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Craniocervical instability
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== Risk factors and comorbidities == Established risk factors for CCI include physical [[trauma]], infection, [[inflammation|inflammatory]] disease, neoplasms and congenital disorders.<ref name=":10" /><ref name=":12">{{Cite journal | last = Sapkas | first = George | last2 = Papadakis | first2 = Stamatios A | last3 = Segkos | first3 = Dimitrios | last4 = Kateros | first4 = Konstantinos | last5 = Tsakotos | first5 = George | last6 = Katonis | first6 = Pavlos | date = 2011-06-02 | title = Posterior Instrumentation for Occipitocervical Fusion | url =https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3139273/|journal=The Open Orthopaedics Journal|volume=5 | pages = 209β218|doi=10.2174/1874325001105010209|issn=1874-3250|pmc=3139273|pmid=21772931}}</ref> More recently, physicians have reported an increased prevalence of CCI in patients with hereditary [[connective tissue disorder]]s.<ref name=":9" /> According to Brodbelt & Flint, however, an "increased range of joint movement, caused by ligamentous laxity, is not the same as [[spinal instability]] resulting from trauma or major inflammatory arthropathies such as (historically) [[rheumatoid arthritis]]."<ref name=":19">{{Cite journal | last = Brodbelt | first = Andrew R. | last2 = Flint | first2 = Graham | date = Aug 2017 | title = Ehlers Danlos, complex Chiari and cranio-cervical fixation: how best should we treat patients with hypermobility? | url = https://www.ncbi.nlm.nih.gov/pubmed/28961036|journal=British Journal of Neurosurgery|volume=31|issue=4 | pages = 397β398|doi=10.1080/02688697.2017.1386282|issn=1360-046X|pmid=28961036|pmc=|quote=|via=}}</ref> Others have argued that "pathological instability at the cranio-cervical junction has not been clearly established in the literature for the [[joint hypermobility]] population."<ref name=":9" /> {| class="wikitable" |'''Cause of instability''' |'''Example''' |- |Physical trauma<ref>{{Cite journal | last = Ghatan | first = Saadi | last2 = Newell | first2 = David W. | last3 = Grady | first3 = M. Sean | last4 = Mirza | first4 = Sohail K. | last5 = Chapman | first5 = Jens R. | last6 = Mann | first6 = Frederick A. | last7 = Ellenbogen | first7 = Richard G. | date = Aug 2004 | title = Severe posttraumatic craniocervical instability in the very young patient. Report of three cases |url =https://www.ncbi.nlm.nih.gov/pubmed/16206980|journal=Journal of Neurosurgery|volume=101|issue=1 Suppl | pages = 102β107|doi=10.3171/ped.2004.101.2.0102|issn=0022-3085|pmid=16206980}}</ref> |Car accident<ref>{{Cite journal | last = Uribe | first = Juan S. | last2 = Ramos | first2 = Edwin | last3 = Baaj | first3 = Ali | last4 = Youssef | first4 = A. Samy | last5 = Vale | first5 = Fernando L. | date = Dec 2009 | title = Occipital cervical stabilization using occipital condyles for cranial fixation: technical case report | url = https://www.ncbi.nlm.nih.gov/pubmed/19934947|journal=Neurosurgery|volume=65|issue=6| pages = E1216β1217; discussion E1217|doi=10.1227/01.NEU.0000349207.98394.FA|issn=1524-4040|pmid=19934947}}</ref><ref>{{Cite journal | last = Volle | first = E. | last2 = Montazem | first2 = A. | date = Jan 2001 | title = MRI video diagnosis and surgical therapy of soft tissue trauma to the craniocervical junction | url =https://www.ncbi.nlm.nih.gov/pubmed/11209518|journal=Ear, Nose, & Throat Journal|volume=80|issue=1 | pages = 41β44, 46β48|issn=0145-5613|pmid=11209518}}</ref>, blow to the head.<ref>{{Cite journal | last = Mathers | first = K. Sean | last2 = Schneider | first2 = Michael | last3 = Timko | first3 = Michael | date = Jun 2011 | title = Occult hypermobility of the craniocervical junction: a case report and review | url =https://www.ncbi.nlm.nih.gov/pubmed/21628827|journal=The Journal of Orthopaedic and Sports Physical Therapy|volume=41|issue=6 | pages = 444β457|doi=10.2519/jospt.2011.3305|issn=1938-1344|pmid=21628827}}</ref> |- |Infection & inflammatory disease |Upper respiratory infection<ref name=":21">{{Cite journal | last = Hettiaratchy|first = Shehan | last2 = Ning | first2 = Chou | last3 = Sabin | first3 = Ian | date = 1998-07-01 | title = Nontraumatic Atlanto-occipital and Atlantoaxial Rotatory Subluxation: Case Report | url = https://academic.oup.com/neurosurgery/article/43/1/162/2856810|journal=Neurosurgery|language=en|volume=43|issue=1 | pages = 162β164|doi=10.1097/00006123-199807000-00110|issn=0148-396X}}</ref><ref name=":22">{{Cite journal | last = Washington | first = Eleby R. | date = Mar 1959 | title = Non-Traumatic Atlanto-Occipital and Atlanto-Axial Dislocation: A Case Report | url = https://journals.lww.com/jbjsjournal/Citation/1959/41020/Non_Traumatic_Atlanto_Occipital_and_Atlanto_Axial.15.aspx|journal=JBJS|language=en-US|volume=41|issue=2 | pages = 341β344|issn=0021-9355}}</ref>, Rheumatoid arthritis<ref>{{Cite journal | last = O'Brien | first = Michael F. | last2 = Casey | first2 = Adrian T.H. | last3 = Crockard | first3 = Alan | last4 = Pringle | first4 = Jean | last5 = Stevens | first5 = John M. | date = 2002-10-15 | title = Histology of the craniocervical junction in chronic rheumatoid arthritis: a clinicopathologic analysis of 33 operative cases |url =https://www.ncbi.nlm.nih.gov/pubmed/12394902|journal=Spine|volume=27|issue=20 | pages = 2245β2254|doi=10.1097/01.BRS.0000029252.98053.43|issn=1528-1159|pmid=12394902}}</ref>, tuberculosis<ref name=":23">{{Cite journal | last = Chaudhary|first = Kshitij | last2 = Potdar | first2 = Prabodhan | last3 = Bapat | first3 = Mihir | last4 = Rathod | first4 = Ashok | last5 = Laheri | first5 = Vinod | date = 2012-06-15 | title = Structural odontoid lesions in craniovertebral tuberculosis: a review of 15 cases |url =https://www.ncbi.nlm.nih.gov/pubmed/22261632|journal=Spine|volume=37|issue=14| pages = E836β843|doi=10.1097/BRS.0b013e31824a4c8f|issn=1528-1159|pmid=22261632}}</ref> |- |Neoplasms |Tumors<ref name=":12" /> such as haemangioma, aneurysmal bone cyst |- |Congenital |Downβs syndrome<ref>{{Cite journal | last = Hankinson | first = Todd C. | last2 = Anderson | first2 = Richard C.E. | date = Mar 2010 | title = Craniovertebral junction abnormalities in Down syndrome | url =https://www.ncbi.nlm.nih.gov/pubmed/20173525|journal=Neurosurgery|volume=66|issue=3 Suppl | pages = 32β38|doi=10.1227/01.NEU.0000365803.22786.F0|issn=1524-4040|pmid=20173525}}</ref>, osΒ odontoideum<ref>{{Cite journal | last = Zhao|first = Deng | last2 = Wang | first2 = Shenglin | last3 = Passias | first3 = Peter G. | last4 = Wang | first4 = Chao | date = May 2015 | title = Craniocervical instability in the setting of os odontoideum: assessment of cause, presentation, and surgical outcomes in a series of 279 cases |url =https://www.ncbi.nlm.nih.gov/pubmed/25635883|journal=Neurosurgery|volume=76|issue=5 | pages = 514β521|doi=10.1227/NEU.0000000000000668|issn=1524-4040|pmid=25635883}}</ref>, dwarfism |- |Hereditary connective tissue disorder |Ehlers Danlos Syndromes<ref name=":0" /><ref name=":1" /> |- |Fluoroquinolones |Connective tissue weakening<ref name=":20">{{Cite journal | last = Etminan | first = M. | authorlink = | last2 = Sodhi | first2 = M. | authorlink2 = | last3 = Ganjizadeh-Zavareh | first3 = S. | author-link3 = | last4 = Carleton | first4 = B. | author-link4 = | last5 = Kezouh | first5 = A. | author-link5 = | last6 = Brophy | first6 = J.M. | author-link6 = | date = 2019-09-17 | title = Oral Fluoroquinolones and Risk of Mitral and Aortic Regurgitation | url =https://www.sciencedirect.com/science/article/pii/S0735109719359789|journal=Journal of the American College of Cardiology|language=en|volume=74|issue=11 | pages = 1444β1450|doi=10.1016/j.jacc.2019.07.035|issn=0735-1097|pmc=|pmid=|access-date=|quote=|via=}}</ref><ref>{{Cite journal | last = Demetrious | first = James S. | date = 2018-07-09 | title = Spontaneous cervical artery dissection: a fluoroquinolone induced connective tissue disorder? | url = https://doi.org/10.1186/s12998-018-0193-z|journal=Chiropractic & Manual Therapies|volume=26|issue=1 | pages = 22|doi=10.1186/s12998-018-0193-z|issn=2045-709X}}</ref>, tendon ruptures<ref>{{Cite journal | last = Stephenson | first = Anne L. | last2 = Wu | first2 = Wei | last3 = Cortes | first3 = Daniel | last4 = Rochon | first4 = Paula A. | date = Sep 2013 | title = Tendon Injury and Fluoroquinolone Use: A Systematic Review | url =https://pubmed.ncbi.nlm.nih.gov/23888427/#|journal=Drug Safety|volume=36|issue=9 | pages = 709β721|doi=10.1007/s40264-013-0089-8|issn=1179-1942|pmid=23888427}}</ref> |} It is not unusual for CCI to co-occur with other structural neurological abnormalities such as [[atlantoaxial instability]] (AAI) and [[chiari malformation]] (CM).<ref>{{Cite journal | last = Camino Willhuber | first = Gaston O. | last2 = Bosio | first2 = Santiago T. | last3 = Puigdevall | first3 = Miguel H. | last4 = Halliburton | first4 = Carolina | last5 = Sola | first5 = Carlos A. | last6 = Maenza | first6 = Ruben A. | date = Jan 2017 | title = Craniocervical spinal instability after type 1 Arnold Chiari decompression: a case report | url = https://www.ncbi.nlm.nih.gov/pubmed/27258364|journal=Journal of Pediatric Orthopedics. Part B|volume=26|issue=1 | pages = 80β85|doi=10.1097/BPB.0000000000000346|issn=1473-5865|pmid=27258364}}</ref><ref name=":0" />
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