CASE STUDY. Resolution of Trigeminal Neuralgia in a Patient Undergoing Atlas Orthogonal Chiropractic Care: A Case Report ABSTRACT

Transcription

1 CASE STUDY Resolution of in a Patient Undergoing Atlas Orthogonal Chiropractic Care: A Case Report Matthew Sweat D.C. 1 & Stephen S. Wallace, D.C. 2 ABSTRACT Objective: To report on the effectiveness of Atlas Orthogonal (AO) chiropractic in the management of an upper cervical subluxation for a patient with trigeminal neuralgia (TN). Clinical Features: A 54-year-old male presented with right-sided facial pain along the distribution of the mandibular branch of the trigeminal nerve for the past 5 years. The patient also has a secondary complaint of lower cervical stiffness which he attributes to a skiing accident. Following digital palpation, comparative leg length analysis, and radiographic examination it was determined that the patient had an atlas subluxation with a left anterior listing. Intervention and Outcomes: Two days following the initial AO adjustment to the atlas, the associated TN pain reduced significantly. After one month under AO care the patient no longer experienced any pain associated with TN. Conclusion: AO needs to be recognized as an initial approach for the immediate and long-term relief of TN. The relationship between an upper cervical subluxation and the referral of pain from the trigeminocervical nucleus to the distribution of the trigeminal nerve is discussed. Key Words: Upper cervical chiropractic, Atlas Orthogonal, upper cervical subluxation, trigeminal neuralgia, mandibular branch, atlas subluxation, trigeminocervical nucleus, trigeminal nerve Introduction (TN) is considered one of the most debilitating facial pain syndromes. 1 The severity of TN is such that it is often referred as the suicide disease because many people who suffer from this disease often contemplate suicide. As many as half of the people who have had TN for 3 years committed suicide. 2 TN is characterized by severe unilateral paroxysmal facial pain restricted to the distribution of the trigeminal nerve, most commonly involving one or both of the mandibular or maxillary branches and rarely the 1. Private Practice of Chiropractic, Tucker, GA 2. Private Practice of Chiropractic, Grove City, OH ophthalmic branch. It also usually affects the right side of the face as opposed to the left. 3 In a study consisting of 411 patients, 246 had right-sided pain, 143 patients had left-sided pain, and 12 had bilateral pain. The pain was usually along the maxillary and mandibular branches, with 40 patients having pain over the entire trigeminal nerve distribution and only eight patients having pain over the ophthalmic branch only. 4 These pain attacks are usually stimulated by physical irritation within the distribution of the trigeminal nerve. Common activities of daily living that routinely cause an attack include J. Upper Cervical Chiropractic Research May 31,

2 shaving, applying makeup, brushing your teeth, or washing your face. The pain can also be evoked by the slightest stimulation such as a draft. Movements of the face such as talking, chewing, or drinking also trigger attacks. 3,5 Patients often describe these attacks as a sudden shock like sensation that occur at the same area of the face and are recurrent, and progressively become more frequent and worse. The pain usually occurs over a period of weeks or months, and then disappears altogether for months to years. 5 Aretaeus of Cappadocia wrote the earliest descriptions of TN in the second century AD. He describes TN as a headache in which spasm and distortion of the countenance take place. 6 There are descriptions of TN written in Arabic that date back to and one of its the first known treatments occurred in 1677 when sulfuric acid was applied to a Duchess to treat her TN. 7 Of all the facial neuralgias, trigeminal neuralgia is also considered the most common. 3 The average annual incidence rate of facial pain is 38.7 patients per 100,000 population with trigeminal neuralgia occurring in 12.6 patients per 100,000 population. Women are 4 times more likely to be affected than men with the incidence rates increasing with age. The peak incidence occurs at years of age and TN is unusual before the age of Earlier studies report the annual incidence of trigeminal neuralgia was 4.3 per 100,000 population, with the overall annual rates for women and men being 5.7 and 2.5 per 100,000 population respectively. The rates for both sexes increased with age with a peak incidence occurring between years of age. TN was found to be unusual before the age of There is no single test that can accurately diagnose TN, so a thorough history is the most important factor in making a diagnosis. 6 The International Headache Society (IHS) has published diagnostic criteria for classical and symptomatic TN. Classical TN demonstrates a refractory period when pain can not be triggered following a pain attack and is caused by compression of the trigeminal root by blood vessels. Symptomatic TN demonstrates no refractory period after an attack and is the result of something other than vascular compression, including a tumor or multiple sclerosis. 9 IHS diagnostic criteria for Classical TN: 9 1) Paroxysmal attacks of pain lasting from a fraction of a second to 2 minutes that affect one or more divisions of the trigeminal nerve. 2) Pain has at least one of the following characteristics: a) intense, sharp, superficial, or stabbing. b) precipitated from trigger areas or by trigger factors. 3) Attacks are stereotyped in the individual patient. 4) There is no evident neurological deficit. 5) Not attributed to another disorder. IHS diagnostic criteria for Symptomatic TN: 9 1) Paroxysmal attacks of pain lasting from a fraction of a second to 2 minutes that affect one or more divisions of the trigeminal nerve. 47 J. Upper Cervical Chiropractic Res. May 31, ) Pain has at least one of the following characteristics: a) intense, sharp, superficial, or stabbing. b) precipitated from trigger areas or by trigger factors. 3) Attacks are stereotyped in the individual patient. 4) It is caused by something other then vascular compression. Although a clinical diagnosis of TN is dependent on a history it is important for all patients to have a magnetic resonance imaging (MRI) scan of the brain to rule out any intracranial abnormality other then vascular compression of the trigeminal root. Other causes of TN are multiple sclerosis (MS) or a brain tumor, both of which can be identified by MRI. 10 Excluding vascular compression of the trigeminal nerve advanced intracranial imaging (Computed Tomography, MRI) identified a structural cause in up to 15% of patients previously diagnosed with TN. 11 The majority of cases of TN are caused by compression of the trigeminal nerve root by a blood vessel near its entry point into the pons. 5 This vascular compression results in the demyelination of the trigeminal nerve root immediately beneath the compression causing hyperactivity of the trigeminal nerve. Hyperactive dysfunction of the trigeminal nerve triggers the nerve to react to stimulation it normally wouldn t react to resulting in the paroxysmal episodes of pain. 2 There is also evidence of focal remyelination at the area of impaction,which could explain why patients with TN experience long periods of remission. 5 Of 411 patients with classical TN who underwent surgery to decompress the vasculature on the trigeminal nerve root a total of 398 had significant improvements following microvascular decompression (MVD) of the trigeminal nerve. 4 Eliminating the vascular compression, resulting in relief in the majority of these patients provides ample evidence that vascular compression commonly causes trigeminal neuralgia. This study also showed that over 80% of the cases involved arterial compression. 4 A study involving patients with arterial neurovascular compression demonstrated that the superior cerebellar artery was at fault in 25 of the 30 patients (83.3%). 12 The symptom relief with MVD, and the high percentage of arterial involvement especially with the superior cerebellar artery is consistent with other studies. Along with detecting specific pathologies that cause symptomatic TN, MRI has also been used to identify vascular compression of the trigeminal nerve in order to predict surgery outcomes. 6,10 However, the sensitivities and specificities in studies determining the accuracy of MRI in detecting neurovascular compression has been inconsistent, therefore the evidence is insufficient to defend or disprove the usefulness of MRI to identify neurovascular compression. 11 Since there is no treatment that has a 100% success rate in curing TN, its management initially consists of symptom relief with the use of pharmacological intervention. Carbamazepine is used as the drug of choice, and it appears that it can reduce the pain associated with TN in about 70% of patients. 7 Similar success rates were seen with oxcarbazepine. 11 Baclofen, lamotrigin, and pimozide are possibly effective for controlling pain in patients with TN. 11 Other medications that have been used, but have yet to be proven effective include clonazepan, gabapentin, tizanidine, topical capsaicin, and

3 valproate. 11 When pain relief is not sufficient enough with carbamazepine or side effects arise the other drugs listed above are usually substituted or added, and a review of the diagnosis should be implemented. Disorders that can be listed in the differential diagnosis include giant cell arteritis, cluster headaches, migraines, paroxysmal hemicranias, tempromandibular joint syndrome, dental pain, glossopharyngeal neuralgia, and nervus intermedius neuralgia. 7 If pharmacological intervention is unsuccessful or the side effects outweigh the benefits then surgery can be performed. There are currently five surgical possibilities, including surgical microvascular decompression (MVD), stereotactic radiation therapy/gamma knife, percutaneous balloon microcompression, percutaneous glycerol rhizolysis, and percutaneous radiofrequency (RF) treatment of the Gasserian ganglion. 7 Of these five techniques MVD is the most recommended in the medical field. During MVD, the trigeminal nerve is separated from the adjacent blood vessels at the nerve-pons junction by placing a piece of shredded Teflon felt between the suspected blood vessel and nerve. 6 In a study of 1,185 patients who underwent MVD for treatment of TN, 70% had excellent results ten years after surgery. Complications in this same study included death (0.2%), brain stem infarction (0.1%), and ipsilateral hearing loss, (1%). 13 Other complications include cerebral spinal fluid leaks, infarcts, hematomas, aseptic meningitis, diplopia, facial weakness, and sensory loss. 11 The less invasive procedures such as the percutaneous techniques are usually recommended for individuals who have a higher risk of mortality following MVD. Despite the low risk of side effects the percutaneous techniques are less likely to cause long lasting relief, and more likely to result in sensory loss. It has been reported that almost 50% of patients undergoing percutaneous techniques had sensory loss following these procedures, and as low as 50% of the patients will be pain free after 3 years post surgery. 11 Within the chiropractic profession there are several claims of successfully treating TN but very few peer-reviewed studies have been written. After searches of several databases 3 full text peer-reviewed studies were located, all of which are case reports. 2,14,15 A case study involving a 57-year-old female underwent chiropractic care to treat her TN after experiencing it for 2 years. After one week of cervical adjustments the patient reported her symptoms to have been considerably reduced in frequency and intensity, and after two years of chiropractic care she is completely pain free. 2 A second case study involved a 56-year-old female who underwent chiropractic care to treat her TN after experiencing it for about 6 years. After about a week of cranial, upper cervical, thoracic, lumbar chiropractic adjustments, and soft tissue therapy the patient reported having a reduction in intensity of pain, and the pain was isolated to a single area. After 3 months the patient revealed she was no longer experiencing any symptoms related to her TN. Eighteen months following the patients last chiropractic treatment she experienced a severe attack. She sought the help of a medical practitioner because her chiropractor had retired. 14 The third study involved a 68-year-old female who had been suffering from TN for over 7 years after a surgical resection of a brain tumor. After several interventions failed to give her long-term relief from her TN she decided to get help from a chiropractor. In addition to chiropractic adjustments to the cervical spine she was also treated with soft tissue therapy, cervical exercises, and ultrasound of the cervical muscles. A week following her first treatment the patient reported a 50% improvement. Over a month of using the same therapies and adjustments of the temperomandibular joint the patient reported having a 75% improvement in symptoms. After 18 months of treatment the patient hasn t had any significant head or face pain for over the past 4 months. 15 The purpose of this study is to report the effectiveness of the upper cervical chiropractic technique Atlas Orthogonal (AO), in the treatment of an upper cervical subluxation for the relief of TN. Chiropractic Philosophy The practice of chiropractic is centered around the correction of the vertebral subluxation. A subluxation is a vertebra that has lost its normal position in relation to adjacent vertebrae resulting in the compression of nervous tissue. When a subluxation disrupts the nervous system it compromises neurological communication resulting in a variety of health problems. In Rydevic s study on the effects of nerve root compression, he discusses the functional changes that occur to the nerve root when it is compressed or chemically irritated and how the body reacts to these changes. First nerve root compression/irritation may compromise nerve function resulting in sensory loss or muscle weakness. Secondly, the nerve root may become hyperirritable causing it to react to the slightest stimulus resulting in pain. 16 Three different types of stress can cause a subluxation. The most common is physical stress, which includes traumas, or repetitive micro traumas. Mental stress is an example of emotional forces that cause subluxations. Chemical stresses can also cause subluxations and these include drugs, and poor diet. A chiropractor s goal is to correct a subluxation by applying a detailed force to a specific vertebra in order to reduce the subluxation that is hindering the nervous system, resulting in improved health. Atlas Orthogonal The technique (AO) utilized in this study is an upper cervical specific technique that limits its application to the first cervical vertebra commonly known as atlas. The atlas is located directly beneath the head connecting the head to the vertebral column. The location of the atlas makes the body especially susceptible to illness because the brainstem unites the brain with the spinal cord at the area of the atlas. Not only is the J. Upper Cervical Chiropractic Research May 31,

4 brainstem at a potential risk to a misaligned atlas but so is the brain s major blood supply, the vertebral artery. The vertebral artery ascends through the transverse foramen of C1- C6. Before the artery enters the cranium through the foramen magnum it courses in a groove on the posterior arch of the atlas. 17 At the location of the posterior arch, the vertebral artery is at its most vulnerable to the slightest atlas subluxation. The atlas is also unique from other vertebrae because it relies upon soft tissue to maintain its orthogonal/neutral position; therefore, the atlas is at more risk to misalignment when compared to other vertebrae that interlock with one another to maintain alignment. 18 AO was developed by Dr. Roy W. Sweat, who is considered one of the leading authorities in health care on the upper cervical spine. He developed this technique based on the work of Dr. John F. Grostic whose x-ray and supine leg check analysis procedures have become the basis of many upper cervical chiropractic techniques. 19 AO uses a low force, high velocity percussion-adjusting instrument that contacts the skin overlaying the atlas transverse process with a stylus in the styloid fossa posterior to the ramus of the mandible. 20 The adjustive force administered to the atlas transverse process by the stylus is approximately 2.7Kg. 20 With the patient in a side lying position their mastoid process opposite of the atlas listing contacts a mastoid support located on a tiltable headpiece. The mastoid support is used to prevent the head from moving when the adjustment is given. 21 During the adjustment a solenoid located in the head of the AO percussion-adjusting instrument transmits a mechanical impulse that sends a percussion force to the atlas causing it to move. 21 The AO procedure used to determine the presence of an upper cervical subluxation includes digital palpation of the cervical spine, a supine leg length assessment, and radiographic analysis. Scanning palpation involves assessment of the suboccipital neuromusculature specifically the C1 and C2 spinal nerve ganglions, and includes both objective and subjective findings. Objective findings include muscular spasms, muscle contractions, edematous swelling, or osseous protrusions. Subjective findings include tenderness, pain, hypersensitivity, hyperirritability, and neurological insult. 22 The objective findings are graded according to degree of severity during the initial exam, before the adjustment, and after the adjustment to determine the presence of a subluxation and whether an adjustment is warranted. A grade 0 indicates no palpable findings, grade 1 indicates mild palpable findings, grade 2 indicates moderate palpable findings, and a grade 3 is established when the palpable findings are severe. After the adjustment there is a consistent reduction in both objective and subjective findings, and the established pre-adjustment grade. A study involving 30 patients presently experiencing neck pain were assessed to determine the interexaminer reliability of manual palpation for cervical spine tenderness. This study demonstrated that there is good interexaminer reliability for the identification for specific points of tenderness along the cervical spine. 23 Another criteria used in AO to determine if a subluxation is warranted and whether an adjustment should be administered to the patient is a comparative supine leg length examination. As is the case with scanning palpation the leg length assessment also helps determine the effectiveness of the adjustment, and whether or not another adjustment is needed. Grostic s Dentate Ligament Cord Distortion Hypothesis helps explain the mechanism behind a functional short leg. According to this hypothesis a subluxation at atlas or axis (C- 2), because of their unique attachments to the spinal cord by means of the dentate ligament, can directly place stress on the spinal cord resulting in the hypertonicity and spasticity of the lower extremity and pelvic girdle muscles. 24 This increased muscle tone may cause pelvic distortions manifesting as a functional short leg. 24 In the AO program, the acceptable margin of error for any observed leg length difference from side to side is a total of 1/8 of an inch. 21 The supine leg length comparison is performed during the initial examination, and after each adjustment. To assist identifying and measuring the leg length difference a leg-check grid with lines spaced ¼ of an inch apart at the bottom of the AO table is used. 21 To properly identify and correct an upper cervical subluxation the AO procedure requires five cervical radiographs to be taken before the adjustment, and three immediately after the initial adjustment in order to identify the accuracy of the first adjustment. The required pre-adjustment cervical radiographic views include a sagittal (lateral), frontal (nasium), horizontal (vertex), AP open mouth (APOM), and AP lower cervical (APLC). The required post-adjustment cervical radiographic views include a sagittal, frontal, and horizontal. When line analysis of the five pre-adjustment radiographs reveals a subluxation of the atlas, an adjustment is administered in order to restore the orthogonal relationship of the atlas. 19 The atlas is said to be orthogonal when it is oriented in a right angle to the spine, and is the goal of the AO adjustment. 22 The sagittal radiograph is required to determine the tube tilt needed to properly take the frontal radiograph. It is also used to evaluate any osseous anomalies, fractures, or pathologies. The frontal and horizontal radiographs determine the extent of the atlas subluxation in the z-axis and y-axis, respectively. The frontal radiograph determines the angle used to determine the Z-vector for correction set on the AO instrument. While the horizontal radiograph provides the Y-vector for correction set on the AO instrument. The accuracy of these vectors is crucial because each establishes the line of drive of the adjustment administered to the patient. The APOM radiograph is used to accurately measure the true axis circle and to view the axis spinous process and the odontoid process. The APLC radiograph is used to view the lower five cervical vertebrae and the most superior thoracic vertebrae. 21 A study involving 6 chiropractors determined the inter- and intra- examiner reliability of upper cervical x-ray marking is very good by observing 30 nasium/horizontal radiographs. 25 This is of 49 J. Upper Cervical Chiropractic Res. May 31, 2012

5 particular importance to the AO analysis procedure because one of the most controversial factors involving AO is the analysis of the horizontal radiograph. Each visit following the initial adjustment includes both digital palpation of the sub-occipital musculature, and a comparative leg length analysis. An adjustment is warranted only if the objective findings determined by these two procedures indicate an atlas subluxation is present. Case Report History A 54-year-old male presented with right-sided facial pain along the distribution of the mandibular branch of the trigeminal nerve for the past 5 years. Four years prior he had been diagnosed with TN after evaluation by a neurologist. The neurologist had the patient undergo a cranial MRI which excluded any tumor or lesion. The patient described the pain as being electrical and shock like in nature and was aggravated by talking, chewing, touch, wind currents, and sometimes was spontaneously triggered. Drinking water actually helped prevent attacks. Each episode lasted a fraction of a second to a minute and would occur times per day. The patient s exacerbation period usually lasted 5-6 months, while the remitting period usually lasted 2-3 months. The current exacerbation period had lasted 7 months. The patient reported the episodes initially were not as frequent, intense, or lingering as they are now. Evaluating the pain on a scale, which ranged from 0 (no pain) to 10 (worst pain ever experienced). He rated the pain 5 years ago as a 5/10, and currently a 10/10. The patient had a secondary complaint of lower cervical stiffness from a skiing accident that had successfully been reduced by another chiropractor practicing diversified technique. He did not receive any immediate medical attention as a result of this accident. The patient had been prescribed carbamazepine (400mg a day) by a neurologist, which he took to help manage the pain associated with his TN. He reported the medication helped reduce the intensity of the pain, but did not reduce the frequency or duration of the attacks. A neurologist suggested that they increase the dosage or even try another medication along with the carbamazepine because of the severity of the patient s current episode. Examination Chiropractic examination revealed the patient had a grade 3 objective rating of both the right and left C2 spinal ganglion upon digital palpation of the sub-occipital neuromusculature, and his right leg was short by ¾ of an inch relative to the left leg. After analysis of the patient s five pre-adjustment cervical x-rays it was determined that atlas had rotated anteriorly on the left in the horizontal plane, and it was elevated on the left in the frontal plane. These radiographs also showed ossification of the atlanto-occipital ligament indicating a posterior ponticle of atlas. Loss of disc space, end plate sclerosis, and osteophyte formation at the C4-C5 and C5- C6 levels was seen indicating intervertebral osteochondrosis. A slight cervical kyphosis was also noted. Intervention Following the initial chiropractic examination it was determined the patient had an atlas subluxation with a left anterior listing. His atlas was adjusted using the AO instrument by contacting the left atlas transverse process with the patient resting his right mastoid process on the mastoid support by lying in the right lateral recumbent position. The Z and Y vectors set on the AO instrument were 25 and anterior 15, respectively. Following each AO adjustment the patient was required to rest for 5 minutes in the supine position before the post adjustment leg length assessment and digital cervical scan. Outcomes After the patient rested for five minutes his supine leg length assessment revealed his legs were even and a grade 1 was established for both C2 spinal ganglion. These postadjustment findings determined the adjustment was effective and post-adjustment radiographs could be taken. The results of the post-adjustment radiographs supported the post-objective findings in that the adjustment of atlas was successful. The sagital radiograph demonstrated a slight increase in cervical lordosis (Figure 1). The frontal radiograph showed the atlas was more level (Figure 2). The horizontal radiograph demonstrated a decrease in anterior rotation of the atlas (Figure 3). The following day the patient came to the clinic for reevaluation. He said that both the intensity and duration of his attacks had decreased and he gave a current rating of his pain as 6/10. Objective evaluation revealed his legs were even in the supine position and a grade 2 for both C2 spinal ganglions. These findings determined the atlas was in alignment and an adjustment was not warranted. However, the patient still had stiffness in his lower neck. The patient came to the clinic two days following his previous visit for another re-evaluation. During the visit the patient said that not only were his symptoms associated with TN improved, but his neck stiffness and cervical range of motion had improved as well. One month, 7 visits, and 3 adjustments after the patient s initial chiropractic exam the patient revealed he no longer was experiencing any attacks associated with his TN and he no longer needed to take his medication (carbamazepine). He also continued to have improvements with his neck stiffness. Twelve weeks following his initial visit the patient still hadn t experienced a pain attack and he was rarely having problems with neck stiffness. The results of the pre- and post- objective findings are listed in Table 1 and Table 2. Discussion If an adjustment of the atlas has the ability to reduce or resolve J. Upper Cervical Chiropractic Research May 31,

6 the symptoms associated with TN there needs to be a structural cause of pain in the cervical region as well as a pathway that can refer pain sensations from the cervical region to the distribution of the trigeminal nerve. The structural cause was indicated through the radiographic analysis of the patient s cervical spine. These radiographs indicate a left anterior atlas misalignment, and degenerative changes throughout the cervical region. The correction of atlas to a more orthogonal position demonstrated on the post-adjustment radiograph, and the immediate relief the patient reported following the adjustment also helps support the adjustment as responsible for the reduction in pain The pathway that refers pain from the cervical region to the face along the trigeminal distribution begins with the trigeminocervical nucleus. The trigeminocervical nucleus is located in the upper cervical region where sensory fibers from both the trigeminal nerve and first three cervical spinal nerves interact. This link of sensory input holds the trigeminocervical nucleus responsible for all nociceptive stimuli from the face, upper cervical region, head, and 15, 26, 27 throat. The sources of upper cervical pain include the occipitalatlanto-axial joint, the zygapophyseal joints extending down to C3-C4, vertebral artery, C2-C3 IVD, dura mater, prevertebral skeletal muscle, and postvertebral skeletal muscle. 27 Noxious stimuli affecting any of the previous sources stimulates the cervical spinal nerves to convey nociceptive input to neurons in the trigeminocervical nucleus. In addition to cervical spinal nerve sensory input some of these neurons also receive sensory input from the trigeminal nerve. According to Bogduk, these are second order neurons that are unable to distinguish cervical spinal nerve input from trigeminal input. 27 Therefore nociceptive input coming from the upper cervical region may be perceived as coming from the trigeminal nerve resulting in referral of pain to distributions of the trigeminal nerve. In the case of the patient reported on in this study, it is theorized that he suffered a subluxation of his atlas after a ski accident in which he hit the back of his head on a stump. The subluxation initially resulted in neck pain but because the primary subluxation (atlas) wasn t completely corrected it eventually referred the pain to his face resulting in TN. The pain was referred to his face from the upper cervical region because the trigeminocervical nucleus misinterpreted the nociceptive input coming from cervical spinal nerves as coming from the trigeminal nerve. As a result, nociceptive pain was referred to the regions of the face supplied by the trigeminal nerve. Conclusion AO is an effective, affordable, and safe procedure for the management of vertebral subluxation and associated neurological disorders and needs to be recognized as an initial approach for the immediate and long term relief of TN. The preferred methods of treatment for TN in the medical profession include pharmacological intervention, and surgery. These approaches have proven to be ineffective especially over the long term for the management of TN. These medical 51 J. Upper Cervical Chiropractic Res. May 31, 2012 treatments also place the patient at risk to a multitude of serious side effects which is not the case with AO. In order to determine if there is a direct correlation between the chiropractic adjustment and the relief of symptoms this study needs to be conducted over a longer period of time because of the remission periods typically associated with TN. The use of a single subject also makes it difficult to assume the adjustment is the only factor that resolved the patient s TN. To determine if there is a relationship between an upper cervical subluxation and the referral of pain from the trigeminocervical nucleus to the distribution of the trigeminal nerve further research needs to be conducted. References 1. Koopman JS, Dieleman JP, Huygen FJ, De Mos M, Martin CG, Sturkenboom MC. Incidence of facial pain in the general population. Pain Dec 15;147(1-3): Burcon MT. Resolution of trigeminal neuralgia following chiropractic care to reduce cervical spine vertebral subluxations: a case study. J Vert Sublux Res Oct 26: Bagheri SC, Farhidvash F, Perciaccante VJ. Diagnosis antreatment of patients with trigeminal neuralgia. J Am Dent Assoc Dec;135(12) Jannetta PJ. Neurovascular compression in cranial nerve and systemic disease. Ann Surg. 1980;192(4): Love S, Coakham HB. Trigeminal neuralgia: pathology and pathogenesis. Brain. 2001;124(12): Nurmikko TJ, Eldridge PR. Trigeminal neuralgiapathophysiology, diagnosis and current treatment. Br J Anaesth Jul;87(1): Van Kleef M, van Genderen WE, Narouze S, Nurmikko TJ, van Zundert J, Geurts JW, et al. 1. Trigeminal neuralgia. Pain Pract Jul- Aug;9(4): Katusic S, Beard M. Bergstralh E, Kurland LT. Incidence and clinical features of trigeminal neuralgia, Rochester, Minnesota, Ann Neurol. Jan;27(1): International Headache Society Classification Subcommittee. The International classification for headache disorders: 2 nd edition. Cephalalgia. 2004;24: Krafft RM.. Am Fam Physician May 1;77(9): Gronseth G, Cruccu G, Alksne J, Argoff C, Brainin M, Burchiel K, et al. Practice parameter: the diagnostic evaluation and treatment of trigeminal neuralgia (an evidence based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the European Federation of Neurological Societies. Neurology Oct 7;71(15):

7 12. Chun-Cheng Q, Qing-Shi Z, Ji-Qing Z, Zhi-Gang W. A single-blinded pilot study assessing neurovascular contact by using high-resolution MR imaging in patients with trigeminal neuralgia. Euro J Radiol Mar;69(3): Barker FG 2 nd, Jannetta PJ, Bissonette DJ, Larkins MV, Jho HD. The long-term outcome of microvascular decompression for trigeminal neuralgia. N Engl J Med Apr 25;334(17): Pederick FO. Cranial and other chiropractic adjustments in the conservative treatment of chronic trigeminal neuralgia: a case report. Chiropr J Aust Mar;35(1): Rodine RJ, Aker P. Trigeminal neuralgia and chiropractic care: a case report. J Can Chiropr Assoc Sep;54(3): Rydevik BL. The effects of compression on the physiology of nerve roots. J Manipulative Physiol Ther Jan;15(1): Moore KL, Dalley AF. Clinically Oriented Anatomy. 5 th ed. Baltimore: Lippincott Williams & Wilkins; p. 18. Bakris G, Dickholtz M, Meyer PM, Kravitz G, Avery E, Miller M, et al. Atlas vertebra realignment and achievement of arterial pressure goal in hypertensive patients: a pilot study. J Hum Hypertens May;21(5): Sweat RW, Sweat MH, Nygarrd D, Ellwood J. An Atlas Orthogonal Technique method of transforming between inches and degrees for practitioners applying the Grostic method of analysis and vertebral listings. J Vert Sublux Res Dec;2(4): Hannah JS. Changes in systolic and diastolic blood pressure for a hypotensive patient receiving upper cervical specific: a case report. Chiropr J Aust Sep;39(3): Sweat RW, Sweat MH, Shoener EM, Sweat T. Atlas Orthogonal Chiropractic Program. 6 th ed. Atlanta: RW Sweat Foundation; 2007: Khorshid KA, Sweat RW, Zemba DA, Zemba BN. Clinical efficacy of upper cervical versus full spine chiropractic care on children with autism: a randomized clinical trial. J Vert Sublux Res Mar 9: Hubka MJ, Phelan SP. Interexaminer reliability of palpation for cervical spine tenderness. J Manipulative Physiol Ther Nov- Dec;17(9): Grostic JD. Dentate ligament cord distortion hypothesis. CRJ Spr;1(1): Jackson BL, Barker W, Bentz J, Gamble AG. Interand intra-examiner reliability of the upper cervical x- ray marking system: a second look. J Manipulative Physiol Ther Aug;10(4): Biondi DM. Cervicogenic headache: a review of diagnostic and treatment strategies. J Am Osteopath Assoc Apr; 105(4 Suppl 2):16S-22S. 27. Bogduk N. The anatomical basis for cervicogenic headache. J Manipulative Physiol Ther Jan;15(1): J. Upper Cervical Chiropractic Research May 31,

8 Table 1. Pre-adjustment digital palpation and comparative leg length findings Visit # C1 Left C1 Right C2 Left C2 Right Leg Length Right ¾ Even Even Right ¼ Right ¼ Even Even Right ¼ Right ¼ Even Table 2. Post-adjustment digital palpation and comparative leg length findings Visit # C1 Left C1 Right C2 Left C2 Right Leg Length Even 2. NA NA NA NA NA 3. NA NA NA NA NA Even Even 6. NA NA NA NA NA 7. NA NA NA NA NA Even Even 10. NA NA NA NA NA NA indicates days the patient was never adjusted. 53 J. Upper Cervical Chiropractic Res. May 31, 2012

9 Figures Figure 1. Sagital pre- and post-adjustment radiographs Pre Figure 2. Frontal pre- and post-adjustment radiographs Post Pre Post Figure 3. Horizontal pre-and post-adjustment radiographs Pre Post J. Upper Cervical Chiropractic Research May 31,