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Chiari Malformation, Cerebellar Tonsillar Ectopia & Upper Cervical Chiropractic

Chiari Malformation, Cerebellar Tonsillar Ectopia & Upper Cervical Chiropractic

Chiari Malformations, Cerebellar Tonsillar Ectopia (C.T.E.) have been Associated with history of head/neck trauma. Upper Cervical Chiropractic Care indicated for potential treatment.

Upper Cervical Chiropractic Research Show #2 – Chiropractic Deep Dive Podcast – A Case-Control Study of Cerebellar Tonsillar Ectopia (Chiari) and Head/Neck Trauma (Whiplash) – Michael D. Freeman, Scott Rosa, David Harshfield, et al.

Chiari Malformations & Cerebellar Tonsillar Ectopia has been correlated with Head/Neck Trauma in the research. Listen to the above podcast or read the transcription below to find out more. We are here to address Chiari and C.T.E. with the 2nd Upper Cervical Chiropractic Research Show on The Chiropractic Deep Dive Podcast. They found that those with past trauma to their head/neck area were more likely to have Chiari or C.T.E. This is a huge finding and suggests patients with Chiari or C.T.E. may receive benefits from Upper Cervical Chiropractic care. Let us know if you have any questions!!

– To Your Health

Dr. Kevin Leach

Dr. Leach: Hello and welcome to this week’s episode of The Upper Cervical Chiropractic Research Show. Hey everyone I wanted to give you a quick rundown of the format of the following video to make sure you can get the most value out of the video as you can. So here’s the format in the breakdown. The first thing Dr. Evans and I are going to go over is just an overview of the research. We’re gonna look at just what the research said what it concluded and some highlights of that. Next we’re going to get into the nitty-gritty, a deep dive into the research. We’re gonna go through every single section. All the little details that a lot of people don’t know about but for those people that want to read research but don’t have the time or don’t want to sit down and just kind of grind through that research. They can listen to this or watch this and they can they can follow that research for the most part to go along and to really understand in depth what the research did. After that Dr. Evans and I are gonna go through just some discussion on how the research relates to patients to doctors and what the authors are doing in the future and right now as far as research. And just kind of give more value for the research and give more context for that. So fast forward through to wherever you want to go to whatever parts you want to see and please give a comment down below in regards to was this valuable what would you like more of any questions anything at all and support us if you can. We appreciate it. We’re trying to bring you value and we want to do that as much as possible. Enjoy.

Dr. Leach: Dr. Tyler Evans how are you sir?

Dr. Evan: I’m doing well Dr. Kevin Leach. How are you?

Dr. Leach: Awesome. So let’s get right into it. So this paper is A Case-Control Study of Cerebellar Tonsillar Ectopia (Chiari) and Head/Neck Trauma (Whiplash) it is by Michael Freeman, Scott Rosa, David Harshfield, Francis Smith, Robert Bennett, and Christopher Centeno et al. This was published in the journal Brain Injury. So before we get into the deep dive of the paper Dr. Evans will you just kind of give a general overview of what the paper is saying? What were they looking for results, conclusions, etc.

Dr. Evans: Yeah. Yeah. So I think it’s important for people to get a 30,000 foot view before we dive in and there are a lot of statistics with this paper. There’s a lot going on but there’s some really great takeaway so we want to make sure that you come away with these. The primary objective was done to study chiari malformations and herniation of the cerebellar tonsils through the foramen magnum. That’s also known as CTE. Not to be confused with the football CTE. They’re different types of brain injury but the point here is that they were the the symptomatic problems people were experiencing they were trying to study based on MRIs what they were seeing and how people responded in terms of symptoms. So when we do a cervical MRI most of the time we lay people flat and the cervical MRI scans for 1,200 neck pain patients were reviewed but some of them were done upright. So 600 trauma cases. So people with trauma to the neck and 600 non-trauma, so they were the control, so they had no trauma to their neck. Half of the groups were scanned in a flat or recumbent position and half were scanned in an upright position and there were two radiologists that reviewed the scans for cerebellar tonsils. And so we’ll go into you know what cerebellar tonsils are and all the details there. So basically the outcomes and the results were that there is a total of 1,195 of 1,200 scans were read. So there were five that just didn’t get read for whatever reason and CTE, Cerebellar Tonsillar Ectopia, was found in 5.7% and 5.3% in the recumbent and upright non-trauma groups verses 9.8% and 23.3% in the recumbent and upright trauma groups. Non-trauma versus trauma there was an increase, a spike, in how many people had CTE. That is a huge finding because they have never shown that before in a paper ever. So that’s point one. The results described in this president investigation are first to demonstrate a neuroradiographic difference between neck pain patients with and without a recent history of whiplash trauma. The results of prior research on these problems were confounded because of a failure to account for possible, basically, neuropathology. So this was a big paper in that they had this really interesting finding at the end between trauma and non trauma and the upright and the recumbent scanning groups.

Dr. Leach: Alright sounds good. That’s a good overview. Any last takeaways for patients, providers, chiropractors for this for this type of research? How is this valuable and what kind of person could really benefit from this evidence?

Dr. Evans: Yeah. So number one. I think it’s very pertinent for anyone who has been diagnosed with chiari malformation. It helps you understand the diagnosis a little bit better. There’s a lot about that and we can get into that later but for people who have chiari or for people who have had car accidents, especially car accidents and whiplash trauma, that if you’re going to be getting a scan of your cervical spine or of your brain to make sure that it is in a upright position if you can find you one close to you and afford it. They’re roughly about $600 for a scan but if you can find an upright scan they’re going to, generally speaking based on what this paper shows, find more of the pathology should show up radiographically speaking in their imaging. And and you may get a different diagnosis because of that. So it’s really important if you’ve had an injury to your head or neck to be doing upright imaging because it shows the problem in gravity. Which we’re walking around in gravity all day long and if you get a scan when you’re laying down on your back the problem may not show up nearly as much because gravity’s not in play like it would be most of the time in your life. Most patient symptoms go away when they lay down. Their headaches get better or their back pain gets better. And so we see that when we sit people up, gravity actually affects this stuff. So this paper is the first paper to actually show that. That’s very important.

Dr. Leach: Let’s review the terminology and what they mean. Chiari malformation is the same as cerebellar tonsillar ectopia, they’re just two different words for the same thing. This is where the cerebellar tonsils, meaning the lower part of the back of your brain, actually sticking out of your head at the bottom of your head into the spinal canal where the head meets the neck. Chiari type 1 malformation is what this paper will be looking into. Type 1 may be associated with Syringomyelia, which is a cyst or a cavity inside the spinal cord and bone abnormalities but can happen in the absence of both of those. Chiari type 2 or Arnold-Chiari malformation is a tonsillar ectopia present at birth and nearly always associated with myelomeningocele, which is spina bifida. The following are the symptoms mostly associated with type 1’s. Type 1 chiari malformation, occipital headaches, neck pain, upper extremity numbness and paresthesia, which is tingling or pins and needles, and weakness and lower extremity weakness and signs of cerebellar dysfunction. Diagnosis for Chiari type 1 malformations is mostly done with MRI. There are different definitions based on different authors of research but they measure how far descended down into the spinal canal the cerebellar tonsils go below the foramen magnum, which is at the opening at the bottom of the head where the brainstem turns into the spinal cord. Some define it as 2 millimeters, some even define it as 5 millimeters below the imaginary line at the foramen magnum called the basion-episthion line, which is drawn from the front to the back of the foramen magnum. The diagnosis comes with or without symptoms present in the patient. This paper is to investigate the question of whether trauma, like a whiplash, can create this condition and what the mechanism and result might be as suggested by previous authors. Some suggest it might be that chiari was there prior to the trauma and that the trauma made these patients symptomatic. Answering the question of whether cerebellar tonsillar ectopia are potentially created by trauma is difficult as most non-traumatic patients do not have MRIs to see if ectopia is present. This study is a case controlled study. It is designed to compare traumatic and non-traumatic patients with neck pain for prevalence of CTE, cerebellar tonsillar ectopia, not only prevalence between trauma and non-trauma, car accident and in non car accident, but between MRIs taken standing and laying down to see if the effect of gravity has a change in the diagnosis. On to the methods. MRI images were taken of the neck and base of the skull of 1,200 consecutive neck pain patients 15 years old or over at four different radiology centers over a three-year period. 600 traumatic car crashes 600 non-traumatic. Half of the traumatic and half of the non-traumatic were each scanned upright and the other half sitting. So there are four groups of 300. 300 upright traumatic, 300 laying down, 300 upright non-traumatic, and 300 laying down non-traumatic. The institutional review board approval was from the spinal injury foundation. Sagittal sequences for the MRI, meaning which slices they looked at, were taken at the area where the cerebellar tonsils were at the lowest point compared to the basion-episthion line or foramen magnum. Films were read by two authors that are board-certified radiologists that were blinded in regards to which patients were traumatic and non-traumatic, so there was no bias there, and positioned seated or standing. When the two radiologists disagreed the measurement that was more conservative more cephalid was taken, meaning more higher, because we were looking to see which is lower. I’m going to go over some definitions and some of the statistical analyses that they did in the paper for those interested to try to make it a little bit more clear. So one of the things that they did is called a three-way analysis of variance it’s called ANOVA, it’s an acronym A N O V A. This means there were three factors involved in the analysis. First one being trauma – non-trauma. Second being seated verse laying down, which is upright and recumbent. And the last one was male – female with the variable being measured as ectopia or descending of the tonsils below the foramen magnum. So they were looking at that in all of these different situations. They also did what’s called a two key pairwise comparison. Now that’s carried out only if there is a significant finding between initial variables analyzed. Meaning if they found that there was no difference in tonsillar level comparing all three variables there’d be no reason to look further. But they saw a difference so they did a two key pair wise comparison. Two key test is used to compare three or more variables to determine whether the interactions are statistically significant. So the ANOVA of the analysis of variance tells you whether there is a significance in the variables but it won’t tell you which were significant. Meaning there was an interaction between some of the variables, yes. Which variables were significant will tell you which ones interacting are significant and that’s what the two to keep pairwise comparison does. Which of the variables were significant when compared to each other. There’s also what’s called a chi-square goodness of fit test, this is a formula in statistics that compares different groups of variables to see how much of a relationship they have. A very low number indicates a strong association a high number indicates a weak association. And the chi-square variable in the study was around 0.0001, it was very very slow. So the lower number indicated a higher stronger association. The p-value, the significance level represented by the greek letter alpha is 0.05. P-value on the study represents whether the variable being analyzed is significant or not. If “p” is less than or equal to 0.05 there is significance. If it’s greater than 0.05 it is not. The Kappa range for agreement between the two radiologists was between 0.85 and 0.95. The kappa range in statistics is one of the most commonly used inter-examiner or inter-rater reliability. 0.81 to 1 is considered almost perfect agreement. 0 to -1 is considered no agreement at all and this study had 0.85 to 0.95 which is high agreement. A 95% confidence interval, this is an interval or range that contains the average measurement 95% of the time. The common misconception of the 95%
confidence interval is that 95% of the measurements fall within this given range but this is false. What this means is that there’s a 95% chance that a random sample of data, meaning if we took the group of 300 and we took 10 of those data points and we created an average range there, then 95% of the time the average of all the samples will fall within that range. The more narrow the confidence interval the more confident we can be with our average. The wider the interval the less accurate. So if you only take 2 samples from a 300 sample population then the interval is going to be very wide and it’s not going to be very accurate but if you take the more samples you take the more closer to the average you’re going to be. So instead of the standard deviation which tells you the average of the values outside of the average, so it’s like a range. It gives you a range your measurements values are 95% likely to fall into 95% as opposed to 90% or 99%. So 95% confidence interval is the value agreed upon by researchers that gives the most useful information. This 95% confidence interval or confidence intervals in general is quite a confusing statistic and an analysis. If anyone wants more further explanation leave that in the comments below and we’ll try to go through that a little bit more for more understanding. Okay let’s get into the results of the study. So 5 of the 1,200 scans were determined unreadable for whatever reason. The agreement between the two radiologists using what is called a kappa range was between 0.85 0.95 which is in the almost perfect range. So they’re just comparing in the study when the radiologists read the studies without the other’s presence did they agree and for the most part they did it was again almost perfect. Both injury status meaning trauma and non trauma and scan type meaning upright and recumbent were found to be statistically significant with p-value being equal or less than 0.0001. Which just means that statistically speaking the end results of those measurements is significant. It’s not just coincidence it’s not the same there’s a significant difference meaning there’s something to be looked at there. The highest to lowest tonsillar level was what you would actually expect. And so non-trauma laying down again without gravity the average height was 2.2 millimeters above the foramen magnum the bottom of the skull the area that was measured and that is measured for the chiari malformation. The next lowest level would be the non-trauma upright so that’s in gravity so we would expect things to settle down a little bit more to be closer to the bottom of the skull where the brain comes out and that was at 1.7 millimeters above the the foramen magnum. And then the third would be the traumatic laying down again without gravity but still had the trauma and that’s at 1.3 millimeters above the foramen magnum. And then obviously the worst one being the traumatic upright with gravity which is what we would expect and that was at 0.1 millimeters. One of the things that they used and one of the methods they used in the results to compare all of these is called a two key pairwise comparison and that showed that the trauma patients were statistically significant lower levels of the tonsils for both the recumbent and the upright compared to non-trauma. So again another comparison another method to show statistical significance. There was a significant difference between male and females that they found as well and the tonsillar herniation of 5 millimeters or more was rare and only found in 6 of the 1,195 scans that were read. The group was also analyzed to see the percentage of patients with tonsils with 1 millimeter or more below that foramen magnum and the results, which is what Dr. Evans just mentioned, the non-traumatic recumbent was 5.7 non-traumatic upright 5.3 and then when those are compared to the trauma recumbent trauma upright we got 9.3 and then 23.3 twenty three point. So that against significant changes going from the non-trauma to the trauma statistically significant. When looking at the male versus female the percentage points was about maybe 1 to 2 more for females compared to the males and that’s in table 2 in the research if anyone’s actually looking at the research right now.

So in the discussion section the study reports that patients with a history of motor vehicle crash associated neck pain have substantially higher frequency of CTE, again CTE is cerebellar tonsillar ectopia, that more than the non-traumatic patients by almost 2 times and then 4 times when scanned in the recumbent position compared to the non-trauma. This is the first large series and study like this of patients to be evaluated for this CTE, so it’s pretty groundbreaking. Obviously more studies need to be done but it’s showing some pretty strong evidence for trauma being related to CTE in the upright position compared to a scan and the recumbent position. Comparison. So the average level of the tonsils and the frequency of the CTE, again obviously with the trauma groups it was found to be more, this suggests a reasonable conclusion that the results reflect a degree of gravity dependent instability in the trauma group. We’re gonna get into the different mechanisms of how that could be which I found interesting from reading the study. A potential source of bias or a variable could be that the images were taken at 4 different imaging facilities. So in the research they want to see what variables could be affecting it so there were 2 recumbent and 2 upright that could be a variable. It’s been suggested that being in an upright position will cause the tonsils to herniate caudally due to gravity alone and so this research was trying to figure out if gravity alone was a factor comparing the non-trauma and the trauma and we see that there was definitely a difference there. This makes sense from a mechanical and gravitational standpoint. Ideally all patients would have been scanned recumbent and upright to see the shifts with potential change. That could be a future study to look at that as well. These findings bring up a question whether the CT was present before the trauma and was awakened by the trauma or if the trauma caused the CTE. Evidence suggests the latter as the occurrence of this CTE was substantially greater in the trauma group upright verse recumbent and then the non-trauma upright verse recumbent group suggesting instability when gravity is involved. One hypothetical mechanism of lower tonsils in the traumatic group is a dural leak due to trauma. So there’s been some past research that has shown lower tonsils after lumbar shunting of CSF in cases of hydrocephalus. There’s clinical evidence that whiplash traumas caused dural leaks especially in the lumbar spine at the dural sleeves. And this is actually measured, if somebody were to actually be looking into getting this tested, radioisotope cisternography would be used which is a specific exam to test spinal fluid leaks. The study shows that whether the CTE observed in a trauma group was from crash trauma or pre-existing the evidence shows CTE is more prevalent in neck pain patients with trauma compared to non-trauma. Some limitations for the study. Lack of detail in the differentiation of trauma and non-trauma regarding recent history of whiplash. It’s reasonable to believe that some of the patients in the non-trauma groups have had a past trauma but not recent enough to be included in the trauma group. Meaning they don’t know that the non-trauma group never had a whiplash injury so that could be a variable in the exam. Meaning maybe those patients healed over time so they’re not in the 9% or the 23% showing the instability when in an upright position. Second limitation of lack of detailed information regarding symptoms of the subject.


Symptom headaches and neck pain are similar in the Chiari following head and neck trauma and symptoms following whiplash. So those are similar they overlap and so a more detailed exam for those patients would would help differentiate as well. Other research has shown association of CTE with fibromyalgia. So the current paper may create an appealing hypothesis that links fibromyalgia to whiplash by a way of acquired CTE. So there’s a lot of overlap and in research we talk about association doesn’t mean causation things like that, so there’s just some interesting things to think about there. A future study that would be good next step would be a study that performed a detailed neurological examination and elicited pre and post injury history of Chiari unique headache symptoms. For example, cough exacerbation as well as recumbent and an upright MRI assessment of CTE. As far as the conclusion section, the research is the first again to demonstrate a substantial neuroradiographic difference between neck pain patients with and without a recent history of motor vehicle crash trauma. CTE is found 2.5 times more in upright compared to recumbent MRI. Future research should seek to confirm results found in this study. Also helpful would be biomechanical research to show mechanisms during whiplash that could cause dural injury and clinicians and patients should consider evaluating patients for CTE with upright MRI of head and neck if persistent occipital headaches occur and symptoms do occur.

Let’s get into our view on the paper.

Dr. Evans: Well Kevin, the strengths of this study are that it really is the first paper to ever show this relationship. It was done by a handful of guys that had been working together using what’s called fonar upright MRI and a man by the name of Raymond Damadian. This is to be debated but he is the developer of the MRI machine back in the 50s, 60s, and 70s I think somewhere in there. Thinking ahead. Thinking about trauma and injuries and how better to help people find a diagnosis and help people find a treatment for whatever problem they might be facing. And so all these guys kind of started to use this technology, the fonar upright MRI. Scott Rosa being one of them, he’s a mentor of ours. That’s how I found out about this paper but they have done some amazing things with this upright MRI technology. And this study of the tonsils and how that affects the fluid flow of the cerebrospinal fluid and we could go into rabbit holes on every single one of these things and do an hour-long talk on cerebrospinal fluid flow, chiari malformation, all the different types. I think there’s like depending on who you talk to there’s 3 or 4 or 5 different types of chiari malformation depending on who you talk to. But this this paper was kind of an unlocking of that information into PubMed and into the world and was the first step in a really really great direction. And so just remembering that trauma definitely in this paper showed a, I don’t want to say causation or even a correlation, but an association. Right, an association between the data that they found on these trauma patients with lower tonsils. A couple of things that are really neat about this is that in this paper they defined any Chiari as below the basion episthion line, the front of the skull or the front of the foramen magnum in the back of the foramen magnum, and that line anything below that by 1 or 2. Was it 1 millimeter? I think it’s 1. 1 millimeter. When in some previous papers it’s been defined as 5.

Dr. Leach: Right.

Dr. Evans: And so that’s significant because I see a lot of patients, and you probably have to Kevin, where people come in and they’ve got these tonsils that are 5 millimeters below their foramen magnum. That’s a lot for your brain to be herniated down below the skull. Right. Obviously there’s going to be a problem but at one millimeter. What’s happening at 1 millimeter or what’s happening at 0 when it’s at the foramen magnum but not below it. All right so we call that actually a chiari 0 and you can look it up, themayfieldclinic.com or something to that effect. They have a whole description on chiari 0 and and some of the explanations on each of the different chiaris. And some believe that it comes from trauma and some believe that it comes from a genetic component when you’re born. I think from my experience I’ve found that it’s probably a little bit of both. Right. And so there’s a lot of research to be done here. In a lot of these patients they just get told well you have Chiari and there’s not a lot we can do about it or they do the surgery and the surgery is aggressive. Right. And so that’s a whole other talk that we can go into later. We can do a paper. I’ve got this paper I just pulled up here does a whole covering of Chiari malformation it’s called Malformations of the Cranial Cervical Junction Chiari Type 1 and Syringomyelia: Classification, Diagnosis, and Treatment. That was done in 2009. At some point we can go into that paper but you get my point that these patients they struggle with headaches, dizziness, vestibular problems, eye problems, light sensitivity, sound sensitivity, problems piecing sentences together, memory retention, brain fog. They have all of this what we call cranialcervical syndrome and that’s not in this paper but in this book that came out later on, this book here.

Dr. Leach: Will you say the title?

Dr. Evans: Yeah, the title is The Craniocervical Syndrome and MRI and it was actually written and the editors were Francis Smith, one of the authors of this paper, who is a radiologist in Scotland I believe. Aberdeen I believe is where he was from. But Francis Smith and Jay Dworkin and a lot of these guys that were in this paper that we’re talking about, they actually put a lot of research into this book and that book talks even more about CTE and cerebrospinal fluid problems and the chiari issues. So there’s a whole new science that’s emerging here is what I’m trying to get at and this paper was the first step into that world. So I don’t know Kevin do you have you have anything that you want to say about that?

Dr. Leach: I was going to ask you. Is it EMP therapy or do you know anything about when they find a dural leak, and they do something where they put some coagulating agents to try to stop the leak and some research shows that that gives an immediate relief? How do you figure out if those patients are in need of that and if they need that isotope cisternography or like how does that therapy or that fix, because it seems like it’s actually a fixing of the cause of the problem, what do you know about that?

Dr. Evans: Well honestly I can’t say a whole lot. I know that a blood patch is one of the things that they do. They take your blood and they put it back into where the hole around the dura would be and what that does is your platelets and your blood then kind of fills that gap and closes that gap. But it’s painful when you have a fluid leak like that. A lot of mothers actually, and that’s what I’ve experienced in my time as a chiropractor, is that a lot of mothers get dura leaks when they get injections right for epidurals right. And so when the needle goes in and sometimes it doesn’t sit just right and it can actually tear the dural sac and then you’ve got this whole other problem of fluid imbalance in the skull and you’ll get a massive migraine until they patch it basically. And oftentimes the ladies don’t recover from that very quickly, if at all. And so that’s something that I have seen and the cisternography is imaging of the cisterns, there’s 4 of them I believe in the skull, and they basically are what houses the CSF, the cerebrospinal fluid. So for everybody out there if you’re listening cerebrospinal fluid is the fluid that bathes your brain, lays on your brain, in between the blood-brain barrier and your brain and it’s what pulls away toxins and brings nutrients to the brain. It also protects the brain as a fluid layer it’s what kind of holds your brain up inside of the skull and protects it from the the hard outside. And so that fluid is really important to have the right balance and have the proper flow around the brain. It starts deep inside the brain. It’s made deep inside the brain and then it pumps out and then it flows down and around the skull and goes down through the spine and then it pumps back up the heart rate, so heartbeat, and lung respiration as well movement. And so as that CSF flows around it does its job but what can happen is that if you have this chiari problem it can literally be a cork in the bottle in the base of the skull.

Dr, Leach: Right.

Dr. Evans: ..and plug that fluid up and then that can be an issue. So that’s something that we see a lot of a lot of patients for and a lot of the research that came out of this paper points to more of that chiari problem with CSF flow.

Dr. Leach: Right. Yeah I said EMP and meant EBP so that’s epidural blood patch just like you said. Just to correct that. So I feel like you’re saying that when patients have that their symptoms might be a little bit more severe like my typical runny fluid out of a nose, runny fluid out of the ear, pain, headache relief by laying down. Those typically go – they get caught. They don’t really go undetected. Is that fair to say? The ones that really need the EBP feel like they might go undetected and that they just need that fix and that would actually help them significantly.

Dr. Evans: Yeah if you have running fluid out of your ear or your nose you’re gonna be in trouble.

Dr. Leach: Definitely red flag.

Dr. Evans: Either way. Yeah.

Dr. Leach: Okay some other talking points. Will you go over the craniocervical syndrome? How that relates to this research.

Dr. Evans: Yeah. So just these doctors that wrote this paper. So the lead author is always the first guy on the paper, so Michael Freeman. He was the lead author. He is a medical forensic scientist and he deals a lot with traumatology and whiplash and injuries. And we can circle back around to your comment about gravity weight bearing and possible damage to the upper neck and how that relates but this is craniocervical syndrome. All these guys are in this world of craniocervical instability / craniocervical syndrome and how they relate. So Freeman is a medical doctor. Actually, Scott Rosa is the only chiropractor on this page. He was the only upper cervical. He’s an upper cervical chiropractor. An atlas orthogonal upper cervical chiropractor and he was the second guy on the paper so he definitely had a lot of input on the paper. David Harshfield, he is a radiologist down south. I can’t remember exactly where but he also looks at craniocervical instability and he does some regenerative therapies like injections. Not sure if it’s pro-low or PRP. I think he does a little bit of both maybe but you’d have to look it up. But David Harshfield, he’s a well-known radiologist that works with Scott Rosa. And then we have Francis Smith, he’s another radiologist. Dr. Bennett, I don’t actually know who that is but I do know Christopher Centeno. I met him at the the symposium we had last June and he does regenerative therapies as well. He uses digital motion x-ray to see ligaments that might be either torn or damaged in movement in the neck. So they do flexion/extension movement with the neck and they look to see how the ligaments might be torn or damaged as well as the upright MRI. So they use all these technologies to image the craniocervical junction meaning cranial skull, cervical neck, junction is right in between the two and that’s a black hole for
really the health community. These guys were the first guys to really get in there and look at it. So what they’re doing is they’re looking at what ligaments might be damaged and injured possibly there’s a minimum of 7 to 9 ligaments in just right up here. It’s 7 to 9 ligaments between the craniocervical junction. Being the apical ligament that attaches from C2 up to the skull. The alar ligaments which are cross-check ligaments that check lateral bending and rotation in movement and so basically they keep your atlas attached to your skull in these movements. And what we find is that sometimes these ligaments are completely blown in some of these whiplash injuries head and neck trauma injuries. And so when they go and dip their head or they tip side to side the bone just goes “whoop” way off to one side and so that’s what we’re talking about and what happens then when you have instability in the in that craniocervical junction. That’s where your brainstem is and that’s the tonsils and they are different parts but it’s all part of that brain stem cerebellar/tonsil area it can dip down because of the weakness there. I think that these guys were one of the first groups to really study that science and use this imaging in a way that they could diagnose and make treatment decisions better. This is an emerging science so if you or someone you know about there is suffering and struggling with head neck traumas and injuries having an upright MRI, having digital motion x-ray, having cone beam CT, having x-rays of the neck to see where the bones are at and how things are sitting is really important to help decide how to move forward.

Dr. Leach: Got it. It’d be interesting to see because it seems like there’s potentially two factors that could be, at least the evidence we have now, two factors indicating why the tonsils could be lowered. One of them is decreased CSF because of a dural leak that could be corrected but another one potentially that ligaments and soft tissue holding the brain and making sure it doesn’t come down could be torn. What are your thoughts on some research that could be done in these positions with torn apical ligaments, or alar ligaments, or these things that could measure the tonsillar level in different positions and differentiating which one it could be and why those tonsils are down? What are your thoughts on doing that as research?

Dr. Evans: So what Dr. Rosa has done and I think he’s one of the only people that has worked hand-in-hand with Dr. Ray Damadian, the inventor of the upright MRI, but what he’s done is he’s developed a collar that goes around the neck that, with Dr. Damadian. They have developed a collar and an imaging modality for the upright MRIs where they look so minutely. You can’t do this with other machines because one you have to be upright so that cuts it down to a certain amount. I think there’s 20 of these machines in the country and every single machine should be an upright MRI machine in my opinion and we should all really push for upright MRI imaging because any problem that you have in your spine your body it’s gonna show up in a more gravity correct way on an upright MRI no matter what your problem is. And then what they’ve done is they’ve taken this collar – they developed a collar that looks specifically at the alar ligaments, at the apical ligaments, and all the other ligaments that are there. The handful of other ligaments that make up the glue that holds the upper neck together and honestly I don’t think anyone else is really doing that or has ever done that and I think it’s quite hard to do and you need very specific imaging for it. So to answer your question Kevin, I think that that’s actually quite hard to do and you need specific protocols and specific tools to do that because a motion x-ray shows you the bones but it doesn’t show you the ligaments. You can guess what ligaments might be injured but you can’t see which bones or you can guess which bones might be injured but you can’t see which ligaments. Does that make sense?

Dr. Leach Yeah. For sure. If patients, doctors, chiropractors, anybody if they feel like they might have some of these symptoms and they feel like maybe they’re getting help or whether they want to see an upper cervical chiropractor whether they want to get an upright MRI do you have some sort of list? What’s the pathway of someone being suspicious that this might be a problem and go into finding out if it’s a problem? Lists of different companies around the the United States that have these upright MRIs and medical doctors that might be able to see this. An upper cervical chiropractor or chiropractors in general that might be able to see this.

Dr. Evans: Yeah that’s a great question and if you type in “upright MRI” all these centers will pop up. You need to call them and you need to ask them do you have an upright MRI and it’s not just fonar centers. Some of the centers for diagnostic imaging, CDI, they have one. So down in Renton, Washington close to where you’re at. That’s the only one in Seattle that I’m aware of. The closest one to us is Yonkers, New York. It used to be in out in Albany but it’s gone now so they’re rare. There’s really only less than 20 but there used to be a website. I tried to find it a second ago. I typed in upright MRI finder but if you look you might be able to find right MRI locator. There used to be a website that you could find upright MRIs for all the way around the country wherever they were at. The other website to go to is fonar.com that is the originator of the upright MRI Center and that is Dr. Ray Damadian’s company. So you can go there and if you call them they might have a locator for you. I think their phone number is on their website somewhere so you just have to look it up but that would be a good way to do that.

Dr. Leach: Got it. So in regards to the work that we do with upper cervical we feel like we could potentially help these patients. If they have a dural leak that’s
another thing but does Dr. Rosa I know he’s done a lot of research with cerebral spinal fluid flow and all these – the upright MRI. Does he have any research looking at pre and post chiari? Read that title of that book one more time.

Dr. Evans: The Craniocervical Syndrome and MRI. In this book it has pre and post images of changes of levels of tonsils. It also has changes in – with Dr. Damadian and fonar they’ve done video MRI, so MRI over time. And what they do is they’ve actually been able to finally watch the CSF flow around the body with the heartbeat and the breathing and they can actually see it get stuck in places and have eddies and swirls and that’s where we start to develop problems because of those tonsils being stuck. So he’s got videos of pre and post. They’ve got – I believe its sonar. It’s in this book where Dr. Damadian did pre and post sonars of the pinging or the banging of the CSF around in the skull and it calms after an upper cervical correction and these tonsils go back more into their normal original place after an upper cervical correction. And I’m sure that you’re seeing patients that they may not even know that they have some tonsillar issues but they have concussions and they have whiplash and they’ve just never had an image properly. Right. Same as me. Same as all the other upper cervical chiropractors across the country.

Dr. Leach: So we’re just not doing the imaging to show the pre and post but it could be potentially there?

Dr. Evans: Yeah. Yeah.

Dr. Leach: Okay fantastic. Is there anything else you want to discuss or comment about in regards to this research, about the researchers, how this is a problem, how this can help people, anything else to let people know in regards to this that could help them out?

Dr. Evans: Yeah. I think it’s really important for people to understand when you have a car accident we have seen over and over and over again the low-speed car accidents, and I know you’ve seen this too Dr. Leach I know you’ve seen this too, that low speed car accidents can cause trauma just as much as high-speed. Obviously high speed accidents are going to sprain and tear loose connective tissue but we see this in low-speed. 10 miles an hour and under it’s traumatic to the brain and the neck and this imaging and some of the other ones that we talked about, digital motion x-ray, can show that. So if you’ve had a car accident it’s important that you get your neck checked because if you don’t 10 years down the road, and I don’t know about you but I see this often, yeah I had a car accident wasn’t too bad. Oh yeah how long ago? 10 years ago. Okay what happened? Oh the car rolled over. No big deal.

Dr. Leach: Yeah.

Dr. Evans: I see it all the time. That matters. The type of accident matters. The direction your head was turned. If your head is turned in a whiplash accident, your head and neck are not meant to do this. If you this and a car accident you are, I don’t know the percentages, but it is more likely that you are going to have trauma to the ligaments, the tendons, and muscles. So it’s very important that when you get into a car accident if you have a head and neck trauma injury in sports whatever go get imaging go see an upper cervical chiropractor see someone to investigate and get you back on track because you may not even know it but there might be an underlying problem that 10 years from now is going to develop into something much worse. It’s important to take care of that one.

Dr. Leach: I agree and I think another point to emphasize is that many people after an accident number one they might just shrug it off maybe they’re a tough guy and oh I’m not gonna go get imaging and they end up being okay in the sense of they didn’t have a brain bleed or anything severe that killed them. But some people do go get checked out by the medical profession they’ll do an MRI they’ll do a CT whatever’s indicated they won’t find a brain bleed. They won’t find anything seriously life-threatening so they get released and we’re very thankful for them to do that. However, if they have a more of a mild injury that could still create issues and problems and health issues then and for the rest of their life that’s when they need to be checked out by an upper cervical chiropractic or someone who knows about this. Who understands post concussion protocol and to find answers when these symptoms don’t go away after the general 7 to 14 day concussion period. There’s plenty of more to do so anybody listening if you want to get checked by the hospital by the urgent care and you checked out and you’re still having problems long after this is something you definitely need to investigate. This is going to be on my Youtube channel and on Dr. Evans’ Youtube channel. Throw a comment down let us know where you are we’ll try to find you somebody if you can’t find anybody. But there’s a pathway of care that needs to be taken in order for you to get the corrective care that you need in order to heal from these from these injuries. And like Dr. Evans just said these low-speed accidents can really cause damage for a lot of people and people you know people might say others no damage to the car so how can there be damage to the patient. Well there’s absolutely damage and there’s plenty of research that has shown that. So definitely reach out and get some answers if you need it. And if you’re a medical provider or some other provider and you want to find a chiropractor that deals with the upper neck, the upper cervical spine, like we do by all means leave a comment get in touch with us our contact information will be below and available. For those on Youtube for the podcast we’ll try to make that available as well. Anything else?

Dr. Evans: That’s all.

Dr. Leach: Awesome. Well Dr. Evans, thank you so much for your time and we’ll do this again in a couple weeks.

Dr. Evans: Thank you, Dr. Leach.

Dr. Leach: Awesome. Thanks doc.

That’s all for this episode. Leave some comments if you have anything to say contribute or have any questions!

Dr. Kevin

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