Craniocervical Junction

by Tyler Cymet, DO, FACOFP

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    00:01 The first area that we examine is the craniocervical junction and that’s because it’s where the brain and spinal cord are.

    00:08 It’s where there’s a lot of nervous system activity going on.

    00:12 And it’s a focus of not just assessment of individuals, but it’s a place we come back to quite a bit.

    00:20 30% of all of our proprioceptors nerves in the body are in the upper cervical spine.

    00:25 And it gives us a sense of the health of the body.

    00:29 It’s also where a lot of our stress focuses.

    00:32 And it’s a good place to look at postural maintenance and how people are doing with standing straight, standing tall, and when they’re going to start to slump.

    00:42 We also talk a lot about the connection to the brain, the tentorium cerebri, and the cranial nerves that exit the skull where they exit because of its effect on the sympathetic and hypersympathetic nervous systems.

    00:55 So again, just taking a minute and focusing on the skull, on the nervous system, and where things enter and exit the brain.

    01:07 The tentorium cerebri is an extension of the dura mater.

    01:12 It’s in the brain, in the skull area, enclosed.

    01:16 And we do talk about it a lot as potentially having areas of interest.

    01:20 While we can’t feel it and don’t know which area we’re feeling or what’s having the motion, we do know that there is some brain motion.

    01:30 Actually, at least 3 different pulses in the brain.

    01:33 One—that’s about 60 to 80—that’s correlated with heart activity and then you’ve got some lymph activity that may be the cranial rhythmic impulse.

    01:43 And then you’ve got other vibratory activity in the cerebellar area.

    01:48 We’re still trying to understand all these motions, how we assess them, and what we can do to moderate them.

    01:55 So with the tentorium cerebri –it’s an extension of the dura mater.

    01:59 It stretches to the foramen magnum in the C2-C3 area and goes all the way down to the sacrum.

    02:05 It is effected with respiration, and we do know that the motion of the brain and the sacrum are connected.

    02:12 And it’s another way of being able to tell what’s going on.

    02:16 And the osteopathic technique that’s used to free up this area is one that you’re going to be taught and need to know in order to help people with headaches, imbalance, and other different areas of disease.

    02:30 The cervicothoracic junction, again, it’s another one of the areas identified by Zink as needing to be referred to a lot.

    02:38 It’s another one that you’re going to have to examine in depth.

    02:41 And the thoracic inlets and outlets and other structures going through here are ones you’re going to have to focus on.

    02:50 He felt this had a lot of significance because of the drainage of the lymphatic system through the thoracic outlet area.

    02:58 And then an impingement on the brachial plexus can cause congestion in the lymphatic systems.

    03:04 And again, lymph is still in its infancy of understanding.

    03:08 We don’t understand where lymph is at any one time, where the majority of lymph is, and how it flows.

    03:16 We do feel that it could affect the GI system and the nervous system.

    03:20 Here’s a picture of the thoracic inlet, just so you can appreciate the structures going through the thoracic inlet and paying specific attention to where the lymph flows, the thoracic duct, and other areas where lymph is dumped back into the circulatory system and then mixes with the blood.

    03:39 So you’re going to focus on thoracic inlet and thoracic outlet.

    03:43 Focusing on supraclavicular edema which could be a sign of impended drainage.

    03:49 We do have hundreds of lymph nodes throughout the body.

    03:52 A significant number of them being in the upper part of the chest and neck area.

    03:58 And should be examined for signs of impeded drainage, swelling, congestion, and also as a focus for us when we want to make people feel better.

    04:08 How do you enhance lymphatic return? We do talk a lot about the thoracic lymphatic pump.

    04:14 We talk about vibratory techniques and other things we can do with the lymph to make people feel better.

    04:21 And, again, there are as many questions, if not more questions than answers here.

    04:25 But philosophically it fits into the body as a single unit, ideology, and the structure-function relationship and how things are all connected.

    04:36 We’re next going to go to the thoracolumbar junction.

    04:39 Particularly, when you have restrictions that effect the abdominal diaphragm.

    04:44 We talk a lot about the abdominal diaphragm, what enters and exits, and what goes through the abdominal diaphragm.

    04:50 And how to focus on this and picture this when doing manipulative treatments, particularly in people who focus on visceral manipulation or somatovisceral issues, when tightness or dysfunction of musculoskeletal system affects how the organs are functioning because we feel that a decrease in diaphragmatic excursion effects the work of breathing and lymphatic return and venous return.

    05:17 There’s some good preliminary evidence that it is effecting venous return and we’ll get more into that later.

    05:24 We also look at the structures where the lymph is coming back into circulation, going through the thoracolumbar junction, and going through the lymphatics that are going through the junction.

    05:35 So here’s a picture of the diaphragm and this is meant to get you to think of the diaphragm as not only a muscle but as a ligamentous and a more fascial-type structure.

    05:47 You can see the crura attachments.

    05:48 You can see the white thickened area in the center and you can see the muscular area that helps with movement.

    05:55 The mnemonic we give people is “I ate 10 eggs at 12.” So when you’re thinking of the diaphragm— I ate—the inferior vena cava comes out at T8, 10 eggs—the esophagus goes through the diaphragm at T10, and at 12— the aorta comes through the diaphragm at T12.

    06:16 So just some ways of thinking about what’s going on as you work on the body from the outside, picturing what’s inside.

    06:25 You also have muscles coming up to the diaphragm— he quadratus lumborum and iliopsoas— effecting the motion of the diaphragm as well as the motion of the lumbar spine and below.

    06:35 So again, this is meant to give you opportunity to think about what techniques you can use, how you can get at these areas, and what can be done to treat a lot of these dysfunctions.

    06:47 It also brings in the thinking about vibratory treatments and other treatments that are part of the armamentarium of osteopathic medicine.

    06:56 As we work our way down the lumbosacral junction, will give you an idea of what’s going on with restrictions in the lumbosacral area and the pelvic diaphragm.

    07:04 Separate from thoracolumbar, we get down there— not a diaphragm that we have focused on or thought about much in osteopathic medicine but definitely one of the diaphragms that exist in the body that can impede lymphatic flow and connection in the body.

    07:20 So as you think of the motion of the diaphragms, there’s motion in the thoracolumbar and lumbosacral diaphragms.

    07:29 And restrictions in this area can effect nervous system functioning as well as flow of lymph, blood and plasma.

    About the Lecture

    The lecture Craniocervical Junction by Tyler Cymet, DO, FACOFP is from the course Introduction to Osteopathic Treatment. It contains the following chapters:

    • Craniocervical Junction
    • Tentorium Cerebelli
    • Cervicothoracic Junction
    • Thoracic Inlet
    • Thoracolumbar Junction
    • Lumbosacral Junction

    Included Quiz Questions

    1. Tentorium cerebelli
    2. Tentorial notch
    3. Dural sinus
    4. Arachnoid
    1. Thoracic inlet, into the jugular and subclavian veins
    2. Thoracic diaphragm
    3. Splenic circulation
    4. Thoracic aorta
    5. Hepatic venous circulation
    1. Esophagus
    2. Inferior vena cava
    3. Superior vena cava
    4. Aorta
    5. The spine

    Author of lecture Craniocervical Junction

     Tyler Cymet, DO, FACOFP

    Tyler Cymet, DO, FACOFP

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