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FIGURE 1 | Illustration depicting the predominant veins and sinuses involved in the craniocervical venous outflow. Venous narrowing is depicted at locations of interest in chronic cerebrospinal venous insufficiency. http://www.frontiersin.org/Endovascular_and_Interventional_Neurology/10.3389/fneur.2011.00044/full

Illustration depicting the predominant veins and sinuses involved in the craniocervical venous outflow. Venous narrowing is depicted at locations of interest in chronic cerebrospinal venous insufficiency. Lazzaro M.A. et al (2011)

‘Recent reports have emerged suggesting that multiple sclerosis (MS) may be due to abnormal venous outflow from the central nervous system, termed chronic cerebrospinal venous insufficiency (CCSVI).’

Lazzaro M.A. et al (2011)

http://www.frontiersin.org/Endovascular_and_Interventional_Neurology/10.3389/fneur.2011.00044/full

This is a very exciting article on the how venous outflow could be implicated in MS. The diagram above shows the sites the researchers have identified as being restricted.

There is a long tradition in cranial work of supporting drainage from the head by working at the thoracic outlet (or inlet, depending on what term you prefer, both are used for the same area). The first craniosacral therapist I ever saw would always start at the thoracic outlet, maybe he was on to something.

In the thoracic outlet hold the hands are above and below the base of the neck – upper hand spread over  the suprasternal notch, first rib and clavicles, the lower hand underneath the the cervical thoracic junction. I like to try and feel the shape of the hole made by the first rib and orient to the health of all the tubes moving through the region (dural tube, oesophagus, trachea, carotid sheaths). Pulsing arteries softening, spreading of the fascia sheets, easing of the movement of C7 and a shift in the first rib and clavicles all speak of change in this region.

The image above includes drainage routes via ‘spinal column drainage route’, ‘pterygoid plexus’ and ‘vertebral vein’ that are fairly new to me – nice bits of anatomy to appreciate.

Another route for cerebrospinal fluid (CSF) to leave the skull you can consider is shown below. A significant amount of CSF drains as lymphatic outflow from the cranial cavity via the ethmoid (and to a lesser degree perineural spaces of cranial and spinal nerves) and is collected by the lymphatic vessels of the head and neck (Pollay 2010).

This research helped me appreciate the dynamics of the ethmoid and cervical lymphatics as important in fluid draining from the skull. Pollay also indicates that poor outflow of CSF is not good for the health of the nervous system.

A great image from Pollay 2010 showing the dual outflow system for drainage of CSF. Outflow is via both the arachnoid villi into the venous sinuses and the lymphatic outflow (mostly through the ethmoid via CN I)

A great image from Pollay 2010 showing the dual outflow system for drainage of CSF. Outflow is via both the arachnoid villi into the venous sinuses and the lymphatic outflow (mostly through the ethmoid via CNI olfactory nerve sheaths)

‘The lymphatic system has been shown to develop earlier than that of the arachnoid villi and therefore appear to be a dominant CSF outflow route in the late fetal and early neonatal period. There is convincing evidence that the arachnoid villi system loses it efficiency with age, which can influence the total turnover rate of the CSF with possible neurodegenerative consequences.’

Pollay 2010

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2904716

See also this post for more on the venous outflow in cranial work

https://cranialintelligence.com/2012/01/19/working-with-the-venous-sinuses/

References

Lazzaro M.A. et al (2011) Endovascular therapy for chronic cerebrospinal venous insufficiency in multiple sclerosis. Front. Neur., 14 July 2011 | doi: 10.3389/fneur.2011.00044

Pollay, M. (2010) The function and structure of the cerebrospinal fluid outflow system. Cerebrospinal Fluid Res. 2010; 7: 9. Published online 2010 June 21. Accessed 2/10/12 via http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2904716

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Amazing footage of an operation to repair a cerebrospinal fluid [CSF] leak. In some patients, the CSF may start leaking spontaneously. This type of leakage occurs into the ear or the sinuses. In this surgical video, you will see the repair of a spontaneous CSF leakage that originated in the posterior fossa. This surgery is performed by Dr. Hamid R. Djalilian, director of otology, neurotology, and skull base surgery. Notice the introduction of fascia and bone wax to help seal the leakage.

http://youtu.be/2HjSTAB6dqM

Check the first two or three minutes of this spinal cord operation. Before the dura is opened you can see the csf  (and cord?) moving through the membrane (around 0.30 plus). When the dura and then arachnoid is opened the flow of csf is clearly visible (around 2.10 to 3.00 plus)

This is a view of the exposed thoracic spinal cord with an abnormal vessel. As the surgeon cuts the abnormal vessel, you can see the pulsing of csf around the cord.

(Thanks to Ciara Dhiomasaigh, biodynamic craniosacral therapist in Galway, for the latter video)

Below are some interesting quotes on CSF flow from recent research using new computer modelling of CSF flow in the third ventricle from MRI scans. There are also some great images on the site of Dr Vartan Kurtcuoglu. (Many thanks to GP Visser, dentist and current student on the current CTET training, for pointing out the papers.)

‘Unlike the cardiac system, there is no dedicated pump, such as the heart, that directly drives the CSF flow. The CSF is propelled in a pulsatile manner, primarily due to brain motion caused by the expansion and contraction of cerebral blood vessels. Superimposed on this motion is flow generated by the secretion of CSF by the choroid plexus in the ventricles at the center of the brain and cerebrospinal fluid absorption, predominantly at the arachnoid villi in the subarachnoid space that surrounds the brain (Davson and Segal, 1996). Additional drainage into the blood-stream is purported to occur through the cerebral extracellular space (Greitz, 1993).’ (Kurtcuoglu et al 2007)

‘The CSF further serves as an intermediary between blood and nervous tissue, providing the latter with nutrients and removing waste products. Recent research shows that the cerebrospinal fluid flow is much more important than previously believed. For example, the pituitary gland and hypothalamus communicate through the CSF and new neurons follow the flow of cerebrospinal fluid in the adult brain.’ (Kurtcuoglu 2011)

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