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Download Article (PDF) BRIEF REPORT Magnetic Resonance Imaging Parameters Selected for Optimal Visualization of the Occipitoatlantal Interspace Richard C. Hallgren, PhD; Jacob J Rowan, DO From the Departments of Context: Disorders of the rectus capitis posterior minor (RCPm) muscles have been Physical Medicine & associated with chronic headache. Magnetic resonance (MR) imaging protocols cur- Rehabilitation (Dr Hallgren) and Osteopathic Manipulative rently used in clinical settings do not result in image sets that can be used to Medicine (Drs Hallgren and adequately visualize the integrity of occipitoatlantal structures or to definitively Rowan) at Michigan State quantify time-dependent functional morphologic changes. University College of Osteopathic Medicine in East Objective: To develop an MR imaging protocol that provides the superior image Lansing. quality needed to visualize occipitoatlantal soft tissue structures and quantify time- Financial Disclosures: dependent pathologic changes. None reported. Methods: Asymptomatic participants were recruited from the Michigan State Support: None reported. University College of Osteopathic Medicine student body. Magnetic resonance Address correspondence to imaging data were collected from each participant at enrollment and 2 weeks after Richard C. Hallgren, PhD, enrollment using a 3T magnet. A conventional spin-echo pulse sequence was used Department of Physical Medicine & Rehabilitation, to construct 24 axial, T1-weighted images with the following measurement para- Michigan State University meters: repetition time, 467 milliseconds; echo time, 13.5 milliseconds; number of College of Osteopathic excitations, 4; slice thickness, 3.0 mm; and in-plane resolution, 0.625×0.625 mm. Medicine, 965 Wilson Rd, St B-411, West Fee Hall, Image planes were aligned approximately perpendicular to the long axes of the East Lansing, MI 48824-1316. RCPm muscles to facilitate the authors’ ability to accurately draw regions of interest fi Email: [email protected] around the speci c muscle boundaries. Cross-sectional area (CSA) of the right and left RCPm muscles was quantified for each participant at the 2 points in time. The Submitted fi May 9, 2018; null hypothesis was that there would be no signi cant difference between mean revision received values of muscle CSA collected at enrollment and 2 weeks after enrollment for a June 19, 2018; given participant and a given side of his or her body. accepted July 2, 2018. Results: Thirteen participants were enrolled. No significant difference was found between mean values of either right or left RCPm muscle CSA for any of the parti- cipants measured at enrollment and 2 weeks after enrollment (all P>.05). Conclusion: The protocol achieves the superior image quality necessary to compare the functional form of occipitoatlantal structures at progressive points in time. J Am Osteopath Assoc. 2019;119(3):173-182 doi:10.7556/jaoa.2019.028 Keywords: MR imaging, myodural bridge, rectus capitis muscles, tendon tear agnetic resonance (MR) imaging techniques have long been used to differ- entiate between normal muscle and muscle with fatty infiltrates1,2 and to M quantify changes in muscle volume and cross-sectional area (CSA) after The Journal of the American Osteopathic Association March 2019 | Vol 119 | No. 3 173 BRIEF REPORT exercise.3 However, sufficient test/retest reliability has nerves. The convergence of trigeminal and cervical only been achieved for muscles with relatively large afferents and irritation of these fibers (eg, stretching) volumes. results in referred headache.11-14 To our knowledge, Hallgren et al4,5 were the first to The functional relationship between RCPm muscles use MR images to report on morphologic changes and the spinal dura is not currently known. However, within rectus capitis posterior minor (RCPm) muscles in 2014, Hallgren et al15 reported that voluntary head in patients with chronic head and neck pain. The RCPm retraction results in a significant increase in electromyo- muscles are a pair of small muscles that arise from the graphy activity as RCPm muscles are stretched during posterior tubercle on the posterior arch of C1 and insert posterior movement of the head within the sagittal into the occipital bone inferior to the inferior nuchal plane without rotation. Atrophy of the RCPm muscles line and lateral to the midline. Rectus capitis posterior would be expected to compromise the functional minor muscles are unique because they are the only relationship between these muscles and the pain- muscles that attach to the posterior arch of the atlas. sensitive spinal dura and is thought to result in abnor- Fatty infiltration of RCPm muscles on MR imaging has mal levels of tension within the dura.16 Head movement been reported in patients with chronic headache asso- is proposed to be an important contributor to cerebro- ciated with both nontraumatic events6 and traumatic spinal fluid dynamics17 that are regulated by forces events such as rear-end motor vehicle crashes.7 generated from structures within the occipitoatlantal Atrophy, as evidenced by increased fatty infiltration interspace.18 over time, has been shown to be predictive of chronic Early detection of fatty infiltration of RCPm muscles whiplash-associated disorders.8 The cause of fatty might be beneficial in the assessment and management infiltration of RCPm muscle in patients with whiplash- of a muscle injury that could progress from an acute to associated disorders is unknown, but it could be a chronic condition. A systematic review19 revealed that expected that it would result from disuse atrophy, single study populations with neck pain showed a sig- neurogenic atrophy, or a tendon tear. Fatty infiltration nificant association between fatty infiltration in cervical would not be expected to directly result in headache, muscles and persistent neck disability. However, the but it would weaken the RCPm muscles and comprom- review failed to conclude that there is an association ise their ability to function normally. A key tenet of between dysfunction of the cervical spine on MR osteopathic medicine is that structure and function are imaging and clinically important outcomes such as reciprocally interrelated and that dysfunction in one pain and disability. The failure was attributed to the het- part of the body can have a negative effect on other erogeneity of the studies reviewed, the relatively small parts of the body. Loss of the functional capacity of sample size of the populations that were studied, and even a small component (eg, the RCPm muscles) the variety of imaging protocols that were used. should not automatically be assumed to have an insig- Unfortunately, the standard MR protocol that is nificant impact on the whole body. Fatty infiltration of commonly used for imaging the cervical spine is not RCPm muscles would result in a reduction in the total adequate to visualize fine structures within the occipi- number of contractile elements and would diminish toatlantal interspace,20 and customized protocols have the capacity of these muscles to generate and sustain not been shown to be adequate for accessing the normal levels of force. temporal development of fatty infiltration.18 A connective tissue bridge is found between the I set out to develop an MR imaging protocol that RCPm muscles and the pain-sensitive spinal dura would provide the superior image quality necessary to mater of the posterior cranial fossa.9,10 The spinal dura reliably quantify the progression of fatty infiltration contains nociceptive fibers that feed into the cervical over time. The analytic strategy was based on the 174 The Journal of the American Osteopathic Association March 2019 | Vol 119 | No. 3 BRIEF REPORT assumption that asymptomatic participants would not scanned using a General Electric Medical Systems have a significant change in skeletal muscle CSA over Signa HDxt 3.0-T scanner. A conventional spin-echo 2 weeks. To test this hypothesis, image resolution suffi- pulse sequence was used to construct 2 image sets cient to resolve fine structures within the occipitoatlan- consisting of: tal interspace and the ability to ensure registration of RCPm muscles between image sets collected at 2 ▪ 14 sagittal, T2-weighted images with measurement points in time was needed. For this discussion, registra- parameters of repetition time, 5250 milliseconds; tion refers to the alignment and overlay of MR image echo time, 100 milliseconds; slice thickness, 2.5 mm; data from a specific point in time with the participant’s and in-plane resolution, 0.43×0.43 mm. own MR image data from another point in time. ▪ 24 axial, T1-weighted images with measurement parameters of repetition time, 467 milliseconds; echo time, 13.5 milliseconds; number of excitations, 4; Methods slice thickness, 3.0 mm; and in-plane resolution, Study Population 0.625×0.625 mm. An email advertisement was used to recruit potential participants from the second-year student population The sagittal image set was used to define the orienta- of the Michigan State University (MSU) College of tion of the axial image planes from which muscle CSA Osteopathic Medicine. Participants were required to be would be quantified. The scan parameters and the free of head and neck pain; be free of significant orientation of the axial image planes were selected to motion restrictions; have had no surgical procedures in optimize our ability to manually draw regions of inter- the region of the upper cervical spine; and have not est (ROI) around RCPm muscle boundaries.22-24 An been involved in a motor vehicle crash within the past in-plane resolution of 0.625×0.625 mm was deemed 30 days. The age of participants was limited to sufficient to resolve structures within the posterior between 20 and 40 years because a progressive loss of atlantoaxial interspace. The acquisition time was muscle mass has been reported to occur at approxi- approximately 8.5 minutes. The following steps were mately 50 years of age.21 The study was approved by taken to ensure image intensities were quantified the MSU Institutional Review Board. within the same region of soft tissue at progressive The research protocol was reviewed with each poten- points in time: tial participant.
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