Download Treatment of the Dura for Concussion

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
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ArbuckleModel
•  20different
regularlyoriented
direc6onalfibers
inDuramater.
•  Anteriorand
Posteriorspinal
fibers.
TheSelectedWri6ngofBerylArbuckle
1944-1958
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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
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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
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Dural Girdles
•  1–retromesencephalic
Dural girdle
•  6 –premesencephalic
Dural girdle
•  7,12 –falx
Blechschmidt
7
Neurology,Hirschfeld,1853France
1831-1854France
AtlasofHumanAnatomyandSurgery,
BourgeryandJacob
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BiomechanicsTerminology
• 
• 
• 
• 
• 
• 
Elas6cdeforma6on
Elas6city
Plas6c
Stress
Strain
Viscosity/viscoelas6city
•  TermsfromBreig
•  Telescoping
•  Histodynamics
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BreigModel1978
LongestShortest
•  Surgical,radiological
andcadaverstudies
•  Theadultspinalcanal
lengthens5-7cmfrom
globalextensionto
globalflexion.
•  Axialmovementof
cordseenwith
respira1on.
AdverseMechanicalTensionintheCentral
NervousSystem,AlfBreig1978,Sweden
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SpinalCord,CervicalSpine
•  Ledisextension,the
vasculatureis
relaxed
•  Rightisflexion,
vasculatureis
stretched.
Breig
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CordMovesInsideofSpinalCanal
•  Onlateralflexion,the
canalislengthenedon
theconvexsideand
shortenedonthe
concave.
•  Inlateralflexion,the
spinalcordmovestothe
sideofincreased
tension,inledside
bendingthecordmoves
totherightside
AdverseMechanicalTensioninTheCentral
Nervoussystem,Breig,1978
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CordChangesLengthandWidth
•  Ledillustra6onis
compression,cord
shortensandwidens
•  Rightillustra6onis
trac6on,cord
lengthensand
narrows.
Breig
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Rota6onoftheHead
•  Rota6ngtheheadto
theledincreasesthe
tensionintheright
trigeminalnerve,
andpullstheponsto
theled.
AdverseMechanicalTensionintheCentral
NervousSystem,Breig
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Pons-CordTract,Transmissionof
Tension
•  Mesencephalon,pons,
medullaoblongata,spinal
cord,cranialnerves5-12,
andspinalnerveroots-all
reactwithplas6c
deforma6onoflengthand
curvaturetosimultaneous
altera6onsinthelength
andcurvatureofthe
spinalcanal.
•  Alltensioninthenerve
rootstrac1ononthePCT.
Breig
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TheatlasofanatomyandSurgery,
BourgeryandJacob1831-1854,France
•  WhatabouttheDural
extensionsintothenerve
roots?
•  Theduraistensed
duringlimbmovements
asaresultof
displacementofthethe
spinalnerves
(Sunderland1980).
Theanatomyoftheintervertebral
foramenandthemechanismsofcompressionandstretchofnerveroots,ModernDevelopmentsinthe
PrinciplesandPrac6ceofChiroprac6c,pages45-64,Sunderland,1980
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Duratothenerveroots
•  TheDuraextendspast
thejunc6onofthe
ventralanddorsal
nerverootsnearthe
intervertebral
foramen,andblends
withtheepineural
connec1ve1ssue
surroundingthespinal
nerve.
BasicandClinicalAnatomyoftheSpine,
SpinalCord,andANS,CramerandDarby,
2005
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WhatDoesThisMean?
•  Anytensioninthe
cervical,brachial,
lumbar,orsacral
plexusaffectsthe
amountoftensionin
thewholeDuraand
brain(ponscord
tract).
ManualTherapyforthePeripheralNerves,
BarralandCrobier,2012
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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
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ModernDuralModel
•  Lateralflexionchangesthelength,widthand
posi6onofthePCTinsidethespinalcanal.
•  Rota6onchangesthelength,widthand
posi6onofthePCTintheheadandspinal
canal.
•  ThePCThasaplas6cadap6ontomovements
ofthebody.
•  SurgicallythePCTisseentomoveaxiallywith
respira6on.
BiomechanicsofthePons-CordTractand
itsEnvelopingStructures:anOverview
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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
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Tes6ngtheDura
•  Testduringflexionor
inhala6on,adda
trac6on.
•  Keepeyesclosed,
visualizeanatomy.
•  Immediate
resistance=cervical
cranialarea.
•  Distensibilityfollowed
byresistance=lower
Dura.
TraumaanOsteopathicApproach,Barral
andCrobier,1999
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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
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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
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BrachialPlexus
•  TheBrachialplexus
passesbetweenthe
anteriorandmedial
scalenemuscles,
nearthesubclavian
artery.
AdamInterac6ve
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BrachialPlexus
•  Thebrachial
plexus(C5-T1
roots)passes
behindthe
clavicle,
pectoralismajor
andminor
muscles,along
theaxillary
artery.
AdamInterac6ve
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TreatmentoftheAxillaryFascia/
BrachialPlexus
•  Onthesideofacervicalarea
posi6veDurallisteningtest,
firstcheckthearmROM.
•  Withthepa6entsidelying,
treatmentsideup,placeyour
relaxedthumbnearthetopof
theaxilla,justbehindpec.
minor.Useyourotherhandon
theshouldertoaddaslight
compression,whilegently
addingananteriorforceto
pec.minor,un6litmelts.
•  RecheckarmROMandspinal
Duratest.
ManualTherapyforthePeripheralNerves,
BarralandCrobier
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Scia6cNerve
•  Thescia6cnerve
recievesrootsfromL4to
S3,passesthroughthe
greaterscia6cforamen,
andusuallyunderthe
piriformismuscle,and
overthesuperiorand
inferiorgemmellus
muscles,andquadratus
femorismuscle.
•  Atthisloca6onthenerve
shouldbeableto
distend1-2cm.
AdamInterac6ve
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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
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Tes6ngandTrea6ngSacralDura
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• 
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
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DistendingSpinalDura,Supineand
Prone
•  InSupine,flexthe
sacrum,andextend
theocciputonC1,
distract
•  Intheprone
posi6on,contact
headandsacrum,
engagethetension,
distend.
TraumaanOsteopathicApproach,Barral
andCrobier
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