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For the past 20 years I have worked with patients who have had a chronic illness. From mercury toxicity, to Lyme, autoimmune disease, and cancer, I had a stable model with which to approach them; and about 85% of the time I was successful in helping them toward healing and recovery. This approach boiled down to two basic problems. They had 1) things in their body that should not be there (toxicity/infection), and they had 2) things missing from their body that should be there: deficiency. With my early training in neural therapy, I would also address some of the structural aspects that would impair autonomic function such as scars and ganglion blockage or toxic root canal teeth or cavitations. With the four-component theory of disease 1) structure; 2) biochemical/microbiological; 3) autonomic balance; 4) spiritual, I thought I had things well understood and under control.
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I was familiar with the chiropractic model of subluxation impairing nerve function, but it was out of my expertise range; and I would refer when I thought it appropriate, but usually only as an afterthought. As a medical doctor my orientation was on "more important" things that cause body disease and illness. Little did I know that there was a very significant part of the structural aspects of health that I knew nothing about nor had any inkling of how significant it was. But that was not until I met my mentor, Dr. Julie Mayer Hunt, DC, DICCP, FCCJP, a world expert in the subject; and we have partnered in helping hundreds of patients that I have referred to her for care.
How many patients do you see with headaches, head pressure, neck pain, migraine, tinnitus, vertigo, POTS, brain fog, memory loss, multiple sclerosis (MS), Parkinson's disease, amyotrophic lateral sclerosis (ALS), and Alzheimer's disease? In how many of those have you considered that they had a structural problem at their cranial cervical junction (CCJ) that either contributed to their condition or was the actual cause of it? What is CCJ? More on that shortly.
It was only a couple of years ago that I met Dr. Julie Hunt quite by accident when a patient told me she had seen her and got an amazing change in her condition of constant head pressure of 15 years following a whiplash injury. Dr. Hunt comes from a family of upper cervical chiropractors. Her dad started their practice 60 years ago, and now Julie, her father, and her son all work together as upper cervical specialists. They are only blocks from my office, and little did I know the miracles that they produce. Because of the incredible impact of upper cervical treatment of the CCJ on my practice, I decided to partner with Dr. Hunt in writing this article to bring awareness of how common this problem is. I knew that if I was a medical doctor working with patients who had chronic illness for 20 years and had no idea of how important it was in health, that there were thousands more like me who would appreciate knowing the science so they could help their patients better. That is the purpose of this article.
Anatomy and Physiology of the Craniocervical Junction (CCJ)
To understand what craniocervical junction (CCJ) chiropractic care encompasses, a review of the basic anatomy is the starting point. The CCJ is the most complex joint region in the body. The CCJ, also referred to as the cranio-vertebral junction, is a collective term that refers to the occiput (posterior skull base), atlas, axis, and very importantly, the supporting ligaments. It is a transitional zone between a relatively rigid cranium and a mobile spinal column enclosing the soft tissue of the brainstem at the cervicomedullary junction (medulla, brainstem and spinal cord). It is critical to fully understand the neurology, biomechanics, and soft tissue integrity, including ligaments,1 blood flow, and cerebral spinal fluid flow at the junction between the brain and the body.2 Figure 1a provides details of the CCJ and the associated anterior supporting structures, including the alar ligaments, the apical ligament tectorial membrane, anterior atlanto-occipital and atlantoaxial membranes. The posterior supporting ligaments are comprised of the posterior atlanto-occipital membrane and atlantoaxial ligament. Figure 1b shows possible post trauma disruption of the posterior stabilizing ligaments of the CCJ.
Figures 1a and 1b
As shown in Figure 2, the vascular parameters of the CCJ include the vertebral arteries which pass through the transverse processes of the atlas and make a total of four ninety degree turns. Additionally, the internal jugular veins pass just anterior to the transverse processes of the atlas vertebrae.4 The positioning of the segments of the CCJ affect blood flow and cerebral spinal fluid (CSF) fluid flow dynamics to and from the brain.
Key biomechanical stabilizers of the brainstem inside the spinal column are the dentate ligaments. These ligaments begin at the atlas level and are responsible for centering the base of the brainstem and spinal cord throughout the spinal canal. Particularly when the CCJ structures are misaligned, the dentate ligaments can create adverse tension on the lateral aspects of the spinal cord, affecting neurological impulses throughout the body and distorting the spinal cord. MRI axial presentation can be from round (normal) to almost football-shaped (abnormal), observable upon MRI imaging of the CCJ. This is shown in Figure 3 where the picture on the left shows a normal round view of the brainstem while the picture on the right shows the football shape distortion of the brainstem caused by dentate ligament tension.
The base of the brain has cerebellar tonsils, which in large part are responsible for our balance and coordination. The brain and spinal cord are one unit. Think of the spinal cord as a long-braided ponytail; it is an extension of the brain. When the base of the skull and the atlas/axis become misaligned, the dentate ligaments supporting and protecting the brainstem can potentially produce caudal tension at the skull base, creating a downward tug at the brain base. The CCJ is the main circuit breaker neurologically as well as being the "mouth" to the brain for fluid exchange, including both CSF and blood. The CCJ is best imaged upright to observe true functional positioning of key components such as the cerebellar tonsils. When MRI imaging is done in a supine fashion, the back of the head can act like something of a "bowl" and the brain tissue tends to slide into the bottom of the bowl. When MRI imaging is performed upright, the brain tissue may occupy a different position; also, spinal misalignments can be observed.
Chiari malformation is a serious neurological disorder where the bottom part of the brain (cerebellar tonsils) descend into the foramen magnum, crowding the brainstem/spinal cord and altering CSF flow dynamics, producing many disabling symptoms. Cerebellar tonsil position is commonly measured using the basion-opisthion line (B-OL, also known as the McRae Line), shown in Figure 4. When the cerebellar tonsils descend five (5) mm or less below the basion-opisthion line (skull base) and into the spinal canal, this is referred to as cerebellar tonsular ectopia (CTE) and may be listed as Chiari 0 or borderline Chiari 1 depending on the exact measurement. A Chiari 1 is measured as more than five (5) mm descent of the tonsils into the spinal canal. Symptoms can vary greatly from one person to another, and some patients may be asymptomatic until a trauma occurs.6 The most common symptoms include cognitive issues, neck pain, headaches, visual abnormalities, poor coordination, difficulty swallowing, nausea, dizziness, anxiety, and depression as shown in Figure 5.7
Anatomical illustrations of the CCJ3 are provided showing normal cerebellar tonsil positioning (Figure 6A) and low-lying cerebellar tonsils (Figure 6B). The low-lying cerebellar tonsils can potentially block cerebral spinal fluid flow and therefore affect brain health and neuroimmune function.
Figures 6a and 6b
Sagittal MRI imaging depicting normal cerebellar position at the CCJ (Figure 7A) and abnormal cerebellar position affecting CCJ CSF fluid mechanics and brain health potential at the CCJ figure (Figure 7B) are provided as additional real-world depictions of the illustrations in Figure 6.2
Figures 7a and 7b
With respect to the craniocervical junction (CCJ), most standard MRI imaging does not observe this region sufficiently. Standard axial brain MRI imaging usually terminates a slice or two under the skull base.8 Standard axial imaging of the cervical spine usually begins at the C2 disc and proceeds caudally to the C7 region as depicted in Figure 8. Sagittal cervical MRI imaging are usually four (4) to five (5) millimeter slices which can miss detailed structures of the CCJ like cerebellar tonsils, which are small peg-like structures at the base of the brain, and CCJ ligaments, which average two (2) mm in diameter. Therefore, the CCJ soft tissue has been routinely overlooked in the mainstream medical community. Keep in mind that the medical acronym WNL, normally meaning "within normal limits," can also mean "we never looked." CCJ imaging in the past has utilized computerized tomography (CT) to rule out fracture without soft tissue considerations.9
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