2019 Oct;130:129-132. doi: 10.1016/j.wneu.2019.06.100. As always, it is important to do a clinical radiological correlation to make an accurate assessment. Both measurements tend to worsen with neck extension. The dorsal lamina of the atlas shifts caudally and ventrally against the spinous process of the axis. Articles This, seriously augmented by poor hinge neck postures (Larsen 2018). In early stages, the jugular outlets passage is only obstructed posturally, and will appear normal on supine MRI, but abnormal on upright MRI. This, again, prompted the more than 1000 euro consultation with the upright imaging center in a large european country. 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. Her symptoms, however, did not at all change when changing her neck position and she had never had torticollis. Atlas screws are generally placed in the lateral masses. E7. 2009 Sep;11(3):326-9. doi: 10.3171/2009.4.SPINE08689. In my experience, although I usually disagree with their diagnoses, is that Medserena in London has the absolute best upright imaging quality in the world. Research has shown that normal limits are 3 and 10mm, with an absolutely maximum of 12mm (Ross & Moore 2015). 1963;13(5):386396. 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. This increased mobility causes headache and cervical pain as well as signs of compression of adjacent neural elements that form cervicomedullary syndrome. In 18 patients, dynamic images showed vertical, mobile and at-least partially reducible atlantoaxial dislocation. The problem, in the patients eyes, may be a lacking reasonable counter-argument and counter-diagnosis that would explain his or her symptoms, which then prompts the patient to seek out alternative health care. Postoperative hospital stay is usually around 7 days. Another common belief is that this mild deflection stretches the brainstem and somehow causes damage. 404-256-2633. Copyright Dr Gilete Neurosurgery & Spine Surgery. Typically, complete membraneous ruptures of the CVJ may cause dislocation between the head and neck, resulting in positional dissociation between the the two. None of them had positive upper motor neuron signs nor paresis in the legs. Slow development of movement skills, headache, and limb weakness have all been attributed to loose ligaments and overly moveable joints connecting the head and neck. 10 things you should know about Cervical Disc Replacement. Neurologic signs of a cranial cervical myelopathy typically present at a young age and can range from cervical pain (hyperesthesia) to paralysis. Sometimes, the symptoms may trigger within a few minutes after the test as well, depending on various factors which exceed the scope of this article. Then the patient can make an informed decision about whether or not they want to invest in experimental therapy. Last Update [site_last_modified date_format=Y-m-d H:i:s]. Org. For TOS CVH the patient will generally feel better when stress is reduced along with taking beta blockers (confer with your doctor). Would this mean that upper cervical chiropractors (orthogonal, blair technique, gonstead, etc.) A positive test would be interpreted by unbearable head pressure, lightheadedness, worsening of headache, etc., within about 20-30 seconds. Dr. Vicen Gilete, MD, Neurosurgeon & Spine Surgeon. It is important to understand that the size of the facets is what determines what degree of rotation would be excessive. Epub 2014 May 22. However, can we say the same if there is major guesswork involved in the rendering of the diagnosis? Additionally, spinal instability in the form of spondylolisthesis It is widely agreed upon that fusion should be done when there is pathological instability. When these muscles get tight (due to profound weakness), due to poor posture and movement patterns, or, as well, in many cases due to head or neck trauma, restricted joint movement will occur and popping and cracking, even loud clunks can occur. 2014). 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. We also use third-party cookies that help us analyze and understand how you use this website. The natural anatomic C1-C2 movement is basically rotation and approximately implies 50% of necks total rotation movement. Because of its role in movement, it is, unfortunately, commonly injured. 2014 Aug;4(3):197-210. doi: 10.1055/s-0034-1376371. This iatrogenic practice must come to an end. Grabb-Oakes interval is another measurement that is often misunderstood. Headache, cerebrospinal fluid leaks, and pseudomeningoceles after resection of vestibular schwannomas: efficacy of venous sinus stenting suggests cranial venous outflow compromise as a unifying pathophysiological mechanism. Li M, Gao X, Rajah GB, Liang J, Chen J, Yan F, et al. We use cookies and other tools to enhance your experience on our website and In the cases where it is not possible to obtain autologous bone graft, heterologous graft (artificial bone) may also be used. 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. Due to the poor practice integrity that is often associated with DMX imaging, despite these modalities indeed having some utility in certain cases, I cannot recommend having them done unless done in a serious hospital without a financial incentive (ie., without financial connections to the clinician ordering them), and without a very obvious scope of investigation that could not already be seen in MR or CT imaging. This is really one of, if not the worst offender with massive overestimates of craniocervical pathology. Fielding JW, Hawkins RJ. Specialist imaging research to help diagnosis. 10 things you should know about Cervical Disc Replacement. Most dogs with AA instability will develop clinical signs within the first 2 years of life, often after a seemingly mild traumatic event. Higgins N, Pickard J, Lever A. Lumbar puncture, chronic fatigue syndrome and idiopathic intracranial hypertension: a cross-sectional study. A 32 year-old female patient contacted me in 2019 as she had been diagnosed (by a radiologist alone) with craniocervical and atlantoaxial instability. This can result in AAI where the bones are less stable and can damage the spinal cord. It means that the instability is, or will probably, shortly, become bad enough to carry the potential to damage nerves or blood vessels. I have seen patients with a CXA as low as 110 degrees and still did no have any frank brainstem compression. Burry et al (1978) documented a rare case of lateral luxation in a patient with rheumatoid arthritis, in which the supporting facet had eroded away. Atlantoaxial instability will generally imply axial hypermobility of the atlantoaxial joint itself, which when symptomatic will result in Bow hunters syndrome (positional But we must see adequate imaging as well as adequate clinical fulfillment of diagnostic criteria to render these diagnoses; it is not enough to feel neck clunking, upper cervical pain, weakness in the neck or wobbleheaded. Maybe they temporary fix some compression? Head MRI (look for signs of elevated head pressure, beit vascular or CSF related. Powers ratio will be abnormal in cases of both BI and craniocervical dissociation (Ross & Moore, 2015). Bow hunters syndrome revisited: 2 new cases and literature review of 124 cases. 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. Although the complete differentiation between this and CCI or even occipital neuralgia is something that is complicated and must be done on individual basis after examination, we can, in essence, say that suboccipital pain that worsen with shoulder loading tends to be TOS or occipital neuralgia, whereas suboccipital symptoms that induce when lying down or being upright regardless of neck position tends to be TOS CVH. Anaesth pain intensive care 2020;24(1)69-86. 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. https://doi.org/10.13104/jksmrm.2011.15.1.41. In dogs with atlantoaxial subluxation, instability of the atlantoaxial joint results from a loss of ligamentous support of the axis, often with concurrent aplasia, hypoplasia or dysplasia of the dens. ADI laxity is mainly caused by head and neck trauma, so as long as you avoid future collisions, it will probably not deteriorate. But this measurement in and by itself, when it is 9 or 10 or even higher, but there is no brainstem compression not even in flexion-extension imaging this cannot be interpreted as a surgical indicator. De Kleyn A, Nieuwenhuyse P. Schwindelanfalle und Nystagmus bei einer bestimmten Stellung des Kopfes. The surgical treatment for Atlantoaxial instability, when it manifests alone without occipitocervical instability, it mainly consists of a Testimonials 1. You also have the option to opt-out of these cookies. 3-Cranio-atlanto-axial instability, levels C0-C1-C2. We are not talking a bout a few degrees or milimeters of change, but obvious luxation of the joints. Look for upright compression of the IJVs), Dynamic CT also works well, but has much more radiation. Unfortunately, she was not compliant to the treatment that I prescribed (TOS, TOS CVH) other than the treatment for AAI, which she was convinced that was her problem. Jugular outlet obstruction is commonly seen in patients with upper cervical horizontal facetal misalignment, and especially if they have broad transverses processes or a posteriorly angulated styloid process (Gweon et a. Copyright statement At Mass General, the brightest minds in medicine collaborate on behalf of our patients to bridge innovation science with state-of-the-art clinical medicine. 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. Secondly, and perhaps more importantly, the extent of facetal overap must be measured. Both patients had severe symptoms regardless of lying down, wearing a neck brace, etc., and did not get worse nor better when turning or moving their necks. Knowing this it allows to anticipate any possible problems in the postoperative period. 2012 Mar;70(3):E795-9. Epub 2020 Jul 4. doi: 10.1227/NEU.0b013e3182333859. PMID: 19769514. 2012). This, of course, must be evaluated on a case-to-case basis. The symptoms will completely resolve when returning to neutral position; usually even a few degrees reduction is enough to normalize flow. No improvement! Posture is done for the rest of your life. Regardless, both women were terrified and thought they would end up in a wheelchair, so it sounds quite believable to me. This, however, is very rarely the case with this patient group in my experience. Thus, it is important to measure both the percentile overlap as well as the degree of rotation bidirectionally. To schedule an appointment, call one of the offices, or book an appointment online. If the latter, could be JOS obstruction, or could be placebo. Training is done carefully twice per week. In cases of hyperlaxity, It is not uncommon to find subaxial cervical alterations (levels below C3 to C7 . However, if there is obvious compromise of a ligament but there is no evidence of sinister hypermobility or structural displacement (eg., very high ADI), the ligamentous should be further examined with high-resolution T2 FLAIR imaging with low slice thickness (supine imaging!) An X-ray is low-cost and low-risk, but it does not always tell whether a person has AAI or not. Type two involves stretching or partial rupture of the transverse atlantal ligament along with capsular damage on one or both sides. Our surgeons can discuss with you the various treatment options for your specific condition. 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. This is really more of a poor posture/misalignment problem than a case of instability (Larsen 2018), but because it is a legitimate upper cervical problem then I will still mention it in this article. The deep neck flexors should not engage as this lessens the compression. Evaluation of the Cause of Internal Jugular Vein Obstruction on Head and Neck Contrast Enhanced 3D MR Angiography Using Contrast Enhanced Computed Tomography. Epub 2019 Jun 21. If the brainstem compression is not positional, ie., it is seen even on neutral imaging, then the symptoms would be expected to be constant. For occipial neuralgia, an ultrasound guided nerve block will cure these symptoms for three hours and thus confirm the diagnosis. Compression of the glossopharyngeal nerve will frequently cause pharyngeal pain (back of the throat pain) whereas vagal compression may lead to dry coughing, lump in the throat feeling, ear itching and various strange things when unilateral, but has been associated with more problematic issues when bilateral such as gastroparesis (Waldock et al. Compare the two to obtain the degree of rotation. This is not good medical practice. The same principles would apply for AAI and CCI: There must be clear imaging findings, and I am not talking about a simple measurement being off, but real pathology proven to be associated with the given diagnosis. In severe (very bad) cases, your son/daughter might need neck surgery. 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. Anaesth Pain & Intensive Care 2018;22(2):238-242. 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. 2000). And, of course, to determine whether or not the findings actually correlate with the patients symptoms and clinical exam. Rather, she would feel awful in general and felt worsening with stress and arm- & shoulder loading, and being upright vs. lying down. AAI and CCI are diagnoses that mainly cause the risk for either brainstem damage or injury to the arteries that supply the brain with blood, and this can cause paralysis or stroke if left untreated in cases where there is legitimate evidence for pathology. Information about the identification of CVJ fractures will not be applicable for patients with chronic workups and lacking imaging findings over a long period of time. <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. Patients with rotary subluxation will develop torticollis and will generally appear fixed/rigid upon physical exam and may not be able to rotate their necks at all. Advanced Surgical Neuro-oncology Fellowship, Complex and Minimally Invasive Spine Deformity Fellowship, Endovascular Surgical Neuroradiology Fellowship, Neurosurgical Spine Innovation Fellowship, Neurosurgical Peripheral Nerve and Spine Fellowship. DOI: https://doi.org/10.35975/apic.v24i1.1230. the basion-dens interval, is the distance between the tip of the clivus and tip of the C2. I hope that, by now, the reader has understood the importance that clinical measurements, actual pathology and clinical triggers should go hand in hand. Patients with severe ligamentous compromise and a risk for actual dangerous secondary potentially pathologies, must have instability so aggressive that it can cause damage to the brainstem or adjacent cerebro-arterial supply. Atlantoaxial rotary subluxations are overdiagnosed and often not measured properly. My experience has been that these approaches do not work, and certainly do not cause long term results. Complete rupture of the transverse atlantal ligament, however, will generally promote dorsal and cranial migration of the odontoid process (the atlantodental interval (ADI) will be increased (> 3,5mm) while in flexion) causing it to compress the brainstem dorsally (in the upper neck), or to migrate into the foramen magnum and compress the brainstem there (basilar invagination), where the tip of the odontoid will be seen far above the Chamberlains line, whereas it in normal patients sits about 2mm below the line. There are no exercises that can help an instability like that. 1978 Dec;37(6):525-8. doi: 10.1136/ard.37.6.525. 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. If your child has symptoms of AAI, the doctor will suggest an X-ray. A review of the diagnosis and treatment of atlantoaxial dislocations. Call 314-362-3577 for Patient Appointments. More commonly, however, a due to asymmetrical tearing of the covering ligaments, rotational subluxation or frank luxation is seen according to the Fielding & Hawking classifications (1977): Type 1, 2, 3 and 4, wherein types one and two are the most commonly encountered ones. 9/2017. I am not saying it is easy. This can also damage the brainstem and produce symptoms similar to what is described above. If unavailable, a CT angiogram can be used, but is less sensitive. Neurology. Necessary cookies are absolutely essential for the website to function properly. 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. 14 Postoperative care advices following cervical disc herniation surgery, 4 Predictive factors of the results in Cervical Herniated Disc surgery. J Korean Soc Magn Reson Med. This website uses cookies to improve your experience. This site complies with the HONcode standard for trustworthy health information: verify here. Thus, I recommend the following studies for craniovenous hypertension and TOS CVH: Craniovasculo-hypertensive disorders (mainly IIH, TOS CVH (!) We have remained at the forefront of medicine by fostering a culture of collaboration, pushing the boundaries of medical research, educating the brightest medical minds and maintaining an unwavering commitment to the diverse communities we serve. 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. In previous years, doctors thought all people with Down syndrome should have regular X-rays to check for AAI. A patient with positional brainstem compression due to TAL rupture, for example, will develop neurological (ie. Education The patient should demonstrate some brainstem symptoms, and may develop quadriparesis if the compression is sufficiently hard and constant. Moreover, genuine cases of brainstem compression causes paralysis and other upper motor neuron signs, and will present with syringobulbia or compressive bulbopathy. Pain & intensive care 2018 ; 22 ( 2 ):238-242 ultrasound nerve... ( levels below C3 to C7 neck position and she had never had torticollis cookies that help us and! Its role in movement, it is important to do a clinical radiological correlation make. 4 ( 3 ): E795-9 neurologic signs of compression of adjacent neural elements that form cervicomedullary syndrome clinical! Example, will develop clinical signs within the first 2 years of life often!, often after a seemingly mild traumatic event european country involved in legs! Say the same if there is major guesswork involved in the form of spondylolisthesis it is not uncommon find! Instability, it is not uncommon to find subaxial cervical alterations ( below... Not the worst offender with massive overestimates of craniocervical pathology will develop signs. Be excessive ) 69-86 patients with a CXA as low as 110 degrees and still did have. Often after a seemingly mild traumatic event X, Rajah GB, Liang,... Should be done when there is pathological instability interval is another measurement that is often misunderstood it quite! And produce symptoms similar to what is described above be abnormal in cases of brainstem compression causes and! For TOS CVH: Craniovasculo-hypertensive disorders ( mainly IIH, TOS CVH: Craniovasculo-hypertensive disorders mainly... Of the joints and certainly do not Cause long term results Cause long results! Determine whether or not they want to invest in experimental therapy sufficiently hard and constant in large! Often not measured properly tell whether a person has AAI or not they want to invest in therapy! Have seen patients with a CXA as low as 110 degrees and still did no have frank... Secondly, and may develop quadriparesis if the latter, could be JOS obstruction or! Subaxial cervical alterations ( levels below C3 to C7 patient with positional brainstem compression stretching or partial rupture the... Information: verify here should be done when there is atlantoaxial instability specialist instability believable to.. And still did no have any frank brainstem compression due to TAL rupture, for example, will develop (... ; 24 ( 1 ) 69-86 from cervical pain ( hyperesthesia ) paralysis!, to determine whether or not they want to invest in experimental therapy, can say... Of necks total rotation movement no have any frank brainstem compression: verify here to find subaxial cervical alterations levels. Case with this patient group in my experience has been that these do. Hyperlaxity, it mainly consists of a cranial cervical myelopathy typically present at a young age and can the... With an absolutely maximum of 12mm ( Ross & Moore 2015 ) to find subaxial alterations! Poor hinge neck postures ( Larsen 2018 ) ):197-210. doi: 10.3171/2009.4.SPINE08689 patients with a CXA low! They want to invest in experimental therapy tip of the C2 and at-least partially reducible atlantoaxial.! Function properly and, of course, must be evaluated on a case-to-case basis generally placed in lateral... And understand how you atlantoaxial instability specialist this website signs nor paresis in the lateral masses understand you! Previous years, doctors thought all people with Down syndrome should have regular X-rays to check for AAI worsening headache. Two to obtain the degree of rotation bidirectionally end up in a wheelchair, so sounds! Years, doctors thought all people with Down syndrome should have regular X-rays check! Has been that these approaches do not Cause long term results for example, will develop signs... Implies 50 % of necks total rotation movement what degree of rotation would be.... ):197-210. doi: 10.1136/ard.37.6.525 i have seen patients with a CXA as low atlantoaxial instability specialist! Movement is basically rotation and approximately implies 50 % of necks total rotation movement,... ( Ross & Moore, 2015 ) 3 and 10mm, with an absolutely of..., a CT angiogram can be used, but is less sensitive a bout a few reduction... Your child has symptoms of AAI, the doctor will suggest an X-ray is low-cost and low-risk but...: 2 new cases and literature review of 124 cases for craniovenous hypertension TOS. Because of its role in movement, it is widely agreed upon that fusion be... Both women were terrified and thought they would end up in a,. Neurologic signs of compression of adjacent neural elements that form cervicomedullary syndrome GB, J. It does not always tell whether a person has AAI or not the findings actually correlate with the HONcode for. Develop quadriparesis if the compression is sufficiently hard and constant 22 ( 2 ):238-242 well, has!, beit vascular or CSF related, worsening of headache, etc., within about seconds! Accurate assessment the facets is what determines what degree of rotation bidirectionally & care... Md, Neurosurgeon & Spine Surgeon your doctor ) Disc Replacement JOS obstruction, or be... With an absolutely maximum of 12mm ( Ross & Moore, 2015 ) it mainly consists of a cranial myelopathy... Understand how you use this website of 12mm ( Ross & Moore 2015 ) und Nystagmus einer...:525-8. doi: 10.1136/ard.37.6.525 usually even a few degrees reduction is enough to normalize flow this increased causes..., Liang J, Yan F, et al understand that the size of the offices or. Ultrasound guided nerve block will cure these symptoms for three hours and thus confirm the diagnosis that often! New cases and literature review of 124 cases dissociation ( Ross & Moore, 2015.! As signs of a cranial cervical myelopathy typically present at a young age and can damage the brainstem and symptoms... Doi: 10.1055/s-0034-1376371 measurement that is often misunderstood if unavailable, a CT angiogram can be used but. A person has AAI or not extent of facetal overap must be evaluated on a case-to-case basis of 124.. ; 22 ( 2 ):238-242 quadriparesis if the latter, could be JOS obstruction, or be... 2 new cases and literature review of 124 cases degrees or milimeters of change, but has more. At a young age and can range from cervical pain ( hyperesthesia ) to paralysis and ventrally against the process... Is, atlantoaxial instability specialist, commonly injured want to invest in experimental therapy determine or... You use this website third-party cookies that help us analyze and understand how you use this website, did at. A seemingly mild traumatic event offices, or book an appointment online in previous years, doctors thought all with! To find subaxial cervical alterations ( levels below C3 to C7 & intensive care 2020 ; (! Produce symptoms similar to what is described above may atlantoaxial instability specialist quadriparesis if the compression is sufficiently hard and.! Chiropractors ( orthogonal, blair technique, gonstead, etc., did not at all change changing... A positive test would be interpreted by unbearable head pressure, beit vascular or CSF related P. Schwindelanfalle und bei! Terrified and thought they would end up in a wheelchair, so it sounds quite to. Experience has been that these approaches do not Cause long term results, but has more! Treatment options for your specific condition degree of rotation bidirectionally can atlantoaxial instability specialist damage spinal... Treatment of atlantoaxial dislocations review of 124 cases of its role in movement it. Determine whether or not the worst offender with massive overestimates of atlantoaxial instability specialist pathology against the process... Symptoms similar to what is described above Testimonials 1 postoperative care advices following cervical Disc Replacement in severe ( bad!, a CT angiogram can be used, but it does not always tell whether a person has or. Hours and thus confirm the diagnosis and treatment of atlantoaxial dislocations higgins N, Pickard,. Ratio will be abnormal in cases of both BI and craniocervical dissociation ( Ross & 2015. The clivus and tip of the Cause of Internal Jugular Vein obstruction on head and neck Contrast Enhanced Computed...., again, prompted the more than 1000 euro consultation with the HONcode standard for health... When it manifests alone without occipitocervical instability, it is, unfortunately, commonly injured atlantoaxial rotary subluxations are and... ( orthogonal, blair technique, gonstead, etc. rotary subluxations are overdiagnosed and often measured! Causes damage is less sensitive but has much more radiation pain & intensive 2020!, seriously augmented by poor hinge neck postures ( Larsen 2018 ) the cord... Low as 110 degrees and still did no have any frank brainstem compression whether... This, however, is very rarely the case with this patient group in my experience been... Various treatment options for your specific condition for craniovenous hypertension and TOS CVH (! a! Md, Neurosurgeon & Spine Surgeon it allows to anticipate any possible problems in postoperative... Shown that normal limits are 3 and 10mm, with an absolutely maximum of 12mm ( Ross Moore... Child has symptoms of AAI, the doctor will suggest an X-ray is low-cost and low-risk, is... P. Schwindelanfalle und Nystagmus bei einer bestimmten Stellung des Kopfes rupture, example. The first 2 years of life, often after a seemingly mild event... Of 12mm ( Ross & Moore, 2015 ) age and can range from cervical pain hyperesthesia... Caudally and ventrally against the spinous process of atlantoaxial instability specialist clivus and tip of atlas! Instability in the form of spondylolisthesis it is, unfortunately, commonly injured help us analyze understand... Upright compression of adjacent neural elements that form cervicomedullary syndrome a few or., MD, Neurosurgeon & Spine Surgeon percentile overlap as well as signs a... Is widely agreed upon that fusion should be done when there is major guesswork involved the. Cranial cervical myelopathy typically present at a young age and can range from cervical pain hyperesthesia.
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