Dennis E. Enix

The obliquus capitis inferior myodural bridge.

This study was designed to examine the obliquus capitis inferior (OCI) muscle from a gross anatomical perspective. The objective was to isolate and identify the OCI myodural bridge, while examining its course and contributing elements. An earlier study of the posterior cervical spine briefly reported a connection between the OCI and the cervical dura mater. To the best of our knowledge, a study has not yet been conducted specifically on this muscle and its relation to the dura mater. In this study, the suboccipital regions of nine embalmed cadavers were dissected. A total of 14 OCI muscles were isolated for examination. All findings were documented via photograph. Of the 14 OCI muscles isolated, all emitted fibrous tissue bands from the anterolateral portion of the muscular belly. These fibers attached to the posterolateral cervical dura mater by route of the atlantoaxial interspace. The OCI myodural bridge appeared to coalesce with the rectus capitis posterior major myodural bridge, giving the appearance of a single atlantoaxial structure that links these two muscles to the dura mater. In conclusion, the OCI was attached to the dura mater in all of the 14 muscle specimens. We hypothesize that the OCI myodural bridge may play a physiological role in monitoring dural tension and preventing dural infolding. It may also contribute to certain clinical symptoms manifesting from alterations in dural tone. Clin. Anat. 2013.

Histological analysis of the rectus capitis posterior major's myodural bridge.

BACKGROUND CONTEXT In recent literature, a soft-tissue communication between the rectus capitis posterior major (RCPma) muscle and the cervical dura mater has been identified. To the best of our knowledge, this communication has yet to be validated from a histological perspective nor has it been examined for neural tissue. PURPOSE The purpose of this study was to examine the composition and true continuity of the communication between the RCPma and the dura mater at a microscopic level. The communication was also inspected for the presence of proprioceptive neurons. STUDY DESIGN An anatomical and histological analysis of a novel structure in the atlantoaxial interspace. METHODS Gross dissection was performed on 11 cadavers to remove the RCPma, the soft-tissue communication, and a section of posterior cervical dura mater as one continuous unit. Paraffin embedding and sectioning followed by hematoxylin and eosin staining was conducted to validate the connection. Staining with antineurofilament protein fluorescent antibodies was performed to identify proprioceptive neural tissue on one specimen, and all findings were recorded via photographic documentation. RESULTS Histological investigation revealed a tendinous matrix inserting into both the RCPma and the posterior aspect of the cervical dura mater in all 11 specimens. In the one specimen examined for neural tissue, antineurofilament protein fluorescence revealed proprioceptive neurons within the communication. Immunoperoxidase staining demonstrated the insertion of these neurons into both the dura mater and the belly of the RCPma. CONCLUSIONS The existence of a true connection between the RCPma and the cervical dura mater provides new insight in understanding the complex anatomy of the atlantoaxial interspace. The presence of a neural component within this connection suggests that it may serve another function aside from simply anchoring this muscle to the dura mater. Such a connection may be involved in monitoring dural tension and may also play a role in certain cervicogenic pathologies. This study also supports previous reports that no true membrane joins the posterior arch of the atlas to the laminae of the axis and contradicts the conventional belief that the ligamentum flavum joins these two structures.

Effects of Biofreeze and chiropractic adjustments on acute low back pain: a pilot study

OBJECTIVE This randomized controlled study was designed to determine the pain-relieving effect of Biofreeze (Performance Health Inc., Export, PA) body surface application and chiropractic adjustments on subjects with acute low back pain (LBP). METHODS The data were collected at the baseline, 2 weeks after treatment, and 4 weeks after treatment for final analyses. Diversified manual adjustments were provided by licensed chiropractors twice a week for 4 weeks to both control and experimental groups. Biofreeze was applied to the lower back area 3 times a day for 4 weeks in the experimental group. Outcome assessments included visual analog scale, Roland Morris Disability Questionnaire, heart rate variability for stress, and electromyography for low back muscle activity. RESULTS A total of 36 subjects were recruited in the study (25 male). The average age was 34 years. Significant pain reduction was found after each week of treatment in the experimental group (P < .05). The Roland Morris Disability Questionnaire did not show significant changes in both groups. There were no significant differences for pain reduction in the control group. Heart rate variability analysis showed no significant change (P > .05) in the experimental group after 4 weeks of Biofreeze and chiropractic adjustments. There were no statistically significant changes in the electromyography readings between the 2 groups. CONCLUSION Biofreeze combined with chiropractic adjustment showed significant reduction in LBP.

Histological examination of the human obliquus capitis inferior myodural bridge

This study was designed to examine the anatomical relationship between the obliquus capitis inferior (OCI) muscle and the cervical dura mater at the histological level. Eight human cadavers, with an average age of 65 ± 7.9 years were selected from a convenience sample for suboccipital dissection. Twelve OCI muscle specimens were excised, 100% of which emitted grossly visible soft tissue tracts that inserted into the posterolateral aspect of the cervical dura. These 12 myodural specimens were excised as single, continuous structures and sent for H&E staining. One sample also underwent immuno-peroxidase staining. Microscopic evaluation confirmed a connective tissue bridge emanating from the OCI muscular body and attaching to the posterolateral aspect of the cervical dura mater in 75% of the specimens. Microtome slices of the remaining 25% were not able to capture muscle, connective tissue and dura within the same plane and were therefore unable to be properly analyzed. The sample sent for neuro-analysis stained positively for several neuronal fascicles traveling within, and passing through the OCI myodural bridge. This study histologically confirms the presence of a connective tissue bridge that links the OCI muscle to the dura mater and the presence of neuronal tissue within this connection warrants further examination. This structure may represent a component of normal human anatomy. In addition to its hypothetical role in human homeostasis, it may contribute to certain neuropathological conditions, as well.

Investigation of meningomyovertebral structures within the upper cervical epidural space: a sheet plastination study with clinical implications

BACKGROUND CONTEXT Over the past two decades, soft-tissue structures communicating with the dura mater within the epidural space have become the focus of many anatomical and histopathologic studies. The relationship between these bridging structures has yet to be evaluated in situ. PURPOSE This is the first study that used E12 sheet plastination to investigate the epidural space of the upper cervical spine in situ and its associated bridging structures. Given the complexity of this space, this study may prove useful to clinical anatomists and surgeons who operate within this region. STUDY DESIGN Anatomical and microscopic analyses of structures that communicate with the dura mater within the upper cervical region were carried out. METHODS Gross dissection in conjunction with microscopy was used to evaluate bridging communications of the upper cervical spine in 10 cadavers. To evaluate the in situ arrangement of these structures, E12 sheet plastination was used on 13 cadavers. RESULTS In all 23 specimens, suboccipital fascia coalesced with the dorsal meningovertebral ligament of the atlas, and inserted directly into the posterior surface of the dura as a single but separable laminar layer. At the level of the atlantoaxial interspace, suboccipital fasciae combined and coalesced with the dorsal meningovertebral ligament of the atlas and the axis. These structures inserted into the posterior surface of the dura mater as a single but separable layer. Microscopy validated these findings and E12 sheet plastination revealed the in situ organization of these soft-tissue structures. E12 sheet plastination also provided new information on dural arrangement at the craniocervical junction, which was observed to be composed of periosteum from the occiput but consisted mainly of deep fascia from the rectus capitis posterior minor. CONCLUSIONS E12 sheet plastination has provided in situ visualization of bridging structures within the cervical epidural space and offers new insight into these structures, as well as the composition and arrangement of the posterior atlantooccipital membrane and cerebrospinal dura at the craniocervical junction. This study aims to expand on the anatomical understanding of the upper cervical region while defining structures that may reduce neurosurgical complications, and aid in the understanding of the pathophysiology of certain neurogenic disorders.

Co-presentation of unilateral femoral and bilateral sciatic nerve variants in one cadaver: A case report with clinical implications

ObjectiveTo present a group of anatomical findings that may have clinical significance.DesignThis study is an anatomical case report of combined lumbo-pelvic peripheral nerve and muscular variants.SettingUniversity anatomy laboratory.ParticipantsOne cadaveric specimen.MethodsDuring routine cadaveric dissection for a graduate teaching program, unilateral femoral and bilateral sciatic nerve variants were observed in relation to the iliacus and piriformis muscle, respectively. Further dissection of both the femoral nerve and accessory slip of iliacus muscle was performed to fully expose their anatomy.ResultsPiercing of the femoral nerve by an accessory iliacus muscle combined with wide variations in sciatic nerve and piriformis muscle presentations may have clinical significance.ConclusionsCombined femoral and sciatic nerve variants should be considered when treatment for a lumbar disc herniation is refractory to care despite positive orthopedic testing.

Diagnostic Ultrasonography of an Ankle Fracture Undetectable by Conventional Radiography: A Case Report

OBJECTIVE The purpose of this study is to present diagnostic ultrasonography assessment of an occult fracture in a case of persistent lateral ankle pain. CLINICAL FEATURES A 35-year-old woman presented to a chiropractic clinic with bruising, swelling, and pain along the distal fibula 3 days following an inversion ankle trauma. Prior radiographic examination at an urgent care facility was negative for fracture. Conservative care over the next week noted improvement in objective findings, but the pain persisted. INTERVENTION AND OUTCOME Diagnostic ultrasonography was ordered to assess her persistent ankle pain and showed a minimally displaced fracture of the fibula 4 cm proximal to the lateral malleolus. The patient was referred to her primary care physician and successfully managed with conservative care. CONCLUSION In this case, diagnostic ultrasonography was able to identify a Danis-Weber subtype B1 fracture that was missed by plain film radiography.

Methodology and demographics of a single blinded, randomized controlled trial of chiropractic compared to physical therapy for balance impairments in community dwelling geriatric patients with or without low back pain

BackgroundPostural control problems effect between 28% and 35% of individuals over the age 65 and increases with age. Musculoskeletal pain in the elderly impacts 20% to 49% of people between the ages of 65 and 75, is a leading falls risk factor, and a robust predictor of morbidity. Polypharmacy in the management of chronic pain is common in the geriatric population. Conservative treatment options for balance and back pain are underrepresented in scientific literature.MethodsThe methods and demographics for a prospective, randomized controlled single blinded clinical trial are described. This study evaluated the use of either chiropractic care or physical therapy as a treatment for patients with balance problems and with low back pain (68.5%) or without low back pain (31.5%) in the geriatric population. One hundred and sixty eight consecutively enrolled community dwelling adults between 60 and 85 years old (72.8 +/- 6.8) were randomly assigned to 6 weeks of either chiropractic care or physical therapy (12 - 18 visits). Testing occurred prior to randomization, after 6 weeks of treatment, and again 6 weeks later. Functional and self-report outcome measures for balance included the Berg Balance Scale, Performance Oriented Mobility Assessment, Timed Up and Go Test, and NeuroCom balance tests. Pain was assessed with the Visual Analog Scale, 21-Point Box Scale, and pressure algometry. Quality of life healthcare questionnaires included the Oswestry, the SF-36, and the Falls Efficacy Scale for confidence in performing everyday activities. Data analysis for this intent-to-treat design was a mixed-model analysis of variance (ANOVA) (p < 0.05) and Bonferroni correction (p < 0.017 and p < 0.025). This study was set in a university biomedical and healthcare research facility and university ethics committee approval was obtained and written informed consent was given by all study participants.ConclusionThe methodology of this multimodal treatment protocol for balance disorders and low back pain in the geriatric population and patient demographics are described in this paper. Additional research in this area is needed for this growing at risk population.Trial registrationNCT02031562.

Management of Acute Patellar Dislocation: A Case Report

OBJECTIVE The purpose of this case study is to describe the evaluation and management of patellar dislocations and the different approaches used from providers in different countries. CLINICAL FEATURES An individual dislocated her left patella while traveling abroad and received subsequent care in Thailand, China, and the United States. INTERVENTION AND OUTCOME Nonoperative treatment protocols including manual closed reduction of the patella, casting of the leg, and rehabilitation exercises were employed. CONCLUSION Receipt of care when abroad can be challenging. The patients knee range of motion and pain continued to improve when she was diligent about performing the home exercise program. This case highlights the importance of a thorough examination, a proper regimen of care, and patient counseling to ensure a full recovery and minimize the chance of re-injury.

Radial neck fracture presenting to a Chiropractic clinic: a case report and literature review

ObjectiveThe purpose of this case report is to describe a patient that presented with a Mason type II radial neck fracture approximately three weeks following a traumatic injury.Clinical featuresA 59-year old female presented to a chiropractic practice with complaints of left lateral elbow pain distal to the lateral epicondyle of the humerus and pain provocation with pronation, supination and weight bearing. The complaint originated three weeks prior following a fall on her left elbow while hiking.Intervention and outcomePlain film radiographs of the left elbow and forearm revealed a transverse fracture of the radial neck with 2mm displacement--classified as a Mason Type II fracture. The patient was referred for medical follow-up with an orthopedist.ConclusionThis report discusses triage of an elbow fracture presenting to a chiropractic clinic. This case study demonstrates the thorough clinical examination, imaging and decision making that assisted in appropriate patient diagnosis and management.