The Netter Collection of Medical Illustrations: Nervous System, Volume 7, Part II - Spinal Cord and Peripheral Motor and Sensory Systems, 2e

311 Pages·2013·124.475 MB·English

by  H. Royden Jones Jr. Jr., Ted Burns, Michael J. Aminoff, Scott Pomeroy

The ultimate Netter
Collection is back!
Netter’s timeless work, now arranged
and informed by modern text and
radiologic imaging!
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VOLUME 7
The Netter Collection

OF MEDICAL ILLUSTRATIONS
Nervous System
Part II—Spinal Cord and Peripheral
Motor and Sensory Systems
2nd Edition
A compilation of paintings prepared by
FRANK H. NETTER, MD
Edited by
H. Royden Jones, MD Michael J. Aminoff, MD, DSc, FRCP
Jaime Ortiz-Patino Chair in Distinguished Professor and Executive
Neurology Vice Chair
Lahey Clinic Department of Neurology
Burlington, Massachusetts; School of Medicine
Clinical Professor of Neurology University of California
Harvard Medical School San Francisco, California
Boston Children’s Hospital
Scott L. Pomeroy, MD, PhD
Boston, Massachusetts
Bronson Crothers Professor of Neurology
Ted M. Burns, MD
Harvard Medical School
Professor and Executive Vice Chair Chair, Department of Neurology
Department of Neurology Neurologist-in-Chief
University of Virginia Boston Children’s Hospital
Charlottesville, Virginia Boston, Massachusetts
Additional Illustrations by Carlos A. G. Machado, MD
CONTRIBUTING ILLUSTRATORS
James A. Perkins, MS, MFA
Anita Impagliazzo, MA, CMI
Kristen Wienandt Marzejon, MS, MFA
Tiffany S. DaVanzo, MA, CMI
John A. Craig, MD
1600 John F. Kennedy Blvd.
Ste. 1800
Philadelphia, PA 19103-2899
THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS: ISBN: 978-1-4160-6386-5
NERVOUS SYSTEM: PART II—SPINAL CORD AND PERIPHERAL
MOTOR AND SENSORY SYSTEMS, Volume 7, Second Edition
Copyright © 2013 by Saunders, an imprint of Elsevier Inc.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic
or mechanical, including photocopying, recording, or any information storage and retrieval system,
without permission in writing from the publisher. Details on how to seek permission, further
information about the Publisher’s permissions policies and our arrangements with organizations such as
the Copyright Clearance Center and the Copyright Licensing Agency can be found at our website:
www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the
Publisher (other than as may be noted herein).
Permission for Netter Art figures may be sought directly from Elsevier’s Health Science Licensing
Department in Philadelphia, PA: phone [phone], ext. 3276, or [phone]; or email
[e-mail]
Notices
Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical
treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in
evaluating and using any information, methods, compounds, or experiments described herein. In
using such information or methods they should be mindful of their own safety and the safety of
others, including parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the
most current information provided (i) on procedures featured or (ii) by the manufacturer of each
product to be administered, to verify the recommended dose or formula, the method and duration of
administration, and contraindications. It is the responsibility of practitioners, relying on their own
experience and knowledge of their patients, to make diagnoses, to determine dosages and the best
treatment for each individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors,
assume any liability for any injury and/or damage to persons or property as a matter of products
liability, negligence or otherwise, or from any use or operation of any methods, products,
instructions, or ideas contained in the material herein.
ISBN: 978-1-4160-6386-5
Senior Content Strategist: Elyse O’Grady
Content Development Manager: Marybeth Thiel
Publishing Services Manager: Patricia Tannian
Senior Project Manager: John Casey
Senior Design Manager: Lou Forgione
Working together to grow
libraries in developing countries
Printed in China www.elsevier.com | www.bookaid.org | www.sabre.org
Last digit is the print number: 9 8 7 6 5 4 3 2 1
ABOUT THE SERIES
Dr. Frank H. Netter exemplified the CUSHING’S SYNDROME IN A PATIENT WITH THE CARNEY COMPLEX
distinct vocations of physician,
artist, and teacher. Even more important—
he unified them. Netter’s illustrations
always began with meticulous research
into the detailed human clinical
anatomy and pathology, a philosophy
that steered his broad and deep medical
Carney complex is characterized
understanding. He often said: “Clarifi­ by spotty skin pigmentation.
Pigmented lentigines and blue
cation is the goal. No matter how beau­ nevi can be seen on the face–
including the eyelids, vermillion
tifully painted, a medical illustration bcoonrdjuenrsc otifv athee, tlhipes s, cthleera–and the
has little value if it does not make clear labia and scrotum.
a medical point.” His greatest challenge Additional features of the
and greatest success was charting a Carney complex can include:
Myxomas: cardiac atrium,
middle course between artistic clarity cutaneous (e.g., eyelid),
and mammary
and instructional complexity. That suc­
Testicular large-cell
cess is captured in this series, beginning calcifying Sertoli cell tumors
in 1948, when the first comprehensive Gsercoewretthin-hgo prmituointaery adenomas
Dr. Frank Netter at work.
collection of Netter’s work, a single Psammomatous
melanotic schwannomas
volume, was published by CIBA Pharmaceuticals. It
met with such success that over the following 40 years
the collection was expanded into an 8­volume series—
each devoted to a single body system.
In this second edition of the legendary series, we are
delighted to offer Netter’s timeless work, now arranged
and informed by modern text and radiologic imaging
contributed by highly respected neurologic authorities
from world­renowned medical institutions, and supple­ PPNAD adrenal glands are usually of normal size and most are
studded with black, brown, or red nodules. Most of the pigmented
mented with new illustrations created by artists working nodules are less than 4 mm in diameter and interspersed in the
adjacent atrophic cortex.
in the Netter tradition. Inside the classic green covers,
A brand new illustrated plate painted by Carlos Machado,
students and practitioners will find hundreds of original
MD, for The Endocrine System, Volume 2, 2nd ed.
works of art—the human body in pictures—paired with
the latest in expert medical knowledge and innovation
and anchored in the sublime style of Frank Netter.
The single-volume “blue book” that paved the way for
the multivolume Netter Collection of Medical Illustrations Noted artist­physician, Carlos Machado, MD, the
series aff ectionately known as the “green books.” primary successor responsible for continuing the Netter
tradition, has particular appreciation for the Green Book
series. “The Reproductive System is of special significance
for those who, like me, deeply admire Dr. Netter’s work.
In this volume, he masters the representation of textures
of different surfaces, which I like to call ‘the rhythm of
the brush,’ since it is the dimension, the direction of the
strokes, and the interval separating them that create the
illusion of given textures: organs have their external
surfaces, the surfaces of their cavities, and texture of their
parenchymas realistically represented. It set the style for
the subsequent volumes of Netter’s Collection—each an
amazing combination of painting masterpieces and
precise scientific information.”
Though the science and teaching of medicine endures
changes in terminology, practice, and discovery, some
things remain the same. A patient is a patient. A teacher
is a teacher. And the pictures of Dr. Netter—he called
them pictures, never paintings—remain the same blend
of beautiful and instructional resources that have guided
physicians’ hands and nurtured their imaginations for
more than half a century.
The original series could not exist without the dedica­
tion of all those who edited, authored, or in other ways
contributed, nor, of course, without the excellence of Dr.
Netter. For this exciting second edition, we also owe our Dr. Carlos Machado at work.
gratitude to the Authors, Editors, Advisors, and Artists
whose relentless efforts were instrumental in adapting
these timeless works into reliable references for today’s
clinicians in training and in practice. From all of us with
the Netter Publishing Team at Elsevier, we thank you.
THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS v
ABOUT THE EDITORS
H.R oyden Jones, MD, is Chair Emeritus of the disorders. Dr. Jones has edited three other Netter pub- Ted M. Burns, MD, is Professor of Neurology at
department of neurology at Lahey Clinic in lications including the 1986 edition of this atlas and two the University of Virginia. He was born and raised
Burlington, Massachusetts, and Emeritus Director of editions of Netter’s Neurology. He has been invited to in a suburb of Kansas City, Kansas. He received his
the electromyography laboratory at Children’s Hospital speak worldwide on childhood neuromuscular disor- undergraduate and medical degrees from the University
Boston. He is Clinical Professor of Neurology at ders. Dr. Jones is a co-founder of the biennial Interna- of Kansas and then attended the University of Virginia
Harvard Medical School and a lecturer in neurology at tional Paediatric EMG Conference based at Great for neurology residency and clinical neurophysiology
Tufts Medical School. At Lahey he holds the Jaime Ormond Street Children’s Hospital, London, England. fellowship. Dr. Burns completed a second fellowship in
Ortiz-Patino Chair of Neurology. Dr. Jones graduated He has broad adult clinical interests particularly neuro- peripheral nerve disorders at Mayo Clinic in Rochester,
from Tufts College and Northwestern University immunologic and paraneoplastic neuromuscular disor- Minnesota. He was on staff at Lahey Clinic in Burling-
Medical School. After interning at Philadelphia General ders. Dr. Jones has contributed over 200 peer-reviewed ton, Massachusetts, for 2 years before joining the neu-
Hospital, he became an internal medicine resident at papers and book chapters. rology department at the University of Virginia in
Mayo, eventually specializing in neurology and clinical Dr. Jones served 8 years as a director of the American 2002. In 2008, he received a Harrison Distinguished
neurophysiology. Dr. Jones served over 3 years in the Board of Psychiatry and Neurology, becoming Chair Professor Chair at the University of Virginia. Dr. Burns
United States Army as Chief of Neurology at 5th of its Neurology Council in 2004. During this tenure is Vice Chair of the neurology department and Director
General Hospital, Bad Cannstatt, Germany. he was a member of the Residency Review Council of the Neurology Residency Program and the Clinical
He joined Lahey Clinic in 1972, initially establishing of the Accreditation Council for Graduate Medical Neurophysiology Fellowship Program. He is also the
their neurology residency affiliations with Boston Education. In 2007 he received the American Associa- Medical Director of the Neurology EMG Laboratory.
City Hospital and later Tufts Medical Center. In 1984 tion of Neuromuscular and Electrodiagnostic Medi- Dr Burns’s clinical focus is on the care of patients
he founded Lahey’s clinical neurophysiology neuro- cine’s Distinguished Physician Award. Lahey Clinic’s with neuromuscular disease, including myasthenia
muscular disorders fellowship and subsequently trained Medical Staff Association recognized Dr. Jones in gravis. He won the Myasthenia Gravis Foundation of
a number of future leaders in this field. At Lahey he 2010 with its highest honor—the Frank Lahey Award America’s “Doctor of the Year” award for 2010. His
has also served as Chairman of the Medical Personnel for “commitment to the values of Dr. Frank Lahey: academic interests include the development and valida-
committee, Chair of Education, and Chair of the Divi- respect, teamwork, excellence, commitment to per- tion of user-friendly outcome measures for myasthenia
sion of Medicine and Medical Specialties and served on sonal best.” In 2011 he received Lahey’s Annual gravis and other neuromuscular disorders. Dr. Burns is
their Board of Governors for 19 years. He now enjoys Research Award. also interested in podcasting for the education of physi-
patient care, clinical research, and teaching responsi- He and his wife have four children. Their daughter cians, patients, and families. He is creator and editor of
bilities full time. is a former New York City prosecutor, their oldest son the Neurology journal’s weekly podcast and the Ameri-
In 1977 Dr. Jones joined the neurology department is a professor at the University of Rochester Simon can Association of Neuromuscular and Electrodiagnos-
at Boston Children’s Hospital, founding the electromy- School of Business, and two other sons are physicians; tic Medicine’s (AANEM) podcast. He is also the creator
ography laboratory in 1979. Noting that no clinical one is an emergency medicine specialist in rural New of the MGFA’s podcast series designed to educate
information was then available in pediatric EMG, this Hampshire, and the other holds the Ackerman endowed patients and families about practical aspects of MG.
became a major clinical research interest of his, eventu- chair of the Culture of Medicine at Harvard College Dr. Burns and his wife, Bonnie, have three wonderful
ally leading to his co-editing three major textbooks on and Medical School. Photography is Dr. Jones’s major children, Charlie, Elizabeth, and Sarah. He and his
childhood clinical neurophysiology and neuromuscular avocation. family live in Charlottesville, Virginia.
vi THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS
About the Editors
Michael J. Aminoff, MD, was born and educated editions, and of a number of chapters on topics related Scott L. Pomeroy, MD, PhD, graduated from
in England, graduating from University College to neurology. His published scientific contributions led Miami University and was the first graduate of the
London in 1962 and from University College Hospital to the award of a Doctorate in Science, an advanced MD/PhD program of the University of Cincinnati. He
Medical School as a physician in 1965. He subsequently doctorate in the Faculty of Science, by the University trained in pediatrics at Boston Children’s Hospital and
trained in neurology and clinical neurophysiology of London in 2000. He is the one of the two editors- in child neurology at St. Louis Children’s Hospital. In
at The National Hospital for Neurology and Neuro- in-chief of the four-volume Encyclopedia of the Neurologi- 1989, he won the Child Neurology Society Young
surgery (Queen Square) in London and also undertook cal Sciences published by Academic Press in 2003 (a new Investigator Award for work done as a postdoctoral
basic research on spinal physiology at its affiliated edition is in press). He is also one of the series editors fellow with Dale Purves at Washington University. He
Institute of Neurology, which led to the award of of the prestigious, multi-volume Handbook of Clinical has won numerous awards for his research and clinical
an MD degree (which, in England, is an advanced Neurology (Elsevier). He was Editor-in Chief of the care of children with embryonal brain tumors including
medical degree based on research) on completion of journal Muscle and Nerve from 1998 to 2007 and also the Sidney Carter Award, the Daniel Drake Medal, and
his thesis. In 1974, he moved from England to the serves on numerous other editorial boards. His other the Compassionate Caregiver Award of the Kenneth
University of California San Francisco School of interests include medical history, and he has written two Schwartz Center.
Medicine, where he has been Professor of Neurology biographies on Brown-Séquard, one published by Dr. Pomeroy currently is the Chair of the Depart-
since 1982 and now holds the title of Distinguished Raven Press in 1993, and the other by Oxford Univer- ment of Neurology and Neurologist-in-Chief of Boston
Professor. He was Director of the Clinical Neuro- sity Press in 2011. Children’s Hospital, the Bronson Crothers Professor of
physiology Laboratories at UCSF until July 2004, Dr. Aminoff has received a number of awards over Neurology at Harvard Medical School, and the Direc-
when he stepped down to assume the role of Execu- the years including the Lifetime Achievement Award of tor of the Eunice K. Shriver National Institutes of
tive Vice Chair of the Department of Neurology. He is the American Association of Neuromuscular and Elec- Child Health and Human Development–funded Intel-
also director of the Parkinson’s Disease Clinic and trodiagnostic Medicine in 2006 and the A.B. Baker lectual and Developmental Disabilities Research Center
Research Center. He is currently involved in a number Award of the American Academy of Neurology in 2007 of Boston Children’s Hospital and Harvard Medical
of clinical trials including one on gene therapy and also for lifetime achievements and contributions to medical School. Dr. Pomeroy and his wife, Marie, live in Boston
in physiological studies of patients with movement education. He served for 8 years as a director of the and have five grown children, Steve, Cole, Ann, Minna,
disorders. American Board of Psychiatry and Neurology, serving and David.
Dr. Aminoff is the author of over 230 original medical as chairman of the board in 2011. He is married, lives
and scientific articles, as well as the author or editor of in San Francisco, and has a daughter who is a pediatri-
numerous books, many of which have gone into several cian and two sons who are attorneys.
THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS vii
FOREWORD
Combining Dr. Frank Netter’s classic medical illus- Dr. Netter’s style is absolutely distinctive. It has the
trations with a first-rate, current text is a brilliant look of mid-20th century illustration art, somewhat
idea. The choice of authors could not be better; as a like Norman Rockwell’s. Not unlike a Rockwell, one
group they are well-regarded clinicians whose experi- can recognize a Netter illustration across the room. He
ence as teachers, having national and sometimes inter- is consistent no matter what his subject; his work,
national reputations, is well illustrated by the clarity of including its vivid coloration, is always particularly
their writing. Very clearly there has been great atten- serious despite its sometimes cartoonish like appear-
tion to achieving a supple, readable style. The added ance. Netter is distinctive the way all truly great artists’
images, such as the MRIs and other visual tools, are work invariably is, no matter what the level of sophis-
very well chosen. Their clarity for teaching purposes tication. Think of Mondrian. Think of Francis Bacon.
matches the text in quality, and these are nicely inte- Totally different than Netter, they are good examples
grated with Netter’s classic imagery. The most impres- of great “high” art that are similarly distinctive and
sive thing about this effort is the marvelous embedding consistent. And such consistency, regardless of the
of Netter’s illustrations into the text with preservation subject, is surely part of what makes for genius with
of coherence. subsequent fame and greatness. Accompanied by their
The original publication of these illustrations in the new text in two detailed parts covering the brain as well
first Netter atlas was a regular, albeit unofficial, part as the spinal cord and its related peripheral motor
of medical school neurologic learning early in my sensory units, Frank Netter’s art has been beautifully
career during the 1960s. Concomitantly, Netter’s resurrected once again. These will surely provide learn-
corollary bi-monthly white-covered slim paperback ing with pleasure to yet another generation of medical
Clinical Symposia was always welcome with the new students during their neurologic studies.
mail … more than one issue were frequently strewn on
my desk. These were essentially mini atlases always Nicholas A. Vick, MD
centered by a striking illustration immediately telling Clinical Professor of Neurology
you what the dedicated subject would be. Each new Pritzker School of Medicine
edition was always accompanied by 15 to 20 new and University of Chicago
now classic Netter illustrations. It was not clear how Chicago, Illinois;
Ciba Pharmaceutical wanted to specifically influence us Department of Neurology
in trade for their marvelous free teaching aids. Now I Northshore University Healthsystem
wish I had saved many of them. Evanston, Illinois
viii THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS
PREFACE, ACKNOWLEDGMENTS, AND DEDICATION
PREFACE
many Netter-illustrated medical texts and atlases that the art and science of neurology. We also express our
This new edition of The Netter Collection of Medical include some fine new artwork created by a superb admiration and thanks to our artist colleagues Carlos
Illustrations: Nervous System recognizes the enduring group of medical artists carrying forward Frank A. G. Machado, MD, John A. Craig, MD, James A.
nature of Dr. Frank Netter’s incomparable artistic Netter’s tradition. Perkins, MS, MFA, Anita Impagliazzo, MA, CMI,
genius and his immense educational vision. Dr. Netter’s As editors of the current two-part volume, we have Tiffany S. DaVanzo, MA, CMI, and Kristen Wienandt
initial atlas dedicated to neurology, first published in combined basic science information with clinical mate- Marzejon, MS, MFA, who have so carefully upheld
1957, provided a very concise introduction to the rial, discussing the anatomy, physiology, pathology, and Frank Netter’s approach to medical illustration. These
nervous system for generations of students of medicine clinical presentation of many neurologic disorders, thus dedicated artists have expertly created a number of out-
and the health sciences. His ability to simplify the supplementing the system-based approach now used standing new plates for these volumes. Additionally,
essentials of very important components, namely the in many medical school curricula. We have been Barry Arnason, MD, the primary author of the multiple
cerebral cortex and diencephalon, the complexities of most privileged during our careers to participate in the sclerosis section in Part 1, significantly contributed to
the hypothalamus, fiber tracts within the brainstem and exponential technologic advances leading to our very the final artwork seen in Plates 10-6 through 10-12 and
spinal cord, the cranial nerves, and the peripheral detailed understanding of the various neurologic disor- 10-14, providing his own detailed sketches, direction,
motor-sensory unit, was very remarkable. Furthermore, ders, particularly the rapid growth in diagnostic and and feedback to an artist. These unique drawings rep-
Dr. Netter’s illustrations are absolutely outstanding in management options now available. However, although resent a very special artistic contribution by an author
comparison to those available in other texts. His paint- these represent wonderful accomplishments not envi- of this text. Most MRI and CT images for many previ-
ings are as vital today as at their artistic inception. sioned at the time of the last printing of this publica- ous plates used in this atlas were supplied by Richard
The initial single-part publication, providing an tion, such advances have created pleasant challenges for A. Baker, MD, of the Lahey Clinic, who has expertly
interaction between the basic neurologic sciences and us both in organization and in definition of the scope and tirelessly worked with Royden Jones on four Netter
clinical neurology, offered a stimulating introduction to of the topics discussed. projects during the past 30 years. Finally, the entire
many intriguing and important clinical aspects of neu- Each of us is ever mindful of the many unanswered Elsevier editorial team, particularly Marybeth Thiel
rologic medicine. Although the scope was somewhat questions, particularly regarding Alzheimer disease and and Elyse O’Grady, have been gracious and cooperative
limited in its clinical depth, its vivid and intriguing other neurodegenerative disorders, various epilepsies, in supporting our goals. It has been a distinct pleasure
plates provided a unique catalyst for students, making autism, schizophrenia, cerebral aneurysms, glioblas- having such professional and dedicated colleagues.
the challenge of learning the neurosciences both excit- toma, multiple sclerosis, and amyotrophic lateral scle-
ing and rewarding. Indeed, Netter’s initial volume was rosis, to name a few disorders that we hope will enjoy
DEDICATION
a major influence in leading some of us to consider a major advances during our lifetimes. We have confi-
neurologic career. dence that our younger colleagues will shed further These two volumes are dedicated to our wives, chil-
Much of the anatomy of the peripheral nervous light on these very enigmatic clinical riddles and bring dren, and grandchildren, whose love and support gave
system and many central and peripheral clinical neuro- comfort and help to future generations of neurologic us the time to work on this project; to our students,
logic disorders were lacking in Netter’s original patients. residents, and fellows, who challenged us to be fine
Nervous System. To expand the scope of neuroanatomy Each of us also hopes that today’s medical students teachers; and to our many and dear patients for whom
and clinical disorders, a second volume was published will find this new edition of the Nervous System an excit- we have been honored and blessed to care.
in 1986. Although their publications were separated ing introduction to the many challenges and rewards
in time, these two parts are referred to as the “first incumbent in a clinical neuroscience career. H. Royden Jones
edition.” We now present a second edition, which is Ted Burns
more comprehensive, carrying forward the vision that Michael J. Aminoff
ACKNOWLEDGMENTS
Frank Netter, MD, so brilliantly developed. Since the Scott Pomeroy
first editions, Elsevier purchased the publishing rights The editors thank their many neuroscience colleagues December 2012
to the entire Netter art library, and it now has a who contributed to this text, as listed on pp. xiv-xvi, as
dedicated division responsible for the publication of well as our many patients through whom we learned
THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS ix