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Advanced non-surgical solutions for craniocervical instability.

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Current Treatment Options for Craniocervical Instability

  • Physical therapy to strengthen the upper neck muscles. This is very specific therapy that few physical therapists understand.
  • Curve restoration. This is a specific type of therapy that uses front-back traction to increase the curve of the neck and offload the upper cervical spine.
  • Upper cervical chiropractic. This is specific adjustments to restore normal alignment of the upper neck.
  • Prolotherapy-This is an injection of substances that cause a brief inflammatory reaction that can cause ligaments to tighten or get stronger. This procedure can only reach the outer ligaments of the neck and not the internal ligaments that frequently cause CCI. 
  • Platelet Rich Plasma or Stem Cells-These procedures inject platelets and/or stem cells that can help repair damaged ligaments, but again, this can only reach the outer ligaments of the neck and not the ligaments that frequently cause craniocervical instability.
  • Surgical Fusion-This procedure places hardware to stabilize all or some or all of the C0-C2 segments of the neck. The problem is that adjacent segment disease is common, which means that the areas above or below the fusion get more wear and tear and arthritis.
  • PICL Procedure-This is the injection we developed. This procedure involves injecting the patient’s own bone marrow stem cells directly into the craniocervical ligaments. The advantage is no surgery and the goal is to strengthen these internal ligaments that stabilze the head on the neck.

CCI Educational Videos

    Common Craniocervical Instability Surgeries

    Cranio-cervical Fusion (Usually Skull Base to C2): A plate is placed with screws from the back of the skull to the C2 or C3 vertebra. The goal is to fuse all aspects of the upper neck. Massive tissue destruction is common as placing this hardware is complex. Severe complication rates are higher than other neck surgeries. Adjacent segment disease below the fusion is common in our experience.

    C1-C2 Posterior Screw Fixation (Fusion): This procedure places a screw through each C1-C2 facet joint. Complications that we have seen include placing the screw inadvertently into the C0-C1 facet joint and adjacent segment disease (where the C0-C1 facet and C2-C3 facets develop arthritis due to the overload).

    Typical Injection Treatments for Craniocervical Instability

    Bulging or Herniated Disc Treatment

    Upper Cervical Facet Injections

    Some patients with smaller amounts of CCJ instability will respond to upper cervical facet injections. This is the injection of platelet-rich plasma or stem cells into these joints. Regrettably, providers with significant experience in injecting the C0-C1 and C1-C2 facet joints under x-ray guidance are few and far between. Many patients who have received prolotherapy where the doctor used an x-ray or ultrasound believe that they have had these joints injected, but in our experience this is usually not the case.

    The CCJ Instability Institute has providers with extensive experience in injecting these joints. As an example, while the average US spine interventionalist may have injected fewer than 20-50 C-C2 facet joints and fewer than 1% of these doctors have injected 100 joints, Dr. Centeno has injected thousands of these joints without incident. In fact, he has published a paper on a new C0-C1 facet injection technique.


    Upper neck injection types by location that are commonly tried by Craniocervical Instability patients include:

    • Facet injections-The doctor uses a fluoroscope (or ultrasound) to inject the upper neck joints, usually with corticosteroid. These injections can damage cartilage.
    • Prolotherapy ligament injections-The physician injects a substance to cause a brief inflammatory healing reaction into damaged or loose ligaments. Only the external ligaments are targeted (and not the Internal CCJ ligaments). Oftentimes these injections are performed blind or if they are performed using fluoroscopy (real-time x-ray), oftentimes this is just to confirm simple placement.
    • Trigger point injections-These are injections into the muscles of the neck to try and relieve tight knots in muscles called trigger points. Another way to accomplish the same thing is to perform dry needling of these upper neck muscles often using acupuncture needles.  This is not traditional Chinese acupuncture and this area must be treated carefully due to the presence of the vertebral artery. 

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    External Versus Internal Craniocervical Ligaments

    The neck and head have external and internal ligaments. We spent years treating the external ligaments in CCI patients with only minimal benefits. Regrettably, all ligament tightening approaches like prolotherapy, platelet-rich plasma, or stem cells focus on tightening these external ligaments. The PICL procedure is the only treatment that can reach the critical internal ligaments.

    The external ligaments that help to hold the head on (stabilize the craniocervical junction of CCJ) are the supra-spinous and interspinous ligaments in addition to the facet capsules. The yellow triangles to the left point to some of these ligaments.

    The internal ligaments include the alar, transverse, and accessory ligaments as well as the posterior atlanto-occipital and tectorial membranes. Based on our experience, to effectively treat CCJ instability patients, these internal CCJ ligaments must be treated through direct injection, which the PICL procedure allows.



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