I will update the article when I am back home in Colombia in the beginning of August. 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. 2014 Aug;4(3):197-210. doi: 10.1055/s-0034-1376371. Specialist imaging research to help diagnosis. The atlantoaxial segment consists of the atlas (C1) and axis (C2) and forms a complex transitional structure bridging the occiput and cervical spine. First of all, studies have shown that FLAIR hyperintensities (suggestive of ligamentous partial rupture or damage) have been found in a lot of asymptomatic patients (Myran et al. November 19, 2014 at 8:19 pm. Supine cervical MRI including T2-w sagittal-oblique sequences at 2mm slice thickness (disc and foraminal health is best evaluated on a supine MRI). An X-ray is low-cost and low-risk, but it does not always tell whether a person has AAI or not. 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. Li M, Gao X, Rajah GB, Liang J, Chen J, Yan F, et al. Abbreviations: BDI: basion dens interval, CXA: clivo axial angle, BAI: basion-axial interval, ADI: Atlantoaxial interval. In addition to reproducible clinical triggers (positions), the patient should preferably undergo a dynamic catheter angiography of the neck. What cervical artificial disc should I choose? At the very least, if the clinician has clinical suspicion but no concrete holdingpoints for their diagnosis, they must be honest about this. Merely feeling worse when standing up, even if indeed feeling awful, is not a strong indicator of AAI CCI As mentioned above, it is the influence of cervical positioning. It mainly consists of the posterior fusion of the affected vertebrae, in this case, the atlas (C1) and the axis (C2). The reports I tend to get from these clinics are often laughable and full of guessing and overestimates. Dynamic angiograms could also be applicable in certain circumstances, cf. In the Axis, pedicle screws are usually the first choice although, depending on the patients anatomy, placement of isthmic screws may be considered. 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. About Also a high quality supine MRI with thin slice thickness to evaluate the thickness of the ligament. doi: 10.1227/NEU.0b013e3182333859. If your son/daughter does not need surgery, it is important for him/her to be very careful playing sports or doing other physical activities. However, appropriate inclusive criteria must be used to render the diagnoses; subtle findings and the lack of a strong clinical correlation is not enough, and will easily lead to misdiagnosis and related anxiety and suffering. None of them had positive upper motor neuron signs nor paresis in the legs. Styloidectomy and Venous Stenting for Treatment of Styloid-Induced Internal Jugular Vein Stenosis: A Case Report and Literature Review. Unless the imaging findings are blatantly obvious, this diagnosis is not rendered by a radiologist alone. 2019 Feb 22;13(1):79-83. doi: 10.14444/6010. She was also said to have ventral brainstem compression, which particularly scared her due to her difficulties with respiration. Therefore before proposing surgery, the evaluation of each case must be done really carefully. Suboccipital symptoms that occur only with cracking, if the MRI shows arthritis or joint effusion, especially if the neck locks in rotary fixation, then this could be a case of legitimate AAI or CCI. 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). Identifying The Signs Of Cervical Instability. <9mm), which overestimate the pathologies and are much misunderstood due to unrealistic consensus of what is normal) will clearly be abnormal, such as the Harris measurement (BAI), basion dens interval (BDI), or Powers ratio. Risk in asymptomatic patients: If the patient has craniovertebral dissociation either due to anterior or superior migration of the head in relation to the cervical column, one may argue that there is a risk for traction injury to the brains blood supply even in cases where the patient has no obvious induction of symptoms upon flexion-, extension or rotation, and has no imaging that demonstrates neurovascular conflict (eg., BHS or positional brainstem compression). Atlas and axis screws are joined in each side by lateral bars that are unifying the instrumented fusion system. Dissection of the vertebral and carotid arteries is fairly rare and can be excluded through a doppler ultrasound or CT angiogram. Radiologic spectrum of craniocervical distraction injuries. However, I also told her that she may end up having fixation surgery in the future to prevent foreseeable compressive damage to the brainstem. If it is, however then flexion/extension and rotational imaging to exclude positional facetal luxation is warranted. 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 atlas can sublux anteriorly, posteriorly, laterally, or vertically. Gweon HM, Chung TS, Suh SH. Now, what if there is no frank compression nor clinically medullary signs and triggers, but there is a very small space both infront and behind the medulla that has been gradually getting worse. 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. Copyright Dr Gilete Neurosurgery & Spine Surgery. This can result in AAI where the bones are less stable and can damage the spinal cord. Atlanto-axial instability (AAI) is a condition that affects the bones in the upper spine or neck under the base of the skull. 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. PMID: 32623537; PMCID: PMC8121728. Apr 2, 2022 Any experience of Atlantoaxial instability? Patients with AAI CCI will be expected to trigger symptoms only with neck movement (being upright alone is not enough) and resolve (fully) when the neck is held still. Why rely on Washington University experts for treatment of your atlantoaxial instability? Atlantoaxial (AAI) and craniocervical instability (CCI) are two potentially sinister diagnoses that cause damage to the segmental neurovascular structures due to overmobility of the upper cervical spine. If there is a 1mm listhesis, however and the patient has no neurological symptoms and the medulla is utterly free of compression, then performing fusion is completely unnecessary. It is widely agreed upon that fusion should be done when there is pathological instability. The atlanto-occipital joint allows your head to move up and down, while the atlantoaxial joint lets your head rotate. -Mummaneni PV, Haid RW. I prefer to compare mid-jugular to the highest pressure found, usually in the torcula or SSS. Higgins N, Pickard J, Lever A. Lumbar puncture, chronic fatigue syndrome and idiopathic intracranial hypertension: a cross-sectional study. Safe Care CommitmentGet the latest news on COVID-19, the vaccine and care at Mass General.Learn more. In the cases where it is not possible to obtain autologous bone graft, heterologous graft (artificial bone) may also be used. In many circumstances, conservative treatment (Larsen 2018, atlas joint article as linked earlier) is appropriate. J Bone Joint Surg Am. zen , nal , Avcu S. Flow volumes of internal jugular veins are significantly reduced in patients with cerebral venous sinus thrombosis. 2012 Mar;70(3):E795-9. 2014 Apr;5(2):59-64. doi: 10.4103/0974-8237.139199. 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). Anaesth pain intensive care 2020;24(1)69-86. Acute or chronic spinal cord compression causing clinical signs consistent with an upper cervical myelopathy can result from this instability [2]. Curr Neurovasc Res. We'll assume you're ok with this, but you can opt-out if you wish. What I prefer to do is to first draw lines that show the actual rotational alignment of the C2 and C1 when looking left and right. 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. Research has shown that normal limits are 3 and 10mm, with an absolutely maximum of 12mm (Ross & Moore 2015). Surgery to address problems in this area can be risky. 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. Global Spine J. Brainstem compression, when symptomatic, will usually cause quadriparesis along with phrenic nerve palsy. Tambin conocer las causas, los signos y los sntomas de la IAA. Posture is done for the rest of your life. 2008 Aug 15;33(18):2012-6. doi: 10.1097/BRS.0b013e31817bb0bd. More information about surgical treatment. Dr. Gilete in Spain, although I often disagree with his diagnoses, tends to order beautiful dynamic CT scans and also good craniovascular scans. It is different from other joints in the vertebral In severe cases, I recommend postural corrections (appropriate, not generic) along with styloidectomy and transversectomy. 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. Eur J Pediatr. We can consider that there is atlantoaxial instability or atlantoaxial subluxation (AA subluxation) in cases where there is principally incompetence of the ligamentous elements of the atlantoaxial (C1-C2) joint, which allow a significant increase in the mobility of this area thus considered pathological mobility. Atlanto-axial instability (AAI) is a condition that affects the bones in the upper spine or neck under the base of the skull. The joint between the upper spine and base of the skull is called the atlanto-axial joint. In people with Down syndrome, the ligaments (connections between muscles) are lax or floppy. Generally, however, in ligamentous laxity, some bowing and lateral hypermobility (evident by lateral flexion overhangs) will almost definitely not result in frank luxations down the line nor do they tend to elicit symptoms from the actual atlantoaxial facet joints. 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 If you or your veterinarian is concerned that your pet may have AA instability, please schedule a consultation with our Neurologist by calling us at our Manchester or Newington location today. 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. Of your Atlantoaxial instability agreed upon that fusion should be done really carefully in patients with Venous! She was also said to have ventral brainstem compression, which particularly scared her to... Instrumented fusion system basion-axial interval, CXA: clivo axial angle,:. 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