The spinal accessory and median nerves SESSION OBJECTIVES as contributing factors to cervical ! To have have a better understanding of the and occipital pain in anatomy of the spinal accessory nerve (SAN) and a patient how it can possibly contribute to pain.
! To understand how to assess the spinal accessory nerve both in, and out of, tension.
! To have an understanding of how to treat the spinal accessory nerve.
HISTORY:
• Skull fx 10 years ago when she feel back on her head while ice skating, no LOC
• Everything healed with the fx but she has “recurring nerve damage”
• She is seeing a local dentist for sleep apnea and TMJ related issues
• Since her injury she had had a lot of tightness in the neck and head region
HISTORY SYMPTOMS
• She has had PT previously • Symptoms are all on the (R) lateral cervical and • Before her injury: posterior lateral cranial region • Focus was strengthening of her shoulder/scapular region • After her injury • Occasional intermittent symptoms in the interscapular area • Stretching, “neck lengthening”, e-stim, NO manual work and anterior chest near coracoid process • Short-term relief only
• Medical History • Hyperthyroid for a period, resolved with meds that she no longer needs • Seasonal allergies
• Medications • Neurontin, Cymbalta, Allegra, Vitamin D
1" SYMPTOMS SYMPTOMS
• She describes her pain as a tightness • Patient denies any clicking or popping of TMJ
• There is no numbness or tingling • Parafunctional habits: • Grinding teeth • • NPRS: 3-6/10 Night • Day • *this was difficult for the patient to do*
• She is sensitive to sound & touch. She can feel her • Headache Impact Test (HIT-6) Score: 76 threshold for inputs are lower than they used to be.
FUNCTIONAL LIMITATIONS OBJECTIVE FINDINGS
• She cannot tolerate working more than a few hours • CROM • Cervical MMT • FB: 70% w/chin deviation • Flexion: Poor DNF activation, SCM dominant to (L) • UE ROM • She feels as if she is operating at 50% abilities • BB: 50% w/chin deviation • WNL w/o symptom • She would be much better at 75% to (R) reproduction • RSB: 50%, tightness on (L) • LSB: WNL, “sensitivity on • UE MMT (R) • 5/5 (B) UE myotomes • RR: WNL, pain suboccipital area • Posture • LR: 80%, pain suboccipital • (R) shoulder depressed area • Head tilted to (R)
OBJECTIVE FINDINGS OBJECTIVE FINDINGS
• Joint mobility • Cranial assessment • Decreased C2-3 side glide to (L) • P-P: min stiffness, (R) suboccipital pain • Mid cervical slightly hypermobile • F-gen: good mobility, (R) temple pain • O-S: decreased sphenoid to (L), (R) temple pain • Palpation • T-T: min stiffness (R), no symptom reproduction, “patient • + (R) OCI**, SCM, longus colli, posterior c/s muscles, report of it “feeling good” scalenes, UT, rhomboids • O-gen: min stiffness, (R) suboccipital pain • + (R) lambdoid and O/M suture • O-F: mod stiffness, no pain reproduction
• O(R)-F(L): mod stiffness, (R) suboccipital pain
• Mandibular motion • O(L)-F(R): mod stiffness, no pain reproduction • Opening: 46 mm, (R) condyle w/min restriction • Protrusion: 8 mm, (R) condyle w/min restriction Findings suggest occiput involvement • Lateral deviation (R): 10 mm; (L) 8 mm
2" TREATMENT
Visits 1-2
• Manual release to longus colli, post c/s muscles • Cranial mobs w/Occiput focus: • O-gen, O-C1, O-S • Local techniques to Lambdoid suture • Specific neural techniques: • Auricular branch of vagus nerve w/direct manual release
Response: Less pain in skull region Improved CROM w/less pain
TREATMENT TREATMENT
Visits 3-5 Visits 6-8 Symptoms Treatment Treatment Results • Patient reports “difficulty • Median & Ulnar nerve relaxing” glides" no sx improvement • Cervical side glides in • Median nerve glides no longer produce occipital • Muscles not responding to • GON glides" improved median nerve tension pain irritability of muscles, CROM soft tissue and cranial • SAN glides techniques as prior sessions improved • Cranial mobs • Occipital mobs • Cervical muscles seemed reproducing less familiar “fidgety” with palpation Visit 5 • O-C1 pain and have notably • + SAN testing • O-gen less resistance with • " pressure • + GON testing SAN glides eliminated sx of • O-S median/ulnar nerve signs, • + median & ulnar nerve most significant reduction in • Lambdoid and OM suture neural tension" occipital muscle irritability pain very minimally tender • SAN glides for HEP
TREATMENT
Visits 9-11
Treatment Results • O-C1 mobs • 60-65% improvement • DN (R) OCI overall • Intraoral release (R) • Median nerve and SAN masseter, no longer produced mylohyoid"referred pain occipital pain to occipital area • (R) condyle • (R) medial pterygoid movements stretch comparable to (L) w/ • Mobs (R) ribs 3-5 jaw motions
3" 1) Working on the mechanical interfaces of the SAN did not resolve symptoms
2) Not maintaining gains from treatment as expected
3) SAN innervates the trapezius
4) Likely trauma to the mechanical interface of the SAN (Occipital bone) SPINAL ACCESSORY 5) Muscles inability to relax during treatment NERVE= 6) Patient fidgety in the neck/shoulder region with treatment PAIN
7) Included median & ulnar nerve testing for reasons #5 and #6 and GON testing due to prior injury
POTENTIAL CONTRIBUTING FACTORS COMMON KNOWLEDGE OF THE SAN TO PAIN
! It is widely accepted to be a motor 1) EMG and histochemical data shows that the C2-C4 nerve nerves are mixed (not purely proprioceptive as thought # motor and sensory functions # may contribute in varying degrees with the ! Injury to the SAN causes contraction of the three parts of the trapezius (Pu et al., 2008; Tubbs et al., 2011, Kim et al 2014) ! SCM and trapezius weakness/ atrophy"limited shoulder motion, scapular 2) Sensory function of the SAN itself winging, pain # Presence of neuronal cell bodies along the course ! Pain in shoulder region of the SAN seen in human cadavers ! Early: prior to perceived weakness # Similar role as those identified in other animals, ! Later: with weakness/atrophy which are recognized as conveying nociceptive (Brown & Stickler 2011; Charopoulous et al 2010; Kelley et al 2008; Sahin et al stimuli (Tubbs et al., 2014) 2007)
3) Nervi Nervorum # Intrinsic innervation of the nerves and their sheaths (Sauer et al.1999; Bove & Light 1997; Han 2010) # Has nociceptive function (Han 2010) # Contains neuropeptides including SP and CGRP (Bove & Light 1997; Sauer et al. 1999) "role in vasodilation
http://www.lapietradelsollievo.it/tessutale.html Bove & Light. The nervi nervorum: Missing link for neuropathic pain? 1997
4" • This nerve originates in the spinal nucleus of the spinal cord of the upper five (Lloyd 2007) or six (Caliot et al 1989; Tawfik et al 2015) cervical segments.
• The fibers merge to form a trunk.
• The spinal root enters the posterior fossa of the cranium through the foramen magnum.
Rubin M & Safdieh JE. Netter’s concise neuroanatomy. Saunders Elsevier, 2007
! The spinal root joins briefly with the cranial ! From here the (internal) root to form a accessory nerve single nerve trunk divides: (accessory nerve).
Rubin M & Safdieh JE. Netter’s concise neuroanatomy. ! cranial portion Saunders Elsevier, 2007 ! spinal portions ! The accessory nerve exits the jugular foramen, heading towards the retrostyloid space (Caliot et al 1989).
Rubin M & Safdieh JE. Netter’s concise neuroanatomy. http://healthfavo.com/jugular-foramen.html Saunders Elsevier, 2007
Digastric ! SAN typically passes laterally to ! The SAN then descends in the internal jugular vein an oblique manner, (Hinsley and Hartig 2010; Saman staying medial to the et al 2011; Taylor et al. 2013) styloid process, stylohyoid and digastric muscles (Lloyd 2007) ! Less frequently, the SAN can pass ! It then travels ! medial (Taylor et al. 2013) ! between the two heads of SAN IJV Hinsley and Hartig 2010 ! split around (Taylor et al. 2013) the SCM muscle (Caliot et al 1989) ! through (Hashimoto et al. 2012; Taylor ! deep to the SCM et al. 2013) (Hong et al 2014)
! In this region the nerve forms an anastomosis with fibers from C2-C4 (Caliot et al 1989; Lanisnik et al. 2013; Kim et al. 2014; Brennan et al. 2015).
Taylor et al. 2013 Saman et al. 2011
5" ! The SAN then travels obliquely through the posterior triangle, towards the deep cervical fascia and trapezius, staying in a fat layer in between the ! EMG and histochemical data shows trapezius and levator scapulae muscles. (Hong et al. 2014; Lloyd 2007) that the C2-C4 nerves are not purely
proprioceptive as thought ****ADD PICTURE**** ! motor and sensory functions ! may contribute in varying degrees with the contraction of the three parts of the trapezius (Pu et al., 2008; Tubbs et al., 2011, Kim et al 2014) ! motor input from the C2-C4 nerves is not consistently present or is irregularly innervated to the three parts of the muscle when it is present (Kim et al. 2014).
! Nociceptive signals from spinal segments as low as C6 or C7 have the potential to interact with the trigeminocervical nucleus ! Afferent sensory signals ascend or descend up to three spinal cord segments in the dorsolateral tract and substantia gelatinosa before entering the spinal dorsal horn. (Biondi 2000)
! Segmental involvement ! The spinal portion of the SAN originates in the spinal nucleus of the spinal cord of the upper five (Lloyd 2007) or six (Caliot et al 1989; Tawfik et al 2015) cervical segments.
MEDIAN NERVE= ! Central sensitization/Expansion of the receptive field 1. Fernández-de-las-Peñas C, Arendt-Nielsen L, Cuadrado ML, Pareja JA. Generalized mechanical pain sensitivity over the nerve tissues in patients with strictly unilateral migraine. OCCIPITAL PAIN Clin J Pain. 2009 Jun;25(5):401-6
2. Scott D, Jull G, Sterling M. Widespread sensory hypersensitivity is a feature of chronic whiplash-associated disorder but not chronic idiopathic neck pain. Clin J Pain. 2005 Mar-Apr; 21(2):175-81.
3. Fernández-Mayoralas DM, Fernández-de-las-Peñas C, Ortega-Santiago R, Ambite-Quesada S, Jiménez-García R, Fernández-Jaén A. Generalized mechanical nerve pain hypersensitivity in children with episodic TTH. Pediatrics. 2010 Jul;126(1):e187-94.
WHERE IS THE SAN?
NEURODYNAMIC ASSESSMENT
SPINAL ACCESSORY NERVE
6" Patient did report some “stretching sensation” in the occipital area= Neurogenic problem vs. neuropathic
CRANIAL TECHNIQUES TO IMPROVE THE STRESS-TRANSDUCER SYSTEM
MECHANICAL INTERFACES OF THE SAN
SAN IN NEURODYNAMIC POSITION
UPPER CERVICAL FLEXION W/CONTRALATERAL SB, SHOULDER DEPRESSION AND RETRACTION **was modified from the sidelying position**
OCCIPUT COMPRESSION OCCIPUT-SPHENOID
3 options for assessment
1. Occiput and Sphenoid pressures in opposite directions 2. Sphenoid pressure on occiput 3. Occiput pressure with stable sphenoid
OCCIPUT ON C1 SUTURE TECHNIQUES
Occipito-mastoid Lambdoid
7" ! Standard passive testing position in supine ! w/head in neutral ! w/head in contralateral side bending
! Cervical side glides with the arm in median nerve bias
NEURODYNAMIC ASSESSMENT
MEDIAN NERVE
SAN SLIDER
Upper cervical flexion/contralateral Upper cervical extension/contralateral SB, shoulder relaxed SB, shoulder depressed and retracted
NEURODYNAMIC TREATMENT
SPINAL ACCESSORY NERVE
*This technique was modified to supine from the original side lying position*
! Sliders with wrist and elbow movements
! Cervical side glides with the arm in median nerve bias w/o symptom provocation
NEURODYNAMIC TREATMENT
MEDIAN NERVE
8" SPECIAL THANKS
• Jennifer Nelson for being the “patient” in the pictures • Savas Koutstantonis for taking the pictures • Michiel Trouw for his input and assistance with finding good SAN’s in class • The 2015 CRAFTA class for offering their SAN’s for pictures for this presentation • Jack Stagge for sharing his slides of Toby Hall’s research
9"