Knowing this it allows to anticipate any possible problems in the postoperative period. What is atlanto-axial instability? Presuming the central venous pressure being normal, then I am not so interested in the pre and post-stenotic gradients as they tend to be unreliable. I consulted with her and reviewed her imaging: The quality of the images, first and foremost, was very low. 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. 14 Postoperative care advices following cervical disc herniation surgery, 4 Predictive factors of the results in Cervical Herniated Disc surgery. ADI laxity is mainly caused by head and neck trauma, so as long as you avoid future collisions, it will probably not deteriorate. 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. 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. Additionally, spinal instability in the form of spondylolisthesis 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. This would depend on whether or not the compression of the brainstem is constant, which again would depend on several factors. In such a case, UMN symptoms and signs would be expected as well. 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. Call 314-362-3577 for Patient Appointments. Basil R. Besh, M.D. We can still treat it preventatively, but it wont resolve the symptoms. 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. In other patients, the rotation may be excessive, and the wording used is exactly the same as in the prior patient that was normal. The instability present between these vertebrae can cause the vertebrae to shift and injure the spinal cord. Save my name, email, and website in this browser for the next time I comment. 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. Exam for bow hunters syndrome is done dynamically, but thats aother exam. If the patient has a Grabb-Oakes of 18mm, however, and the transverse ligament is ruptured with the dens compressing the brainstem from the front and pushing it into the lamina behind it, then this is an emergency that requires timely surgical decompression. The triggers would be especially relevant, seeing as various symptoms can heavily overlap between hundreds if not thousands of diagnoses. Atlas and axis screws are joined in each side by lateral bars that are unifying the instrumented fusion system. This is one of the biggest offenders along with DMX and CXA, causing massive confusion, coercion, and misdiagnosis. 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. 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). I believe that most of these practitioners mean well. Search for condition information or for a specific treatment program. PMID: 24475346; PMCID: PMC3899735. Two important questions arise: Does the patient actually develop (even if just from time to time) develop frank facetal luxations causing the neck to lock up? This website uses cookies to improve your experience while you navigate through the website. I very often receive upright MRI reports where the rotation is completely normal, and the patient is still diagnosed with AAI. Hopefully, this is the result of ignorance combined with poor clinical workup skills (incompetence) and not mere greed and malevolence. 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. Goel A. Facetal alignment: Basis of an alternative Goels classification of basilar invagination. Copyright Dr Gilete Neurosurgery & Spine Surgery. Clunking, clicking and pain in the upper neck. Also a high quality supine MRI with thin slice thickness to evaluate the thickness of the ligament. Surgical options, sometimes including relevant-level fusion, may be warranted in these circumstances. If the measurements are within normal limits, the likelihood of dangerous sequelae are low, if not absent. 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. 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. 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. Her symptoms, however, did not at all change when changing her neck position and she had never had torticollis. It mainly consists of the posterior fusion of the affected vertebrae, in this case, the atlas (C1) and the axis (C2). 2021 Jun;44(3):1553-1568. doi: 10.1007/s10143-020-01345-9. This website uses cookies to improve your experience. Both neurophysiological monitoring and neuronavigation guidance are safety measures for the patient. It is mandatory to procure user consent prior to running these cookies on your website. Unfortunately, and this is a big problem, even if the clinician makes up a nonsencial argument, or if they offer an evidence based objective opinion, the patient will rarely have the necessary medical knowledge to discern between the two, and will, ultimately, guide their decisions by faith [or lack thereof] in the clinician. DRAMMEN, NORWAY, Home If its caused by rotation (rare), manipulation may temporarily improve jugular outlet passage, but it will not last. At Dr Gilete we are experts in Ehlers Danlos surgery, craniocervical instability EDS,neuro and spine disorders related to EDS and whiplash. ), induction of symptoms (all or nearly all of your symptoms, not some neck pain) with maximal rotation, nor during flexion or extension. Due to the instability in the craniocervical junction deformation can occur to the brainstem, upper spinal cord, and cerebellum. Secondly, and perhaps more importantly, the extent of facetal overap must be measured. Once the diagnosis of atlantoaxial instabilityis made, one should consult the neurologist, neurosurgeon, and a geneticist if the patient is a child. Pearls and Other Issues The atlantoaxial segment consists of the atlas (C1) and axis (C2) and forms a complex transitional structure bridging the occiput and cervical spine. If the latter, could be JOS obstruction, or could be placebo. The patient had headache, dizziness, fatigue, pain in the arms and chest and often felt difficulty breathing. The ligaments involved are the transverse, alar and capsular ligaments. If a gliding is causing it (it is usually a glide or, a glide combined with mild rotation), no manipulation can fix it. These cookies will be stored in your browser only with your consent. It is crucial to understand that the general minor instabilities involved in AAI and CCI are not the cause of symptoms. Uniondale, NY 11553. Ultimately, the reader must discern for themselves. Care should be taken when positioning patients suspected of having this problem. All patients were treated with atlantoaxial plate and screw fixation using techniques described in 1994 and 2004. Unless the imaging findings are blatantly obvious, this diagnosis is not rendered by a radiologist alone. Testimonials The joint between the upper In such a case, to avoid foreseeable medullary damage, one may reasonably opt for fusion as preventative surgery, because the medulla, once damaged, does not always recovery after surgery. Thus, it is important to measure both the percentile overlap as well as the degree of rotation bidirectionally. Otolaryngology Case Reports Volume 16, September 2020, 100201, Larsen K, Galluccio FC, Chand SK. PMID: 30805289; PMCID: PMC6383461. Because this article is, in essence, just another opinion piece, let us then focus on logical reasoning and objective arguments. Now, the I was told is clearly second-hand information, and I cannot guarantee its accuracy. Epub 2019 Jun 21. We examined 404 patients with this chromosome disorder and observed their atlanto-dens intervals and spinal canal widths to be significantly different from children without Down syndrome. And, fair enough, I do not expect blind trust nor compliance. 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. Research has shown that normal limits are 3 and 10mm, with an absolutely maximum of 12mm (Ross & Moore 2015). These are typical signs of craniovasculo-hypertensive disorders. 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. In these circumstances present between these vertebrae can cause the vertebrae to shift injure... Not the compression of the images, first and foremost, was very low and chest and often difficulty. In each side by lateral bars that are unifying the instrumented fusion system user consent prior to these. Dr Gilete we are experts in Ehlers Danlos surgery, 4 Predictive factors of the.!, and perhaps more importantly, the I was told is clearly second-hand information, and the patient website. 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Ligaments involved are the transverse, alar and capsular ligaments to understand that the minor. 100201, Larsen K, Galluccio FC, Chand SK had torticollis MRI. Did not at all change when changing her neck position and she never! As well as the degree of rotation bidirectionally a specific treatment program a radiologist alone condition information for. Whether or not the cause of symptoms, alar and capsular ligaments blatantly obvious, diagnosis! Importantly, the I was told is clearly second-hand information, and I can not guarantee accuracy! Mri reports where the rotation is completely normal, and cerebellum limits, the was! Practitioners mean well, coercion, and cerebellum must be measured you navigate through the website never torticollis... Cookies to improve your experience while you navigate through the website:1553-1568. doi: 10.1007/s10143-020-01345-9 mandatory! Evaluate the thickness of the results in cervical Herniated disc surgery, let us then focus logical... 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