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Upper Cervical Spine Alignment and the Skull

Upper Cervical Spine Alignment and the Skull
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Chronic Headaches, Balance Problems, Brain Fog, and More

Chiropractic clinical practice acknowledges that there is a unique and important relationship between the alignment of the skull and the upper cervical spine. Nearly all chiropractic techniques (specific treatment approaches) treat alignment problems of the upper cervical spine, but many chiropractors only treat the upper cervical spine, a testament to the importance of the region and the clinical benefits such treatment delivers.

Chiropractors that specialize in alignment of the skull and the upper cervical spine often analyze the biomechanics of the region with precision radiography. This analysis is the basis of carefully applied vector forces to correct biomechanical alignment problems. This approach has proven to result in effective clinical outcomes (1). Recently, advanced imaging, specifically upright MRI, has been used to establish the pathology associated with skull/upper cervical spine alignment problems, as well as to explain the clinical benefits of upper cervical spine chiropractic care (2).

The Jim McMahon Story

Jim McMahon was a great football quarterback. He was born in 1959. He played college football at Brigham Young University, earning All-American status in 1980 and 1981. The Chicago Bears drafted him in the first round of the NFL draft in 1982.

In 1982, McMahon was UPI NFC Rookie of the Year. He earned a Pro Bowl appearance in 1986, and two Super Bowl Rings. He appeared on the cover of Sports Illustrated numerous times (3). During his playing career, McMahon suffered four documented concussions. McMahon retired in 1996 at the age of 37 years.

Sixteen years after he retired from football, at age 53, McMahon appeared on the cover of Sports Illustrated (September 10, 2012 issue) once again (4). It was an article detailing his struggles with dementia. McMahon’s behaviors included:

  • Lying on the bed watching the ceiling fan go round and round.
  • Significant excessive sleeping, like “hibernating.”
  • Not remembering where he wanted to go.
  • Stumbling on furniture he felt had been rearranged (it had not).
  • Being unable to find the bathroom.
  • Not knowing where he was.
  • A change in personality: no longer charismatic, sweet, confident, funny, or warm.
  • Boarding the wrong airplane flight.
  • He would drop to his knees, break into a cold sweat and turn a ghostly white, complaining of a pain that he compares to having an ice pick in his brain.

To compensate, his girlfriend:

  • Printed a card with his vital statistics and her phone number and placed it in his wallet.
  • Programmed their car’s GPS with their address and her phone number.
  • Made sure the home alarm was on at all times in case he tried to wander off alone.

Recently (2016), Jim McMahon has appeared prominently again in the media. He has been profiled in an ESPN Special Report as a consequence of a change in his clinical status. The signs and symptoms of his chronic neurodegenerative disorder have quickly and dramatically improved, and consistent with his character, he’s talking about it (5).

An upright weight-bearing MRI was taken of McMahon’s head and neck. As noted above, the imaging showed an accumulation of fluid (cerebral spinal fluid) in his skull and around his brain. Consistent with the biomechanics and physiology reviewed in this article, McMahon’s upper cervical specific chiropractor took precise radiographs of McMahon’s upper neck and skull. A careful, precise, mathematical analysis of his radiographs showed that there was a meaningful malalignment between the skull and the atlas vertebra. Such findings are consistent with an impairment of fluid flow (venous, arterial, cerebral spinal) between the skull (brain) and the spinal canal. This biomechanical finding could account for the increased fluid noted in the MRI of his brain. The increased brain fluid could account for the plethora of signs and symptoms McMahon was suffering from.

Prior to this unique treatment, the ESPN Special noted that McMahon, age 56, was suffering from:

  • Bad headaches
  • “Pressure in my skull”
  • Couldn’t see very well
  • Couldn’t talk very well
  • “All I wanted to do is lay down because my head was constantly pounding”

Following the precise analysis of his upper cervical spine-occiput biomechanical relationships, Jim McMahon was carefully chiropractically adjusted. The sole goal of the adjustment was to establish perfect alignment between the occiput and the atlas vertebrae. This goal was achieved, verified by post-adjustment radiographs that were similarly biomechanically analyzed. The improvement in his signs and symptoms were essentially instantaneous.

A post adjustment upright weight-bearing MRI of McMahon’s brain and spinal cord showed a remarkable reduction of fluid, as if an inverted bottle had been uncorked. McMahon’s improvement in clinical status is both substantial and appears to be long lasting. Within two minutes of the chiropractic adjustive procedure, McMahon commented:

  • “It was like the toilet flushed”
  • “I could feel the stuff leaving my brain”
  • “My eyes cleared up”
  • “My speech cleared up”

A post treatment MRI showed significantly less fluid accumulation on McMahon’s brain. McMahon commented that the procedure “kept me from having bad pains and suicidal thoughts, and having me function fairly normally.”

Following the chiropractic upper cervical spine adjustment, in July 2016, Jim McMahon was participating in the Tahoe South Celebrity-Am golf event when a Sacramento Bee sports reporter caught up with him for a story (6). The interview mentions that McMahon was one of the original plaintiffs in the concussion lawsuit that former players filed against the NFL. When questioned about his pain, fatigue, and brain function, McMahon replied:

“I’ve got my good days and bad. As long as I keep my neck and head in alignment, I’m fairly normal.”

The article notes that McMahon visits a chiropractor in New York every two or three months to keep everything lined up, stating:

“It keeps the spinal fluid flowing properly. When it gets out of whack, all I want to do is lay down in a dark room.”

A year later, July 2017, Jim McMahon is once again participating in the celebrity American Century Championship golf tournament. This time he was caught by San Francisco Chronicle sports reporter Scott Ostler (7). Ostler’s article notes that McMahon is now 57 years of age, and states:

“Five years ago, a Sports Illustrated story spotlighted his head problems. McMahon had been diagnosed with early-onset dementia.”

“The reports had McMahon in bad shape, in near constant pain, wandering through life in a fog, frustrated and angry. He’d drive to an errand, phone his girlfriend and ask, like a lost child, ‘Where am I?’”

When asked about his head:

“He says it’s good. After his woes became public in 2012, McMahon was contacted by a person who said he might be able to help him. A New York chiropractor… told McMahon he had neck-alignment problems.”

“The misaligned parts were short-circuiting the flow of cerebrospinal fluid up and down his brainstem and spine.”

“Some adjusting… freed the flow, kind of like un-kinking a garden hose.” “The relief was instant and dramatic.”

“McMahon says his short-term memory is much improved. The ice-pick headaches are gone. He’s a functioning human being. Whenever symptoms return, he goes back for a tune-up and is good to go for another few months.”


The physiology and health of the brain and spinal cord is dependent upon the flow and movement of cerebral spinal fluid. The cerebral spinal fluid is generated in the brain and circulates throughout the brain and the spinal cord. To get to the spinal cord, the cerebral spinal fluid must pass through a hole in the skull, the foramen magnum. The top of the spinal column also has a hole through which the cerebral spinal fluid must flow, the atlas vertebrae, also known as cervical-1 or C-1.

Starting in 2003, studies began to show that radiographically measured biomechanical misalignment between the foramen magnum hole and the atlas vertebrae hole impaired the flow of cerebral spinal fluid between the skull and the spine (8). The author, Marshall Deltoff notes (8):

“Upper cervical practitioners utilize the radiographic measurement of static vertebral misalignment to help determine on which side and at what angle the adjustment [specific spinal manipulation] should be given.” p. 59

“MRI is an invaluable aid in diagnosing disorders of the brainstem, medulla, upper cervical cord an spinal canal. Congenital lesions, intramedullary and extramedullary intradural disease, including tumours, infection, ischaemia and demyelination can be assessed. MRI also provides valuable information about the encompassing bony and ligamentous structures of the cranio-vertebral junction and the cervical spine.” p. 57

With MRI technology, water accumulation (swelling, etc.), images differently than tissues/regions that have less water (swelling, etc.). When water/fluid accumulates in a region, MRI technology can easily document this water/fluid accumulation. Impairments of water/fluid flow (cerebral spinal fluid flow) are best documented with upright weight-bearing MRI (2).

overlapping circles

misaligned overlapping circles

A small misalignment between the hole of the skull (foramen magnum) and the spine (atlas vertebrae) causes:

  • An accumulation of cerebral spinal fluid in the brain
  • An increase in cerebral spinal fluid pressure in the brain

This model of skull-atlas misalignment impairment of cerebral spinal fluid flow causing increased cerebral spinal fluid pressures in the brain, is associated with symptomology and dysfunction. The benefits of upper cervical spine chiropractic adjusting is gaining scientific support and media attention. Supportive studies include the following:


In 2011, a study appeared in the journal Physiological Chemistry and Physics and Medical NMR, and titled (9):

The Possible Role of Cranio-Cervical Trauma and Abnormal CSF
Hydrodynamics in the Genesis of Multiple Sclerosis

In this study, eight multiple sclerosis (MS) patients and seven normal volunteers were MRI scanned with a quadrature head-neck combination coil to visualize the overall cerebral spinal fluid (CSF) flow pattern. The findings were best visualized with an upright weight-bearing MRI. These authors note:

“Upright cerebrospinal fluid (CSF) cinematography and quantitative measurements of CSF velocity, CSF flow and CSF pressure gradients in the upright patient revealed that significant obstructions to CSF flow were present in all MS patients.”

Abnormal CSF flows were found in all eight MS patients. “The abnormal CSF flows corresponded with the cranio-cervical structural abnormalities found on the patients’ MR images.”

“Every MS patient exhibited obstructions to their CSF flow when examined by phase coded CSF cinematography in the upright position.”

“All MS patients exhibited CSF flow abnormalities that were manifest on MR cinematography as interruptions to flow or outright flow obstructions somewhere in the cervical spinal canal, depending on the location and extent of their cervical spine pathology. Normal examinees did not display these flow obstructions.”

“The abnormal CSF flow dynamics found in the MS patients of this study corresponded to the MR cervical pathology that was visualized.”

“The findings raise the possibility that interventions might be considered to restore normal intracranial CSF flow dynamics and intracranial pressure.”

“The findings further suggest that going forward, victims of Motor Vehicle Whiplash injuries with persisting symptoms, e.g., headache, neck pain, should be scanned by UPRIGHT(R) MRI to assure that their CSF hydrodynamics and cervical anatomy (C1-C7) are normal. Should their CSF hydrodynamics prove abnormal, they should be monitored by UPRIGHT(R) MRI to assure they are restoring to normal over time, or ultimately decompressed by expansion stenting or cervical realignment if they are not.”

This study is particularly important for chiropractors. These authors suggest that cervical spine malalignment obstructs the flow of cerebral spinal fluid. This obstruction of CSF flow increases intracranial pressure, leading to additional brain pathology and dysfunction.

These authors suggest that the improvement in cranial-cervical malalignment could improve cerebral spinal fluid flow, stopping the aforementioned cascade. In fact, in one of the MS patients, the UPRIGHT MRI found a malalignment of the occiput-C1. This malalignment was successfully treated by an upper cervical chiropractor. The authors noted:

“The patient’s symptoms, severe vertigo accompanied by vomiting when recumbent and stumbling from unequal leg length, ceased upon treatment [with a chiropractic upper cervical spine adjustment].” Objective improvements in obstructed CSF fluid was also noted “immediately following treatment with the [chiropractic adjustment].”


In 2015, another supportive study appeared in the journal Neurology Research International, and titled (10):

The Role of the Cranio-cervical Junction in Cranio-spinal
Hydrodynamics and Neurodegenerative Conditions

The author notes that cranio-spinal hydrodynamics refers to the relationship between blood and cerebral spinal fluid (CSF) volume, pressure, and flow in the relatively closed confines of the compartments of the cranial vault and spinal canal. He notes that cranio-spinal hydrodynamics can be disrupted by a number of mechanical lesions (congenital, degenerative, an acquired) of the cranio-cervical junction (CCJ), stating:

“The CCJ links the vascular and cerebrospinal fluid (CSF) systems in the cranial vault to those in the spinal canal.”

“The cranio-cervical junction (CCJ) is a potential choke point for cranio-spinal hydrodynamics and may play a causative or contributory role in the pathogenesis and progression of neurodegenerative diseases such as Alzheimer’s disease, Parkinson’s disease, multiple sclerosis, and ALS, as well as many other neurological conditions including hydrocephalus, idiopathic intracranial hypertension, migraines, seizures, silent-strokes, affective disorders, schizophrenia, and psychosis.”

“Malformations and misalignments of the CCJ cause deformation and obstruction of blood and CSF pathways and flow between the cranial vault and spinal canal that can result in faulty cranio-spinal hydrodynamics and subsequent neurological and neurodegenerative disorders.”

Congenital malformations/anomalies of the cranio-cervical junction (CCJ) can block blood and CSF flow between the cranial vault and spine, pushing the cerebellar tonsils and/or brainstem into the cervical canal, which further blocks the flow of CSF. This causes an accumulation of fluid in the cranial vault (hydrocephalus). Such conditions include:

  • Chiari malformations
  • Abnormal clivoaxial angle (11)
  • Hypoplasia of the posterior cranial fossa
  • Basilar invagination
  • Platybasia
  • Hypoplasia of the foramen magnum
  • Hypoplasia of the jugular foramen
  • Anomalies of the odontoid process
  • Premature closure of cranial sutures (craniosynostosis)

An acquired blockage to CSF flow, important to chiropractors, is a misalignment of the atlas on the occipital condyles. This author states:

“Misalignments of the CCJ [atlas-occiput articulation] can obstruct blood flow through the vertebral arteries and veins that can lead to chronic [brain/cranial] ischemia and edema.”

“Blockage of blood and CSF flow due to malformations and misalignments of the CCJ may play a role in chronic [brain/cranium] ischemia, edema, hydrocephalus, and ventriculomegaly [enlargement].”

“The CCJ is a potential choke point for blood and CSF flow between the cranial vault and spinal canal that can cause faulty cranio-spinal hydrodynamics and subsequent chronic ischemia, edema, and hydrocephalus.”

“Malformations and misalignments of the CCJ may play a role in chronic [brain/cranial] ischemia and edema, which may in turn lead to neurodegenerative processes and subsequent diseases.”

“Malformations, misalignments, and deformation of the CCJ compress the vertebral veins, which may affect CSF flow.” “An increase in CSF volume in the brain can compress veins and decrease drainage.”

This author emphasizes that the cranial-cervical junction is a choke point for cerebral spinal fluid flow between the cranial vault and spinal canal. He believes that manual, mechanical, and surgical correction of cranial-cervical junction structural problems will improve faulty cranio-spinal hydrodynamics and improve patient pathology and symptomatology, stating:

“Manual and surgical methods for correcting obstructions, as well as manipulation of blood and CSF flow, may help to restore or improve faulty cranio-spinal hydrodynamics in certain cases and decrease the prevalence, progression, and severity of neurodegenerative and other neurological conditions.”

The author notes that the blockage of cerebral spinal fluid flow at the cranial-cervical junction may be predisposed by a combination of congenital and/or degenerative conditions. Small misalignments of cranial-cervical alignment, superimposed on such congenital and/or degenerative conditions, increase the likelihood of an obstruction of the cerebral spinal fluid flow. The author notes that manual therapy/manipulation of the upper cervical spine has the potential to improve the flow of cerebral spinal fluid, improving the patient’s signs and symptoms.


In 2015, the most authoritative book written to date detailing the pathogenic potential, diagnosis, and treatment of cranio-cervical junction alignment problems was published (2). The reference book is titled The Craniocervical Syndrome and MRI. The editors are professor Francis W. Smith (London) and physician Jay S. Dworkin (New York). Three chapters of the book are particularly relevant to this discussion:

  • “Upright Magnetic Resonance Imaging of the Craniocervical Junction” by Francis W. Smith
  • “Concussion Update: Immunoexcitotoxicity, the Common Etiology of Post-concussion Syndrome, Chronic Traumatic Encephalopathy and Posttraumatic Stress Disorder” by Joseph Maroon, Jeff Bost, Austin Amos, Robert Winkelman,
  • Christina Mathyssek From the Department of Neurosurgery, University of Pittsburgh
  • “Cerebrospinal Fluid Physiology and Its Role in Neurologic Disease” by William Bradley from the Department of Radiology, University of California, San Diego
  • “The Craniocervical Junction: Observations Regarding the Relationship Between Misalignment, Obstruction of Cerebrospinal Fluid Flow, Cerebellar Tonsillar Ectopia, and Image-Guided Correction” by Scott Rosa and John Baird

These references make the following key points:

“Upright MRI provides the decisive utility of cerebrospinal fluid flow studies around the craniocervical junction.”

“Cerebrospinal fluid accumulation may play a role in traumatic brain injury” signs and symptoms.

“Magnetic resonance imaging (MRI) is conveniently performed in the supine position, in which no information about the effect of gravity on the patient in the upright position is possible.” [emphasis added]

“Head trauma commonly results in craniocervical trauma, which is theorized to cause cervical CSF flow abnormalities.”

“MRI may show CSF accumulation.”

“C1 misalignment may contribute to cerebrospinal fluid (CSF) flow obstruction.”

“Craniocervical junction misalignments can compromise the normal flow of spinal fluid in and out of the cranial vault.”

“Craniocervical junction misalignments can cause headaches, neck pain (skull base pain), nausea, dizziness, tinnitus and facial pain, to name a few.”


The anecdotal observation of former NFL quarterback Jim McMahon is fascinating. Advances in science and imaging, especially upright weight bearing MRI, create biological plausible explanations as to why upper cervical spine chiropractic can help many persons with chronic head and neck symptoms. Cervical-occiput misalignments impair the cerebrospinal fluid flows between the brain and spinal cord. Specific upper cervical chiropractic adjustment that results in improved alignment between the occiput an the atlas can “uncork” the flow of cerebrospinal fluid between the brain and spinal cord, resulting in an improvement of a number of clinical signs and symptoms.


  1. Bakris G, Dickholtz M, Meyer PM, Kravitz G, Avery E, Miller M, Brown J, Woodfield C, Bell B; Atlas vertebra realignment and achievement of arterial pressure goal in hypertensive patients: a pilot study; Journal of Human Hypertension; May 2, 2007; Vol. 21; No. 5; pp. 347-357.
  2. Smith FW, Dworkin JS; The Craniocervical Syndrome and MRI; Karger; 2015.
  3. Hendricks M; Super Bowl-winning quarterback Jim McMahon says he wishes he had played baseball; Yahoo!; September 27, 2012.
  4. Segura M; The Other Half Of the Story; THE WOMEN BEHIND THE MEN; Sports Illustrated; September 10, 2012.
  6. Furillo A; Shoeless Golf is a Perfect Fit for McMahon; Sacramento Bee; July 21, 2016; pp. 1C and 5C.
  7. Ostler S; Quarterbacking a Gypsy Lifestyle, Renewed Outlook for Former NFL Star; San Francisco Chronicle, July 15, 2017; pp. B1 and B7.
  8. Deltoff MN; “Diagnostic Imaging of the Cranio-Cervical Region”, Chapter 4, in The Cranio-Cervical Syndrome, Mechaniscm, Assessment and Treatment; Edited by Howard Vernon; Butterworth Heinemann; 2003.
  9. Damadian RV, Chu D; The Possible Role of Cranio-Cervical Trauma and Abnormal CSF Hydrodynamics in the Genesis of Multiple Sclerosis; Physiological Chemistry and Physics and Medical NMR; September 20, 2011; 41; pp. 1–17.
  10. Flanagan MF; The Role of the Cranio-cervical Junction in Cranio-spinal Hydrodynamics and Neurodegenerative Conditions; Neurology Research International; November 30, 2015. [epub]
  11. Coban G, Coven I, Cifci BE, Yildirim E, Yazici AC, Horasanli B; The Importance of Craniovertebral and Cervicomedullary Angles in Cervicogenic Headache; Diagnostic and Interventional Radiology; March–April 2014; Vol. 20; pp. 172–177.

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