ISSN 0008-3194 (p)/ISSN 1715-6181 (e)/2014/184–192/$2.

00/©JCCA 2014

The cervical myodural bridge, a review of

literature and clinical implications
Dennis E. Enix, DC, MBA1
Frank Scali, DC2
Matthew E. Pontell, BSc3

The role of posterior cervical musculature in Le rôle de la musculature cervicale postérieure dans le
sensorimotor control, cervicocephalic pain, and contrôle sensorimoteur, la douleur cervico-céphalique
stabilization of the spinal cord has been recently et la stabilisation de la moelle épinière n’a que
described. Anatomical soft tissue connections which récemment fait l’objet d’une description. Les connexions
cross the cervical epidural space link suboccipital anatomiques des tissus mous qui traversent l’espace
muscle fascia and dura. These myodural bridges provide épidural cervical lient le fascia et la dure-mère des
passive and active anchoring of the spinal cord. They muscles sous-occipitaux. Ces ponts myoduraux offrent
may also be involved in a dural tension monitoring un point d’ancrage passif et actif à la moelle épinière.
system to prevent dural infolding, and maintain patency Ils peuvent aussi participer au système de contrôle
of the spinal cord. Modulation of dural tension may be de la tension durale afin de prévenir le repliement
initiated via a sensory reflex to muscular contractile dural et de maintenir la perméabilité de la moelle
épinière. Les modulations de la tension durale peuvent
être provoquées par un réflexe sensoriel aux tissus
musculaires contractiles. Les mouvements non anticipés

1
 Associate Professor, Division of Research, Logan University
2
 American University of the Caribbean, School of Medicine
3
 Department of Anatomical Sciences, St. George’s University, School of Medicine
Corresponding author’s contact information:
Dennis E. Enix DC, MBA
E-mail: [email protected]
Address: Research Division, Logan University
1851 Schoettler Rd., Chesterfield, MO, 63017 U.S.A.
Phone (636-230-1951)
©JCCA 2014

Institutions where work was performed: Cadaveric tissue samples were obtained at the Department of Anatomical Sciences at Logan University
and the Department of Anatomical Sciences at St. George’s University, School of Medicine. Histological analysis of tissues was performed at the
Research Microscopy Core in the Department of Pathology at Saint Louis University School of Medicine.

Declaration: The authors have no financial associations, commercial associations or other possible conflicts of interest relevant to this study to
disclose. Dr. Enix receives salary support from Logan University and partial funding support from HRSA grant # R18HP15125 and a grant from
Standard Process corp.

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 DE Enix, F Scali, ME Pontell

tissues. Unanticipated movements such as hyperflexion comme les blessures résultant d’une hyperflexion-
extension injuries stimulate deep suboccipital muscles extension stimulent les muscles sous-occipitaux profonds
and transmit tensile forces through the bridge to the et transmettent des efforts de traction par le pont sur la
cervical dura. Due to its larger cross sectional area, dure-mère cervicale. En raison de sa plus grande section
the rectus capitis posterior major myodural bridge may transversale, le pont myodural grand droit postérieur
exert greater mechanical traction on the dura than peut exercer une plus grande traction mécanique
the rectus capitis posterior minor. University ethics sur la dure-mère que le muscle petit droit postérieur.
committee approval and anatomical donor consent was L’approbation du comité d’éthique de l’université et le
obtained for this study. consentement du donneur anatomique ont été obtenus
pour la présente étude.

(JCCA 2014;58(2):184-192) (JCCA 2014;58(2):184-192)

k e y w o r d s : rectus capitis posterior major, obliquus m o t s c l é s   : grand droit postérieur, oblique inférieur
capitis inferior, myodural bridge, dura mater de la tête, pont myodural, dure-mère, chiropratique

Introduction Schoenen, Haldeman, Fernandez-De-Las-Penas and

The cervical spine is a complex anatomical structure others.9,14-17 Changes in cervical proprioception, balance,
that is of interest to anatomists, biomechanists, and clin- sympathetic tone, conversion of muscle type, and dural
icians. Soft tissue communications linking suboccipital enfolding secondary to cervical spine injuries have been
muscle fascia and the dura and its role in cervical neuro- described by several authors including Palmgren, Rix,
muscular control have been examined recently.1-8 These Uhlig, Cailliet, Lusczyk.18-25,
myodural bridges have been associated with the etiology Anatomical research and reviews of existing literature
of cervicocephalic headaches, and cervicocephalic pain concerning the fascial connections between the suboccipi-
syndromes.3,9 These epidural connections may also be in- tal muscles and the cervical dura have been reported re-
volved passively as a dural anchor and as an active stabil- cently.1-8 In 1992 a fascial connection between was briefly
izer of the spinal cord.4,6,10 mentioned by Kahn et al., in a report of the posterior
Recent studies have described myodural communi- intervertebral spaces of the cervical craniovertebral joint.1
cations bridging the epidural spaces between the rectus It was noted however, that a true membrane connecting
capitis posterior minor (RCPmi), rectus capitis poster- the posterior arch of the atlas to the laminae of the axis
ior major (RCPma), and obliquus capitis inferior (OCI) did not exist, but rather two fibrous planes that transected
suboccipital muscles and the dura mater of the cervical this space.1 Hack et al, reported on a myodural bridge be-
spine.1-8 Anatomical studies by Khan, Hack, Scali, Pon- tween the fascia of the rectus capitis posterior minor (RC-
tell, and others have reported on the presence of myodural Pmi) muscles in 1995.2,26 An examination of the posterior
bridges linking sub-occipital muscles with the dura mater atlantooccipital interspace showed a continuous band of
of the cervical spine.1,2,4,6 Additional studies by Shin- tissue with fibers oriented primarily perpendicular to the
omiya, Humphreys, Nash, Zumpano and Tagil confirmed muscle and dura.2,26 A animal model study of 43 speci-
these findings.13,10-13 Connections between the suboccipi- mens in 1996 by Shinomiya et al. examined the ligament-
tal musculature fascia and cervical dura mater have impli- ous attachments within the cervical posterior epidural
cations in cervicocephalic pain syndromes, sensorimotor space.10 They confirmed the presence of abundant pos-
function, and postural control.14-17 The clinical relevance terior epidural ligaments attaching to the posterior dura
of these cervical epidural membranes and their relation- mater.10 Dissections of seven human cadaveric specimens
ship to cervicogenic and tension headache syndromes by Rutten et al. in 1997, agreed with previous findings of
has been discussed by multiple authors including Bates, an epidural connection between the RCPmi and the pos-

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The cervical myodural bridge, a review of literature and clinical implications

terior wall of the spinal cord dura mater.24 Alix and Bates staining showed a pattern of nerve distribution through-
reported on previous anatomical findings and suggested out one tissue sample (fig 4).5 Pontell et al. dissected nine
that the ligamentous connection between muscle and the human cadaveric specimens, examining 14 OCI muscles
pain sensitive dura mater may provide an anatomic and and surrounding tissue.6 We documented a continuous fi-
physiological basis for cervicogenic headaches.9 After a brous tissue originating at the anterior fascia of the OCI
gross anatomical dissection of 30 cadaveric specimens in muscle belly and projecting anteriorly across the atlanto-
2003, followed by magnetic resonance imaging (MRI) of axial interspace and attaching to the posterolateral aspect
4 specimens, Humphreys’ et al, also confirmed the pres- of the cervical dura mater between the first and second
ence of a fibrous connection bridging the epidural space cervical vertebrae.6 Histological analysis was performed
linking the dura and RCPmi.13 In a case report describing on 12 OCI suboccipital muscles, connective tissue, and
an anatomical variation of a bifurcated RCPmi discovered dura mater from human cadavers between the ages of
during a routine dissection in 2005, Tagil confirmed the 49 to 81.7 Microscopic examination of OCI myodural
presence of dense connective tissue linking suboccipital tissues stained with hematoxylin and eosin showed the
muscle fascia to the cervical dura mater.3 Nash et al, em- connective tissue emanating from the ventral OCI mus-
ployed sheet plastinations and confocal microscopy in an cular fascia and inserted directly into the posterolateral
examination of the posterior atlanto-occipital interspace.12 aspect of the cervical dura mater.7 A single OCI myodural
They noted the presence of connective tissue attaching the connection stained for immuno-peroxidase using Dako’s
RCPmi fascia and the spinal dura mater in the posterior neurofilament protein monoclonal antibodies revealed
cranio-cervical region in adult human cadavers.12 A larger fascicles traveling perpendicular, and parallel with the
study of seventy five cadavers by Zumpano et al. in 2006, OCI myodural bridge.7 Due to proximity, the RCPma
examined variations in prevalence, tissue-type, gender in and OCI muscles appear to form a single atlantoaxial
the soft-tissue bridge between RCPmi and dura mater.11 myodural bridge, they are however, separate structures.7
They reported similar findings in the structure of the RC- We were unable to find a similar connection between the
Pmi myodural bridge as previous authors.27 According obliquus capitis superior and the dura mater.7 To examine
to Kahkeshani and Ward, the myodural bridge has been the prevalence of these structures, T-2 weighted magnetic
underreported due the time necessary to properly dissect resonance imaging (MRI) of the atlanto-axial interspace
this region.27 To encourage further study; they describe a of 240 individuals was performed in 2012 by Scali et, al.8
method for the deep dissection of the suboccipital triangle Sixty four percent of the MRI’s reviewed demonstrated a
which preserves the RCPmi and its attachments for fur- posterior concavity of the cervical dura mater consistent
ther inspection.27 with a ligament attachment site.8 Of this group, 24% also
We recently reported on two additional epidural con- had oblique, linear hypointense fibers which appeared to
nections to the cervical dura.4-7 Myodural bridges ex- attach to the cervical dura mater.8 The breadth of studies
tending from the anterior fascia of the rectus capitis pos- which have examined these soft tissue dural connections,
terior major (RCPma) and obliquus capitis inferior (OCI) precludes them being considered variations of normal
muscles, attaching on the cervical dura mater was docu- anatomy.1-8,11-13,27
mented recently by Scali, and Pontell in 2011 and 2013 In this article, we focus on the anatomical, functional
(fig1).4-7 In an anatomical study by Scali et al., 13 em- significance, and clinical relevance of the RCPma and
balmed human cadaveric specimens showed broad fascial OCI myodural bridge. Consideration of its function as a
connections traversing the cervical epidural space from passive and active stabilizer of the cervical spinal cord is
the RCPma muscle fascia, anterio-inferiorly to the poster- discussed.
ior dural surface (fig 2).4 RCPma myodural tissues from
11 specimens stained with hematoxylin and eosin indicat- Anatomy of the suboccipital muscles
ed that the fascial connection inserted directly into the fa- The RCPma and OCI muscles share a common innerva-
scia surrounding the RCPma and attached to the posterior tion by the suboccipital nerve and some actions, with the
surface of the dura (fig 3).5 Immunohistochemical analy- RCPma acting to extend and slightly ipsilateral rotate the
sis using anti-neurofilament protein fluorescent antibody head and neck, while the OCI muscle ipsilaterally rotators

186 J Can Chiropr Assoc 2014; 58(2)

 DE Enix, F Scali, ME Pontell

Figure 1
Illustration of a dissection of the deep
suboccipital region of the cervical spine.
The rectus capitis posterior minor (RCPmi),
rectus capitis posterior major (RCPma),
and the obliquis capitis inferior (OCI)
muscle fascia have communications with
the dura mater via soft tissue. The encircled
illustration (right) depicts a midsagittal
dissection revealing the RCPma, RCPmi, and
OCI muscles. The cervical myodural bridge
(a) traverses the epidural space between
the posterior elements of the C1 and C2
vertebrae. Both myodural structures link the
suboccipital muscle fascia in to the cervical
dura mater (*).Used with permission from:
Magnetic resonance imaging investigation of
the atlanto-axial interspace. Clin Anat. 2013
May; 26(4):444-9. Scali et al.
(Original anatomical artwork by
Frank Scali, D.C., and Danny Quirk)

Figure 2
A myodural bridge (MDB) extending from the
anterior fascia of the rectus capitis posterior
major (RCPma) and obliquus capitis inferior
(OCI) muscles, attaching on the cervical
dura mater. The myodural bridge (MDB)
communicates with the posterior aspect of the
cervical dura mater between the C1 and C2
vertebrae. Used with permission from: The
Obliquis Capitis Inferior Myodural Bridge,
Clin Anat 2013 26:450 45. Pontell M, Scali
F, Marshall E, Enix D. (Original anatomical
artwork by Danny Quirk)

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The cervical myodural bridge, a review of literature and clinical implications

Figure 3
Hematoxylin and eosin stained tissues of left side sagittal section showing the soft tissue communication (a) between
the RCPma (b) and the cervical dura mater (c) in a male cadaveric specimen. The magnified area shows the soft tissue
communication at the point of contact with the dura mater (d). Used with permission from: Histological Analysis of
the Connection between the Rectus Capitis Posterior Major’s myodural bridge, The Spine Journal 13 (2013) 558-563.,
Scali F, Pontell M, Enix D, Marshall E.

Figure 4
Sagittal section of the myodural bridge between the rectus capitis posterior major and the cervical dura mater
depicting positive fluorescence after staining with antineurofilament protein antibodies. Used with permission from:
Histological Analysis of the Connection between the Rectus Capitis Posterior Major’s myodural bridge, The Spine
Journal 13 (2013) 558-563., Scali F, Pontell M, Enix D, Marshall E.

188 J Can Chiropr Assoc 2014; 58(2)

 DE Enix, F Scali, ME Pontell

the cervical spine.3,4,22 Cervical suboccipital muscles are al ligaments and dura mater have been reported with cer-
richly innervated and contain relatively high muscle spin- vical spine extension.22-25,34 Cervical extension can create
dle content.18,21 Muscle spindle fibers found in the RC- infolding of the ligamentum flavuum, which encroaches
Pma and OCI muscles are a source of primary afferents, upon the cord.30 It is the elastin fibers found in the in the
representing major contributors to cervical spine neuro- ligamentum flavuum that function to inhibit this inward
muscular control.3,18,19,28,29 Consistent with their function buckling of the ligament into the spinal cord.22,24,34,35 The
of complex coordination and organization, high muscle dura mater, which is densely populated with nociceptors,
spindle concentrations are typically found in smaller also contains elastin fibers which are oriented in such a
muscle groups responsible for fine motor skills.18,29,30 way as to resist the load placed on them.34,35 The strain
Kulkarni et al. documented the density of muscle spindles on the posterior side being greater than on the anterior
in fetal tissue per gram of muscle tissue.18 A large num- side.25,34,35 Our recent histological analysis of cervical
ber of muscle spindles were noted in both the OCI and dura elastin fibers in eight cadaveric specimens, con-
RCPma suboccipital muscles, with 242 and 98 spindles firms that elastin density changes from caudal to cranial
per gram of muscle tissue, compared to the trapezius and as well as the orientation of fibers which run parallel
latissimus dorsi postural muscles with 2.2 and 1.4 muscle and perpendicular to each other. Cervical extension may
spindles per gram.18 Muscle spindles are typically more therefore also cause inward buckling of the dura itself,
concentrated in regions richest in slow fibers, and while compromising the dorsal subarachnoid space.31,34,36 In a
the OCI muscles have been reported as a blend of un- prospective analysis of fifty patients receiving cervical
evenly dispersed type I and II fibers, their muscle spindles injections under myelography; six percent demonstrat-
are distributed disproportionately in the deep areas rich- ed dural infolding on cervical extension, narrowing the
est in slow twitch fibers.18,29 This unique configuration of posterior subarachnoid space.36 Traumatic and iatrogenic
muscle types suggests that these muscles may serve mul- tears to the cervical dura can effect up to 36% of cervical
tiple functions including monitoring kinesthetic changes, spine injuries.23 Inflammation of the meninges, subdural
maintaining constant force for eccentric head posture, hematomas, epidural infections, and nerve root compres-
and creating fast phasic movements when needed.18,29,31 sion and postural headaches are all the sequel of cerebral
An electromyographic examination showed the RCPmi to spinal fluid leaks with dural tears.23,25 Meningeal vascu-
be under active contraction while the head is in an upright lar irritation can also cause hypertonicity of the posterior
neutral position, with muscle activity increasing signifi- neck muscles, resulting in permanent tension on the dura,
cantly during cervical retraction.32 The cervical muscles stimulating nociceptive dural fibers.23,26,37 Considering the
are subject to conversion from slow twitch to fast twitch close proximity of the leptomeninges to the dura mater, a
muscles with injury.20,21 Alteration in muscle type, to a system to maintain the integrity of the subarachnoid space
more glycogenic morphology creates a muscle prone to and, cerebrospinal fluid flow may exist.14,15,25,28 Simi-
facilitation.21,31 This change can alter the discharge of pri- lar to the denticulate ligaments which secure the spinal
mary afferents to the central nervous system effecting cer- cord within the subarachnoid space, the myodural bridge
vical neuromuscular control.19-21,31 Additionally, a loss of crosses the epidural space to anchor the spinal dura during
proprioceptive inhibition of nociceptors at the dorsal horn head and neck motion.4,6,10,23,25,28
of the spinal cord can result in chronic pain.3,25
Neuromuscular stabilization of the spinal cord
Clinical implications Contraction of the RCPma, RCPmi, and OCI sub-occipi-
The spinal canals’ midsagittal diameter of 10 mm which tal muscles which puts the myodural bridge under tension,
increases with flexion and decreases with extension, can transmitting forces across it to place the dura under ten-
impact the patency of the cervical cord.22,25 In a study sion and stabilize the spinal cord.4,6,26,38,39 In addition to ac-
of 19 cadaveric specimens by Hong et. al., showed sig- tive contraction, the suboccipital muscles respond reflex-
nificant differences in dural thickness between different ively to involuntary and unanticipated movements of the
levels in the thoracic and lumbar spines, with the dura head and neck.20,25 Modulation of dural tension may also
slightly thicker in men than women.33 Buckling of cervic- be initiated via a sensory reflex to muscular contractile

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The cervical myodural bridge, a review of literature and clinical implications

tissues.5,7 Central nuclei that exert control over the deep deur proposed that the RCPmi plays a role in preventing
suboccipital muscles, including the RCPma, RCPmi and dural crimping when the head is extended or moved
OCI muscles could respond reflexively as a feedback con- backward, inhibiting normal circulation of cerebrospinal
trol of dural tension.5,7,25,28 Like many systems involving a fluid.38 Humphries reported on previous studies describ-
feedforward or feedback mechanism of control, dural ten- ing the primary mechanical function of the RCPmi to re-
sion regulated through muscular contraction of suboccipi- sist dural buckling during cervical extension, preventing
tal muscles is dependent on internal and external factors damage to the spinal cord.13 In a case report describing
affecting those systems.4,6,28,31 The regulation of tension an anatomical variation of the suboccipital muscles, Tagil
across the myodural bridge as a spinal cord stabilizer may also noted that the spinal cord is believed to be protected
prevent dural infolding, reducing stimulation of nocicep- by the dense connective tissue that links the suboccipital
tive pain mechanisms.5,7,39 Hypertrophy of suboccipital muscles to the cervical dura mater.3 Kahkeshani and Ward
muscles or a failure of this system to maintain constant indicated that a direct connection linking the musculo-
tension, may result in clinical manifestations arising from skeletal system to the dura mater provides a mechanical
increased dural tension.1,4,6,9,20 explanation for the efficacy of cervical massage and ma-
nipulative treatment for headaches.27
Discussion Along with the description of the RCPma myodural
bridge by Scali et al., we proposed that modulation of
Functional anatomy of the myodural bridges cervical dural tension may include factors other than a
Many authors have speculated on the functional signifi- myotatic reflex.4,5 Myodural biofeedback may play a role
cance of the myodural bridge, generally attributing a in maintaining the integrity of the subarachnoid space.4,5
mechanical advantage to it in stabilizing the spinal cord We noted during dissection that manual traction applied
from dural enfolding.1-13 The reflexive myotatic response to the RCPma caused movement of the spinal root within
of suboccipital muscles has been proposed by several several levels.4 Due to its larger cross sectional area, the
authors as a likely mechanism to place the dura under rectus capitis posterior major myodural bridge may exert
tension.4-9,38,39 In a study of 20 cadavers, Nakagawa re- greater mechanical traction on the dura than the rectus
ported that cervical cephalocaudal stresses may be due to capitis posterior minor.4 We described another soft tissue
the parallel orientation of elastin fibers in the dura and connection traversing the epidural space between the OCI
concluded its function was to resist hyperextension and muscle fascia and the posterior sleeve of the dura mater
compressive infolding of the dura.34 Hack suggested that in a paper by Pontell et al.6 It was reported that the OCI
the purpose of the RCPmi myodural bridge might be to myodural connections function dynamically to prevent
assist in resisting dural infolding, previously noted by dural infolding during cervical extension, similar to the
Burt.2,36 Shinomiya et. al., concluded that the role of the RCPmi and RCPma bridges.6,7
posterior cervical epidural ligaments is to provide an We agree with previous authors who describe a stabil-
anchor to stabilize the dura mater from anterior transla- izing function of the RCPmi muscle myodural bridge and
tion during flexion.10 Without a posterior epidural attach- propose a similar role for the RCPma and OCI muscle
ment, the dural canal can shift anteriorly compressing the myodural bridges. In addition to the passive anchoring of
spinal cord causing flexion myelopathy.10 Rutten reported the dura described by Nakagawa, Hack, Humphries, and
on high muscle spindle content in the RCPmi, postulat- Shinomiya, a myo-reflexive response described by Rutten
ing that the myodural bridges function may to monitor provides an active stabilizing component.2,7,10,13,19,34,28,34
stresses on the cervical dura mater, reflexively preventing Besides the reflexive myotatic response of the suboccipital
infolding.24 They reported that tissue injury from cervical muscles, the presence of neuronal fibers in these tissues,
whiplash could affect mechanoreceptive properties, caus- may suggest functions other than the passive anchoring of
ing the monitoring system that maintains dural tension to these muscles to the posterolateral dura mater.5,7
fail.21,24,31 Alix & Bates also discussed the duras tendency The clinical relevance of these soft tissue connections
to fold inward on the spinal cord, and the myodural bridg- to dural generated pain mechanisms, cervicocephalic
es ability to resist this movement.9 McPartland and Bro- headaches, subarachnoid space and cord impingement

190 J Can Chiropr Assoc 2014; 58(2)

 DE Enix, F Scali, ME Pontell

make this an area of great interest.9,13-17,20,39 The anatom- 6. Pontell ME, Scali F, Marshall E, Enix DE. The
ical and histological evidence of these soft tissue com- obliquus capitius, inferior myodural bridge. Clin Anat.
munications bridging the epidural space from the RCPma 2013;26(4):450-4.
7. Pontell M, Scali F, Enix DE, Marshall E. Histological
and OCI muscles to the dura mater offers insight into the examination of the human obliquus capitis inferior
cervical spines’ complex function of neuromuscular con- myodural bridge. Annals Anatomy. 2013;195(6):522-26.
trol.5,7,18,39 Further examination of the tensile forces in the 8. Scali F, Pontell ME, Welk AB, Malmstrom TK, Marshall E,
myodural bridge is needed. Biomechanical testing to con- Kettner NW. Magnetic resonance imaging investigation of
firm the tensile forces on these tissues currently in prog- the atlanto-axial interspace. Clin Anat. 2013;26(4):444-9.
9. Alix ME, Bates DK. A proposed etiology of cervicogenic
ress. headache: the neurophysiologic basis and anatomic
relationship between the dura mater and the rectus capitis
Conclusion posterior minor muscle. J Man Manip Ther. 1999;22:534-
Anatomical soft tissue bridges which cross the cervical 9.
epidural space, connecting suboccipital muscle fascia and 10. Shinomiya K, Dawson J, Spengler DM, Konrad P,
dura have passive and active functions to anchor the spinal Blumenkopf B. An analysis of the posterior epidural
ligament role on the cervical spinal cord. Spine.
cord. These myodural bridges may be involved in a dural 1996;21:2081-8.
tension monitoring system to prevent dural infolding and 11. Zumpano MP, Hartwell S, Jagos C. Soft tissue connection
maintain patency of the spinal cord. Failure of this system between rectus capitis posterior minor and the posterior
could result in altered cerebral spinal fluid flow, changes atlanto-occipital membrane. Clin Anat. 2006; 19:522-527.
in sensorimotor function, cervicocephalic headaches, and 12. Nash L, Nicholson H, Lee ASJ, Johnson G M, Zhang M.
Configuration in the posterior atlanto-occipital interspace.
dural related pathologies. Spine. 2005;30:1359-1366.
13. Humphreys BK, Kenin S, Hubbard B, Cramer G.
Acknowledgements: Investigation of connective tissue attachments to the
The authors would like to thank Logan University gradu- cervical spinal dura mater. Clin Anat. 2003; 16:484-493.
ate students Patrick Battaglia, and Robbyn Keating for 14. Bogduk N. Cervicogenic Headache: anatomic basis and
assistance with cadaveric dissections and manuscript re- pathophysiologic Mechanisms. Current Pain and Headache
Reports. 2001; 5:382-386.
view and Dr. Jan Ryerse at the Research Microscopy Core 15. Haldeman S, Dagenais S. Cervicogenic headaches: a
in the Department of Pathology at Saint Louis University critical review. Spine J. 2001;1(1):31-46.
school of Medicine for preparation and interpretation of 16. Fernandez-De-Las-Penas C. Clinical evaluation of
histological data and Danny Quirk for original illustra- cervicogenic headache: a clinical perspective. J Man
tions. Manip Ther. 2008;16:81.
17. Schoenen J, Fumal A. Tension-type headache: current
research and clinical management. Lancet Neurology.
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