Neuroanatomy, Medial Lemniscus (Reils Band, Reils Ribbon)


Article Author:
Daniel Navarro-Orozco


Article Editor:
Pradeep Bollu


Editors In Chief:
Michael Labanowski


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes


Updated:
10/27/2018 12:31:42 PM

Introduction

The medial lemniscus is a second order neuron of the dorsal column-medial lemniscus pathway (DCML), which, with somatotopic arrangement, transports the sensory spinothalamic information of conscious proprioception, vibration, fine touch, and 2-point discrimination of skin and joints of the body and head; from the caudal medulla to the ventral posterolateral nucleus of the thalamus, and subsequently the primary somatosensory cortex. The medial lemniscus (second-order neuron of DCML) commences at the nucleus gracilis and nucleus cuneatus at the caudal medulla; the arcuate fibers decussate at the caudal medulla and ascend via the medial lemniscus contralaterally in the brainstem until synapsing at the ventral posterolateral nucleus of the thalamus, point at which the third order neuron of the DCML pathway commences. The third order neuron ascends from the ventral posterolateral nucleus until synapsing with the primary somatosensory region of the brain cortex. Due to the unique somatosensory information and location this pathway, the dorsal column-medial lemniscus tract may be used as an important clinical clue to pinpoint a possible site of injury and manage the patient accordingly.

Structure and Function

The primary function of the medial lemniscus as a second-order neuron of the dorsal column-medial lemniscus pathway (DCML) is to transport the sensory spinothalamic information of conscious proprioception, vibration, fine touch, and 2-point discrimination of skin and joints of the body and head; from the caudal medulla to the ventral posterolateral nucleus of the thalamus, and subsequently the primary somatosensory cortex.

Embryology

The embryological origin of the medial lemniscus, just like the entire nervous system is of neural ectoderm origin. The neural ectoderm further divides into 3 main sub-divisions that contribute to the DCML pathway.

The neural plate, responsible for the central nervous system (CNS) develops cerebral vesicles including:

  • The myelencephalon, which develops into the medulla oblongata
  • The metencephalon developing into the pons
  • The mesencephalon developing into the midbrain
  • The diencephalon developing into the thalamus 
  • The telencephalon developing into the cerebral cortex

As previously described, all of these structures are important components of the DCML tract and its development. Furthermore, the protein Netrin-1 secreted from the floor plate of the medulla oblongata plays an important role in the development and migration of the axons forming the medial lemniscus.[1]

The neural crest cells responsible for the peripheral nervous system (PNS) including the somatic sensory nerves gives rise to first-order neurons of the DCML pathway. It contributes to the development of tactile mechanoreceptors such as Meissner corpuscles giving light touch and vibrations, Ruffini corpuscles detecting tension in skin, Merkel discs detecting pressure, and Pacinian corpuscles detecting high-frequency vibration.

Lastly, the ectodermal placodes, which provide cranial sensory ganglia, develop into the chief sensory nucleus of the trigeminal nerve whose axons also join the medial lemniscus pathway with the purpose of providing conscious proprioception, vibration, fine touch, and 2-point discrimination of the head.

Blood Supply and Lymphatics

The blood supply of the medial lemniscus varies in accordance with the level of the brainstem. The nucleus gracilis and nucleus cuneatus are located in the medial posterior aspect of the medulla and are irrigated by the posterior spinal artery. The arcuate fibers decussate in the medial anterior aspect of the medulla and are irrigated predominantly by the anterior spinal artery. The medial lemniscus begins ascending contralaterally in the brainstem in the medial aspect of the medulla and is irrigated by the anterior spinal artery. As the medial lemniscus continues to ascend, it begins shifting posteriorly and laterally; at the level of the pons, the medial lemniscus is irrigated by the basilar artery. By the time the medial lemniscus makes it to the midbrain, it is predominantly located in the posterior lateral aspect of the midbrain, and the posterior cerebral artery irrigates it.[2]

Infarction of certain regions of the brainstem may present with loss of conscious proprioception, vibration, fine touch, and 2-point discrimination due to the medial lemniscus being located at different positions of the brainstem, and thalamus.

Surgical Considerations

The medial lemniscus (second-order neuron of the DCML pathway) is contained in its majority within the brainstem. Due to the high density of neurological tracts and nuclei in the brainstem, it is complex to perform surgery targeting specific pathways within it. Surgery in the brainstem may result in additional neurologic tracts being damaged; therefore, surgery has been historically reserved for clear-cut cases in which benefits outweigh risks. A prospective randomized clinical trial was conducted, in which motor deficit and neurological status outcomes were evaluated using preoperative diffusion tensor imaging (DTI) and diffusion tensor tractography (DTT) in patients undergoing surgery for cavernous brainstem malformations. Although it is too early to make any conclusions; results seem promising as specific tracts and pathologies may be visualized, allowing for better surgical approach, decision making, and potentially decreasing morbidities.[3]

Clinical Significance

The DCML pathway may be affected at numerous points throughout its first, second, and third order neurons. The clinical presentation may be convoluted due to its proximity to other neurologic tracts; furthermore, the absence of conscious proprioception, vibration, fine touch, and 2-point discrimination of skin and joints is pathognomonic for damage of the DCML pathway. The level at which the DCML pathway is affected will determine the clinical presentation. Below is a list of pathologies in which the DCML pathway is affected.

  1. Tabes dorsalis: This pathology is caused by the spirochete Treponema pallidum in advanced tertiary syphilis. Although rarely seen due to T. pallidum sensitivity to penicillin, tabes dorsalis results in demyelination of the dorsal column and roots, typically affecting the lower limbs due to the lumbosacral region being the one that is predominantly affected. The lack of conscious proprioception, vibration, fine touch, and 2-point discrimination of skin and joints results in neuropathic osteoarthropathy (Charcot joint). The Charcot joint presents with progressive degeneration of weight-bearing joints, the most common joint affected is the midfoot. This may complicate with bone fractures and ulcerations of the site of injury. Management of this condition is targeting the underlying infectious agent with intravenous penicillin.

  2. Vitamin B12 deficiency: Subacute, combined degeneration is the demyelination of the dorsal columns, lateral corticospinal tracts, and spinocerebellar tracts due to vitamin B12 deficiency. Vitamin B12 is rarely deficient in the United States; however, one must always rule it out in specific patient groups at higher risk such as strict vegans, patients suffering from inflammatory bowel disease (IBD), chronic malabsorption, pernicious anemia, history of gastrectomy, diphyllobothrium latum infection, and cystic fibrosis. The condition may be diagnosed by obtaining methylmalonic acid levels. The treatment is vitamin B12 supplementation; however, the extent of recovery will be dependent on the duration and extent of the neuronal damage.

  3. Brown-Sequard syndrome: This pathology is a theoretical injury that is rarely seen in practice as clear cut as described in medical textbooks. It is composed of a hemisection of the spinal cord, typically due to trauma, ischemia, a large unilateral tumor, or infectious agents. The hemisection results in loss of the ipsilateral DCML pathway, ipsilateral corticospinal tract damage, contralateral spinothalamic tract damage; in addition, it results in flaccid paralysis and loss of all sensation at the level of injury. The clinical presentation is with loss of conscious proprioception, vibration, fine touch, and 2-point discrimination of skin and joints on the ipsilateral side of injury, spasticity and hyperreflexia on the ipsilateral side of injury, loss of pain and temperature in the contralateral side of injury, and flaccid paralysis and loss of all sensation at the level of injury. Diagnosis may be done through magnetic resonance imaging, and a neurologic exam detailing a clinical presentation similar to those mentioned above. Treatment is specific to the underlying pathology.

  4. Medial medullary syndrome: Medial medullary syndrome is an infarction of the medial aspect of the medulla oblongata due to occlusion of the paramedian branches of the anterior spinal artery. The infarction results in loss of conscious proprioception, vibration, fine touch, and 2-point discrimination of skin and joints of the contralateral side due to damage to the medial lemniscus. Also, it presents with contralateral hemiparesis due to damage to the corticospinal tract before decussation at the medullary pyramids and ipsilateral tongue deviation due to hypoglossal nerve fibers damage. The evaluation includes coagulation studies, echocardiogram, and CT angiography. Management is dependent on the time of onset, and type of stroke (ischemic versus hemorrhagic).

  5. Paramedian artery occlusion: The paramedian arteries are a branch of the basilar artery that supplies oxygenated blood to the pons. Paramedian artery occlusion is also a condition that is rarely seen in the clinic. However, it is important to point out that the paramedian arteries irrigate the medial basal pons, pontine nuclei, corticospinal fibers, and the medial lemniscus as it ascends through the pons. The evaluation includes coagulation studies, echocardiogram, and CT angiography. Management is dependent on the time of onset, and type of stroke (ischemic versus hemorrhagic).

  6. Upper dorsal pontine syndrome: This syndrome is also known as “Raymond Cestan syndrome” and is due to occlusion of the long circumferential branches of the basilar artery. The occlusion of the results mentioned above in damage to the medial lemniscus pathway, resulting in contralateral loss of conscious proprioception, vibration, fine touch, and 2-point discrimination of skin and joints. Furthermore, it may present with ipsilateral ataxia, ipsilateral paralysis to the muscles of mastication, ipsilateral sensory loss of the face, horizontal gaze palsy, contralateral loss of touch pain and temperature, and contralateral hemiparesis of the face and body. The evaluation includes coagulation studies, echocardiogram, and CT angiography. Management is dependent on the time of onset, and type of stroke (ischemic versus hemorrhagic).

In addition to the syndromes above, the following may present with damage to the medial lemniscus pathway:

  • Dorsal midbrain syndrome due to occlusion of the paramedian branches of the basilar artery may result in medial lemniscus damage if the occlusion has a lateral extension. 

  • Thalamic strokes causing damage to the ventral posterolateral nucleus due to occlusion of thalamic branches of the posterior cerebral artery could result in damage to the third order neuron of the DCML pathway.


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Neuroanatomy, Medial Lemniscus (Reils Band, Reils Ribbon) - Questions

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A 67-year-old male presents to the emergency department with his wife. The wife describes that the patient suddenly started acting oddly with sudden memory loss and visual issues she cannot quite describe. Upon further questioning and physical exam, it is determined the patient has right sided homonymous hemianopia with macular sparing, right-sided hemisensory loss of touch, proprioception, vibration, and two-point discrimination, as well as vertigo, and memory loss. A left-sided posterior cerebral artery stroke is suspected. Coagulation studies, CT angiography, and echocardiogram are ordered. The loss of proprioception, vibration, and two-point discrimination is likely due to involvement of which of the following thalamic nuclei?



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A 75-year-old male presents to the emergency department with suspected medial medullary syndrome due to occlusion of the paramedian branches of the anterior spinal artery. After workup and management, your attending physician explains that infarction of the medial aspect of the medulla oblongata results in loss of function of the medial lemniscus, corticospinal fibers of the pyramidal tract, and hypoglossal nerve fibers. To evaluate your understanding of the dorsal column-medial lemniscus pathway, your attending physician asks you the following question: The fibers of which nuclei give rise to the medial lemniscus?



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A 72-year-old male presents to the emergency department after sudden onset weakness of the right arm and leg and deviation of the tongue to the left upon attempted protrusion. Infarction of the medial aspect of the medulla oblongata is suspected due to occlusion of the paramedian branches of the anterior spinal artery. Coagulation studies, CT angiography, and an echocardiogram are ordered. What additional sign(s) is likely to be present in this patient?



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A 20-year-old college student comes to your clinic for his yearly checkup. Upon history taking, he tells you that he is a pre-med biology major student who has taken numerous courses and is well versed in the medical field. While checking his reflexes, he volunteers information regarding the posterior column pathway; however, he cannot remember what the dorsal column pathway is called in the brainstem. What is the term for the large ascending bundle in the medulla which constitutes the second neuron of the posterior column pathway conveying conscious proprioception, vibration, fine touch, and two-point discrimination of skin and joints sense to the ventral posterolateral nucleus of the thalamus?



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An 8-year-old male presents to your clinic for evaluation of a focal brainstem glioma. An MRI shows a focal glioma in the midbrain, and the neurosurgical team is debating on neurosurgery, chemotherapy, or radiation therapy. Diffusion tensor imaging is used preoperatively to visualize the neuronal tracts in the midbrain. If the surgical approach is taken, damage to the medial lemniscus at the level of the midbrain will most likely result in which of the following?



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Neuroanatomy, Medial Lemniscus (Reils Band, Reils Ribbon) - References

References

Kubota C,Nagano T,Baba H,Sato M, Netrin-1 is crucial for the establishment of the dorsal column-medial lemniscal system. Journal of neurochemistry. 2004 Jun     [PubMed]
Romanowski CA,Hutton M,Rowe J,Yianni J,Warren D,Bigley J,Wilkinson ID, The Anatomy of the Medial Lemniscus within the Brainstem Demonstrated at 3 Tesla with High Resolution Fat Suppressed T1-Weighted Images and Diffusion Tensor Imaging. The neuroradiology journal. 2011 May 15     [PubMed]
Li D,Jiao YM,Wang L,Lin FX,Wu J,Tong XZ,Wang S,Cao Y, Surgical outcome of motor deficits and neurological status in brainstem cavernous malformations based on preoperative diffusion tensor imaging: a prospective randomized clinical trial. Journal of neurosurgery. 2018 Mar 16     [PubMed]

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