DiagnosisandTreatmentoftheDura

•  AOAConven6on2016

•  KennethLossingDO

1

SutherlandModel,1899-1954

•  Basedonpalpa6on•  Pa6entsupine•  SpinalDuraascendsduringinhala1onphase

•  FalxCerebri•  Falxcerebelli•  Tentoriumcerebelli•  Diaphragmsellae

OsteopathyintheCranialField,edi6on1MagounandSutherland1951 2

ArbuckleModel

•  Basedondissec6onin200pediatricautopsies.

•  Foundwhitecollagenfibersregularlyarrangedintheyellowelas6cfibers

TheSelectedWri6ngsofBerylArbuckle1944-1958 3

ArbuckleModel•  20differentregularlyorienteddirec6onalfibersinDuramater.

•  AnteriorandPosteriorspinalfibers.

TheSelectedWri6ngofBerylArbuckle1944-1958 4

HistologyoftheDuraMater•  “Asit’snamesuggests(Dura

mater=hardmother)thisoutermostmembranelayerisoftoughconsistencyandmadeofdenseconnec6ve6ssue.ThecollagenicfiberstendtorunlongitudinallyinthespinalDura,butmoreirregularlyinthecranialDura.”

•  Type:Somehistologybookssaydenseregular,somesaydenseirregular,dependingonwheretheylooked.

Histology,8thedi6on,HamandCormack1979 5

The Stages of Human Development Before Birth, Blechschmidt 1961 6

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

Blechschmidt 7

Dural Girdles

•  1–retromesencephalic Dural girdle

•  6 –premesencephalic Dural girdle

•  7,12 –falx

Neurology,Hirschfeld,1853France

1831-1854France

AtlasofHumanAnatomyandSurgery,BourgeryandJacob 10

BiomechanicsTerminology

•  Elas6cdeforma6on•  Elas6city•  Plas6c•  Stress•  Strain•  Viscosity/viscoelas6city

•  TermsfromBreig•  Telescoping•  Histodynamics

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BreigModel1978

•  Surgical,radiologicalandcadaverstudies

•  Theadultspinalcanallengthens5-7cmfromglobalextensiontoglobalflexion.

•  Axialmovementofcordseenwithrespira1on.

AdverseMechanicalTensionintheCentralNervousSystem,AlfBreig1978,Sweden 12

LongestShortest

SpinalCord,CervicalSpine

•  Ledisextension,thevasculatureisrelaxed

•  Rightisflexion,vasculatureisstretched.

Breig 13

CordMovesInsideofSpinalCanal

•  Onlateralflexion,thecanalislengthenedontheconvexsideandshortenedontheconcave.

•  Inlateralflexion,thespinalcordmovestothesideofincreasedtension,inledsidebendingthecordmovestotherightside

AdverseMechanicalTensioninTheCentralNervoussystem,Breig,1978 14

CordChangesLengthandWidth

•  Ledillustra6oniscompression,cordshortensandwidens

•  Rightillustra6onistrac6on,cordlengthensandnarrows.

Breig 15

Rota6onoftheHead

•  Rota6ngtheheadtotheledincreasesthetensionintherighttrigeminalnerve,andpullstheponstotheled.

AdverseMechanicalTensionintheCentralNervousSystem,Breig 16

Pons-CordTract,TransmissionofTension

•  Mesencephalon,pons,medullaoblongata,spinalcord,cranialnerves5-12,andspinalnerveroots-allreactwithplas6cdeforma6onoflengthandcurvaturetosimultaneousaltera6onsinthelengthandcurvatureofthespinalcanal.

•  Alltensioninthenerverootstrac1ononthePCT.

Breig 17

TheatlasofanatomyandSurgery,BourgeryandJacob1831-1854,France

•  WhatabouttheDuralextensionsintothenerveroots?

•  Theduraistensedduringlimbmovementsasaresultofdisplacementofthethespinalnerves(Sunderland1980).

Theanatomyoftheintervertebralforamenandthemechanismsofcompressionandstretchofnerveroots,ModernDevelopmentsinthe

PrinciplesandPrac6ceofChiroprac6c,pages45-64,Sunderland,198018

Duratothenerveroots

•  TheDuraextendspastthejunc6onoftheventralanddorsalnerverootsneartheintervertebralforamen,andblendswiththeepineuralconnec1ve1ssuesurroundingthespinalnerve.

BasicandClinicalAnatomyoftheSpine,SpinalCord,andANS,CramerandDarby,

2005

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WhatDoesThisMean?

•  Anytensioninthecervical,brachial,lumbar,orsacralplexusaffectstheamountoftensioninthewholeDuraandbrain(ponscordtract).

ManualTherapyforthePeripheralNerves,BarralandCrobier,2012 20

ModernDuraModel

•  ThespinalDuraissuspendedbythedentateligaments,thebrainstembythecranialnerves.

•  Thepons-cordtractchangeslengthby4.5-7.5cm(0.8-1.4cmbrainstem,1.8-2.8cervical,.9-1.3cmthoracic,1-2cminlumbosacralcord)duringdorsalextensionandventralflexion.

•  Theponscordtracttelescopeswithdorsalextension.

•  ThePonscordtractiscon6nuouswiththespinalnerverootsandperipheralnerves.

BiomechanicsofthePons-CordTractanditsEnvelopingStructures:anOverview,Rossii1993 21Reviewofliteraturefrom1870-1992

ModernDuralModel•  Lateralflexionchangesthelength,widthandposi6onofthePCTinsidethespinalcanal.

•  Rota6onchangesthelength,widthandposi6onofthePCTintheheadandspinalcanal.

•  ThePCThasaplas6cadap6ontomovementsofthebody.

•  SurgicallythePCTisseentomoveaxiallywithrespira6on.

BiomechanicsofthePons-CordTractanditsEnvelopingStructures:anOverview 22

ModernDuralModel•  TheDuramateriscomposedofcollagenandelas6cfibersarrangedinoblique,crossedandlongitudinalbandswhichmaybesplitintoseverallayers.

•  Duringsurgeryinthehead,thecranialDurawaspenetratedwithextremelysmallforce(notmeasurable)whentheindenter6pwasparalleltothepredominantdirec6onofthefibers,and203lbs.offorce(903N),whenatrightangles(about50%oftheforcerequiredtopenetratethehumanskin).

•  ThePCTreactstoextremelysmallforces,lessthanagram.

BiomechanicsofthePons-CordTractanditsEnvelopingStructures:anOverview 23

Tes6ngtheDura•  Testduringflexionorinhala6on,addatrac6on.

•  Keepeyesclosed,visualizeanatomy.

•  Immediateresistance=cervicalcranialarea.

•  Distensibilityfollowedbyresistance=lowerDura.

TraumaanOsteopathicApproach,BarralandCrobier,1999 24

Barral 25

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.!

TraumaanOsteopathicApproach,BarralandCrobier 26

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 inferior- cranial Dura.!

•  Listening inferior and a little lateral- cervical Dura.!

•  Listening inferior and quite lateral- lumbosacral Dura.!

BrachialPlexus

•  TheBrachialplexuspassesbetweentheanteriorandmedialscalenemuscles,nearthesubclavianartery.

AdamInterac6ve 27

BrachialPlexus

•  Thebrachialplexus(C5-T1roots)passesbehindtheclavicle,pectoralismajorandminormuscles,alongtheaxillaryartery.

AdamInterac6ve 28

TreatmentoftheAxillaryFascia/BrachialPlexus

•  Onthesideofacervicalareaposi6veDurallisteningtest,firstcheckthearmROM.

•  Withthepa6entsidelying,treatmentsideup,placeyourrelaxedthumbnearthetopoftheaxilla,justbehindpec.minor.Useyourotherhandontheshouldertoaddaslightcompression,whilegentlyaddingananteriorforcetopec.minor,un6litmelts.

•  RecheckarmROMandspinalDuratest.

ManualTherapyforthePeripheralNerves,BarralandCrobier 29

Scia6cNerve•  Thescia6cnerverecievesrootsfromL4toS3,passesthroughthegreaterscia6cforamen,andusuallyunderthepiriformismuscle,andoverthesuperiorandinferiorgemmellusmuscles,andquadratusfemorismuscle.

•  Atthisloca6onthenerveshouldbeabletodistend1-2cm.

AdamInterac6ve 30

Scia6cNerveTreatment•  OnthesideofalowerspinalDuralisteningtest,placeyourfingeronthescia6cnerve.Gentlyengageitinferiorly.Useourotherhandontheknee,bringthekneesuperior,lateral,thenmedial.Repeat2-36mes.

•  Recheckscia6cdistensabilityandDurallisteningtests.

TherapyofthePeripheralNerves,BarralandCrobier 31

TraumaanOsteopathicApproach,BarralandCrobier 32

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,BarralandCrobier 33

DistendingSpinalDura,SupineandProne

•  InSupine,flexthesacrum,andextendtheocciputonC1,distract

•  Intheproneposi6on,contactheadandsacrum,engagethetension,distend.