sub-occipital release. myodural release 참 좋은 치료기법이네.

[문형철]

참 좋은 치료법이다.

다양한 이론의 조합에 의한 새로운 치료법

1. anatomy train

2. sub-occipital release

3. 자율이완, 심호흡

4. nerve stretching(anke flex, ext)

후두하근 근육에 대한 모든 것(클릭클릭)

myodural adhesions

myodural release

sub-occipital release를 잘 해주면 두통, 근막-근육 유착에 의한 목, 어깨통증, 심지어 허리통증까지 좋은 치료적 영향을 미친다.

근막의 유착은 머리에서 발끝까지 움직임을 제한하고, 통증을 유발하는 중요한 요인이다. 

panic bird...

Rectus capitis posterior minor-a small but important suboc.pdf

Brief Communication

Chronic Headache Relief After Section of Suboccipital Muscle Dural Connections: A Case Report

Gary D. Hack, DDS; Richard C. Hallgren, PhD

The presence of a connective tissue bridge, attaching suboccipital muscles to the dura mater, is now recognized as a feature of normal human anatomy. The role that this myodural bridge may play in headache production is uncertain; however, a new conceptual model is emerging. Postsurgical myodural adhesions have been reported as a complication resulting from excision of acoustic tumors. Extensive research now exists implicating these myodural adhesions as a possible source of postoperative headache. Integrating these 2 types of myodural unions (anatomic and pathologic) into a unified theory of headache production, we report a single patient who experienced relief from chronic headache after surgical separation of the myodural bridge from the suboccipital musculature.

- 결합조직 bridge의 존재, 후두하근육의  dura mater 부착은 정상 인체 해부학의 특성으로서 인지되고 있음. 

- 근경막 bridge는 두통발생에 중요한 역할을 할 수있다는 사실은 불명확함. 하지만 새로운 이론 모델이 출현하고 있음. 

- 수술후 근경막 유착은 acoustic 암 절제의 합병증으로 보고ㅎ됨. 많은 연구에 의하면 근경막 유착은 수술후 두통의 근원이라고 보고하고 있음. 

(Headache 2004;44:84-89)

The naturally occurring physical connection between suboccipital muscles and the dura mater at the atlanto-occipital junction (Figure 1) has been described in recent studies.1-9 The 38th edition of Gray’s Anatomy now notes the presence of a myodural bridge connecting the rectus capitis posterior minor muscles to the dura mater.1 Humphreys et al and Rothman et al have independently observed the myodural bridge by means of magnetic resonance imaging (MRI).2,3 Physical manipulation of the nuchal musculature, and specifically the rectus capitis posterior minor muscles in fresh cadaveric specimens (Figure2), has been shown to produce observable changes in the position of the dura.4 

While researchers speculate about the functional significance of the myodural bridge,5,6 its precise function is unknown. In the absence of pathology, researchers have suggested that the myodural bridge provides anatomic and physiologic answers to the etiology of some headache conditions.8,9 More relevant to the present article is the possibility that pathology may facilitate the transmission of excessive or abnormal muscular forces through the myodural bridge to the pain-sensitive dura, resulting in headache. 

Alix and Bates suggest the myodural bridge, acting as a dynamic connection, may transmit abnormal levels of tension from hypertrophied suboccipital muscles to the pain sensitive dural membrane.7 The mechanism by which the myodural bridge might transmit abnormal tractional forces to the pain sensitive dura is well supported (Figure 3). The dura is innervated by the same nerves that supply the upper 3 cervical segments.10,11 It has been demonstrated that tension applied to the dura, during neurosurgical procedures, induces pain that is interpreted as headache. It is also known that dural traction caused by tumors or other space-occupying lesions produces headache.12

CASE HISTORY

The role that the myodural bridge may play in headache production has been eval‎uated in a patient with chronic headache.13 A 40-year-old man  complained of long-term headache which was initially precipitated by physical trauma. These headaches had become debilitating from the age of 32 years, and rendered him unable to work from the age of 35. Intracranial pathology had been excluded as a cause of the pain. The headaches failed to respond to antimigraine

drug therapy. By early 1996, the patient was grossly overweight, contracting frequent respiratory and intestinal infections. 

He was taking up to 720 mg per day of morphine in an attempt to control the pain. There was consensus among the treating physicians that the headache was probably cervicogenic in origin, as the patient’s suboccipital musculature ap-

peared hypertrophied when examined by MRI. After reviewing the publication describing the myodural bridge,4 and the accompanying comments postulating a possible association between the myodural bridge and head pain,5 the medical team elected to attempt surgical relief of these headaches by severing the connection between the hypertrophic suboccipital muscles and the dura mater. Informed consent was obtained, and Dr. H. Edeling performed the “myodural

release.” 

The myodural bridge was easily identified  and the nuchal musculature appeared hypertrophied, possibly because of a history of repeated neck trauma (Figure 4). During surgery, all tissue attachments connecting the nuchal musculature to the dura were severed. Passive displacement of the suboccipital musculature produced visible movement of the dura. The site of severance was made well away from the dura to reduce the possibility of dural puncture. In an attempt to prevent postoperative adhesions from restoring the myodural connection, a dural substitute was placed between the nuchal musculature and the dura. The patient, followed postoperatively for 2 years, reported significant relief of his chronic headaches following this surgical procedure.13

COMMENTS

Hypertrophy of the nuchal muscles, with accompanying headache, has been reported in the literature and represents a pathophysiological extreme that may produce headache.14,15 Support for the concept of muscle/dural tension-producing headache comes from extensive literature describing a high incidence of postoperative headache (POH) following surgical removal of acoustic tumor, particularly when the surgery is performed via the suboccipital approach.16-45 In the traditionally performed operation, surgical access was gained by permanent bone removal, leaving the dura in intimate contact with the nuchal musculature post surgery. 

Consequently, dense adhesions formed post operatively that directly attached the posterior cervical muscles to the surgically exposed dura. These adhesions between the neck muscles and the dura have frequently been observed in cases of a second op-eration and have been demonstrated histologically.16

Schessel et al demonstrated histologic adherence of nuchal musculature to the dura in a patient with persistent severe POH undergoing reoperation for tumor recurrence (Figure 5). The patient had experienced 7 months of head pain after previous suboccipital excision of an acoustic tumor. Schessel et al proposed that POH is the result of adherence of the nuchal musculature to the pain-sensitive dura with dural traction produced by the adherent musculature. It has been

reported that surgically separating the adherent dura from the neck muscles during reoperation results in relief of this type of headache. For example, Soumekh et al demonstrated that severing the myodural adhesions could substantially palliate POH.17 According to the “nuchal-dural-adhesion theory,”18 traction on the dura, because of activation of the neck muscles, stimulates nociceptive dural fibers with resultant pain.19 Postoperative head pain mimics cervicogenic headache, which is also unilateral, originates in the neck, and then spreads to the head. 

This is in accordance with the observation that many of these patients noted that coughing, straining, or head

and neck movement aggravated the POH.18 Schaller and Baumann, in their retrospective study, recently concluded that these postoperative myodural adhesions may indeed produce abnormal dural tension and help to explain the etiology of POH.19

We suggest that increased tension within suboccipital muscles may produce abnormal traction on the dura, stimulating dural nociceptive fibers with resultant head pain, even in the absence of pathology.

CONCLUSIONS

We propose that formation of pathologic myodural connections, resulting from physical trauma or surgical complications, may result in abnormal dural tension accompanied by chronic head and neck pain. Procedures such as botulinum toxin injections and spinal manipulative therapy should be considered as possible alternatives to surgery, especially in high-risk patients.46-49

In addition, we suggest that the so-called suboccipital headache, in some instances, may result from increased tension in cervical muscles being transmitted to the pain-sensitive spinal dura through the myodural bridge. This may serve to explain why some cases of headache, particularly those with no specific pathology and often diagnosed as cervicogenic headache, have been so resistant to standard treatment protocols.

[김수형]

자료 감사합니다.

[heoss]

유익한 자료 감사합니다.^^

[jinnys]

좋은 감사합니다!

[즐거움]

8년 전에 미국에서도 유명한 Osteopath에게서 cranial therapy를 교육받으면서 이것도 배웠었죠. 정말 효과가 좋은 치료법입니다. 그런데 osteopathy분야 중 특히 cranial 분야는 치료사가 환자의 몸과 대화를 나눌 수 있어야 좋은 결과를 볼 수 있습니다. 내가 치료하겠다고 나서면 안되구요, 환자 몸의 조직들이 하는 말을 듣고 느껴서 환자 몸이 스스로 좋아지도록 공감해 주는 역할을 해야 한다는 마음으로 접근해야 합니다. 그런데 그렇게 하면 정말 놀라운 경험을 하게 됩니다.

[즐거움]

영어 실력이 좋은 선생님은 Dr. A.T. Still의 저서들을 읽어보세요. Philosophy of osteopathy, Osteopathy(Research & practice) 아마 전율을 느끼실 겁니다. 오래전에 돌아가신 분이시지만 그분이 말씀하시길 "공장에서 만들어진 이세상의 모든 약은 인류의 재앙이므로 바다에 던져버려야 한다. Form=Function이다. 인체의 모든 질병은 모든 조직이 제자리에서 제역할을 하도록 도와주면 자연치유된다. 나는 이 방법을 통해 50년간 병들과의 전쟁에서 항상 이겨왔다."

[즐거움]

내가 학창시절에 이걸 알았다면 코피터지게 공부해서 미국가서 osteopath가 됬을 텐데, 적어도 울 나라에서 의대 들어가려고 발버둥 쳤을 텐데 라는 생각을 했더랬죠. 현실은 PT사 ㅠㅠ.

[문형철]

그러셨군요.. 멋진 즐거움님. ㅎㅎㅎ 물리치료 선생님이시군요 ㅎㅎ 화이팅..