Upper Cross System Headaches Head Injuries

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Upper Cross SystemHeadachesHead Injuries Neck
Injuries
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Upper Cross System

• When a chain reaction evolved muscle shortening
  and reciprocal weakening in predictable patterns
  causing predictable imbalances or syndromes

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Upper Cross System Imbalances
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Changes due to Upper Cross System

• Occiput and C1/2 hyperextend with the head pushed
  forward
• Lower cervical to 4th thoracic vertebrae are
  stressed through posture
• Rotation and abduction of the scapulae
• Altered direction of the glenoid fossa
• Results in the need for humeral stability
  (increases levator and upper trap activity
  supraspinatus)

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Cervical Spine Forces

• A) Absolute rotation angle (ARA) of overall
  lordosis magnitude. B) Relative rotation angle
  (RRA) or magnitude of intersegmental angle. C)
  Linear measure of forward displacement of head
  relative to upper dorsal spine

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Results of Postural Imbalance

• Greater cervical segment strain with possible
  referred pain to the chest (trigger points)
• Pain mimicking angina may be noted
• Rotator Cuff strain/tendonitis
• TMJ
• Lower Cross System may occur due to eye gaze
• In order to see straight ahead, individual must
  anteriorly tilt pelvis
• Breathing dysfunction reduce in diaphragmatic
  efficiency due to postural restriction of lower
  rib cage

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Headaches
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Boney Anatomy

• The Skull has many specialized areas. We sill
  focus on Major areas
• Frontal
• Parietal
• Temporal
• Occipital

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Special Boney Areas

• External Occipial Protuberance (notch in
  occipital area
• Mastoid Process (behind Ear)
• Zygomatic Arch (Cheekbone)
• Orbit (eye socket)
• Maxilla (upper jaw)
• Mandible (lower Jaw)

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Anatomical Locations of Cranial Nerves
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Cranial Membranes
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Headaches

• The first step in treating our head pain is to
  get an accurate diagnosis. This is very important
  for a couple of reasons
• Head pain can be a symptom of various diseases or
  physical anomalies such as tumors or aneurysms. A
  CAT Scan of the sinus cavities is helpful, as is
  an MRI to rule out tumors and other problems.
  Keeping a headache diary will also be helpful to
  your doctor for diagnosis purposes.
• Treatment methods and medications for different
  types of head pain vary. For example, the triptan
  drugs used to treat migraine (e.g. Imitrex) do
  nothing for sinus/allergy headaches.

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Types of Headaches

• Migraine Headaches
• TENSION A DULL ache on both sides of the head is
  the sign of a Tension Headache. It has been
  described as "feeling like a tight band across
  the head."
• SINUS Rather uncommon, opposing to popular
  belief. Most people who feel they have a Sinus
  Headache essentially have Tension or Migraine
  headaches.
• CLUSTER Signs of a Cluster Headache is
  reasonably infrequent sharp-as-knife pains around
  one eye. Around Ninety percent are male. Most are
  between the ages of Twenty-Thirty years old.

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Migrane Headaches

• A chronic aching pain that frequently affects one
  side of your head.
• The pain usually begins in and around your eye
  or temple and ranges from mild to intense, severe
  or even devastating. This is usually accompanied
  by nausea, sensitivity to light and sound, and
  sometimes vomiting.
• Over 25 million people around the world suffer
  from migraine headaches. 75 are women. Around
  Seventy percent of these individuals have family
  members who also suffer with similar conditions.
• It is seen that approximately Twenty percent of
  migraine sufferers experience "aura." "Aura" is
  visual disturbances such as flashing lights or
  lines during an attack.
• "classic Migraine," experienced by about 20 of
  Migraineurs is preceded by warning signs called
  an "Migraines without the aura are termed "common
  Migraine" aura" 

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Headache Type

• Cluster Headache
• severe, sharp, stabbing pain
• usually on one side of the head, centered around
  the eye
• almost always severely incapacitating
• occur in clusters of 1 - 4 headaches a day for
  several weeks, lasting 10 minutes to two hours
  each, then stopping for months
• on the affected side, the eye tears, and the nose
  is often stuffy or runny
• most frequent among men
• occur most often in the fall and spring

• Migraine Cont. 
• throbbing, intense pain, generally moderate to
  severe
• usually one-sided, though the pain can move from
  side to side, and sometimes affects both sides
• may last hours, days, or even weeks
• Migraines may continue long enough to require an
  emergency room visit, or even hospitalization, so
  that stronger medications can be given to break
  the cycle. (status migrainous) 
•  

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Headache Types

• Sinus/Allergy Headache 
• pain generally mild to moderate
• centered around sinuses, above and below eyes
• pressure often makes teeth ache as well
• may be accompanied by feeling of pressure behind
  the eyes
• often relieved by decongestants, antihistimines,
  or other allergy medications.
• often seasonal

• Tension Headache 
• constant, dull pain, usually mild to moderate
  pain
• not incapacitating
• pain is often accompanied by muscle tightness in
  the shoulders and neck
• often on both sides of the head
• may last an hour, a week, or anywhere in between
• the pain is often described as a band of pain
  around the head or "like a vise" 

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Cervical Spine Correlation to Headaches

• Cluster, migraine, and the many forms of tension
  headaches, as well as post-concussion and
  "whiplash" headache, may also be consequences of
  traumatic cervical spine injury.
• Soft structures about the head, neck, and
  shoulder girdle play in the etiology of many
  headaches

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When to Refer

• The headache gets worse instead of better, or has
  changed in nature.
• Three or more headaches a week. Patient takes a
  pain reliever every day, or almost on a daily
  basis, to relieve headache.
• Headache is accompanied by any of the following
  symptoms
• 1. Stiff neck and/or fever
• 2. Shortness of breath
• 3. Unexpected symptoms that affect your eyes,
  ears, nose or throat
• 4. Dizziness, slurred speech, weakness, lack of
  sensation or tingling
• 5. Uncertainty or drowsiness6. Constant or severe
  vomiting

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When to Refer Continued

• Headaches begin after, or are triggered by, a
  head injury, hard work, coughing, bending or
  sexual activity.
• Headaches began after you reached the age of
  Fifty

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Referral Pain Patterns of C-Spine

• Headache and pain in the head and face originate
  in weak fibro-osseous attachments of tendons to
  the occipital bone (A, B, C, D) as weak fibers
  relax under normal tension and allow
  tension-overstimulation of sensory nerves of the
  cervical spine. Such pain is almost always
  referable to a specific location

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Injury Healing

• Traumatic skeletal pain is most exquisite at the
  points of attachment of tendons and ligaments to
  bone.
• During the healing process, which requires three
  to four weeks, bone and fibrous tissue
  proliferate at these fibro-osseous junctions.
• Another three to four weeks is needed for
  maturing and strengthening of the fibro-osseous
  bond. Interference with normal healing due to
  motion at the site of injury, or to a deficient
  healing capacity results in a weak attachment,
  designated as ligament relaxation.
• If spontaneous repair has not occurred 1 1/2 to 2
  months after injury, it is not likely to occur
  later (Hackett, 1958).

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Trigger Point Relationship

• Trigger points often elicit muscle spasm and pain
  in patients with headache.
• a. Prone patient. Laminar and articular points
  (x).
• b. Supine patient.
• Points at scalenus, sternomastoid, and trapezius
  insertions.

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Signs and Symptoms

• Compression of the head downward on the neck
  often increases the pain
• Manual traction of the head upward from the neck
  may relieve it.
• Pain may also be increased by isometric pressure
  at the occiput, whereas pressure at the curve of
  the neck may decrease it.
• Palpation often reveals muscle spasm of one or
  more of the supporting posterior neck muscles

• Physical examination may reveal
• one shoulder lower than the other
• head rigid.
• The examiner should determine the degree of
  limitation in the range of active and passive
  motion of the head on the neck in all directions
  and record the amount of pain produced by
  attempting to extend each motion.

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Signs and Symptoms Cont.

• Neurologic and general systemic evaluations are
  usually normal.
• There may be non-specific changes in the reflexes
  and atrophy of muscles about the shoulder girdle
  or the arm.
• X-ray examination may show narrowed
  intervertebral disk spaces and hypertrophic
  arthritic changes about the Luschka interbody
  joints representing previous pathology

• Small, tender areas of spasm in other muscles
  (trigger points)
• or exquisite tenderness at the origin or
  insertion of the muscles to the occiput, cervical
  spine, or shoulder girdle.
• Coincidentally there often is limitation of
  motion and malalignment of the dorsal lumbar
  spine or lumbosacral or sacroiliac joints.

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Acute Injury and Therapy

• With an acute injury, there is usually loss or
  reversal of the normal lordotic curve or
  increased laxity of supporting ligaments, or
  both.
• The range of motion is so restricted--either by
  spontaneous spasm, by attempting to hold the head
  rigidly on the neck, or by prolonged use of a
  cervical collar--that a cycle of spasm, reflex
  pain, weakness, and atrophy of the tissues exists.

• Therapy must aim to
• (1) remove the tender trigger areas which serve
  as foci of referred pain and spasm,
• (2) correct malalignments, subluxations, and
  restricted range of motion to as near normal as
  possible, and
• (3) strengthen the local supporting ligaments and
  tendons to prevent further malalignment and
  subluxation.

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Head Evaluation and Treatment
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Head Injury Background

• Skull - Hard casing with pudding like substance
  inside
• Protected by coverings
• Nutrients by rich blood supply
• Neural Components at base of skull

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Head Injury

• Mechanism
• Coupe
• Contra-Coupe
• These mechanisms can cause injury and swelling
• Concussion
• Epidural/subdural Hematoma

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Bleeding in the Brain
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Assessing Head Injury

• Check
• Visual Acuity eye movement
• Facial movement
• Headache
• ringing in the ears
• Nausea
• Behavioral Changes (unlike normal personality)
• Amnesia (retrograde/ post-concussive)

• MUST SIT OUT 20 MINUTES AND REASSESS
• If symptoms increase send to emergency
• This is a limited list

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Head Injury

• First Degree
• No Concussion - Bell rung resolution of symptoms
  within Lucid Interval
• Second Degree
• Loss of Consciousness brief less than 15 seconds.
  No resolution within lucid interval

• Third Degree
• Loss of Consciousness more than 15 seconds
• increasing severity within lucid interval
• This is only one type of scale many variations

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Post-Concussive Syndrome

• Residual symptoms post concussion including
• Nausea
• Headache
• Tinnitus
• etc.
• These may occur with movement, daily activities,
  rising from bed etc.
• Must not participate during this period of time

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Second Impact Syndrome

• Injury while still recovering from initial
  concussion
• 100 morbidity
• Very important that post-concussive syndrome has
  resolved

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Decisions on Head Injuries

• MUST SEND TO EMERGENCY IF
• Blood out of ears /or nose (from blow to head)
• Any unconscious episode
• Symptoms increase during 20 minute waiting period
  or when activity resumes
• DO NOT RETURN TO ACTIVITY IF
• Symptoms are not resolved
• Activity exacerbates headache

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Blood Supply to the Brain

• CSF is main nutrition to the neural structures.
• Blood supply to the brain is via a paired
  arteriole system
• Two internal carotid arteries enter the brain
  through the neck

• Two vertebral arteries travel up the posterior
  aspect of the neck through the transverse foramen
  and at the level of the pons. This then becomes
  the basilar artery.
• The basilar will nourish the pons and the
  cerebellum along the way to the area of the
  midbrain where it will divide into the posterior
  cerebral arteries

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Athlete Return to Activity

• First Concussion 1º
• 1 week post resolution of Symptoms
• Second Concussion or 2 º
• 1 month post resolution of symptoms

• Third Concussion or 3 º
• End of Season needs discussion of career
• Start with bike activity - if no symptoms
  increase functional activity before full return
• Above subject to Dr Discretion

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Circle of Willis

• Two communicating links exist
• Posterior communicating artery links the
  posterior and middle cerebral arteries
• The anterior communicating artery unites the two
  anterior cerebral arteries

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Circle of Willis

• 1. Anterior Cerebral Arteries
• 2. Inter-Carotid Arteries
• 3/5. Middle Cerebral
• 4. Posterior Communicating Arteries
• 6/7.Posterior Cerebral Arteries
• 8. Basilar Arteries
• 9. Vertebral Arteries

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Where the Head Ends and Neck Begins

• Plane between the external occipital protuberance
  and inferior surface of the mandible
• Neck
• Anterior triangle is bordered by Mandible
  (above), Cervical midline(laterally) and
  Sternomastoid (anteriorly

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Where the Head Ends and Neck Begins

• Neck
• Posterior triangle is bordered by Clavicle
  (below), trapezius (posteriorly) and
  Sternomastoid (anteriorly)

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Arteries
Middle Cerebral Artery
Posterior Cerebral Artery
ICA
Anterior Cerebral Artery
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Neck Anatomy, Evaluation and Treatment
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Boney Anatomy of the Neck

• Typical Vertebrae are C3-C6
• Characteristics
• Small bodies with large vertebral foramen
• bifed spinous process
• foramen in each transverse process
• articular facets lie at 45 in transverse plane

• Atypical Vertebrae
• Atlas - 1st cervical vertebrae
• Axis - 2nd Cervical Vertebrae

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Atlas

• Has a short anterior and long posterior arch
• Atlas has no actual body
• Has Circular facet (Fovia Dentis) in the anterior
  arch which is for the articulation of the dens of
  C2

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Atlas/Axis Ligaments

• Anterior Atlanto-Axial and atlanto-Occipital
  Ligaments
• Lie on the anterior surface of the axis and
  passes to the anterior surface of the anterior
  arch of the atlas and onto the the tubercle of
  the occiput

This is an extension of the anterior
longitudinal Ligament
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Atlas/Axis Ligaments

• Posterior Atlanto-Axial and atlanto-Occipital
  Ligaments
• Extends for the lamina of the axis to the
  posterior arch of the atlas and on up to the
  occiput.

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Atlas/Axis Ligaments

• Tectorial Membrane
• Extends on the posterior aspect of the body of
  the axis covering the dens and its associated
  ligaments but not touching it. It continues up to
  the anterior edge of the foramen magnum

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Axis Anatomy

• Second Cervical Vertebra
• DENS which is fused body of the atlas and axis
• helps in the formation of the first
  intervertebral foramen which the second cervical
  nerve passes through

Lateral View
Overhead View
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Axis Anatomy

• Cruciform Ligament
• Most vital of the ligaments. IF consists of 2
  ligaments (Apical Alar) which cross.
• Apical Attaches the tip to the occiput
• Alar Also attaches to occiput
• Transverse lig over apical but does not attach
  to it

Lateral View
Odontoid Anterior View
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Jefferson Fracture Burst Fracture

• Etiology
• Axial Loading of the head/compression of the
  atlas between occiptial condyles
• Pathology
• Bilateral burst fracture of both the anterior and
  posterior arched of C-1 with lateral displacement
  of masses - increasing the distance between
  anterior arch of the atlas and odontoid process
  of axis ( 3mm). AN UNSTABLE INJURY WITHOUT
  SPINAL CORD TRAUMA

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Avulsion teardrop Fracture (Axis)

• Etiology
• Hyperextension
• Pathology
• Triangular shaped avulsion fracture of the
  anterior-inferior margin of the C-2 vertebral
  body at the insertion of the anterior
  longitudinal ligament

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Teardrop Fracture (vertebral Body)

• Etiology
• Axial Loading/compression and Flexion Buckling
• Pathology
• A Burst fracture of the vertebral body with
  associated rupture of the posterior ligament,
  posterior displacement of the posterior fracture
  fragment and spinal cord encroachment acute
  anterior spinal cord injury syndrome TYPE IV
  compression fracture

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Fractures of Neural Arch

• Etiology
• Axial Loading/flexion or extension buckling
• Pathology
• Unilateral or bilateral fractures of the lamina
  and/or pedicles
• Avulsion fracture of the spinous process usually
  involving C-6, C-7 (most common)

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Unilateral Facet Subluxation/Dislocation

• Etiology
• Axial Loading/flexion-rotation
• Pathology
• Rupture of the anterior and posterior ligaments,
  capsular ligaments (bilateral) and intervertebral
  disc with anterior subluxation (less than 50 of
  vertebral body) or dislocation (more than 50 of
  vertebral body/locked facets). An unstable injury

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Atlantoaxial Subluxation/Dislocation

• Etiology
• Flexion or axial loading/flexion buckling
• Pathology
• Rupture of transverse and alar ligaments with
  anterior dislocation of C-1 on C-2/increase in
  ADI (distance between anterior arch of atlas and
  odontoid process of axis greater than 3mm)

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Fracture of Posterior Arch (atlas)

• Etiology
• Extreme hyperextension or axial
  loading/compression of the atlas between the
  occipital condyle and the axis
• Pathology
• Fracture of the posterior arch , most commonly at
  the thin, weak junction. Possible associated
  fracture including pedicle of C2 (hangmans
  fracture) avulsion teardropfracture of the axis
  etc.

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Odontoid Fractures (Axis)

• Etiology
• Axial Loading/Compression shearing forces
• Pathology
• Type I - Avulsion fracture (Alar ligament) of the
  tip of the odontoid unstable
• Type II - Fracture at the junction of odontoid
  and body of axis (unstable
• Type III - Fracture of the body of the axis
  (unstable)

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Hangmans Fracture

• Etiology
• Hyperextension or axial loading/extension
  Buckling
• Pathology
• A bilateral arch fracture of C-2 (traumatic
  spondylolysis) with anterior dislocation of C-2
  and C-3 (spondylolithesis) An unstable injury

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Face Injury - LaForte Fracture

• LaForte I
• LaForte II
• LaForte III