atlantoaxial instability specialist

This, of course, must be evaluated on a case-to-case basis. 2-Atlantoaxial instability, levels C1-C2 (atlas-axis). In early stages, the jugular outlets passage is only obstructed posturally, and will appear normal on supine MRI, but abnormal on upright MRI. In most cases it is convenient to put bone graft, usually autologous, taken from the iliac crest or the patients own rib. Typically, complete membraneous ruptures of the CVJ may cause dislocation between the head and neck, resulting in positional dissociation between the the two. 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. Sometimes, an X-ray shows AAI when there are no symptoms. Treatment depends on your son/daughters symptoms. collected, please refer to our Privacy Policy. 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. PMID: 25083363; PMCID: PMC4111952. And if yes, do they completely normalize when resuming neutral position? Just anterior to the transverse process in patients with normal necks, emerge the internal jugular veins as well as the glossopharyngeal, vagus and accessory nerves. Some research suggests that ventral brainstem compression (what this really means is, in tangent) occurs at approximately 130 degrees of CXA. 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. ADI laxity is mainly caused by head and neck trauma, so as long as you avoid future collisions, it will probably not deteriorate. This category only includes cookies that ensures basic functionalities and security features of the website. 14 Postoperative care advices following cervical disc herniation surgery, 4 Predictive factors of the results in Cervical Herniated Disc surgery. Would this mean that upper cervical chiropractors (orthogonal, blair technique, gonstead, etc.) Styloidogenic jugular venous compression syndrome: diagnosis and treatment: case report. The success rate of this surgery is 80% or greater; however, there are many potential complications and a mortality rate of 5-10%. Does it matter whether these are done laying or sitting down? In such cases I tell my patients that, yes, you do have mild AAI, but it is not causing your symptoms. J NS 2015, V8 issue 4. 9/2017. We also use third-party cookies that help us analyze and understand how you use this website. Uniondale, NY Location HSS Long Island The Omni. Learn about the many ways you can get involved and support Mass General. 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. Apr 2, 2022 Any experience of Atlantoaxial instability? However, as stated, in most cases this is just locked facets that suddenly reduce (realign) with a pop. This, with or without accompanied neurological symptoms, be it vascular or neurological. Both measurements tend to worsen with neck extension. As always, it is important to do a clinical radiological correlation to make an accurate assessment. TOS is often considered a mere upper limb nerve pathology, but this is not the case. Uniondale, NY 11553. Surgical reduction and fixation would be the only appropriate treatment. Second, because it is such a controversial topic that lacks medical consensus, poor understanding of the actual mechanism of pathology leads to misunderstandings. -Mummaneni PV, Haid RW. 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. I told her clearly that her brainstem was normal and that she did not have any positional induction of symptoms. Patients with legitimate CCI or AAI will generally have intermittent induction of symptoms with full rotation, flexion or extension that resolves in netural position, presuming there is no constant crushing of the brainstem or vertebral artery dissection. Get the latest news, explore events and connect with Mass General. For TOS CVH the patient will generally feel better when stress is reduced along with taking beta blockers (confer with your doctor). 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. These cookies do not store any personal information. Atlantoaxial instability treatment Contact Dr. Gilete C1 C2 fusion surgery Contact Dr. Gilete Our commitment to reliable health and medical information on the internet This site complies with In circumstances of gross trauma, the ligamentous damage may be so severe that the entire vertebrae luxate (dislocate) from normal position. Call 314-362-3577forPatient Appointments. If the patients neck often completely locks up due to facetal luxations, then atlantoaxial fixation may certainly be a viable option for treatment, especially if conservative stabiization fails (capsular and alar ligamentous prolotherapy, postural corrections, strengthening of the suboccipital, longus capitis and levator scapulae muscles). Luxation of the atlantoaxial joints, ie., luxation that surpasses what is seen in Cock Robin syndrome, can also occur with traumatic and gross ligamentous rupture. The ligaments supporting these joints are quite strong, but if they become What cervical artificial disc should I choose? This pain tends to get worse with stress and with high heart rates, and are often also worse in the morning after lying down. Both neurophysiological monitoring and neuronavigation guidance are safety measures for the patient. PMID: 749697; PMCID: PMC1000289. 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. 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. Prior to surgery we perform a surgical planning of the intraoperative neuronavigation to confirm the trajectories of screws and special anatomical dispositions of structures. The surgical treatment for Atlantoaxial instability, when it manifests alone without occipitocervical instability, it mainly consists of a Moreover, tractioning the neck of these vulnerable patients can often cause undesirable effects. These problems will mainly endanger the brainstem. It is crucial to understand that the general minor instabilities involved in AAI and CCI are not the cause of symptoms. How is one supposed to know, if no one knows what you have in the first place? The success rate of this surgery is 80% or greater; however, there are many potential complications and a mortality rate of 5-10%. In previous epidemiologic studies, the prevalence of atlantoaxial instability in persons with Down syndrome was found to be between 9% and 31%. Craniocervical Instability (CCI), also known as the Syndrome of Occipitoatlantialaxial Hypermobility. Another patient was told by a well-known pain physician in the US that she had brainstem compression and required several expensive prolotherapy procedures. Many of these patients who have been misdiagnosed with AAI or CCI may feel neck wobbliness, heaviheaded, neck weakness, and clicking or clunking in the neck upon movement, often along with upper neck pain. Yang SY, Boniello AJ, Poorman CE, Chang AL, Wang S, Passias PG. AAI is less common in adults with Down syndrome. Burry HC, Tweed JM, Robinson RG, Howes R. Lateral subluxation of the atlanto-axial joint in rheumatoid arthritis. Symptoms of brainstem compression are respiratory crisis and quadriplegia, but can also manifest more diffusely. I see massive amounts of patients with alleged AAI who have normal atlantoaxial facetal overlap, and of course, also lacking clinical correlation. 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). Signs of ligamentous damage. See my youtube channel for appropriate training. 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. I have not receiving anything that comes close of what they produce. The patient will hinge back at their neck while simultaneously flexing the cranium. 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. You also have the option to opt-out of these cookies. It is not due to mild overall instability that does not cause neurovascular conflicts. Copyright 2007-2023. #11760. For occipial neuralgia, an ultrasound guided nerve block will cure these symptoms for three hours and thus confirm the diagnosis. Often times if surgery is required, the bones between C1 and C2 are fused together, requiring less than 48 hours of an in-hospital stay. Copyright Dr Gilete Neurosurgery & Spine Surgery. Not sure what you mean here. In people with Down syndrome, the ligaments (connections between muscles) are lax or floppy. For patients with post-traumatic ligamentous injuries where measurements are still within normal limits, obvious segmental effusion should be seen despite otherwise normal anatomical positioning. This site complies with the HONcode standard for trustworthy health information: verify here. Aggressive craniovertebral junction ligamentous injuries can also result in vertical displacements. If you have a normal neck and head CTA and MRI and your craniocervical measurements are normal or close to normal, and if you have no obvious movement induction of symptoms, then CCI or AAI is probably not what is causing your symptoms. Styloidectomy and Venous Stenting for Treatment of Styloid-Induced Internal Jugular Vein Stenosis: A Case Report and Literature Review. Type one involves sole rotary luxation of the facet joints, usually along with damage to either the alar ligaments and capsular ligaments. The deep neck flexors should not engage as this lessens the compression. There can be, and are indeed many more potential explanations for these symptoms than just AAI and CCI. It mainly consists of the posterior fusion of the affected vertebrae, in this case, the atlas (C1) and the axis (C2). 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 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. J Korean Soc Magn Reson Med. If there is a translational BDI or BAI that surpasses normal limits, however, which is maximally 12mm for BDI and BAI. 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. Flexion-extension and cervical rotation on both sides should be evaluated. The brainstem must be compressed from the front and the back, not merely deflected from the front. I consulted with her and reviewed her imaging: The quality of the images, first and foremost, was very low. Moderator. The atlantoaxial segment consists of the atlas (C1) and axis (C2) and forms a complex transitional structure bridging the occiput and cervical spine. Atlantoaxial instability is a relatively frequent finding in individuals with Down syndrome. 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. Testimonials 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. Radiographics 2000;20:S237-50. 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. 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. PMID: 18708935. J Neurosurg Spine. Headaches certainly can develop from instability of C1-2. In BI, brutally low clivo-axial angles and Grabb-oakes measurements will also be seen. In severe (very bad) cases, your son/daughter might need neck surgery. Lateral bowing of the inferior atlantal facets in netural position is a sign of transverse atlantal ligament laxity. Get the latest news on COVID-19, the vaccine and care at Mass General. 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 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. One or 2 out of every 100 children with Down syndrome have symptoms of AAI, but doctors do not know the exact number yet. 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. Moreover, genuine cases of brainstem compression causes paralysis and other upper motor neuron signs, and will present with syringobulbia or compressive bulbopathy. This category only includes cookies that ensures basic functionalities and security features of the website. Otolaryngology Case Reports Volume 16, September 2020, 100201, Larsen K, Galluccio FC, Chand SK. Anaesth pain intensive care 2020;24(1)69-86. Dr. Vicen Gilete, MD, Neurosurgeon & Spine Surgeon. Is maximally 12mm for BDI and BAI anaesth pain intensive care 2020 ; (... Bone graft, usually along with taking beta blockers ( confer with your doctor ) the only appropriate.! Pathology, but it is not due to mild overall instability that does not cause neurovascular conflicts required expensive. 130 degrees of CXA General minor instabilities involved in AAI and CCI limits, however, as stated, tangent... Cervical artificial disc should i choose i have not receiving anything that comes close of they! 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