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DiagnosisandTreatmentoftheDura • AOAConven6on2016 • KennethLossingDO 1 SutherlandModel,1899-1954 • Basedonpalpa6on • Pa6entsupine • SpinalDuraascends duringinhala1onphase • FalxCerebri • Falxcerebelli • Tentoriumcerebelli • Diaphragmsellae OsteopathyintheCranialField,edi6on1 MagounandSutherland1951 2 ArbuckleModel • Basedondissec6on in200pediatric autopsies. • Foundwhite collagenfibers regularlyarrangedin theyellowelas6c fibers TheSelectedWri6ngsofBerylArbuckle 1944-1958 3 ArbuckleModel • 20different regularlyoriented direc6onalfibers inDuramater. • Anteriorand Posteriorspinal fibers. TheSelectedWri6ngofBerylArbuckle 1944-1958 4 HistologyoftheDuraMater • “Asit’snamesuggests(Dura mater=hardmother)this outermostmembranelayer isoftoughconsistencyand madeofdenseconnec6ve 6ssue.Thecollagenicfibers tendtorunlongitudinallyin thespinalDura,butmore irregularlyinthecranial Dura.” • Type:Somehistologybooks saydenseregular,somesay denseirregular,depending onwheretheylooked. Histology,8thedi6on,HamandCormack 1979 5 Half a World Away- Dissection • 3,8 –right frontal Dural girdle, anlagen of coronal and sagittal sutures, and part of falx. • 4 –right parietal Dural girdle • 6,11–occipital Dural girdle, connective tissue anlagen of lambdoidal suture The Stages of Human Development Before Birth, Blechschmidt 1961 6 Dural Girdles • 1–retromesencephalic Dural girdle • 6 –premesencephalic Dural girdle • 7,12 –falx Blechschmidt 7 Neurology,Hirschfeld,1853France 1831-1854France AtlasofHumanAnatomyandSurgery, BourgeryandJacob 10 BiomechanicsTerminology • • • • • • Elas6cdeforma6on Elas6city Plas6c Stress Strain Viscosity/viscoelas6city • TermsfromBreig • Telescoping • Histodynamics 11 BreigModel1978 LongestShortest • Surgical,radiological andcadaverstudies • Theadultspinalcanal lengthens5-7cmfrom globalextensionto globalflexion. • Axialmovementof cordseenwith respira1on. AdverseMechanicalTensionintheCentral NervousSystem,AlfBreig1978,Sweden 12 SpinalCord,CervicalSpine • Ledisextension,the vasculatureis relaxed • Rightisflexion, vasculatureis stretched. Breig 13 CordMovesInsideofSpinalCanal • Onlateralflexion,the canalislengthenedon theconvexsideand shortenedonthe concave. • Inlateralflexion,the spinalcordmovestothe sideofincreased tension,inledside bendingthecordmoves totherightside AdverseMechanicalTensioninTheCentral Nervoussystem,Breig,1978 14 CordChangesLengthandWidth • Ledillustra6onis compression,cord shortensandwidens • Rightillustra6onis trac6on,cord lengthensand narrows. Breig 15 Rota6onoftheHead • Rota6ngtheheadto theledincreasesthe tensionintheright trigeminalnerve, andpullstheponsto theled. AdverseMechanicalTensionintheCentral NervousSystem,Breig 16 Pons-CordTract,Transmissionof Tension • Mesencephalon,pons, medullaoblongata,spinal cord,cranialnerves5-12, andspinalnerveroots-all reactwithplas6c deforma6onoflengthand curvaturetosimultaneous altera6onsinthelength andcurvatureofthe spinalcanal. • Alltensioninthenerve rootstrac1ononthePCT. Breig 17 TheatlasofanatomyandSurgery, BourgeryandJacob1831-1854,France • WhatabouttheDural extensionsintothenerve roots? • Theduraistensed duringlimbmovements asaresultof displacementofthethe spinalnerves (Sunderland1980). Theanatomyoftheintervertebral foramenandthemechanismsofcompressionandstretchofnerveroots,ModernDevelopmentsinthe PrinciplesandPrac6ceofChiroprac6c,pages45-64,Sunderland,1980 18 Duratothenerveroots • TheDuraextendspast thejunc6onofthe ventralanddorsal nerverootsnearthe intervertebral foramen,andblends withtheepineural connec1ve1ssue surroundingthespinal nerve. BasicandClinicalAnatomyoftheSpine, SpinalCord,andANS,CramerandDarby, 2005 19 WhatDoesThisMean? • Anytensioninthe cervical,brachial, lumbar,orsacral plexusaffectsthe amountoftensionin thewholeDuraand brain(ponscord tract). ManualTherapyforthePeripheralNerves, BarralandCrobier,2012 20 ModernDuraModel • ThespinalDuraissuspendedbythedentate ligaments,thebrainstembythecranialnerves. • Thepons-cordtractchangeslengthby4.5-7.5cm (0.8-1.4cmbrainstem,1.8-2.8cervical,.9-1.3cm thoracic,1-2cminlumbosacralcord)during dorsalextensionandventralflexion. • Theponscordtracttelescopeswithdorsal extension. • ThePonscordtractiscon6nuouswiththespinal nerverootsandperipheralnerves. Reviewofliteraturefrom1870-1992 BiomechanicsofthePons-CordTractanditsEnveloping Structures:anOverview,Rossii1993 21 ModernDuralModel • Lateralflexionchangesthelength,widthand posi6onofthePCTinsidethespinalcanal. • Rota6onchangesthelength,widthand posi6onofthePCTintheheadandspinal canal. • ThePCThasaplas6cadap6ontomovements ofthebody. • SurgicallythePCTisseentomoveaxiallywith respira6on. BiomechanicsofthePons-CordTractand itsEnvelopingStructures:anOverview 22 ModernDuralModel • TheDuramateriscomposedofcollagenandelas6c fibersarrangedinoblique,crossedandlongitudinal bandswhichmaybesplitintoseverallayers. • Duringsurgeryinthehead,thecranialDurawas penetratedwithextremelysmallforce(not measurable)whentheindenter6pwasparalleltothe predominantdirec6onofthefibers,and203lbs.of force(903N),whenatrightangles(about50%ofthe forcerequiredtopenetratethehumanskin). • ThePCTreactstoextremelysmallforces,lessthana gram. BiomechanicsofthePons-CordTractand itsEnvelopingStructures:anOverview 23 Tes6ngtheDura • Testduringflexionor inhala6on,adda trac6on. • Keepeyesclosed, visualizeanatomy. • Immediate resistance=cervical cranialarea. • Distensibilityfollowed byresistance=lower Dura. TraumaanOsteopathicApproach,Barral andCrobier,1999 24 ToCheckCranialVs.SpinalDura • To find out if the Dura is more restricted in the skull or in the spinal area, place the patient supine, and do a local listening at C2. If the listening is superior-skull. If the listening is inferior-spinal Dura.! Barral 25 GeneralListeningtotheDura • By compressing the sacrum anteriorly and superiorly, and the cranium inferiorly, we put the spinal Dura on slack, and can listen to it more effectively.! • Listening straight inferiorcranial Dura.! • Listening inferior and a little lateral- cervical Dura.! • Listening inferior and quite lateral- lumbosacral Dura.! TraumaanOsteopathicApproach,Barral andCrobier 26 BrachialPlexus • TheBrachialplexus passesbetweenthe anteriorandmedial scalenemuscles, nearthesubclavian artery. AdamInterac6ve 27 BrachialPlexus • Thebrachial plexus(C5-T1 roots)passes behindthe clavicle, pectoralismajor andminor muscles,along theaxillary artery. AdamInterac6ve 28 TreatmentoftheAxillaryFascia/ BrachialPlexus • Onthesideofacervicalarea posi6veDurallisteningtest, firstcheckthearmROM. • Withthepa6entsidelying, treatmentsideup,placeyour relaxedthumbnearthetopof theaxilla,justbehindpec. minor.Useyourotherhandon theshouldertoaddaslight compression,whilegently addingananteriorforceto pec.minor,un6litmelts. • RecheckarmROMandspinal Duratest. ManualTherapyforthePeripheralNerves, BarralandCrobier 29 Scia6cNerve • Thescia6cnerve recievesrootsfromL4to S3,passesthroughthe greaterscia6cforamen, andusuallyunderthe piriformismuscle,and overthesuperiorand inferiorgemmellus muscles,andquadratus femorismuscle. • Atthisloca6onthenerve shouldbeableto distend1-2cm. AdamInterac6ve 30 Scia6cNerveTreatment • Onthesideofalower spinalDuralistening test,placeyourfingeron thescia6cnerve.Gently engageitinferiorly.Use ourotherhandonthe knee,bringtheknee superior,lateral,then medial.Repeat2-3 6mes. • Recheckscia6c distensabilityandDural listeningtests. TherapyofthePeripheralNerves,Barral andCrobier 31 Tes6ngandTrea6ngSacralDura • • To test posterior Dura: push the apex anteriorly, and slightly flex the spine. To test the anterior Dura, slightly extend the spine and push the sacral base anteriorly.! To treat: Take the sacral Dura to the direction of the tension, follow the listening in the sacral hand, and unwind using the body as a lever arm. Repeat the motions until there is no restriction left.! TraumaanOsteopathicApproach,Barral andCrobier 32 DistendingSpinalDura,Supineand Prone • InSupine,flexthe sacrum,andextend theocciputonC1, distract • Intheprone posi6on,contact headandsacrum, engagethetension, distend. TraumaanOsteopathicApproach,Barral andCrobier 33