Journal of Contemporary JCC Chiropractic

Trigeminal Berry, Oakley and Harrison IS ONE CAUSE OF TRIGEMINAL NEURALGIA SUBLUXATION OF CRANIOCERVICAL POSTURE? Robert H. Berry, DC1, Paul A. Oakley, DC2, Deed E. Harrison, DC3

ABSTRACT is usually unilateral in presentation and is triggered by innocuous sensory stimuli. (2) TN is rare and estimated Objective: To describe the successful treatment of a to affect about 4-13 per 100,000 persons. (1) patient with trigeminal neuralgia treated by the correction of craniocervical posture by Chiropractic Biophysics® Typical treatment options for TN include , technique methods. surgery, and complementary approaches. (1) First-line treatment approaches typically include anti-epileptic and Clinical Features: A 64-year-old male developed tricyclic antidepressant medications. (1) trigeminal neuralgia following a dental procedure. He is the drug of choice although other anti-epileptics had failed to get lasting relief after several prior dental including , , , treatments. Radiographic assessment revealed a lateral , and topiramate are also commonly prescribed. head translation as well as forward head posture and a (3) Multidrug treatment regimens are useful in selected military neck with notable degenerative changes between patients. (2) Surgical management of TN patients are C 4- C7. reserved for those with severe, non-remitting symptoms, for those who have experienced failed pharmaceutical Intervention and Outcome: Treatment was directed at treatment with at least 3 medications, and/or for those improving the craniocervical subluxation misalignments who suffer from intolerable pharmaceutical side-effects. using Chiropractic Biophysics methods. Mirror image® (1) corrective exercises and traction techniques were used along with spinal manipulative therapy. After The surgical treatment of choice for treating TN is initial improvement in posture, symptoms improved. microvascular decompression (MVD). (2,3) Other Unforeseen worsening of posture correlated with neurosurgical options include gamma knife radiosurgery, worsening of symptoms, and then a re-correction of percutaneous balloon compression, glycerol , posture again, dramatically improved patient symptoms. and radiofrequency thermocoagulation procedures. (3) A year follow-up indicated the patient remained well. In some cases, partial sensory root sectioning may be indicated. (3) Emerging techniques include deep brain Conclusion: This case is unique in that the correction, and motor cortex neuro-modulatory stimulation as worsening, and re-correction of posture appeared options to those patients who cannot use pharmacologic directly related to the painful symptoms of trigeminal or surgical methods. (1) neuralgia. Subluxation of the craniocervical posture may be a plausible cause in some cases of this disorder. Many mechanisms of pathogenesis may be involved Radiographic assessment is necessary to quantify in producing TN symptoms, such as pathologies at postural deformity in this disorder. (J Contemporary the root (compression or traction), Chiropr 2020;3:28-35) dysfunction of the brain stem and basal ganglion or cortical modulatory mechanisms. (3) Neurovascular Key Indexing Terms: Trigeminal Neuralgia; Cervical compromise (NVC) is the prevailing theory of TN Lordosis; Cervical Rehabilitation pathogenesis. (1-3)

INTRODUCTION Alf Breig pioneered the biomechanics of the central Trigeminal neuralgia (TN or tic douloureux) is described nervous system. (4-6) He showed, using cadaveric as recurrent attacks of lancinating facial pain along the specimens, that flexion of the cervical spine unfolded the dermatomal distribution of the trigeminal nerve. (1) It cord and could traction the to the level below the tentorium and that cervical extension relaxes the cord tension, also relaxing the tension in the lower brain 1 Private Practice, Montour Falls, NY, USA 2 Private Practice, Newmarket, ON, Canada structures. In patients with TN, Breig noted that most 3 CBP NonProfit, Inc. could elicit facial pain on head flexion and stated “there

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Table 1. Health-related quality of life scores.

Health Physical Role- Role- Social Mental Bodly Energy/ Date Perception Functioning Physical Emotional Functioning Health Pain Fatigue Normal 72 84 81 81 83 75 75 61 Initial 35 80 50 33 50 44 45 40 12-Month 60 80 75 100 63 60 65 50 24-Month 45 90 75 67 63 56 45 55 are other, hitherto overlooked, mechanisms for the is particularly interesting about this case is that after precipitation of trigeminal neuralgia, amongst them the initial improvement in both craniocervical posture and elongation the spinal canal and stretching of the - TN symptoms, further treatment led to worsening of cord tract accompanying flexion of the cervical spine or posture and reaggravation of TN symptoms, which was the whole column.” (5) then followed again by an improvement in posture and the reduction of TN symptoms. Breig was a neurosurgeon and recommended cervicolordodesis (CLD) to place the cervical spine in CASE REPORT an extended position to relax the spinal cord and related neural tissues in the treatment of various neurological A 64-year old male developed TN following a dental disorders including TN. Strong evidence suggests that procedure. Prior to seeking chiropractic care, he had extension traction methods as developed by Chiropractic received 2 nerve blocks that had provided temporary Biophysics® (CBP®) technique methods may restore the relief; when the pain returned, he underwent 2 stereotactic lordotic cervical alignment in craniocervical patients radiosurgeries. The first round of a highly concentrated presenting with cervical hypolordosis/kyphosis, (7-15) dose of radiation to the right side of his head near the and it also aids in improving neurological symptoms. temporal area relieved his symptoms by about 75% (8,10,13) for approximately 4 months. The second stereotactic radiosurgery failed. He was prescribed Neurontin but This report describes the successful outcome of a patient suffering from TN who was treated by the correction of craniocervical posture by CBP technique methods. What

Figure 2. Posterior-anterior cervical radiographs. Left: Figure 1. Posture pictures. Top: Front view; Bottom: Sagittal Pre-treatment; Right Post-treatment taken at the 3-month view; Left: Initial pictures; Right: After treatment pictures. follow-up.

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Figure 3. Lateral cervical radiographs. First: Pre-treatment; Second: Initial post-treatment (6-month) after initial improvement; Third: Second post-treatment (9-month) showing regression of alignment; Forth: Third post-treatment (12-month) showing improved alignment again; Fifth: 24-month follow-up (1-yr since ending intensive ‘corrective care’). later switched to TegretolTM (Carbamazepine), and was images. These methods are reliable and repeatable, as is currently taking a dose of 800mg daily. posture. (18-20) The images revealed a complete lack of cervical lordosis absolute rotation (ARA) angle from C2- He reported his facial pain level to be a 7/10 on a C7=-1°; (normal =-34-42° (21-23)), forward head posture numerical rating scale (NRS: 0=no pain; 10=worst pain (FHP=35mm vs. <15mm normal (22)), and an atlas plane ever). He scored a 16% on the neck disability index line (APL) of 10° (vs. -24-29° normal (21,22)) (Figure (NDI). (16) The patient also scored lower than normal on 3). The patient had well-demarcated osteoarthritic bone all 8 indices of the short form-36 (SF-36) Health-Related spurs from C4-C7 (Figure 3). On the posterior-anterior Quality of Life Questionnaire (Table 1). (17) All cervical cervical radiograph, the patient had a left head translation ranges of motion were within normal limits; however, of 7mm (vs. 0mm normal) (Figure 2). there was muscular rigidity upon palpation bilaterally along the cervical spine. All orthopedic tests were Treatment Protocol unremarkable, and facial sensation was also normal. He was active playing in the senior games, softball, and The patient started care with the goal of improving bowling leagues. He had constant “lightning-bolt” pain the craniocervical biomechanical postural on the right side of his face and stated that his parameters in order to provide pain relief from the only took the edge off. TN. CBP technique is an evidence-based spine and A full-spine radiographic assessment (Figures 2 and 3) posture correcting method that features mirror was taken and analyzed using the Harrison posterior image® exercises, spinal adjustments, and traction tangent method (18,19) for the sagittal images and the methods. (24-26) Much supporting evidence exists modified Risser-Ferguson method (19) for the coronal substantiating CBP methods as being effective for increasing the cervical lordosis (7-15) and other craniocervical parameters. (7-15,27) Typical CBP treatment regimens include sessions 3 times per week for 36 total sessions between assessments. (25,26) This is the regimen that this patient received throughout care. The patient received corrective care (3 times per week) for approximately 1 year, and then was treated on a maintenance schedule (2 times per month) Figure 4. Mirror image corrective exercises (left) and traction (right) in the coronal plane. This was the treatment for the first for another year. A timeline of events is reported 3-months of ‘corrective care.’ in Table 2. The initial 4 treatments were aimed at

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Table 2. Timeline of treatment description, radiographic measures, pain and disability scores and self-reported outcomes.

Description of Care and Initial 3-Month 6-Month 9-Month 12-Month 24-Month Outcome Measures Assessment f/u f/u f/u f/u f/u Type of Care Completed n/a Corrective Corrective Corrective Corrective Maintenance Frequency of Treatment n/a 3x/wk 3x/wk 3x/wk 3x/wk 2x/Month Number of Treatments n/a 36 72 108 144 168 Traction Completed n/a Side-Shift Ext-Comp Ext-Comp Ext-Comp Ext-Comp

AP Cervical Side Shift 7mm 0mm n/a n/a n/a n/a

Forward Head Translation 45mm n/a 24mm 33mm 26mm 21mm C2-7 Cervical Lordosis -1 n/a -17 -10 -14 -18 Atlas Plane Line -10 n/a -20 -17 -18 -22

Pain Intensity (0-10) 7/10 7/10 2.5/10 4/10 2/10 2/10 Neck Disability Index 16% 18% 12% n/r n/r n/r

Dose of Tegretol/Day 800mg 800mg 100mg 400mg None None

'No shock-like 'Severe right 'Pretty good' 'More 'Feeling was Self-Reported Symptoms 'No relief' lightening bolt facial ' 'Some pain' discomfort' better' pains' loosening the cervical spine and to provide pain 5). After reassessment at 9-months, however, the relief and involved spinal manipulative therapy patient had an unexpected regression of symptoms (SMT) as well as cryotherapy. On the fifth treatment, and craniocervical posture (Figure 3). Therefore, he structural ‘corrective care’ was initiated and included was put back on to the original static neck extension CBP® mirror image exercises, traction, and spinal traction (extension-compression 2-way), where after adjustments. The patient performed right-sided another 3-months (12-months total), the patient head translation exercises and traction (www. again experienced a significant relief of symptoms berrytranslations.com, NY) (Figure 4), and received and thereafter, was put on ‘maintenance care.’ A 1-year ‘instrument adjustments’ (Impac Inc., Salem, OR) follow-up assessment (two years total treatments) (a handheld percussion instrument is held to the was also performed and is reported on. The patient cervical paraspinal tissues and provides stimulation gave verbal and written consent for the publication of while the patient actively translates the head to the these results. opposite position), as well as full-spine SMT. The next 3-month block of care (3 treatments/week) was directed at correcting the sagittal posture of the head and neck and traction was changed to a static type ‘extension-compression 2-way’ (Figure 5). The patient also performed head retraction exercises (Figure 5). Upon re-assessment at the 6-month mark, the patient was transitioned to a more dynamic neck extension traction, ‘seated dynamic extension- Figure 5. Corrective mirror image exercises and traction in the compression 2-way’ traction which was thought to be sagittal plane. Left: Head retraction exercises; Middle: Static more aggressive to continue the correction (Figure 2-way extension-compression traction; Right: Dynamic 2-way extension-compression traction.

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Results DISCUSSION After the initial 3-months (Figure 2), his left head This paper discusses improvement in trigeminal translation was completely re-aligned to midline. His neuralgia symptoms in an older male after improving pain levels remained a 7/10 and still complained of cervical spine posture in the sagittal and coronal right-sided facial pains. After another 3-months of planes. Interestingly, unforeseen regression of the sagittal cervical static extension-compression 2-way patient’s sagittal cervical posture coincided with traction (Figure 5), his pain intensity dropped to the re-emergence of neurological symptoms; these 2.5/10, and he also reduced his Tegretol use to 100mg/ symptoms again diminished using a re-correction day (vs. 800mg/day initially). His FHP reduced of the alignment accomplished by reperforming (24mm vs. 33mm), lordosis increased (-17° vs. -1°), the originally successful cervical extension traction and APL increased (-20° vs. -10°). methods. Following another 3-months of a more dynamic type As mentioned, Breig (4-6) illustrated in several books of cervical extension 2-way traction (Figure 5), he definitive causes of neurological impingements regressed, having a resurgence of pain levels (4/10) based on spinal positions, including cervical flexion corresponding with worsening postural radiographic as eliciting symptoms in patients with trigeminal parameters (FHP increased to 33mm; ARA increased neuralgia. (5) This is because any flexion of the spine to -10°; APL reduced to -17°). He also increased his lengthens the spinal canal and leads to an unfolding medication to 400mg/day. He was encouraged by his the cord and nerve roots. (4,5) Once a spinal position family to quit treatment, but he chose to continue surpasses some threshold, normal physiological cord as long as he could re-commence the former static unfolding changes to abnormal pathological cord extension-compression 2-way traction that had tension. This is where a patient’s poor (forward flexed) achieved the initial symptom relief. posture may lead to neurologic symptoms. He was put back on the initial static extension- Since the correction of craniocervical posture may compression 2-way traction that had resulted in the lead to improvements in neurological pathologies, initial symptomatic relief. After 3 further months of (8,10,13) it is logical that the correction of posture treatment (12-months overall), he again improved in patients with TN may also result in simultaneous having an NRS of 2/10, reducing FHP to 26mm, relief of symptoms due to the reduction in pathologic increasing ARA to -14°, and increasing APL to -14°. tension in the pons-cord tract that may be tensioning He was for the first time able to stop taking Tegretol, the trigeminal nerve. The fact that our patient and also reported no facial ‘shock-like, lightning- experienced initial relief with improved posture, then bolt’ pains. He also improved on 7/8 SF-36 QOL regression of relief with worsening posture, and then indices (Table 1). This finalized 1 year of ‘corrective again, relief from TN pains coinciding directly with the care,’ where, moving forward, he continued on a re-improvement in posture confirms in this patient, maintenance care plan (1-2 treatments per month). that the cause was related to the spinal subluxation (forward head position and hypolordosis). A 1-year follow-up assessment (2 years since initial presentation) demonstrated he had maintained Why did the patient have a regression of posture wellness, having an NRS of 2/10 and a further slight during treatment? He was transitioned at the 6-month improvement of lateral craniocervical radiographic mark to a dynamic 2-way extension compression parameters (21mm FHP, -18° ARA, -22° APL). He had traction, as this type of traction is known to be improved on half of the SF-36 QOL indices, though more aggressive due to it being ‘dynamic,’ i.e. using showed lower scores for half the indices, including gravity. For unforeseen reasons, he did not respond pain possibly due to a recent onset of acute low- well to this altered type of traction; the reasons are back pain due to cutting wood and playing softball. still unknown, though it may be due to the amount Regarding his former complaint of TN, he said he felt of degenerative changes in the cervical spine, which ‘the best ever’ and chose to discontinue further care.

J Contemp Chiropr 2020, Volume 3 32 Trigeminal Neuralgia Berry, Oakley and Harrison presents a challenge to a practitioner attempting to CONCLUSION re-align it, although it can be done. (28) This case is interesting in that the correction, Further confirmation for the craniocervical posture worsening, and re-correction of posture was directly induced TN theory for the current case is supported related to the painful symptoms of trigeminal by the fact that former treatments received by the neuralgia. Subluxation of the craniocervical posture patient either failed or only provided short-term may be a plausible cause in some cases of this disorder. relief, and these included 2 nerve blocks, 2 stereotactic Radiographic assessment is necessary to quantify radiosurgeries and the use of the anti-epileptic postural deformity in this disorder. pharmaceutical, TegretolTM, which the patient had Conflict of Interest been reliant on, consuming 800mg per day. RHB manufactures and sells ‘Berry translation’ One can question the whether the treatment duration traction tables as used in this case; PAO is a paid and number of treatments given to this patient were consultant to CBP NonProfit, Inc.; DEH teaches necessary, and/or ethical given recommendations to chiropractic rehabilitation methods and sells products limit treatment number to 6-12 treatments and to to physicians for patient care as used in case. provide care based on pain management only. (29-31) As highlighted recently (32,33), there are evidence- REFERENCES based approaches to spine and posture correction 1. Jones MR, Urits I, Ehrhardt KP et al. Comprehensive that center on the reestablishment of spinopelvic review of trigeminal neuralgia. Curr Pain Rep 2019;23:74 parameters to achieve superior patient outcomes, beyond simple pain-based, spinal manipulation. 2. Tai AX, Nayar VV. Update on trigeminal neuralgia. Curr CBP methods has a significant amount of research Treat Options Neurol 2019;21:42 supporting its use in this context for patient care. 3. Yadav YR, Nishtha Y, Sonjjay P, Vijay P, Shailendra (7,34,35) Due to the presentation of challenging R, Yatin K. Trigeminal neuralgia. Asian J Neurosurg 2017;12:585-597 clinical cases, frequent treatments over long durations may be necessary to achieve the best patient outcomes 4. Breig A. Biomechanics of the central nervous system. (25,26) and has been presented in several recent Stockholm, Sweden; Almqvist & Wiksell International, 1960 published cases. (36-39) 5. Breig A. Adverse mechanical tension in the central The limitations to this case are that it is a single case nervous system. Relief by functional neurosurgery. report. Although there is a 1-year follow-up, the patient Stockholm, Sweden; Almqvist & Wiksell International, 1978 was receiving maintenance treatments (2x/month). The regression and reemergent symptomatology 6. Breig A. Skull traction and cervical cord injury. A new approach to improved rehabilitation. New York, NY; with the worsening of posture during the course of Springer-Verlag, 1989 treatment, followed by the mirrored relief of symptoms by the continued correction in posture shows a 7. Harrison D, Moustafa I, Oakley P. Systematic review of Chiropractic Biophysics® (CBP®) methods employed in unique trend of the TN symptoms correlating with the rehabilitation of cervical lordosis. Proceedings from the craniocervical posture. These findings also agree the 14th International Society on Scoliosis Orthopedic with Breig and point to the possible pathogenesis of and Rehabilitation Treatment (SOSORT) meeting, San Francisco, April 25-27, 2019:156 TN by subluxated craniocervical posture. This also implicates the treatment approach for those suffering 8. Moustafa IM, Diab AM, Ahmed A, Harrison DE. The efficacy of cervical lordosis rehabilitation for nerve from TN by the correction of posture; this may be root function, pain, and segmental motion in cervical one cause of TN. Future research should examine this spondylotic . PhysioTherapy 2011;97 plausible mechanism in the pathogenesis of TN. Suppl: 846-847

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9. Moustafa IM. Does improvement towards a normal 19. Harrison DE, Holland B, Harrison D, Janik TJ. Further cervical configuration aid in the management of reliability analysis of the Harrison radiographic line- fibromyalgia. A randomized controlled trial. Bull Fac drawing methods: crossed ICCs for lateral posterior Ph Th Cairo Univ 2013;18:29-41 tangents and modified Risser-Ferguson method on AP views. J Manipulative Physiol Ther 2002;25:93–98 10. Moustafa IM, Diab AA, Taha S, Harrison DE. Addition of a sagittal cervical posture corrective orthotic device 20. Harrison DE, Harrison DD, Colloca C, Betz J, Janik to a multimodal rehabilitation program improves TJ, Holland B. Repeatability over time of posture, short- and long-term outcomes in patients with radiograph positioning, and radiograph line drawing: discogenic cervical radiculopathy. Arch Phys Med an analysis of six control groups. J Manipulative Rehabil 2016;97:2034-2044 Physiol Ther 2003;26:87–98

11. Moustafa IM, Diab AA, Harrison DE. The effect of 21. Harrison DD, Janik TJ, Troyanovich S, Holland B. normalizing the sagittal cervical configuration on Comparisons of lordotic cervical spine curvatures to dizziness, neck pain, and cervicocephalic kinesthetic a theoretical ideal model of the static sagittal cervical sensibility: a 1-year randomized controlled study. Eur J spine. Spine 1996;21:667–675 Phys Rehabil Med 2017;53:57-71 22. Harrison DD, Harrison DE, Janik TJ, Holland B. 12. Moustafa IM, Diab AAM, Hegazy FA, Harrison DE. Modeling of the sagittal cervical spine as a method Does rehabilitation of cervical lordosis influence to discriminate hypolordosis: results of elliptical and sagittal cervical spine flexion extension kinematics circular modeling in 72 asymptomatic subjects, 52 in cervical spondylotic radiculopathy subjects? J Back acute neck pain subjects, and 70 chronic neck pain Musculoskelet Rehabil 2017;30:937-941 subjects. Spine 2004;29:2485–2492

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17. McHorney CA, Ware JE Jr, Raczek AE. The MOS 36-Item 28. Fortner MO, Oakley PA, Harrison DE. Non-surgical Short-Form Health Survey (SF-36): II. Psychometric improvement of cervical lordosis is possible in and clinical tests of validity in measuring physical and advanced spinal osteoarthritis: A CBP® case report J mental health constructs. Med Care 1993;31:247-263 Phys Ther Sci 2018;30:108-112

18. Harrison DE, Harrison DD, Cailliet R, Troyanovich 29. Lisi AJ, Salsbury SA, Hawk et al. Chiropractic integrated S, Janik TJ, Holland B. Cobb method or Harrison care pathway for low back pain in veterans: results of a posterior tangent method: which to choose for lateral delphi consensus process. J Manipulative Physiol Ther cervical radiographic analysis. Spine 2000;25:2072– 2018 Feb;41(2):137-148. 2078 30. Walker BF. The new chiropractic. Chiropr Man Therap 2016 Jun 30;24:26

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31. Schneider M, Murphy D, Hartvigsen J. Spine care as a framework for the chiropractic identity. J Chiropr Humanit 2016 Nov 4;23(1):14-21. eCollection 2016 Dec.

32. Oakley PA, Ehsani NN, Harrison DE. Repeat radiography in monitoring structural changes in the treatment of spinal disorders in chiropractic and manual medicine practice: evidence and safety. Dose Response 2019;17(4):1559325819891043

33. Oakley PA, Cuttler JM, Harrison DE. x-ray imaging is essential for contemporary chiropractic and manual therapy spinal rehabilitation: radiography increases benefits and reduces risks. Dose Response 2018;16(2):1559325818781437

34. Oakley PA, Moustafa IM, Harrison DE. Restoration of cervical and lumbar lordosis: CBP® Methods overview. In: Bettany-Saltikov J, Kandasamy G. Spinal Deformities in Adolescents, Adults and Older Adults. IntechOpen DOI: http://dx.doi.org/10.5772/ intechopen.90713.

35. Harrison DE, Moustafa IM, Oakley PA: Systematic review of Chiropractic Biophysics® (CBP®) methods employed in the rehabilitation of lumbar lordosis. Proceedings from the 14th International SOSORT meeting, San Francisco, CA, April 25–27, 2019. Poster 24, p 157

36. Harrison DE, Oakley PA. Non-operative correction of flat back syndrome using lumbar extension traction: a CBP® case series of two. J Phys Ther Sci 2018;30(8):1131-1137

37. Harrison DE, Oakley PA, Betz JW. Anterior head translation following cervical fusion-a probable cause of post-surgical pain and impairment: a CBP® case report. J Phys Ther Sci 2018;30(2):271-276

38. Oakley PA, Harrison DE. Alleviation of pain and disability in a post-surgical C4-C7 total fusion patient after reducing a lateral head translation (side shift) posture: a CBP® case report with a 14 year follow-up. J Phys Ther Sci 2018;30(7):952-957

39. Oakley PA, Ehsani NN, Harrison DE. Non-surgical reduction of lumbar hyperlordosis, forward sagittal balance and sacral tilt to relieve low back pain by Chiropractic BioPhysics® methods: a case report. J Phys Ther Sci 2019;31(10):860-864

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