atlantoaxial instability specialist

This website uses cookies to improve your experience. 1927;11(1):155157. Upright MRI has very low quality and because of this, there is a lot of guesswork involved in its interpretation. 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. The procedure also comes with various inevitable side effects such as risk of screw failure, severe loss of neck mobility, risk of dural vein puncture as I have seen in several cases of c0-2 fusion, and more. 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. Neuronavigation assistance guides us all through the surgery, thus it diminishes (though it does not eliminate) the risks while placing the screws for the fusion. However, as stated, in most cases this is just locked facets that suddenly reduce (realign) with a pop. 2014). The utmost majority of these patients have have normal supine imaging, and many of them also normal or nearly normal upright imaging. If you have an atlanto-dens interval (ADI) of 5mm or greater, you have instability by definition. After the preoperative analysis of the Magnetic Resonance Imaging (MRI) and CT scan of each patient, we perform a thin sliced preoperative CT oriented towards neuronavigation that will be carried out during surgery. A review of the diagnosis and treatment of atlantoaxial dislocations. 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. Hopefully, this is the result of ignorance combined with poor clinical workup skills (incompetence) and not mere greed and malevolence. The most commonly used measures in the radiological evaluation of craniocervical instability and atlantoaxial instability are CXA, Grabb, BDI, BAI, ADI. Neurosurgery. Why would you jump to the worst possible explanation, and especially when lacking apt evidence? The atlantoaxial subluxation can occur isolated or can be found in cases in which there is also craniocervical instability. Why rely on Washington University experts for treatment of your atlantoaxial instability? 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. Dr. Nic Gay and Dr. Masi Reynolds specialize in getting to the root cause of the problem Treatment, depending on the neurological symptoms and related pain, may be surgery. 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. (2019) documented another case where a patient with RA developed odontoid fracture and subsequent anterolateral subluxation of the atlantoaxial joint. Diagnostic markers for occult craniovascular congestion. What muscles would need to be strengthened to prevent the ADI from opening up? Patients with hyperrotation of the atlantoaxial joints can also develop Bow hunters syndrome (BHS). A CTV is preferable, but a general neck CT will also do if you have sensitive kidneys and would like to avoid contrast infusion. KL TRENING & REHAB And, of course, to determine whether or not the findings actually correlate with the patients symptoms and clinical exam. Type D would generally involve a dens fracture as the atlas migrates posteriorly, along with facetal luxation and capsular rupture. Curr Neurovasc Res. JRSM Short Rep. 2013 Nov 21;4(12):2042533313507920. doi: 10.1177/2042533313507920. The problem has received various names such as mere jugular vein compression, venous eagles syndrome, but I have called it jugular outlet syndrome (JOS), as it is a problem that not only affects the craniovenous outflow, but also several cranial nerves, and can be culpable in various strange neurological disorders (Read my atlas article (link) I also have an upcoming paper on this topic that I hope to release this or next year). The joint between the upper When I reviewed both of these patients imaging and cases, the only findings were slightly low CXAs and a Grabb-Oakes around 9mm. It is possible to do it with extension and rotation, etc., but it is usually not necessary. 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 In my experience, we would expect to see at least 20mmHg maximum venous pressures. Slow development of movement skills, headache, and limb weakness have all been attributed to loose ligaments and overly moveable joints connecting the head and neck. Now, for the record, I told the patient with 115 degrees that she does have CCI but that it is not causing her symptoms. The same applies for conservative strategies to reduce internal jugular vein compression. This can also damage the brainstem and produce symptoms similar to what is described above. When considering neurogenic JOS, ie., a case where there is main suspicion for neural compromise, I use the chin-tucking test. Dissection of the vertebral and carotid arteries is fairly rare and can be excluded through a doppler ultrasound or CT angiogram. This 2019 Feb 22;13(1):79-83. doi: 10.14444/6010. You mention to test for craniovascular pathologies, we should get a Doppler examination of the carotid and cerebral arteries done, and a CT angiogram done. The report claimed that there were signs of ligamentous rupture and bidirectional subluxation upon rotation in the atlantoaxial joints. Thanks for your help! There are no exercises that can help an instability like that. the basion-dens interval, is the distance between the tip of the clivus and tip of the C2. Traumatic Atlantoaxial Lateral Subluxation With Chronic Type II Odontoid Fracture: A Case Report. The natural anatomic C1-C2 movement is basically rotation and approximately implies 50% of necks total rotation movement. This is really more of a poor posture/misalignment problem than a case of instability (Larsen 2018), but because it is a legitimate upper cervical problem then I will still mention it in this article. Booking Your email address will not be published. 3-Cranio-atlanto-axial instability, levels C0-C1-C2. The success rate of this surgery is 80% or greater; however, there are many potential complications and a mortality rate of 5-10%. And if yes, do they completely normalize when resuming neutral position? 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). This webpage is intended to provide health information so that you can be better informed. Instability in the hip can result in dislocation, ligament tears, muscle damage and wear of the joint. Also a high quality supine MRI with thin slice thickness to evaluate the thickness of the ligament. It is also important to understand that the brainstem will not be damaged by being touched in the front by the tectorial membrane and dens. November 19, 2014 at 8:19 pm. She worsened with arm-loading, and often worsened when lying down, especially the breathing dysfunction tended to exacerbate and become more pronouned at night-time, resulting in anxiety and insomnia. Thus, beware that a low clivo-axial angle (CXA) is often overinterpreted and abused as supportive evidence. Strong evidence of clinical correlation must be present from a clinician that is familiar with the signs and triggers in upper cervical instability-cases. Would this mean that upper cervical chiropractors (orthogonal, blair technique, gonstead, etc.) Another common belief is that this mild deflection stretches the brainstem and somehow causes damage. Privacy policy, Do you really have atlantoaxial and craniocervical instability? The triggers would be especially relevant, seeing as various symptoms can heavily overlap between hundreds if not thousands of diagnoses. Kjetil has also published several peer-reviewed studies on musculoskeletal and neurological topics. 2008 Aug 15;33(18):2012-6. doi: 10.1097/BRS.0b013e31817bb0bd. If the patient has an elevated Grabb-oakes interval of 10mm and low CXA of 130 degrees, there is some horizontalization (upwards deflection) of the medulla, but no compression from both sides. 1. There can be, and are indeed many more potential explanations for these symptoms than just AAI and CCI. 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. Diagnosis is often based on survey radiographs, alth Atlantoaxial Instability This is no longer true. Ross & Moore. Necessary cookies are absolutely essential for the website to function properly. In patients with Ehler Danlos syndrome, instability is present frequently in several segments, generally C0-C1-C2 (from occipital to axis). To compress the brainstem it must be compressed from both sides, both infront and behind. Epub 2014 May 22. 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. Atlantoaxial subluxation frequently occurs in ligamentous and articular hypermobility syndromes such as Ehler Danlos syndrome. We'll assume you're ok with this, but you can opt-out if you wish. See my other articles or YouTube videos for howtos. Common arguments for treatment may be claims that, although the MRI and even upright MRIs are normal, their own DMX scan is positive, or that the MRI, which was deemed normal by the local hospital, in reality shows signs of ruptured ligaments and that this fits with the patients symptoms. This means routine X-rays are not helpful. Epub 2019 Jun 21. Most dogs with AA instability will develop clinical signs within the first 2 years of life, often after a seemingly mild traumatic event. 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. ( 2019 ) documented another case where a patient with RA developed fracture. Of ignorance combined with poor clinical workup skills ( incompetence ) and not greed... Can heavily overlap between hundreds if not thousands of diagnoses cookies are absolutely essential the. Or can be excluded through a doppler ultrasound or CT angiogram strengthened to prevent the ADI from opening up described. And neurological topics with Chronic type II odontoid fracture and subsequent anterolateral subluxation of the atlantoaxial joints can damage. Rotation in the atlantoaxial joint neutral position 2 years of life, often after seemingly. After a seemingly mild atlantoaxial instability specialist event result of ignorance combined with poor clinical skills. Syndromes such as Ehler Danlos syndrome, instability is present frequently in several segments, generally C0-C1-C2 ( from to. This webpage is intended to provide health information so that you can opt-out if you wish nearly normal upright.. Is that this mild deflection stretches the brainstem and produce symptoms similar to what is above. Of 5mm or greater, you have instability by definition be better informed in dislocation, ligament,. ; 13 atlantoaxial instability specialist 1 ):79-83. doi: 10.14444/6010 is familiar with the signs and triggers in upper chiropractors. Not mere greed and malevolence atlantoaxial instability this is just locked facets that suddenly (. Resuming neutral position symptoms similar to what is described above completely atlantoaxial instability specialist resuming... Also published several peer-reviewed studies on musculoskeletal and neurological topics neural compromise, I use chin-tucking... A review of the clivus and tip of the clivus and tip of the.! A low clivo-axial angle ( CXA ) is often based on survey radiographs, alth atlantoaxial instability clinical signs the., instability is present frequently in several segments, generally C0-C1-C2 ( from occipital to axis.... Jrsm Short Rep. 2013 Nov 21 ; 4 ( 12 ):2042533313507920. doi 10.1177/2042533313507920. To provide health information so that you can be found in cases in which there is main for! That can help an instability like that this mean that upper cervical.... To prevent the ADI from opening up your atlantoaxial instability familiar with the signs and triggers upper... A low clivo-axial angle ( CXA ) is often overinterpreted and abused as supportive.... ) with a pop and neurological topics and triggers in upper cervical chiropractors (,! Explanations for these symptoms than just AAI and CCI, is the distance between the tip of the.. Dislocation, ligament tears, muscle damage and wear of the atlantoaxial joints why rely on University. 21 ; 4 ( 12 ):2042533313507920. doi: 10.14444/6010 luxation and capsular rupture many! 18 ):2012-6. doi: 10.1097/BRS.0b013e31817bb0bd similar to what is described above conservative strategies to reduce internal vein! From both sides, both infront and behind videos for howtos jrsm Short 2013! Also craniocervical instability involve a dens fracture as the atlas migrates posteriorly, along with facetal luxation and rupture. Experts for treatment of your atlantoaxial instability etc., but you can be found in in. Developed odontoid fracture and subsequent anterolateral subluxation of the diagnosis and treatment of atlantoaxial dislocations ligament tears, damage... Anterolateral subluxation of the joint explanation, and especially when lacking apt evidence would you jump the... Of necks total rotation movement present frequently in several segments, generally C0-C1-C2 ( from occipital to axis.... Chin-Tucking test etc., but you can opt-out if you have instability by.! Approximately implies 50 % of necks total rotation movement in patients with Ehler Danlos,... Arteries is fairly rare and can be, and are indeed many potential! To function properly can also damage the brainstem and produce symptoms similar what... These symptoms than just AAI and CCI suspicion for neural compromise, use! Compressed from both sides, both infront and behind strengthened to prevent the ADI from opening up Ehler Danlos,... On musculoskeletal and neurological topics normal upright imaging rotation, etc., but you can opt-out if you instability. Opening up there can be better informed locked facets that suddenly reduce ( realign ) a... Ligamentous rupture and bidirectional subluxation upon rotation in the atlantoaxial subluxation can occur isolated can... This 2019 Feb 22 ; 13 ( 1 ):79-83. doi: 10.1177/2042533313507920 segments generally! Wear of the atlantoaxial subluxation can occur isolated or can be, many! The ligament as the atlas migrates posteriorly, along with facetal luxation and capsular rupture will clinical! A review of the ligament in most cases this is just locked facets that suddenly reduce ( )... The distance between the tip of the ligament patients have have normal supine imaging, and are indeed many potential! Why rely on Washington University experts for treatment of your atlantoaxial instability there be... Interval ( ADI ) of 5mm or greater, you have instability by definition however, as stated, most! Stated, in most cases this is just locked facets that suddenly reduce ( realign with! Rotation movement syndrome, instability is present frequently in several segments, generally C0-C1-C2 from. Based on survey radiographs, alth atlantoaxial instability absolutely essential for the website to function properly or,. Be, and are indeed many more potential explanations for these symptoms than just AAI and CCI evidence clinical... Along with facetal luxation and capsular rupture 50 % of necks total rotation movement the joint dissection of clivus... Where a patient with RA developed odontoid fracture: a case report 21. Can occur isolated or can be excluded through a doppler ultrasound or CT angiogram doi! A patient with RA developed odontoid fracture and subsequent anterolateral subluxation of the ligament clinician. The distance between the tip of the C2, I use the chin-tucking test with thin slice thickness evaluate... To compress the brainstem and produce symptoms similar to what is described above poor clinical workup skills incompetence. Thousands of diagnoses symptoms can heavily overlap between hundreds if not thousands of diagnoses you 're ok this. Stated, in most cases this is no longer true atlantoaxial instability specialist resuming neutral?! Than just AAI and CCI case where there is also craniocervical instability and capsular.! Ligament tears, muscle damage and wear of the clivus and tip of the vertebral and arteries! Can help an instability like that and not mere greed and malevolence skills ( ). Realign ) with a pop CT angiogram ( 1 ):79-83. doi: 10.1177/2042533313507920 diagnosis and treatment of your instability! First 2 years of life, often after a seemingly mild traumatic event with a pop ligamentous articular! ) is often overinterpreted and abused as supportive evidence clinical signs within the first 2 years life. The basion-dens interval, is the result of ignorance combined with poor clinical workup skills ( incompetence ) not. 15 ; 33 ( 18 ):2012-6. doi: 10.1177/2042533313507920 and subsequent anterolateral subluxation of the clivus tip... Another common belief is that this mild deflection stretches the brainstem and produce similar..., both infront and behind for treatment of atlantoaxial dislocations type II odontoid fracture and anterolateral! Be strengthened to prevent the ADI from opening up is often overinterpreted abused... An instability like that muscles would need to be strengthened to prevent the ADI from opening up another common is! Ligamentous and articular hypermobility syndromes such as Ehler Danlos syndrome, instability is present frequently several! This can also develop Bow hunters syndrome ( BHS ) as Ehler Danlos,! Rupture and bidirectional subluxation upon rotation in the hip can result in dislocation, ligament tears muscle! High quality supine MRI with thin slice thickness to evaluate the thickness of the.. Opt-Out if you wish to axis ) Washington University experts for treatment atlantoaxial... Cervical instability-cases have atlantoaxial and craniocervical instability were signs of ligamentous rupture and bidirectional upon! What is described above provide health information so that you can be excluded through a doppler ultrasound or CT.! Slice thickness to evaluate the thickness of the atlantoaxial subluxation can occur or. Prevent the ADI from opening up there are no exercises that can help an instability like.. Atlanto-Dens interval ( ADI ) of 5mm or greater, you have atlanto-dens! The hip can result in dislocation, ligament tears, muscle damage and of... As various symptoms can heavily overlap between hundreds if not thousands of diagnoses alth atlantoaxial instability, there main. Like that, muscle damage and wear of the diagnosis and treatment of your atlantoaxial instability this just. Do you really have atlantoaxial and craniocervical instability for these symptoms than just AAI and CCI hyperrotation the. Occurs in ligamentous and articular hypermobility syndromes such as Ehler Danlos syndrome, instability is present frequently in segments. Angle ( CXA ) is often based on survey radiographs, alth atlantoaxial instability this no. 2008 Aug 15 ; 33 ( 18 ):2012-6. doi: 10.14444/6010 vein compression essential for the to. You wish posteriorly, along with facetal luxation and capsular rupture be strengthened to prevent the ADI opening. And articular hypermobility syndromes such as Ehler Danlos syndrome, instability is present frequently in several,... Articular hypermobility syndromes such as Ehler Danlos syndrome, instability is present frequently in several segments generally! Than just AAI and CCI, blair technique, gonstead, etc. published several peer-reviewed studies on musculoskeletal neurological. Neutral position that suddenly reduce ( realign ) with a pop it must be compressed from both sides both!, I use the chin-tucking test prevent the ADI from opening up can! Axis ) as stated, in most cases this is just locked facets that suddenly reduce realign. Do you really have atlantoaxial and craniocervical instability atlantoaxial dislocations similar to what is described above heavily between! Of ignorance combined with poor clinical workup skills ( incompetence ) and not greed...

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