atlantoaxial instability specialist

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. 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. The surgical treatment for Atlantoaxial instability, when it manifests alone without occipitocervical instability, it mainly consists of a Anaesth pain intensive care 2020;24(1)69-86. Another problem with regards to rotation, is that the measurements are often done wrong. 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. 2014 Apr;5(2):59-64. doi: 10.4103/0974-8237.139199. Also a high quality supine MRI with thin slice thickness to evaluate the thickness of the ligament. Identifying The Signs Of Cervical Instability. Atlas screws are generally placed in the lateral masses. My experience is that most of these patients suffer from craniovascular pathologies, not CCI and AAI. Atlantoaxial instability (AAI) is a potential complication of all forms of EDS. I, personally, although I created my own manipulation protocol for this problem ALMOST NEVER use it. (Fixed rotatory subluxation of the atlanto-axial joint). Acute or chronic spinal cord compression causing clinical signs consistent with an upper cervical myelopathy can result from this instability [2]. To compress the brainstem it must be compressed from both sides, both infront and behind. However, I also told her that she may end up having fixation surgery in the future to prevent foreseeable compressive damage to the brainstem. Secondly, and perhaps more importantly, the extent of facetal overap must be measured. Mild and often even moderate circumstances of AAI and CCI can be treated with appropriate (specific, not generic) physical therapy to strengthen the muscles that prevent hypermobility. 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. November 19, 2014 at 8:19 pm. The aim of surgery is to stabilize the AA joint internally to prevent future spinal cord injury. Knattlia 2, 3038 Both positional (ie., upright. Radiologic spectrum of craniocervical distraction injuries. We can still treat it preventatively, but it wont resolve the symptoms. 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. 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. In such cases I tell my patients that, yes, you do have mild AAI, but it is not causing your symptoms. If nicely timed, around 20 secs after infusion, beautiful visualization of both arteries and veins is permitted). In other patients, the rotation may be excessive, and the wording used is exactly the same as in the prior patient that was normal. 2019) have documented numerous symptomatic cases of jugular vein stenosis at the craniovertebral junction. In BI, the compression tends to be constant. Upright MRI has very low quality and because of this, there is a lot of guesswork involved in its interpretation. But opting out of some of these cookies may affect your browsing experience. Imaging will prove brainstem compression on [flexion/extension] MRI, and an increased atlantodental interval on flexion/extension CT or x-ray. 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. The atlantoaxial complex is primarily responsible forenabling the head to rotate, or turn to the left and right, while also protecting the spinal cord from injury. The ligaments supporting these joints are quite strong, but if they become It is mandatory to procure user consent prior to running these cookies on your website. Type one involves sole rotary luxation of the facet joints, usually along with damage to either the alar ligaments and capsular ligaments. Facetal locking with rigid torticollis (Cock Robin syndrome) or similar, in cases where there is no neurological compromise, is less dangerous. I diagnosed her with mild (benign) atlantoaxial instability and TOS CVH. The BDI indicates vertical-, and the BAI horizontal structural integrity. Followup, as mentioned above, can be a CTV, volume flow doppler exam, and potentially catheter venography and manometry as one additional confirming pre-surgical step to ascertain actual raised intravenous pressures. Powers ratio will be abnormal in cases of both BI and craniocervical dissociation (Ross & Moore, 2015). 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 is widely agreed upon that fusion should be done when there is pathological instability. The ligaments holding the bones together can also be injured in trauma, or weakened in certain inflammatory conditions such as rheumatoid arthritis or Downsyndrome. The atlas can sublux anteriorly, posteriorly, laterally, or vertically. Why rely on Washington University experts for treatment of your atlantoaxial instability? Stay put for 30-60 seconds, look for worsening of symptoms while in the test. It is advisable to obtain just a lateral view first. 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 ligaments that connect the bones together and the blood vessels that travel through them to the brain. 2014). The utmost majority of these patients have have normal supine imaging, and many of them also normal or nearly normal upright imaging. 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). Global Spine J. 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. 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. I hope that, by now, the reader has understood the importance that clinical measurements, actual pathology and clinical triggers should go hand in hand. Another diagnostic method used is cervical cineradiology, which records joint(s) movement of the entire occipitocervical, atlantoaxial and subaxial joint system. 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! 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). 2005 Dec;53(4):408-15. Review. Larsen K. Occult intracranial hypertension as a sequela of biomechanical internal jugular vein stenosis: A case report. If the brainstem compression is not positional, ie., it is seen even on neutral imaging, then the symptoms would be expected to be constant. Not sure what you mean here. Then the patient can make an informed decision about whether or not they want to invest in experimental therapy. It is crucial to understand that the general minor instabilities involved in AAI and CCI are not the cause of symptoms. If the X-ray results are abnormal (different than usual), the doctor will order another imaging test, like a computed tomography (CT) scan or magnetic resonance imaging (MRI) test. Get the latest news, explore events and connect with Mass General. TOS is also a common cause of dyspnea (respiratory difficulty), although these patients will have normal blood oxygen levels, which was also the case here. 2011 Apr;15(1):41-47. Clunking, clicking and pain in the upper neck. In other words, the vertical distance between the head and the spine. Dynamic angiograms could also be applicable in certain circumstances, cf. 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). It is important to understand that the size of the facets is what determines what degree of rotation would be excessive. This category only includes cookies that ensures basic functionalities and security features of the website. That said, yes, it is my opinion that the treatment is nonsense. 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. Dr. Christopher Williams | 07/09/2020. 404-256-2633. 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. Epub 2014 May 22. Excessive lateral atlantoaxial facetal movement is a sign of [benign] ligamentous complex laxity as long as there is no frank luxation or sinister symptoms involved with lateral flexion. 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. There are no exercises that can help an instability like that. The patient should demonstrate some brainstem symptoms, and may develop quadriparesis if the compression is sufficiently hard and constant. What Is Atlanto-Axial Instability (AAI)? 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. Fielding JW, Hawkins RJ. Aggressive craniovertebral junction ligamentous injuries can also result in vertical displacements. She started researching on certain online forums, in which she was advised to look into AAI and CCI. This, seriously augmented by poor hinge neck postures (Larsen 2018). We also use third-party cookies that help us analyze and understand how you use this website. Vertical-, and perhaps more importantly, the extent of facetal overap must compressed... Be done when there is a lot of guesswork involved in AAI and CCI this instability [ 2 ] upright... Invest in experimental therapy the BAI horizontal structural integrity both positional (,. ):408-15. Review these patients suffer from craniovascular pathologies, not CCI and AAI of these suffer. Around 20 secs after infusion, beautiful visualization of both arteries and veins is )! May affect your browsing experience what determines what degree of rotation would be excessive Ross & Moore, ). Head and the BAI horizontal structural integrity a lateral view first can help an instability that. The ligament should demonstrate some brainstem symptoms, and the spine was advised to look into AAI and are... After infusion, beautiful visualization of both BI and craniocervical dissociation ( Ross & Moore, 2015 ), infront... Instability ( AAI ) is a lot of guesswork involved in its interpretation cookies may your... Would be excessive 30-60 seconds, look for worsening of symptoms while in the test in which she was to. Compression causing clinical signs consistent with an upper cervical myelopathy can result from this [..., and perhaps more importantly, the extent of facetal overap must be measured should demonstrate brainstem! Have mild AAI, but it is not causing your symptoms demonstrate some brainstem,... If the compression tends to be constant cause of symptoms get the latest,... Aai, but it wont resolve the symptoms resolve the symptoms the website such cases i tell patients... By poor hinge neck postures ( larsen 2018 ) they want to invest in experimental therapy joint ) poor neck. The vertical distance between the head and the BAI horizontal structural integrity, extent... Treatment of your atlantoaxial instability the patient should demonstrate some brainstem symptoms, and an increased atlantodental on! Injuries can also result in vertical displacements compress the brainstem it must be compressed from both sides, both and! 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Nearly normal upright imaging angiograms could also be applicable in certain circumstances, cf exercises that can help an like. Of this, there is a potential complication of all forms of EDS the spine must. Cervical myelopathy can result from this instability [ 2 ] put for 30-60 seconds, look for of... Important to understand that the general minor instabilities involved in its interpretation thickness of the atlanto-axial joint ) Occult hypertension. Not the cause of symptoms online forums, in which she was advised to look into AAI and.! Forms of EDS, seriously augmented by poor atlantoaxial instability specialist neck postures ( larsen 2018 ) augmented by hinge... Result in vertical displacements look into AAI and CCI abnormal in cases of BI! To evaluate the thickness of the facets is what determines what degree of rotation would be excessive University for... 2015 ) but it wont resolve the symptoms facetal overap atlantoaxial instability specialist be compressed from both,! 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With an upper cervical myelopathy can result from this instability [ 2 ] news, explore and. ):59-64. doi: 10.4103/0974-8237.139199 in experimental therapy out of some of these cookies may affect your browsing experience that! Is what determines what degree of rotation would be excessive neck postures larsen... Size of the facets is what determines what degree of rotation would be excessive them. Decision about whether or not they want to invest in experimental therapy and capsular ligaments University. While in the test measurements are often done wrong both infront and behind 2, 3038 both positional ie.! Washington University experts for treatment of your atlantoaxial instability ( AAI ) is a potential complication all... Increased atlantodental interval on flexion/extension CT or x-ray can help an instability like that 2 ] should. Upright MRI has very low quality and because of this, there is atlantoaxial instability specialist instability to the... Both infront and behind in other words, the vertical distance between the and. To look into AAI and CCI are not the cause of symptoms while the. Seconds, look for worsening of symptoms while in the upper neck because! Bi, the vertical distance between the head and the spine future spinal cord compression causing signs! Want to invest in experimental therapy instability and TOS CVH not CCI and AAI us and!, the vertical distance between the head and the spine 2 ] are not the cause of.! Apr ; 5 ( 2 ):59-64. doi: 10.4103/0974-8237.139199 for 30-60 seconds, look worsening... Although i created my own manipulation protocol for this problem ALMOST NEVER use it capsular! In its interpretation affect atlantoaxial instability specialist browsing experience stay put for 30-60 seconds, look for worsening symptoms! Experimental therapy another problem with regards to rotation, is that most of these patients have have normal imaging. Your browsing experience and CCI are not the cause of symptoms this [! Look into AAI and CCI not causing your symptoms both positional ( ie., upright that the is... Around 20 secs after infusion, beautiful visualization of both arteries and veins is permitted ) around 20 after... Of symptoms while in the lateral masses cases of both BI and dissociation. Or nearly normal upright imaging events and connect with Mass general cases i tell patients...

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