Craniocervical instability: Difference between revisions

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CCI usually develops as a result of physical trauma such as a car accident, an inflammation disease such as rheumatoid arthritis or a congenital disorder such as Down syndrome.<ref name=":10">{{Cite journal|last=Ashafai|first=Nabeel S.|last2=Visocchi|first2=Massimiliano|last3=Wąsik|first3=Norbert|date=2019|title=Occipitocervical Fusion: An Updated Review|url=https://www.ncbi.nlm.nih.gov/pubmed/30610329|journal=Acta Neurochirurgica. Supplement|volume=125|pages=247–252|doi=10.1007/978-3-319-62515-7_35|issn=0065-1419|pmid=30610329}}</ref> More recently, physicians have recognized an increased prevalence of CCI in patients with hereditary disorders of connective tissue such as Ehlers Danlos Syndromes (EDS).<ref name=":9">{{Cite web|url=https://www.researchgate.net/publication/302923107_Cranio-cervical_Instability_in_Patients_with_Hypermobility_Connective_Disorders|title=(PDF) Cranio-cervical Instability in Patients with Hypermobility Connective Disorders|website=ResearchGate|language=en|access-date=2019-06-03}}</ref> There have also been anecdotal reports of patients with myalgic encephalomyelitis/chronic fatigue sydrome (ME/CFS) who were diagnosed with CCI <ref>{{Cite web|url=https://forums.phoenixrising.me/index.php?threads/have-you-ruled-out-chiari-as-a-cause-of-your-cfs.56908/|title=Have you ruled out Chiari as a cause of your CFS|last=|first=|date=|website=Phoenix Rising|archive-url=|archive-date=|dead-url=|access-date=}}</ref><ref>{{Cite web|url=https://rsci.app.link/3LpJOxcTaX?_p=f3542c5bfc29c2616780177b27|website=rsci.app.link|access-date=2019-06-01}}</ref>, although no scientific publication on this subject exists.
CCI usually develops as a result of physical trauma such as a car accident, an inflammation disease such as rheumatoid arthritis or a congenital disorder such as Down syndrome.<ref name=":10">{{Cite journal|last=Ashafai|first=Nabeel S.|last2=Visocchi|first2=Massimiliano|last3=Wąsik|first3=Norbert|date=2019|title=Occipitocervical Fusion: An Updated Review|url=https://www.ncbi.nlm.nih.gov/pubmed/30610329|journal=Acta Neurochirurgica. Supplement|volume=125|pages=247–252|doi=10.1007/978-3-319-62515-7_35|issn=0065-1419|pmid=30610329}}</ref> More recently, physicians have recognized an increased prevalence of CCI in patients with hereditary disorders of connective tissue such as Ehlers Danlos Syndromes (EDS).<ref name=":9">{{Cite web|url=https://www.researchgate.net/publication/302923107_Cranio-cervical_Instability_in_Patients_with_Hypermobility_Connective_Disorders|title=(PDF) Cranio-cervical Instability in Patients with Hypermobility Connective Disorders|website=ResearchGate|language=en|access-date=2019-06-03}}</ref> There have also been anecdotal reports of patients with myalgic encephalomyelitis/chronic fatigue sydrome (ME/CFS) who were diagnosed with CCI <ref>{{Cite web|url=https://forums.phoenixrising.me/index.php?threads/have-you-ruled-out-chiari-as-a-cause-of-your-cfs.56908/|title=Have you ruled out Chiari as a cause of your CFS|last=|first=|date=|website=Phoenix Rising|archive-url=|archive-date=|dead-url=|access-date=}}</ref><ref>{{Cite web|url=https://rsci.app.link/3LpJOxcTaX?_p=f3542c5bfc29c2616780177b27|website=rsci.app.link|access-date=2019-06-01}}</ref>, although no scientific publication on this subject exists.
== Symptoms ==
== Symptoms ==
Characteristic symptoms of craniocervical instability include severe headache, neck pain and neurological abnormalities such as numbness, motor weakness, dizziness, and gait instability. <ref>{{Cite journal|last=Bobinski|first=Lukas|last2=Levivier|first2=Marc|last3=Duff|first3=John M.|date=2015-2|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=2014-8|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=2007-10|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=2018-1|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=PMCPMC5748419|pmid=28258417}}</ref> Patients frequently describe pain at the lower back of the head and 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.  
Characteristic symptoms of craniocervical instability include headache, neck pain and neurological abnormalities such as numbness, motor weakness, dizziness, and gait instability. <ref>{{Cite journal|last=Bobinski|first=Lukas|last2=Levivier|first2=Marc|last3=Duff|first3=John M.|date=2015-2|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=2014-8|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=2007-10|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=2018-1|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=PMCPMC5748419|pmid=28258417}}</ref> Patients frequently describe pain at the lower back of the head and 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.  


Other symptoms of CCI include:
Other symptoms of CCI include:

Revision as of 18:24, June 6, 2019

Craniocervical instability (CCI) is a pathological condition of increased mobility at the craniocervical junction, the area where the skull meets the spine. In CCI the ligamentous connections of the craniocervical junction can be stretched, weakened or ruptured.[1] This can lead to compression of the brainstem, upper spinal cord, or cerebellum and result in myelopathy, disabling neck pain and a range of other symptoms.[2]

CCI usually develops as a result of physical trauma such as a car accident, an inflammation disease such as rheumatoid arthritis or a congenital disorder such as Down syndrome.[3] More recently, physicians have recognized an increased prevalence of CCI in patients with hereditary disorders of connective tissue such as Ehlers Danlos Syndromes (EDS).[4] There have also been anecdotal reports of patients with myalgic encephalomyelitis/chronic fatigue sydrome (ME/CFS) who were diagnosed with CCI [5][6], although no scientific publication on this subject exists.

Symptoms[edit | edit source]

Characteristic symptoms of craniocervical instability include headache, neck pain and neurological abnormalities such as numbness, motor weakness, dizziness, and gait instability. [7][8][9][10][11] Patients frequently describe pain at the lower back of the head and the feeling that their head is too heavy for their neck to support (“bobble-head”).[4] No particular symptom is mandatory for a diagnosis of CCI.

Other symptoms of CCI include:

Risk factors and comorbidities[edit | edit source]

Established risk factors for CCI include physical trauma, inflammatory disease, congenital disorders, neoplasms and hereditary hypermobility connective tissue disorders.[3][24]

Cause of instability Example
Physical trauma[25] Car accident[26][27], blow to the head.[28]
Inflammatory disease Rheumatoid arthritis[29], tuberculosis[30]
Neoplasms Tumors[24] such as haemangioma, aneurysmal bone cyst
Congenital Down’s syndrome[31], os odontoideum[32], dwarfism
Hereditary hypermobility connective tissue disorders Ehlers Danlos Syndromes[12][13]

It is not unusual for CCI to co-occur with other structural neurological abnormalities such as atlantoaxial instability (AAI) and chiari malformation (CM).[33][12]

Diagnosis[edit | edit source]

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The diagnosis of CCI is based on symptom presentation, a supportive history, demonstrable neurological findings and abnormal imaging.

Imaging[edit | edit source]

CCI is typically diagnosed via a cervical MRI, whether supine or upright. If supine, a 3 Tesla MRI is preferred over a 1.5 Tesla. Most neurosurgeons prefer upright MRI with flexion and extension.[34] According to Henderson FC, “ventral brainstem compression may exist in flexion of the cervical spine, but appear normal on routine imaging.”[4]

Measurements[edit | edit source]

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 line, which measures focal compression; the Clivo-Axial Angle (CXA), which measures brainstem deformity by the odontoid process; and the Basion Dens Interval, which measures vertical instability (cranial settling). Acorrding to a 2013 consensus statement on the assessment of CCI a CXA of 135 degrees or less should be considered as "potential pathological."[35]

Traction[edit | edit source]

Manual traction and invasive cervical traction are often used to aid in the diagnosis of CCI. Symptomatic improvement with traction can help determine whether a patient will benefit from craniocervical fusion surgery.

Treatment[edit | edit source]

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Conservative treatment[edit | edit source]

Treatment of CCI can include “conservative measures” such as rest, pain management, bracing with a cervical collar, or physical therapy to strengthen neck muscles.[36] Many conservative therapies have little to no supporting evidence of efficacy.

There is no evidence for the efficacy of experimental treatments for CCI such as prolotherapy and upper cervical chiropractic.

Surgery[edit | edit source]

When non-invasive treatments for CCI fail to work, occipito-cervical fusion (OCF) can be considered.[12] OCF is a surgery that aims at a biomechanical stabilization of the craniocervical junction. Patients with objective radiological findings, a clinical picture supportive of the diagnosis, a positive response to traction, and who are significantly impaired may be candidates for this surgery. Different surgical procedures for OCF exist, but the current standard involves internal fixation of the upper spine by mechanical screws. Surgery typically involves using titanium hardware to fixate the occiput, axis and atlas (i.e., C0 to C2) along with rib graft or cadaver bone graft. When cervical instability is present below C2, additional vertebrae may also be fused if the patient is symptomatic.

Risks and complications[edit | edit source]

The outcome of OCF is generally favorable with most patients experiencing symptom relief post-surgery.[12] The complications of OCF however can be serious[37] and occur in an estimated 10% to 33% of patients.[3][38][2][39] Common complications include screw failure, wound infection, dural tear and cerebrospinal fluid leakage[2] In some cases revision surgery is needed to treat infection or to remove hardware. Severe complications include meningitis and accidental injury of the vertebral artery by misplaced screws.

Side effects[edit | edit source]

OCF causes a substantial reduction in the neck’s range of motion, estimated at approximately 40% of total cervical flexion–extension.[40]

Cost[edit | edit source]

OCF is estimated to cost tens of thousands of dollars, although some insurance schemes fully cover the cost of surgery depending on the country located and neurosurgeons involved.

Dysautonomia and CCI in EDS[edit | edit source]

As CCI might lead to a compression of the brain stem, some researchers speculate this might cause some of the autonomic symptoms such as tachycardia and orthostatic intolerance that are frequently seen in patients with Ehlers Danlos Syndromes (EDS). In a 2007 influential paper Milhorat et al. followed-up on patients with Chiari malformation who did not improve with treatment and surgery. The authors discovered that many of these patients suffered from EDS and had other structural abnormalities at the upper spine such as CCI and cranial settling. Milhorat et al. speculated that the resulting compression of the brainstem might be the cause of the autonomic and other symptoms these patients were suffering from.[41] In conference presentations, neurosurgeons have indicated that they think CCI can cause dysautonomia symptoms such as postural orthostatic tachycardia sydrome (POTS) [42] [OTHER REFERENCE NEEDED].

Henderson et al. tested this theory by following 20 CCI patients with comorbid Chiari Malformation and hereditary hypermobility connective tissue disorders for a period of 5 years after OCF-surgery. Patients were satisfied with the surgery and experienced significant improvements in some CCI-related symptoms such as vertigo, headaches, imbalance, dysarthria dizziness or frequent daytime urination. There was however only a small increase in objective outcomes such as work resumption with 60% of patients remaining unable to work or go to school. Participants attributed this to other medical problems related to EDS such as musculoskeletal pain, fatigue, gastrointestinal issues and POTS, indicating these were not significantly improved after OCF-surgery.[12]

Mechanical basis theory[edit | edit source]

Five ME/CFS patients diagnosed with CCI report to have experienced spectacular improvements and even remission of their ME/CFS symptoms following OCF-surgery. Some of them have dual diagnosis of EDS.[43][44] They speculate that mechanical compression of the brainstem due to CCI has the potential to cause characteristic ME/CFS symptoms such as post-exertional malaise[45], although this theory is currently not supported by scientific evidence. The current literature does not suggest a connection between ME/CFS and CCI. Others have raised concerns about CCI surgery in patients with ME/CFS given the lack of research on OCF in this patient population.[46]

Synonyms[edit | edit source]

  • Syndrome of Occipitoatlantialaxial Hypermobility[13]
  • Hypermobility of the Craniocervical Junction[47]

See also[edit | edit source]

Learn more[edit | edit source]

References[edit | edit source]

  1. 1.0 1.1 1.2 1.3 1.4 1.5 Henderson, Fraser C.; Austin, Claudiu; Benzel, Edward; Bolognese, Paolo; Ellenbogen, Richard; Francomano, Clair A.; Ireton, Candace; Klinge, Petra; Koby, Myles (2017). "Neurological and spinal manifestations of the Ehlers–Danlos syndromes". American Journal of Medical Genetics Part C: Seminars in Medical Genetics. 175 (1): 195–211. doi:10.1002/ajmg.c.31549. ISSN 1552-4876.
  2. 2.0 2.1 2.2 Lua error in Module:Citation/CS1/Identifiers at line 1131: attempt to index local 'id' (a nil value).
  3. 3.0 3.1 3.2 Ashafai, Nabeel S.; Visocchi, Massimiliano; Wąsik, Norbert (2019). "Occipitocervical Fusion: An Updated Review". Acta Neurochirurgica. Supplement. 125: 247–252. doi:10.1007/978-3-319-62515-7_35. ISSN 0065-1419. PMID 30610329.
  4. 4.0 4.1 4.2 "(PDF) Cranio-cervical Instability in Patients with Hypermobility Connective Disorders". ResearchGate. Retrieved June 3, 2019.
  5. "Have you ruled out Chiari as a cause of your CFS". Phoenix Rising. Cite has empty unknown parameter: |dead-url= (help)
  6. rsci.app.link https://rsci.app.link/3LpJOxcTaX?_p=f3542c5bfc29c2616780177b27. Retrieved June 1, 2019. Missing or empty |title= (help)
  7. Bobinski, Lukas; Levivier, Marc; Duff, John M. (2015-2). "Occipitoaxial spinal interarticular stabilization with vertebral artery preservation for atlantal lateral mass failure". Journal of Neurosurgery. Spine. 22 (2): 134–138. doi:10.3171/2014.10.SPINE14131. ISSN 1547-5646. PMID 25415481. Check date values in: |date= (help)
  8. O'Brien, Michael F.; Casey, Adrian T. H.; Crockard, Alan; Pringle, Jean; Stevens, John M. (October 15, 2002). "Histology of the craniocervical junction in chronic rheumatoid arthritis: a clinicopathologic analysis of 33 operative cases". Spine. 27 (20): 2245–2254. doi:10.1097/01.BRS.0000029252.98053.43. ISSN 1528-1159. PMID 12394902.
  9. Young, Richard M.; Sherman, Jonathan H.; Wind, Joshua J.; Litvack, Zachary; O'Brien, Joseph (2014-8). "Treatment of craniocervical instability using a posterior-only approach: report of 3 cases". Journal of Neurosurgery. Spine. 21 (2): 239–248. doi:10.3171/2014.3.SPINE13684. ISSN 1547-5646. PMID 24785968. Check date values in: |date= (help)
  10. Botelho, Ricardo V.; Neto, Eliseu B.; Patriota, Gustavo C.; Daniel, Jefferson W.; Dumont, Paulo A. S.; Rotta, José M. (2007-10). "Basilar invagination: craniocervical instability treated with cervical traction and occipitocervical fixation. Case report". Journal of Neurosurgery. Spine. 7 (4): 444–449. doi:10.3171/SPI-07/10/444. ISSN 1547-5654. PMID 17933321. Check date values in: |date= (help)
  11. Lua error in Module:Citation/CS1/Identifiers at line 1131: attempt to index local 'id' (a nil value).
  12. 12.00 12.01 12.02 12.03 12.04 12.05 12.06 12.07 12.08 12.09 12.10 12.11 12.12 Henderson, Fraser C.; Francomano, C. A.; Koby, M.; Tuchman, K.; Adcock, J.; Patel, S. (January 9, 2019). "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". Neurosurgical Review. doi:10.1007/s10143-018-01070-4. ISSN 1437-2320.
  13. 13.0 13.1 13.2 13.3 13.4 13.5 13.6 13.7 13.8 Francomano, Clair A.; McDonnell, Nazli B.; Nishikawa, Misao; Bolognese, Paolo A.; Milhorat, Thomas H. (December 1, 2007). "Syndrome of occipitoatlantoaxial hypermobility, cranial settling, and Chiari malformation Type I in patients with hereditary disorders of connective tissue". Journal of Neurosurgery: Spine. 7 (6): 601–609. doi:10.3171/SPI-07/12/601.
  14. 14.0 14.1 14.2 14.3 14.4 14.5 "MRI video diagnosis and surgical therapy of soft tissue trauma to the craniocervical junction - ProQuest". search.proquest.com. Retrieved June 1, 2019.
  15. 15.0 15.1 Rebbeck, Trudy; Liebert, Ann (December 1, 2014). "Clinical management of cranio-vertebral instability after whiplash, when guidelines should be adapted: A case report". Manual Therapy. 19 (6): 618–621. doi:10.1016/j.math.2014.01.009. ISSN 1356-689X.
  16. 16.0 16.1 Mathers, K. Sean; Schneider, Michael; Timko, Michael (2011-06). "Occult Hypermobility of the Craniocervical Junction: A Case Report and Review". Journal of Orthopaedic & Sports Physical Therapy. 41 (6): 444–457. doi:10.2519/jospt.2011.3305. ISSN 0190-6011. Check date values in: |date= (help)
  17. 17.0 17.1 17.2 17.3 17.4 17.5 17.6 Bergholm, Ulla; Johansson, Bengt H.; Johansson, Hakan (January 1, 2004). "New Diagnostic Tools Can Contribute to Better Treatment of Patients with Chronic Whiplash Disorders". Journal of Whiplash & Related Disorders. 3 (2): 5–19. doi:10.3109/J180v03n02_02. ISSN 1533-2888.
  18. Ghanem, Ismat; El Hage, Samer; Rachkidi, Rami; Kharrat, Khalil; Dagher, Fernand; Kreichati, Gabi (March 1, 2008). "Pediatric cervical spine instability". Journal of Children's Orthopaedics. 2 (2): 71–84. doi:10.1007/s11832-008-0092-2. ISSN 1863-2521. PMC 2656787. PMID 19308585.
  19. Janjua, M. Burhan; Hwang, Steven W.; Samdani, Amer F.; Pahys, Joshua M.; Baaj, Ali A.; Härtl, Roger; Greenfield, Jeffrey P. (January 1, 2019). "Instrumented arthrodesis for non-traumatic craniocervical instability in very young children". Child's Nervous System. 35 (1): 97–106. doi:10.1007/s00381-018-3876-9. ISSN 1433-0350.
  20. Henderson, Fraser C.; Austin, Claudiu; Benzel, Edward; Bolognese, Paolo; Ellenbogen, Richard; Francomano, Clair A.; Ireton, Candace; Klinge, Petra; Koby, Myles (2017). "Neurological and spinal manifestations of the Ehlers–Danlos syndromes". American Journal of Medical Genetics Part C: Seminars in Medical Genetics. 175 (1): 195–211. doi:10.1002/ajmg.c.31549. ISSN 1552-4876.
  21. Montazem, Abbas (2000). "Secondary tinnitus as a symptom of instability in the upper cervical spine: Operative management" (PDF). International Tinnitus Journal.
  22. Henderson, Fraser C.; Henderson, Fraser C.; Wilson, William A.; Mark, Alexander S.; Koby, Myles (January 1, 2018). "Utility of the clivo-axial angle in assessing brainstem deformity: pilot study and literature review". Neurosurgical Review. 41 (1): 149–163. doi:10.1007/s10143-017-0830-3. ISSN 1437-2320. PMC 5748419. PMID 28258417.
  23. Lua error in Module:Citation/CS1/Identifiers at line 1131: attempt to index local 'id' (a nil value).
  24. 24.0 24.1 Lua error in Module:Citation/CS1/Identifiers at line 1131: attempt to index local 'id' (a nil value).
  25. Ghatan, Saadi; Newell, David W.; Grady, M. Sean; Mirza, Sohail K.; Chapman, Jens R.; Mann, Frederick A.; Ellenbogen, Richard G. (2004-8). "Severe posttraumatic craniocervical instability in the very young patient. Report of three cases". Journal of Neurosurgery. 101 (1 Suppl): 102–107. doi:10.3171/ped.2004.101.2.0102. ISSN 0022-3085. PMID 16206980. Check date values in: |date= (help)
  26. Uribe, Juan S.; Ramos, Edwin; Baaj, Ali; Youssef, A. Samy; Vale, Fernando L. (2009-12). "Occipital cervical stabilization using occipital condyles for cranial fixation: technical case report". Neurosurgery. 65 (6): E1216–1217, discussion E1217. doi:10.1227/01.NEU.0000349207.98394.FA. ISSN 1524-4040. PMID 19934947. Check date values in: |date= (help)
  27. Volle, E.; Montazem, A. (2001-1). "MRI video diagnosis and surgical therapy of soft tissue trauma to the craniocervical junction". Ear, Nose, & Throat Journal. 80 (1): 41–44, 46–48. ISSN 0145-5613. PMID 11209518. Check date values in: |date= (help)
  28. Mathers, K. Sean; Schneider, Michael; Timko, Michael (2011-6). "Occult hypermobility of the craniocervical junction: a case report and review". The Journal of Orthopaedic and Sports Physical Therapy. 41 (6): 444–457. doi:10.2519/jospt.2011.3305. ISSN 1938-1344. PMID 21628827. Check date values in: |date= (help)
  29. O'Brien, Michael F.; Casey, Adrian T. H.; Crockard, Alan; Pringle, Jean; Stevens, John M. (October 15, 2002). "Histology of the craniocervical junction in chronic rheumatoid arthritis: a clinicopathologic analysis of 33 operative cases". Spine. 27 (20): 2245–2254. doi:10.1097/01.BRS.0000029252.98053.43. ISSN 1528-1159. PMID 12394902.
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