Advanced Imaging & Chiropractic

CBCT, Chiropractic, upper cervical

Posterior view of the upper cervical region.

Here is a recent publication from the Journal of Upper Cervical Chiropractic Research by researchers Dr. Jonathan Verderame and Dr. Jake Hollowell. What makes this article impressive is that the patient was evaluated using the cone beam CT (CBCT) technology in a chiropractic setting. This is really unique and, as the article states, “the utilization of CBCT in a clinical chiropractic setting has not been explored.”

While CT is said to be an ‘extremely valuable tool’ that is a ‘widely available noninvasive modality for evaluating abnormalities of the spine’ it has never been used for bio-mechanical assessment of the occipital-atlanto-axial misalignment for chiropractic analysis.

The intervention that was provided to a 75-year-old patient that suffered from chronic migraines was a specialty in chiropractic known as Blair Upper Cervical Technique, or Blair for short. Traditionally this method of chiropractic requires various x-ray images to evaluate the structure and mechanics that are involved in the upper cervical region of the spine. With the CBCT technology, a chiropractor will not only be able to assess the alignment of the vertebrae but also be able to identify small and significant congenital or acquired anomalies that may effect the clinical recommendations of the patient.

CBCT unit by Scanora

CBCT unit by Scanora

This is a fairly new and highly specialized field in chiropractic. The CBCT is more commonly found in a dentist or orthodontist office and used to evaluate structures of the jaw and teeth. While traditional chiropractic care is excellent in caring for migraines and headaches, the research confirmed that the patient only needed two corrections in the 10 week evaluation period.  The use of such equipment in chiropractic specialties has implications that a patient may see greater improvement with less interventions. There is a potential to reach individuals with more complex conditions.

The article address the risk of radiation and states that the CBCT uses “between 98.5% and 76.2% [less radiation] compared to traditional CT.” The way this is done is by “pulsing” the radiation so the patient is not subject to it during the whole procedure. With reduced exposure to radiation and improved image for evaluation, this modality for examining the spine may prove useful in certain cases.

The drawbacks might include the cost to both the practitioner and the patient, specialized training in the use of the imaging software and patient exposure to radiation. As with everything, there’s a risk vs benefit factor.

Read full article


  • Verderame, Johnathan and Hollowell, Jake. “Cone-beam Computerized Tomography for the Bio-mechanical Assessment of the Occipito-atlanto-axial Articulation in a 75-year-old Woman with Migraines Undergoing Blair Technique” Journal of Upper Cervical Chiropractic Research. July 2013.

Induced Spinal Cord Compression in Mice

10 June 2013 1 comment

While there have been several pro-chiropractic studies demonstrating the effects of a spinal cord compression, this is a in-lab study done on mice. I am not in favor with animal testing, however this topic is so intriguing that I couldn’t pass it up. The study was designed to essentially observe the cellular effect of a chronic spinal cord compression. To a chiropractor, it is easy to understand that spinal cord compression could be caused by a misaligned vertebra, but in this study they used a artificial calcified mass that  continued to grow as the mice matured. The damaged that was caused by the compression was measured by the tissue response. You might want to catch up on your histology before reading the original.

It is also a nice coincidence that the location they decided to compress the spinal cord was at the C1-C2 region. We should all understand that the body has an intelligence that governs every function. Our body responds to the stresses it receives and compensates accordingly. For the most part, our body processes the stress and regains homeostasis. When there is a compressive force interfering with the communication in our body, it starts to break down. This may include a decreased cellular function or hypersensitivity to stress. As the compression continues to exist, the rest of the body begins to suffer from the decreased communication and compensations occur in various regions. The article demonstrates this breakdown in scientific terms and at the site of compression on a cellular level.

Cervical compressive myelopathy, e.g. due to spondylosis or ossification of the posterior longitudinal ligament is a common cause of spinal cord dysfunction. Although human pathological studies have reported neuronal loss and demyelination in the chronically compressed spinal cord, little is known about the mechanisms involved. In particular, the neuroinflammatory processes that are thought to underlie the condition are poorly understood.

I would certainly add “subluxation” to this list of common obstructions to the spinal cord. As for a correction of this compressive force, the article recommended “The only treatment available at present is the surgical removal of the cause of chronic spinal cord compression.” I agree, in part. Remove the interference and restore proper communication and function to the brain and body. In the case of a large calcified mass compressing on the cord, you might need the extreme option. It is much more likely that a misaligned bone may be causing the compression and can be removed by a skilled upper cervical doctor.

If this interest you, read the article. This study was not written by or for chiropractors, however the findings are relevant to chiropractic principles that every effect has an cause, that there can exist an interference caused by subluxation (compression on spinal cord by misaligned vertebrae), and this will cause dis-ease within the body.

Read full article headache


Case Study: Chronic Neck Pain

The purpose of this case study is to demonstrate the application of Cone Beam CT (CBCT) scan as an effective imaging method for highly specific upper cervical chiropractic corrections.

Patient History

A 38 year old male presented to the clinic with a chief complaint of neck pain that has persisted for the past 7-8 years. The pain was progressing and becoming intrusive in his desired lifestyle. The patient stated that when the pain is at it’s worst, it radiates into bilateral shoulders and arms.

The precipitating cause is unknown. However the patient did have a MVA 4-5 years prior to the onset of symptoms and has actively participated in soccer for the past 30 years and recalls several times that the symptoms have increased following games where the head was used to deflect the ball.

The patient listed several associated complaints including lightheadedness and loss of equilibrium causing the patient to stop his routine and rest until the spell has past.

The patient also describes headache symptoms of both a tension headache and classic migraine precipitated by alcohol use. Pt states 2 episodes/week. Family history includes similar symptoms of migraine headaches. There is also mid back pain localized to the thoracic/lumbar region that is most notable in the evening.

Patient utilizes pain medication to manage the neck and headache symptoms, which helps but the problem persists.

Chiropractic Exam

Flexion of the neck causes increased pain refereed to the shoulders and arms. There was a negative sharp purser orthopedic test. Left C1 – C4 point tenderness and inflammation nodules were found at the posterior lateral vertebral joints.

The patient had muscle tightness on the left side of the neck as well as multiple muscle spams of the right upper Trapezius and Levator scapulae.

Posture analysis concluded an elevated left head by 2 cm, even shoulders and a high right hip by 1 cm.

Leg length inequality check revealed a 2 cm right short leg with a positive right c2 challenge.

Cervical temperature pattern was established using a Titron thermographic instrument.

Imaging Analysis

Imaging was ordered utilizing a seated 3D CBCT unit. OnDemand3D software was used for the analysis of the images following a variation of the Blair x-ray analysis.

The Foramen Magnum/Spinal Canal study found a large right rotation of axis. This was confirmed on the 3D view. The simulated protracto views found a double posterior misalignment of atlas. An exceptionally “tilted” atlas was found on the posterior 3D view that is also observed on the frontal generated x-ray view.


Upper cervical chiropractic care following the Blair corrective protocol was elected to correct this upper cervical misalignment. Following the first correction and a 20 min rest period the thermographic scan demonstrated a change. The leg length inequality was found to be normal. The patient commented that he felt a bilateral burning sensation in the lower leg region, following the Achilles tendon.

A follow up visit two days later found the burning sensation in the lower legs continued. Cervical thermographic scan and leg length inequality tests were performed and found to negative. This means that the scan was remarkable different from the pattern that was established prior to care and the legs that were found to be uneven before care were found equal after the initial adjustment and continue to be equal 2 days later. The patient also noted a decrease in neck symptoms.

In all, 4 upper cervical adjustments were given in a 3 month period and the patient continued to improve. The patient experiences fewer and less severe episodes of lightheadedness and reports that the tension headaches have become an infrequent occurrence.


Neck pain is a common finding in the population. It is one of the main reasons people seek chiropractic care. Using a CBCT, the chiropractor will have a clearer understanding of the structures involved and be able to screen for anomalies that make some cases particularly difficult.

As with the case above, many times the cause of neck pain is unknown. It is very plausible that the case above was caused or at least exacerbated by the Motor Vehicle Accident sustained a few years earlier. It is also common to find that little traumas, such as deflecting a soccer ball with your head, can complicate and increase the intensity of the existing problem. Identifying and correcting the underlying cause will yield the best result whether that is correcting a bone, changing a habit or modifying the lifestyle.

The Holy Grail

Cross section of the spinal cord.

Cross section of the spinal cord.

If there is one thing chiropractors can agree on, it is that the nervous system can be disturbed and cause negative effects on the body. There are varying theories as to the reason for this but most chiropractors conclude it is related to the bones in the vertebral column being out of alignment. The Dentate Ligament – Cord Distortion Hypothesis is just one of those theories. This is, to some chiropractors, the Holy Grail to their rational and purpose in caring for patients.

The Dentate Ligament theory follows the premise that the spinal cord is anchored to various points in the vertebral column and chronic mal-positioning of these structures could lead to torsion of the spinal cord. The torsion on the spinal cord may irritate and cause disturbances in transmission of mental signals or impulses leading to a diverse number of symptoms to appear in the person.

If the spinal cord is directly attached to the upper cervical spine, and if the vertebra were put out of alignment, would that cause interference with the nervous system?

Dr. John D. Grostic explains in his research:

This hypothesis states that misalignments of the upper cervical vertebrae, because of their unique attachment to the spinal cord by means of the dentate ligaments, can directly stress and deform the spinal cord. Subsequently, this stress on the cord, in addition to direct mechanical irritation, may produce venous occlusion with stasis of blood and resulting anoxia in particular areas of the upper cervical cord.

Venous occlusion and stasis of blood in the cranial region is something being heavily researched for it implications on neuro-degenerative diseases such as Multiple Sclerosis and Parkinson’s Disease. This is being looked at by vascular surgeons as a possible accessory to the cause of some of these diseases.

The research identifies three “challenges” that validate the presupposition that a misaligned vertebra in the upper cervical region will cause torsion on the spinal cord rendering interference of mental impulses and demonstrating physical and/or neurological manifestations.

Challenge 1

Is the dentate ligament mechanically linked to the osseous structures of the upper cervical spine?

Challenge 2

Is the dentate ligament strong enough to deform the spinal cord?

Challenge 3

Are the osseous misalignments large enough to cause mechanical irritation to the cord?

The author relates positive findings of all three challenges, confirming the theory that the plausibility of a misalignment in the upper cervical region to cause physical and neurological disturbances in the individual.

I encourage you to read the full article to gain a better understanding of how this phenomena is explained.

Read full article


  • Grostic, John D. The Dentate Ligament – Cord Distortion Hypothesis Chiropractic Research Journal published 1988

Arnold-Chiari I Malformation

The yellow arrow indicates the herniated tonsil. This part should stay above the horizontal yellow line.

The yellow arrow indicates the herniated tonsil. This part should stay above the horizontal yellow line.

Chiari I Malformation (CMI) is a condition in which the cerebellar tonsils sink down from the cerebellum into the foramen magnum. This may affect various functions. First, this area of the body (the brainstem) is very sensitive and crowded. The sagging of the tonsils can compress these sensitive tissues or otherwise take up space impeding their function. Additionally there is a nutrient rich fluid, Cerebral Spinal Fluid (CSF), which flows out of the ventricles and baths the brain and spinal cord. As there is not blood circulating the inner brain and spinal cord, CSF provides nutrients to this area. As these tonsils start to droop or sag, they stop up the fluid like a cork in a wine bottle. This decrease in CSF movement to the rest of the spinal canal may also keep the spinal cord from receiving sufficient nutrients giving rise to a variety of symptoms.

From the abstract of one article, “The diagnosis and management of Chiari I malformations (CMI) remains controversial, particularly since it is often an incidental finding on cervical MR scans performed for neck pain and/or headaches.”

Because the cerebellum is in the cranial vault, traditional treatment options have been few and extremely invasive. The goal of surgical interventions, as the article states, is to “restore normal CSF flow dynamics at the craniocervical junction, and hence, decrease the signs and symptoms attributed to CMI”. The goal is spot-on, but the methods are risky at best.

One treatment commonly employed is a craniectomy. This is a removal of part of the patients skull in an attempt to reroute the fluid. Another procedure is to remove the posterior portion of the first two vertebra allowing the CSF to detour around the herniated tonsils.

chiari malformation

“Posterior fossa decompression surgery is performed on adults with [Chiari I Malformation] to create more space for the cerebellum and to relieve pressure on the spinal column. Surgery involves making an incision at the back of the head and removing a small portion of the bottom of the skull and sometimes part of the spinal column to correct the irregular bony structure. The neurosurgeon may use a procedure called electrocautery to shrink the cerebellar tonsils. This surgical technique involves destroying tissue with high-frequency electrical currents.”

Wow! I thought cave men were barbaric when they were said to have bored holes in their heads to relieve pressure. This goes one step further by literally frying or cauterizing tissue. We are talking about a persons brain! Unfortunately, essential anatomy is overlooked in favor of attempting to bypass the problem, and in the process, creating new ones. The skull is protecting the brain. How many times have you hit the back of your head? Simple put, you need your skull.

There is an alternative way to manage this “irregular bony structure”. A traditional chiropractic manipulation of the neck is not advised. A Chiari Malformation is contraindicated for general chiropractic and could lead to serious injury. However, a specific chiropractor that has training beyond normal curriculum in the upper cervical spine may be able to help. This chiropractor will complete a thorough exam and take appropriate imaging of the neck, in addition to the imaging that may have already been taken. If there is any twisting or cracking of the neck, you know you’re not in the right place.

Complex anatomy of the upper cervical spine. (Image by Danny Quirk)

Complex anatomy of the upper cervical spine. (Image by Danny Quirk)

An upper cervical chiropractor understands the relationship of the various structures surrounding the upper cervical spine. This doctor can accurately analyze and correct the misalignment of the first vertebra with a light maneuver. Some upper cervical chiropractors use an instrument to align this vertebra. The additional imaging is to see exactly how the vertebrae are misaligned. This is essential to know before any correction is to be performed.

As the structures of the upper cervical spine are put into proper alignment, the mechanical plug of the cerebellar tonsils may release and relieve the area of pressure. The body will then begin to heal and respond positively so long as the correct alignment is maintained.

Additional Resources

Smith, JL. Effects of upper cervical subluxation concomitant with a mild Arnold-Chiari malformation: a case study.  Chiropractic Research Journal, 1997;4(2):77-81

Baisden J. Controversies in Chiari I malformations. Surgical Neurology International 2012; 3:232-7.

York, Craig. Video: Chiari 0 Case Study., June 2011

A Case For Improved Headache Evaluation

Several causes of headaches relate to the alignment of the first two bones of the neck.

Headaches, in general terms, lie on a spectrum from an occasional annoyance to debilitating and causing loss time at work and enjoying family. Headaches come in all shapes and sizes and so do the treatments. There have been studies demonstrating the effectiveness of many types of treatments.

First off, we need to agree that a normal headache does not exist. Headaches are alarms telling you that something is amiss in your body. This could be as subtle as not drinking enough water to experiencing a stroke. If you have headaches, even if they are just occasional, understand that this is not a normal function of the body.

In the study published in the “Headache: The Journal of  Head and Face Pain” on chronic headache due to hypertonic muscles that attach to the dura matter, a surgical intervention was performed to sever the muscles from the spinal cord. The article explains a normally occurring muscle in the sub-occipital region attaches to the spinal cord. The patient, 35 year old male, had a traumatic incident and subsequent tightness of this muscle putting tension and distortion on the spinal cord/brainstem and causing symptoms of a headache. It was noted that since the incident, the patient had developed a poor immune response as evidenced by the frequency of respiratory and intestinal infection.

The intervention was to surgically sever the tight muscle in hopes that this would relieve the tension and torsion on the spinal cord/brainstem and decrease the severity of the headaches. While the intervention was successful in the sense that the muscle was severed and the patient recovered from surgery, the headaches lessened only in intensity, not in frequency. Common side effects of such procedures are described as “post operative headaches”.

The patient’s complaint persists and is a failure on the part of the exam doctor to understand the anatomy and the mechanics involved. The other attachments of this muscle are on the back of the skull and the first bone in the neck – Atlas. It is very probable and likely that during the traumatic incident that the Atlas became misaligned and torqued, a condition called an upper cervical subluxation, pulling on the muscle and various other structures causing distortion of the spinal cord/brainstem. This is evidenced by several features common in an upper cervical subluxation: sudden onset of headaches following a traumatic incident, tight sub-occipital muscles due to misalignment of bone structures, decreased immune response owed to reduced communication of the brain to the body.

Various structures are affected by an upper cervical subluxation.

This is further demonstrated by a failure to only partially reduce the symptoms of a headache. The procedure eliminated one instigating agent but did not address the various other factors of an upper cervical subluxation, so the patient would not be able to fully heal. There is so much happening at this location with skeletal, ligamentous and muscular tissue not to mention the nervous tissue that carries body intelligence to every part of your body. An appropriate evaluation of this area is essential to proper treatment of upper cervical subluxation for the best patient care.

Effective upper cervical care can be accomplished and thousands of patients have been helped by removing the causative agent of many types of headaches. This is done without exposing the patient to chemical drugs, surgery, or other lengthy procedures. Not only do the symptoms subside, the effect is realized throughout the entire body improving the immense response and decreasing blood pressure in many cases. Headaches do not need to interfere with your quality of life. Check out the links on the right for other research and testimonies of patients with headaches and become informed of your treatment options.

Another popular management option that does not address the cause of the symptoms is medication. Medication may silence the symptoms, but the inciting problem persists and you can expect the symptoms to return. The liver and kidneys take the brunt of the effects of the medication and there are almost always negative events in response to these chemicals.

Again there is no such thing as a normal headache. Turning off the alarm without addressing the fire will only result in ashes.

Natural Treatment for Hypertension

5 April 2012 1 comment

As I started to read an article on hypertension and upper cervical care from the Journal of Human Hypertension, the very first sentence of the abstract struck me as eye opening and I re-read it to absorb it meaning. “Anatomical abnormalities of the cervical spine … associated with relative ischaemia of the brainstem circulation…” What?! I knew that blood pressure is commonly decreased with upper cervical care but I had no idea ischemia or inadequate blood flow was taking place – at the brainstem no less. If there is and part of your body that you want continuous blood flow to, it’s your brain.

Lets look at the anatomy involved:

So how does a misalignment cause increased blood pressure? I am not 100% sure and the study was not helpful in discovering an exact explanation. The study did hypothesis that there would be a concurrent drop in heart rate with the correction of the misalignment which was not the case. If this had occurred, then that would lead to suspicion of sympathetic involvement and blood vessel control. There may yet be a neurological component but it is clear that a mechanical decrease of blood flow is possible with the tortuous path of the vertebral artery and all the dynamic anatomy surrounding it.

The presentation of this study, albeit small sample size(n=50), follows the traditional methodology of medical research, double blind and use of a placebo group. During the study no hypertensive medication was taken by either group. The intervention included a NUCCA evaluation (described in the article) and NUCCA adjustment of the Atlas vertebra. The outcome was that the treatment group had a decrease in systolic blood pressure by more than 13 points and a 7 point drop in diastolic blood pressure.

Interestingly, the criteria for a new antihypertensive drug to be cleared by the FDA is that it lowers diastolic blood pressure by at least 5mmHg and free of serious side effects. This part sums up the application of this research in a nutshell:

“The improvement in BP following the correction of Atlas misalignment is similar to that seen by giving two different antihypertensive agents simultaneously. Moreover, this reduction in BP persisted at 8 weeks and was not associated with pain or pain relief or any other symptom that could be associated with a rise in BP.”

Some related studies show that 90.6% of people that suffer hypertension have compression of the vertebral artery at the level of Atlas. This is an option for anyone that is hypertensive or even borderline hypertensive to help regulate your blood pressure and health.

Other natural consideration in addition to upper cervical care that have shown to help decrease blood pressure are: exercise, improve quality of diet, fish oil supplement, weight loss, decrease stress and avoid tobacco & alcohol.

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