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The CCJ Instability Institute





craniocervical instability institute

Advanced Non-surgical Solutions for Craniocervical Instability


About the CCJ Instability Institute

There are strong ligaments that hold your head on and these can be traumatically injured or otherwise become loose due to connective tissue disorders. At the CCJ Instability Institute, healing these ligaments is what we do. While these patients of craniocervical instability often get very dangerous and invasive surgery, we have developed a non-surgical, injection-based approach that uses your own bone marrow concentrate (containing stem cells), carefully delivered into the alar, transverse, and accessory ligaments using our one of a kind, PICL (Percutaneous Implantation of the CCJ Ligaments).

The CCJ Instability Institute is currently located at the Centeno-Schultz Clinic which serves as the International HQ for the Regenexx network. 

What is Craniocervical Instability (CCI)?

Craniocervical instability is a medical condition with numerous names, including cranio-cervical instability (CCI), cranial instability, cranio-cervical syndrome, occipitoatlantialaxial hypermobility, the Syndrome of Barre Lieou, upper cervical instability, and others. The head is held onto the neck with strong ligaments. When these ligaments are injured or damaged or just loose due to congenital problems (like Ehler-Danlos Syndrome which can cause stretchy ligaments), the head can become unstable on the upper neck. This is called CCJ instability.

This extra motion can lead to many different issues. These include early onset arthritis in the upper neck joints. This can cause local pain in the upper neck, as well as headaches and/or dizziness and other symptoms due to spinal cord compression. In addition, the natural position sense provided by this part of the neck can become abnormal, causing other parts of the body to become misaligned and painful. Finally, there are many muscles that have tendons that can be beat up over time, leading to tendinopathy and pain.

Common symptoms of CCI

We see many different craniocervical instability symptoms, but the more common ones are:

  • Headaches (with the sensation that your head feels too heavy)
  • Dizziness or imbalance
  • Visual changes
  • Neck pain
  • Numbness and tingling
  • Rapid heart rate
  • Feeling spacey or disoriented
  • Fatique
  • Muscle weakness 


alar ligaments in craniocervical instability

Why The CCI Institute for Regenexx is homed in Centeno-Schultz Clinic

CCI Series

A series of key insights for those with CCI

CCI Series - Episode 1: "Understanding CCI Measurements vs. Instability"

How craniocervical instability is measured is one of the most confusing things for patients. Dr. Chris Centeno talks about the shortcomings of conventional medical imaging and how it relates to how CCI is and should be measured.

Read Episode 1 of the CCI Series >

CCI Series - Episode 2: "What Goes into the PICL Procedure for CCI Instability"

Dr. Chris Centeno discusses the PICL procedure and what’s involved in it. 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. They have also asked why we don’t authorize any other Regenexx clinic to perform this procedure.

Read Episode 2 of the CCI Series >

CCI Series - Episode 3: "C1-C2 Fusion – Complications are Common"

Dr. Chris Centeno discusses C1-C2 fusion surgery and how and why they often lead to life-altering complications. This is a must read if you’re facing this surgery in the near future….

Read Episode 3 of the CCI Series >

CCI Series - Episode 4: "A New Ligament is Rediscovered"

Dr. Chris Centeno reports on the rediscovery of a ligament associated with CCI. 

Read Episode 4 of the CCI Series >

CCI Series - Episode 5: "PICL Rehab"

Dr. Chris Centeno discusses post-op rehabilitation for patients that have undergone the PICL procedure. 

Read Episode 5 of the CCI Series >

CCI Series - Episode 6: "Understanding Common Injections for CCI Patients"

Dr. Centeno goes over 4 different ways people have treated craniocervical instability. He gives the pros and cons for each one. 

Read Episode 6 of the CCI Series >

Your Alternative to Cervical Fusion Surgery!

At the CCJ Institute, our proprietary, research-driven techniques allow us to concentrate your body’s own cells and place them in the precise area of injury to promote healing and to achieve optimal outcomes for patients suffering from Craniocervical instability.

Your Craniocervical Instability Treatment Options

  • 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 Bone Marrow Concentrate Injections – These procedures inject platelets and/or bone marrow concentrate 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 CCI.
  • 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 concentrate 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.
Alar ligaments in CCI operation

 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 bone marrow concentrate 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. 

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 bone marrow concentrate 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.


PICL Procedure: The Non-Surgical Option

The PICL (Percutaneous Implantation of the CCJ Ligaments) procedure is a highly precise, direct injection of the CCJ ligaments including the alar, transverse, and accessory ligaments for the treatment of craniocervical instability. The tectorial and PAO membranes can also be injected. The implantation part of the acronym refers to placing the patient’s own bone marrow concentrate into these ligaments to promote healing.

In order to reach these ligaments, the only safe route (that avoids the upper cervical spinal cord) is through the posterior oropharynx (back of the throat). To accommodate this, the patient is put to sleep using advanced anesthesia techniques and a specialized and custom 3D printed oral appliance is used to hold the tongue down and the airway open while allowing x-ray guidance using fluoroscopy.

Our CCI treatment is dramatically less invasive than upper neck fusion surgery – with fewer complications, less pain, and less recovery time. Its goal is to heal damaged ligaments rather than screwing together bones. At its heart, it’s a complex and technically demanding injection rather than an invasive open surgery. 

Our Research on Regenerative Treatments for CCJ Instability

Is the PICL Procedure Safe?

We have been performing the PICL procedure since 2014. We took the adoption and development of this technique very slowly, adding advancements as we learned more. Given our experience to date, we can safely say that the procedure has produced no severe adverse events that were no easily treated. In addition, based on the published rates of complications with CCJ surgeries, the risk profile of the PICL procedure is far less than these procedures. Additional research continues and we will continue to publish our procedural results and complications.


Your Alternative to Surgery

At the CCJ Institute, our proprietary, research-driven techniques allow us to concentrate your body’s own cells and place them in the precise area of injury to promote healing and to achieve optimal outcomes for patients.


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