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So 7 out of 8 MS patients had abnormal cervical spine anatomy but so did 75% of the normal patients as well. In these normal patients, if abnormal spinal anatomy is presumed to be the cause of the CSF flow abnormalities, we should have expected CSF flow abnormalities in the normal controls. But they all had normal CSF flow.Another unexpected finding was the high percentage of “normal” adults that did not qualify
as normal. It was found that a large percentage of normal examinees (as high as 75%)
did not qualify as normal with respect to their cervical spine anatomy, e.g., exhibiting localized
disc herniations (or significant bulges) at C5/6 or elsewhere, or localized interruptions
of CSF flow. Such examinees were entirely asymptomatic currently and
historically, but were nonetheless unable to meet a standard for normal cervical spine
anatomy. With the cervical spine being the most active segment of the spine, the finding,
though unexpected, is not inconsistent with the cervical spine’s high degree of biomechanical
activity.
I was expecting us to have slowed CSF flow, but this is saying we have elevated CSF flow velocity.Among the MS patients, three of the eight patients had significantly (P < .05) elevated
peak CSF outflow (systolic) velocities (cm/sec) from the brain (2.58, 1.80, 2.03 cm/sec)
in the upright position (Table 2A, col. 2, patients #2, #4 and #5) compared to the mean
value for the normal examinees in the upright position (.893 ± .32 cm/sec, Table 2B,
col. 2). Outflow velocities for all three of these MS patients were more than twice the upright
outflow peak velocities for the normal examinees. Four (patients #1, #2, #4, and #5)
had significantly elevated peak CSF outflow velocities (cm/sec) (1.52, 1.39, 2.71 and 2.14
cm/sec, Table 2A, col. 3) in the recumbent position, two of which (2.71 and 2.14 cm/sec)
were more than twice the normal value (.896 ± .17 cm/sec, Table 2B, col. 3). A fifth MS
patient (patient #3) had a recumbent CSF outflow velocity of .336 cm/sec that was significantly
reduced relative to normal (.896 ± .17 cm/sec).
In addition, two of the eight MS patients (Table 2A, col. 4, patients #2 and #5) exhibited
significantly elevated peak inflow velocities in the upright position (Table 2A, col. 4,
1.047, and .731 cm/sec) relative to the peak inflow velocities of normal examinees (.400
cm/sec) in the upright position (Table 2B, col. 4). Importantly, therefore, five of the eight
MS patients had at least one significantly abnormal peak CSF velocity measurement in
three of the parameters measured (upright outflow, recumbent outflow, and upright
inflow), and three of the MS patients exhibited elevated peak velocities in both the upright
and recumbent positions (patients #2, #4, and #5, Table 2A, col. 2 & 3).
I'm reminded of idiopathic intracranial hypertension.Struck and Haughton have pointed out in their study of CSF flow obstruction in Chiari patients
that “the increased CSF flow velocities are associated with steeper pressure gradients
across the foramen magnum” (10).
Alperin et al. have further established that there is a linear correlation between the measured
CSF pressure gradient and the measured CSF Intracranial Pressure (ICP) when CSF
dynamics are measured in vivo (11). As Alperin reported, “A twofold increase in the amplitude
of the oscillating pressure (ICP) yielded a twofold increase in the amplitude of the
pressure gradient” (11, p. 881).
CRANIO-CERVICAL TRAUMA AND ABNORMAL CSF HYDRODYNAMICS IN MS 13
Accordingly, the elevated peak CSF velocities measured in the MS patients of this
study would indicate the existence of elevated intracranial pressures (ICP) in these MS
patients.