Magnetic resonance imaging of craniovertebral structures: clinical significance in cervicogenic headaches

Biological markers of brain network connectivity and pain sensitivity distinguish low coping from high coping Veterans with persistent post-traumatic headache

Headache is the most common type of pain following mild traumatic brain injury. Roughly half of those with persistent post-traumatic headache (PPTH) also report neck pain which is associated with greater severity and functional impact of headache. This observational cohort study aimed to identify biological phenotypes to help inform mechanism-based approaches in the management of PPTH with and without concomitant neck pain. Thirty-three military Veterans (mean (SD) = 37±16 years, 29 males) with PPTH completed a clinical assessment, quantitative sensory testing, and magnetic resonance imaging of the brain and cervical spine. Multidimensional phenotyping was performed using a Random Forest analysis and Partitioning Around Medoids (PAM) clustering of input features from three biologic domains: 1) resting state functional connectivity (rsFC) of the periaqueductal gray (PAG), 2) quality and size of cervical muscles, and 3) mechanical pain sensitivity and central modulation of pain. Two subgroups were distinguished by biological features that included forehead pressure pain threshold and rsFC between the PAG and selected nodes within the default mode, salience, and sensorimotor networks. Compared to the High Pain Coping group, the Low Pain Coping group exhibited higher pain-related anxiety (p=0.009), higher pain catastrophizing (p=0.004), lower pain self-efficacy (p=0.010), and greater headache-related disability (p=0.012). Findings suggest that greater functional connectivity of pain modulation networks involving the PAG combined with impairments in craniofacial pain sensitivity, but not cervical muscle health, distinguish a clinically important subgroup of individuals with PPTH who are less able to cope with pain and more severely impacted by headache.

Preoperative visualization of the greater occipital nerve with magnetic resonance imaging in candidates for occipital nerve decompression for headaches

Occipital nerve decompression is effective in reducing headache symptoms in select patients with migraine and occipital neuralgia. Eligibility for surgery relies on subjective symptoms and responses to nerve blocks and Onabotulinum toxin A (Botox) injections. No validated objective method exists for detecting occipital headache pathologies. The purpose of the study is to explore the potential of high-resolution Magnetic Resolution Imaging (MRI) in identifying greater occipital nerve (GON) pathologies in chronic headache patients. The MRI protocol included three sequences targeting fat-suppressed fluid-sensitive T2-weighted signals. Visualization of the GON involved generating 2-D image slices with sequential rotation to track the nerve course. Twelve patients underwent pre-surgical MRI assessment. MRI identified four main pathologies that were validated against intra-operative examination: GON entanglement by the occipital artery, increased nerve thickness and hyperintensity suggesting inflammation compared to the non-symptomatic contralateral side, early GON branching with rejoining at a distal point, and a connection between the GON and the lesser occipital nerve. MRI possesses the ability to visualize the GON and identify suspected trigger points associated with headache symptoms. This case series highlights MRI's potential to provide objective evidence of nerve pathology. Further research is warranted to establish MRI as a gold standard for diagnosing extracranial contributors in headaches.

The association between cervical degenerative MRI findings and self-reported neck pain, disability and headache: a cross-sectional exploratory study

BACKGROUND

Neck pain and headache are highly prevalent conditions and leading causes of disability worldwide. Although MRI is widely used in the management of these conditions, there is uncertainty about the clinical significance of cervical MRI findings in patients with neck pain or headache. Therefore, this study aims to investigate the association between cervical degenerative MRI findings and self-reported neck pain, neck disability, and headache.

METHODS

This study was a secondary analysis of a cohort of patients with low back pain aged 18-40 years recruited from a non-surgical outpatient spine clinic. The cervical MRI and outcome measures used in this analysis were collected at a four-year follow-up (2014-2017). Self-reported outcome measures included neck pain intensity, neck disability as measured by the Neck Disability Index, and headache as measured by a single NDI item. Cervical MRI findings included disc degeneration, disc contour changes, and vertebral endplate signal changes (VESC). Multivariable logistic regression analyses, adjusted for age and sex, were used to analyse the associations between MRI findings and neck pain, neck disability, and headache.

RESULTS

A total of 600 participants who underwent MRI and completed the relevant questionnaires at follow-up were included. The median age was 37 years (interquartile range 31-41) and 325 (54%) were female. Of the included participants, 181 (31%) had moderate or severe neck pain, 274 (59%) had moderate or severe neck disability, 193 (42%) reported headaches, and 211 (35%) had one or more cervical degenerative MRI findings. Cervical disc degeneration and disc contour changes were positively associated with moderate or severe neck pain with odds ratio 1.6 (95% CI 1.1-2.4) and 1.6 (1.1-2.3), respectively. VESC was associated with moderate or severe neck disability with odds ratio 3.3 (1.3-8.4). No statistically significant associations were found between the MRI findings assessed and headache.

CONCLUSIONS

In this cross-sectional exploratory study, we found that cervical disc degeneration and disc contour changes were associated with neck pain, and VESC was associated with neck disability. None of the MRI findings were associated with headache. The results suggest that cervical degenerative changes may contribute to the aetiology of neck symptoms, but the associations are modest and cannot guide clinical decisions.

Do measures of physical function enhance the prediction of persistent pain and disability following a whiplash injury? Protocol for a prospective observational study in Spain

INTRODUCTION

Not all factors that predict persistent pain and disability following whiplash injury are known. In particular, few physical factors, such as changes in movement and muscle behaviour, have been investigated. The aim of this study is to identify predictive factors that are associated with the development of persistent pain and disability following a whiplash injury by combining contemporary measures of physical function together with established psychological and pain-related predictive factors.

METHODS AND ANALYSIS

A prospective observational study will recruit 150 consecutive eligible patients experiencing whiplash-related symptoms, admitted to a private physiotherapy clinic in Spain within 15 days of their whiplash injury. Poor outcome will be measured using the Neck Disability Index (NDI), defined as an NDI score of 30% or greater at 6 months post injury. Candidate predictors, including demographic characteristics, injury characteristics, pain characteristics, self-reported psychosocial factors and physical factors, will be collected at baseline (within 15 days of inception). Regression analyses will be performed to identify factors that are associated with persistent neck pain and disability over the study period.

ETHICS AND DISSEMINATION

The project has been approved by the Ethics Committee of the province of Malaga, Spain (#30052019). The results of this study will be published in peer-reviewed journals.

Headache and neck

Cervicogenic headache (CEH) is currently identified with different diagnostic criteria. The latest one is the International classification of headache disorders (ICHD), 3rd edition (2018). At the present time, there are not enough published articles with reliable sensitivity and specificity that may support a classification for clinical and research purposes. Current literature suggests improvement to the classification(s). The ICHD criteria should be modified to reach an optimal sensitive and specific level to identify CEH as a secondary headache. The B, C1, and C2 criteria should be implemented with proposed suggestions. The C3 criterion should be upgraded. Criteria such as mechanical precipitation of pain by digital pressure on neck trigger points and specific movements, strictly unilateral pain without side-shift, diffuse unilateral shoulder and arm pain, pain starting posteriorly and spreading anteriorly should be integral part of the classification.

Inter-examiner reliability of radiographic measurements from Open-mouth lateral bending cervical radiographs

Background

Following head and neck trauma, the involvement of the cranio-cervical junction (CCJ) and its contribution to a patients transition to chronic pain, is poorly understood. The detection of hypermobility in this region is dependent on clinical examination and static imaging modalities such as x-ray, CT and MRI. Sagittal plane hypermobility of the CCJ is evaluated using saggital view, flexion-extension cervical radiographs. Frontal plane hypermobility is typically assessed using lateral bending and open mouth cervical radiographs. Unfortunately there is no established reliability surrounding the use of these measures. This study explores the reliability of radiographic measurements of lateral-bending open-mouth cervical radiographs.

Methods

Cervical open-mouth lateral-bending X-ray images were collected from 56 different patients between 18 and 60 years of age patients following cervical spine injury. These images were interpreted by two musculoskeletal radiologists and two clinicians (physiatrist and chiropractor), using a standard set of measurements. Measurements included qualitative and quantitative assessments of the amount of asymmetry noted between various osseous landmarks. Reliability statistics were calculated for levels of agreement using kappa coefficients (κ) and Intraclass Correlation Coefficients (ICC) for dichotomous and continuous variables, respectively.

Results

Reliability (κ) for qualitative assessments were moderate to substantial for asymmetry of neutral C2 spinous position, dens-lateral mass spacing, and “step off” between the lateral borders of the articular pillars of C2 and C1 lateral mass (κ range = .47–.78). ICC values for the quantitative measurements of dens-lateral mass spacing and “step off” between the lateral borders of the C2 articular pillars and C1 lateral mass were moderate to excellent (ICC range = .56–.97).

Conclusions

The qualitative and quantitative measurements used in this study demonstrated good to excellent inter-examiner reliability. Correlation with clinical findings is necessary to establish the utility of these measurements in clinical practice.

DTI of great occipital nerve neuropathy: an initial study in patients with cervicogenic headache

AIM

To assess differences in bilateral great occipital nerves (GONs) in patients with unilateral cervicogenic headache (CEH) using diffusion tensor imaging (DTI).

MATERIALS AND METHODS

Twenty-three patients with unilateral CEH underwent GON magnetic resonance imaging (MRI). The clinical characteristics and fractional anisotropy (FA) and the apparent diffusion coefficient (ADC) values in bilateral GONs were determined by two observers with 7 and 3 years of experience in MRI. Three segments of GON were defined based on anatomy. The correlation of DTI measurements to the clinical characteristics and inter-/intra-observer performance were also evaluated.

RESULTS

The mean GON FA for the symptomatic side was significantly lower (0.198±0.056) than that on the other side (0.311±0.04; p=0.000). The mean GON ADC for the symptomatic side was significantly higher (0.682±0.174) than that on the other side (0.465±0.138; p=0.000). Among the three defined segments of GON, statistically significant differences of ADC values were not found at segment S3 (0.692±0.257 versus 0.557±0.230; p=0.068). There were statistically significant differences of FA and ADC values in bilateral GON of segments S1 and S2. The intraclass correlation coefficient (ICC) of intra-/interobserver statistical analysis showed excellent inter/intra-observer agreement for FA and ADC. Significant correlation was only found between the duration and ADC.

CONCLUSION

In patients with unilateral CEH, quantitative evaluation of the GON using DTI demonstrated FA decreases and ADC increases of the symptomatic side. Larger population and other occipital nerve neuropathy can be included in future research.

Diagnostic accuracy and validity of three manual examination tests to identify alar ligament lesions: results of a blinded case-control study

INTRODUCTION

Tests to evaluate the integrity of the alar ligaments are important clinical tools for manual therapists, but there is limited research regarding their validity.

METHOD

A single blinded examiner assessed alar ligament integrity using the lateral shear test (LST), rotation stress test (RST) and side-bending stress test (SBST) on a sample of convenience comprising 7 subjects with MRI confirmed alar ligament lesions and 11 healthy people. Alar ligament lesions were identified using both supine and high-field strength upright MRI.

RESULTS

The RST had a sensitivity of 80% and a specificity of 69.2%. The SBST and the LST both showed a sensitivity of 80% and a specificity of 76.9%. In cases where all three tests were positive, the specificity increased to 84.6%.

DISCUSSION

Tests of manual examination of alar ligament integrity have some diagnostic utility; however, these findings require further corroboration in a larger sample.

Increased mechanosensivity of the greater occipital nerve in subjects with side-dominant head and neck pain - a diagnostic case-control study

Objectives: To investigate differences in pressure pain thresholds (PPTs) and longitudinal mechanosensitivity of the greater occipital nerve (GON) between patients with side-dominant head and neck pain (SDHNP) and healthy controls. Evaluation of neural sensitivity is not a standard procedure in the physical examination of headache patients but may influence treatment decisions. Methods: Two blinded investigators evaluated PPTs on two different locations bilaterally over the GON as well as the occipitalis longsitting-slump (OLSS) in subjects with SDHNP (n = 38)) and healthy controls (n = 38). Results: Pressure pain sensitivity of the GON was lower at the occiput in patients compared to controls (p = 0.001). Differences in pressure sensitivity of the GON at the nucheal line, or between the dominant headache side and the non-dominant side were not found (p > 0.05). The OLSS showed significant higher pain intensity in SDHNP (p < 0.001). In comparison to the non-dominant side, the dominant side was significantly more sensitive (p = 0.004). Discussion: Palpation of the GON at the occiput and the OLSS may be potentially relevant tests in SDHNP. One explanation for an increased bilateral sensitivity may be sensitization mechanisms. Future research should investigate the efficacy of neurodynamic techniques directed at the GON. Level of Evidence: 3b.

Neurostimulation for Refractory Cervicogenic Headache: A Three-Year Retrospective Study

BACKGROUND

Occipital nerve stimulation (ONS) has been used for the treatment of neuropathic pain conditions and could be a therapeutic approach for refractory cervicogenic headache (CeH).

AIM

The aim of this study is to assess the efficacy and safety of unilateral ONS in patients suffering from refractory CeH.

METHODS

We conducted a retrospective chart review on patients implanted from 2011 to 2013 at CHUM. The primary outcome was a 50% reduction in headache days per month. Secondary outcomes included change in EuroQol Group Visual Analog Scale rating of health-related quality of life (EQ VAS), six item headache impact test (HIT-6) score, hospital anxiety and depression scale (HADS) score, work status, and medication overuse.

RESULTS

Sixteen patients fulfilled the inclusion criteria; they had suffered from daily moderate to severe CeH for a median of 15 years. At one year follow-up, 11 patients were responders (69%). There was a statistically significant improvement in the EQ VAS score (median change: 40 point increase, p = 0.0013) and HIT-6 score (median change: 17.5 point decrease, p = 0.0005). Clinically significant anxiety and depression scores both resolved amongst 60% of patients. At three years, six patients were responders (37.5%). Out of the 11 responders at one-year post implantation, five had remained headache responders (R-R) and one additional patient became a responder (NR-R). There was a statistically significant improvement in the EQ VAS score (median change: 15 point increase, p = 0.019) and HIT-6 score (median change: 7.5 point decrease, p = 0.0017) compared with baseline. Clinically significant anxiety and depression scores both, respectively, resolved among 22.5% and 33.9% of patients. Five out of seven disabled patients were back to work.

CONCLUSION

ONS may be a safe and effective treatment modality for patients suffering from a refractory CeH. Further study may be warranted.

Treatment of Cervicogenic Headache: New Insights on the Treatment of Pain in the Neck

This manuscript served as a companion piece for the original article “Pregabalin for the Management of Cervicogenic Headache; A Double Blind Study” by Guy P. Boudreau and Luc Marchand, which was published in the September 2014 issue ofThe Canadian Journal of Neurological Sciences.1

The importance of craniovertebral and cervicomedullary angles in cervicogenic headache

PURPOSE

Many studies have indicated that cervicogenic headache may originate from the cervical structures innervated by the upper cervical spinal nerves. To date, no study has investigated whether narrowing of the craniovertebral angle (CVA) or cervicomedullary angle (CMA) affects the three upper cervical spinal nerves. The aim of this study was to investigate the effect of CVA and/or CMA narrowing on the occurrence of cervicogenic headache.

MATERIALS AND METHODS

Two hundred and five patients diagnosed with cervicogenic headache were included in the study. The pain scores of patients were determined using a visual analog scale. The nonheadache control group consisted of 40 volunteers. CVA and CMA values were measured on sagittal T2-weighted magnetic resonance imaging (MRI), on two occasions by two radiologists. Angle values and categorized pain scores were compared statistically between the groups.

RESULTS

Intraobserver and interobserver agreement was over 97% for all measurements. Pain scores increased with decreasing CVA and CMA values. Mean angle values were significantly different among the pain categories (P < 0.001). The pain score was negatively correlated with CMA (Spearman correlation coefficient, rs, -0.676; P < 0.001) and CVA values (rs, -0.725; P < 0.001).

CONCLUSION

CVA or CMA narrowing affects the occurrence of cervicogenic headache. There is an inverse relationship between the angle values and pain scores.

Occipital and craniocervical pain and brain MRI in children with migraine

BACKGROUND

Both cervical and occipital pain has been reported in pediatric patients with migraine. There are no descriptions of anatomical changes on conventional brain magnetic resonance imaging that can explain the pathophysiology of headache with cervical and occipital pain in this age group. Our aim was to evaluate the frequency of cervical and occipital pain in children and adolescents with migraine as opposed to other types of headache and to seek corresponding anatomic abnormalities on brain magnetic resonance imaging.

METHODS

The cohort included 194 patients with headache attending the ambulatory headache clinic of a pediatric tertiary medical center. Data were collected by medical file review and revision of conventional magnetic resonance scans.

RESULTS

Patients were divided into two groups: migraine headache (n = 125) and other types of headache (n = 69). Occipital pain was reported by 16.4% of the patients and cervical pain by 4.1%; neither type of pain was characteristic of migraine headache in particular. Brain magnetic resonance imaging did not show any anatomic changes specific to migraine or other headache types, regardless of the presence of occipital or cervical pain.

CONCLUSIONS

Occipital and cervical pain are not characteristic symptoms of any headache group in the pediatric age group, and their presence or absence does not correspond to changes on conventional brain magnetic resonance imaging.

Therapeutic options for cervicogenic headache

The term cervicogenic headache (CeH) describes a syndrome originating from the cervical spine. There are a variety of therapeutic approaches used for the management of CeH, but scientific evidence of their effectiveness is scarce. No medication drug has proven to be effective. The evidence for greater occipital nerve blocks, cervical nerve blockades, facet joint injections and surgical procedures is limited. Several physical therapy interventions are proposed for CeH, with spinal manipulation and soft tissue interventions being the most commonly used. However, the lack of solid evidence of positive effects and risks of serious complications for spinal manipulation should be considered in favor of other physical therapy interventions associated with less risk. The inconsistent results in the literature can be related to the fact that maybe not all therapeutic interventions are appropriate for all patients with CeH or maybe not all patients with CeH will benefit from particular interventions.

Magnetic resonance imaging signal changes of alar and transverse ligaments not correlated with whiplash-associated disorders: a meta-analysis of case-control studies

PURPOSE

Hypothesis that loss of integrity of the membranes in the craniocervical junction might be the cause of neck pain in patients with whiplash-associated disorders (WADs) has been proposed. In recent years, with development of more detailed magnetic resonance imaging (MRI) techniques, morphologic changes of the ligaments and membranes in the craniocervical junction, especially alar and transverse ligaments have been discussed. A meta-analysis was performed to evaluate the relationship of MRI signal changes of alar and transverse ligaments and WADs.

METHODS

A systematic search of EMBASE, PUBMED, and Cochrane Library and references from eligible articles were conducted. Comparative studies reporting on evaluating the relationship between MRI high-signal changes of alar and transverse ligaments and WADs were regarded eligible. A pooled estimate of effect size was produced.

RESULTS

Alar ligaments: Six studies (total n = 622) were included. MRI signal changes of alar ligaments did not appear to be related with WADs (P = 0.20, OR = 1.54, 95 % CI = 0.80-2.94). Heterogeneity was present (I (2) = 46 %, P = 0.10), which was eliminated upon sensitivity analysis bringing the OR to 1.27 (95 % CI = 0.87-1.86, I (2) = 0 %). Transverse ligaments: Four studies (total n = 489) were included. MRI signal changes of transverse ligament did not appear to be related with WADs (P = 0.51, OR = 1.44, 95 % CI = 0.49-4.21). Heterogeneity was present (I (2) = 77 %, P = 0.005), which was eliminated upon sensitivity analysis bringing the OR to 0.79 (95 % CI = 0.49-1.28, I (2) = 0 %).

CONCLUSION

MRI signal changes of alar and transverse ligaments are not supposed to be caused by whiplash injury, and MRI examination of alar and transverse ligaments should not be used as the routine workup of patients with WADs.

Manual therapies for cervicogenic headache: a systematic review

This paper systematically reviewed randomized clinical trials (RCT) assessing the efficacy of manual therapies for cervicogenic headache (CEH). A total of seven RCTs were identified, i.e. one study applied physiotherapy ± temporomadibular mobilization techniques and six studies applied cervical spinal manipulative therapy (SMT). The RCTs suggest that physiotherapy and SMT might be an effective treatment in the management of CEH, but the results are difficult to evaluate, since only one study included a control group that did not receive treatment. Furthermore, the RCTs mostly included participant with infrequent CEH. Future challenges regarding CEH are substantial both from a diagnostic and management point of view.