Adaptation in the spinal cord after stroke: Implications for restoring cortical control over the final common pathway

Control of voluntary movement is predicated on integration between circuits in the brain and spinal cord. Although damage is often restricted to supraspinal or spinal circuits in cases of neurological injury, both spinal motor neurons and axons linking these cells to the cortical origins of descending motor commands begin showing changes soon after the brain is injured by stroke. The concept of 'transneuronal degeneration' is not new and has been documented in histological, imaging and electrophysiological studies dating back over a century. Taken together, evidence from these studies agrees more with a system attempting to survive rather than one passively surrendering to degeneration. There tends to be at least some preservation of fibres at the brainstem origin and along the spinal course of the descending white matter tracts, even in severe cases. Myelin-associated proteins are observed in the spinal cord years after stroke onset. Spinal motor neurons remain morphometrically unaltered. Skeletal muscle fibres once innervated by neurons that lose their source of trophic input receive collaterals from adjacent neurons, causing spinal motor units to consolidate and increase in size. Although some level of excitability within the distributed brain network mediating voluntary movement is needed to facilitate recovery, minimal structural connectivity between cortical and spinal motor neurons can support meaningful distal limb function. Restoring access to the final common pathway via the descending input that remains in the spinal cord therefore represents a viable target for directed plasticity, particularly in light of recent advances in rehabilitation medicine. image Abstract figure legend A coarse approximation of the organization of white matter tracts that transmit descending commands from cortical motor areas to spinal motor neuron pools. Fibres that roughly segregate into each tract at the level of the brainstem overlap in cortical origin and intermingle throughout their cranial course. Corticospinal fibres that decussate in the medullary pyramids exist both anterior and posterior to the central canal in the lateral funiculus. A considerably smaller portion of corticospinal fibres cross more caudally in the cervical spinal cord and course along the median fissure in the ventral funiculus. Rubrospinal fibres originating in the red nucleus that decussate at the midbrain are sparse in the spinal cord when actually observed in human cases and do not exist below upper cervical segments. Reticulospinal fibres originating in the pontine reticular formation exist throughout the spinal cord but do not form a compact bundle and tend to be scattered in the cord, coursing anterior to corticospinal fibres. Propriospinal fibres are found near dorsal and ventral horns most prominently at cervical and lumbar enlargements, with short fibres closest to the spinal grey matter and long fibres more lateral. Created with image