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Cervical Medullary Syndrome

The headaches, dizziness, and brain fog have been unrelenting.  They started after a slow-speed rear-end motor vehicle accident and have been progressive.  Physical therapy, medications, and rest have failed to provide any benefit.  Referrals to specialists including neurologists, orthopedic surgeons, and neurosurgeons have been draining and discouraging.  Many physicians are dismissive and recommend psychological counseling.  My chiropractor believes there is irritation of the brain and may be causing my symptoms.  

What is the brainstem and what is its role?  What is Cervical Medullary Syndrome? What are the symptoms of Cervical Medullary Syndrome? What are the four major causes of Cervical Medullary Syndrome? How does Craniocervical Instability cause Cervical Medullary Syndrome? Meet Pam.  How is Cervical Medullary Syndrome treated?  Let’s dig in. 

Introduction

Cervical Medullary Syndrome is a clinical condition that occurs as a result of injury to the lower part of the brain. 

Important Neck Anatomy

The brain is contained in a protective boney shell called the skull.  There are many different parts of the brain.  The lowest part of the brain is called the medulla.  It connects the Cerebellum to the spinal cord and is tubular in shape.  The Brainstem is responsible for vital functions of life such as breathing, heart rate, and blood pressure. 

The Medulla is protected and encircled by cerebral spinal fluid.  This is illustrated in the sagittal MRI of the brain and neck shown below.  This is a side-view image of the anatomy.  The Medulla is dark in color and located at the base of the skull.  It connects directly with the spinal cord which is also dark in color.  The bones of the cervical spine stack one upon another. In contrast, the Cerebral Spinal Fluid (CSF) is white in color and that provides an important layer of protection.

There are 7 vertebral bones that make up the cervical spine.  They sit in front of the spinal fluid and spinal cord.   The second highest bone is the C2 bone and is identified in white.  

What Exactly Is Cervical Medullary Syndrome? 

Cervical Medullary Syndrome is a clinical condition that occurs as a result of inflammation, deformity, or compression of the lower part of the brain (1). Symptoms can be extensive with fluctuating severity based upon the extent of the underlying injury. For example, mild irritation of the brainstem may cause only mild, intermittent symptoms.  

What Are the Symptoms of Cervical Medullary Syndrome?

Symptoms of cervical medullary syndrome will vary depending upon the severity of the injury.  Common symptoms include

  • Headache
  • Neck pain
  • numbness and weakness in the arms, hands, legs 
  • Dysautonomia
  • POTS (postural orthostatic tachycardia syndrome) 
  • Reduced or loss of breathing
  • Visual disturbances
  • Problems with Swallowing
  • Dizziness

Brain Fog

Brain fog is one of the hallmark symptoms of Craniocervical instability. It is characterized by slow thinking, difficulty focusing, confusion, lack of concentration, forgetfulness, or haziness in thought. The severity of symptoms varies from patient to patient. Ever had a bad hangover or high fever and had trouble concentrating or completing simple tasks? This brain fog. Some patients describe it as a generalized haziness in thought as if cotton were stuck in the head. In addition to cognitive impairments, many patients also report generalized mental fatigue making complex tasks almost impossible. The exact cause of brain fog is unknown. Possible explanations include…

Read More About Brain Fog

Cervicalgia / Neck Pain

Cervicalgia is also known as neck pain, which is an all-too-common, unpleasant pain. Read here to learn the symptoms, diagnosis, and treatment options. We will discuss other causes for cervicalgia. What symptoms are associated with cervicalgia? How is cervicalgia diagnosed? What are the treatment options for cervicalgia? Cervicalgia is a medical term used to describe neck pain. It is very common and affects approximately 2/3 of the population at some point in their life. Cervicalgia is the 4th major cause of disability. Risk factors include injury, prior history of neck and musculoskeletal pain, jobs that require a lot of desk work, low social support, job insecurity, physical weakness, and poor computer station setup.

Read More About Cervicalgia / Neck Pain

Chronic Fatigue

Have you ever had a challenging all-day hike, athletic endeavor, or worked a double shift and felt exhausted the next day? Later that day or the next morning, moving across the room may have seemed almost impossible and took herculean power. Now image this occurs on a daily basis without any provocation. 24/7 simple tasks are nearly impossible due to a lack of strength and energy. This is chronic fatigue, and it is one of the common symptoms associated with craniocervical instability. Severity can vary and in severe cases, patients are confined to their beds. Aggravating and alleviating factors often times can not be identified.

Read More About Chronic Fatigue

Chronic Headaches

Do you suffer from chronic headaches? Maybe it’s a daily issue, maybe once a week, maybe even less often, but one thing’s for sure—when a chronic headache kicks in, it can be a real pain in the neck, literally. In order to effectively address chronic headaches, you have to first determine if the pain is caused by a problem in your neck. Let’s take a look at a few neck issues that can cause headaches: Weak neck muscles – The head, on average, weighs about ten pounds, so when the neck muscles are weak, it can make your head feel a bit like a bowling ball that your neck can’t quite balance. There are many muscles that, along with the cervical spine, work together to help support the neck and aid movement…

Read More About Chronic Headaches

Muscle Pain After Cervical Fusion Surgery

Cervical Fusion is a major surgery that involves joining one or more of the spinal bones together using screws, bolts, and plates (1). The hardware may be placed in the front (anterior) or the back( posterior) of the cervical spine. The disc between the spinal bones is often times removed and replaced with a bone graft or a spacer. The neck of composed of 7 boney building blocks that are numbered from 1-7. The letter C is associated with the numbers to designate the cervical spine. Hence the bones in the neck are C1 through C7. Sandwiched between neck bones are important shock absorbers called discs. A cervical fusion surgery removes…

Read More About Muscle Pain After Cervical Fusion Surgery

Neck Pain and Dizziness

Our body’s balancing system is compromised of three separate systems that work closely together to keep the body in balance: the eyes, inner ear, and upper cervical spine. The upper cervical spine contains and processes information about your position in space and communicates this information to your eyes and inner ears via nerves. There is a constant highway of electrical signals between the cervical spine, inner ear, and eyes that keep us upright, make us aware of our position and enable us to walk, move and run. This balancing system requires the inner ear, eyes and cervical spine to be operational…

Read More About Neck Pain and Dizziness

Neck Pain at the Base of Skull

The base of the skull is a complex area.  It involves the upper cervical spine, facet joints, muscles, tendons, ligaments, and nerves.  Irritation or injury to any one of these structures can result in pain at the base of the skull.  Unfortunately, this area is not understood by many providers.  This can lead to a delay in treatment and unnecessary pain and suffering.Treatment options depend upon the underlying cause of the pain.  Conservative therapy in the form of physical therapy when appropriate is the best first-line treatment.  Steroids are often recommended but should be avoided as they are toxic to orthopedic tissue and have significant side effects…

Read More About Neck Pain at the Base of Skull

Rapid Heart Rate

Rapid heart rate can be debilitating, compromising your wellbeing and ability to complete the easiest of tasks, and, unfortunately, it is a common symptom of craniocervical instability or other upper cervical conditions. Normal resting adult heart rate ranges from 60-85 beats per minute. Tachycardia is a medical term for heart rates of 100 beats per minute. Most of us have experienced rapid heart rates after vigorous exertion or exercise. Remember how your heart was rapidly beating after wind sprints or chasing after your dog who jumped the fence? Your heart is rapidly pounding in your chest. Unfortunately for some patients that is their baseline.

Read More About Rapid Heart Rate

Stiff Neck

Conventional wisdom states that stiff neck symptoms can be treatable with nonsurgical remedies. However, not all stiff neck symptoms are benign, and leaving the stiff neck untreated can lead to a limited range of motion that can affect your overall health and quality of life. A stiff neck can cause pain, tightness, popping, and clicking noises and sensations and affect daily activities. A detailed examination of stiff neck symptoms can determine the exact condition affecting the stiffness of one’s neck. Where does the neck hurt? Neck stiffness can occur at the base of the head, down to the shoulders. This can be associated with pain, crunching noises, or popping sensations and may…

Read More About Stiff Neck
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Four Major Conditions that Can Cause Cervical Medullary Syndrome

The upper cervical spine and brain are complex with multiple structures.  These structures reside within the skull and protective confines of the cervical spine.  Neither expands to accommodate inflammation, injury, and disease.  Rather the delicate tissues of the brain and spinal cord are irritated or compressed.   The 4 major conditions that cause cervical medullary syndrome are:

Chiari Malformation chiari malformation

Chiari Malformation is a medical condition where a part of the brain bulges through a normal opening at the base of the skull. Check out the Chiari Malformation page to learn more.

Craniocervical Instability

Craniocervical instability (CCI) is a medical condition where the strong ligaments that hold your head onto your upper neck are loose or injured. To learn about the 7 most common symptoms of CCI please click here. To download our newest CCI ebook please click here

Atlantoaxial Instability

The C1 bone is oftentimes referred to as the atlas.  The C2 bone is also called the axis.  The C1 and C2 bones stack upon one another forming a joint.  The joint is called the atlantoaxial joint (AA).  Trauma and ligament instability are the most common causes of Atlantoaxial instability.  To learn more about the atlantoaxial joint and its importance please click here

Cervical Spinal Stenosis

Stenosis simply means narrowing. Cervical spinal stenosis is a medical condition where there is a narrowing of the spinal canal which can cause irritation or injury to the spinal cord and nerves resulting in pain, numbness, and dysfunction. 

How Does Craniocervical Instability (CCI) Cause Cervical Medually Syndrome? 

CCI and cervical medullary syndrome

Under normal conditions, the C2 bone fits inside the C1 bone as shown above.  This enables the C2 to rotate around the C1 bone which is the spot where half of your neck rotation originates.

There are two strong ligaments that hold the C2 bone (axis) to the C1 bone (atlas).  They are the Alar and Transverse ligaments which are illustrated below.  The image is a cross-section view from the top down.  You know.  As if an angel were looking down upon you.  The Alar and Transverse ligaments are in red and snuggly hold the top of the C2 bone into place.  Behind the C2 bone is the cerebral spinal fluid along with the brainstem (Medulla).  The cerebral spinal fluid is white in color whereas the brainstem is yellow.  The Alar and Transverse ligaments snuggly hold the C2 bone preventing it from striking or injuring the medulla.  

Image with no description

Now let’s look at what happens with patients that have Craniocervical instability (CCI).  This is a condition where there is injury or damage of the alar and or transverse ligaments. This is illustrated below.  Because the alar and transverse ligaments are loose the C2 bone is no longer held snuggly into place.  Rather it moves backward and contacts the medulla when a patient bends their head and neck.    The protective cerebral spinal fluid is displaced and is no longer able to act as a buffer.  The medulla is very, very sensitive tissue that is easily irritated or compressed by the C2 bone.  This gives rise to symptoms of cervical medullary syndrome.

Meet Pam

Pam is 50 y/o patient evaluated in the clinic with a 4-year history of brain fog, headaches, memory problems, fatigue, and visual disturbances.  She was enjoyed gymnastics and cheerleading in high school and considered herself very flexible.  She had a history of multiple small traumas due to sports.   Symptoms were severely aggravated by a motor vehicle accident.  She was evaluated by a number of specialists including neurologists, orthopedic surgeons, and neurosurgeons without a clear explanation of the symptoms.  The traditional MRI studies were “normal”.  

An upright flexion/ extension MRI clearly demonstrated the problem.  The side view section of Pam’s MRI  is shown below.  it demonstrates what is happening when Pam bends her head and neck forward. 

Image with no description

The C2 bone is identified by a yellow triangle.  The brainstem is black in color, tubular in structure, and immediately behind the C2 bone.  It is a continuation of the brain and connects to the spinal cord.  It is a fragile tissue that is susceptible to irritation, inflammation, and injury. Cerebral spinal fluid provides important protection for the Brainstem and spinal cord.  It is white in color and surrounds the Brainstem and spinal cord.  Unfortunately in Pam’s case when she bends her head forward that protective layer is not longer present. Rather her Brainstem strikes the backside of the C2 bone causing her symptoms.  Ouch!  

How Is Cervical Medullary Syndrome Treated? 

The first-line treatment is often physical therapy or specific upper cervical chiropractic.  In our experience, the latter is usually more successful in some patients, as it more directly addresses the malposition of C1 on C2, which tend to rotate on each other when there are loose or damaged ligaments. When this doesn’t help, a surgical Fusion of the upper neck bones is usually recommended. This involves using screws and sometimes plates or rods to make sure the upper neck bones don’t move. However, this is a high-risk procedure that can’t be undone. In addition, it can also cause Adjacent Segment Disease (ASD), which means that the spinal levels above and below can get worn out and damaged, requiring the need for more Fusions.

An alternative is trying to tighten the ligaments through very specific x-ray guided injections. While prolotherapy (ligament tightening injections) on the ligaments in the back of the neck can be tried, the ligaments discussed here that cause the Cervical Medullary Syndrome can’t be reached or treated using that method. The PICL procedure does treat these ligaments directly. The procedure is only performed at the Centeno-Schultz Clinic in Broomfield and Lone Tree, Colorado.  To learn more about the Percutaneous Implantation of CCJ Ligaments please click on the video below.

 

Cervical Fusion

Cervical Fusion is often recommended when chronic neck pain problems worsen over time. What exactly is it? Cervical Fusion is a major surgery that involves joining one or more of the spinal bones together using screws, bolts, and plates (1). The hardware may be placed in the front (anterior) or the back( posterior) of the Cervical spine. The disc between the spinal bones is often times removed and replaced with a bone graft or a spacer. The neck of composed of 7 boney building blocks that are numbered from 1-7. The letter C is associated with the numbers to designate the Cervical Spine.

Read More About Cervical Fusion

NSAIDs

The other day I was evaluating a patient and reviewing the treatment options for their spine condition.  After discussing prior treatments, we got to the topic of medications taken for pain relief. She explained that she mainly utilized anti-inflammatory (NSAID) medications and then she told me to hold much she takes and has been for many years…..she takes close to 2 grams (2000 milligrams) on a daily basis which equated to about 9-10 capsules of medication per day.  I was shocked, considering she was pre-diabetic and with high blood pressure plus the kicker of it is that her PCP (primary care physician) is ok with this…

Read More About NSAIDs

Occipital Cervical Fusion

An Occipital Cervical Fusion also known as Occipitocervical Susion is a Major Surgery. It is not a routine operation and is a challenging procedure due to complex anatomy of the upper neck. The procedure involves rods, plates and screws that are placed into the Cervical Spine and Occiput. A plate secured by screws are placed at the base of the Occiput. Screws are also placed into one or more Cervical bones. Rods then connect the Occipital plate to the Cervical screws as shown below. The goal of Occipital Cervical Surgery is a boney fusion between the skull and neck and to relieve…

Read More About Occipital Cervical Fusion

PICL Procedure

CCI stands for cranial cervical instability which means that the ligaments that hold the head on are too loose. To help that problem, we developed a new procedure called PICL which stands for Percutaneous Implantation of the CCJ Ligaments. This is still an investigational procedure that has already changed many lives and helped patients avoid a complication-laden upper cervical fusion. Given the interest in the PICL procedure from patients who have CCI, there are lots of questions. Since the procedure isn’t yet covered by insurance, a few have asked why it costs more than their co-pay and deductible if they decide to have a more invasive cervical fusion.

Read More About PICL Procedure

In Conclusion

Cervical Medullary Syndrome is a clinical condition that occurs as a result of inflammation, deformity, or compression of the lower part of the brain.

There are numerous symptoms with fluctuating severity based upon the extent of the underlying injury. 

The most common symptoms of Cervical Medullary Syndrome include headache, neck pain, numbness and weakness in the arms, hands, and leg, dysautonomia, visual disturbances, and dizziness.

The four most common conditions that cause Cervical Medullary Syndrome are:

First-line treatment when appropriate is physical therapy and chiropractic care.  When conservative treatment options fail surgery is often recommended in the form of a Fusion.

Tightening and strengthening the Alar and Transverse ligament is now possible through the PICL procedure. 

The PICL is a non-surgical treatment. 

If you or a loved one have ongoing neck pain, headache, and dizziness that has not responded to conservative treatment, please schedule a telephone Candidacy discussion with a board-certified, fellowship-trained physician. At the Centeno-Schultz Clinic, we are experts in the evaluation and treatment of upper neck injuries.  From the comfort of your home or office learn what treatment options for CCI are available for you.

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Our Doctors Who Treat Cervical Medullary Syndrome

Christopher J. Centeno, MD

Christopher J. Centeno, M.D. is an international expert and specialist in Interventional Orthopedics and the clinical use of bone marrow concentrate in orthopedics. He is board-certified in physical medicine and rehabilitation with a subspecialty of pain medicine through The American Board of Physical Medicine and Rehabilitation. Dr. Centeno is one of the few physicians in the world with extensive experience in the culture expansion of and clinical use of adult bone marrow concentrate to treat orthopedic injuries. His clinic incorporates a variety of revolutionary pain management techniques to bring its broad patient base relief and results. Dr. Centeno treats patients from all over the US who…

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John Schultz, MD

My passion and specialization are in the evaluation and treatment of cervical disc, facet, ligament and nerve pain, including the non-surgical treatment of Craniocervical instability (CCI). I quit a successful career in anesthesia and traditional pain management to pursue and advance the use of PRP and bone marrow concentrate for common orthopedic conditions. I have been a patient with severe pain and know firsthand the limitations of traditional orthopedic surgery. I am a co-founder of the Centeno-Schultz Clinic which was established in 2005. Being active is a central part of my life as I enjoy time skiing, biking, hiking, sailing with my family and 9 grandchildren.

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1.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

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