Morphological classification and comparison of suboccipital muscle fiber characteristics

Effectiveness and Safety of Pharmacopuncture on Inpatients with Tension Headache Caused by Traffic Accidents: A Pragmatic Randomized Controlled Trial

Background: This study investigated the effectiveness and safety of pharmacopuncture for pain relief and functional improvement in patients with traffic accident (TA)-induced acute tension headaches. Methods: The study employed a parallel, single-centered, pragmatic, randomized controlled trial design. Eighty patients complaining of acute tension headaches were randomized into the integrative Korean medicine treatment (IKM treatment) group and the pharmacopuncture group on suboccipital muscles (suboccipital muscles pharmacopuncture + IKM treatment), with 40 participants assigned to each group. The patients in the pharmacopuncture group underwent pharmacopuncture as an add-on therapy, consisting of three sessions. Both groups were reassessed 2 months post-intervention. To assess the outcomes, the Numeric Rating Scale (NRS) for Headache, NRS for Neck Pain, Headache Disability Index, Headache Impact Test-6, EuroQol 5-Dimension, and Patient Global Impression of Change were used. Results: The improvement in the outcomes of the pharmacopuncture group was significantly greater than that of the comparison group on day 4 of hospitalization in terms of pain (difference in NRS of headache -2.59, 95% CI -3.06 to -2.12; NRS of Neck pain -1.05, 95% CI -1.50 to -0.59) and function (difference in HDI -24.78, 95% CI, -31.79 to -17.76; HIT-6 -6.13, 95% CI, -9.47 to -2.78). Additionally, in 2 months of follow-up, the recovery rate of headache was significantly higher in the pharmacopuncture group than in the comparison group. Conclusions: The pharmacopuncture group demonstrated superior outcomes in symptom improvement than the comparison group did, providing insights into novel and useful applications of pharmacopuncture in the clinical practice of Korean medicine.

Evidence for chronic headaches induced by pathological changes of myodural bridge complex

Clinical studies have shown that there may be a certain relationship between pathological changes of the myodural bridge complex (MDBC) and chronic headaches of unknown cause. But there is still a lack of experimental evidence to explain the possible mechanism. This study aims to further confirm this relationship between MDBC and chronic headaches and explore its potential occurrence mechanism in rats. Bleomycin (BLM) or phosphate-buffered saline (PBS) was injected into the myodural bridge fibers of rats to establish the hyperplastic model of MDBC. After 4 weeks, the occurrence of headaches in rats was evaluated through behavioral scores. The immunohistochemistry staining method was applied to observe the expression levels of headache-related neurotransmitters in the brain. Masson trichrome staining results showed that the number of collagen fibers of MDBC was increased in the BLM group compared to those of the other two groups. It revealed hyperplastic changes of MDBC. The behavioral scores of the BLM group were significantly higher than those of the PBS group and the blank control group. Meanwhile, expression levels of CGRP and 5-HT in the headache-related nuclei of the brain were increased in the BLM group. The current study further confirms the view that there is a relationship between pathological changes of MDBC and chronic headaches of unknown cause. This study may provide anatomical and physiological explanations for the pathogenesis of some chronic headaches of unknown cause.

An anatomical investigation of the suboccipital- and inferior suboccipital triangles

The suboccipital triangle (ST) is a clinically relevant landmark in the posterior aspect of the neck and is used to locate and mobilize the horizontal segment of the third part of the vertebral artery before it enters the cranium. Unfortunately, this space is not always a viable option for vertebral artery exposition, and consequently a novel triangle, the inferior suboccipital triangle (IST) has been defined. This alternative triangle will allow surgeons to locate the artery more proximally, where its course is more predictable. The purpose of this study was to better define the anatomy of both triangles by measuring their borders and calculating their areas. Ethical clearance was obtained from the University of Pretoria (reference number: 222/2021) and both triangles were subsequently dissected out on both the left and right sides of 33 formalin-fixed human adult cadavers. The borders of each triangle were measured using a digital calliper and the areas were calculated using Herons Formula. The average area of the ST is 969.82±153.15 mm2, while the average area of the IST is 307.48±41.31 mm2. No statistically significant differences in the findings were observed between the sides of the body, ancestry, or sex of the cadavers. Measurement and analysis of these triangles provided important anatomical information and speak to their clinical relevance as surgical landmarks with which to locate the vertebral artery. Of particular importance here is the IST, which allows for mobilisation of this artery more proximally, should the ST be occluded.

Assessment of axial rotation movement in cervical dystonia using cone-beam computed tomography

BACKGROUND

Cervical dystonia is a neurological disorder characterized by involuntary muscle contractions and abnormal postures of the head and neck. Botulinum neurotoxin injection is the first-line treatment. Imaging determination of the cervical segments involved (lower or upper according to the torticollis-torticaput [COL-CAP] Classification) is an aid in determining the muscles to be injected. We aimed to clarify the impact of dystonia on posture and rotational movement of cervical vertebrae in the transverse plane.

METHODS

A comparative study was conducted in a movement disorders department. Ten people with cervical dystonia and 10 matched healthy subjects (without cervical dystonia) were recruited. 3-D images of posture and cervical range of motion in axial rotation in the sitting position were recorded by using a cone-beam CT scanner. Range of rotational motion of the upper cervical spine from the occipital bone to fourth cervical vertebra was measured and compared between the two groups.

FINDINGS

The head posture analysis showed that the total cervical spine position was more significantly distant from the neutral position for people with dystonia than healthy subjects (p = 0.007). The rotational range of motion of the cervical spine was significantly lower in cervical dystonia participants than in healthy subjects for the total (p = 0.026) and for upper cervical spine (p = 0.004).

INTERPRETATION

We demonstrated, by means of cone-beam CT, that the disorganization of movements due to cervical dystonia affected the upper cervical spine and mostly the atlantoaxial joint. The involvement of rotator muscles at this cervical level should be considered more in treatments.

Morphological Changes of the Suboccipital Musculature in Women with Myofascial Temporomandibular Pain: A Case-Control Study

Temporomandibular disorder (TMD) is an umbrella term including pain problems involving the cranio-cervical region. It has been suggested that patients with TMD also exhibit cervical spine disturbances. Evidence suggests the presence of morphological changes in the deep cervical muscles in individuals with headaches. The objective of this study was to compare the morphology of the suboccipital muscles between women with TMD and healthy controls. An observational, cross-sectional case-control study was conducted. An ultrasound examination of the suboccipital musculature (rectus capitis posterior minor, rectus capitis posterior major, oblique capitis superior, oblique capitis inferior) was conducted in 20 women with myofascial TMD and 20 matched controls. The cross-sectional area (CSA), perimeter, depth, width, and length of each muscle were calculated by a blinded assessor. The results revealed that women with myofascial TMD pain exhibited bilaterally reduced thickness, CSA, and perimeter in all the suboccipital muscles when compared with healthy women. The width and depth of the suboccipital musculature were similar between women with myofascial TMD and pain-free controls. This study found morphological changes in the suboccipital muscles in women with myofascial TMD pain. These changes can be related to muscle atrophy and are similar to those previously found in women with headaches. Future studies are required to investigate the clinical relevance of these findings by determining if the specific treatment of these muscles could help clinically patients with myofascial TMD.

Suboccipital Muscles, Forward Head Posture, and Cervicogenic Dizziness

Dizziness or vertigo can be caused by dysfunction of the vestibular or non-vestibular systems. The diagnosis, treatment, and mechanism of dizziness or vertigo caused by vestibular dysfunction have been described in detail. However, dizziness by the non-vestibular system, especially cervicogenic dizziness, is not well known. This paper explained the cervicogenic dizziness caused by abnormal sensory input with references to several studies. Among head and neck muscles, suboccipital muscles act as stabilizers and controllers of the head. Structural and functional changes of the suboccipital muscles can induce dizziness. Especially, myodural bridges and activation of trigger point stimulated by abnormal head posture may be associated with cervicogenic dizziness.

Effect of high intensity laser therapy in the treatment of acute atlantoaxial rotatory subluxation: A case report

BACKGROUND

Sudden onset of acute torticollis in children is rare and is usually diagnosed as atlantoaxial rotatory subluxation (AARS). The common treatment for acute AARS without neurological symptoms is halter traction in conjunction with muscle relaxant and sedative agents, followed by cervicothoracic orthotic immobilization. To the best of our knowledge, a case of acute AARS treatment with high-intensity laser therapy (HILT) has not yet been reported so far.

OBJECTIVE

We aimed to report a case of acute AARS treatment with HILT successfully and to discuss about the clinical effect of HILT in AARS.

METHODS

We reported a 9-year-old girl with acute onset of torticollis visiting the rehabilitation outpatient department.

RESULS

The physical examination revealed a typical cock robin position without neurological symptoms. A series of evaluations, including open-mouth odontoid radiograph and soft tissue sonography, confirmed the diagnosis of acute AARS. The patient received HILT over the left suboccipital and upper back muscle groups, which started on the day of the first rehabilitation clinic visit, once a week, for four weeks. Torticollis and neck pain improved gradually with each session of HILT, and the symptoms resolved completely after the fourth session. Dynamic computed tomography (CT) of the cervical spine showed no evidence of obvious AARS after the treatment.

CONCLUSIONS

The patient had no complaints after HILT in a case of acute AARS resulting from a mechanical factor. Due to its pain-relief and muscle-release characteristics, HILT indicates the probable benefit of relaxation of spastic muscles for patients with AARS.

Upper cervical spine dysfunction and dizziness

Although various causes of dizziness have been identified, many patients suffer from dizziness of unknown etiology and continue to visit hospitals to resolve their symptoms. Problems that occur in the ligaments or muscles of the upper cervical spine can cause confusion in proprioception. These changes can convey misinformation to the vestibular nucleus, resulting in abnormal reactions that can lead to cervicogenic dizziness (CGD). Though CGD remains controversial, it should be considered while diagnosing patients with dizziness. Understanding CGD can help create treatment strategies for them. This article suggested a relationship between the structure and function of the upper cervical spine and dizziness, and presented evaluations and treatments for the same.

Implied Evidence of the Functional Role of the Rectus Capitis Posterior Muscles

Context

Osteopathic physicians often target the rectus capitis posterior minor (RCPm) and rectus capitis posterior major (RCPM) muscles when using muscle energy or soft tissue cervical techniques to treat patients with head and neck pain. The RCPm and RCPM muscles are located deep within the posterior occipitoatlantal and atlantoaxial interspaces, respectively.

Objective

To characterize the functional role of RCPm and RCPM muscles by comparing electromyographic (EMG) activation patterns of these muscles with EMG activation patterns of specific flexor and extensor muscles of the head and neck, the sternocleidomastoid (SCM), and the splenius capitis (SC) muscles, respectively.

Methods

Asymptomatic participants were recruited from the Michigan State University College of Osteopathic Medicine student body. Disposable 25-gauge, bipolar fine-wire intramuscular electrodes were used to collect EMG data from the right and left RCPm and RCPM muscles. Surface electrodes were used to collect EMG data from the right and left SCM and SC muscles. Data were collected as participants performed 4 cycles of flexion and extension with an external 4-lb force applied to the back of the head and the forehead.

Results

In RCPM muscles, EMG activity was significantly greater (P<.003) during flexion and extension of the head and neck when an external force was applied to the back of the head. EMG activity in SCM muscles was significantly greater (P<.0001) during flexion and extension of the head and neck when an external force was applied to the forehead. The authors observed that EMG activity in SC muscles was significantly greater (P<.015) during flexion and extension of the head and neck when an external force was applied to the back of the head. No significant difference was found in EMG activity in RCPm muscles (P<.834) during flexion and extension of the head and neck, regardless of whether the external force was applied to the back of the head or the forehead.

Conclusion

The EMG activation patterns of the RCPm muscles suggest that their functional role may be to stabilize the occipitoatlantal joint by helping maintain congruency of the joint surfaces. In contrast, the EMG activation patterns of the RCPM muscles suggest that their functional role may be to contribute to extension of the head, primarily at the occipitoatlantal and the atlantoaxial joints.

Cadaveric and ultrasonographic validation of needling placement in the obliquus capitis inferior muscle

BACKGROUND

Evidence suggests that suboccipital musculature plays an important role in headache. Proper therapeutic approaches targeting this muscle are needed.

OBJECTIVE

Our aim was to determine with fresh cadavers and ultrasound imaging if a solid needle is able to properly penetrate the obliquus capitis inferior muscle during the application of dry needling.

DESIGN

A cadaveric and human descriptive study.

METHODS

Needling insertion and ultrasound imaging of the obliquus capitis inferior muscle was conducted on 10 pain-free healthy subjects and 5 fresh cadavers. Needling insertion was performed using a 40 mm needle inserted midway between the spinous process of C2 and transverse process of C1. The needle was advanced from a posterior to anterior direction into the obliquus capitis inferior muscle with an inferior-lateral angle to reach the lamina of C2. For the cadaveric study, the obliquus capitis inferior placement was verified by resecting the superficial upper trapezius, splenius capitis, and semispinalis capitis muscles. For ultrasographic study, a linear transducer was aligned with the long axis of the obliquus capitis inferior muscle after needle insertion.

RESULTS

Both the cadaveric and ultrasonic studies showed that the needle penetrated the obliquus capitis inferior muscle during its insertion and that the tip of the needle rested against C2 laminae, thereby reaching the targeted muscle.

CONCLUSION

This anatomical and ultrasound imaging study supports the assertion that needling insertion of the obliquus capitis inferior muscle can be properly conducted by an experienced clinician.