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Craniocervical Instability Explained: Symptoms, Causes, and More

Medically Reviewed By:

Dr. Chaz Fausel, MD

Dr. Chaz Fausel is a Denver-based interventional orthopedics specialist and Regenexx educator, trained at Emory and the Centeno-Schultz Clinic.

“Cervical” refers to the neck, and “instability” describes when a joint or spinal segment moves excessively (1). In craniocervical instability (CCI), the strong ligaments that stabilize the junction between the skull and upper cervical spine become lax or stretched (2). These ligaments may include the alar, transverse, accessory, and apical dens ligaments.

Ligaments normally restrict joint motion to prevent damage. When they are stretched or torn, excessive movement may occur, leading to joint strain, neurological symptoms, and, over time, the development of arthritis.

What Causes Craniocervical Instability?

The cervical spine includes seven levels from C0 (the skull) to C7 (base of the neck). These levels rely on ligaments and connective tissue for stability. The most common causes of CCI include:

  • Genetic ligament laxity: Conditions like Ehlers-Danlos Syndrome (EDS) cause abnormal collagen production, making ligaments too stretchy. CCI is more common in these individuals and may worsen with age (3).
  • Trauma: In individuals without genetic laxity, trauma such as car accidents, falls, or neck manipulation may stretch or damage ligaments (4). For those with EDS, trauma can double the risk of developing CCI.
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What Are the Signs and Symptoms of Craniocervical Instability?

Symptoms associated with craniocervical instability may include headaches, upper neck discomfort near the base of the skull, dizziness or imbalance, visual disturbances, brain fog, rapid heart rate, and other related issues. The following provides a closer look at these potential symptoms:

  • Headaches can be caused by a number of tissues, including upper neck joints like C0-C1, C1-C2, or C2-C3 that are injured or arthritic, irritated occipital nerves at the back of the skull, irritated spinal or cranial nerves (5,6), or tendons pulling on the covering of the brain (7).
  • Upper neck pain near the skull is usually caused by the upper neck joints, muscles, and tendons in this area becoming strained due to instability.
  • Dizziness or imbalance is a feature related to the fact that the upper neck is a major contributor to balance (8). The upper neck provides positional sense that coordinates with balance information from the eyes and inner ear.
  • Visual disturbances can happen because the upper neck supplies information to the brain to guide eye position and vice versa (9).
  • Rapid heart rate can happen as the vagus nerve gets irritated by the extra motion where the skull meets the neck.
  • Head Feels Heavy: A sensation of a heavy head with weak neck muscles may result from poor posture, muscle fatigue, or cervical spine instability. It can cause neck discomfort, headaches, and difficulty holding the head upright for extended periods. Read More About Head Feels Heavy.
  • Cervicogenic Headache: A cervicogenic headache originates from the neck due to muscle tension, joint dysfunction, or nerve irritation. It often presents as one-sided head pain, stiffness, and discomfort that worsens with neck movement. Read More About Cervicogenic Headaches.
  • Jugular Vein Compression: Compression of the jugular vein due to craniocervical instability (CCI) may lead to other symptoms such as head pressure, dizziness, brain fog, and visual disturbances. These symptoms may worsen with certain head positions or prolonged upright posture. Read More About Jugular Vein Compression. 
  • Straightening Of The Cervical Lordosis And What May Cause It: The cervical spine normally curves forward in a shape called cervical lordosis. This curve helps distribute weight, absorb shock, and support smooth head and neck movement. When the curve straightens, it may place excess stress on spinal joints, muscles, and… Read More About Straightening Of The Cervical Lordosis And What May Cause It
  • What Could Pain In The Side Of The Neck And Head Mean?: Pain in the side of the neck and head often originates from injuries to joints in the upper neck, called facet joints. Another potential cause is a lesser-known nerve in the neck that supplies these regions. Because this nerve connects… Read More About What Could Pain In The Side Of The Neck And Head Mean?
  • Chronic Nerve Pain: Nerve pain or neuropathic pain occurs when nerves are damaged or malfunctioning, leading to sharp, shooting, or burning sensations. Unlike muscle or joint pain, which originates from physical structures, nerve pain stems from the nervous system. Read More About Chronic Nerve Pain.
  • Tightness In The Side Of The Neck: Tightness along the side of the neck may result from muscle tension, poor posture, or nerve irritation. It can cause stiffness, reduced range of motion, and discomfort, often worsening with prolonged sitting or stress. Read More About Tightness In The Side Of The Neck.

How Is Craniocervical Instability Diagnosed?

Individuals with craniocervical instability generally fall into two categories. A smaller group presents with a significant dislocation of one of the upper cervical vertebrae, which may be identified through imaging such as X-ray, CT scan, or MRI (10). This type of presentation is typically easier to detect and is often diagnosed at an earlier stage.

In contrast, most individuals experience symptoms consistent with craniocervical instability but do not show marked dislocation on standard imaging. As a result, diagnosis in these cases may be delayed, sometimes for months or even years.

For those with symptoms but without clearly dislocated vertebrae, diagnosis is often guided by advanced imaging methods such as the following:

  • Specialized Neck MRI Using a Head Coil:
  • Upright MRI:
  • DMX or Movement-based X-rays:

There are also several different measurements that can be used to make the diagnosis that patients may hear about:

  • Grabb-Oakes measurement:
  • Powers Ratio:

Treatment Options That May Help Manage Craniocervical Instability

As noted earlier, most individuals with craniocervical instability do not exhibit severe dislocations of the upper cervical spine that would necessitate immediate surgical intervention. In cases where significant dislocation is present, surgical fusion may be required (11). 

However, many individuals experience milder forms of instability that may still interfere with movement or daily activities, but can often be managed through non-surgical approaches such as:

  • Upper cervical low-force chiropractic (NUCCA)
  • Physical therapy or exercises focused on CCI exercises
  • Bracing
  • Curve restoration therapy (CBP)
  • Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): Nonsteroidal anti-inflammatory drugs (NSAIDs) help reduce pain and inflammation in conditions affecting joints, muscles, and the spine. While they provide temporary relief, prolonged use may increase heart, kidney, and gastrointestinal risks, requiring careful management. Read More About NSAIDs.
  • C0-C1 Facet Injectates: A C0-C1 facet injection delivers medication into the uppermost spinal facet joint, located between the skull and first cervical vertebra. It may help reduce inflammation and discomfort. Read More About C0-C1 Facet Injectates.

What To Know About Surgical Fusion 

Many different surgical fusion options involve connecting upper neck bones or the skull. These procedures may be considered in certain cases when other treatments have not been effective.

However, based on clinical observations, these surgeries may carry a higher risk of complications. Reported issues after fusion may include:

  • Arthritis or pain near the fused area
  • Hardware affecting nearby joints or nerves
  • Incomplete bone fusion between vertebrae

The Regenexx Approach For A Less Invasive Option 

If initial conservative treatments offer limited relief, the next level of care may involve targeted cervical ligament injections or upper cervical facet injections (12). In cases where individuals do not respond to these measures, another option may include the PICL procedure, which involves the precise, image-guided injection of the alar, transverse, and accessory ligaments.

This procedure uses the Regenexx SD injectate, prepared using Regenexx lab processes, and is performed by physicians within the licensed network. The goal of this approach is to support the body’s natural healing response by addressing ligament instability at the craniocervical junction.

Take A More Informed Approach To Managing Your Condition

In some cases, when other less invasive procedures have not provided sufficient relief, surgical fusion may be considered as a treatment option. For certain individuals, it may offer meaningful improvements in symptoms and stability when carefully selected and performed.

To learn more about additional non-surgical options that may help support craniocervical stability, including the PICL procedure using Regenexx lab processes, click here.

References

(1) Klein GN, Mannion AF, Panjabi MM, Dvorak J. Trapped in the neutral zone: another symptom of whiplash-associated disorder?. Eur Spine J. 2001;10(2):141–148. doi:10.1007/s005860100248

(2) Offiah CE, Day E. The craniocervical junction: embryology, anatomy, biomechanics and imaging in blunt trauma. Insights Imaging. 2017;8(1):29–47. doi:10.1007/s13244-016-0530-5

(3) Castori M, Voermans NC. Neurological manifestations of Ehlers-Danlos syndrome(s): A review. Iran J Neurol. 2014;13(4):190–208.

(4) Yang SY, Boniello AJ, Poorman CE, Chang AL, Wang S, Passias PG. A review of the diagnosis and treatment of atlantoaxial dislocations. Global Spine J. 2014;4(3):197–210. doi:10.1055/s-0034-1376371

(5) Hall T, Briffa K, Hopper D. Clinical evaluation of cervicogenic headache: a clinical perspective. J Man Manip Ther. 2008;16(2):73–80. doi:10.1179/106698108790818422

(6) Antonaci F, Bono G, Chimento P. Diagnosing cervicogenic headache. J Headache Pain. 2006;7(3):145–148. doi:10.1007/s10194-006-0277-3

(7) Enix DE, Scali F, Pontell ME. The cervical myodural bridge, a review of literature and clinical implications. J Can Chiropr Assoc. 2014;58(2):184–192.

(8) Thompson-Harvey A, Hain TC. Symptoms in cervical vertigo. Laryngoscope Investig Otolaryngol. 2018;4(1):109–115. Published 2018 Nov 28. doi:10.1002/lio2.227

(9) Ischebeck BK, de Vries J, Van der Geest JN, et al. Eye movements in patients with Whiplash Associated Disorders: a systematic review. BMC Musculoskelet Disord. 2016;17(1):441. Published 2016 Oct 21. doi:10.1186/s12891-016-1284-4

(10) Radcliff K, Kepler C, Reitman C, Harrop J, Vaccaro A. CT and MRI-based diagnosis of craniocervical dislocations: the role of the occipitoatlantal ligament. Clin Orthop Relat Res. 2012;470(6):1602–1613. doi:10.1007/s11999-011-2151-0

(11) Joaquim AF, Patel AA. Craniocervical traumatic injuries: evaluation and surgical decision making. Global Spine J. 2011;1(1):37–42. doi:10.1055/s-0031-1296055

(12) Centeno CJ1, Elliott J, Elkins WL, Freeman M. Fluoroscopically guided cervical prolotherapy for instability with blinded pre and post radiographic reading. Pain Physician. 2005 Jan;8(1):67-72. https://www.ncbi.nlm.nih.gov/pubmed/16850045

Medically Reviewed By:

Dr. Chaz Fausel, MD

Dr. Chaz Fausel is a Denver-based interventional orthopedics specialist and Regenexx educator, trained at Emory and the Centeno-Schultz Clinic.
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