In the last few months I have finally come across reliable evidence supporting the association between atlas subluxation (also being called craniocervical instability), and compromise to the cerebrospinal fluid drainage from the brain, jugular venous drainage from the brain, vertebral artery compromise, and finally stretch and compression injuries to the brainstem.
I am presenting some links to that evidence in this post.
Please note that while in some cases the material is more targeted at Ehler’s Danlos syndrome and Chiari malfomation, both of which are more complex problems that usually involve at least some cervicocranial instability the same considerations apply to simple craniocervical instability/ atlas malalignment and it appears that the upper cervical issues are in play in both those syndromes.
One of the most important issues that I have noted is that it is likely that the instability at the top of the neck is the problem, rather than a static subluxation. That is valuable knowledge that explains why many people do not do well with a single treatment.
These anatomical issues are related to 2 neuropsychological symptom clusters:
and Cerebellar Cognitive Affective Syndrome.
Both of these are relatively newly described and the exact boundaries of them are yet to be established. It is likely that there are many individuals around with more mild versions of these problems which are difficult to diagnose as we have been unfamiliar with these patterns
The specific mechanisms being proposed are:
Impaired cerebrospinal fluid flow.
Impaired jugular venous drainage from the skull.
Vertebral artery compression causing intermittent brain stem dysfunction. ( I am suspecting a muted lateral medullary syndrome)
Impingement on the brain stem/spinal cord base caused by the inflammatory pannus that develops over the odontoid peg of C2 in cases of cervicocranial instability.
Tension stretching the brainstem and spinal cord both longitudinally and laterally through the dentate ligaments. This can cause direct neural dysfunction (like the odd sensations you get in your hand when you hit your funny bone) and it ca also cause in the longer term degeneration in the stretched neurones. It also appears to interfere with the venous drainage of the cord around those dentate ligaments.
Pressure on the upper cervical spinal cord on extension of the neck, caused by a failure of an atrophied rectus capitis superior minor to pull the dura out of the way during neck extension.
The rest of this page will be devoted to covering the evidence for all these assertions.
Dr Scott Rosa
CV from the CSVVI alliance:
“Dr. Scott Rosa is doing the most compelling upper cervical chiropractic research in the world today. He has spent the last 15 years working developmentally with the inventor of the MRI (Dr. Raymond Damadian) and FONAR Corporation – maker of the UPRIGHT Multi-positional MRI, in developing his advanced dynamic imaging procedure. He has worked with FONAR Corporation in developing cine cerebrospinal fluid (CSF) flow software as well as cine motion MRI and vertebral artery flow studies which have been instrumental in providing advanced images validating upper cervical adjusting pre and post C-1 correction, as well as patho-physiological changes at the cranio-cervical junction.
Dr. Rosa’s latest research is in the area of neuro-degenerative brain disease, cerebellar tonsillar ectopia (CTE), altered CSF and arterial/venous flow dynamics and their correlation to the cranio-cervical junction (gateway between the brain and spinal column), and atlas misalignment. Cerebrospinal fluid is no longer thought of as JUST a cushion for the brain. Recent studies have shown the importance of CSF to clear toxins of the brain through the glymphatic system; also, the draining of CSF from the central nervous system into the deep cervical lymph nodes by the newly found meningeal lymphatic vessels. It is highly important that the CSF is unencumbered in order for these systems to work effectively.”
How Craniocervical Misalignment Effects Fluid Flow
Observations at the craniocervical junction, CTE and observations of CSF.
The second talk- is centred around this paper:
The Craniocervical Junction: Observations regarding the Relationship between Misalignment, Obstruction of Cerebrospinal Fluid Flow, Cerebellar Tonsillar Ectopia, and Image-Guided Correction
Rosa S.a · Baird J.W.b Smith FW, Dworkin JS (eds): The Craniocervical Syndrome and MRI. Basel, Karger, 2015, pp 48-66
Key points and time within the talk
3:42 These Chiari Syndromes are not the same as the congenital ones in which the base of the skull is flatter than normal.
4:53 Research study of 43 MVA patients, but 4 had MS and 2 had Parkinsons
Imaging- all the neuro-degenerative patients had a misalignment of C1 C2 at the skull base, all had low lying cerebellar tonsils, all had obstructed spinal fluid flow
Introduced flow studies- started to find CSF turbulence and backjetting- into lesioned areas.
18:20 Mechanical issues with upper cervical malalignment
Cord can be tethered by the dentate ligaments- this will pull on the cord, esp spino thalamic (touch, pain and temperature) and spinocerebellar tract
Note that often brain fog diminishes with in hours to days of atlas treatment.
Transverse process of C1 can impinge on vessels like the jugular veins
correction of misalignment can improve vascular supply to the brain stem
Cranio-Cervical Syndrome The vulnerability of the neck and its impact on fluid flow. (CCS) Symposium – April 6, 2013, Scott Rosa, DC, BCAO
5:42 3,000,000 car accidents per year in USA ; 35-50% will never recover, 40% of those will be disabled for the rest of their lives
10 mile an hour collision is the equivalent of catching a 200 pound bag of cement dropped from one story.
Patients usually don’t hurt when they are lying down
The correct imaging post trauma often not done
Upper Cx spine the most complex part of the spine sacrifices strength for mobility Strong simultaneous shear and extension forces at 50-120 mSec
S curve- retraction of chin into neck
muscle guarding does not start until 200 mSec
8.6 mile an hour accident– head acceleration is 15 G
Cranio-Cervical Syndrome (CCS) Symposium – April 6, 2013, Raymond V. Damadian, MD.
Dr Damadian is the inventer of MRI and has been closely involved with Dr Rosa’s work.
craniocervical syndromes- and the possibility that they will turn into neurodegenerative diseases 5:12
resolution of low back pain with severe arthritic changes post upper cervical treatment
9:45 CSF cine pictures of CSF flow vs obstruction
Myles Koby, MD: Imaging Cervical and Cranio-Cervical Instability in Connective Tissue Disorders
See imaging at 2:32 ff
5:31 odontoid process of C2 pushing on brainstem- screenshot 6:40 slide of skull on neck
8:36 3D CT of neck C1-2 instability
9:13 MRI disc prolapse Cx spine- problem is not just the movement but stretching and pulling of the spinal cord/brainstem.
Forward and back sliding implies ligamentous failure and excess stretching of the spinal cord (NOT desirable).
Craniocervical Instability (Dr Henderson the 2012 EDNF Conference)
(Fraser C Henderson MD Neurosurgeon Chevy Chase Maryland)
2:00 flexion stretches the glossopharyngeal nerve, and the back of the brainstem (dissection) Stretching underlies symptoms
2:42 deformative stress brain stem- on flexion- total bending should be worst on the dorsal side
3:34 out of plane loading (intrusive pressure) on the spinal cord and brainstem leads to local histopathological changes AND increased tensile stretch
4:29 Histological evidence/ electron microscopy
6:20 epigenetic effects leading to preprogrammed apoptosis (upregulation of NMDA receptors leading to increased reactive oxygen species, mitochondrial dysfunction and
7:00 snoring and sleep apnoea- remove ventral brainstem compression and sleep apnoea goes away Respiratory abnormalities due to craniovertebral junction compression in rheumatoid disease 1994
7:36 Deformative stresses occur in Chiari
Cranio- cervical instability atlanto-axial subluxation
Cervical hyper -angulation
Tethered cord syndrome
11:44 Basilar impression due to softening of bone. (causes)
11:50 Cranio- cervical instability (loss of ability under physiological loads to maintain the relationship of the vertebra and occiput in such a way that there is no irritation of the spinal cord, nerve roots and there is no development of incapacity, deformity or pain due to structural changes.
Cranio-Cervical Syndrome (CCS) Symposium – April 6, 2013, Francis W. Smith, MD.
Cranio-Cervical Syndrome (CCS) Symposium – April 6, 2013, Joel Franck, MD.
Some direct evidence of restoration of CSF flow following upper cervical treatment:
What is pleasing about the above is that we have clear cooperation occurring between chiropractors, neurosurgeons and radiologists, (including Dr Demadian, the inventer of MRI) clarifying an area that has been the source of much doubt for many decades.
The following link comes from the FONAR (upright MRI) site and is well worthwhile reviewing for the cluster of symptoms being discussed. Those symptoms resemble closely a cluster of symptoms being called cervicomedullary syndrome by some neurosurgeons.
Cranio-Cervical Syndrome (CCS) Symptomatology and Its Origin in Prior Trauma to the Neck
This one is a very detailed discussion with a long symptom list. It largely mirrors other material here- but is worth reading.
Another talk by a radiologist:
Cranio-Cervical Syndrome (CCS) Symposium – April 6, 2013, Francis W. Smith, MD.
This one is pretty technical and probably only of interest to those with a professional interest.
6:10 venous drainage upright and horizontal
6:45 advances in anatomy
8:00 anatomy MRI can demonstrate even small ligaments (such as the alar ligaments that hold C1 in place on C2
13:20 – normal Cx MRI sagittal
14:20 posterior longitudinal ligament injury
15:50 Sagittal MRI clinically unstable Cx spine – acute- inc haemorrhage
17:40 atlanto occipital dislocation
18:30 tectorial and posterior atlanto- occipital membranes
20:30 Cervico myodural bridge- also vis on MRI
24:30 Cerebellar tonsils – nb fluidity of these tissues- as opposed to cadavers
26:19 50 yo female neck pain yrs C5-6 disc bulge, transient loss muscle tone in legs transient paresthesiae, drop attacks upright MRI = Chiari I- position dependent
Chiari II is congenital- medulla also displaced
A further issue of significance is that injuries of the upper neck often cause atrophy of one particular neck muscle (rectus capitis posterior minor).
This muscle runs from the spinous process of C2 (the second cervical vertebra) up to the base of the skull, but one small slip of it actually tethers to the dura (the membranes around the spinal cord) and appears to act to pull that soft tissue out of the way when extending the neck. Without its action the risk is that these membranes will bunch up and compromise the vertebral artery as it enters the skull. This can be a cause of a cluster of symptoms called cervicomedullary syndrome.
This posterior view of the skull and back of neck shows the position of the relevant muscles:
This question is well covered at this link, which actually shows cine MRI of the upper neck showing the dural membranes around the upper spinal cord kinking upon extension of the neck:
Further detail is also available here:
https://www.ncbi.nlm.nih.gov/pubmed/27116115 ( Spine 2017 Jan 1;42(1):49-54.)
A Systematic Review of the Soft-Tissue Connections Between Neck Muscles and Dura Mater: The Myodural Bridge.
Finally, on the question of cerebellar cognitive affective syndrome ( a cluster of symptoms associated with cerebellar dysfunction) this talk with its 2 2 case histories of severe psych disorder being resolved through surgery is of great interest.
“Cerebellar Cognitive Affective Syndrome: Anatomy & Implications” – Jeremy D. Schmahmann, MD
2:10 The doctors don’t listen because there is no fertile ground (the symptoms don’t fit their recognised pattern sets and they don’t know what to do with the symptom complex presented)
This is very true, but I don’t think I have ever hears anyone, express the problem so succinctly. That was very well put.
5:54 First case- symptoms include mania