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Duplicatures of the dura mater. Important functions of the dura mater. Functions of hard shells

Anatomy and physiology play an important role in the membranes of the brain (spinal and brain). Their features, structure and functions are given special attention, since the functioning of the entire human body depends on them.

shell?

The meninga is the connective tissue membranous structure that surrounds both the spinal cord and the brain. It could be as follows:

  • hard;
  • arachnoid;
  • soft or vascular.

Each of these species is present in both the brain and the spinal cord and is a single entity that passes from one brain to another.

Anatomy of the membrane covering the brain

The dura mater of the brain is a formation with a dense consistency that is located under the inner surface of the skull. Its thickness in the arch area varies from 0.7 to 1 mm, and at the base of the cranial bones - from 0.1 to 0.5 mm. In places where there are openings, vascular grooves, protrusions and sutures, as well as at the base of the skull, it fuses with the bones, and in other areas its connection with the bones of the skull is looser.

During the development of pathologies, detachment of the described membrane from the cranial bones may occur, resulting in the formation of a gap between them, which is called the epidural space. In places where it is present, when the integrity of the cranial bones is violated, the formation of epidural hematomas occurs.

The inside walls of the solid are smoother than the outside. There it loosely connects with the underlying arachnoid membrane with the help of a multilayered accumulation of specific cells, rare connective tissue filaments, thin vascular stems and nerves, as well as pachyonic granulations of the arachnoid membrane. Normally, there is no space or gap between these two membranes.

In some places, delamination of the dura mater of the brain is possible, resulting in the formation of two sheets. Between them there is a gradual formation of venous sinuses and the trigeminal cavity - the location of the trigeminal node.

Processes extending from the hard shell

Between the brain formations, 4 main processes extend from the dura mater. These include:

  • Sickle cerebri. Its location is the sagittal plane, located between the hemispheres. Its front part enters this plane especially deeply. In the place where the cockscomb is located, located on the ethmoid bone, there is the beginning of this process. Next, its convex edge is attached to the lateral ribs of the groove located on the superior sagittal sinus. This process of the meninges reaches the occipital protrusion and then passes into the outer surface, which forms the tentorium of the cerebellum.

  • Falx cerebellum. It originates on the internal occipital protuberance and follows its ridge to the posterior edge of the large foramen in the occiput. There it passes into two folds of the dura mater, the task of which is to limit the posterior opening. The cerebellar falx is located between the cerebellar hemispheres in the area where its posterior notch is located.
  • tentorium of the cerebellum. This process of the dura mater stretches over the fossa of the posterior cranial surface, between the edges of the temporal bones, as well as the grooves located on the transverse sinuses of the occipital bone. It separates the cerebellum from the occipital lobes. The tentorium of the cerebellum looks like a horizontal plate with the middle part pulled upward. Its free edge, located in front, has a concave surface, forming a notch of the tentorium, which limits its opening. This is the location of the brain stem.
  • Seat diaphragm. The process received this name due to the fact that it is stretched over the sella turcica and forms its so-called roof. Below the diaphragm sella is the pituitary gland. In its middle there is a hole through which a funnel passes, holding the pituitary gland.

Anatomy of the spinal cord membrane

The thickness of the dura mater is less than that of the brain. With its help, a sac (dural) is formed, which houses the entire spinal cord. A thread from the hard shell extends from this sac, leading downwards, and is subsequently attached to the coccyx.

There is no fusion between the dura mater and the periosteum, resulting in the formation of an epidural space, which is filled with loose, unformed connective tissue and internal venous vertebral plexuses.

With the help of the hard shell, fibrous sheaths are formed, located near the roots of the spinal cord.

Functions of hard shells

The main function of the dura mater is to protect the brain from mechanical damage. They perform the following role:

  • Ensure blood circulation and its removal from the vessels of the brain.
  • Thanks to their dense structure, they protect the brain from external influences.

Another function of the dura maters is to create a shock-absorbing effect as a result of cerebrospinal fluid circulation (in the spinal cord). And in the brain they take part in the formation of processes that delimit important areas of the brain.

Pathologies of the dura mater of the brain

Pathologies of the meninges may include developmental disorders, damage, diseases associated with inflammation, and tumors.

Developmental disorders are quite rare and often occur against the background of changes in the formation and development of the brain. In this case, the dura mater of the brain remains underdeveloped and defects may form in the skull itself (windows). In the spinal cord, developmental pathology can lead to local splitting of the dura mater.

Damage may result from traumatic brain or spinal cord injury.

Inflammation in the dura mater is called pachymeningitis.

Inflammatory disease in the lining of the brain

Often the cause of the inflammatory process in the dura mater of the brain is an infection.

In the practice of doctors, patients develop hypertrophic (basal) pachymeningitis or HPM. It is a manifestation of pathology in the described structure. Most often, men in young or middle age are affected by this disease.

The clinical picture of basal pachymeningitis is represented by inflammation of the membranes. This rare pathology is characterized by local or diffuse thickening of the dura mater at the base of the brain, most often in places where the falx or cerebellar tentorium is located.

In the case of the autoimmune variant of HPM, examining the cerebrospinal fluid, one can detect pleocytosis, increased protein content, and a lack of microbial growth.

Pathology of the dura mater of the spinal cord

External pachymeningitis often develops. During its development, inflammation occurs, affecting the epidural tissue, after which inflammation spreads to the entire surface of the dura mater of the spinal cord.

Diagnosing the disease is quite difficult. But the incidence of spinal pachymeningitis is higher than the development of pathologies associated with inflammation in the dura mater of the brain. To identify it, it is necessary to build on the patient’s complaints, medical history, as well as laboratory tests of cerebrospinal fluid and blood.

Tumors

The dura mater can undergo the development of both benign and malignant tumors. Thus, in the described structures or their processes, meningiomas can develop, growing towards the brain and compressing it.

Damage to the dura mater by malignant tumors most often occurs due to metastases, resulting in the formation of single or multiple nodes.

Diagnosis of this pathology is carried out by examining cerebral or cerebrospinal fluids for the presence of tumor cells.

Meninges of the brain

The brain, like the spinal cord, is surrounded by three meninges. These connective tissue sheets cover the brain, and in the area of ​​the foramen magnum they pass into the membranes of the spinal cord. The outermost of these membranes is the dura mater of the brain. It is followed by the middle one - the arachnoid, and inwardly from it there is the inner soft (choroid) membrane of the brain, adjacent to the surface of the brain.

Dura mater of the braindura mater encephali \ cra- nialis]. This shell differs from the other two in its special density, strength, and the presence in its composition of a large number of collagen and elastic fibers. Lining the inside of the cranial cavity, the dura mater of the brain is also the periosteum of the inner surface of the bones of the cerebral part of the skull. With the bones of the vault (roof) of the skull is solid

Rice. 162. Relief of the dura mater of the brain and the exit site of the cranial nerves; bottom view. [Lower skull (base) removed.]

1-dura mater encephali; 2 - n. opticus; 3- a. carotis interna; 4 - infundibulum; 5 - n. oculomotorius; 6-n. trochlearis; 7 - n. trigeminus; 8 - n. abducens; 9-n. facialis et n. vestibulocochlearis; 10-nn. glossopharyn-geus, vagus et accessorius; 11-n. hypoglossus; 12 - a. vertebralis; 13 - n. spi-nalis.

the membrane of the brain is loosely connected and is easily separated from them. In the area of ​​the base of the skull, the shell is firmly fused with the bones, especially in the places where the bones connect with each other and in the places where the cranial nerves exit the cranial cavity (Fig. 162). The hard shell surrounds the nerves for some extent, forming their sheaths, and fuses with the edges of the openings through which these nerves leave the cranial cavity.

At the inner base of the skull (in the region of the medulla oblongata), the dura mater of the brain fuses with the edges of the foramen magnum and continues into the dura mater of the spinal cord. The inner surface of the dura mater, facing the brain (towards the arachnoid membrane), is smooth. In some places, the dura mater of the brain is dis-

Rice. 163. Dura mater of the brain, dura mater encephali [ cranialisj.

1 - falx cerebri; 2 - sinus rectus; 3 - tentorium cerebelli; 4 - diaphragma sellae; 5 - n. opticus et a. carotis interna.

it splits and its inner leaf (duplicate) is deeply indented in the form of processes into the cracks that separate parts of the brain from each other (Fig. 163). In the places where the processes originate (at their base), as well as in areas where the dura mater is attached to the bones of the internal base of the skull, in the splits of the dura mater of the brain, triangular-shaped channels lined with endothelium are formed - dura mater sinusesshells,sinus Durae tnatris.

The largest process of the dura mater of the brain is the falx cerebri (large falciform process), located in the sagittal plane and penetrating into the longitudinal fissure of the cerebrum between the right and left hemispheres. falx cerebri. This is a thin crescent-shaped plate of the hard shell, which in the form of two sheets penetrates the longitudinal fissure of the cerebrum. Without reaching the corpus callosum, this plate separates the right and left hemispheres of the cerebrum from each other. In the split base of the falx cerebri, which in its direction corresponds to the groove of the superior sagittal sinus of the cranial vault, lies the superior sagittal sinus. In the thickness of the free edge of the large sickle

The brain also has an inferior sagittal sinus between its two layers. In front, the falx cerebri is fused with the cock's crest of the ethmoid bone. The posterior part of the falx at the level of the internal occipital protrusion fuses with the tentorium of the cerebellum. Along the line of fusion of the posteroinferior edge of the falx cerebellum and the tentorium cerebellum, in the fissure of the dura mater of the brain, there is a straight sinus connecting the inferior sagittal sinus with the superior sagittal, transverse and occipital sinuses.

Namet(tent) cerebellum,tentorium cerebelli, hangs in the form of a gable tent over the posterior cranial fossa, in which the cerebellum lies. Penetrating the transverse fissure of the cerebellum, the tentorium cerebellum separates the occipital lobes from the cerebellar hemispheres. The anterior margin of the tentorium cerebellum is uneven. It forms a tentorium notch, incisura tentorii, to which the brain stem is located in front.

The lateral edges of the tentorium cerebellum are fused with the upper edge of the pyramids of the temporal bones. Posteriorly, the tentorium of the cerebellum passes into the dura mater of the brain, lining the inside of the occipital bone. At the site of this transition, the dura mater of the brain forms a transverse sinus adjacent to the groove of the same name in the occipital bone.

Falx cerebellum(small falciform process), fdlx cerebelli, like the falx cerebri, located in the sagittal plane. Its anterior edge is free and penetrates between the cerebellar hemispheres. The posterior edge of the cerebellar falx continues to the right and left into the inner layer of the dura mater of the brain from the internal occipital protuberance above to the posterior edge of the foramen magnum below. The occipital sinus forms at the base of the falx cerebellum.

Diaphragm(Turkish) saddles,diaphragma sellae, It is a horizontal plate with a hole in the center, stretched over the pituitary fossa and forming its roof. The pituitary gland is located in the fossa under the diaphragm of the sella. Through an opening in the diaphragm, the pituitary gland is connected to the hypothalamus using a funnel.

Sinuses of the dura mater of the brain. The sinuses (sinuses) of the dura mater of the brain, formed by splitting the shell into two plates, are channels through which venous blood flows from the brain into the internal jugular veins (Fig. 164).

The sheets of hard shell that form the sinus are stretched tightly and do not collapse. Therefore, on the cut, the sinuses gape; Sinuses do not have valves. This structure of the sinuses allows venous blood to flow freely from the brain, regardless of fluctuations in intracranial pressure. On the inner surfaces of the skull bones, in the locations of the sinuses of the dura mater,

Rice. 164. The relationship of the meninges and the superior sagittal sinus with the cranial vault and the surface of the brain; section in the frontal plane (diagram).

1 - dura mater; 2- calvaria; 3 - granulationes arachnoidales; 4 - sinus sagittalis superior; 5 - cutis; 6 - v. emissaria; 7 - arachnoidea; 8 - cavum subarachnoidale; 9 - pia mater; 10 - brain; 11 - falx cerebri.

there are corresponding grooves. The following sinuses of the dura mater of the brain are distinguished (Fig. 165).

1. Superior sagittal sinus,sinus sagittalis superior, located along the entire outer (upper) edge of the falx cerebri, from the cock's crest of the ethmoid bone to the internal occipital protrusion. In the anterior sections, this sinus has anastomoses with the veins of the nasal cavity. The posterior end of the sinus flows into the transverse sinus. To the right and left of the superior sagittal sinus there are lateral lacunae communicating with it, lacunae laterdles. These are small cavities between the outer and inner layers (leaves) of the dura mater of the brain, the number and size of which are very variable. The cavities of the lacunae communicate with the cavity of the superior sagittal sinus; the veins of the dura mater of the brain, cerebral veins and diploic veins flow into them.

Rice. 165. Sinuses of the dura mater of the brain; side view.

1 - sinus cavernosus; 2 - sinus petrosus inferior; 3 - sinus petrosus superior; 4 - sinus sigmoideus; 5 - sinus transversus; 6 - sinus occipitalis; 7 - sinus sagittalis superior; 8 - sinus rectus; 9 - sinus sagittalis inferior.

    inferior sagittal sinus,sinus sagittalis inferior, located in the thickness of the lower free edge of the falx cerebri;

    it is significantly smaller than the top one. With its posterior end, the inferior sagittal sinus flows into the straight sinus, into its anterior part, in the place where the lower edge of the falx cerebellum fuses with the anterior edge of the tentorium cerebellum.sinus Direct sine, rectus

    located sagittally in the split of the tentorium cerebellum along the line of attachment of the falx cerebellum to it. The straight sinus connects the posterior ends of the superior and inferior sagittal sinuses. In addition to the inferior sagittal sinus, the great cerebral vein drains into the anterior end of the straight sinus. At the back, the straight sinus flows into the transverse sinus, into its middle part, which is called the sinus drainage. The posterior part of the superior sagittal sinus and the occipital sinus also flow here.sinus Transverse sinus,, transversus

lies in the place where the tentorium cerebellum departs from the dura mater of the brain. On the inner surface of the squama of the occipital bone it is This sinus corresponds to a wide groove of the transverse sinus. The place where the superior sagittal, occipital and straight sinuses flow into it is called the sinus drainage (fusion of the sinuses),. confluens

    sinuumsinus On the right and left, the transverse sinus continues into the sigmoid sinus of the corresponding side., lies at the base of the falx cerebellum. Descending along the internal occipital crest, it reaches the posterior edge of the foramen magnum, where it divides into two branches, covering this foramen from the back and sides.

    Each of the branches of the occipital sinus flows into the sigmoid sinus on its side, and the upper end into the transverse sinus.sinus sigmoid sinus, sigmoideus

    (paired), located in the groove of the same name on the inner surface of the skull, has an S-shape. In the area of ​​the jugular foramen, the sigmoid sinus passes into the internal jugular vein.sinus cavernous sinus,, cavernosus sinus paired, located at the base of the skull on the side of the sella turcica. The internal carotid artery and some cranial nerves pass through this sinus., This sinus has a very complex structure in the form of caves communicating with each other, which is why it got its name. Between the right and left cavernous sinuses there are communications (anastomoses) in the form of anterior and posterior intercavernous sinuses,

    intercavernosisinus which are located in the thickness of the diaphragm of the sella turcica, in front and behind the pituitary infundibulum. The sphenoparietal sinus and the superior ophthalmic vein flow into the anterior parts of the cavernous sinus., Sphenoparietal sinus,

    sphenoparietalissinus paired, adjacent to the free posterior edge of the lesser wing of the sphenoid bone, in the split of the dura mater of the brain attached here. Superior and inferior petrosal sinuses,­ petrosus su sinus paired, adjacent to the free posterior edge of the lesser wing of the sphenoid bone, in the split of the dura mater of the brain attached here. inferior, period

et paired, lie along the upper and lower edges of the pyramid of the temporal bone.. Both sinuses take part in the formation of pathways for the outflow of venous blood from the cavernous sinus to the sigmoid sinus. The right and left inferior petrosal sinuses are connected by several veins lying in the cleft of the dura mater in the area of ​​the body of the occipital bone, which are called the basilar plexus. This plexus connects through the foramen magnum to the internal vertebral venous plexus.. In some places, the sinuses of the dura mater of the brain form anastomoses with the external veins of the head with the help of emissary veins - graduates, paired, lie along the upper and lower edges of the pyramid of the temporal bone.. vv emissariae

veins of the head. Thus, venous blood from the brain flows through the systems of its superficial and deep veins into the sinuses of the dura mater of the brain and further into the right and left internal jugular veins.

In addition, due to anastomoses of the sinuses with diploic veins, venous graduates and venous plexuses (vertebral, basilar, suboccipital, pterygoid, etc.), venous blood from the brain can flow into the superficial veins of the head and neck.

Vessels and nerves of the dura mater of the brain. TO The dura mater of the brain is approached through the right and left spinous foramina by the middle meningeal artery (a branch of the maxillary artery), which branches in the temporo-parietal portion of the shell. The dura mater of the brain lining the anterior cranial fossa is supplied with blood by the branches of the anterior meningeal artery (a branch of the anterior ethmoidal artery from the ophthalmic artery). the jugular foramen, as well as the meningeal branches from the vertebral artery and the mastoid branch from the occipital artery, which enters the cranial cavity through the mastoid foramen.

The veins of the soft shell of the brain flow into the nearest sinuses of the hard shell, as well as into the pterygoid venous plexus (Fig. 166).

The dura mater of the brain is innervated by the branches of the trigeminal and vagus nerves, as well as by sympathetic fibers entering the shell in the thickness of the adventitia of blood vessels. The dura mater of the brain in the region of the anterior cranial fossa receives branches from the optic nerve (the first branch of the trigeminal nerve). A branch of this nerve, the tentorial (shell) branch, supplies the tentorium of the cerebellum and the falx cerebellum. The middle meningeal branch from the maxillary nerve, as well as a branch from the mandibular nerve, approach the membrane in the middle medullary fossa. In the membrane lining the posterior cranial fossa, the meningeal branch of the vagus nerve branches.

Arachnoid membrane of the brain,arachnoidea mater (encephali) [ cranialis]. This membrane is located medially to the dura mater of the brain. The thin, transparent arachnoid membrane, unlike the soft membrane (vascular), does not penetrate into the cracks between individual parts of the brain and into the sulci of the hemispheres. It covers the brain, moving from one part of the brain to another, and lies over the grooves. The arachnoid is separated from the soft shell of the brain subarachnoid(subarachnoid) space,cavitas [ spdtium] sub- arachnoidalis [ subarachnoideum], which contains cerebrospinal fluid, liquor cerebrospindlis. In places,

Rice. 166. Veins of the pia mater of the brain.

1 place where the veins enter the superior sagittal sinus; 2 - superficial cerebral veins; 3 - sigmoid sinus.

where the arachnoid membrane is located above wide and deep grooves, the subarachnoid space is expanded and forms a larger or smaller size subarachnoid cisterns,cister- paesubarachnoideae.

Above the convex parts of the brain and on the surface of the convolutions, the arachnoid and pia mater are tightly adjacent to each other. In such areas, the subarachnoid space narrows significantly, turning into a capillary gap.

The largest subarachnoid cisterns are the following.

    Cerebellomedullary cistern,clsterna cerebellomedulla- ris, located between the medulla oblongata ventrally and the cerebellum dorsally. At the back it is limited by the arachnoid membrane.

    This is the largest of all tanks.Cistern of the lateral fossa cerebri, cisterna­ fos sae cerebri, laterlls

    is located on the inferolateral surface of the cerebral hemisphere in the fossa of the same name, which corresponds to the anterior sections of the lateral sulcus of the cerebral hemisphere.Cistern of the lateral fossa cerebri, cross tank, [ chiasmatis], chiasmatica

    located at the base of the brain, anterior to the optic chiasm.Cistern of the lateral fossa cerebri, interpeduncular cistern,, interpeduncularis

is determined in the interpeduncular fossa between the cerebral peduncles, downward (anterior) from the posterior perforated substance.

The subarachnoid space of the brain in the region of the foramen magnum communicates with the subarachnoid space of the spinal cord. The cerebrospinal fluid that fills the subarachnoid space is produced by the choroid plexuses of the ventricles of the brain. From the lateral ventricles through the right and left interventricular foramina, cerebrospinal fluid enters the III The cerebrospinal fluid that fills the subarachnoid space is produced by the choroid plexuses of the ventricles of the brain. From the lateral ventricles through the right and left interventricular foramina, cerebrospinal fluid enters the ventricle, where there is also a choroid plexus. From

ventricle through the cerebral aqueduct, cerebrospinal fluid enters the fourth ventricle, and from it through the unpaired foramen in the posterior wall and the paired lateral aperture into the cerebellocerebral cistern of the subarachnoid space. The arachnoid membrane is connected to the soft membrane lying on the surface of the brain by numerous thin bundles of collagen and elastic fibers. Near the sinuses of the dura mater of the brain, the arachnoid membrane forms peculiar protrusions -granulation of the arachnoid membrane,- gra arachnoideae (Pachionian granulations). These protrusions protrude into the venous sinuses and lateral lacunae of the dura mater. On the inner surface of the skull bones, at the location of the arachnoid granulations, there are depressions - granulation dimples. Granulations of the arachnoid membrane are organs where the outflow of cerebrospinal fluid into the venous bed occurs.

Soft(vascular) lining of the brain,Ria mater encephali [ cranialis]. This is the innermost layer of the brain. It adheres tightly to the outer surface of the brain and extends into all the cracks and grooves. The soft shell consists of loose connective tissue, in the thickness of which there are blood vessels leading to the brain and feeding it. In certain places, the soft membrane penetrates into the cavities of the ventricles of the brain and forms choroid plexus,plexus choroideus, producing cerebrospinal fluid.

Review questions

    Name the processes of the dura mater of the brain. Where is each process located in relation to the parts of the brain?

    List the sinuses of the dura mater of the brain. Where does each sinus flow (open)?

    Name the cisterns of the subarachnoid space.

    Where is each tank located?

Where does cerebrospinal fluid flow from the subarachnoid space? Where does this fluid come from into the subarachnoid space?Age-related features of the membranes of the brain

and spinal cord

The arachnoid and soft membranes of the brain and spinal cord in a newborn are thin and delicate. The subarachnoid space is relatively large. Its capacity is about 20 cm 3, and increases quite quickly: by the end of the 1st year of life up to 30 cm 3, by 5 years - up to 40-60 cm 3. In children 8 years old, the volume of the subarachnoid space reaches 100-140 cm 3, in an adult it is 100-200 cm 3. The cerebellocerebral, interpeduncular and other cisterns at the base of the brain in a newborn are quite large. Thus, the height of the cerebellocerebral cistern is about 2 cm, and its width (at the upper border) varies from 0.8 to 1.8 cm.

Restoring the balance of the dura mater is the link between myofascial stretching and craniosacral therapy. While restoring balance is a necessary element of craniosacral therapy, it is not always necessary for myofascial strain. However, there are cases where it is impossible to perform myofascial release in the usual way, and nothing seems to help. Limitations are anticipated more intuitively than felt. And despite all the stretching, there are signs of limitation.

There are four situations when performing myofascial stretching when it is necessary to restore the balance of the dura mater:

1. The patient lying on the table is quite symmetrical, but when standing up, asymmetry is revealed;

2. Myofascial structure, which is subject to stretching or does not respond at all, or gives in very weakly. This often occurs when the erector longus and abdominal muscles are strained;

3. The correction disappears as soon as the new grip is released. This often occurs when the muscles attached to the base of the skull relax and is similar to an elastic rubber band immediately returning to its unstretched position;

4. You feel with your hands that something else needs to be stretched, but the doctor is not able to determine this structure. In these cases, restoring the balance will indicate whether the treatment was successful or not.

For example, I worked with a patient who had chronic neck and lower spine pain, myofascial restrictions in the abdomen, and myofascial trigger points. Manual release of trigger points was only partially successful (using a diffuse stretch technique).

My assistant and I tried to apply longitudinal stretching together and were unable to relax the abdominal muscles. They remained stiff and inelastic until the dura was rebalanced. As soon as this happened, a relaxation of the abdominal muscles followed, wave-like, within a few seconds, and all this immediately after the start of longitudinal stretching. You cannot directly place your hands on the dura mater and there is no feedback.

There is still no full explanation of how and why this technique works; does not exist. In fact, it is not clear what happens in this case: restoration of balance or stretching of the dura mater. It is also unclear what restrictions will be lifted. Having taken these facts into account, the rest is (according to Aplenger's theory) an explanation of what happens in the dura mater. Whether this explanation is correct or not is unknown, but it is clear that changes in the dura mater are closely related to normal physiological movements.



EFFECT OF INCREASED STRESS IN SOLID
BRAIN

Apledger considers the bones of the cranial vault to be the most difficult place in the membrane system of the dura mater. Therefore, the bones of the skull, sacrum, and coccyx can be used as a means of influence in the diagnosis and treatment of increased stress.

Apledger believes that increased tension in the membrane system of the dura mater is the most common case of dysfunction, histologically reflected in the structure of the fibers of the dura mater, which in case of increased tension is aligned along the tension line.

ANATOMY OF A SOLID MEMBRANE SYSTEM
BRAIN

The brain is soft and jelly-like in consistency, while the consistency of the spinal ligaments is somewhat harder. The membranes, spinal column and skull, together with accompanying ligaments, protect the central nervous system from mechanical stress. The membranes consist of the dura mater, which is a thick outer layer, a more fragile vascular and thin layer. The thin membrane fits tightly to the brain and spinal cord. The thin and choroidal membranes form the subarachnoid space, which is filled with cerebrospinal fluid. The dura mater and cerebrospinal fluid provide basic support and protection to the brain and spinal cord. The cranial dura mater is attached to the periosteum, lining the inner surface of the skull. The periosteum of the inner surface passes into the periosteum of the outer surface of the skull at the border with the foramen magnum and openings for nerves and blood vessels /87/.



The cranial dura mater is a durable layer of collagenous connective tissue penetrated by nerve endings and blood vessels. The spinal dura mater is a tube penetrated by the roots of the spinal nerves, which extends from the foramen magnum to the second sacral segment. The spinal dura mater is separated from the wall of the spinal canal by the epidural space, which contains fatty tissues, venous plexuses and cerebrospinal fluid. The spinal dura mater is also heavily innervated and contains many vessels. A detailed description can be found in Wagg and Kiernan /87/. Suffice it to say that the cranial and spinal dura mater are richly innervated so that a slight curvature of the dura mater quickly radiates to the central nervous system and is accompanied by a corresponding muscle reaction.


NORMAL MOVEMENT OF THE DURAL MEMBRANE SYSTEM

Movement of the head and spine causes physiological changes in the tension of the dura mater surrounding the brain and spinal cord /88/. These changes occur due to the plastic adaptability of nervous tissue; the spinal column changes length and shape during normal movements. The dura mater folds and stretches like an accordion between the vertebrae, allowing the nerve tissue to move freely.

If soft tissue restrictions or bony deformities interfere with normal movement of the dura mater, normal movement of the nerve tissue is impaired. Conversely, the contracted dura mater allows for significant bone deformations without traumatizing the nerve roots.

Thus, in the case of serious anomalies there may be minimal neuralgic changes, and with minimal bone changes there may be major neuralgic disorders.

There is a significant difference in the mobility of the anterior and posterior surfaces of the dura mater of the cervical and lumbar regions, this is reflected in the anatomical structure. The dorsal dura mater is an inelastic membrane that moves, folding like an accordion, while the anterior part of the dura mater is attached to the posterior surface of the vertebral bodies and is fixed by nerve endings /89-91/.

When the patient's head is in rotation, the cervical canal narrows, while the first cervical vertebra, along with the dura mater, moves laterally. The spinal foramen becomes smaller when the dura mater folds, as this happens with a camera when the diaphragm narrows /88/. Therefore, if the dura mater is shortened by even minimal disc protrusion or bone abnormality, this will provoke pain and dysfunction /92/.

In healthy subjects, head flexion increases dural tension /92/. When the patient's chin is pressed to the chest as much as possible, the maximum amplitude of flexion occurs, and more pressure will be applied to the dura mater. The dorsal part of the dura mater between the occipital bones and the sacrum is 0.5 cm longer than the anterior part. Using cadavers, Brieg was able to show that the thin meninges stretched and immediately transferred the resulting tension to the lumbosacral part of the membrane, nerve roots and sacral endings, if the patient's torso was straight and the cervical spinal column was tilted forward /90/.

With hyperextension of the head, the length of the dura mater decreases, causing relaxation of the spinal ligaments and nerve fibers /90/. The anterior surface of the dura mater relaxes and forms harmony-type folds at the level of the discs. This allows the anterior portion of the dura mater to blend into the spinal canal. At the same time, its lateral and posterior surface, which lies between the vertebral arches, folds and protrudes into the spinal canal. Since the dura mater is attached to the arches by connective tissue, it does not have freedom of action inside the canal /88/. Therefore, during head flexion, the roots of the cervical nerves move upward. This increases the distance between the nerve roots and the dura mater /93/, and possibly causes compression of the nerve endings if the spinal foramina are somehow narrowed or if the dura mater is shortened. The greatest opportunity for shortening and lengthening of the dura lies in the posterior part of the cervical spinal canal.

Lateroflexion of the head causes folding of the dura mater on the concave surface and stretching and smoothing on the convex surface. Nerve endings are often pinched on the convex surface, as they are located on the surface of the concave side, approaching the vertebrae.

At the atlanto-occipital joint, axial folding of the dura mater takes place; as well as in the lower parts of the cervical and thoracic spine with a straight posture. When the head rotates, the axial fold of the dura mater deepens between the 1st cervical vertebra and the back of the head. The stronger the rotation, the further in the periphery this effect of chipping of the dura mater is observed /78/.

The appearance of lordosis or kyphosis in the lumbar region leads to the same movements of the dura mater. At maximum kyphosis, Brieg found that the posterior dura mater stretched by 2.2 mm /88/. While Charniey determined that the difference in the length of the lumbar spine during flexion and extension is 5 mm /91/. If this movement were distributed along the entire length of the lumbar vertebrae, then each spinal root would have very little movement. Therefore, when the patient is asked to flex (tilt) the pelvis, the posterior part of the dural tube is stretched and lengthened. If the patient is then asked to raise his head, the dura mater is stretched to its maximum, transmitting tension from the sacrum to the occiput and vice versa.

PAIN AS A SIGN OF HARD SHORTENING
BRAIN

Pain from the dura mater is felt locally, according to anatomical restrictions. Thus, damage to the cervical area can cause pain spreading from the middle of the neck to the shoulder blade and temple, and forehead, and into the depths of the eyes. The complete localization of pain corresponds to the presence of twelve dermatomes in the human body, and in accordance with the irradiation of pain along the sinuverteral nerves /96/.

Regardless of the area of ​​limitation of the dura mater, pain is provoked by coughing, simulating the provocation of a disc herniation.

DIAGNOSTICS OF DURAL SHORTENING

Patients with decreased muscle tone often take a “fetal” position in static form. Maitland (12) often uses this test as a sign of dural shortening, and refers to it as the static instability test. Excessive pressure placed on the spine causes it to rotate. Stretching of the dura mater is accompanied by straightening of the knee joints and the disappearance of dorsal flexion of the back. Often, shortening of the dura mater is accompanied by ischemic pain.

Traction of the patient's legs causes stretching of the dura from the LIY level. Shortening of the dura mater occurs especially often in cases where flexion of the cervical spine causes pain in the lumbar spine or when traction on the patient’s legs causes flexion of the body. Cyriax and Maitland treated with spinal manipulation, while Barnes and Upledger used dural release techniques.

DURAL RELAXATION BY ONE DOCTOR

The patient lies on his side, the head is flexed, the hip and knee joints are bent so that the torso and legs are in the fetal position, the head is neutral. The patient lies on his side (Fig. 112), with a pillow under his head. You need to sit on a chair next to the couch in the middle of the distance between the buttocks and the head, put your hand on the back of your head, covering it with your palm, while your fingers rest lightly and freely on the back of your head. The other hand is positioned on the sacrum so that the base of the palm fixes the base of the sacrum (Fig. 113-114). It is necessary to simultaneously gently flex the head and extend the sacrum (Fig. 115). Hold until you feel relaxed and spontaneous movement appears. Let the doctor's hands follow this movement until a stop occurs. It is necessary to again gently “press” on the back of the head and sacrum and release the pressure, simulating swinging movements (Fig. 116), following the relaxation and its stop in the mode that appears. The result will be achieved if the rhythm becomes regular and relaxation is complete.

Rice. 113. Position of the hand on the head to correct imbalance of the dura mater. The base of the skull is fixed with the doctor's palm, and the fingers rest gently on the back of the head.

Rice. 114. Position of the hand on the sacrum to correct imbalance of the dura mater. The edge of the palm is pressed tightly to the sacrum, and the fingers tightly but easily touch the buttocks.

NEVER stop a patient if their rhythm is irregular. If the sacrum and occiput do not swing in synchronized rhythm, it is important to repeat the procedure until the rhythm is symmetrical. Having finished restoring the balance of the dura mater, it is important to return again to ineffective techniques that were previously used without success.

If the patient is unable to take a comfortable position on the band, this procedure can be performed with the patient lying on his stomach (Fig. 117), although passive maximum relaxation is impossible in this position. The “sitting” position is also possible (Fig. 118), although the sacrum is fixed in this position.

Rice. 115. Correction of imbalance of the dura mater in position
lying on the side A – the position of the hands on the skeleton attached to the patient’s body.

B - a gentle displacement of the head and sacrum forward after preliminary stretching of the dura mater, then you can follow the response movement of the tissues until it stops, and then the rhythmic oscillation resumes.

Rice. 116. A gentle shift of the head and sacrum towards each other; when a rhythmic movement appears, it is necessary to follow the movement of the tissues until it stops, and then the rhythmic oscillation resumes.

Rice. 117. Correction of imbalance of the dura mater.
The patient lies on his stomach.

Rice. 118. Correction of imbalance of the dura mater.

Rice. 119. Correction of dural imbalance by two doctors. The patient is positioned on his back, legs flexed.

RELAXING THE DURAL MINING WITH THE HELP OF TWO DOCTORS

Relaxation by two specialists can be aimed at the dura mater or the pelvic floor and thoracic inlet muscles separately and simultaneously. The patient lies on his back, legs are flexed at the joints (Fig. 119). Before the procedure, the patient raises the pelvis so that you can move your hand between your legs and flex the dorsal surface of the sacrum. The doctor's fingers are bent and adjacent to the base of the sacrum (Fig. 120). The patient lowers the pelvis onto the couch, and the doctor applies traction to the sacral area. Next, the patient straightens his legs while the doctor’s hands rest on the elbow and applies additional traction, shifting his body dorsally (Fig. 121). The second hand, located above the pubic symphysis, moves it in the caudo-cranial direction, achieving relaxation of the pelvic floor muscles (Fig. 122). The second assistant simultaneously applies gentle cervical traction (Fig. 37-40). The doctor, exercising greater mobility, stands at the patient's head. Any of the previously described posterior cervical musculature tractions can be used. At the same time, you can relax the muscles at the entrance to the chest (Fig. 123).

Rice. 120. Correction of dural imbalance by two doctors

A – The patient is positioned on his back, the pelvis is raised. The doctor places his hand between the patient's legs and flexes the sacrum.

B – Correction of dura mater imbalance.

C – Position of the hand on the sacrum.

D – Position of the hand on the skeleton attached to the patient.

Rice. 121. Technique for restoring the balance of the dura mater. Position of the doctor and the patient for applying traction to the sacrum during restoration of the balance of the dura mater.

Rice. 122. Technique for restoring the balance of the dura mater. The position of the 2 doctors and the patient before the start of the procedure. Performing pelvic floor relaxation.

Rice. 123. Technique for restoring the balance of the dura mater. Perform pelvic floor and chest cavity release techniques.

VISUAL DIAGNOSTICS

When it comes to myofascial treatment, the doctor must perform a detailed postural examination in addition to the usual assessment for diagnosis. When conducting this examination, the doctor must be alert to those signals and symptoms that do not correspond to the usual picture of this diagnosis. The examination never ends, but always precedes the treatment.

Since myofascial traction is reflected in changes in posture, this examination should be very detailed in order to record these changes in your clinical notes, reports to the doctor, insurance companies, lawyers and, most importantly, in your conversations with the patient. The patient often cannot assess his changes clearly enough, especially at the initial stage of his treatment, when these changes are so small that the untrained eye will not quickly notice them. In these cases your documentation is very helpful. And the main reason for documentation, of course, is to determine whether changes are going in the right direction.

When posture changes, the central nervous system is retrained to new sensations that come from an increased level of coordination. This initially causes a conflict between the statics to which the nervous system is adapted and the statics that are formed anew with coordination that the nervous system perceives relative to the previous one as incorrect. This conflict is accompanied by a temporarily decreased stability, which can bring the patient a feeling of discomfort and increased pain. If this happens, it is necessary to show the patient changes in his posture. This will give you the opportunity to reassure him that the changes are for the better and that once his body adjusts, he will feel better.

Written descriptions can be confusing for the patient. Therefore, usually for the mutual benefit of both the patient and one’s own, I always take photos on the first visit and afterwards. I take pictures of all four posture positions. If possible, the patient should wear a minimum of clothing. And these photographs and negatives are kept in the patient’s personal file. The photographs are dated, numbered and marked as to whether they were taken before or after treatment.

A qualitative assessment of posture is difficult, since you do not want to stand close to the patient with a ruler, goniometer, or plumb line. It is enough to evaluate it periodically by eye. A standard range of movement measurements should also be part of the overall examination. The assessment forms (found in the appendix) give a broad overview of the techniques that are used. Sometimes, depending on the patient's complaints, a little more or less detail is required for examination and assessment. If you choose photocopies and use the following forms, be sure to establish the degree of deviation if, for example, one shoulder of the patient is higher than the other.

One advantage of the scoring scheme is that, at a minimum, all of its items can be assessed periodically. This way, changes to each item can be noted, recorded, and communicated to your physician, insurance company, or attorney. All doctors know well how difficult it is to sit and constantly write explanations and reports and look for inconsistencies in the use of specific drugs. Tedious work is kept to a minimum by using mark sheets. I also use computer-generated flow programs to speed up descriptions of changes. After each inspection, changes are made to the flow-sheet. When it is filled out, it is all printed and entered into the patient’s medical history, where progress in the condition is noted (progress letter). Thus, the doctor is always aware of changes and improvements in the patient’s condition.

During the first visit, the main attention is paid to interviewing the patient, as many details as possible are clarified from the anamnesis. The conversation is recorded on a tape recorder. Sometimes I record everything on a tape recorder, then transcribe it and store it as part of the medical record. If the initial injury was due to an accident, this history can be an important aid in determining which joints have suffered traction, compression, or hyperextension. Initial treatment should be directed at these joints until the myofascial feedback begins to guide treatment.

The history is placed at the end of the card. It is necessary to find an opportunity to listen to the patient for the simple reason that the patient needs to tell someone and this serves to establish mutual understanding between them. To begin treatment, an assessment of posture is more important to me than the patient’s own story. However, if the treatment is to include somato-emotional relaxation, this side information helps me assess what physiological movements may occur.

The second part of the first visit is a posture assessment. It is done only visually, without hands. The patient is photographed at the beginning of the examination, when the patient tries to maintain his best posture. Then, during treatment, when changes in posture appear when relaxing. Major changes are most likely in the presence of trunk rotation.

Dictation serves three purposes. The first is speed. The second secretary listens to the dictation, fills out forms and writes down the doctor’s comments. Needless to say, filling out forms by computer is the most efficient method, but photocopies are also good. Third, during dictation, the patient, hearing my various comments, pays more attention to his posture. And then, looking in the mirror, he can also notice changes. This turns him from a passive subject into an accomplice. Often this turns into a game: “I was the first to see it,” when the patient is eager to be the first to notice and talk about changes in posture.

To assess posture, ask the patient to stand with his back to the wall so that his legs are a few cm from the wall. There is no particular difference in distance. A patient who has problems with balance or spatial orientation will stand closer to the wall and even try to lean against it. You can ask the patient to move away from the wall and silently write down his observations. Later you will understand why the patient is standing this way. Maybe he just misunderstood the directions. It is important to try to look the patient in the face and not talk behind his back. Ask the patient to focus their vision on a point above your head. I always try to sit during the examination so that the patient does not crane his head to look above his head. I prefer to make the assessment after the patient removes the glasses. This makes the eyes more clearly visible. This also makes it possible to provoke coordination problems, since it can be compensated by vision. If it is impossible to remove the glasses because it causes stress or imbalance, then ask him to move them at least while examining him from the front. Before you begin dictating, ask the patient to remove hair from their ears and neck. There is no need for him to support the hair with his hand as this changes his posture.

At the end of the examination, if the patient’s legs are not parallel and the torso is rotated, you must ask him to stand facing you with his legs parallel. It is important to stand closer to the patient because many patients lose their balance when asked to do so. If this does not cause loss of balance, you can move away and perform the visual inspection again. With legs standing parallel, rotation of the shoulder girdle may increase. Do not leave the patient in this position for a long time, as the discomfort may irritate the patient.

Once the posture assessment is completed, skin mobility can be assessed while the patient is standing. The patient's skin mobility can also be assessed in a standing and sitting patient. During such an examination, the scars should be palpated for restrictions.

In a standing patient, after assessing skin mobility, the mobility of the spine and sacroiliac joint should be checked /98/. Before proceeding with palpation, it is necessary to visually assess the movement. The quality of movement is the most important aspect. It is necessary to answer the symmetry and asymmetry of movement. In general, with symmetrical movement, it is possible to improve compensation in a shorter time. Very rarely there is symmetry in pathology. The patient often makes movements without the participation of those spinal motion segments in which the patient feels pain. If only the number of movements is assessed, then most of the information is missed. Immobility and hypermobility can be localized at the vertebral level.

Many doctors usually easily diagnose the mobility of the lumbar spine and often forget to perform the same procedure at the thoracic and cervical level. It is necessary to assess the mobility of the sacroiliac joints and lumbar motion segments with the patient in a sitting position in order to diagnose the effect of muscle shortening on pelvic mobility. The assessment process is a systematic approach that will enable the limitations of myofascial structures to be identified and treatment initiated.

Myofascial restrictions identified in this way are the most severe and superficial when judged by their effect on the body as a whole. What is revealed during the initial examination may not be the main limitation. The body is a single kinematic chain. Changes in the mobility of one part of the body entail changes in the mobility of other parts; asymmetrical posture of any part of the body leads to asymmetry of its other parts.

The most dramatic example of the effect of asymmetry of one part of the body on another is in patients with peripheral paralysis when a peripheral nerve is damaged as a result of illness or accident. In fact, myofascial stretching is the safest method for peripheral paralysis, since feedback from the patient will not allow overstretching and, thus, maintaining protective tissue tension.

Once the sitting and standing assessment has been completed, it is important to begin assessing leg length from the most comfortable position. Many differences in mog length dating back to childhood can be corrected using myofascial release. Anatomical changes cannot be corrected, but it is possible to change the soft tissue response.

CONCLUSION

This guide is only an introduction to the theory of myofascial release. The key to myofascial release is the sensitivity of the therapist's hands. The only way to develop this skill is to carry out diagnostics with the hands of as many patients as possible in order to feel the soft tissues and their reactions. Then you must learn to trust the sensations in your hands and respond to it. Give the patient the opportunity to guide you. It is important to learn to relax and feel comfortable.

APPLICATION

INSPECTION SCHEME VISUAL INSPECTION AND POSTURE ASSESSMENT

The dura mater spinalis et encephali (Fig. 510) lines the inner surface of the skull and spinal canal.

The hard shell consists of two layers - outer and inner. In the skull it functions as periosteum and over most of it easily peels off from the bones. It is firmly attached to the bone along the edges of the openings of the base of the skull, on the crista galli, on the posterior edge of the lesser wings of the sphenoid bone, on the edges of the sella turcica, on the body of the sphenoid and occipital bones (clivus) and on the surface of the pyramids of the temporal bone. In the outer layer of the dura mater, as well as in the grooves of the bone, nerves, arteries, and two veins each accompany the arterial trunk. The inner layer of the dura mater is smooth, shiny and loosely connected to the arachnoid, forming the subdural space.

The dura mater surrounding the spinal cord is an extension of the dura mater of the brain. It starts from the edge of the foramen magnum and reaches the level of the third lumbar vertebra, where it ends blindly. The hard shell of the spinal cord consists of dense outer and inner plates consisting of collagen and elastic fibers. The outer plate makes up the periosteum and perichondrium of the spinal canal (endorachis). Between the outer and inner plates there is a layer of loose connective tissue - the epidural space (cavum epidurale), in which the venous plexuses are located. The inner plate of the dura mater is fixed on the spinal roots in the intervertebral foramina. In the cranial cavity, the dura mater forms crescent-shaped processes in the fissures of the brain.
1. The falx cerebrum (falx cerebri) is a very elastic plate located vertically in the sagittal plane, penetrating into the gap between the hemispheres of the brain. In front, the sickle is attached to the blind foramen of the frontal bone and the cock's crest of the ethmoid bone, its convex edge is fused along its entire length with the sagittal groove of the skull and ends on the internal occipital eminence (eminentia occipitalis interna) (see Fig. 510). The inner edge of the falx cerebri is concave and thickened, as it contains the inferior sagittal sinus and overhangs the corpus callosum. The posterior part of the falx cerebri is fused with a transversely located process - the tentorium of the cerebellum.

510. Internal base of the skull with cranial nerves passing through it.
1 - n. opticus; 2 - a. carotis interna; 3 - n. oculomotorius; 4 - n. trochlearis; 5 - n. abducens; b - n. trigeminus; 7 - n. facialis; 8 - n. vestibulochlearis; 9 - n. glossopharyngeus; 10 - n. vagus; 11-n. hypoglossus; 12 - confluence sinuum; 13 - sinus transversus; 14 - sinus sigmoideus; 15 - sinus petrosus superior; 16 - sinus petrosus inferior; 17 - sinus intercavernousus; 18 - tr. olfactorius; 19 - bulbus olfactorius

2. The tentorium (tentorium cerebelli) is located horizontally in the frontal plane between the lower surface of the occipital lobes and the upper surface of the cerebellum. The posterior edge of the cerebellar tent is fused with the falx cerebrum, the internal eminence, the transverse sulcus of the occipital bone, the upper edge of the pyramid of the temporal bone and the posterior sphenoid process of the sphenoid bone. The anterior free edge limits the notch of the cerebellar tent, through which the cerebral peduncles pass into the posterior cranial fossa.

3. The cerebellar falx (falx cerebelli) is located in the posterior cranial fossa vertically along the sagittal plane. It starts from the internal eminence of the occipital bone and reaches the posterior edge of the foramen magnum. It penetrates between the cerebellar hemispheres.

4. The diaphragm of the sella turcica (diaphragma sellae) limits the fossa for the pituitary gland.

5. The trigeminal cavity (cavum trigeminale) is a steam room, located at the apex of the pyramid of the temporal bone, where the trigeminal nerve ganglion is located.

The hard shell forms the venous sinuses (sinus durae matris). They are a stratified hard shell over the grooves of the skull bones (see Fig. 509). The elastic wall of the sinuses is formed by collagen and elastic fibers. The inner surface of the sinuses is lined with endothelium.

Venous sinuses are collectors that collect venous blood from the bones of the skull, dura and soft meninges, and brain. There are 12 venous sinuses inside the skull (see).

Age-related features of the meninges. The dura mater in newborns and children has the same structure as in an adult, but in children the thickness of the dura mater and its area are smaller than in adults. The venous sinuses are relatively wider than those of an adult. In children, peculiarities of fusion of the dura mater with the skull are noted. Up to 2 years it is strong, especially in the area of ​​fontanelles and grooves, and then fusion with the bone occurs, as in an adult.

The arachnoid membrane of the brain under the age of 3 years has two layers separated by space. Arachnoid granulations only develop for about 10 years. In children, the subarachnoid space and cisterna cerebellomedullaris are especially wide. In the soft shell, after 4-5 years, pigment cells are detected.

The amount of cerebrospinal fluid also increases with age: in newborns it is 30-35 ml, at 6 years old - 60 ml, at 50 years old - 150-200 ml, at 70 years old - 120 ml.

(dura mater; synonym pachymeninx) external M. o., consisting of dense fibrous connective tissue, adjacent in the cranial cavity to the inner surface of the bones, and in the spinal canal separated from the surface of the vertebrae by the loose connective tissue of the epidural space.

  • - 1. A thin layer of mesoderm surrounding the brain of the embryo. From it, most of the skull and the membranes surrounding the brain subsequently develop. See also Cartilaginous skull. 2. See Meninges...

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  • - the inner of the three membranes surrounding the brain and spinal cord. Its surface adheres tightly to the surface of the brain and spinal cord, covering all the grooves and convolutions present on it...

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  • - The outer, thickest of the three meninges, surrounding the brain and spinal cord. It consists of two plates: outer and inner, and the outer plate is also the periosteum of the skull...

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  • - the outer of the three meninges covering the brain and spinal cord. Source: "Medical...

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  • - an altered mucous membrane of the uterus, which forms during pregnancy and is rejected with the placenta after the birth of the child...

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  • - Sinuses of the dura mater. falx cerebri; inferior sagittal sinus; anterior intervertebral sinus; sphenoparietal sinus; posterior intervertebral sinus; superior petrosal sinus; tentorium cerebellum...

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  • - M. o., adjacent directly to the substance of the brain and spinal cord and repeating the relief of their surface...

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  • - M. o., located between the dura and pia maters...

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  • - see. Soft mater of the brain...

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