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Craniocervical instability
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=== Measurements === More than twenty radiological measurements have been proposed or used in the diagnosis of CCI. However, three measurements are most commonly used: the [[Grabb-Oakes measurement|Grabb-Oakes]] line, which measures ventral brainstem compression; the [[Clivo-axial angle|Clivo-Axial Angle (CXA)]], which measures brainstem deformity by the [[odontoid]] process; and the Basion Dens Interval, which measures vertical instability ([[cranial settling]]). According to a 2013 consensus statement on the assessment of CCI, a CXA of 135 degrees or less should be considered as "potentially pathological."<ref name=":13">{{Cite web | url = https://bobbyjonescsf.org/csf-video/review-colloq-2014/ | title = REVIEW OF THE 2013 CSF RESEARCH COLLOQUIUM & CONSENSUS ON CRANIOCERVICAL INSTABILITY β Bobby Jones CSF | last = CSF|first = Bobby Jones {{!}}|language=en-US|access-date=2019-09-18}}</ref> as it is reported to be uncommon in the healthy population.<ref>{{Cite journal | last = Batista | first = Ulysses C. | last2 = Joaquim | first2 = Andrei F. | last3 = Fernandes | first3 = Yvens B. | last4 = Mathias | first4 = Roger N. | last5 = Ghizoni | first5 = Enrico | last6 = Tedeschi | first6 = Helder | date = Apr 2015 | title = Computed tomography evaluation of the normal craniocervical junction craniometry in 100 asymptomatic patients |url =https://www.ncbi.nlm.nih.gov/pubmed/25828499|journal=Neurosurgical Focus|volume=38|issue=4| pages = E5|doi=10.3171/2015.1.FOCUS14642|issn=1092-0684|pmid=25828499}}</ref><ref>{{Cite journal | last = Botelho|first = Ricardo Vieira | last2 = Ferreira | first2 = Edson Dener Zandonadi | date = Oct 2013 | title = Angular craniometry in craniocervical junction malformation | url =https://www.ncbi.nlm.nih.gov/pubmed/23640096|journal=Neurosurgical Review|volume=36|issue=4 | pages = 603β610; discussion 610|doi=10.1007/s10143-013-0471-0|issn=1437-2320|pmc=3910287|pmid=23640096}}</ref><ref>{{Cite journal | last = Bundschuh|first = C | last2 = Modic | first2 = Mt | last3 = Kearney | first3 = F | last4 = Morris | first4 = R | last5 = Deal | first5 = C | date = 1988-07-01 | title = Rheumatoid arthritis of the cervical spine: surface-coil MR imaging | url =https://www.ajronline.org/doi/abs/10.2214/ajr.151.1.181|journal=American Journal of Roentgenology|volume=151|issue=1 | pages = 181β187|doi=10.2214/ajr.151.1.181|issn=0361-803X}}</ref> Others have argued that these radiological measurements are "not accepted internationally as indicating instability."<ref name=":19" /> {| class="wikitable" |+ !Measurement !Units !Description ! scope="col" style="width: 75px;" | Normal Range ! scope="col" style="width: 75px;" | Borderline Range ! scope="col" style="width: 75px;" | Pathological Range ! scope="col" style="width: 75px;" | Alternate Ranges !Instability Measured !Pathology Measured !Refs |- |'''Clivo-axial angle (CXA)''' |Degrees |Angle between clivus line and the posterior axial line |170 -150 |149 -136 |β€ 135 | |More sensitive for horizontal |Brainstem deformity |<ref name="Bolognese2014yt">{{Cite web | last = Bolognese | first = Paolo | authorlink = | date = 2014 | title = Videoed Presentation at: ASAP Chiari & Syringomyelia Conference Paolo Bolognese, MD "Complex Chiari. Timecode 14:28 | url = https://www.youtube.com/watch?v=uiyk0Qbx2TQ&t=14m28s | website = YouTube|quote=|via=}}</ref> |- |'''Grabb-Oakes''' |mm |Distance from the dura to the line drawn from the basion to the posterior inferior edge of the C2 vertebra |< 6 |β₯ 6 and < 9 |β₯ 9 |Some use pathological β₯ 8 |More sensitive for horizontal |Brainstem compression |<ref>{{Cite web | last = Bolognese | first = Paolo | authorlink = | date = April 12, 2018 | title = Videoed presentation at: EDS Awareness Educational Series. Timecodes: 49:30 and 53:47 | url = https://www.youtube.com/watch?v=MsYDA3SXTkg&t=49m30s | website = YouTube|quote=|via=}}</ref><ref name=":9" /> |- |'''Basion-Axial Interval (BAI)''' |mm |Distance from tip of basion to posterior axial line |< 12 Β | |β₯ 12 | | | |<ref name=":15">{{Cite web | last = Henderson | first = Fraser | authorlink = | date = | title = Videoed presentation at: Chiari & Syringomyelia Foundation, Patient Conference of Action, June 24, 2018. Timecode: 10:34. | url = https://www.youtube.com/watch?list=WL&v=sEi9AlHQTJc&t=10m34s|journal=|volume=|issue=| pages=|quote=|via=}}</ref> |- |'''Basion-Dens interval (BDI)''' |mm |Vertical distance between the basion and the dens |< 12 | |β₯ 12 |Some use pathological β₯ 10 |Vertical |Cranial settling |<ref name=":15" /><ref name=":9" /> |- |'''Translational BAI''' |mm |Change in BAI between flexion and extension positions of the head |< 1 |β₯ 1 and β€ 2 |> 2 |For surgery > 4 needed |Horizontal |Skull sliding over spine |<ref>{{Cite journal | last = Henderson | first = Fraser C. | last2 = Francomano | first2 = C.A. | last3 = Koby | first3 = M. | last4 = Tuchman | first4 = K. | last5 = Adcock | first5 = J. | last6 = Patel | first6 = S. | date = 2019-01-09 | title = Cervical medullary syndrome secondary to craniocervical instability and ventral brainstem compression in hereditary hypermobility connective tissue disorders: 5-year follow-up after craniocervical reduction, fusion, and stabilization | url =https://doi.org/10.1007/s10143-018-01070-4|journal=Neurosurgical Review|language=en|doi=10.1007/s10143-018-01070-4|issn=1437-2320}}</ref><ref name=":0" /> |- |'''Translational BDI''' |mm |Change in BDI between flexion and extension positions of the head | | | | | | | |- |'''Dynamic BDI''' |mm |Change in BDI value when the head is pulled upward with traction force of typically up to 35 lbs | | | | |Vertical |Cranial settling | |- |'''Dens Over Chamberlain''' |mm |How far tip of the dens extends above Chamberlain's line |< 2 |β₯ 2 and β€ 3 |β₯ 3 | |Vertical |Basilar invagination |<ref>{{Cite web | last = Hain | first = Timothy C. | authorlink = | date = | title = Basilar Invagination, Basilar Impression and Atlantoaxial Subluxation | url =https://www.dizziness-and-balance.com/disorders/central/cerebellar/basilar%20invagination.htm | website = dizziness-and-balance.com|quote=|via=}}</ref>{{citation needed | date = 2022)) |} Some of the measurement ranges in the above table are also to be found in the 2nd International CSF Dynamics Symposium Consensus Statement (2013).<ref name=":13" />
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