The injury was mild but your headaches and dizziness persist. All the studies are normal. The recommended medications and treatments are not working. Your doctor is baffled. What is Cranial Instability? What does Cranial Instability feel like? Who is at risk for Cranial instability? How do you test for Cranial Instability? How is Cranial Instability treated? Are there non-surgical treatment options? Let’s dig in.
What Is Cranial Instability? (Aka Cranial Cervical Instability)
Cranial Instability better known as Cranial Cervical Instability (CCI) is a medical condition characterized by injury and instability of the ligaments that hold your head onto the neck (1). The major ligaments involved are the alar, transverse and accessory ligaments. To learn more about CCI please check on the video below.
What Does Cervical Instability Feel Like? (BAD!)
Excessive movement between your head and neck can cause movement and damage of upper cervical facet joints, discs, nerves, and blood vessels. Symptoms vary depending upon the severity of the ligament instability. In general the greater the instability the greater and more severe the symptoms. Common symptoms include.
1. Painful, Heavy Head
A constant to near-constant head pain that can be described as feeling like the head is too heavy for the neck to support. Many describe feeling like they have a “bobble-head”.
2. Headache
This is not your normal headache caused by your in-laws or excessive consumption of alcohol. This is a debilitating headache that is constant in duration and miserable. Headache is often caused by injury to the upper neck joints, muscles, and tendons due to ongoing instability.
3. Rapid Heart Rate
Elevated heart rate may occur as the Vagus nerve gets irritated by the extra motion in the upper neck. Another cause of elevated heart rate is Postural Orthostatic Tachycardia Syndrome (POTS). POTS is a medical condition that causes malfunction of the autonomic nervous system. It is estimated to impact between 1,000,000 and 3,000,000 Americans. The autonomic nervous system controls involuntary body functions such as heart rate and blood pressure. Malfunction of the autonomic nervous system causes a number of symptoms which include rapid heart rate.
4. Brain Fog
Patients with CCI can struggle with memory, concentration, and ability to complete tasks. Every day can feel like your brain is stuffed full of cotton.
5. Neck Pain
Pain is typically localized at the base of the skull and aggravated bending forward and rotation. The pain can shoot up into the base of the skull, top of the head, forehead or behind the eyes.
6. Visual Problems
Visual disturbances can vary from mild to severe involving a number of different symptoms. Visual disturbances can happen because the upper neck supplies information to the brain to guide eye position and vice versa (2).
7. Dizziness
Balance problems can be a significant issue (3). Dizziness or imbalance is a feature related to the fact that the upper neck is a major contributor to balance (4). The upper neck provides position sense that has to be coordinated with balance information from the eyes and inner ear.
8. Chronic Fatigue
Excessive movement between the head and neck can cause irritation and dysfunction of the nervous system. The autonomic nervous system is the most affected. A common symptom of autonomic dysfunction is chronic fatigue.
Who Is at Risk for Cranial Instability? (Trauma and Hypermobile)
Cranial Cervical Instability can occur as a result of a number of different events or conditions.
The 4 most common are:
Trauma
Classic examples include motor vehicle accidents, sports injuries, or forceful chiropractic adjustments (5). Some patients describe a traumatic injury followed by the immediate onset of neck pain, mental fog, and dizziness.
Inflammatory Conditions
Chronic inflammatory diseases can be debilitating. In such cases, a patient’s own immune system attacks itself resulting in inflammation, injury, and pain. Common examples include rheumatoid arthritis, scleroderma, and lupus. Patients with rheumatoid arthritis are at risk for Cranial Instability.
Congenital
Congenital disorders are also known as birth defects. There are many different types of birth defects which include cleft lip, cerebral palsy, and Down’s syndrome. Patients with Down’s syndrome are a risk for Cranial Instability (6).
Connective Tissue Disorders
There are a number of medical conditions where the ligaments are loose due to defects in the connective tissue. These patients have overly flexible joints that allow them to very, very flexible. Ehlers Danlos Syndrome is a classic example of such patients (7). There are thirteen different subtypes. Symptoms can vary depending upon the severity of the condition. Patients with EDS can easily bend their thumbs backward so that it can touch their forearm.
Ligaments are thick pieces of connective tissue that connect bone to bone. They also hold your head on to your neck. Loose or compromised ligaments in the upper neck can cause cranial instability.
How Do You Test for Craniocervical Instability? (7 Main Criteria)
Regrettably, many clinics and providers focus on treating symptoms. For example, neck pain is often treated with NSAID’s, muscle relaxants, stretching, heat, and cold. Rarely is the underlying cause of the neck pain discussed or identified. All too often a haphazard group of treatments is undertaken with no specific goal. Securing an accurate diagnosis is critical. This will allow for the definitive treatment plan which in turn will allow for the best clinical outcome.
Diagnosing Craniocervical Instability involves 7 main criteria which include:
Mechanism of Injury (How Did It Occur)
Understanding how and when the injury occurred is important. The two most common causes of Cranial Cervical Instability (CCI) are trauma and medical conditions that cause people to have loose or compromised ligaments (8). Motor vehicle accidents, contact sports, and forceful manipulations by chiropractors are the most common examples of trauma. Ehlers Danlos Syndrome (EDS) is a group of inherited disorders that affect your ligaments and connective tissues (8).
Symptoms (Headache, Neck Pain and Neurologic Symptoms)
The symptoms associated with CCI can be extensive depending upon the severity of the instability. The most common symptoms include headache, upper neck pain, dizziness, visual disturbances, and brain fog.
Physical Examination
In the age of managed care and 15-minute appointments, the art and practice of physical examination by a physician is almost gone. At the Centeno -Schultz Clinic all new patient evaluations undergo an extensive physical examination. Why? It is important to view the body as a whole and there are multiple potential physical findings in the neck, head, shoulder, and low back in patients with Cranial Cervical Instability.
Radiographic Studies for Cranial Instability ( Upper Neck MRI or DMX)
There are various types of radiographic studies which include x-ray, CT scan, and MRI. Unfortunately, traditional MRI and CT studies do not evaluate the upper cervical spine or alar and transverse ligaments. Special radiographic studies are required which include upper cervical MRI or rotatory CT scan. In addition, there are additional studies that involve the patient moving during the examination. These studies are useful to identify instability. Examples include upright MRI with upright flexion/extension. To see how this works please click on the video below.
Finally, a Digital Motion X-ray (DMX) is important in establishing the diagnosis of CCI. This is an x-ray examination that is recorded in which the patient is put through various movements including bending the neck forward, backward, and to the side. To learn more about DMX please click on the video below.
Response to Conservative Care
The common symptoms of CCI can also arise from different clinical conditions. For example, headaches with dizziness may arise from tight or contracted neck muscles. It is important that patients undergo conservative care such as rest, heat, stretching, physical therapy, massage, and chiropractic care. In some cases, symptoms improve with conservative therapy.
Response to Diagnostic Injections
A diagnostic injection is a precise injection into a specific structure asking the question of whether or not it resolved the pain. Often times this is very helpful in the evaluation of patients with CCI. All diagnostic injections are performed under ultrasound or x-ray or both. Examples of diagnostic injections include:
C0-1 and C1/2 facet injections
Occipital nerve blocks
Superficial Cervical Plexus Blocks
Ligament injections
Level of Disability
Due to the severity of the symptoms, many patients are not able to complete their domestic or professional responsibilities. In severe cases of CCI, patients are confined to their homes and are socially isolated. The level of disability is important in evaluating and diagnosing Craniocervical Instability (CCI).
How Is Cranial Instability Treated? (Conservative, Surgery or Stem Cell)
There are three major types of treatments. The specific type of treatment will depend on the amount of instability and a patient’s clinical symptoms.
Conservative
Patients with small amounts of instability can oftentimes be managed with conservative care. This would include:
1. Upper cervical chiropractic care. Look for members of NUCCA (National Upper Cervical Chiropractic Association)
2. Physical Therapy
3. Bracing (insert an image of contrast.)
4. Curve restoration. Look for chiropractors that specialize: Chiropractic BioPhysics.
5. Injected contrast into the C0/1 joint confirms accurate placement of the needle
If conservative care fails to provide clinical improvement the next step is x-ray guided injections of PRP or stem cells into the upper cervical ligaments and facet joints. Not all injections are the same. Accurate needle placement requires the use of contrast. This is a dye that is used under x-ray to confirm the exact location of the needle. This is critical because if the needle is not in the targeted joint, the injected PRP or stem cells will NOT magically get into the joint. Some clinics deceive patients as they have an x-ray machine in the procedure room but do NOT use contrast. As a patient, demand that your procedures are performed with contrast. Without contrast, there is no way to confirm that the injected PRP or stem cells actually got into the targeted facet joint or ligament. Below is a recent x-ray image of a needle accurately placed in the C0/1 facet joint which is filled with contrast.
Surgery
Cranial Instability Surgery: Fusion of Head to Neck
If conservative care and injections fail many patients are referred for surgery. There are many different types of surgical options all of which include Fusion. The most common is a fusion of the head to the cervical spine. This is illustrated in the picture to the right. It involves multiple screws and rods that are placed into the skull and neck. The procedure is major surgery with significant risks which include eventual arthritis above and below the fusion, misplaced screws in nerves of facet joints, and failure of the bones to fuse (non-union). Neck range of motion is permanently altered and in most cases severely restricted.
Stem Cells
In 2015 a nonsurgical treatment option for Cranial Cervical Instability was developed at the Centeno-Schultz Clinic. It involves the injection of a patient’s own bone marrow-derived stem cells into the damaged Alar, Transverse ligaments. The procedure is very demanding and only performed at the Centeno-Schultz Clinic in Broomfield Colorado. The procedure is called Percutaneous Implantation of Cervical Ligaments (PICL) To learn more about this groundbreaking procedure please click on the video below.
In Conclusion
Cranial Instability better known as Cranial Cervical Instability (CCI) is a medical condition characterized by injury and instability of the ligaments that hold your head onto the neck. Common symptoms of Cranial Cervical Instability include painful, heavy head, headache, rapid heart rate, brain fog, neck pain, visual problems, dizziness, and chronic fatigue. Trauma is the most common cause of CCI however patients with hypermobility are at risk. There are 7 main criteria to establish the diagnosis of Cranial Cervical Instability. These include:
- Mechanism of Injury
- Symptoms
- Physical Examination
- Radiographic Studies
- Response to Conservative Care
- Response to Diagnostic Injections
- Level of Disability
Treatment options depend upon the severity of the instability and clinical symptoms. When conservative treatments fail many patients are often referred to surgery. This involves a fusion of the head to the neck. This is a major surgery where multiple screws and rods are inserted into the skull and neck. It is associated with significant risks and complications. The PICL procedure is an effective non-surgical alternative whereby a patient’s own stem cells are injected into the damaged upper cervical ligaments. It is performed exclusively at the Centeno-Schultz Clinic in Broomfield Colorado.
If you or a loved one has sustained an injury with ongoing headaches, neck pain, and brain fog please schedule a telephone candidacy discussion with a board-certified, fellowship-trained physician. From the comfort of your home or cabin learn what treatment options are available for you. Call today and stop the pain, misery, and suffering. Do so before you become dependent upon all the medications your doctor has prescribed or you find yourself in a surgeon’s office desperate for relief.
References
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2.Ischebeck BK, de Vries J, Van der Geest JN, et al. Eye movements in patients with Whiplash Associated Disorders: a systematic review. BMC Musculoskelet Disord. 2016;17(1):441. Published 2016 Oct 21. doi:10.1186/s12891-016-1284-4
3.Biesinger E. and Vertigo caused by disorders of the cervical vertebral column. Diagnosis and treatment. Adv Otorhinolaryngol. 1988; 39: 44– 51.
4.Thompson-Harvey A, Hain TC. Symptoms in cervical vertigo. Laryngoscope Investig Otolaryngol. 2018;4(1):109–115. Published 2018 Nov 28. doi:10.1002/lio2.227
5.Henderson FC Sr, Francomano CA, Koby M, Tuchman K, Adcock J, Patel S. Cervical medullary syndrome secondary to craniocervical instability and ventral brainstem compression in hereditary hypermobility connective tissue disorders: 5-year follow-up after craniocervical reduction, fusion, and stabilization. Neurosurg Rev. 2019;42(4):915-936. doi:10.1007/s10143-018-01070-4
6.Ashafai, Nabeel S.; Visocchi, Massimiliano; Wąsik, Norbert (2019). “Occipitocervical Fusion: An Updated Review”. Acta Neurochirurgica. Supplement. 125: 247–252. doi:10.1007/978-3-319-62515-7_35. ISSN 0065-1419. PMID 30610329.
7.Henderson, Fraser. (2016). Cranio-cervical Instability in Patients with Hypermobility Connective Disorders. Journal of Spine. 05. 10.4172/2165-7939.1000299.
8. Sobey G. Ehlers-Danlos syndrome – a commonly misunderstood group of conditions. Clin Med (Lond). 2014;14(4):432-436. doi:10.7861/clinmedicine.14-4-432