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NEUROANATOMY Draw It to Know It This Page Intentionally Left Blank NEUROANATOMY Draw It to Know It NEUROANATOMY Draw It to Know It This page intentionally left blank NEUROANATOMY Draw It to Know It ADAM FISCH, MD Washington University in St. Louis School of Medicine Department of Neurology St. Louis, MO 1 2009 1 Oxford University Press, Inc., publishes works that further Oxford University’s objective of excellence in research, scholarship, and education. Oxford New York Auckland Cape Town Dar es Salaam Hong Kong Karachi Kuala Lumpur Madrid Melbourne Mexico City Nairobi New Delhi Shanghai Taipei Toronto With offices in Argentina Austria Brazil Chile Czech Republic France Greece Guatemala Hungary Italy Japan Poland Portugal Singapore South Korea Switzerland Thailand Turkey Ukraine Vietnam Copyright © 2009 by Adam Fisch. Published by Oxford University Press, Inc. 198 Madison Avenue, New York, New York 10016 www.oup.com Oxford is a registered trademark of Oxford University Press All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of Oxford University Press. Library of Congress Cataloging-in-Publication Data Fisch, Adam. Neuroanatomy : draw it to know it / Adam Fisch. p. cm. Includes bibliographical references and index. ISBN 978-0-19-536994-6 1. Neuroanatomy—Graphic methods. I. Title. QM451.F57 2009 611.8—dc22 2008047543 9 8 7 6 5 4321 Printed in the United States of America on acid-free paper This book is dedicated in loving memory to my younger brother, David, whose humility and enthusiasm for learning remain a source of inspiration. This page intentionally left blank FOREWORD EUROANATOMY IS A nightmare for neuroimaging, the actual practice of neurology, most medical students. The complex array of whether it is done by a neurologist or a Nnuclei, ganglia, tracts, lobes, Brodmann areas non-neurologist involves localizing the problem. The and cortical layers seem to the uninitiated as the nervous system is just too complicated to skip this height of useless trivia. My own memory of my step. Without an organized approach based on a neuroanatomy class in medical school is vivid. Our reasonable understanding of functional professor, a Ph.D. neuroanatomist, ordered each neuroanatomy, clinical neurology becomes member of the class to buy a set of colored pencils; the incomprehensible. kind you had in third grade. Each color was coded for In his wonderful book, Neuroanatomy: Draw particular structures (red for the caudate, green for It to Know It, neurologist Adam Fisch applies my old the putamen, yellow for the claustrum and burnt neuroanatomy professor’s colored pencil idea in a sienna for the globus pallidus). At our senior play, manner that actually works, and it’s fun! Over the which poked fun at our professors, a beleaguered course of 39 chapters, most of the clinically important medical student was asked to name the components of neuroanatomically important subjects are covered, the basal ganglia. Without knowing what the ranging through the overall organization of the structures even were or did, he responded “red, green, nervous system, the coverings of the brain, the yellow, and burnt sienna.” Almost forty years later, this peripheral nervous system, the spinal cord, the remains a class joke. Except for the handful of us who brainstem, the cerebellum and the cerebral cortex. went into neurology, neurosurgery and psychiatry, the It is clear that the book was written by an experienced basal ganglia to the rest of my class is just a fading joke neurologist, as the topics are organized in a fashion from the distant past. that illuminates the principle of anatomical- And yet, no one can practice even rudimentary pathophysiological correlation, which is the neurology without some basic understanding of the tool with which neurologists approach clinical neuroanatomy. Non-neurologists in particular, many problems. of whom see large numbers of patients with This book should be of great interest to all neurological complaints, have no hope of sorting out neurologists, neurosurgeons, neurology residents and common problems such as headache, dizziness, students of neurology. Others who see patients with tiredness, fatigue, sleep disorders, numbness and neurological complaints, such as internists, tingling and pain, without a reasonable grasp of how emergency physicians and obstetrician-gynecologists the nervous system is organized. Despite all of the should also review their neuroanatomy if they wish to marvelous advances in neuroscience, genetics and provide excellent care to their patients. As any VII experienced teacher knows, one only really knows a information learned in this manner is likely to stick. subject when one can teach it oneself. By drawing the Adam Fisch has done us all a great service by anatomy, the reader of this book literally teaches the rekindling the enjoyment in learning the relevant, subject to himself. By making it clinically relevant, the elegant anatomy of the nervous system. Martin A. Samuels, MD, DSc(hon), FAAN, MACP Chairman, Department of Neurology Brigham and Women’s Hospital Professor of Neurology Harvard Medical School Boston, MA VIII FOREWORD PREFACE YNEUROANATOMYMENTOR, the late body, imagine cognitive sensory deficits, and Dr. William DeMyer, often remarked, “if rigorously draw and re-draw the structures and Myou can’t draw it, you don’t know it.” His pathways of the nervous system until they become teaching method was straightforward: to learn the second nature. structures and fiber pathways of the nervous system, The text is comprehensive but pearls of draw and re-draw them, and when you think you neuroanatomy are highlighted for those who are know them well, draw them some more. This book short on time. Anatomic and radiographic images tries to emulate his approach. It is written in an accompany the figures to clarify what the drawings instructive rather than a didactic manner so that we cannot. Synonymous terms are listed to mitigate use the material to learn it. confusion; inter-textual discrepancies are brought The analogy is simple: if you want to become a to attention; and historical and current contexts table expert, put one together. Invariably, you will for the anatomical structures are discussed. In screw the legs on backwards and hammer on the top short, this book provides the tools you need to learn upside down first, but how else will you learn about neuroanatomy in a practical and complete way so the washers and wing-nuts, bolts and fillets that fasten that you can use it at the bedside. one together? How else will you understand what I apologize to readers who are unable to perform makesatablestrongorlearnitsweakpointsandthe exercises in this book due to physical impairments. If ways to improve upon one? Reading about tables will you have trouble imagining them, please write to me never teach you: you have to put one together, and I will gladly try to find alternative exercises yourself. for you. With this book, we will trace nerve pathways down Neuroanatomy is hardly simple but it should our limbs, demonstrate eye movements and vestibular always be fun, so let’s enjoy this trip through directionality with our hands, palpate sensory the nervous system and every trip back distributions and muscle patterns across our face and through it. IX This page intentionally left blank ACKNOWLEDGMENTS OTRYTOACKNOWLEDGEall of the people Mohammed Al-Lozi, Joseph Black, Kelly Brown, I ought to would be impossible and William DeMyer, Adriana Escandon, Stephen Tself-defeating so I will only mention a few. Duntley, Mark Jacquin, David Holtzman, William The foremost is Susan Pioli who, along with my Landau, Abdullah Nassief, Robert Pascuzzi, Beth uncle, Bruce, championed this book from the start. Ward, Thomas Woolsey, and Allyson Without her enthusiasm for this project, it never Zazulia. would have been done. I’d also like to thank my editor, I’d also like to thank Denny Fiske, Paul Lysy, and Craig Panner, and his editorial assistant, David Michael Schwartz for their help generating the muscle D’Addona, as well as the book’s production manager, testing photographs, and Tammie Benzinger and Jennifer Bossert; they, along with many others at Robert Cargile in the Department of Neuroradiology Oxford University Press, steered this book to at Washington University in St. Louis for their help completion with remarkable vision. creating the diffusion tensor images. I am grateful to the faculty and staff in the I owe special thanks to my family for all of their Departments of Anatomy and Neurology at Indiana encouragement during this process. University and Washington University in St. Louis and Most of all, though, I owe my wife, Kate, all of my to Robert J. Schwartzman of Drexel University School love and gratitude for allowing the cat and me to of Medicine for all they taught me about devote our mornings, nights, and weekends to writing neuroanatomy and clinical neurology during my and illustrating this book. We look forward to being a neurology training. Special thanks are owed to part of your life, again. XI This page intentionally left blank CONTENTS 2 Chapter 1, Organization of the Nervous System 4 Chapter 2, Orientational Terminology 6 Chapter 3, Meninges and Ventricular System 24 Chapter 4, Nerve Roots and Rami 28 Chapter 5, Brachial Plexus 36 Chapter 6, Median Nerve 44 Chapter 7, Ulnar Nerve 54 Chapter 8, Radial Nerve 62 Chapter 9, Lumbosacral Plexus 68 Chapter 10, Sciatic Nerve 76 Chapter 11, Femoral Nerve 78 Chapter 12,
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