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Spinal cord disorders Anatomical Approach
1. SPINAL CORD DISORDERS
ANATOMICAL APPROACH
Dr PS Deb MD, DM
Director Neurology
Guwahati Neurological Research Institute
Assam, India
2. SPINAL CORD
īĸ Information highway between brain and body
īĸ Extends through vertebral canal from foramen magnum to L1
īĸ Each pair of spinal nerves receives sensory information and issues
motor signals to muscles and glands
īĸ Spinal cord is a component of the Central Nervous System while the
spinal nerves are part of the Peripheral Nervous System
3. SPINAL CORD FUNCTIONS
īĸ Conduction
ī bundles of fibers passing information up and down spinal cord
īĸ Locomotion
ī repetitive, coordinated actions of several muscle groups
ī central pattern generators are pools of neurons providing control of flexors and
extensors (walking)
īĸ Reflexes
ī involuntary, stereotyped responses to stimuli (remove hand from hot stove)
ī involves brain, spinal cord and peripheral nerves
4. SPINAL CORD - ANATOMY
īĸ Runs through the vertebral canal
īĸ Extends from foramen magnum to second
lumbar vertebra
īĸ Regions
ī Cervical
ī Thoracic
ī Lumbar
ī Sacral
ī Coccygeal
īĸ Gives rise to 31 pairs of spinal nerves
ī All are mixed nerves
īĸ Not uniform in diameter
ī Cervical enlargement: supplies upper
limbs
ī Lumbar enlargement: supplies lower limbs
īĸ Conus medullaris- tapered inferior end
ī Ends between L1 and L2
īĸ Cauda equina - origin of spinal nerves
extending inferiorly from conus medullaris
6. SPINAL CORD: LONGITUDINAL EXTENT
īĸ Spinal cord stretches from
foramen magnum till coccyx in
fetal life then due to growth of
spine it fall short
ī At 3rd fetal month up to coccyx
ī At birth lower border of L3
ī Adult spinal cord ends at lower
border of L1 body
8. COVERING OF SPINAL CORD
īĸ Connective tissue
membranes
ī Dura mater: outermost layer;
continuous with epineurium of
the spinal nerves
ī Arachnoid mater: thin and
wispy
ī Pia mater: bound tightly to
surface
īĸ Forms the filum terminale
īĸ anchors spinal cord to coccyx
īĸ Forms the denticulate ligaments
that attach the spinal cord to the
dura
īĸ Spaces
ī Epidural: external to the dura
īĸ Anesthestics injected here
īĸ Fat-fill
ī Subdural space: serous fluid
ī Subarachnoid: between pia
and arachnoid
īĸ Filled with CSF
10. SPINAL CORD TRANSVERSE SECTION
īĸ Anterior median fissure and
posterior median sulcus
ī deep clefts partially separating
left and right halves
īĸ Gray matter: neuron cell bodies,
dendrites, axons
ī Divided into horns
īĸ Posterior (dorsal) horn
īĸ Anterior (ventral) horn
īĸ Lateral horn
īĸ White matter
ī Myelinated axons
ī Divided into three columns
(funiculi)
īĸ Ventral
īĸ Dorsal
īĸ lateral
ī Each of these divided into
sensory or motor tracts
11. SPINAL CORD TRANSVERSE SECTION
īĸ Commissures: connections between left
and right halves
ī Gray with central canal in the center
ī White
īĸ Roots
ī Spinal nerves arise as rootlets then
combine to form dorsal and ventral
roots
ī Dorsal and ventral roots merge laterally
and form the spinal nerve
12. SPINAL CORD GRAY MATTER
īĸ Dorsal half â sensory roots and ganglia
īĸ Ventral half â motor roots
īĸ Based on the type of neurons/cell bodies located in each horn, it is
specialized further into 4 regions
ī Somatic sensory (SS) - axons of somatic sensory neurons
ī Visceral sensory (VS) - neurons of visceral sensory neur.
ī Visceral motor (VM) - cell bodies of visceral motor neurons
ī Somatic motor (SM) - cell bodies of somatic motor neurons
13. GRAY MATTER OF SPINAL CORD
īĸ Lamina I - posteromarginal nucleus
īĸ Lamina II - substantia gelatinosa of
Rolando
īĸ Lamina III, IV - nucleus proprius
īĸ Lamina V, VI
īĸ Lamina VII - intermediate gray
intermediolateral cell column (ILM)
Clarkeâs column (Nucleus dorsal
intermediomedial cell column (IMM)
īĸ Lamina VIII
īĸ Lamina IX - anterior horn (motor) cell
īĸ Lamina X - gray commissure
16. WHITE MATTER OF SPINAL CORD
īĸ Divided into three funiculi (columns) â posterior, lateral, and anterior
ī Columns contain 3 different types of fibers (Ascend., Descend., Trans.)
īĸ Fibers run in three directions
ī Ascending fibers - compose the sensory tracts
ī Descending fibers - compose the motor tracts
ī Commissural (transverse) fibers - connect opposite sides of cord
īĸ Pathways decussate (most)
īĸ Most consist of a chain of two or three neurons
īĸ Most exhibit somatotopy (precise spatial relationships)
īĸ All pathways are paired
ī one on each side of the spinal cord
18. CORTICOSPINAL TRACT
īĸ Originate in the precentral gyrus
of brain (aka, primary motr area)
ī I.e., cell body of the UMN located
in precentral gyrus
īĸ UMN synapses in the anterior
horn with LMN
ī Some UMN decussate in
pyramids = Lateral corticospinal
tracts
ī Others decussate at other levels
of s.c. = Anterior corticospinal
tracts
īĸ LMN (anterior horn motor
neurons)
ī Exits spinal cord via anterior root
ī Activates skeletal muscles
īĸ Regulates fast and fine (skilled)
movements
19. EXTRAPYRAMIDAL TRACTS
īĸ Includes all motor pathways not part of the pyramidal system
īĸ Upper motor neuron (UMN) originates in nuclei deep in cerebrum (not in cerebral
cortex)
īĸ UMN does not pass through the pyramids!
īĸ LMN is an anterior horn motor neuron
īĸ This system includes
ī Reticulospinal tracts â originates at reticular formation of brain; maintain balance
ī Rubrospinal tracts â originate in âred nucleusâ of midbrain; control flexor muscles
ī Tectospinal tracts - originate in superior colliculi and mediate head and eye
movements towards visual targets (flash of light)
ī Vestibulospinal Tract â muscle tone in relation to head and neck movement
īĸ Regulate:
ī Axial muscles that maintain balance and posture
ī Muscles controlling coarse movements of the proximal portions of limbs
ī Head, neck, and eye movement
22. ASCENDING PATHWAY
īĸ The central processes of first-order neurons branch diffusely as they enter
the spinal cord and medulla
īĸ Some branches take part in spinal cord reflexes
īĸ Others synapse with second-order neurons in the cord and medullary nuclei
īĸ The nonspecific and specific ascending pathways send impulses to the
sensory cortex
ī These pathways are responsible for discriminative touch (2 pt. discrimination) and
conscious proprioception (body position sense).
īĸ The spinocerebellar tracts send impulses to the cerebellum and do not
contribute to sensory perception
24. DIRECT SPINOTHALAMIC TRACT
īĸ Include the lateral and
anterior spinothalamic tracts
īĸ Lateral: transmits impulses
concerned with pain and
temp. to opposite side of
brain
īĸ Anterior: transmits impulses
concerned with crude touch
and pressure to opposite
side of brain
īĸ 1st order neuron: sensory
neuron
īĸ 2nd order neuron:
interneurons of dorsal horn;
synapse with 3rd order
neuron in thalamus
īĸ 3rd order neuron: carry
impulse from thalamus to
postcentral gyrus
26. SPINOHTALAMIC PAIN TYPES
īĸ Fast Pain Slow Pain
īĸ Sharp, pricking Dull, burning
īĸ Group III (Aī¤) fiber Group IV (C) fiber
īĸ Short latency Slower onset
īĸ Well localized Diffuse
īĸ Short duration Long duration
īĸ Less emotional Emotional, autonomic response
īĸ Not blocked by morphine Blocked by morphine
īĸ Neospinothalamic Tract Paleospinothalamic Tract
27. 13-27
SPINORETICULAR TRACT
īĸ Pain signals from tissue injury
īĸ Decussate in spinal cord and ascend with spinothalamic fibers
īĸ End in reticular formation (medulla and pons)
īĸ 3rd and 4th order neurons continue to thalamus and cerebral cortex
28. SPINOCEREBELLAR
TRACTS
Spinocerebellar Tract
īĸ Proprioceptive signals from limbs and
trunk travel up to the cerebellum
īĸ Second order nerves ascend in
ipsilateral lateral column.Transmit
info. about trunk and lower limb
muscles and tendons to cerebellum
īĸ No conscious sensation
Anterior SCbllT
(superior
cerebellar
peduncle)
anterior
spinocerebellar
tract
anterior white
commissure
posterior root
Posterior SCbllT
Inferior
cerebellar
peduncle
cuneocerebellar
tract
(upper body)
posterior
white column
posterior root
29. (A) THE DORSAL (POSTERIOR) SPINOCEREBELLAR TRACT.
(B) THE CUNEOCEREBELLAR TRACT. SEE TEXT FOR DETAILS.
31. POST. COLUMN
Dorsal Column Tract
1. AKA Medial lemniscal pathway
2. Fibers run only in dorsal column
3. Transmit impulses from receptors in
skin and joints
4. Detect discriminative touch and
body position sense =proprioception
1st order neuron - a sensory neuron
synapses with 2nd order neuron in nucleus
gracilis and nucleus cuneatus of medulla
2nd order neuron.- an interneuron
decussate and ascend to thalamus where it
synapses with 3rd order neuron
3rd-order (thalamic neurons)
transmits impulse to somato-
sensory cortex (postcentral gyrus)
32. VASCULAR SUPPLIES OF SPINAL CORD
Posterior spinal artery Anterior spinal artery
Origin Vertebral arteries
inside the skull
Posterior inferior
cerebellar artery
Formed by the union of the 2
arteries which are arising
from the vertebral artery
inside the skull
Position Descends on the
posterior surface of
the spinal cord close
to the posterior nerve
roots
Descends on the anterior
surface of the spinal cord
within the anterior median
fissure
Supply Posterior 1/3 of the
spinal cord
Anterior 2/3 of the spinal
cord
Remark Small in the upper
thoracic region
Small in the upper and lower
thoracic segment of the
spinal cord
Risk of
ischemia
T1-T3 segments if the
segmental or radicular
arteries are occluded
T4 & L1 segments if the
segmental or radicular
arteries are occluded
34. FEATURES SUGGESTIVE OF SPINAL CORD DISEASE
System Features
Motor â weakness Acute Flaccid
Chronic Spastic
Sensory - Loss Spinothalamic Below the level contralateral
Post. Column Ipsilateral below the level
Autonomic - Loss Acute Retention, flaccid
Chronic Automatic, spastic
Reflex - Altered Acute â Loss of all reflex
Chronic Deep â exaggerated
Superficial â Altered â abdominal,
cremastic absent, plantar extensor
Other features Level of consciousness - maintained
Cognition - Normal
Cranial nerve - Normal
35. SPINAL CORD SYNDROMES
1. Nature of pathology
1. Compressive
1. Intramedullary
2. Extra medullary
1. Intradural
2. Extradural
2. Non compressive
2. Anatomical location of lesion
1. Transverse
2. Longitudinal
3. Progression and onset of symptoms
1. Acute
2. Chronic
4. Age of onset
1. Childhood
2. Adulthood
3. Elderly
36. SPINAL CORD: EXTRINSIC
īĸ Radicular involvement
īĸ Asymetric, progression in
inverted U pattern
īĸ Ipsi Lateral Hemiplegia,
īĸ contralateral spinothalamic
lesion
īĸ Ipsilateral posterior column
sensory loss
38. signs intramedullary extramedullary
Radicular pain unusual common
Vertebral pain unusual common
Funicular pain common Less common
Umn Sign +, late +, early
Lmn sign +++, diffuse Unusual,
segmental
Paraesthesia progr descending ascending
sphincter early late
Trophic common unusual
39. Extramedullary Intramedullary
Motor
a)UMN signs Common Late
b)LMN signs 1or2segments at the site of
root compression
wide (Ant horn cell)
Sensory
a)Pain Root pain Funicular pain
b)Dissociated sensory loss Absent present
c)Sacral sensation Lost Preserved
d)Joint sensation Lost Late involvement
e)Lhermitte`s sign present absent
Autonamic involvement â
Bowel and Bladder
Late Early
Intradural Extradural
Mode of onset Asymmetrical , acute,rapid
malignant
Symmetrical,slow,
progressive
benign
Vertebral No Pain and gibbus Pain and Gibbus
45. A. TRANSACTION OF CORD
īĸ Etiology
ī Trauma
ī Demyelination
ī Vascular
ī Tumor
ī Infection
ī Radiation
46. CLINICAL FEATURES
īĸ At the level of lesion
ī Band like radicular pain or
ī Segmental paraesthesia
ī Lower motor signs
ī Localised vertebral spine pain- destructive lesions
īĸ Below the level of lesion
ī Sensory loss (all modalities)
ī Motor loss (Paraplegia, Quadriplegia)
ī Arflexia -> hypereflexia
ī Bladder bowel involvement
47. STAGES OF ACUTE CORD SYNDROME (RIDDOCH)
īĸ Stage of spinal shock
ī Motor autonaumic areflexia for 1-6weeks
ī Sometimes last longer or permanent with minimal recovery
īĸ Mechanism
ī Release of supraspinal control
ī Vascular
īĸ Stage of hightended activity
ī Below the lesion
īĸ Tendon hyperreflexia
īĸ Babinski sign
īĸ Flexor spasm
īĸ Reflex bladder bowl mass reflex
īĸ Increased by infection and nociceptive stimuli
ī Above the lesion
īĸ Autonaumic dysreflexia- Disinhibited sympathetic adrenal and medullary discharge->
sweating flussing hypertension, bradycardia
48. B. CENTRAL CORD SYNDROME
īĸ Etiologies
1. Trauma: Especially with
1. Cervical arthritis
2. Older patients
3. Spondylitic myelopathy
2. Syringomyelia
3. Neoplasm:
1. Metastatic, Glioma, lymphoma
49. CLINICAL FEATURES
īĸ Sensory loss
īĸ Pain & temperature (crossing fiber of spinothalamic tract) > Thermo
anaesthesia, analgesia in a âvest likeâ or âsuspendedâ bilateral
distribution with preservation soft touch sensation and proprioception--
- dissociation of sensory loss
īĸ Sparing: Sacral
īĸ Weakness: Arms > legs (Man in Barrel)
īĸ May occur in absence of spinal fracture
50. PROGRESSION OF CENTRAL CORD
īĸ Forward extension of disease
anterior horn cells inv- segmental neurogenic atrophy, paresis,
areflexia
īĸ Lateral extension
I/L horner syndrome
kypho scoliosis
spastic paralysis
īĸ Dorsal extension
I/L position sense, vibratory loss
īĸ Extreme venterolateral extension
thermo anaesthesia, analgesia with sacral sparing
īĸ Neuropathic arthropathy
īĸ Pain
51. C. ANTERIOR CORD SYNDROME
īĸ Etiology:
ī Anterior spinal artery territory ischemia
ī Disc: osteophytes
īĸ Clinical Feature
ī Loss: Motor function Legs > Arm (Corticospinal tract)
ī Pain & temperature sensation loss with preservation: Position sense
(Dissociated anesthesia)
52. D. ANTERIOR HORN CELL SYNDROME
īĸ Aterior horn cell, cranial motor
nuclei involved
īĸ Autosomal recessive spinomuscular
atrophy
īĸ Diffuse weakness and atrophy,
fasciculations of trunk and
extremities
īĸ Muscle tone& DTR â
īĸ Sensation intact
53. COMBINED ANTERIOR HORN CELL AND PYRAMIDAL TRACT
DISEASE
īĸ Progressive diffuse LMN signs with
UMN dysfunction
īĸ Striated muscles except pelvic floor
mucles affected
īĸ U/L, muscles of hands and foot are
involved
īĸ Sparing rectal and urethral sphincter
īĸ Bulbar and pseudobulbar inv super
imposed
54. E. POSTERIOR CORD SYNDROME
īĸ Etiology
ī Posterior spinal artery damage
ī Diffuse atherosclerosis: Deficient collateral perfusion
ī B12 deficiency
ī Lipoma
ī Ligamentum flavum hypertrophy
ī Bimondoâs post column degeneration
ī Tabes dorsalis
īĸ Clinical Features
ī Loss: Position sense
ī Relative preservation: Motor, pain & temperature
ī Prognosis: Better than anterior syndrome
55. F. POSTERO LATERAL COLUMN DISEASE
īĸ Etiology
ī SACD- B12 def
ī Vacuolar myelopathy- AIDS-HTLV
1, tropical spastic paraparesis
ī Cervical spondylosis
īĸ Clinical
ī paraesthesia,
ī diffficulty with gait , balance,
ī loss of vibration and
proprioception, sensory ataxia,
rombergs +,
ī bladder atony,
ī reflexes lost or hypo active â
super imposed peripheral
neuropathy
56. G. ANTERIOR HORN CELL SYNDROME
īĸ Aterior horn cell, cranial motor
nuclei involved
īĸ Autosomal recessive
spinomuscular atrophy
īĸ Diffuse weakness and atrophy,
fasciculations of trunk and
extremities
īĸ Muscle tone& DTR â
īĸ Sensation intact
57. H. COMBINED ANTERIOR HORN CELL AND PYRAMIDAL
TRACT DISEASE
īĸ Progressive diffuse LMN signs
with UMN dysfunction
īĸ Striated muscles except pelvic
floor mucles affected
īĸ U/L, muscles of hands and foot
are involved
īĸ Sparing rectal and urethral
sphincter
īĸ Bulbar and pseudobulbar inv
super imposed
58. I. BROWN-SÃQUARD: HEMICORD INJURY
īĸ Etiologies
ī Tumor: Dumbbell
Facet; Luschka joint
ī Trauma: Penetrating
ī Radiation
ī Decompression sickness
īĸ Clinical Features
ī Ipsilateral loss
īĸ Weakness
īĸ Position sense
ī Contralateral loss
īĸ Pain & temperature
60. FORAMEN MAGNUM SYNDROME & LESIONS OF UPPER
CERVICAL CORD:
īĸ Sub occipital pain in C2 distribution, neck stiffness, electric shock like sensation
sub occipital paraesthesia, syringo myelic type of sensory dissociation, finger tip
numbness and tingling
Spastic tetraparesis, long tract sensory findings, lower cranial nerve palsy
âaround the clock presentation of UMN type of weakness
foramen magnum lesion- down beat nystagmus, papilloedema ,cerebelar ataxia
causes: tumour,cx spondylosis, basilar invagination in pagets disease , syrinx,
C1C2 subluxation, chiari, MS
61. Pyramidal tract decussates at cervicomedullary jn- lesion at
this place causes HEMIPLEGIA CRUCIATA, onion skin
pattern of facial sensory loss, respiratory insufficiency,
bladder dysfunction
Compressive lesion of C1-C5 cord segment may compromise
the cranial nerve 11
C3-C5 lesion produces diaphragmatic paralysis
High cervical cord lesion- respiratory arrest
62. īĸ Lesions of C5-C6:
LMN signs at corresponding segment level. UMN sign below the lesion, LMN paresis
of arm associated with spastic para paresis of lower extremities.
C5 level:
Diaphragmatic function compromised
BJ&BRJ âve
TJ & FFR ++++
Inversion of brachio radialis reflex
Sensory loss entire body below neck and anterior shoulder
C6 level:
BJ,BRJ,TJ âve & FFR ++++
Sensory loss samme as that of C5 lesion sparing the lateral part of arm
63. īĸ Lesion at C7:
Diaphragm fn normal
Paresis of flexors and extensors of wrist and fingers
BJ,BRJ-Normal, FFR++++
Paradoxical triceps jerk
Sensory loss at /below 3rd 4th finger
īĸ Lesion at C8 T1:
Weakness of small muscles of hands with spastic paraparesis
C8 inv- TJ &FFR-ve
T1 inv-TJ âNormal, FFR-ve
U/L or B/l horner syndrome
Sensory loss starts from fifth digit
64. īĸ Lesion of thoracic segment level:
Root pain , paraesthesia mimicking intercostal neuralgia
Segmental LMN paralysis
Paraplegia and sensory loss below a thoracic level
Bladder, bowel sexual dysfunction
Lesion above T5- orthostatic hypotension, episodic autonomic
dysreflexia
Lesion at T10- +ve Beevors sign
Lesion at T6- abdominal reflex âve
Lesion at T10 â upper, middle part +ve
Lesion at T12- abdominal reflex intact
65. īĸ Lesion at L1:
All muscles of lower extremities â weak
Lower abd musc- Internal oblique, tr abd weak
Sensory loss â both lower limbs up to groin, to a level above buttocks
Chronic lesion- patellar++++, ankle++++
īĸ Lesion at L2:
Spastic paraparesis
Cremasteric reflexââ, patellar reflex ââ
Ankle jerk ++++
Sensation in upper anterior aspect preserved
66. īĸ Lesion at L3:
Some preservation of hip flexion, adduction
KJ ââ, ankle++++
Sensation upper anterior aspect of thigh normal
īĸ Lesion at L4:
Better hip flexion, adduction
Able to stand stabilising knee
KJââ , ankle++++
Sensation normal in anterior aspect of thigh, superomedial aspect of knee
īĸ Lesion at L5:
Normal hip flexion, adduction
KJ- normal, ankle++++ pt extends knee against resistance
Sensation normal in antr aspect of thigh, medial aspect of legs ankle and sole
67. īĸ Lesion at S1:
Weakness of triceps surae, flexors of foot, and small muscles of foot
Ankle reflexââ, KJ-normal
Sensory loss- sole, heel, outer aspect of foot and ankle, medial aspect of calf, posterior
thigh, outer aspect of saddle area also anaesthetic
īĸ S2 lesion:
Triceps surae spared, flexors of toes, small muscles of foot weakness
Ankle jerk ââ
Sensory loss- upper part of dorsal aspect of calf, dorsolateral aspect of thigh and
saddle area
68. ROOT SYNDROMES
Root Sensation Index Muscle Reflex Comments
C3/4
Pain or hypalgesia in
shoulders
Paresis of diaphragm,
occasionally rhomboids
None
C3 anterior diaphragm,
C4 posterior diaphragm
C5
Pain or hypalgesia laterally
over upper arm and shoulders
Paresis of deltoid,
supraspin-atus, infra-
spinatus, rhomboids
Diminished
biceps reflex
Common causes include
brachial neuritis, upper
plexus injury, cervical
spondylosis
C6
Pain or hypalgesia of radial
forearm, thumb, and index
finger
Paresis of biceps,
brachialis, brachiorad-ialis,
Extensor carpi radialis
Diminished
biceps,
brachiorad ialis
reflex
Common causes include
spondylosis, acute disc
lesion (20%)
C7
Pain or hypalgesia over
triceps, mid- forearm and
middle finger
Paresis of triceps,
latissimus dorsi, pectoralis
major, ext. carpi ulnaris ,
flex. carpi radialis
Diminished or
absent triceps
reflex
Common causes
includes acute disc
lesions (70%),
spondylosis, DDX
includes CTS (triceps
reflex present)
C8
Pain or hypalgesia over ulnar
forearm, 4th/5th digits
Paresis of flex. dig. sup. &
profundus, flex. poll.
longus, flex. carpi ulnaris
Diminished
finger jerk
(Hoffmans or
Tromner)
Caused rarely by
spondylosis or acute
disc lesion; DDX
includes ulnar nerve
palsy
69. ROOT SYNDROMES
Root Sensation Index Muscle Reflex Comments
T1
Pain or hypalgesia from axilla to
olecranon
Paresis of all small
hand muscles and
hypothenar wasting
None
Common causes
include outlet
syndrome, pancoast
tumor, metastatic Ca of
deep cervical nodes
L3
Pain or hypalgesia across upper
anterior thigh
Paresis of quadriceps
femoris
Patellar reflex
decreased or
absent
DDX includes femoral
nerve palsy
L4
Pain or hypalgesia from lateral
thigh, over patella to medial calf and
inner foot
Paresis of quadriceps
femoris, and tibialis
anterior
Patellar reflex
diminished
5% lumbar discs, DDX
includes femoral nerve
palsy
L5
Pain or hypalgesia from postero-
lateral thigh to lateral calf to dorsum
of foot
Paresis of EHL, occ
EDB
Posterior tibial
reflex decreased;
useful only if
elicitable on other
side
40% lumbar discs; DDX
includes peroneal
nerve palsy
S1
Pain or hypalgesia from posterior
thigh down to lateral aspect and
sole of foot
Paresis of triceps
surae, hamstrings,
gluteus maximus
Achilles tendon
reflex decreased
45% lumbar discs