonomic ganglia.
6. Discuss the central autonomic pathways.

Peripheral Nervous System

1. Differentiate between segmental and peripheral innervation.
2. Diagram the anatomy of the spinal nerve root.
3. Diagram and dDiscuss the cervical, brachial, and lumbosacral plexi.
4. Outline the anatomy of the major peripheral nerves of the upper and lower extremity including:
   1. axillary
   2. suprascapular
   3. median
   4. ulnar
   5. radial
   6. long thoracic
   7. musculocutaneous
   8. lateral femoral cutaneous
   9. femoral
   10. obturator
   11. sciatic
   12. saphenous
   13. peroneal
   14. tibial
5. Describe the microanatomy of the peripheral nerves in detail.
6. Explain the difference between myelinated and unmyelinated nerves.
7. Review the anatomy of the Schwann cell.
8. List the peripheral afferent receptors and describe the anatomy of each.
9. Segregate peripheral neurons by size and explain the rationale for such a classification scheme.

Muscle

1. Explain the concept of the motor unit.
2. Describe the anatomy of the motor end plate.
3. Describe the microscopic anatomy of striated and smooth muscle.
4. Discuss the subcellular components of muscle.

Middle Level:

1. Discuss the clinical presentation in anatomical terms of syndromes of the brain and its coverings including:
   1. epidural hematoma
   2. acute subdural hematoma
   3. chronic subdural hematoma
   4. subgaleal hematoma
   5. injury to innervation of the scalp
2. Discuss the syndromes produced by mass lesions affecting the cranial nerves including:
   1. suprasellar lesions
   2. lesion of jugular foramen
   3. lesion of internal auditory canal
   4. lesions or distortion at the incisura
3. Review the expected effects of stroke or mass lesion at different locations within the brain stem and cerebellum.
4. List the expected effects of destructive lesions in the basal ganglia and cerebellum.
5. Describe the expected effects of ischemic or destructive lesions of the white matter tracts of the cerebrum.
6. Discuss the expected effect of destructive lesions of specific regions of the cerebral cortex.
7. Review the clinical presentation of strokes in the distribution of the supratentorial cerebral blood vessels.
8. Discuss the relationship of the spinal nerves to the vertebral level of exit.
9. Diagram the structures comprising the boundaries of the spinal neural foramina.
10. Discuss the clinical manifestation of injury for each of the major peripheral nerves.
11. Describe the anatomy and presentation of common entrapment syndromes of peripheral nerves including:
    1. thoracic outlet syndrome
    2. carpal tunnel syndrome
    3. ulnar nerve entrapment syndrome at wrist and elbow
    4. anterior interosseous syndrome
    5. posterior interosseous syndrome
    6. meralgia paresthetica
    7. peroneal nerve palsy
    8. tarsal tunnel syndrome
12. Describe the surgical exposure of common peripheral nerve entrapments including:
    1. carpal tunnel
    2. ulnar nerve at elbow
    3. ulnar nerve at wrist
    4. lateral femoral cutaneous nerve
    5. peroneal nerve
13. Discuss the clinical presentation and neurological deficits associated with common lesions of and injuries to the spinal cord and nerve roots.

COMPETENCY-BASED PERFORMANCE OBJECTIVES:

Middle Level:

1. Identify at the time of surgery:
   1. occipital artery
   2. superficial temporal artery
   3. frontalis muscle
   4. pterion
   5. inion
   6. asterion
   7. coronal suture
   8. sagittal suture
   9. middle meningeal artery
   10. sagittal sinus
   11. transverse sinus
   12. foramen rotundum
   13. foramen ovale
   14. foramen spinosum
   15. superior orbital fissure
   16. jugular foramen
   17. internal auditory canal
   18. superior sagittal sinus
   19. sigmoid sinus
   20. incisura
   21. each cranial nerve
   22. each named cerebral artery and vein
   23. components of the brain stem
   24. named structures on the floor of the fourth ventricle
   25. Foramina of Magendie and Luschka
   26. cerebral peduncles
   27. components of the cerebellum
   28. cerebellar tonsils
   29. brachium cerebelli
   30. vermis
   31. major supratentorial gyri
   32. supratentorial lobes
   33. sylvian fissure
   34. central sulcus
2. Identify at the time of surgery structures visible in the lateral ventricles including:
   1. Foramen of Monro
   2. fornix
   3. caudate
   4. thalamus
   5. choroidal fissure
   6. named veins
   7. glomus of the choroid plexus
   8. hippocampus
3. Identify the parts of the vertebral column, spinal cord, and nerve roots at the time of surgery including:
   1. spinous process
   2. lamina
   3. superior facet
   4. inferior facet
   5. pedicle
   6. pars interarticularis
   7. uncovertebral joint
   8. neural foramen and nerve root
   9. nerve root ganglion
   10. disc space
   11. vertebral artery
   12. dorsal column and lateral column of spinal cord
   13. intradural afferent and efferent rootlets