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The CCJ Instability Institute

Home of the PICL – The Trusted Non-Surgical Craniocervical Instability Treatment

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The PICL - The Trusted Non-surgical Craniocervical Instability Treatment

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, helping your body heal 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, carefully delivered into the alar, transverse, and accessory ligaments using our one of a kind PICL (Percutaneous Implantation of the CCJ Ligaments), the trusted non-surgical craniocervical instability treatment. 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, atlantoaxial 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 
Watch Dr. Schultz’s video on the most common symptoms of CCI

Recommended Reading

Understanding CCI Measurements vs. Instability (CCI Series, Episode 1)

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 about important CCI measurements >

What Goes into the PICL Procedure for CCI? (CCI Series, Episode 2)

Dr. Centeno discusses the PICL procedure, what’s involved in it, and why Centeno-Schultz Clinic is the only Regenexx clinic authorized to perform it.

Read about the PICL Procedure >

C1-C2 Fusion – Complications are Common (CCI Series, Episode 3)

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

Read about C1-C2 fusion complications >

A New Ligament is Rediscovered (CCI Series, Episode 4)

Dr. Chris Centeno reports on the rediscovery of the Superficial Anterior Atlanto-occipital Ligament (SAAOL).

Read about the rediscovered ligament for Craniocervical Instability >

Post-PICL Rehab (CCI Series, Episode 5)

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

Read about CCI Exercises >

Understanding Common Injections for CCI Patients (CCI Series, Episode 6)

Dr. Centeno goes over 4 different craniocervical instability treatment options and the pros and cons for each.

Read about common injections used for CCI patients >


Ehlers Danlos Syndrome & Craniocervical Instability: What to Know!

What’s the connection between EDS and CCI? Dr. Schultz does a deep dive in the connection between the two, their treatment options, and much more.

Learn more about Ehlers Danlos Syndrome & Craniocervical Instabiity in this article.

7 Criteria for Diagnosing Craniocervical Instability

How is craniocervical instability diagnosed? The truth is that a lot of professionals can overlook it because it takes more than static imaging to truly identify CCI.

Read “7 Criteria for Diagnosing 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 our non-surgical craniocervical instability treatment. 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 stabilize the head on the neck.

The PICL Procedure

The Trusted Craniocervical Instability Treatment 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. 

Upper Cervical Conditions the PICL Treats

Atlantoaxial Instability (AAI)

Instability simply means that bones move around too much, usually due to damaged ligaments. In the spine, this can cause nerves to get banged into and joints to get damaged. In the craniocervical junction, instability can cause the upper cervical spinal nerves to get irritated, leading to headaches. In addition, the C0-C1 and C1-C2 facet joints can also get damaged. In addition, there are other nerves that exit the skull here that can get irritated, like the vagus nerve, which can cause rapid heart rate. What’s the Difference Between CCI and AAI? CCI refers to instability in any part of the craniocervical junction…

Read More About Atlantoaxial Instability (AAI)

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. 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. 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… 

Read More About Cervical Medullary Syndrome

Chiari Malformation

Chiari Malformation Is a medical condition where a part of the brain at the back of the skull abnormally descends through an opening in the skull. It is named after Dr. Hans Chiari who was an Austrian pathologist who in the late 1880’s studied deformities of the brain.The brain is a large structure divided into different parts that reside within the skull. Important parts of the brain called the Cerebellum and Brainstem sit at the base of the skull. The Foramen Magnum is a large hole at the base of the skull that allows the brain to join the spinal canal. The Cerebellum…

Read More About Chiari Malformation

Craniocervical Instability

Craniocervical Instability 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 a painful, heavy head, headache, rapid heart rate, brain fog, neck pain, visual problems, dizziness, and chronic fatigue.CCI or neck ligament laxity treatment options depend upon the severity of the instability and clinical symptoms. When appropriate, conservative care should always be the first-line treatment. Craniocervical Instability Surgery is often recommended when conservative care fails. This involves a fusion of the head to the neck which is a major surgery that is associated with significant risks and complications…

Read More About Craniocervical Instability

Ehlers-Danlos Syndrome (EDS)

Disorders that affect and weaken the connective tissues such as tendons and ligaments. It is a hereditary disorder which means you are born with it.  EDS has many different signs and symptoms which can vary significantly depending upon the type of EDS and its severity.   It most commonly affects the skin, joints, and blood vessels.  Joints are typically hypermobile with excessive joint range of motion because of a defect in collagen formation. In most cases Ehlers-Danlos syndrome is inherited. That is to say that you are born with it. The two main ways EDS is inherited are: autosomal dominant inheritance and autosomal recessive inheritance…

Read More About Ehlers-Danlos Syndrome (EDS)

Jugular Vein Compression

The Jugular is a large vein in the neck/head region.  It is an important structure as it collects blood from the brain, face, and neck and delivers it to the heart.  We all have two Jugular Veins:  an external and an internal Jugular Vein. The is one on the right and one on the left. The internal Jugular Vein is the focus of today’s discussion and can be affected by Craniocervical Instability.  When the Jugular Vein is compressed the blood is not able to drain into the heart and backs up in the brain. As shown above, the internal Jugular Vein…

Read More About Jugular Vein Compression


The temporomandibular joint (TMJ) is the joint connection between your jaw and your skull. If you run your fingers along either side of your jaw line toward your ears, you can actually feel where the jaw bone ends and the skull bone begins. If you open and close your mouth, the difference between the two is dramatic as the jaw bone moves, thanks to the TMJ joint, while the skull bone remains stable. The TMJ and any of its surrounding structures can become painful and inflamed, and this can become so bad that it can prevent patients from even being able to move their jaw bone to chew.

Read More About TMJ
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Read 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.

Download Your Copy of CCI 101: Understanding Craniocervical Instability and the Road to Recovery

Dr. Centeno’s new book on Craniocervical Instability is now ready to go! This covers everything from conservative care to surgery to newer precise injection procedures like PICL that can help existing ligaments tighten down and stabilize the upper neck. This book is a must-read for anyone diagnosed with CCI.

This is version 1 of this book and while it has been read by several CCI patient advocates who made suggestions if you find things that require correction or have ideas for improvements, please send a quick email to the author at [email protected]!