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Craniocervical instability
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== Symptoms == Symptoms of craniocervical instability include occipital [[headache]], [[neck pain]] and [[Nervous system|neurological]] abnormalities such as [[numbness]], [[paresis|motor weakness]], [[dizziness]], and [[gait instability]].<ref>{{Cite journal | last = Bobinski|first = Lukas | last2 = Levivier | first2 = Marc | last3 = Duff | first3 = John M. | date = Feb 2015 | title = Occipitoaxial spinal interarticular stabilization with vertebral artery preservation for atlantal lateral mass failure | url =https://www.ncbi.nlm.nih.gov/pubmed/25415481|journal=Journal of Neurosurgery Spine|volume=22|issue=2 | pages = 134–138|doi=10.3171/2014.10.SPINE14131|issn=1547-5646|pmid=25415481}}</ref><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 = 2245–2254|doi=10.1097/01.BRS.0000029252.98053.43|issn=1528-1159|pmid=12394902}}</ref><ref>{{Cite journal | last = Young|first = Richard M. | last2 = Sherman | first2 = Jonathan H. | last3 = Wind | first3 = Joshua J. | last4 = Litvack | first4 = Zachary | last5 = O'Brien | first5 = Joseph | date = Aug 2014 | title = Treatment of craniocervical instability using a posterior-only approach: report of 3 cases |url =https://www.ncbi.nlm.nih.gov/pubmed/24785968|journal=Journal of Neurosurgery. Spine|volume=21|issue=2 | pages = 239–248|doi=10.3171/2014.3.SPINE13684|issn=1547-5646|pmid=24785968}}</ref><ref>{{Cite journal | last = Botelho|first = Ricardo V. | last2 = Neto | first2 = Eliseu B. | last3 = Patriota | first3 = Gustavo C. | last4 = Daniel | first4 = Jefferson W. | last5 = Dumont | first5 = Paulo A.S. | last6 = Rotta | first6 = José M. | date = Oct 2007 | title = Basilar invagination: craniocervical instability treated with cervical traction and occipitocervical fixation. Case report | url = https://www.ncbi.nlm.nih.gov/pubmed/17933321|journal=Journal of Neurosurgery. Spine|volume=7|issue=4 | pages = 444–449|doi=10.3171/SPI-07/10/444|issn=1547-5654|pmid=17933321}}</ref><ref>{{Cite journal | last = Henderson | first = Fraser C. | last2 = Henderson | first2 = Fraser C. | last3 = Wilson | first3 = William A. | last4 = Mark | first4 = Alexander S. | last5 = Koby | first5 = Myles | date = Jan 2018 | title = Utility of the clivo-axial angle in assessing brainstem deformity: pilot study and literature review | url =https://www.ncbi.nlm.nih.gov/pubmed/28258417|journal=Neurosurgical Review|volume=41|issue=1 | pages = 149–163|doi=10.1007/s10143-017-0830-3|issn=1437-2320|pmc=5748419|pmid=28258417|quote=|via=}}</ref> Patients sometimes describe the feeling that their head is too heavy for their neck to support (“bobble-head”).<ref name=":9" /> No particular symptom is mandatory for a diagnosis of CCI and each symptom listed might have a cause other than CCI. Other symptoms reported in patients with CCI include: * [[Muscle weakness]],<ref name=":0">{{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|volume=92|issue= | pages = 915–936|language=en|doi=10.1007/s10143-018-01070-4|issn=1437-2320}}</ref> [[numbness|numbness,]]<ref name=":1">{{Cite journal | last = Francomano|first = Clair A. | last2 = McDonnell | first2 = Nazli B. | last3 = Nishikawa | first3 = Misao | last4 = Bolognese | first4 = Paolo A. | last5 = Milhorat | first5 = Thomas H. | date = 2007-12-01 | title = Syndrome of occipitoatlantoaxial hypermobility, cranial settling, and Chiari malformation Type I in patients with hereditary disorders of connective tissue | url =https://thejns.org/view/journals/j-neurosurg-spine/7/6/article-p601.xml|journal=Journal of Neurosurgery: Spine|language=en-US|volume=7|issue=6 | pages = 601–609|doi=10.3171/SPI-07/12/601}}</ref><ref name=":2" /> [[paralysis]], [[paresthesia]]s<ref name=":0" /><ref name=":4">{{Cite web | url = https://search.proquest.com/openview/34b3b18a8854c04ffa0fc50273d68313/1?pq-origsite=gscholar&cbl=47886 | title = MRI video diagnosis and surgical therapy of soft tissue trauma to the craniocervical junction - ProQuest | website = search.proquest.com|language=en|access-date=2019-06-01}}</ref><ref name=":5">{{Cite journal | last = Rebbeck|first = Trudy | last2 = Liebert | first2 = Ann | date = 2014-12-01 | title = Clinical management of cranio-vertebral instability after whiplash, when guidelines should be adapted: A case report | url = http://www.sciencedirect.com/science/article/pii/S1356689X14000101|journal=Manual Therapy|volume=19|issue=6 | pages = 618–621|doi=10.1016/j.math.2014.01.009|issn=1356-689X}}</ref><ref name=":6">{{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.jospt.org/doi/full/10.2519/jospt.2011.3305|journal=Journal of Orthopaedic & Sports Physical Therapy|language=en|volume=41|issue=6 | pages = 444–457|doi=10.2519/jospt.2011.3305|issn=0190-6011}}</ref> * Poor [[proprioception]],<ref name=":7">{{Cite journal | last = Bergholm|first = Ulla | last2 = Johansson | first2 = Bengt H. | last3 = Johansson | first3 = Hakan | date = 2004-01-01 | title = New Diagnostic Tools Can Contribute to Better Treatment of Patients with Chronic Whiplash Disorders |url =https://doi.org/10.3109/J180v03n02_02|journal=Journal of Whiplash & Related Disorders|volume=3|issue=2 | pages = 5–19|doi=10.3109/J180v03n02_02|issn=1533-2888}}</ref> [[impaired coordination]], [[gait]] changes<ref name=":0" /><ref name=":7" /> * [[Dizziness]], [[vertigo|vertigo,]]<ref name=":0" /><ref name=":2" /><ref name=":7" /><ref name=":4" /><ref name=":6" /><ref name=":5" /> syncope,<ref name=":0" /><ref name=":1" /><ref name=":2" /><ref name=":7" /> nausea<ref name=":1" /><ref name=":2" /> * [[Tension-type headache|Headache behind the eyes]],<ref name=":6" /> [[stiff neck|neck stiffness]], torticollis,<ref name=":7" /><ref>{{Cite journal | last = Ghanem|first = Ismat | last2 = El Hage | first2 = Samer | last3 = Rachkidi | first3 = Rami | last4 = Kharrat | first4 = Khalil | last5 = Dagher | first5 = Fernand | last6 = Kreichati | first6 = Gabi | date = 2008-03-01 | title = Pediatric cervical spine instability | url = https://online.boneandjoint.org.uk/doi/full/10.1007/s11832-008-0092-2|journal=Journal of Children's Orthopaedics|volume=2|issue=2 | pages = 71–84|doi=10.1007/s11832-008-0092-2|issn=1863-2521|pmc=2656787|pmid=19308585}}</ref> posterior scalp irritation,<ref name=":7" /> [[facial pain]] * Apnea,<ref>{{Cite journal | last = Janjua | first = M. Burhan | last2 = Hwang | first2 = Steven W. | last3 = Samdani | first3 = Amer F. | last4 = Pahys | first4 = Joshua M. | last5 = Baaj | first5 = Ali A. | last6 = Härtl | first6 = Roger | last7 = Greenfield | first7 = Jeffrey P. | date = 2019-01-01 | title = Instrumented arthrodesis for non-traumatic craniocervical instability in very young children | url =https://doi.org/10.1007/s00381-018-3876-9|journal=Child's Nervous System|language=en|volume=35|issue=1 | pages = 97–106|doi=10.1007/s00381-018-3876-9|issn=1433-0350}}</ref><ref name=":1" /><ref name=":3">{{Cite journal | last = Henderson | first = Fraser C. | last2 = Austin | first2 = Claudiu | last3 = Benzel | first3 = Edward | last4 = Bolognese | first4 = Paolo | last5 = Ellenbogen | first5 = Richard | last6 = Francomano | first6 = Clair A. | last7 = Ireton | first7 = Candace | last8 = Klinge | first8 = Petra | last9 = Koby | first9 = Myles | date = 2017 | title=Neurological and spinal manifestations of the Ehlers–Danlos syndromes |url =https://onlinelibrary.wiley.com/doi/abs/10.1002/ajmg.c.31549|journal=American Journal of Medical Genetics Part C: Seminars in Medical Genetics|language=en|volume=175|issue=1 | pages = 195–211|doi=10.1002/ajmg.c.31549|issn=1552-4876}}</ref> [[dyspnea]] (shortness of breath),<ref name=":0" /><ref name=":1" /> and [[dysphagia]] (difficulty swallowing)<ref name=":1" /><ref name=":2" /> * [[visual dysfunction|Visual disturbance]]s<ref name=":4" /> downward [[nystagmus]] (irregular eye movements),<ref name=":1" /><ref name=":7" /> [[tinnitus]]<ref>{{Cite journal | last = Montazem|first = Abbas | authorlink = | date = 2000 | title = Secondary tinnitus as a symptom of instability in the upper cervical spine: Operative management | url = https://www.tinnitusjournal.com/articles/secondary-tinnitus-as-a-symptom-ofinstability-of-the-upper-cervical-spineoperative-management.pdf | journal=International Tinnitus Journal|volume=6|issue=2 | pages = 130-3|pmid=14689631|quote=|via=}}</ref><ref name=":4" /> * [[Fatigue]],<ref name=":0" /><ref name=":14">{{Cite journal | last = Henderson | first = Fraser C. | last2 = Henderson | first2 = Fraser C. | last3 = Wilson | first3 = William A. | last4 = Mark | first4 = Alexander S. | last5 = Koby | first5 = Myles | date = 2018-01-01 | title = Utility of the clivo-axial angle in assessing brainstem deformity: pilot study and literature review | url =https://doi.org/10.1007/s10143-017-0830-3|journal=Neurosurgical Review|language=en|volume=41|issue=1 | pages = 149–163|doi=10.1007/s10143-017-0830-3|issn=1437-2320|pmc=5748419|pmid=28258417}}</ref><ref>{{Cite journal | last = Henderson | first = Fraser C. | last2 = Wilson | first2 = William A. | last3 = Mott | first3 = Stephen | last4 = Mark | first4 = Alexander | last5 = Schmidt | first5 = Kristi | last6 = Berry | first6 = Joel K. | last7 = Vaccaro | first7 = Alexander | last8 = Benzel | first8 = Edward | date = 2010-07-16 | title = Deformative stress associated with an abnormal clivo-axial angle: A finite element analysis |url =https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2940090/|journal=Surgical Neurology International|volume=1|doi=10.4103/2152-7806.66461|issn=2152-7806|pmc=2940090|pmid=20847911}}</ref> [[Sleep dysfunction]],<ref name=":0" /><ref name=":4" /> [[Cognitive dysfunction|cognitive impairment]],<ref name=":4" /> and [[Memory problems|memory loss]].
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