- Email: [email protected]
neck pain
CONFERENCES
Cont from page 47 the profession itself. Fortunately, there is a growing interest in this topic by scientists and clinicians from other professions. This interprofessional, governmental and institutional interest in chiropractic has created the opportunity to conduct research into these areas. It will be up to the chiropractic profession to decide whether or not to recognise the opportunities that exist and take advantage of them. If this is accomplished we may well be able, within a few years, to understand both the benefits of chiropractic care and the mechanisms by which these benefits are achieved. It is only then that newer and better methods of treating patients can be developed and incorporated into the training and practice of chiropractic.
It is well known that head/neck pain can originate from cervical spine structures. Head pain in particular can arise from muscle, ligaments, zygoapophyseal joints and dura innervated by the Cl-3 cervical nerves, due to the convergence of receptive fields of the cervical nerves with the trigeminal nucleus in the trigemino-cervical nucleus of the brainstem [I]. As a result, nociceptive sensory information from any of the above structures has the potential to produce chronic benign headaches and neck pain of unknown aetiology. As the spinal dura may be an important factor in the genesis of chronic benign headache, especially related to trauma, the purpose of this study was to investigate the anatomical relationship of the posterior spinal dura to structures in the upper cervical spine. The identification of posterior dural attachments to surrounding structures in the crania-cervical region is not new. Von Lanz, a celebrated German anatomist, described in 1929, a series of dural attachments arising mainly from posterior aspects of vertebrae in the upper cervical spine [2]. Nothing new was forthcoming until 1995 when a team from the University of Maryland led by Hack, demonstrated a connection between the rectus capitis posterior minor muscle (RCPm muscle) and the posterior spinal dura at the atlantooccipital junction [3]. In 1998, Mitchell, Humphreys and O’Sullivan reported a strong dural attachment between ClC2, arising from the ligamentum nuchae (LN) [4]. Currently, no studies have correlated the separate findings or evaluated the Magnetic Resonance Imaging (MRI) appearance of the dural attachments to their anatomic appearance.
48
This study consisted of two parts. Part A investigated the MRI appearance of the dural attachments before dissection as well as twice after dissection, with or without enhancement. Specimens were progressively dissected in a posterolateral approach followed by a right-sided laminectomy to identify the connective tissue attachments. Post-dissection, specimens were scanned once, then the attachment sites were painted with mineral oil to enhance their image, and scanned again. For part B, 17 head and neck cadaveric specimens were dissected using the same procedure as in Part A. In particular, identification of attachments was made between (i) LN and dura, (ii) LN and RCPm muscle, and (iii) RCPm muscle ancl posterior spinal dura. In addition, long axis traction was applied to the connective tissue attachments manually, using forceps, in order to gauge qualitatively, the strength of dural attachments. The results of this study, identified for the first time, a connective tissue complex connecting the three dural attachments, hitherto described as separate. In particular, the complex is a broad, flat structure arising from the funicular portion of the LN between the base of the occiput to the C23 level. The connective tissue complex sends off attachments to the inferior portion of the RCPm at the base of the occiput and to the posterior spinal dura between atlas and axis. The complex is linked to dura at the craniocervical junction (Hacks ligament) through the RCPm muscle. MRI scans were used to correlate their appearance with the anatomic specimens. Of note, the attachment images were clearly seen without the need for enhancement. This complex was also found to be firmly attached to the spinous of C2 as well as aspects of the posterior arch of Cl. On manual distraction, the LN to dura and the RCPm muscle to dura attachments were found to be strong while the LN to RCPm muscle was moderately strong. Preliminary light microscopy using Orcein stain, indicated that the attachment sites were made up of dense regular connective tissue, interspersed with an abundance of elastin fibres. This is the first study to have identified a robust, three-part attachment complex in the upper cervical spine, consisting of two parts linking the dura to the LN and RCPm muscle respectively and one pan linking the LN to the RCPm muscle. This is also the first study to have correlated the attachments sites on MRI with the anatomic specimens. This complex may be of particular interest to
chiropractors, as it firmly attaches posterolateral aspects of the spinal dura to elements of Cl and C2 vertebrae as well as to suboccipital muscle and the ligamentum nuchae. Most likely this complex plays a role in protecting the dura from damage due to infolding during spinal movements, particularly extension. However, dysfunction of the crania-cervical region, especially in cases of trauma and whiplash, may give rise to conditions such as chronic benign headache or mechanical neck pain. An understanding of this complex may provide both an anatomical explanation for these conditions as well as a rationale for the use of manipulation in their management.
Leon Chaitow, Fibromyalgia syndromes
l
ND, DO.
and chronic pain - the role of manual therapy.
Carolyn
McMakin, MA, DC. study of cervical trauma and chronic pain. Donald Murphy, DC, DACAN. Overview of cervical spine pain management. Cervical spine management protocols. l
A chiropractic
l
l
The British Journal
of Chiropractic,
2000; Vol 4, No 2
Cont from page 47 the profession itself. Fortunately, there is a growing interest in this topic by scientists and clinicians from other professions. This interprofessional, governmental and institutional interest in chiropractic has created the opportunity to conduct research into these areas. It will be up to the chiropractic profession to decide whether or not to recognise the opportunities that exist and take advantage of them. If this is accomplished we may well be able, within a few years, to understand both the benefits of chiropractic care and the mechanisms by which these benefits are achieved. It is only then that newer and better methods of treating patients can be developed and incorporated into the training and practice of chiropractic.
It is well known that head/neck pain can originate from cervical spine structures. Head pain in particular can arise from muscle, ligaments, zygoapophyseal joints and dura innervated by the Cl-3 cervical nerves, due to the convergence of receptive fields of the cervical nerves with the trigeminal nucleus in the trigemino-cervical nucleus of the brainstem [I]. As a result, nociceptive sensory information from any of the above structures has the potential to produce chronic benign headaches and neck pain of unknown aetiology. As the spinal dura may be an important factor in the genesis of chronic benign headache, especially related to trauma, the purpose of this study was to investigate the anatomical relationship of the posterior spinal dura to structures in the upper cervical spine. The identification of posterior dural attachments to surrounding structures in the crania-cervical region is not new. Von Lanz, a celebrated German anatomist, described in 1929, a series of dural attachments arising mainly from posterior aspects of vertebrae in the upper cervical spine [2]. Nothing new was forthcoming until 1995 when a team from the University of Maryland led by Hack, demonstrated a connection between the rectus capitis posterior minor muscle (RCPm muscle) and the posterior spinal dura at the atlantooccipital junction [3]. In 1998, Mitchell, Humphreys and O’Sullivan reported a strong dural attachment between ClC2, arising from the ligamentum nuchae (LN) [4]. Currently, no studies have correlated the separate findings or evaluated the Magnetic Resonance Imaging (MRI) appearance of the dural attachments to their anatomic appearance.
48
This study consisted of two parts. Part A investigated the MRI appearance of the dural attachments before dissection as well as twice after dissection, with or without enhancement. Specimens were progressively dissected in a posterolateral approach followed by a right-sided laminectomy to identify the connective tissue attachments. Post-dissection, specimens were scanned once, then the attachment sites were painted with mineral oil to enhance their image, and scanned again. For part B, 17 head and neck cadaveric specimens were dissected using the same procedure as in Part A. In particular, identification of attachments was made between (i) LN and dura, (ii) LN and RCPm muscle, and (iii) RCPm muscle ancl posterior spinal dura. In addition, long axis traction was applied to the connective tissue attachments manually, using forceps, in order to gauge qualitatively, the strength of dural attachments. The results of this study, identified for the first time, a connective tissue complex connecting the three dural attachments, hitherto described as separate. In particular, the complex is a broad, flat structure arising from the funicular portion of the LN between the base of the occiput to the C23 level. The connective tissue complex sends off attachments to the inferior portion of the RCPm at the base of the occiput and to the posterior spinal dura between atlas and axis. The complex is linked to dura at the craniocervical junction (Hacks ligament) through the RCPm muscle. MRI scans were used to correlate their appearance with the anatomic specimens. Of note, the attachment images were clearly seen without the need for enhancement. This complex was also found to be firmly attached to the spinous of C2 as well as aspects of the posterior arch of Cl. On manual distraction, the LN to dura and the RCPm muscle to dura attachments were found to be strong while the LN to RCPm muscle was moderately strong. Preliminary light microscopy using Orcein stain, indicated that the attachment sites were made up of dense regular connective tissue, interspersed with an abundance of elastin fibres. This is the first study to have identified a robust, three-part attachment complex in the upper cervical spine, consisting of two parts linking the dura to the LN and RCPm muscle respectively and one pan linking the LN to the RCPm muscle. This is also the first study to have correlated the attachments sites on MRI with the anatomic specimens. This complex may be of particular interest to
chiropractors, as it firmly attaches posterolateral aspects of the spinal dura to elements of Cl and C2 vertebrae as well as to suboccipital muscle and the ligamentum nuchae. Most likely this complex plays a role in protecting the dura from damage due to infolding during spinal movements, particularly extension. However, dysfunction of the crania-cervical region, especially in cases of trauma and whiplash, may give rise to conditions such as chronic benign headache or mechanical neck pain. An understanding of this complex may provide both an anatomical explanation for these conditions as well as a rationale for the use of manipulation in their management.
Leon Chaitow, Fibromyalgia syndromes
l
ND, DO.
and chronic pain - the role of manual therapy.
Carolyn
McMakin, MA, DC. study of cervical trauma and chronic pain. Donald Murphy, DC, DACAN. Overview of cervical spine pain management. Cervical spine management protocols. l
A chiropractic
l
l
The British Journal
of Chiropractic,
2000; Vol 4, No 2