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image from J‑NN 2024 shows the DCML pathway with Gracilis linking the legs and cuneatus linking the arms

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1. Beyond the Dorsal Column Medial Lemniscus in Proprioception and Stroke – MDPI Brain Sciences 2022 (investigates proprioceptive impairments beyond DCML)

-proprioception has been viewed as a function of the ascending dorsal column medial lemniscus (DCML) and spinocerebellar pathways.

2. Characteristic MRI Features of Dorsal Column Myelopathies – J‑NN 2024 (clinical imaging focus)

-The dorsal column-medial lemniscus (DCML) pathway is an ascending sensory pathway by which sensory information from peripheral nerves is relayed to the cerebral cortex. It conveys fine touch, vibration, and proprioceptive information from the entire body below the head.

3. Neuroanatomy of Posterior Column (StatPearls review, 2020) – includes DCML microanatomy and clinical relevance

-The dorsal horn is derived embryologically from the alar plate, which is a dorsal thickening of the neural tube, whereas the motor horn derives from the basal plate, which is a ventral thickening of the neural tube.

4. Physiopedia summary of DCML – function, clinical exam, relevance (2021–22 revision)

-There are three synapses, three order neurons within in the DCML.

First Order Neuron: Pseudo-Unipolar Neuron. Sensory in skin, joint, muscles. Ends in Nu. Gracilis/Cuneatus in the Medulla

Second Order Neuron: Nucleus Gracilis/Cuneatus in the medulla begins. Decussation occurs in the medulla (crossing over). Ends in VPL of thalamus

Third Order Neuron: Start in VPL of thalamus, ends in primary somatosensory cortex

5. PNAS: Cortical reorganization following dorsal spinal injury – 2024 (DCML role in recovery)

-Within spinal cord lesions, monkey models showed that alternate spinal cord pathways can develop within a critical period before the 9th postnatal day, but not later.

6. Video manuscript on bedside dorsal column exam (PMC) – includes testing method illustration

--> Clinical Case Literature

-The clinical signs of the DCML pathway lesions include loss of soft touch, vibratory sense, proprioception, discrimination sense, and a positive Rhomberg test.

7. Neuroanatomy, Posterior Column (Dorsal Column) - StatPearls - NCBI Bookshelf

--> Clinical Case Literature

The posterior spinal artery supplies the DCML pathway. Thus, infarction of the posterior spinal artery leads to neurological sensory deficits relayed by the DCML pathway. This is the mechanism of injury in posterior cord syndrome, also known as posterior spinal artery syndrome.

8. Cho et al. (2017) – “Medial Lemniscus Tract Lesion After High‑Voltage Electrical Injury: A Case Report”, Annals of Rehabilitation Medicine

Case of a 33‑year‑old man with severe bilateral lower limb proprioceptive loss (below T11) following electrical injury; initial MRI was unremarkable, but diffusion tensor tractography showed absent medial lemniscus and posterior column lesions—clinical DCML dysfunction clearly demonstrated.

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Gustin et al. (2015) – “Diagram of the pathway of the trigeminal nerve, spinal trigeminal tract, and ipsilateral and contralateral trigeminothalamic tracts,” illustrating tract segmentation including volumes of interest (trigeminal root entry zone, spinal trigeminal nucleus, trigeminal lemniscus, thalamus)

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1. Shanker et al. (2021) – “Trigeminal neuralgia induced by brainstem infarction treated with pontine descending tractotomy: illustrative case” (Journal of Neurosurgery: Case Lessons)

--> clinical case

61‑year‑old man developed persistent right‑sided facial pain (V2/V3) from a dorsolateral pontomedullary infarct involving the spinal trigeminal tract/trigeminal lemniscus. After multiple failed interventions, pontine descending tractotomy achieved durable relief over a 50‑month follow‑up—highlighting the trigeminal lemniscus system’s role in central neuropathic orofacial pain.

2. https://www.researchgate.net/publication/359046831_The_trigeminal_pathways?

Detailed anatomy and neuromodulation strategies in trigeminal pain management, covering trigeminal lemniscus pathways.

3. Trigeminal Lemniscus - an overview | ScienceDirect Topics

StatPearls (2022–2024)

Description of trigeminal nerve sensory nuclei: principal sensory nucleus (fine touch), spinal nucleus (pain/temperature), decussation, ventral trigeminal tract to VPM.

4. Frontiers | New Insights in Trigeminal Anatomy: A Double Orofacial Tract for Nociceptive Input

Frontiers in Neuroanatomy review (2016) – identifies double orofacial trigeminothalamic tracts (dorsal & ventral) merging into trigeminal lemniscus.

5. https://www.researchgate.net/publication/359046831_The_trigeminal_pathways

“The trigeminal pathways” (review, 2025) – comprehensive synthesis from nerve divisions through brainstem and cortical targets, with clinical correlations.

6. Spinal Trigeminal Nucleus - an overview | ScienceDirect Topics

--> Clinical Case

ScienceDirect Topics: Spinal trigeminal nucleus – afferent pain/temperature pathway through trigeminal lemniscus.

7. Kenhub (2023 anatomical review) – Fast overview of trigeminal nerve branches, nuclei, and ascending central sensory tracts, with labeled diagrams that clarify lemniscal organization

--> Clinical Case

-Trigeminal nerve anatomy, divisions, nuclei, and ascending lemniscal tracts with clear diagrams.

8. Andra Yusari et al. (2024) – “Secondary Trigeminal Neuralgia after a Brainstem Hemorrhagic Stroke with Adverse Reaction to Carbamazepine”

Case of a 28-year-old woman who developed persistent right-sided facial pain (V2/V3) following a brainstem hemorrhagic stroke affecting the pontine/midbrain trigeminal sensory pathway. Standard anticonvulsants were not tolerated, and fluoxetine provided symptom relief—underscoring trigeminal lemniscus involvement in central poststroke neuralgia.

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StatPearls figure (2025) – schematic diagram of spinothalamic tract pathway through cord, brainstem, thalamus.  

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1. StatPearls, Al-Chalabi et al. (2023–24) – Thorough overview of neuroanatomy: first-, second-, and third-order neurons, decussation in anterior commissure, somatotopic organization, VPL nucleus targets, clinical relevance of lateral and anterior tracts

-Provides a structured overview of the tract's three-neuron chain, starting in dorsal horn lamina I/II, crossing via the anterior commissure, and ending in the VPL thalamus.

2. Kenhub review (2023) – Detailed functional anatomy of spinothalamic tract as part of broader anterolateral system including spinoreticular and spinotectal tracts

-Explains the functional division: the lateral spinothalamic tract conveys pain and temperature, while the anterior tract carries crude touch.

3. Spinothalamic Tract - an overview | ScienceDirect Topics ScienceDirect Topics (2024)

-Highlights the descending modulation of pain in the anterolateral system—particularly how the periaqueductal gray (PAG) and raphe nuclei can suppress pain signals traveling this pathway.

4. Somatotopic organization of the human spinothalamic tract: in vivo computed tomography–guided mapping in awake patients undergoing cordotomy in: Journal of Neurosurgery: Spine Volume 30 Issue 5 (2019) Journals

-This DTI tractography study maps the somatotopy of the spinothalamic tract in vivo—showing leg fibers are lateral, while arm and trunk fibers are more medial.

5. Cozzens & Michael (2020) – “Anterior Sensory Myelopathy: A Retrospective Observational Case Series of an Overlooked Neurological Disorder”, Clin Surg.

--> Clinical Case

-Seven patients aged 33–52 presented with isolated contralateral loss of pain and temperature below cervical disc herniation, with no weakness, reflex changes, or vibration/proprioception loss—MRI showed selective compression of the anterolateral spinothalamic tract. Highlights a pure sensory myelopathy variant often overlooked in clinical practice.

6. StatPearls diagram (2025) – Clear schematic of spinothalamic tract across spinal cord, brainstem, and thalamus as part of Anterolateral System

-schematic diagram of spinothalamic tract pathway through cord, brainstem, thalamus. The figure above linked shows how spinothalamic fibers ascend anterior-laterally, passing through the brainstem and synapsing in the VPL.

7. Tsuda et al. (2014) – “Crossed Pain and Temperature Sensation Disturbance with Peripheral Facial Palsy Due to a Localized Lateral Inferior Pontine Infarction,” Journal of Medical Case Reports

-A 47‑year‑old man developed left‑sided facial analgesia‑thermoanesthesia plus peripheral facial palsy, with right‑sided body pain/temperature loss. MRI confirmed a small infarct in the left lateral inferior pons—demonstrating the anatomical adjacency of spinal trigeminal nucleus (face) and spinothalamic tract (body) within the pons. Symptoms resolved within ~3 weeks.

8. Cozzens & Michael (2020) – “Anterior Sensory Myelopathy: A Retrospective Observational Case Series of an Overlooked Neurological Disorder,” Clin Surg.

-Seven patients (ages 33–52) presented with isolated contralateral loss of pain and temperature below a cervical disc herniation, with preserved motor strength, reflexes, and proprioception/vibration sensation. MRI showed compression of the anterolateral spinothalamic tract only—demonstrating a pure spinothalamic sensory myelopathy variant.

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Image 1 (Fig 3 from Kim & Chung, 2023): Depicts the three-neuron chain of the trigeminal sensory system. Second-order neurons cross midline and ascend via the trigeminal lemniscus to the VPM—demonstrating how pain/temperature fibers join third-order thalamic relay. 

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1. Kim HK et al. (2024), Int. J. Mol. Sci. – "The Trigeminal Sensory System and Orofacial Pain"

-A modern review linking trigeminal nuclei anatomy (mesencephalic, principal, spinal) with orofacial pain syndromes and central synaptic pathways. Emphasizes how primary sensory nuclei feed into trigeminothalamic tracts delivering exteroceptive and proprioceptive signals to the thalamus

2. StatPearls, Neuroanatomy – Trigeminal Nucleus (2024)

-Subdivides spinal trigeminal nucleus into pars oralis/interpolar/caudalis with somatotopic face mapping. Clarifies how second-order neurons project via both ventral and dorsal trigeminothalamic tracts to VPM thalamus

3. Frontiers in Neuroanatomy review (2016) – "New insights in trigeminal anatomy: a double orofacial tract..."

-Demonstrates existence of dual trigeminothalamic tracts—ventral (crossed) and dorsal (uncrossed)—emphasizing bilateral sensory representation and implications for pain localization

4. ScienceDirect Topics: Sensory Trigeminal Nucleus overview (2023)

-Explains how sensory nuclei extend from spinal cord to midbrain and feed ascending trigeminothalamic pathways. Highlights that spinal nucleus relays pain/temperature while principal nucleus handles fine touch

5. StatPearls, Trigeminal Nucleus – Anatomy (2024)

-Specific breakdown of dorsal vs. ventral trigeminal tracts: dorsal tract carries ipsilateral discriminative touch; ventral carries contralateral crude touch and pain/temperature—parallels body’s DCML & spinothalamic systems

6. Trigeminal neuralgia associated with a solitary pontine lesion (Pain journal, 2020)

--> Clinical Case

-A 42‑year‑old woman developed classic TN symptoms refractory to medical management; MRI revealed a single pontine lesion implicating central trigeminothalamic fibers rather than peripheral nerve compression. Demonstrates how central lesions in the pons alter face pain without typical vascular compression

7. CT‑guided trigeminal tractotomy‑nucleotomy for refractory craniofacial pain (Eur. J. Neurosurg., 2024)

-->Clinical Case

-A 50‑year‑old female with long‑standing TN underwent CT‑guided tractotomy targeting descending trigeminal pain fibers. The procedure selectively interrupted second-order trigeminal fibers while preserving touch pathways—demonstrating surgical precision in targeting trigeminothalamic pain transmission

8. Trigeminal neuralgia from upper cervical cord injury (PMCID, 2019)

-->Clinical case

-A patient developed trigeminal neuralgia symptoms after atlantoaxial instability following C2 fracture. Injury affected spinal trigeminal tract and ascending trigeminothalamic fibers at spinal level, leading to facial pain onset months post trauma—illustrating extension of the system into upper cervical cord

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Betz cell origins in motor cortex, internal capsule, midbrain peduncles, pons, and medullary pyramids; highlights decussation (~75–90%) forming the lateral CST and remaining fibers descending ipsilaterally as the anterior CST.

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1. Natali et al., StatPearls (2025 update)

-Provides a structured journey from cortical Betz cells through the pyramid decussation in the medulla to synapse on spinal alpha motor neurons. It also covers anatomical variants like the anterior segmental corticospinal tract and aberrant pyramidal fibers.

2. Liu et al. & Jang et al., stroke-focused review (2021 update)

-Summarizes how axonal integrity and remodeling of CST fibers correlate with upper limb recovery after stroke. Techniques like DTI and transcranial magnetic stimulation (TMS) are highlighted as prognostic tools.

3. eLife (2021) – Moreno‑Lopez et al.

-In mice, the CST does more than drive movement—it modulates sensory input via spinal interneurons, suppressing reflexes during skilled motor tasks.

4. Filippopulos et al. (2021), Eur J Neurol

-Describes uncrossed corticospinal tracts in a healthy adult presenting with ipsilateral hemiparesis after a stroke, confirmed via DTI imaging.

5. Frontiers in Physiology (2025)

-Resistance training increases corticospinal excitability, decreases cortical inhibition, and lowers motor activation thresholds—indicating adaptive plasticity of the CST.

6. Yozbatiran N et al. (2017) – “White matter changes in corticospinal tract associated with improvement in arm and hand functions in incomplete cervical spinal cord injury,” Spinal Cord Series & Cases.

-->Clinical Case

In a cohort of four adults with chronic cervical spinal cord injury, transcranial direct current stimulation paired with robotic-assisted rehabilitation led to improved arm and hand function—concurrent with increased FA values in CST fiber bundles on DTI mapping.

7. Case Report (2022) – CST Decussation Alteration

-->Clinical Case

A healthy adult developed ipsilateral hemiparesis following a left frontoparietal hemorrhage due to uncrossed corticospinal fibers—a rare physiological variant confirmed by DTI.

8. Child with CST Rewiring After Hypoxia (2023 Case)

-->Clinical Case

A 3‑year-old child recovered motor function after severe hypoxic injury, with corticospinal reorganization via the supplementary motor area (SMA) pathway.