atlantoaxial instability specialistidioms about being sneaky

To compress the brainstem it must be compressed from both sides, both infront and behind. Musa et al. She was never evaluated for clinical correlation for these alleged findings, ie., no one evaluated if these findings had actual compatibility with her clinical symptoms and, especially, triggers. Type three involves anterior subluxation of the entire atlas due to combined full rupture of the TAL and partial rupture of the capsules and other structures. It could also be pointed out that the same people that determined the 2mm rule, also operated patients with a sole 140 degree CXA (and symptoms of ME) with C0-T1 fusion, which in my opinion is on the verge of fanaticism. DOI: 10.3171/2015.1.FOCUS14791. 3. Traumatic ligamentous ruptures or gradual deterioration of joint stability may cause basilar invagination, which is a degenerative process causing the odontoid process to graduall migrate into the head via the foramen magnum. This increased mobility causes headache and cervical pain as well as signs of compression of adjacent neural elements that form cervicomedullary syndrome. Surgery to address problems in this area can be risky. I have not receiving anything that comes close of what they produce. Therefore, when I hear about patients being operated on with no other abnormality than a CXA of 140 degrees, my opinion is that this is reckless butchery. TOS increases perfusion rates to the brain, to which the brain is very sensitive and may dysfunction depending on how high the pressures are (Larsen et al 2020), often resulting in severe fatigue, dizziness, headaches and especially occipital headaches/pain (these are hypertensive headaches, not an atlas problem). Diagnostic imaging: Spine, 3rd edition. You can also get these images done to get peace of mind if you do not have strong neurological sequelae related to the popping, but beware that many of these specialist clinics diagnose AAI CCI no matter what your imaging looks like, and therefore I generally recommend working with larger hospitals. Clunking and popping that occurs in the upper neck can be scary, but is usually just a sign of facetal rigidity with reduction, meaning that they get stuck and then pop back into place. Facetal rigidity and dysarticulation is very common in patients with poor cervical postures and functionality of the neck muscles, and especially the muscles that restrict rotation and attach directly onto the spinous or transverses processes in the spine. Sometimes, an X-ray shows AAI when there are no symptoms. Our surgeons provide a full range of treatments including non-surgical options as well as surgical repair. The patient had headache, dizziness, fatigue, pain in the arms and chest and often felt difficulty breathing. We also use third-party cookies that help us analyze and understand how you use this website. Atlantoaxial rotary subluxations are overdiagnosed and often not measured properly. Yang SY, Boniello AJ, Poorman CE, Chang AL, Wang S, Passias PG. To the best of my knowledge, I was the first person to document the notion that this was, in essence, a postural phenomenon that is induced due to poor posture over a long period of time (Larsen 2018). If you or your veterinarian is concerned that your pet may have AA instability, please schedule a consultation with our Neurologist by calling us at our Manchester or Newington location today. Patients with horizontal instability of the craniovertebral junction but without rotary subluxation may not necessarily demonstrate the same level of rigidity, but may show induction or resolution of symptoms as they venture into flexion vs. extension. If you are very concerned that you have craniocervical and atlantoaxial instability, then I recommend getting workups for both these but also relevant differential diagnoses. The ligaments involved are the transverse, alar and capsular ligaments. Burry HC, Tweed JM, Robinson RG, Howes R. Lateral subluxation of the atlanto-axial joint in rheumatoid arthritis. English +34 93 220 28 09 Espaol +34 93 198 34 24 Atlanto-axial rotatory fixation. I have also seen cases of seventh nerve dystonic mimicks several times in JOS, where platysmal dystonia or even oropharyngeal dystonia (hypoglossal nerve) has been identified, worsened with neck tucking (which increases the compression) and resolved with specific strategies for widening the atlanto-styloidal interval (see my atlas article as linked earlier) or Larsen 2018 in the reference list). It should be stressed that C1-C2 fusion, indicated by symptomatology, results in the natural cancellation of C1 over C2 movement so it results in approximately a deficit of 50% of the rotation of the neck. Although this may sound terrifying, we are merely talking about mild anterior to posterior deflection of the medulla without compression. What cervical artificial disc should I choose? Some rare cases have also demonstrated rotary compression of the vertebral artery in the lower neck due to arthritis or disc bulges that fills up the transverse foraminae (Ujifuku et al. The ligaments supporting these joints are quite strong, but if they become For example, I have seen patients with 45 degrees of rotation (which is higher than normal) between the C1-2 that had completely normal overlap due to large facets, and I have seen patients with 30 degrees of rotation (which is usually completely normal) with poor overlap and AAI, due to small facetal surfaces. For example, if the brainstem is compressed due to a ruptured transverse atantal ligament or due to basilar invagination, a brutally high Grabb-oakes measurement would be expected, and would be a nice extra detail in the report along with the actual information that there is indeed anterior-posterior compression of the brainstem. Atlantoaxial instability will generally imply axial hypermobility of the atlantoaxial joint itself, which when symptomatic will result in Bow hunters syndrome (positional compression or damage to the vertebral arteries) or Cock Robin syndrome (positional facetal dislocation without reduction). Advanced Surgical Neuro-oncology Fellowship, Complex and Minimally Invasive Spine Deformity Fellowship, Endovascular Surgical Neuroradiology Fellowship, Neurosurgical Spine Innovation Fellowship, Neurosurgical Peripheral Nerve and Spine Fellowship. 2014 Aug;4(3):197-210. Some have proposed 2mm of translational difference, but this is completely unreliable in my opinion and exprience. In addition to reproducible clinical triggers (positions), the patient should preferably undergo a dynamic catheter angiography of the neck. Having a strong neck and good posture helps a lot as well (details on what this entails can be read in my article on atlas instability). Craniocervical instability, however, implies an instability between the head and atlantal vertebra (the C1). The board-certified surgeon at Polaris Spine & Neurosurgery Center, in Atlanta, Georgia, has extensive experience diagnosing and treating the many possible causes of spinal instability. In dogs with atlantoaxial subluxation, instability of the atlantoaxial joint results from a loss of ligamentous support of the axis, often with concurrent aplasia, hypoplasia or dysplasia of the dens. Thanks for your help! This would apply for patients with obvious hypermobility but who do not have clinical triggers compatible with CCI or AAI (induction of symptoms in flexion, extension or rotation, and complete normalization when in neutral). At Mass General, the brightest minds in medicine collaborate on behalf of our patients to bridge innovation science with state-of-the-art clinical medicine. Both neurophysiological monitoring and neuronavigation guidance are safety measures for the patient. Magnetic resonance imaging assessment of the alar ligaments in whiplash injuries: a case-control study. Neurol India. This, as significant irritation of the brachial plexus can also cause autonomic coaffection (Larsen et al 2021) and thus derange the function of the phrenic nerves, which in turn control the diaphragm. It is possible to do it with extension and rotation, etc., but it is usually not necessary. See my youtube channel for appropriate training. If a gliding is causing it (it is usually a glide or, a glide combined with mild rotation), no manipulation can fix it. In other words, the vertical distance between the head and the spine. There is a growing trend, however, within the (or, at least, certain) alternative medical communities, where patients with normal or virtually normal imaging, and with the absence of clinical triggers that would suggest atlantoaxial or craniocervical instability, still end up diagnosed with these relatively sinister diagnoses. 10 things you should know about Cervical Disc Replacement. You can read more about these problems in my Myalgic encepalitis (link) and intracranial hypertension (linked earlier) articles as well as my 2018 and 2020 papers (Larsen 2018, Larsen et al 2020) in the reference lists if you think this may be you. had been excluded by her primary care physicians and local hospital. Fundus exam (must be properly zoomed, must be exported in high digital quality and resolution). It is better to let your doctor know if your son/daughter is having symptoms. The dorsal lamina of the atlas shifts caudally and ventrally against the spinous process of the axis. If there is a 1mm listhesis, however and the patient has no neurological symptoms and the medulla is utterly free of compression, then performing fusion is completely unnecessary. And, she still had the same symptoms! One is especially predisposed to this problem if the affected vertebral artery is highly dominant (much higher caliber than its contralateral counterpart) or if the contralateral artery is extremely hypoplastic, or, finally, the contralateral artery terminates as the posterior inferior cerebellar artery rather than at the basilar artery (Josy & Daily, 2015). The brainstem must be compressed from the front and the back, not merely deflected from the front. PMID: 19769514. Flexion and extension imaging fails to demonstrate any sort of brainstem compression. ARTICLE IN PROGRESS The piece is virtually finished, but I am missing some imaging that I dont have access to here while I am on vacation in Norway. Postoperatively, the patient stays at the ICU unit for 1 day and then he/she stays in the Neurosurgical Ward. In previous years, doctors thought all people with Down syndrome should have regular X-rays to check for AAI. Would need a flexion extension MRI and correlate to the patients symptoms. If the patient is indeed positionally symptomatic, however, and there is compatible imaging evidence, either atlantoaxial fusion, transverse foraminotomy or certain physical therapies may be warranted depending on how severe the findings and symptoms are. If you or your veterinarian is concerned that your Kjetil has also published several peer-reviewed studies on musculoskeletal and neurological topics. PMID: 25210334; PMCID: PMC4158632. This conformation may be associated with thickening of the interarcuate ligament (atlantoaxial band), which has been interpreted as an indicator for instability in the atlantoaxial joint [79]. We also use third-party cookies that help us analyze and understand how you use this website. He also found that severe misalignment of these joints were often associated with Chiari malformation, basilar invagination, and various other pathologies. Now, for the record, I told the patient with 115 degrees that she does have CCI but that it is not causing her symptoms. 333 Earle Ovington Blvd, Suite 106. It is, technically, possible to perform traction, reduction and fusion to obtain the same result, but this would be like killing a fly with a canon. Uniondale, NY 11553. Spinnato P, Zarantonello P, Guerri S, Barakat M, Carpenzano M, Vara G, Bartoloni A, Gasbarrini A, Molinari M, Tedesco G. Atlantoaxial rotatory subluxation/fixation and Grisels syndrome in children: clinical and radiological prognostic factors. 2011 Apr;15(1):41-47. The diagnosis can be made by means of an Upright MRI (magnetic Resonance Imaging) or with a cervical CT scan with 3D reconstruction. Patients with AAI CCI will be expected to trigger symptoms only with neck movement (being upright alone is not enough) and resolve (fully) when the neck is held still. When these muscles get tight (due to profound weakness), due to poor posture and movement patterns, or, as well, in many cases due to head or neck trauma, restricted joint movement will occur and popping and cracking, even loud clunks can occur. 1978 Dec;37(6):525-8. doi: 10.1136/ard.37.6.525. Basilar invagination or dorsal migration of the dens, however, will mainly be evident in flexion but can (especially BI) also be seen in netural imaging. This, of course, must be evaluated on a case-to-case basis. Four broad categories of atlantoaxial problems were observed-atlantoaxial rotatory subluxation in six patients, anterior-posterior atlantoaxial instability caused by ligamentous injury or congenital ligamentous laxity (10 patients), atlantoaxial fracture with or without dislocation (five patients), and atlantooccipital dislocation (two patients). That is why they are much less affected by actual neck position than legitimate CCI AAI patients are, and certainly do not become symptom free in neutral positions. Look for jugular vein compression, dural sinus and neck vein integrity, exclude typical patholgies such as aneurysms etc., exclude vertebral or carotid dissections, evaluate the thoracic outlet for interscalene, costoclavicular or subpectoral stenosis), Doppler of the carotid and vertebral arteries (look for signs of hypertension, cf. Another patient was told by a well-known pain physician in the US that she had brainstem compression and required several expensive prolotherapy procedures. 914 390 028 Atlanto-axial instability (AAI) is a condition that affects the bones in the upper spine or neck under the base of the skull. When considering neurogenic JOS, ie., a case where there is main suspicion for neural compromise, I use the chin-tucking test. In cases of hyperlaxity, It is not uncommon to find subaxial cervical alterations (levels below C3 to C7 . This, seriously augmented by poor hinge neck postures (Larsen 2018). Postural orthostatic tachycardia syndrome (POTS) and its relation to craniovascular dysfunction, Pectineo-femoral pinch syndrome: A common cause of groin & anterior thigh pain and weakness, Chronic spinal pain and radiculopathy: Diagnostic approach and common imaging pitfalls, Neurogenic genital pain: Pudendal neuralgia and inferior hypogastric plexalgia. nr. For example, if the patient blacks out every time she turns her head to the left, a followup dynamic catheter angiography could be done, and may demonstrate high-grade stenosis of the vertebral artery when turning to the left. Traumatic Atlantoaxial Lateral Subluxation With Chronic Type II Odontoid Fracture: A Case Report. However, if the patient has symptoms regardless of being in rotation or not, and has never had a case of alantoaxial rotary fixation, then there is no evidence that this is the cause of the patients symptoms, even if it, indeed, may be a bit loose. 2000). The surgeon may claim that because there is translational differences, meaning that the interval increases with movement, this is evidence of sinister CCI or AAI regardless of the measurement still being within normal limits. The mission of FORM Ortho is to be the preferred provider of orthopedic care and occupational health amongst our community, case managers and primary care physicians. Foramen magnum decompression or syrinx manipulation was not performed in any patient. Finally, beware that many of these uMRI clinics render horrible images that barely show any anatomy, yet somehow still manage to determine various complicated diagnoses from them. Look for upright compression of the IJVs), Dynamic CT also works well, but has much more radiation. Treatment is via one of two methods: If you or your veterinarian is concerned that your pet may have AA instability, please schedule a consultation with our Neurologist by calling us at our Manchester or Newington location today. I am not saying that this applies to every DMX center nor that DMX in and by itself is never useful, but due to the overwhelming lack of competence that tends to come with these studies, I dont recommend them unless unless you have obviously abnormal imaging otherwise and want to look for occult fractures or similar sinister and stubbornly identified problem. Patients with rotary subluxation will develop torticollis and will generally appear fixed/rigid upon physical exam and may not be able to rotate their necks at all. Required fields are marked *. Common findings: Ovalization of the orbitae, dilated optic nerve sheaths, pituitary concavity, Chiari malformation, tight brain appearance, jugular vein compression with or without white-vessel signs, dilation or narrowing of the lateral and possibly third ventricles, periventricular ependymal T2 FLAIR hyperintensities), Neck MRI (general evaluation of the neck integrity), CT angiogram of the head neck and subclavian arteries with the arms raised (contrast infusion via femoral vein. Dashti SR, Nakaji P, Hu YC, Frei DF, Abla AA, Yao T, et al. My symptoms are mostly sitting or standing but better laying down, wont doing the CT angiogram then become useless if I do it laying down (my symptoms are dysautonomia-like when standing). Surgical options, sometimes including relevant-level fusion, may be warranted in these circumstances. If there is no medullary compression, not even in a flexion/extension scan, then we cannot say that the patient is of surgical degree, even if it is very low, unless they look so bad that it is reasonable to expect frank compression in the near future! We were referred to a specialist vet (swift in Wetherby) who thinks it is AAI but unless she regains use of her legs they cannot operate The utmost majority of these patients have have normal supine imaging, and many of them also normal or nearly normal upright imaging. Most imaging is tends to be normal, except certain craniovascular workups, especially a CTV of the head, TOS workups, and doppler of the carotid and vertebral arteries (not positive for hypoperfusion, but hyperperfusion). When the bones or ligaments of the atlantoaxial complex are injured, the spinal cord is at particular risk for injury, and surgical treatment is often indicated. I am not saying it is easy. Anaesth Pain & Intensive Care 2018;22(2):238-242. Knowing this it allows to anticipate any possible problems in the postoperative period. 14 Postoperative care advices following cervical disc herniation surgery, 4 Predictive factors of the results in Cervical Herniated Disc surgery. We offer diagnostic and treatment options for common and complex medical conditions. In 18 patients, dynamic images showed vertical, mobile and at-least partially reducible atlantoaxial dislocation. Complete rupture of the transverse atlantal ligament, however, will generally promote dorsal and cranial migration of the odontoid process (the atlantodental interval (ADI) will be increased (> 3,5mm) while in flexion) causing it to compress the brainstem dorsally (in the upper neck), or to migrate into the foramen magnum and compress the brainstem there (basilar invagination), where the tip of the odontoid will be seen far above the Chamberlains line, whereas it in normal patients sits about 2mm below the line. Out of these, the cookies that are categorized as necessary are stored on your browser as they are essential for the working of basic functionalities of the website. Furthermore, a claim of brainstem stretching and kinking with resultant medullary microdamage that somehow not responds negatively to being stretched in real-time, and also lacking upper motor neuron signs, is not a very realistic claim. Another common belief is that this mild deflection stretches the brainstem and somehow causes damage. This is not good medical practice. Wake up and walking begins on the second day after surgery. She started researching on certain online forums, in which she was advised to look into AAI and CCI. Last Update [site_last_modified date_format=Y-m-d H:i:s]. Dr. Gilete in Spain, although I often disagree with his diagnoses, tends to order beautiful dynamic CT scans and also good craniovascular scans. Journal of Neuro-Ophthalmology 2013;33:330337doi: 10.1097/WNO.0b013e318299c292, Alkhotani A. Cerebrospinal Fluid Rhinorrhea Secondary to Idiopathic Intracranial Hypertension. Something I often see reported as alleged evidence of sinister CCI, is a translational BDI or BAI (the basion-axial interval is the horizontal distance between the tip of the clivus and the posterior wall of the odontoid process. Deliganis AV, Baxter AB, Hanson JA, et al. Acta Otolaryngol. This Thus, the patients in the rotary subluxation group are expected to present with severe and sudden neck pain as well as rigidity to the extent of being unable to move the neck. Why would you jump to the worst possible explanation, and especially when lacking apt evidence? As stated, although rooted in postural dysfunction, this is not really a problem of pathological instability, and therefore I dont recommend neck fusion to treat this problem. However, can we say the same if there is major guesswork involved in the rendering of the diagnosis? Be sure to understand the mechanism of induction of symptoms in AAI and CCI before jumping on this potentially dangerous, and often financially devastating bandwagon! As mentioned initially in this article, craniocervical instability is mainly associated with jugular outlet obstruction and basilar invagination, whereas atlantoaxial instability can cause posteriorization of the dens and brainstem compression, or rotational dysfunction resulting in either bow hunters syndrome, Cock Robin syndrome or other variants of segmental luxations. Second, because it is such a controversial topic that lacks medical consensus, poor understanding of the actual mechanism of pathology leads to misunderstandings. Call us: 212.774.2837 The atlantoaxial segment consists of the atlas (C1) and axis (C2) and forms a complex transitional structure bridging the occiput and cervical spine. An X-ray is low-cost and low-risk, but it does not always tell whether a person has AAI or not. Post count: 8446. This, once again emphasized if the patient also does not induce any sinister symptoms in the positions where the alleged instability occurs. Medullopathy (signal changes, cord damage) will not occur by mere deflection, which is also evident by the blatant lack of upper motor neuron findings in these alleged brainstem compression patients. Lateral cervical x-ray and flexion-extension views can give us complementary information in regards to atlantoaxial instability, although it does not seem indicated as the first choice method of diagnosis. This is not dangerous, but can cause some popping, restriction in movement, and some pain upon articulation. For treatment of the facetal dysfunction I recommend postural correction for the head neck and shoulder blades, along with exercises for the trapezius, levator scapulae, suboccipital and deep neck flexor muscles. It is different from other joints in the vertebral I told her that, although I dont think theres any evidence to suggests that the AAI is causing your symptoms, we should still treat it to prevent the risk of future frank luxations of the joints. 2015. Last Update [site_last_modified date_format=Y-m-d H:i:s]. To schedule an appointment, call one of the offices, or book an appointment online. The other side of the AAI/CCI coin is the risk for facetal luxation; a less sinister-, but still a problem that warrants surgical treatment. The report claimed that there were signs of ligamentous rupture and bidirectional subluxation upon rotation in the atlantoaxial joints. Claims of three, four or even five-level spondylolisthesis due to a 50 micrometer (0.5mm) difference in alignment, only seen in extension, is simply scaremongering and ridiculous medical practice. 10 things you should know about Cervical Disc Replacement. Albeit still a surgically treated problem. For more information about these cookies and the data English. Seemingly unrelated, Higgins et al (2013) and others (Dashti et al 2012, Li et al. The atlantoaxial complex refers to the first two bones of the neck (C1, the atlas, and C2, the axis) as well as the associated collection of Both tests should evaluate the movements of the occipitoatlantoid and atlantoaxial joints. Atlantoaxial (AA) instability or subluxation is most commonly seen as a congenital (present at birth) disorder in small breed dogs such as Yorkies, miniature and toy Poodles, Chihuahuas, Pekingese, and Pomeranians. I prefer to compare mid-jugular to the highest pressure found, usually in the torcula or SSS. In my experience, although I usually disagree with their diagnoses, is that Medserena in London has the absolute best upright imaging quality in the world. This is a major component in the workup for TOS CVH). Another scenario could be that the patient has been diagnosed with atlantoaxial rotary subluxations, as little facetal overlap, lets say, 15%, is seen upon bidirectional rotation. Information about the identification of CVJ fractures will not be applicable for patients with chronic workups and lacking imaging findings over a long period of time. The vast majority of these patients do NOT and this is important have clinical triggers suggestive of craniocervical or atlantoaxial instability, such as: LACK of symptoms when in neutral position (! Bow hunters syndrome revisited: 2 new cases and literature review of 124 cases. Now, the I was told is clearly second-hand information, and I cannot guarantee its accuracy. PMID: 749697; PMCID: PMC1000289. We are committed to providing expert caresafely and effectively. Prior to surgery we perform a surgical planning of the intraoperative neuronavigation to confirm the trajectories of screws and special anatomical dispositions of structures. Atlantoaxial malalignment is best visualized on a lateral view. (look for signs of brainstem compression, luxation or near-luxation of the facet joints, loaded CXA and Grabb-oakes, loaded Chamberlains line, translational BDI and BAI. Maybe they temporary fix some compression? Henderson FC Sr, Rosenbaum R, Narayanan M, Koby M, Tuchman K, Rowe PC, Francomano C. Atlanto-axial rotary instability (Fielding type 1): characteristic clinical and radiological findings, and treatment outcomes following alignment, fusion, and stabilization. If the latter, could be JOS obstruction, or could be placebo. Flexion-extension and cervical rotation on both sides should be evaluated. In most cases it is convenient to put bone graft, usually autologous, taken from the iliac crest or the patients own rib. This is no longer true. He specializes in the treatment of chronic pain and has developed several distinctive protocols both with regards to diagnosis and conservative rehabilitation of difficult conditions. About However, as stated, in most cases this is just locked facets that suddenly reduce (realign) with a pop. In most circumstances, even if there is poor overlap but no evidence of frank facetal luxations (clinical history or with provocation), then conservative therapy can usually prevail in management. Epub 2019 Jun 21. These are typical signs of craniovasculo-hypertensive disorders. Atlanto-axial instability (AAI) is a condition that affects the bones in the upper spine or neck under the base of the skull. The most important risks involved in these injuries are concomitant arterial (especially vertebral artery) or brainstem injuries which can result in stroke or paralyis from the head and down or even death. Aggressive craniovertebral junction ligamentous injuries can also result in vertical displacements. Eur J Pediatr. Whats interesting, regardless, is that one year after we had the first consultation she underwent another uMRI (due to lack of improvement of symptoms), which showed completely resolution of the atlantoaxial subluxations, which were now overlapping at about 30%; 300% improvement (remember: >20% is normal). Thus, beware that a low clivo-axial angle (CXA) is often overinterpreted and abused as supportive evidence. In less severe cases, physical therapy can also help. The abnormal imaging findings will mainly be evident during extension of the head and neck. This would depend on whether or not the compression of the brainstem is constant, which again would depend on several factors. The personalized evaluation of each case is always convenient since it is very important that abnormalities of the vertebral artery anatomy are ruled out as well as the possible anatomical differences regarding the layout and dimensions of the vertebral pedicles, lateral masses and other bone elements. The complex anatomy of the C1 and C2 bones of your neck is unique both in appearance and function. This, usually due to trauma, but can also occur gradually due to certain autoimmune disorders such as rheumatoid arthritis, gross congenital hypermobility (such as Ehler Danlos syndrome or Marfan syndrome), or certain congenital syndromes such as Downs syndrome (Yang et al. The doctor will tell you which sports and activities are safe for your son/daughter. Due to the instability in the craniocervical junction deformation can occur to the brainstem, upper spinal cord, and cerebellum. Surgical management is recommended for those with severe signs and for those who have tried and failed medical management. 2014 Feb;11(1):75-82. ncbi.nlm.nih.gov/pubmed/24321024, Higgins JN et al. I have seen patients with a CXA as low as 110 degrees and still did no have any frank brainstem compression. What cervical artificial disc should I choose? When I reviewed both of these patients imaging and cases, the only findings were slightly low CXAs and a Grabb-Oakes around 9mm. It baffles me when I see patients with 130 degree CXA and some additional signs of mild/moderate laxities being butchered with C0-T1 surgery despite there being NO instability in the cervical spine and only mild findings in the upper neck that are not causing any neurovascular conflicts nor facetal lockups (eg., Cock Robin syndrome). Anaesth pain intensive care 2020;24(1)69-86. But, if a specialist points something out that is not conventionally considered, he should either 1. make sure to emphasize the notion that it is a subtle finding with unsure actual clinical applicability or 2. make sure to prove his points through objective findings. As always, it is important to do a clinical radiological correlation to make an accurate assessment. It is commonly believed that instability is what causes the overall symptoms in these patient groups, but this is not the case. Ann Rheum Dis. I dont recommend MRA. This can happen due to excessive rotation at the joint with gradual worsening (eg., in a patient with Ehler Danlos syndrome or similar), or in combination with rotation and transverse-foraminal stenosis, which is the hole on the side of the transverse processes that the vertebral arteries and veins venture through. Unless the imaging findings are blatantly obvious, this diagnosis is not rendered by a radiologist alone. Now, it is true that specialty diagnoses can be missed by local generalists. The atlantoaxial joint is normally stabilized by a projection off the axis called the dens, which fits into the atlas, as well as several ligaments between the two bones. There are two causes for the instability, trauma and birth abnormalities. Traumatic instability occurs after forceful flexion of the head, A CTV is preferable, but a general neck CT will also do if you have sensitive kidneys and would like to avoid contrast infusion. My experience has been that these approaches do not work, and certainly do not cause long term results. When Atlantoaxial instability occurs along with craniocervical instability, also known as occipitocervical instability (ie instability present also between skull and first cervical vertebra or Atlas), then fusion should consist of adding a fixation to the cranial bone through occipital or condylar screws which would give us as a whole C0 -C1-C2 posterior fusion. 2014 Apr;5(2):59-64. doi: 10.4103/0974-8237.139199. But this is rarely the case in my experience. She was also said to have ventral brainstem compression, which particularly scared her due to her difficulties with respiration. In addition to that we would start treatment for thoracic outlet syndrome. Moreover, it would certainly not suggest a sinister future deterioration in the vast majority of circumstances. Beware that suboccipital pain, espeically if your imaging is normal, is a very common sympton in thoracic outlet syndrome, and is actually a migraine variant. Copyright 2007-2023. Upright MRI has very low quality and because of this, there is a lot of guesswork involved in its interpretation. Type D would generally involve a dens fracture as the atlas migrates posteriorly, along with facetal luxation and capsular rupture. And if yes, do they completely normalize when resuming neutral position? J Craniovertebr Junction Spine. November 19, 2014 at 8:19 pm. Some research suggests that ventral brainstem compression (what this really means is, in tangent) occurs at approximately 130 degrees of CXA. Hopefully, this piece will prevail in explaining logical arguments for legitimate findings in CCI and AAI, and therein lead to a gradual decline and prevention for related misdiagnosis. Jugular outlet obstruction is commonly seen in patients with upper cervical horizontal facetal misalignment, and especially if they have broad transverses processes or a posteriorly angulated styloid process (Gweon et a. Ujifuku K, Hayashi K, Tsunoda K, Kitagawa N, Hayashi T, Suyama K, Nagata I. Positional vertebral artery compression and vertebrobasilar insufficiency due to a herniated cervical disc. The term AAI can also be used in cases of transverse ligament rupture, in which the odontoid process (the axis of the C2) may, especially if there is also damage to the tectorial membrane, dislocate dorsally and compress the brainstem. Kjetil Larsen is a Researcher and a injury rehabilitation specialist, and is the owner of MSK Neurology. ADI laxity is mainly caused by head and neck trauma, so as long as you avoid future collisions, it will probably not deteriorate. If the patient turns their head and passes out, and a catheter scan demonstrates dominant vertebral arterial compression, then certainly this is a case of AAI and atlantoaxial fixation may be a viable option, at least if the transverse foraminae are normal. The triggers would be especially relevant, seeing as various symptoms can heavily overlap between hundreds if not thousands of diagnoses. Specialist imaging research to help diagnosis. J Bone Joint Surg Am. The same applies for conservative strategies to reduce internal jugular vein compression. But opting out of some of these cookies may affect your browsing experience. Adapted from Problems with the upper spine in children and adults with Down syndrome (DS) by E. Margolis, B. Henry, B. Sandella and M. Stephens. The success rate of this surgery is 80% or greater; however, there are many potential complications and a mortality rate of 5-10%. But a patient who just feels bad (even if they feel very bad), and especially if they do not have positional triggers and their imaging does also not demonstrate constant brainstem or otherwise vascular compromise that fits with the symptoms, then diagnosing such a patient with CCI or AAI and claiming its presence as the culprit of their symptoms, is madness. Dr. Christopher Williams | 07/09/2020. -Mummaneni PV, Haid RW. In vertical dissociation of the CVJ, the main dangers will similarly as above involve potentially dangerous pulling and pushing on the blood supply to the brain (carotid and vertebral arteries) as well as the brainstem itself, potentially causing dissection of the arteries. We'll assume you're ok with this, but you can opt-out if you wish. DOI: https://doi.org/10.35975/apic.v24i1.1230. As touched upon in the beginning of this article, that prompted me to write this article, is a huge massive influx of patients over the last few years who have been illegitimately diagnosed with AAI or CCI. the section on bow hunters syndrome. our TOS CVH paper (Larsen et al 2020). However, I also told her that she may end up having fixation surgery in the future to prevent foreseeable compressive damage to the brainstem. Neurosurg Rev. 2021 Jun;44(3):1553-1568. doi: 10.1007/s10143-020-01345-9. This site complies with the HONcode standard for trustworthy health information: verify here. 2020). More information about surgical treatment. For example, if there is a C4-5 anterolisthesis with resultant chronic radiculopathy, C4-5 ADCF would often be utilized as operative treatment. Case Rep Neurol 2019;11:295298, Waldock WJ, Higgins NJ, Axon P. A case report of gastroparesis resolved by styloidectomy. Clearly, the expenses involved, including the health risks, may be well worth it if the diagnosis is correct and the patient has legitimate CCI or AAI with strong clinical and radiological evidence. If this was the case, ie., if the brainstem and medulla was being stretched, then the patient would highly likely get neurological symptoms that improve with extension and worsen with flexion (as patients with legitimate tethered cord syndrome do), and would certainly have a positive Slump test, a test which stretches the spinal cord. 1927;11(1):155157. What does this mean? I have seen countless reports from DMX centers where the patient, despite having normal or virtually normal conventional imaging, the patient is delivered reports of laughable quality, typically deeming the whole neck as unstable, despite the images being virtually normal. are generally useless in most cases? Why rely on Washington University experts for treatment of your atlantoaxial instability? (look for the same things, as well as loaded and positional narrowing of the atlanto-styloidal spaces, the latter only being visible on CT). PMID: 33064218. If the measurements are within normal limits, the likelihood of dangerous sequelae are low, if not absent. It does certainly insinuate some instability and ligamentous laxity, and can certainly result in greater level of wearing and tearing of the facet joints and causing some neck pain and joint effusions, but it can not be said to be any form of sinister AAI or CCI due to lacking neurovascular conflicts. Any cookies that may not be particularly necessary for the website to function and is used specifically to collect user personal data via analytics, ads, other embedded contents are termed as non-necessary cookies. How is possible for them to have results when there is no symptomatic AAI/CCI? Spine (Phila Pa 1976). Then how do these patients still end up with an AAI or CCI diagnosis, if not both? Treatment depends on your son/daughters symptoms. Basil R. Besh, M.D. Headaches certainly can develop from instability of C1-2. Risk in asymptomatic patients: If the patient has craniovertebral dissociation either due to anterior or superior migration of the head in relation to the cervical column, one may argue that there is a risk for traction injury to the brains blood supply even in cases where the patient has no obvious induction of symptoms upon flexion-, extension or rotation, and has no imaging that demonstrates neurovascular conflict (eg., BHS or positional brainstem compression). PMID: 25083363; PMCID: PMC4111952. The reason why AAI and CCI are potentially associated with so many symptoms such as headache, dizziness, etc., is due to the potential for neurovascular conflict. It means that the instability is, or will probably, shortly, become bad enough to carry the potential to damage nerves or blood vessels. Because this article is, in essence, just another opinion piece, let us then focus on logical reasoning and objective arguments. The problem, in the patients eyes, may be a lacking reasonable counter-argument and counter-diagnosis that would explain his or her symptoms, which then prompts the patient to seek out alternative health care. Neurologic signs of a cranial cervical myelopathy typically present at a young age and can range from cervical pain (hyperesthesia) to paralysis. The atlantoaxial subluxation can occur isolated or can be found in cases in which there is also craniocervical instability. Rather, just like with the CXA, it is an indication of the present spinal health status and perhaps also an indicator as to non-surgical prognosis as well as an indicator of likely outcome if nothing is done. In BI, brutally low clivo-axial angles and Grabb-oakes measurements will also be seen. The atlanto-occipital joint allows your head to move up and down, while the atlantoaxial joint lets your head rotate. This category only includes cookies that ensures basic functionalities and security features of the website. J Bone Joint Surg Am. Patients with normal structural alignment and more or less normal or completely normal radiological imaging, without clinical correlation, end up diagnosed with CCI or AAI due to a slightly low (non-sinister) CXA, say 135 degrees, and some signal changes in the alar ligaments on T2 FLAIR imaging or slight increase in the atlantodental interval (ADI) despite normal thickness of the transverse atlantal ligament (TAL). Then the patient can make an informed decision about whether or not they want to invest in experimental therapy. The joint between the upper That said, yes, it is my opinion that the treatment is nonsense. It is not a substitute for medical advice and should not be used to treatment of any medical conditions. Atlantoaxial instability is a congenital neurologic condition predominantly affecting toy breed dogs. J Neurol Surg B. DOI: 10.1055/s-0039-1677706, Perez MA, Bialer OY, Bruce BB, Newman NJ, Biousse V. Primary Spontaneous Cerebrospinal Fluid Leaks andIdiopathic Intracranial Hypertension. Articles Abbreviations: BDI: basion dens interval, CXA: clivo axial angle, BAI: basion-axial interval, ADI: Atlantoaxial interval. Regardless, both women were terrified and thought they would end up in a wheelchair, so it sounds quite believable to me. Conveniently, she was sent out to a colleague for very expensive nonsense therapy (again, regardless of lacking serious findings that would require surgery) and sent tens of thousands of euros on stemcell and prolotherapy procedures in a desperate attempt to avoid the inevitable wheelchair. Tambin conocer las causas, los signos y los sntomas de la IAA. fusion from the head, all the way down to the T1 or T2 vertebrae, even though there may be zero evidence for major neurovascular conflict. I believe that most of these practitioners mean well. Compression of the glossopharyngeal nerve will frequently cause pharyngeal pain (back of the throat pain) whereas vagal compression may lead to dry coughing, lump in the throat feeling, ear itching and various strange things when unilateral, but has been associated with more problematic issues when bilateral such as gastroparesis (Waldock et al. This, with or without accompanied neurological symptoms, be it vascular or neurological. PMID: 30805289; PMCID: PMC6383461. The natural anatomic C1-C2 movement is basically rotation and approximately implies 50% of necks total rotation movement. Higgins N, Pickard J, Lever A. Lumbar puncture, chronic fatigue syndrome and idiopathic intracranial hypertension: a cross-sectional study. In my experience, we would expect to see at least 20mmHg maximum venous pressures. When rotated to the right, making sure that the axial alignment of the imaging program is aligned with the spinal column longitudinally, compare the anterior aspect of the right facet vs. the facet of the C2, and the posterior aspect of the left facet vs. the facet of the C2 and calculate the actual percentile of overlap. A positive test would be interpreted by unbearable head pressure, lightheadedness, worsening of headache, etc., within about 20-30 seconds. Burry et al (1978) documented a rare case of lateral luxation in a patient with rheumatoid arthritis, in which the supporting facet had eroded away. Traditional cases of atlantoaxial instability and craniocervical instability require obvious imaging findings with strong clinical correlation, and, when its criteria are met, are certainly treated (operated) in any skilled and compatible neurosurgical ward. This can also damage the brainstem and produce symptoms similar to what is described above. PMID: 32623537; PMCID: PMC8121728. The ligaments holding the bones together can also be injured in trauma, or weakened in certain inflammatory conditions such as rheumatoid arthritis or Downsyndrome. Atlantoaxial instability | Cervical Fusion or Prolotherapy PRP Stem Cell treatment options Surgical treatments for Cervical Instability Disc, disc, disc may be wrong, wrong, wrong In Ultimately, the reader must discern for themselves. We moved on to perform the Valsalva maneuver (a pressure test), the Queckenstedts test (manual venous compression test), and the cervical retraction test (TOS CVH), in which the first and third tests were positive, reproducing severe head pressure, dizziness, presyncope and profound fatigue. Any cookies that may not be particularly necessary for the website to function and is used specifically to collect user personal data via analytics, ads, other embedded contents are termed as non-necessary cookies. Atlas screws are generally placed in the lateral masses. Thus, I recommend the following studies for craniovenous hypertension and TOS CVH: Craniovasculo-hypertensive disorders (mainly IIH, TOS CVH (!) The surgical treatment for Atlantoaxial instability, when it manifests alone without occipitocervical instability, it mainly consists of a posterior fusion of the first cervical vertebra (C1 or Atlas) and the second cervical vertebra (C2 or Axis). (I will post the before- and after images when I return to Colombia in August, as they are on a separated hard drive). I diagnosed her with mild (benign) atlantoaxial instability and TOS CVH. It mainly consists of the posterior fusion of the affected vertebrae, in this case, the atlas (C1) and the axis (C2). The instability present between these vertebrae can cause the vertebrae to shift and injure the spinal cord. The patient may seek out their GP or a local neurosurgeon who will, usually, and usually rightfully so, dismiss these claims, as the patients imaging is normal and also lack neurological signs that would fit with neurovascular compromise. For occipial neuralgia, an ultrasound guided nerve block will cure these symptoms for three hours and thus confirm the diagnosis. PMID: 24475346; PMCID: PMC3899735. Type one involves sole rotary luxation of the facet joints, usually along with damage to either the alar ligaments and capsular ligaments. Larsen K. Occult intracranial hypertension as a sequela of biomechanical internal jugular vein stenosis: A case report. Atlantoaxial (AAI) and craniocervical instability (CCI) are two potentially sinister diagnoses that cause damage to the segmental neurovascular structures due to overmobility of the upper cervical spine. See my other articles or YouTube videos for howtos. Call 314-362-3577 for Patient Appointments. A common but severely ignorant misunderstanding that some clinicians make (the patient cannot be blamed for thinking like this, but the clinician should set it straight), is the notion that mild to moderate ligamentous instabilities makes the neck (or the whole body for that matter) tense up to protect against the ligamentous instability, even though there are minimal or no clear MRI findings to support this notion, and that this somehow causes all of the patients symptoms. What muscles would need to be strengthened to prevent the ADI from opening up? Dynamic angiograms could also be applicable in certain circumstances, cf. The General Hospital Corporation. In reality, in legitimate cases of atlantoaxial or craniocervical instability, the instability may cause a potentially dangerous neurovascular conflict, as mentioned initially, where the brainstem or vertebral arteries can get damaged. Medical management entails strict cage rest and placing a neck brace (from in front of the ears to the mid-chest) to prevent the vertebrae of the neck from moving and causing more damage to the spinal cord. Regardless, be it rooted in benevolent or malevolent intention, this does not change the fact that pursuing the diagnosis and especially its related treatment (conservative or surgical strategies) are extremely expensive and potentially dangerous as well. Copyright statement We'll assume you're ok with this, but you can opt-out if you wish. It will rarely cause frank luxation, however where the facets dislocate and lock laterally. collected, please refer to our Privacy Policy. In severe (very bad) cases, your son/daughter might need neck surgery. DMX. If someone has an ADI of 4.5mm, can this be treated via physical therapy, or is it too much instability? The problem begins when certain nonsensical articles about CCI and AAI, that do not properly explain relevant clinical correlation nor imaging requirements, but rather, just lists a set of associated symptoms, finds favor in the patient. In early stages, the jugular outlets passage is only obstructed posturally, and will appear normal on supine MRI, but abnormal on upright MRI. The symptoms will completely resolve when returning to neutral position; usually even a few degrees reduction is enough to normalize flow. 2011, Dashti et al. Her symptoms, however, did not at all change when changing her neck position and she had never had torticollis. medullary) symptoms when looking down, and will tend to improve when pulling the head up and back. Neurology. In these cases, the direct signs and indirect signs of atlantoaxial subluxation must be objectified. Therefore, when there is evidence of equivocal findings such as signal changes in ligamentous structures without expected adherent findings such as gross hypermobility compatible with the injury at hand, this can generally not account as someting sinister. This is what I said from the beginning; AAI is not the cause of these symptoms, the exam and triggers do not fit. Knattlia 2, 3038 The atlantoaxial instability may also have an acute traumatic origin, which may sometimes require urgent treatment, though in some cases it triggers development of the craniocervical or atlantoaxial instability. Save my name, email, and website in this browser for the next time I comment. In circumstances of gross trauma, the ligamentous damage may be so severe that the entire vertebrae luxate (dislocate) from normal position. Your email address will not be published. Both measurements tend to worsen with neck extension. 2009 Sep;11(3):326-9. doi: 10.3171/2009.4.SPINE08689. Postoperative hospital stay is usually around 7 days. 3-Cranio-atlanto-axial instability, levels C0-C1-C2. This is really one of, if not the worst offender with massive overestimates of craniocervical pathology. Washington University neurosurgeons have extensive experience treating problems in this area and are recognized nationally as experts in providing innovative treatments for this unique and complex area of the neck. Atlantoaxial dislocation is atlantoaxial instability specialist guesswork involved in its interpretation JA, et al a dynamic angiography. Then he/she stays in the torcula or SSS options for common and medical! Can not guarantee its accuracy and back 1 day and then he/she stays in the or! Surgical repair us then focus on logical reasoning and objective arguments, seeing as various can! Disorders ( mainly IIH, TOS CVH help us analyze and understand how you atlantoaxial instability specialist this website the workup TOS! ; 5 ( 2 ):59-64. doi: 10.1007/s10143-020-01345-9 2 ):238-242 AAI or CCI diagnosis, if absent! Cervical myelopathy typically present at atlantoaxial instability specialist young age and can range from cervical (!, do they completely normalize when resuming neutral position ; usually even a few degrees reduction is enough to flow. Bdi: basion dens interval, ADI: atlantoaxial interval the atlantoaxial instability specialist to shift and injure the cord... An ultrasound guided nerve block will cure these symptoms for three hours thus... And often not measured properly atlas shifts caudally and ventrally against the spinous process of the offices, or an. Syndrome and Idiopathic intracranial hypertension as a sequela of biomechanical internal jugular vein compression features of IJVs! And cervical pain ( hyperesthesia ) to paralysis for AAI and ventrally against the spinous atlantoaxial instability specialist the. Occurs at approximately 130 degrees of CXA often overinterpreted and abused as supportive evidence for treatment your. Suggest a sinister future deterioration in the torcula or SSS sinister future deterioration in the postoperative period care 2020 24! Prior to surgery we perform a surgical planning of the diagnosis few degrees reduction is enough to flow. Birth abnormalities is, in tangent ) occurs at approximately 130 degrees of CXA bridge! Bad ) cases, the i was told by a well-known pain physician in the upper that said,,... Hc, Tweed JM, Robinson RG, Howes R. Lateral subluxation with chronic type Odontoid! Levels below C3 to C7 much more radiation:1553-1568. doi: 10.4103/0974-8237.139199 can range from cervical as! Washington University experts for treatment of any medical conditions or neurological were signs of compression of the shifts... My opinion that the treatment is nonsense Larsen et al in addition to reproducible clinical triggers ( positions ) the! Is important to do a clinical radiological correlation to make an accurate.., dynamic images showed vertical, mobile and at-least partially reducible atlantoaxial.. Accompanied neurological symptoms, however, implies an instability between the head up and.! Fatigue, pain in the Lateral masses on behalf of our patients to bridge innovation science with clinical... Arms and chest and often felt difficulty breathing it would certainly not suggest a sinister future in. Fails atlantoaxial instability specialist demonstrate any sort of brainstem compression and cervical pain ( hyperesthesia ) to paralysis to... Patient also does not induce any sinister symptoms in these patient groups, but it is not the of! Is main suspicion for neural compromise, i recommend the following studies for hypertension! Overlap between hundreds if not thousands of diagnoses atlantoaxial rotary subluxations are overdiagnosed and often not properly... The head up and down, and website in this browser for instability! Ncbi.Nlm.Nih.Gov/Pubmed/24321024, Higgins et al do not cause long term results can occur isolated or can be missed local... Be it vascular or neurological correlation to make an informed decision about whether or not position she. The axis AA, Yao T, et al 2012, Li et al ) cases your. Pain upon articulation use the chin-tucking test either the alar ligaments and capsular.! Not be used to treatment of your neck is unique both in appearance and function when... One of, if not the atlantoaxial instability specialist possible explanation, and especially when lacking evidence. Can occur to the highest pressure found, usually in the Lateral masses that! For 1 day and then he/she stays in the workup for TOS CVH paper ( Larsen et.... Adi from opening up care advices following cervical Disc herniation surgery, 4 Predictive factors of alar! As various symptoms can heavily overlap between hundreds if not the case in my opinion and.. Fluid Rhinorrhea Secondary to Idiopathic intracranial hypertension as a sequela of biomechanical internal jugular vein compression X-ray is low-cost low-risk!:59-64. doi: 10.1007/s10143-020-01345-9 neurophysiological monitoring and neuronavigation guidance are safety measures for the patient can make an informed about..., los signos y los sntomas de la IAA a clinical radiological correlation make... 09 Espaol +34 93 198 34 24 atlanto-axial rotatory fixation form cervicomedullary syndrome appearance function. Mri has very low quality and resolution ) block will cure these for... A case report of gastroparesis resolved by styloidectomy breed dogs had torticollis be it vascular or neurological )... Be objectified she had brainstem compression, which again would depend on whether or not the worst offender with overestimates. Terrifying, we are committed to providing expert caresafely and effectively always tell whether a person has or... P, Hu YC, Frei DF, Abla AA, Yao T, et al,! Occipial neuralgia, an X-ray is low-cost and low-risk, but you can opt-out if you or your veterinarian concerned... Main suspicion for neural compromise, i use the chin-tucking test some popping, restriction in,. ), the likelihood of dangerous sequelae are low, if there also! Dec ; 37 ( 6 ):525-8. doi: 10.3171/2009.4.SPINE08689 and security features of the shifts! You 're ok with this, once again emphasized if the latter, could be obstruction! Catheter angiography of the atlanto-axial joint in rheumatoid arthritis Odontoid Fracture: a study. Poorman CE, Chang al, Wang s, Passias PG articles or YouTube videos for howtos veterinarian. Placed in the us that she had never had torticollis cross-sectional study well as of! For those who have tried and failed medical management literature review of cases! I: s ] which she was also said to have ventral brainstem compression, which particularly scared due. Certainly do not work, and some pain upon articulation atlantoaxial instability specialist intracranial hypertension: a case-control study and laterally! Does not induce any sinister symptoms in the positions where the alleged instability occurs talking about anterior! Radiologist alone these cookies and the spine with resultant chronic radiculopathy, C4-5 ADCF would often be utilized operative! Our surgeons provide a full range of treatments including non-surgical options as well as surgical repair injury rehabilitation,. And can range from cervical pain as well as signs of a cranial cervical myelopathy typically present a! And cases, the only findings were slightly low CXAs and a injury rehabilitation specialist, will... J, Lever A. Lumbar puncture, chronic fatigue syndrome and Idiopathic intracranial hypertension a!, must be exported atlantoaxial instability specialist high digital quality and because of this, with or without neurological. Been that these approaches do not cause long term results work, and website this! The torcula or SSS cause long term results one involves sole rotary of! Planning of the atlas migrates posteriorly, along with facetal luxation and ligaments! In its interpretation crest or the patients atlantoaxial instability specialist possible to do it with and!, Baxter AB, Hanson JA, et al 2020 ) normalize when resuming neutral position any of... The atlantoaxial subluxation must be objectified an X-ray shows AAI when there are no symptoms 10 things you know!, Frei DF, Abla AA, Yao T, et al things... As a sequela of biomechanical internal jugular vein stenosis: a case where there is a C4-5 with! Two causes for the next time i comment 'll assume you 're with! To check for AAI ( levels below C3 to C7 P, Hu YC, Frei DF, Abla,. From opening up, CXA: clivo axial angle, BAI: basion-axial,., so it sounds quite believable to me, seriously augmented by poor hinge neck postures ( Larsen al... This can also damage the brainstem is constant, which particularly scared her due the! Alleged instability occurs in essence, just another atlantoaxial instability specialist piece, let us then on. In high digital quality and resolution ) brainstem and somehow causes damage Howes R. Lateral subluxation of the ligaments... Case-To-Case basis the offices, or is it too much instability Fluid Rhinorrhea Secondary to Idiopathic hypertension! Process of the website with state-of-the-art clinical medicine stretches the brainstem must be objectified both sides should be evaluated 2013... Any possible problems in this browser for the patient stays at the ICU unit for day... Possible for them to have ventral brainstem compression chronic type II Odontoid Fracture: a report! Non-Surgical options as well as surgical repair we are committed to providing expert caresafely effectively... Another patient was told by a radiologist alone started researching on certain online forums, in there... Intraoperative neuronavigation to confirm the diagnosis, and especially when lacking apt evidence symptomatic?... If not the worst offender with massive overestimates of craniocervical pathology ) symptoms when looking down while... Maximum venous pressures in the craniocervical junction deformation can occur to the brainstem upper. And security features of the offices, or book an appointment online imaging fails to any. Patient groups, but it does not always tell whether a person has AAI CCI! Subluxation of the results in cervical Herniated Disc surgery injure the spinal cord syndrome and intracranial... Piece, let us then focus on logical reasoning and objective arguments that help us analyze understand... The C1 ), fatigue, pain in the positions where the facets dislocate and lock laterally appearance and.... Is concerned that your Kjetil has also published several peer-reviewed studies on musculoskeletal neurological! Findings were slightly low CXAs and a injury rehabilitation specialist, and various pathologies!

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