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The spinal accessory and median nerves

as contributing factors to cervical

and occipital pain in a patient

SESSION OBJECTIVES

! To have have a better understanding of the anatomy of the spinal accessory nerve (SAN) and 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

•  She has had PT previously •  Before her injury: •  Focus was strengthening of her shoulder/scapular region

•  After her injury •  Stretching, “neck lengthening”, e-stim, NO manual work •  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

SYMPTOMS

•  Symptoms are all on the (R) lateral cervical and posterior lateral cranial region •  Occasional intermittent symptoms in the interscapular area

and anterior chest near coracoid process

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SYMPTOMS

•  She describes her pain as a tightness

•  There is no numbness or tingling

•  NPRS: 3-6/10 •  *this was difficult for the patient to do*

•  She is sensitive to sound & touch. She can feel her threshold for inputs are lower than they used to be.

SYMPTOMS

•  Patient denies any clicking or popping of TMJ

•  Parafunctional habits: •  Grinding teeth •  Night •  Day

•  Headache Impact Test (HIT-6) Score: 76

FUNCTIONAL LIMITATIONS

•  She cannot tolerate working more than a few hours

•  She feels as if she is operating at 50% abilities •  She would be much better at 75%

OBJECTIVE FINDINGS

•  CROM •  FB: 70% w/chin deviation

to (L) •  BB: 50% w/chin deviation

to (R) •  RSB: 50%, tightness on (L) •  LSB: WNL, “sensitivity on

(R) •  RR: WNL, pain

suboccipital area •  LR: 80%, pain suboccipital

area

•  Cervical MMT •  Flexion: Poor DNF

activation, SCM dominant

•  UE ROM •  WNL w/o symptom

reproduction

•  UE MMT •  5/5 (B) UE myotomes

•  Posture •  (R) shoulder depressed •  Head tilted to (R)

OBJECTIVE FINDINGS

•  Joint mobility •  Decreased C2-3 side glide to (L) •  Mid cervical slightly hypermobile

•  Palpation •  + (R) OCI**, SCM, longus colli, posterior c/s muscles,

scalenes, UT, rhomboids •  + (R) lambdoid and O/M suture

•  Mandibular motion •  Opening: 46 mm, (R) condyle w/min restriction •  Protrusion: 8 mm, (R) condyle w/min restriction •  Lateral deviation (R): 10 mm; (L) 8 mm

OBJECTIVE FINDINGS

•  Cranial assessment •  P-P: min stiffness, (R) suboccipital pain •  F-gen: good mobility, (R) temple pain •  O-S: decreased sphenoid to (L), (R) temple pain •  T-T: min stiffness (R), no symptom reproduction, “patient

report of it “feeling good” •  O-gen: min stiffness, (R) suboccipital pain •  O-F: mod stiffness, no pain reproduction •  O(R)-F(L): mod stiffness, (R) suboccipital pain •  O(L)-F(R): mod stiffness, no pain reproduction

Findings suggest occiput involvement

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TREATMENT

•  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

Visits 1-2

TREATMENT

Symptoms •  Patient reports “difficulty

relaxing” •  Muscles not responding to

soft tissue and cranial techniques as prior sessions

•  Cervical muscles seemed “fidgety” with palpation

•  + GON testing •  + median & ulnar nerve

neural tension" occipital pain

Treatment •  Median & Ulnar nerve

glides" no sx improvement •  GON glides" improved

irritability of muscles, CROM improved

Visit 5 •  + SAN testing •  SAN glides" eliminated sx of

median/ulnar nerve signs, most significant reduction in muscle irritability

•  SAN glides for HEP

Visits 3-5

TREATMENT

Treatment •  Cervical side glides in

median nerve tension •  SAN glides •  Cranial mobs •  O-C1 •  O-gen •  O-S

Results •  Median nerve glides no

longer produce occipital pain

•  Occipital mobs reproducing less familiar pain and have notably less resistance with pressure

•  Lambdoid and OM suture very minimally tender

Visits 6-8

TREATMENT

Treatment

•  O-C1 mobs •  DN (R) OCI •  Intraoral release (R)

masseter, mylohyoid"referred pain to occipital area

•  (R) medial pterygoid stretch

•  Mobs (R) ribs 3-5

Results

•  60-65% improvement overall

•  Median nerve and SAN no longer produced occipital pain

•  (R) condyle movements comparable to (L) w/jaw motions

Visits 9-11

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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)

5)  Muscles inability to relax during treatment

6)  Patient fidgety in the neck/shoulder region with treatment

7)  Included median & ulnar nerve testing for reasons #5 and #6 and GON testing due to prior injury

SPINAL ACCESSORY NERVE=

PAIN

COMMON KNOWLEDGE OF THE SAN

! It is widely accepted to be a motor nerve

! Injury to the SAN causes !  SCM and trapezius weakness/

atrophy"limited shoulder motion, scapular winging, pain

! Pain in shoulder region ! Early: prior to perceived weakness ! Later: with weakness/atrophy (Brown & Stickler 2011; Charopoulous et al 2010; Kelley et al 2008; Sahin et al 2007)

POTENTIAL CONTRIBUTING FACTORS TO PAIN

1) EMG and histochemical data shows that the C2-C4 nerves are mixed (not purely proprioceptive as thought

#  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)

2) Sensory function of the SAN itself #  Presence of neuronal cell bodies along the course of the SAN seen in human cadavers

#  Similar role as those identified in other animals, which are recognized as conveying nociceptive stimuli (Tubbs et al., 2014)

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

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•  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 (internal) root to form a single nerve trunk (accessory nerve).

! The accessory nerve exits the jugular foramen, heading towards the retrostyloid space (Caliot et al 1989).

http://healthfavo.com/jugular-foramen.html

Rubin M & Safdieh JE. Netter’s concise neuroanatomy. Saunders Elsevier, 2007

! From here the accessory nerve divides:

! cranial portion ! spinal portions

Rubin M & Safdieh JE. Netter’s concise neuroanatomy. Saunders Elsevier, 2007

! SAN typically passes laterally to the internal jugular vein

(Hinsley and Hartig 2010; Saman et al 2011; Taylor et al. 2013)

! Less frequently, the SAN can pass ! medial (Taylor et al. 2013)

! split around (Taylor et al. 2013)

! through (Hashimoto et al. 2012; Taylor et al. 2013)

Saman et al. 2011

Hinsley and Hartig 2010 IJV

Digastric

Taylor et al. 2013

SAN

! The SAN then descends in an oblique manner, staying medial to the styloid process, stylohyoid and digastric muscles

(Lloyd 2007)

! It then travels ! between the two heads of

the SCM muscle (Caliot et al 1989) ! deep to the SCM (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).

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! EMG and histochemical data shows that the C2-C4 nerves are not purely proprioceptive as thought ! 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).

****ADD PICTURE****

! The SAN then travels obliquely through the posterior triangle, towards the deep cervical fascia and trapezius, staying in a fat layer in between the trapezius and levator scapulae muscles.

(Hong et al. 2014; Lloyd 2007)

MEDIAN NERVE= OCCIPITAL PAIN

! 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.

! 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. 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.

NEURODYNAMIC ASSESSMENT SP INAL ACCESSORY NERVE

WHERE IS THE SAN?

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U P P E R C E R V I C A L F L E X I O N W / C O N T R A L AT E R A L S B , S H O U L D E R D E P R E S S I O N A N D R E T R A C T I O N

SAN IN NEURODYNAMIC POSITION

Patient did report some “stretching sensation” in the occipital area= Neurogenic problem vs. neuropathic

**was modified from the sidelying position**

CRANIAL TECHNIQUES TO IMPROVE THE STRESS-TRANSDUCER SYSTEM

MECHANICAL INTERFACES OF THE SAN

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

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NEURODYNAMIC ASSESSMENT MEDIAN NERVE

! 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 TREATMENT SP INAL ACCESSORY NERVE

SAN SLIDER

Upper cervical flexion/contralateral SB, shoulder relaxed

Upper cervical extension/contralateral SB, shoulder depressed and retracted

*This technique was modified to supine from the original side lying position*

NEURODYNAMIC TREATMENT MEDIAN NERVE

! Sliders with wrist and elbow movements

! Cervical side glides with the arm in median nerve bias w/o symptom provocation

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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