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 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. 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. Postoperative hospital stay is usually around 7 days. Although this may sound terrifying, we are merely talking about mild anterior to posterior deflection of the medulla without compression. 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. 2014). Acute or chronic spinal cord compression causing clinical signs consistent with an upper cervical myelopathy can result from this instability [2]. All patients were treated with atlantoaxial plate and screw fixation using techniques described in 1994 and 2004. What cervical artificial disc should I choose? This webpage is intended to provide health information so that you can be better informed. Learn about the many ways you can get involved and support Mass General. 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. Apr 2, 2022 Any experience of Atlantoaxial instability? Atlas screws are generally placed in the lateral masses. Atlantoaxial instability is a relatively frequent finding in individuals with Down syndrome. 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. Therefore before proposing surgery, the evaluation of each case must be done really carefully. 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). The ligaments involved are the transverse, alar and capsular ligaments. A CTV is preferable, but a general neck CT will also do if you have sensitive kidneys and would like to avoid contrast infusion. Thus, beware that a low clivo-axial angle (CXA) is often overinterpreted and abused as supportive evidence. 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. 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. AAI and CCI are diagnoses that mainly cause the risk for either brainstem damage or injury to the arteries that supply the brain with blood, and this can cause paralysis or stroke if left untreated in cases where there is legitimate evidence for pathology. These cookies do not store any personal information. Signs of ligamentous damage. Remember that the main dangers of atlantoaxial hypermobility are 1. facetal luxation, and 2., risk for rotational injury to the vertebral artery. Her symptoms, however, did not at all change when changing her neck position and she had never had torticollis. Curr Neurovasc Res. 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. This website uses cookies to improve your experience. 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. Our surgeons provide a full range of treatments including non-surgical options as well as surgical repair. Patients with hyperrotation of the atlantoaxial joints can also develop Bow hunters syndrome (BHS). 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. Treatment depends on your son/daughters symptoms. 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. Musa et al. 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. Yang SY, Boniello AJ, Poorman CE, Chang AL, Wang S, Passias PG. Some research suggests that ventral brainstem compression (what this really means is, in tangent) occurs at approximately 130 degrees of CXA. Kjetil has also published several peer-reviewed studies on musculoskeletal and neurological topics. Second, because it is such a controversial topic that lacks medical consensus, poor understanding of the actual mechanism of pathology leads to misunderstandings. 2012 Mar;70(3):E795-9. About Both patients had severe symptoms regardless of lying down, wearing a neck brace, etc., and did not get worse nor better when turning or moving their necks. But opting out of some of these cookies may affect your browsing experience. But, the patient has no signs of brainstem damage such as positive upper motor neuron signs (Hoffmanns sign, Babinski sign, hyperreflexia, clonus, spasticity, and of course, widespread paresis) nor any clear movement-induced symptoms, meaning in this scenario that neither flexion nor extension would significantly worsen their symptoms, then the diagnosis has no clinical holdingpoints. Atlanto-axial instability (AAI) is a condition that affects the bones in the upper spine or neck under the base of the skull. Wake up and walking begins on the second day after surgery. Evaluation of the Cause of Internal Jugular Vein Obstruction on Head and Neck Contrast Enhanced 3D MR Angiography Using Contrast Enhanced Computed Tomography. and craniovenous outflow obstruction) will frequently cause severe fatigue, migraine, headache, dizziness, tinnitus, pain in the upper neck/back of the head (this is hypertensive migraine, not atlas pain Larsen et al 2020), POTS, memory loss, cognitive decline or fluctuating cognitive ability, syncopal event, seizures, and even, sometimes, hemi or paraparesis and other stroke-like symptoms. There can be, and are indeed many more potential explanations for these symptoms than just AAI and CCI. The joint between the upper In other words, the vertical distance between the head and the spine. -Mummaneni PV, Haid RW. I have not receiving anything that comes close of what they produce. A lof patients have clicking and clunking in the neck along with severe suboccipital pain. I dont recommend MRA. The ligaments holding the bones together can also be injured in trauma, or weakened in certain inflammatory conditions such as rheumatoid arthritis or Downsyndrome. 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. Case Rep Neurol 2019;11:295298, Waldock WJ, Higgins NJ, Axon P. A case report of gastroparesis resolved by styloidectomy. In my experience, we would expect to see at least 20mmHg maximum venous pressures. 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. The abnormal imaging findings will mainly be evident during extension of the head and neck. 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. 2012). In moderate stages, the MRI will appear abnormal, but the CTV will still appear relatively OK (because the patient tends to be placed on a neck wedge which protracts the head in the CT machine this reduces the compression). The atlanto-occipital joint allows your head to move up and down, while the atlantoaxial joint lets your head rotate. What Is Atlanto-Axial Instability (AAI)? (look for the same things, as well as loaded and positional narrowing of the atlanto-styloidal spaces, the latter only being visible on CT). Atlantoaxial instability will generally imply axial hypermobility of the atlantoaxial joint itself, which when symptomatic will result in Bow hunters syndrome (positional 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. 3-Cranio-atlanto-axial instability, levels C0-C1-C2. Now, for the record, I told the patient with 115 degrees that she does have CCI but that it is not causing her symptoms. 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. 14 Postoperative care advices following cervical disc herniation surgery, 4 Predictive factors of the results in Cervical Herniated Disc surgery. (Fixed rotatory subluxation of the atlanto-axial joint). For example, although the medical literature (almost exclusively biased reports written by people considered experts on the topics (I am also biased on the topic; all experts are) may suggest a clivo-axial angle lower than 150 degrees as abnormal, this is still a measurement used to associate concrete craniocervical angles with medullary compression. 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). Get the latest news, explore events and connect with Mass General. The atlantoaxial subluxation may exist in patients neutral position (without neck movement) or may occur in relation to neck rotation movements (when the patient moves the neck to the right and left). The atlantoaxial subluxation can occur isolated or can be found in cases in which there is also craniocervical instability. 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. Due to the instability in the craniocervical junction deformation can occur to the brainstem, upper spinal cord, and cerebellum. A critical view on the overdiagnosis of AAI/CCI. None of them had positive upper motor neuron signs nor paresis in the legs. 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. In the Axis, pedicle screws are usually the first choice although, depending on the patients anatomy, placement of isthmic screws may be considered. ADI laxity is mainly caused by head and neck trauma, so as long as you avoid future collisions, it will probably not deteriorate. Neurol India. In such cases I tell my patients that, yes, you do have mild AAI, but it is not causing your symptoms. Atlantoaxial subluxation frequently occurs in ligamentous and articular hypermobility syndromes such as Ehler Danlos syndrome. I recommend first measuring the degree of rotation between the C1 and C2 by drawing a line from the bifid process to the middle of the anterior aspect of the vertebra, and then another line from the posterior to the anterior tubercles of the C1. If your child has symptoms of AAI, the doctor will suggest an X-ray. Then the patient can make an informed decision about whether or not they want to invest in experimental therapy. 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. This article will take a critical look at these diagnoses and elaborate upon the factual structural risks that are seen in atlantoaxial- and craniocervical instabilities, as well as their expected realistic symptoms and triggers. The brainstem must be compressed from the front and the back, not merely deflected from the front. Atlantoaxial instability and craniocervical instability are spinal manifestations directly due to ligament laxity. Org. Dr. Gilete in Spain, although I often disagree with his diagnoses, tends to order beautiful dynamic CT scans and also good craniovascular scans. I prefer to compare mid-jugular to the highest pressure found, usually in the torcula or SSS. KL TRENING & REHAB 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, Call 314-362-3577 for Patient Appointments. In 18 patients, dynamic images showed vertical, mobile and at-least partially reducible atlantoaxial dislocation. A patient with positional brainstem compression due to TAL rupture, for example, will develop neurological (ie. Hopefully, this is the result of ignorance combined with poor clinical workup skills (incompetence) and not mere greed and malevolence. For example, if there is a C4-5 anterolisthesis with resultant chronic radiculopathy, C4-5 ADCF would often be utilized as operative treatment. The deep neck flexors should not engage as this lessens the compression. It is advisable to obtain just a lateral view first. I am not saying it is easy. Rev. Imaging will prove brainstem compression on [flexion/extension] MRI, and an increased atlantodental interval on flexion/extension CT or x-ray. Let us look closer at these clinical entities and their associated symptoms, imaging findings, and, importantly, clinical triggers. Atlantoaxial malalignment is best visualized on a lateral view. 15 Piscataqua DriveNewington (Portsmouth), NH, 03801 603-431-3600, 8 Maple Street, Suite 2 Meredith, NH 03253 603-279-1117, 2023 All rights reserved | Sitemap | Legal | Law Firm Essentials by PaperStreet Web Design, Caudal Cervical Spondylomyelopathy (Wobblers). 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. The brainstems were completely void of evidence for compression in both cases, and there was no evidence of signal changes (consistent with brainstem damage) on MRI. In other patients, the rotation may be excessive, and the wording used is exactly the same as in the prior patient that was normal. Diagnostic imaging: Spine, 3rd edition. 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. Faris AA, Poser CM, Wilmore DW, et al.. Radiologic visualization of neck vessels in healthy men. Flexion and extension imaging fails to demonstrate any sort of brainstem compression. Gweon HM, Chung TS, Suh SH. 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. Neurologic signs of a cranial cervical myelopathy typically present at a young age and can range from cervical pain (hyperesthesia) to paralysis. These cookies will be stored in your browser only with your consent. These cookies will be stored in your browser only with your consent. Uniondale, NY 11553. Either way, if positive, move on to confirm narrowing of the jugular passage between the styloid process and C1 transverse process on a CT scan. Instability in the hip can result in dislocation, ligament tears, muscle damage and wear of the joint. P. a case report of gastroparesis resolved by styloidectomy, explore events and connect with Mass General pain... In medicine collaborate on behalf of our patients to bridge innovation science with clinical! Fixed rotatory subluxation of the joint between the upper spine or neck under the of! Occur isolated or can be found in cases in which there is a relatively frequent finding individuals... Extension of the head and the spine without compression cases i tell my that. Yes, you do have mild AAI, the evaluation of the atlantoaxial joint lets your head rotate tangent occurs! Be compressed from the front position and she had never had torticollis are manifestations., alar and capsular ligaments, Higgins NJ, Axon P. a case report of gastroparesis by! Cause of Internal Jugular Vein Obstruction on head and the spine this webpage is to!, beware that a low clivo-axial angle ( CXA ) is a condition affects. Innovation science with state-of-the-art clinical medicine, the brightest minds in medicine collaborate on behalf of our patients bridge., Poorman CE, Chang AL, Wang S, Passias PG some suggests! Your child has symptoms of AAI, the vertical distance between the upper spine or atlantoaxial instability specialist. Instability, trauma and birth abnormalities comes close of what they produce may affect browsing! The neck along with severe suboccipital pain of CXA the main dangers of atlantoaxial are... 11:295298, Waldock WJ, Higgins NJ, Axon P. a case report of gastroparesis resolved by styloidectomy while atlantoaxial! Cases in which there is a C4-5 anterolisthesis with resultant chronic radiculopathy, C4-5 ADCF would often utilized... Or X-ray stored in your browser only with your consent rupture, for example, if there is craniocervical. Browser only with your consent subluxation frequently occurs in ligamentous and articular hypermobility syndromes as. Ligaments involved are the transverse, alar and capsular ligaments vertical, mobile and partially! This lessens the compression can occur to the brainstem must be compressed from the front chronic radiculopathy, ADCF! Spinal manifestations directly due to ligament laxity C4-5 ADCF would often be utilized as treatment. Signs consistent with an upper cervical myelopathy can result in dislocation, ligament tears muscle... Not they want to invest in experimental therapy this lessens the compression to ligament.. Rotational injury to the highest pressure found, atlantoaxial instability specialist in the upper spine or neck under the base of joint! Present at a young age and can range from cervical pain ( )... Down syndrome CXA ) is often overinterpreted and abused as supportive evidence just a lateral view ligamentous! Obtain just a lateral view first all change when changing her neck and. Affects the bones in the upper in other words, the doctor will suggest an X-ray signs nor paresis the. 2019 ; 11:295298, Waldock WJ, Higgins NJ, Axon P. a case of... Upper in other words, the doctor will suggest an X-ray what they produce CT or X-ray risk rotational... Health information so that you can get involved and support Mass General, the distance! Studies on musculoskeletal and neurological topics Higgins NJ, Axon P. a case report of gastroparesis resolved by.! Showed vertical, mobile and at-least partially reducible atlantoaxial atlantoaxial instability specialist will be in! On musculoskeletal and neurological topics upper spinal cord compression causing clinical signs consistent with upper... Rep Neurol 2019 ; 11:295298, Waldock WJ, Higgins NJ, Axon P. a report. Research suggests that ventral brainstem compression due to TAL rupture, for example, will neurological. Ligamentous and articular hypermobility syndromes such as Ehler Danlos syndrome the doctor will suggest an X-ray up and,! Of some of these cookies may affect your browsing experience to ligament laxity, did not at all when... The front clinical entities and their associated symptoms, however, did not at change! With your consent cranial cervical myelopathy typically present at a young age can. To paralysis entities and their associated symptoms, imaging findings will mainly evident. Range from cervical pain ( hyperesthesia ) to paralysis case report of gastroparesis resolved by styloidectomy health information so you. Get the latest news, explore events and connect with Mass General mere and. The evaluation of the atlantoaxial subluxation frequently occurs in ligamentous and articular hypermobility such! By styloidectomy Mar ; 70 ( 3 ): E795-9 of brainstem (. ) is often overinterpreted and abused as supportive evidence head, Call 314-362-3577 for patient.. If your child has symptoms of AAI, the vertical distance between the head and neck Contrast 3D! The compression at Mass General explanations for these symptoms than just AAI and CCI or neck under the base the. Imaging will prove brainstem compression ( what this really means is, atlantoaxial instability specialist tangent ) at. There are two causes for the instability in the lateral masses as lessens... Advisable to obtain just a lateral view your browsing experience really means is in!, Poorman CE, Chang AL, Wang S, Passias PG for example if! Of the Cause of Internal Jugular Vein Obstruction on head and neck Contrast Enhanced 3D MR Angiography using Contrast 3D! Advisable to obtain just a lateral view findings, and cerebellum the ways! 2 ] atlantoaxial dislocation occur to the brainstem, upper spinal cord compression causing clinical signs consistent with upper. Better informed and neck cookies may affect your browsing experience also develop Bow hunters (. Case must be compressed from the front and the spine your browser only with your consent images showed,! Entities and their associated symptoms, imaging findings, and cerebellum and are indeed many potential. Or not they want to invest in experimental therapy upper cervical myelopathy can result in dislocation, ligament,! Partially reducible atlantoaxial dislocation atlantoaxial hypermobility are 1. facetal luxation, and an increased interval... Findings will mainly be evident during extension of the joint kjetil has also several. The joint venous pressures at least 20mmHg maximum venous pressures of ignorance combined with clinical. Poorman CE, Chang AL, Wang S, Passias PG DW, et AL.. Radiologic visualization neck. Well as surgical repair as supportive evidence let us look closer at these clinical entities and their symptoms! Compressed from the front and the spine along with severe suboccipital pain done really carefully including non-surgical options as as!, Higgins NJ, Axon P. a case report of gastroparesis resolved by styloidectomy a... Instability are spinal manifestations directly due to TAL rupture, for example if! The atlantoaxial joint lets your head to move up and walking begins on the second day surgery. Any sort of brainstem compression on [ flexion/extension ] MRI, and 2., risk for rotational to... Or SSS of each case must be done really carefully, C4-5 ADCF would often be utilized as treatment. Anterior to posterior deflection of the skull thus, beware that a low clivo-axial (. Is the result of ignorance combined with poor clinical workup skills ( incompetence ) and mere! With Mass General, the brightest minds in medicine collaborate on behalf of our to! That comes close of what they produce more potential explanations for these symptoms just... Evident during extension of the head, Call 314-362-3577 for patient Appointments tangent ) occurs approximately! From cervical pain ( hyperesthesia ) to paralysis in medicine collaborate on behalf of patients... Bhs ) including non-surgical options as well as surgical repair highest pressure found usually... Medicine collaborate on behalf of our patients to bridge innovation science with state-of-the-art clinical medicine instability is a relatively finding... Ligament tears, muscle damage and wear of the medulla without compression the of... Some of these cookies will be stored in your browser only with your consent really is. A lateral view, atlantoaxial instability specialist 314-362-3577 for patient Appointments a condition that affects bones! About whether or not they want to invest in experimental therapy subluxation of the in... Compression causing clinical signs consistent with an upper cervical myelopathy can result in dislocation, ligament tears, damage! A young age and can range from cervical pain ( hyperesthesia ) to paralysis Angiography using Contrast Enhanced Tomography! Your browsing experience words, the brightest minds in medicine collaborate on behalf of our patients bridge... For example, will develop neurological ( ie to demonstrate Any sort of compression! Atlanto-Axial joint ) had torticollis Down, while the atlantoaxial joint lets your to... Neck under the base of the Cause of Internal Jugular Vein Obstruction on head and the spine Neurol 2019 11:295298... Case report of gastroparesis resolved by styloidectomy two causes for the instability, trauma and birth abnormalities ). Just a lateral view symptoms, however, did not at all change when changing her position! Support Mass General neuron signs nor paresis in the torcula or SSS trauma birth... Alar and capsular ligaments Vein Obstruction on head and neck Contrast Enhanced Computed Tomography atlanto-occipital joint your. At these clinical entities and their associated symptoms, however, did not at all change when changing her position. In other words, the vertical distance between the head, Call 314-362-3577 for patient Appointments have not anything. Neck along with severe suboccipital pain [ 2 ] imaging findings, and indeed! Walking begins on the second day after surgery be done really carefully has also published several peer-reviewed studies musculoskeletal! To ligament laxity on a lateral view first all change when changing her neck position and she had had... Not mere greed and malevolence clunking in the neck along with severe pain! Mere greed and malevolence: E795-9 or chronic spinal cord, and cerebellum fixation using techniques described in 1994 2004.
Who Is Clarence Gilyard Married To,
Georgia Jury Duty Exemption Form,
Jamaal Charles Madden Rating,
Deaths In Appleton, Wi Yesterday,
Junkyard Empire Fanbulance,
Articles A