A Case Study of Severe CCJ Instability and Our PICL Procedure

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CCJ instability is a life-changing problem. Think about the havoc that could be caused by the ligaments that hold your head being injured by trauma or becoming loose due to a connective-tissue disease. Headaches, imbalance, and a myriad of other symptoms become the new normal when you attempt to do anything. This morning, after several years in the making, I’d like to discuss the objective results of our new PICL procedure by reviewing the case of a patient with severe CCJ instability.

Defining CCJ Instability

The craniocervical junction (CCJ) is at the top of the spinal column where the head meets the neck. Strong ligaments—the alar, transverse, and accessory ligaments (and others)—hold the CCJ together. A new ligament complex called the ventradural ligament (VDL) has also recently been discovered here. CCJ instability occurs either when there is an injury to these ligaments or due to disease and normal wear and tear with aging. The result is that the ligaments loosen and the upper-neck joints become unstable. This can lead to arthritis in these joints, tendon inflammation, nerves being pinched, and so on.

What might cause an injury to the CCJ ligaments? While there are congenital conditions, such as Ehlers-Danlos syndrome (EDS) that are associated with CCJ instability, the ligaments can also suffer traumatic injuries, such as head or neck trauma. Examples include a rear-end car accident or a blow to the head in sports or some other activity or accident. Symptoms can include dizziness, visual and cognitive disruptions, headaches, and so on.

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A Rose by Any Other Name

Before we discuss this new procedure or the results of this treatment, it’s important to note that CCJ instability has many different names. Other monikers include, cranial-cervical syndrome, hypermobility of the cranial-cervical junction, atlanto-axial instability, atlanto-occipital instability, craniocervical instability, craniocervical injury, upper cervical instability, and so on. Now let’s review our interventional orthopedic procedure for addressing CCJ instability called the PICL procedure.

What Is a PICL Procedure, and How Is It Performed?

PICL stands for percutaneous implantation of the CCJ ligaments. I’ve been slowly blogging on this topic for years, revealing more about this new procedure each time. I wanted to wait until we got well past 100 safe procedures and until I had a chance to fully grasp its efficacy before giving it a name. However, it’s now time for what we had called the “CCJ instability procedure” or “alar procedure” to get the more formal PICL label.

During a PICL procedure, bone marrow concentrate (BMC) that contains a stem cell fraction (same-day stem cell procedure) is injected directly into the CCJ ligaments. The percutaneous approach to reach these ligaments is through the posterior oropharynx (the back of the throat). It requires an endoscope to establish and maintain a sterile field and place the needles. It then also uses advanced and precise fluoroscopic (real-time X-ray) guidance with radiographic contrast to ensure the correct ligaments are being injected. The red arrow in the image below provides a visual of the injection vector.

Why is a PICL procedure better? This is an interventional orthopedic procedure that utilizes a percutaneous minimally invasive technique to treat CCJ instability, meaning it’s much less invasive than surgery. The purpose is to prevent highly invasive cervical fusion surgery, which will immobilize the upper neck by bolting the head to the upper neck bones and will create more problems, such as adjacent segment disease, down the road. Learn more about our PICL procedure for CCJ instability in my early video below:

A PICL Procedure Case Study of a CCJ Instability Patient

The patient is a physical therapist who was involved in a car crash in 2009. He had severe CCJ instability, a lower cervical disc bulge with pinched nerves, upper cervical facet joint injuries, and a traumatic brain injury. He had symptoms in his arms due to the lower-neck disc bulge, but most of his disability was related to the upper neck. I had treated the lower-neck for a couple of years with platelet lysate epidurals, which managed the symptoms in his arms.

He was seen this week for his fourth procedure, after a series of three PICL procedures. His first was in February 2017, the second was in October 2017, and the third was June 2018. Before, during, and after these three procedures, I measured the lateral movement of the C1 neck bone on the C2, called the C1–C2 overhang, while the patient bent his head to the side. A damaged alar ligament allows too much overhang, and that can cause upper cervical symptoms. You can watch my featured video at the top of the page for a detailed timeline and dramatic visuals of his progress, but briefly, here are his current results (prior to his fourth procedure):

  • Left C1–C2 overhang has reduced by more than 50% (5.6 mm to start, currently 2.3 mm)
  • Right C1–C2 overhang has reduced by a whopping >80% (7.2 mm to start, currently 1.2 mm)

How do these results translate to the patient? He’s reporting about a 65% improvement. Before his procedures, he could only walk about 100 yards max; now he can do four miles. He does still have some head injury symptoms, and it’s important to note that there are things he still doesn’t do. However, his life has changed from highly disabled to just significantly limited in certain activities. In summary, the PICL procedure has dramatically improved his function, and objective imaging that measures his CCJ instability has supported that conclusion.

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Where Is the PICL Procedure Performed? Are There Research Studies?

Currently, the PICL procedure can only be performed at our Regenexx HQ in Colorado. We have a few physicians there who have trained directly with me and who also perform it. Given the complexity of the anesthesia, the use of multiple imaging modalities, and the procedure itself, it’s unlikely that I will be teaching this one to anyone else outside of Colorado for a while. That will have to wait until we get multiple publications in print.

We have an ongoing randomized controlled trial (RCT) research study currently in process for our PICL procedure. This is a free study, but you have to meet certain inclusion and exclusion criteria as well as agree to be randomized to the sham procedure (where you will be put to sleep and the back of your throat will be poked without the PICL procedure being performed). The good news is that you can cross over from the placebo group to the real PICL procedure at six months.

We have been very cautious over the last four years as we have developed this procedure, and now we feel comfortable with the risk-benefit profile to share the first clinical results. These will generate a large case series publication with objective imaging analysis, which is in the works. So we’ll have research published even before the RCT is completed.

The New CCJ Instability Institute

One of the things we have seen in treating CCJ instability for more than 20 years is that few physicians know much about this issue. This extends to specialists such as surgeons and interventional spine doctors who should know more. As an example, just arranging an upper-cervical facet injection for our CCJ instability patients is tough. There are fewer than 100 US physicians who have any substantial experience (performed 20 or 30 or more of these injections) and fewer than 10 who have a lot of experience (performed more than 100). As a comparison, we have performed thousands.

As a result, we are forming the CCJ Instability Institute. This will highlight the fact that we’re one of the few places on Planet Earth with expertise in the minimally invasive treatment of the upper-cervical spine. In addition, one of the missions of the institute will be to educate physicians on these problems so that CCJ instability patients don’t get a blank stare when they see a doctor. So stay tuned for more info as this is launched.

The upshot? The PICL procedure is proving itself to be a game changer. While we know we have much more research to finish to prove our point that most CCJ instability patients don’t need a hyperinvasive surgical fusion, we will begin to share more and more results. Also, we’re launching an entire institute to make sure that CCJ instability patients who want to avoid surgery have a home.

This blog post provides general information to help the reader better understand regenerative medicine, musculoskeletal health, and related subjects. All content provided in this blog, website, or any linked materials, including text, graphics, images, patient profiles, outcomes, and information, are not intended and should not be considered or used as a substitute for medical advice, diagnosis, or treatment. Please always consult with a professional and certified healthcare provider to discuss if a treatment is right for you.

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32 thoughts on “A Case Study of Severe CCJ Instability and Our PICL Procedure

  1. Sam

    Great blog, great patient outcome, great news (CCJ Instability Institute), and cool name (PICL) – Thanks!
    PICL procedure could resolve issues related to strain on PICA …

    1. Regenexx Team

      Hi Sam,
      Thanks! It’s possible…

  2. Janelle W

    This is freaking phenomenal! I am so excited about this announcement, and your dedication to the cause! CCJ issues are just absolutely devastating and it is beyond frustrating to basically have to be your own doctor and research everything and take it to the professionals to then try and get any help. You and your team are amazing! Total angels on earth! Thank you!

    1. Regenexx Team

      Hi Janelle,
      Thankful to be able to help!

  3. DanS

    I 100% second Janelle’s comment. Thank you so much for all your work. The CCJ injuries are truly devastating. It’s also a very lonely injury. Very few doctors understand it and up until you developed this procedure there were really no treatments besides very risky cervical fusions which produced questionable outcomes. Thank you also for starting the CCJ Instability Institute. It’s desperately needed. I live in Canada and there is absolutely zero help and treatment for these injuries here. I wish and really hope that our healthcare system reaches out to you and starts something here. I would be more than happy to be a voice here, a patient advocate, if you are ever looking for for something like that within Canada. I had my first procedure with you in December and even though there is a long and windy road to recovery it gave me hope for which I’m incredibly grateful.

    1. Regenexx Team

      Hi Dan,
      So thankful to be able to help!

  4. Graziella

    Hi, I would like to know if you guys treat kids. My son is 10. He has bordenline cerebellar tonsils and CCI. His clioaxial angle is 128’. He doesn’t have dizziness, balance issues etc. His main symptom is pains, at head, face, eyes, tongue, teeth, nose, ears, mouth, neck, shoulders, arms, fingers, hips, stomach, legs, feet! He says the pains are between 2 and 6 in a scale of 10. Any hope that we can avoid a fusion? Thanks

    1. Regenexx Team

      Unfortunately, your son would not be a Candidate for this procedure, however, once the the CCJ Instability Institute gets up and running, it may have helpful information. This also may be of help: https://asap.org/index.php/resources/local-support-groups/

  5. Ray Nagell

    My daughter Julia has had fantastic results from this procedure and her life has been transformed. While she is still in need of addition treatment, the progress she’s made so far is really remarkable. So glad to see you are rolling out the Institute and taking this to the next level.

    1. Regenexx Team

      Hi Ray,
      Wonderful news! So thankful to be able to help!

  6. Stacey Kaufman

    I am a ccj patient of Dr. Schultz, who is awesome. Only one stem cell Alar procedure so far, and I know this is all so new that we don’t know yet what the prognosis for any of us will be. Would so love it if the clinic would start FB groups for us so we as your patients can compare notes on how much/how fast/how many procedures to see what kind of progress, and to cheer each other on. Would also be awesome if the groups could be broken down by cause of damage, (EDS, car accident….). It would make the daily pain and neurological symptoms easier to endure if we could see that we are on track with each other. Thank you to everyone at Centeno-Schultz for their kindness, dedication and the hope you give us that we can get at least some healing when most of the rest of the medical community dismisses us and/or has no answers for us.

    1. Regenexx Team

      Hi Stacey,
      So thankful to be able to help!

  7. Jan Fost

    Yeah pickle!!

  8. Juan Figueroa

    I was hit from behind and for many years over 20 years I have suffered pain in my neck back shoulders when I first had the access the car hit me from behind I had I had tingling in my arms and my vision was blurred and headaches and head MRIs done and they didn’t find anything and I’ve suffered for over 25 years now pain and only recently I’ve gotten some encouragement with this Chinese herb that I’ve been taking it’s supposed to act on the nervous system and it’s very been working helping to me along with prayer glad to hear that you guys are making some progress in this area

  9. Sue Corrigan Yo

    I am sure this is what I need. I have been having PRP treatment from Dr Newton (Regenexx, Chevy Chase, MD). He is a wonderful doctor, could you train him to do it or give me more information as to whether I am a viable candidate? Plus can you let me know how much is it per treatment.

    1. Regenexx Team

      Hi Sue,
      This treatment is only done in Colorado. We will have the Patient Liaison team contact you to fill you in on the Candidacy Criteria and other details.

  10. Helen

    I was recently diagnosed with ehlers danlos. I was also in a bad car accident 7/2016 and am in great pain from that still pain has spread to my joints throughput my arms and legs but the pain began in c1-c3 i think I got the criteria. Could someone contact me please? The pain has been so bad this past week I’ve begun researching treatment options again as I’ve been bedbound

    1. Regenexx Team

      Hi Helen,
      We will have the Patient Liaison team reach out to you on Monday.

  11. John F. Dorey

    I inherited my 9mm Bi-Lateral C1 C2 overhang after being hit by a impaired driver at 50+ MPH, (80+ MPH kinetic weight, size perpetrator’s vehicle) head on. In Canada physicians etc. intentionally don’t document symptoms. Had I been diagnose based on approved protocol procedures an open mouth X-Ray to reveal uneven Paraodontoid space, sublux etc. would of been done in 2009 instead of Aug. 24th 2009 stopping all tests. Clinically backed procedures that include research here for CCJ Complex instability are badly needed in Canada ASAP as it is a death sentence.

    1. Regenexx Team

      Hi John,
      Sorry to hear of your very long term situation. CCJ Instability can be incredibly debilitating. At the moment, the CCJ Instability procedure, even in the US, is only done in Broomfield, Colorado. Please let us know if you would like to see if you would be a Candidate for this procedure.

    2. Regenexx Team

      Hi John,
      You may find Dr. Centeno’s Blog today interesting as it contains a great deal of new info on CCJ Instability as well as the link to the CCJ Instability Institute: https://regenexx.com/blog/craniocervical-instability-measurements/

  12. Linda

    I was told I need total neck fusion. I assume this means my case is severe…can I do PICL at your office instead of PRP first? Thanks

  13. Monique

    I’ve got two daughters (20/18) who are having a upright MRI wednesday to confirm the diagnoses. Both EDS, both in the same car accident. We’re from Holland. Do you take patiënts from Europe?

    1. Regenexx Team

      Hi Monique,
      The PICL (CCJ Instability) procedure is only done in Broomfield, CO. There is very specific criteria to be a Candidate for this procedure which can sometimes be difficult for International patients to accomplish locally. Please see: https://regenexx.com/blog/candidacy-for-ccj-instability-procedure/ We will contact you next week to see where you are in that process.

    2. Regenexx Team

      Hi Monique,
      This is a new Blog with great new CCJ Instability information: https://regenexx.com/blog/craniocervical-instability-measurements/

  14. Daniel


    I have done an upright MRI which revealed damage and/or laxity of the alar and cruciate ligaments. My symptoms have become incredibly debilitating:

    Generalized malaise, dyspnea at rest, blurry vision, tinnitus, vertigo, nausea, and more.

    Did you guys ever see this kind of dysfunction and resolution via your treatments?

    Thank you, fingers crossed

    1. Regenexx Team

      Hi Daniel,
      We have seen impressive improvements in function. There is very specific Candidacy criteria for this procedure. To see if your particular case would be a candidate, please use the “Are You a Candidate” link at the top right of the page here: https://ccjinstability.com/

  15. anj pat

    Hi, do you have anyone in GA who performs PICL and/or the posterior injections in the neck?

    1. Chris Centeno, MD Post author

      The PICL procedure is Colorado only, Chris Williams may be able to help you with the upper neck posterior injections.

  16. Dan

    I have recently been diagnosed with excess movement/laxity between my C1 and C2 on both sides (worse on the right). This coming after years of neck muscle and other neurological problems. After a disastrous experience with Botox, I was able to reach this potential diagnosis. Now I am in the care of a new neurologist who is planning to inject my c1/c2 facet joints with PRP. I have read on your website that the PICL procedure is meant to yield better results then injecting the posterior facets, but I’m curious if it’s a logical first step to try before jumping on a plane to Colorado. In other words, am I potentially wasting my time?

    1. Chris Centeno, MD Post author

      Dan, if this is true CCI, then injecting the facet joints with PRP is usually only a temporary fix. Also, it’s critical that this doctor inject your joints using contrast and x-ray guidance as described here: https://regenexx.com/blog/ccj-instability-patients-dont-know-doctors-dont-tell/ Hopefully you mean that the doctor is an interventional spine expert as the vast majority of neurologists wouldn’t have the skills needed to safely inject the C1-C2 facet joints.

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