Is human cerebrospinal fluid reabsorbed by ? Lymph drainage therapy (LDT) and manual drainage of the central nervous system by Bruno Chikly, MD (France)

"The lymphatics are closel y and universally Scientists agree that production of CSF is done mainly by connected with the spinal cord and all other the highly vascularized choroid plexus. However, other ex- perimentation found that the choroid plexus are responsible nerves, long or short, universal or separate, for only 60 to 85 percent of the total production of CSF."3-1•71 and all drink from the waters of the brain. Some studies have shown that about 15 to 30 percent of CSF

A.T. Still. Philosophy of Osteopathy. pg. 105. is produced in an extrachoroidal origin." The en- dothelium of the cerebral tissue is believed to be the major source of extrachoroidal CSF production." u" "" "Possibly less is known of the lymphatics than any other division Cerebrospinal fluid (CSF) absorption: of the life-sustaining machinery of man. 1 ) Choroid Plexus: A.T. Still. The Philosophy and Mechanical The choroid plexus may absorb about I/10th of their Principles of Osteopathy. pg. 66. own secretion." For that reason. the function of these structures has been compared to that of the proximal renal tubule. hese two quotes from the father of osteopathy still today remains so contemporary. The latest scien 2) Arachnoid rah and granulations (pacchionian T tific reports agree that about half of cerebrospinal bodies: the venous side fluid (CSF) may be reabsorbed by the lymphatic circula- In 1914, Weed made an important discovery when he tion. That proportion can even be greater when the CSF showed that the arachnoid villi and granulations are pressure increases."-" .86 But in spite of this new informa- the major source of CSF absorption." tion, the relationship between lymphatic circulation and CSF still generates controversy among experts espousing Villi and granulations are covered by a epithelium with their various theories. very tight junctions. On the apical cap of arachnoid cells, This article describes some of the new concepts con- the dural coat is lacking, and the presence of open chan- cerning the circulation between CSF, cerebral interstitial nels has been shown to connect the arachnoid bodies to fluid (CIF) and lymph. It also will present some specific the venous side. The exact role of the arachnoid villi and lymphatic techniques (Lymph Drainage Therapy) that can granulations in reabsorption of CSF is still unclear. Well help facilitate the exchange of these fluids. limited channels up to 100 microns in diameter have been described at the apical cap of the arachnoid granulations Cerebrospinal fluid (CSF) production and seem to be in continuity with the SAS.2.18.19-"34.58.93 -...the cerebrospinal fluid is (me of the highest known el- Pinocytosis or vesicles seem to be another possible mecha- ements that are contained in the body... "A.T. Still. The Phi- nism of CSF transfer." losophy and Mechanical Principles of Osteopathy, pg. 44. We can already observe that a link between intracra- nial and extracranial exist. The cranium is made of

28/AAO Journal Winter 1998 an inner and outer plate (lamina) of resistant compact bone Their model held until 1914 when Weeds, who judi- with an intervening layer of light, spongy bone (the dip- ciously used alternatively two solutions of a ferrous cya- loe). The diploe is covered by a network of veins (the nide then acid, observed precipitation of blue crystals into diploic veins: anterior and posterior temporal diploic veins, the lateral ventricles of cats and rabbits. He concluded frontal and occipital diploic veins) that receive venous that the arachnoid villi were the dominant way for CSF to drainage of the entire . Emissary veins are veins with- be reabsorbed."'" After reviewing Weed's work today, we out valves that pass through the cranial bones to connect know he observed that a certain amount of dye colored with the superficial extracranial veins, for example the the course of and cervical lymphatics, but superficial temporal . There is a connection between he concluded at the time that the lymphatics are an "ac- intracranial veins, dipoic veins, emissary veins and ex- cessory pathway" for CSF absorption. After that, the theory tracranial veins (temporal, occipital, parietal). of central nervous system lymphatic drainage was slowly Clinical studies also have shown that stimulation of discarded. lymphatic drainage also activates venous reabsorption" Numerous published studies show that some constitu- Specific manual lymphatic drainage techniques can spe- ents of the CSF in animals drain into cervical I ymph nodes. cifically facilitate extracranial lymphatic circulation and Passage from the CSF to the deep cervical nodes occurs are able to activate CSF/venous exchanges/lymphatic ex- within I mn in the rabbit," and 30mn in the rat and guinea changes. p i g 1.11.59 In 1968, Foldi was one of the first scientist to use liga- 3) The lymphatic side tion of the cervical lymphatics to provoke lymphostatic "...the lymphatics are almost the soul requisite of the encephalopathy in dogs. m4" The recent research by Boulton both'..." A.T. Still. Philosophy of Osteopathy, pg. 109. et al's' illustrates that about one half (48 percent) of the protein tracer injected in the lateral ventricles of sheep is Lymphatic vessels have been noted only in the dura, the transported into extracranial lymphatics. pia maim"' the pituitary capsule, the orbit, the nasal mu- Mistakes or imprecision in standard studies have mini- cosa, and the middle ear. To date, a has not mized the role of lymph in CSF reabsorption. Courtice been identified within the brain itself. However, some type and Simmonds, in 1951, injected radio-labeled albumin of lymphatic-like drainage is necessary to evacuate the small and recovered about 5 percent in the cervical lymph amount of proteins of the central nervous system, which be- nodes."s" They reported that 95 percent was reabsorbed comes particularly important in cases of edema, hemorrhage by arachnoid villi. Actually, they recovered only 14 per- or infection. 1625 The significant presence of the lymphatic cent of all the radioactive substances. After correcting the system to helps the scavengers cells (macrophages and mi- calculations, their experiments showed that approximately croglia) evacuate large proteins in extracranial connective 30 percent was reabsorbed in the cervical lymphatics. tissue is lacking in the central nervous system. After several experiments, Brinker et al showed that at In addition, the central nervous system requires fast path- least 50 percent of CSF is reabsorb through the lymphat- ways equivalent to the lymphatic system, for circulation of ics rather than arachnoid villi.'' The increase in CSF in- immunocompetent cells, which lead to lymphatic nodes and/ traventricular pressure eventually will augment the amount or the in order to activate a significant immunologi- of CSF drained by the lymphatics" .'6"'""" and amount of cal response/ 13'1' '"' the fluid recovered seems to depend on the molecular weight. A) Lymphatic Drainage of the CSF: However, strong scienti tic evidence of these findings "Perineural Pathways" in human subjects is still insufticient. 21 Smith showed that various tumors of the central nervous system (medullo- By injecting Berlin Blue dye into a dog's subarachnoid blastoma, glioblastoma), can metastasize into the lym- space, Schwalbe, in 1869, made the first observation that phatic system.' Ogilvy also observed gliomas spread to the lymphatic pathways were the major means to absorb deep ." CSF." Later, in 1872. Quincke theorized that the CSF can In addition, clinical observations help us understand leave the subarachnoid spaces through small areas sur- that some of the constituents of the CSF are reabsorbed in rounding the nerve roots .8" the periphery of the body. McComb observed that chil- In 1875, Key and Retzius were the first to demonstrate dren with hydrocephalus develop nasal congestion, facial the circulation through the arachnoid granulations into and periorbital edema when their cranial shunts develop lymphatic vessels in the nasal mucosa, the frontal sinus an obstruction." and along cranial nerves using dye-colored gelatin."

Winter 1998 AAO JouniaU29 II Drainage through nasal lymphatics: lymph nodes, external auditory meatus. and auricle of the The historical experiment of Schwalbe using Berlin blue ears also can be used clinically. dye, showed some quantity of the marker passing along olfactory bundle nerve pathways. Numerous experiments 4) Other nerves pathwa ys: trigeminal nerves, facial with different species confirmed the existence of this path- nerves and other cranial nerves. way.". i 0.11.23,3 i .37.55.59.66.67.71.72.87,88.97.103.105 This circulation can be activated with extensive lym- Jackson showed in 1979 that inflammatory blockage phatic drainage of the and face. of nasal mucosa lymphatics can facilitate central nervous system retrograde viral infection. 5) Spinal nerve root: Carbon particles and labeled proteins follow the olfac- In 1928, Pigalew injected a tracer in the lumbar dural tory tracts and pass through the cribriform plate ( lamina space and found it in the abdominal and pelvic lymphat- cribrosa ) to the nasal mucosa, the retropharyngeal lymph ics, including the , suprarenal glands and nodes and the angulus venosus at the base of the neck paraaortal lymph nodes. Brierley and Field" detected In- (, subclavian vein. brachio-cephalic dian ink suspension in the lumbar and sacral nerve roots. vein). Later a small quantity of this marker was observed in the At the level of the fila olfactoria passing through the lumbar para-aortic lymph nodes." cribriform plate. the layer of dura and arachnoid fuses and Lymphatic drainage of the spine is accessible follow- becomes continuous with the one-layer thick perineurium. ing deep or superficial lymphatic pathways. Deep lym- Perhaps 90 percent of radio-labeled particles follow this phatic drainage involves pathways through the intercos- route in the rabbit.'" tal nodes to the paraspinal nodes or through the quadratus The perineurium space seems to communicate freely lumborum. The superficial drainage of the spine follows with the loose interstitial tissue of the submucosa (pas- three distinct lymph territories, or lymphotomes, that drain sive escape pressure-dependent. no tight junctions). Pi- to the cervical. axillary or inguinals lymph nodes. nocytosis is another mechanism that has been proposed." Adjacent lymphatic vessels can easily reabsorb constitu- 6) Direct dural pathway ents of the CSF and escape into the nasal mucosa. Intranasal Under high pathological pressure, the CSF can escape and intraoral lymphatic drainage (including soft and hard from the arachnoid barrier and be reabsorbed by the lym- palate. palatoglossal and palatopharyngeal arches. subglossal phatics of the ." lymph circulation) can help activate this circulation.

2) Drainage through optic nerve pathways: B. Lymphatic drainage of cerebral Numerous studies also identify the optic pathways as a interstitial fluid (CIF): "Intravascular/ route for the SAS to be reabsorbed from the central ner- 5.1 1.35.0.69.71.88 VOUS system. perivascular pathways" Markers injected in the SAS also have been shown to Passage from the brain to the deep cervical nodes takes reach the retro-orbital connective tissue. Shen found some place in 3 hours in the rabbit,'''' 8 hours in cat and sheep."' arachnoidal trabecular network at transitional areas at the Dubois-Ferriere first demonstrated the connections end of the SAS and the posterior uveal/periorhital com- between the intraadventitial circulation and the cervical partment." lymphatics." These studies, which were followed by those Lymphatic drainage of the orbits and periorhital tis- of Kozma, Casley-Smith and others, showed that carbon sues to the temporal and parotidians lymph nodes helps particle markers injected in the cerebral cortex were de- activate this circulation. tected in the adventitia of cerebral blood vessels both in- tra- and extra-cranially.''.'"''."" 3) Drainage through auditory pathways: Virchow (1851) and Robin (1859) described spaces Some experimental animal studies have shown that located inside the main cerebral blood vessels, located constituents of the CSF also may drain via the perilymph between the basement membrane of the glial limitans ex- then the fenestra rotunda, to the mucosa of the middle ternally and the ." 94'"5 These spaces have been ear.' The communication between SAS and the ear takes described as perivascular or more appropriately place through the cochlear duct." Activation of lymph flow intraadventitial.-' 123,-"596" through drainage of the preauricular and post auricular Extra cerebral blood vessels present in the adventitia a circulation of minute vessels and nerves that is called the

30/AAO Journal Winter 1998 "vasa-vasorum": the vessels inside the vesse1. 51 "." Cere- passing you by as a fthlure, until you are by knowledge bral vessels after passing through the layer of dura mater qualified to deal with the lymphatics" A.T. Still. Philosophy have no vasa- vasorum in the adventitia'" and their endot- of Osteopathy. pg. 105. helial cells are joined by tight junctions.'" However, the surface of the adventitia contains many circular openings Lymphology has evolved as a new branch of medicine measuring 1 to 3 microns (stomata), which connect with as medical science is only beginning to fully understand the the intraadventitial spaces on one side and CSF on the role that lymph plays in the body. The first recorded use of other side. 1°4 A free communication between the perivas- gentle manual techniques to activate the lymphatic flow took cular pathways and SAS has also been described.'"1"s place at the beginning of the 20th century. Osteopath F. P. Two schools of thought exist concernin g whether the Millard, a graduate of the Kirksville Osteopathic College, delicate layer of pia mater coats the blood vessels when was the first practitioner to document specific techniques they enter the cerebral tissue. The possible continuity be- working on the lymphatic system.' Specific lymphatic tech- tween the SAS and perivascular spaces is yet another sub- niques, like cranial techniques, were introduced in a second ject of controversy. time, in the history of osteopathic manipulation. Several investigators support the viewpoint that the pia Scientific descriptions of a lymphatic rhythm have been mater follows the blood v essels in the SAS that enter the described in human 39.46,61.91.92 but very few practitioners cerebral parenchyma. 45•47•64.65.".s4•"418"" Zhang showed that are working with stimulating lymph circulation in a di- intracortical are coated at their source by a sheath rect and specific manner in the same way we work with of cells derived from the pia mater, while veins are cov- the CSF circulation There is a whole new and very rich ered incompletely by some pial cells. field of osteopathy to deepen and expand into. Other studies concluded that the pia mater does not Lymph Drainage Therapy is an original method of lym- accompany the blood vessels in the cerebral tis- phatic drainage developed by French physician Bruno sue.211.21.22.23.26.37.40.41.42.43.44.54.65.101 Chikly. The particularities of LDT are that it teaches prac- Foldi11.5162 and his team ligated the cervical lymphatics titioners how to manually attune to the I) specific rhythm, of numerous animals. In his report. he stated that research- 2) direction 3) depth and 4) quality of the lymph flow ers noted lymphostatic hemangiopathy characterized by consistent with scientific discoveries.".`"." spaces in the blood vessels of the neck, edema fluid in the adventitia of intracranialextracerebral as well as intrac- I) Human lymphatic rhythm: erebral vessels (...)" those spaces being 6-10 time larger The main vessel of the lymphatic system ( lymphatic than usual:" collectors) consists of two or three layers of spiral muscles Intraadventitial spaces, which follow the course of with specific contractions that are innervated by the sym- blood vessels, are present throughout the body. The fact pathetic and parasympathetic system (49, 56, 73. 78, 81). they do not present valves and that retrograde lymph flow Contrary to some views, the lymphatic system is not a is possible, constitutes an alternate pathway, if needed, passive system; lymph does not need to be pushed with for lymph circulation. In the case of the CNS, these struc- our fingers like a tube of toothpaste. Obstruction on the tures represent a natural escape for some of the constitu- way has to be removed, specific pressure and rhythm needs ents of the CIF in order to drain into lymphatic pathways. to be applied in synchrony with the lymphatic system. In conclusion CSF and CIF may choose between two Even though one main lymphatic rhythm has been scien- major pathways: the neurolymphatic pathways along tifically described in humans in practice two different lym- perineurium of nerves, principally olfactory nerves, and phatic rhythms have been identified: the capillary and hemangiolymphatic pathways, perivascular/intravascular lymphangions rhythm. and a pre-lymphatic (connective pathways, along major arteries and veins. tissue) rhythm.

Clinical applications: 2) Direction of the lymph flow: lymph drainage therapy Advanced LDT practitioners can assess and manually "We lay much stress on the uses of blood and the pow- "map- the flow of the lymphatic circulation during ses- ers of the nerves, but have we any evidence that the y are sions. This method consists of manually assessing the spe- of more vital importance than the lymphatics?" A.T. Still. cific direction of lymphatic flow and finding areas of fluid The Philosophy and Mechanical Principles of Osteopath pg. 65. retention, edemas or fibrosis. The mapping tools are very

"...your patient had better save his life and money by

Winter 1998 AAO Journal/31 important in cases of fluid obstruction when it can be used Mater in Man: Anatomical and Ultrastructural Observations?' to find the most accurate alternate lymphatic pathways to Neuropathol. and Appl. Neurobiol.. 1988. 14: 1-17. 2. Arnold W.. Nitze H.R., Ritter R.. "Qualitative Untersuchungen evacuate stagnant fluids. Der Verbindungswege Des Subarachnoidalraumes Mit Dem Lymphatischen System Des Kopfes Und Des Halses," 3) Depth and pressure: ActaOtolaryngol. (Stockh). 1972. 74: 411-424. The ideal pressure has been calculated as no more than 3. Arnold W.. "The Ear and the Lymphatic Systems," 33 mm of mercury per cm2. 4 The standard pressure used Lymphangiology. Foldi M., Casley-Smith J.R. (Eds.), Schattauer, Stuttgart. 1983. is very similar to that applied in cranial work. We need to 4. Asdonk J.. "Lymphdrainage Und Molekularmassage," Phys. be identify the specific depth of the lymph circulation we Medizin Une Rehabilitation, Heft 10. 1967. are addressing: working on superficial epifascial circula- 5. Berens Von Rautenfeld D.. Kaiser FL E., Foldi M. & Al. "The tion. lymph circulation below the fascia, muscles, inter- Leptomeningeal Sheath of the Optic Nerve as an Area of Lym- costal spaces, viscera. periosteum will require a different phatic Resorption of Cerebrospinal Fluid," Progress In intention and depth. Lymphology XIV. Sept. 1993. Witte M.H. And Witte C.L., Eds., Lymphology 27 (Suppl.). 1994. p. 685-68'7. 6. Botel C. Brinker T. et al, "A Species Comparing Study of Lym- 4) Qttalitv: phatic Absorption of Cerebrospinal Fluid. - Progress in Quality of lymph need also to be assessed. Lymph can Lymphology XIV. Sept. 1993, Witte M.H. and Witte C.L., Eds., be quite viscous in cases of chronic lymph retention like Lymphology 27 (Suppl.). 1994, p.688-691. allergies, fibromyalgia, chronic fatigue syndrome. chronic 7. Boulton M.. Flessner M., Armstrong D., Hay J., Johnston M.. inflammation, etc. Emotional "fluidity" is also usually re- "Lymphatic Drainage of The CNS: Effects of Lymphatic Diver- sion / Ligation on CSF Protein Transport to Plasma:' Am. J. lated to lymph fluidity. Physiol.. 1997, 272: 1613-1619. For drainage of the central nervous system, the main 8. Boulton M.. Flessner M., Armstrong D.. Hay J., Johnston M.. goal of LDT is to activate resorption and cleansing of some "Determination of Volumetric Cerebrospinal Fluid Absorption into constituents of CSF through the neurolymphatic or Extracranial Lymphatics in Sheep:' Am. J. Physiol., 1998, 274: haemangiolymphatic pathways. A small study showed that 88-96. lymphatic drainage techniques can reduce intracranial 9. Bradbury M.W.B.. Cole D.E. "The Role of the Lymphatic Sys- tem in Drainage of the Cerebrospinal Fluid and Aqueous Humor;' pressure dramatically, even more effectively in some case J. Physiol., 1980, 299: 353-365. than Mannitol." 10. Bradbury M.W.B., Westrop RI, "Factors Influencing Exit of Sub- Many other lymphatic functions also can be applied stances from the Cerebrospinal Fluid into Deep Cervical Lymph for different clinical cases. Lymph flow stimulation acti- ofthe Rabbit." J. Physiol.. 1983. 339: 5 19-534. vates all other fluid fluctuations of the body, locally de- II. Bradbury M.W.B.. Westrop Rt. "Lymphatics and the Drainage creases chronic pain, spasms and chronic inflammations, of Cerebrospinal Fluid."' Hydrocephalus. N.Y., Raven Press, 1984, p. 69. and drains toxins," fat and macro molecules (proteins) 12. Bradbury M.W.B., Cserr H.F.. "Drainage of Cerebral Interstitial away from tissues. Activation of lymph flow through the Fluid and of Cerebrospinal Fluid into Lymphatics.- Exper. Biol. lymphatic nodes also stimulates the immune system. in- of the Lymphatic Circulation. Johnston M. (Ed.),Elsevier, creasing production of lymphoc ytes by about 30 percent. Amsterdam. 1985. Clinically these lymphatic techniques may seem to a 13. Brent L.. "Immunological Privileged Sites. - Pathophysiology of patient, quite similar to a cranial technique: a very light the Blood-Brain Barrier, Johansson B.B. et al (Ed), Elsevier, Amsterdam. 1990. p. 383-402. touch of few grams per cm2, a very slow rhythm, stimu- 14. Brierly J.B.. Field E.F., "The Connections of the Spinal Sub-Arach- lating the parasympathetic tone. The overall quality of the noid Space with the Lymphatic System?' J. Anat.. 1948, 82: 153- lymphatic stroke is very often described as a "love touch-. I 66. 15. Brightman .W.. "The Intracerebral Movement of Proteins Injected Dr Chiklv will present a lecture and seminar at the into Blood and Cerebrospinal Fluid of Mice." Prog. Brain Res., 1968, 29: 19. next AAO Convocation in St. Louis, MO. Dr Chiklv can 16. Brinker T.. Seifert V.. Stolke D., "Acute Changes of Cerebrospi- be contacted at: P.O. Box 14, San Gregorio, CA 94074- nal Fluid System Dynamics During Experimental Subarachnoid 0014 or phone/fax: (650)747-9764, e-mail: BCHIK Hemorrhage?' Neurosurg., 1990, 27: 369372. @ aol. corn. 17. Brinker T.. Baer M., Foldi M., "Manual Lymphatic Drainage of the Head and the Neck for Treatment of Increase Intracranial Pres- sure. "Progress In Lymphology XIV, Witte M.N.. Witte C.L. (Eds.). This article was excerpted from DI: Chiklvs new book. Lymphology ,1994. 27 (Suppl.): 614-617. 18. Brinker T., Ludemann W. et al, "Dynamic Properties of Lym- References phatic Pathways for the Absorption of Cerebrospinal Fluid," Acta I. Alcolado J.C., Weller R.O. et al. "The Cranial Arachnoid and Pia Neuropathol. (Berl.). 1997. 94:493-498.

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