New Craniocervical Instability Book!
Craniocervical Instability or CCI is one one the most confusing topics in medicine to research online. Why? There are only a few pockets of information that all appear to be diametrically opposed to each other. Hence, like I’ve done a few times now, I wrote a book to try and get good information all in one place.
What Is CCI?
CCI means that the ligaments that hold the head on are injured and loose. It’s can happen due to trauma or congenital loose ligament disorders like EDS. Many of these patients end up with high-risk upper neck fusions and other surgeries. This new book is written to explore all of the options for treating this problem, including the new orthobiologic solutions that I developed (the PICL procedure) and have perfected with the help of my colleagues at the Centeno-Schultz Clinic in Colorado.
Here’s the link to the new book: https://centenoschultz.com/cci-101/
Here’s the forward from the new book:
Forward and History
Way back when, when I was a young doctor with brown hair (it’s grey now) and more enthusiasm than common sense, I had a patient who was different. She had headaches, but also dizziness and brain fog. In looking through the chart, I saw an ENG study by a local audiologist Ed Jacobsen, Ph.D., so I called him and that began an odyssey that ultimately led to a new way to treat CCI.
The audiologist I met that day told me about patients he was seeing for dizziness and imbalance that his ENG tests told him had neck issues as the cause. I hadn’t really heard about anything like that, but after some on-line research (back then you had to have software to search the National Library of medicine), I saw that he was right. This neck and balance connection went way back to the 1920s when two physicians (Barre and Lieou), one French and one Chinese, independently described the syndrome. At the time they thought that this collection of symptoms which included headaches, imbalance, brain fog and other things was caused by damage to the cervical sympathetic chain (posterior cervical sympathetic syndrome). However, what Barre and Lieou are now credited for is figuring out that headaches and other symptoms can come from the neck.
The next big advance in neck and balance came during NASA research in the 1960s as scientists tried to figure out what damage to the front neck muscles would do to astronauts exposed to levels of acceleration never before experienced by humans. They began to cut the sternocleidomastoid muscles of primates and found that the monkeys lost their balance and would bang into walls.
Then in the 1990s, a new procedure to help neck pain was developed called radiofrequency ablation. The procedure used a radiofrequency probe placed using x-ray guidance to burn the nerves taking pain from the neck joints and reduce neck pain. However, when the early doctors began to treat the C2-C3 joint in the neck, some patients got permanently dizzy. While later advancements in the technique solved this issue, the upper neck was now firmly implicated in balance.
After confirming what Dr. Jacobsen had told me I soon began treating the upper necks of these patients who had whiplash injuries and also had headaches and dizziness. At first with simple muscle trigger point injections and then with upper neck facet injections into the C2-C3 neck joints. Many of them got better. Hence, as more physicians and colleagues learned that this was becoming an area of expertise for our clinic, they referred more of these patients.
However, in this group of patients, we had some people who never got better. When a local chiropractor, Evan Katz came to Boulder and began using a DMX (Digital Motion X-ray), we both began to see that these were those patients who had excessive motion due to damaged upper neck ligaments. Hence, my interest in craniocervical instability (CCI) was born. While more aggressively treating the posterior ligaments helped a bit, most remained largely untreatable.
What was available to these patients? First, many were often bounced from specialist to specialist without answers or any diagnosis. Second, almost all of them would flare up in physical therapy, so many physicians would blame the lack of progress on that patient’s lack of effort. Finally, the few that got a diagnosis were just beginning to be offered upper neck fusion, a procedure that in the past would have only been offered to those with neck fractures or severe life-threatening dislocations of the upper neck bones.
Then one day in 2013, I began to play with a model we had of the upper neck bones and ligaments. I literally had it on my desk and would look at it periodically to see if we could access these ligaments. While some of my spinal interventionalist colleagues thought it might be possible to access the ligaments that hold the head on (alar and transverse) from the back, after trying this in a few patients I concluded that it couldn’t be done safely as the spinal cord was in the way. It then dawned on me that injections from the front might work as there was a tiny bony tunnel between the C1 and C2 vertebrae.
I then spent months reviewing the anatomy of this area to make sure we wouldn’t injure someone and going back and forth with experts on this issue. I tried my first patients in 2015 and by 2016 had enough dialed in that we were starting to see amazing results in these formerly untreatable patients. We added many procedural improvements as the years went on and the rest as they say, is history.
I’ve written this book to help CCI patients. My goal is to go over everything they need to know about all of their options. So, I’ll cover anatomy, diagnosis, conservative care, surgery, and the procedure we developed. Why take the time to do this as a busy physician? Because patients who know more, in my experience, are the ones that can successfully navigate our medical system to get the best possible results.
However, please realize that in writing this book, I’ve also tried to “thread the needle” between a patient book and one with enough detail so that patients can give it to their physicians. Why? There is still a serious and devastating lack of knowledge on CCI and this adversely impacts patients in all sorts of ways. Hence, oftentimes patients need a resource that they can hand to their doctors so that the physician can understand what’s wrong with the patient.