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Alar Ligament Treatment for CCJ Instability

POSTED ON IN Back and Neck Procedure Outcomes Headaches Latest News Neck/Cervical Regenexx-SCP Regenexx-SD Research Presentations/Publications BY Chris Centeno

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Due to our high level of expertise in the field, for many years, our practice has collected a group of patients with upper cervical (CCJ) instability. This awful problem has been very difficult to treat, but the patients have been generally happy that any physician knows what’s wrong with them and is willing to do something about it. However, for years I’ve known that there was more that could be done, but there was just no way to get it done. This is the story of a new injection technique (alar ligament treatment) we now use to help these difficult-to-treat patients.

The Upper Cervical Spine and CCJ

The uppermost neck is calledCraniocervical Junction CCJ the craniocervical junction (CCJ). It includes the skull, which sits on the atlas bone (C1 vertebra), which sits on the axis bone (C2 vertebra). So the CCJ is the skull though C2.

As we develop in the womb, the upper neck and head actually develop as one unit. Hence your brain doesn’t differentiate one from the other when it comes to deciphering pain signals. Hence, patients with upper neck problems often experience headaches.

The upper neck has facet joints, just like the rest of the spine. These normally finger-sized joints are larger than usual and are actually the biggest spine joints. The C0–C1 joint facilitates a head-nodding motion, and the C1–C2 joint allows for 50% of head rotation. In fact, the C1–C2 facet joint is the most mobile joint in the spine.

C1-C2 jointC0-C1 joint

 

 

 

 

 

The C1 and C2 vertebrae fit together like a complex puzzle. There’s aatlas projection on the C2 bone (called the dens) that sticks up and acts as a pivot point for the C1 bone. The skull then fits together with the C1 bone with two projections from the bottom (occipital condyles) that sit into the C1 bone.

 

The Ligaments That Hold This Area Together

alar transverse ligamentsLigaments are like duct tape that hold the bones together. In the CCJ, the two main ligaments are the alar and the transverse. They literally hold your head on.

The alar ligaments (blue in the image to the left) come up from the dens and connect the C2 vertebra to the skull. The transverse ligament (red) acts as like a seat belt for the dens. These ligaments stabilize the upper neck when                                                         you look down, turn your head, or do both.

What Happens When These Ligaments Get Injured?

Any ligament in the body can be injured in two ways—it can be broken in half and can snap back like a rubber band (known as failure), or it can stretch and get partially torn (subfailure). In the case of the alar and transverse ligaments, the former type of ligament injury is much more common. This means that the upper neck bones become unstable and move around too much. Just like other areas of the spine, when this happens the facet joints (in this case C0–C1 and C1–C2) can be beat up by that movement, leading to arthritis. The muscles and tendons that should stabilize this area become overwhelmed and injured. Finally the nerves can become irritated.

What Causes These Injuries, and What Are the Symptoms?

Injuries to the alar and transverse ligaments can occur with head trauma. Through the years I’ve heard many ways that these areas can be injured including the following:

  • A rear-end car crash, especially one where the head hits the back window (e.g., a pickup truck)
  • A sudden jolt to the neck/head
  • Something falling on the head
  • Placing axial loads on the head (e.g., one patient who performed a neck exercise by arching his back to place his whole weight on the head)

Patients usually complain of headaches; dizziness/vertigo (but not always); visual disturbances; disorientation; and/or problems thinking, concentrating, or reading. The symptoms are usually worse with head turning or looking down. There may be clicking or popping and activity such as exercise or physical therapy usually makes the problem worse. Very specific upper cervical manipulation (i.e., by an experienced upper cervical chiropractor or high-level manual therapist) can provide temporary relief.

What Alar Ligament Treatment Is Available for These Patients When Conservative Care Fails?

Many different kinds of injection therapy can be attempted in these patients, but few of them yield any long-term or “home run” results. Through the years, we’ve tried traditional cervical facet injections at C0–C1, C1–C2, and C2–C3. We’ve tried platelet rich plasma (PRP) and stem cell injections into the joints as well. We’ve also tried injecting the ligaments in this area (prolotherapy, PRP, and stem cells). All of this only provides either temporary or small amounts of relief. The same holds true for alternative therapies, including acupuncture, massage, body work, craniosacral therapy, etc…

The big problem with all of this treatment is that there has been no way to get at these ligaments. When coming from the traditional posterior (from the back) approach, the spinal cord is in the way. Several years ago we began to wonder if there was any way that these ligaments could be accessed.

Why is an Non-surgical Alar Ligament Treatment Important?

CCJ fusion surgeryThe most common surgery offered these patients when conservative and injection-based therapies fail is CCJ fusion. While there may be patients who have such severe CCJ ligament injuries that only bolting together the bones will work, as I tell my patients, “Fusion is a dog with fleas.” This means that fusing any segments of the spine will result in the spinal segments above and below getting overloaded and degenerative. Just take a look at the X-ray here to get a sense of why a CCJ fusion should be avoided if possible.

Getting at the Alar/Transverse Ligament

I spent several years occasionally noodling this problem. This then progressed into about a year spent focusing on how to make this work. I figured out a few posterior approaches to the ligaments, but they all seemed to work better in theory than practice as the spinal cord was always in the way. Then one day I was playing with a model of the upper cervical spine we have in the office. I noticed that the model had a little hole between the C1 and C2 bones. Could it be possible that a needle could be placed through this “articular gap”? Theoretically it should be possible, but nobody had ever attempted this procedure.

C1-C2 articular gapI spent the next year researching this approach, reviewing anatomy texts, and consulting with high-level colleagues to ensure this procedure would be possible. In February of 2015, I was ready, and given that we had a collection of these CCJ instability patients that had failed everything, it wasn’t hard to find a patient who had been living with this nightmare collection of symptoms.

Before the first procedure, we had many questions. Was it possible that this “articular gap” was a figment of the imagination of anatomy textbooks and models and wouldn’t allow a needle alar transverse ligament treatmentthrough? Was there some other reason that this couldn’t be done? Thankfully the first procedure went well, and we soon found out that this “articular gap” was for real. We got a very thin 25-gauge needle into this gap and then into the alar/transverse ligaments from the front. A blue-collar guy who had years of headaches after a car crash, who I couldn’t help in any way, told me that while he was sore for two weeks, one day he noticed a dramatic improvement and most of his headaches went away.

More Experience with This First-of-Its-Kind Procedure

Over the last year, as the video discusses, we were able to treat seven patients in 10 different procedures. All of these patients (except one who was not worked up by us) had failed all other treatments. Five of seven had excellent results for the first time ever, with many logging dramatic results. Examples included a patient who couldn’t sit in meetings who can now have one-hour meetings with a several-minute break and do this all day. This same patient can now cross-country ski for the first time in years. A patient who couldn’t sit in a car without her upper neck “going out” e-mailed that she went on a multimile backpacking and hiking trip! She had been treated by us for a decade with only small, incremental improvements.

Of the two patients who didn’t respond, one had a suboptimal injection (before we had perfected the procedure) and another had a poor diagnostic work-up before seeing us. In that patient, his pain was actually coming from an injured C1–C2 joint, which we later discovered (i.e., CCJ instability was not the problem that was driving his symptoms).

Above is a video that goes into this topic in much more depth. It represents our first public presentation of this technique at a medical conference, which occurred this week at the annual AAOM meeting.

The upshot? Alar ligament treatment is feasible and seems to give home-run results in the patients who had failed many other therapies. We’ll now move from seeing if this procedure is feasible to more formal study of the results when many more patients are injected. The meantime, I’m grateful that we now have a way to help these poor patients with this awful problem.

 

    comments

    Sam says

    Thanks for sharing this presentation. It was quite interesting to find about such an ultra precise injection technique with anterior approach.

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    Regenexx Team says

    Sam,
    Glad you enjoyed it...it's a good tool!

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    chris says

    that video blew my mind!

    if someone tore those ligaments, can you see any kind of treatment besides surgery in ten years?

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    Robert says

    I have been suffering since 1992 when I was injured on the carrier flight deck in the Navy. I am hesitant to let the VA perform anything like this on me. Besides yourself , are there other doctors using this method?

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    Chris Centeno says

    Robert,
    Dr. Centeno is the inventor of the procedure, and currently the only Physician performing it. While it has been transformative for patients, it is still considered experimental, so to be a Candidate you need to have gone through a series of more conservative procedures which have failed to help, first. If you'd like to evaluated as a Candidate for the procedure or the necessary preliminary procedures, please submit the Candidate Form. http://www.regenexx.com/alar-ligament-treatment/ On another note, the Interventional Orthopedics Foundation has a Program for wounded veterans which helps funds these types of procedures if you meet the criteria. It might be worth looking into, as many of the Regenexx Physicians are participating Doctors. https://interventionalorthopedics.org/wounded-warriors-program/

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    Michael says

    I'm so glad, that you people at Regenexx found a cure for this terrible illness.
    Could you give an update on the status of this procedure, please. How many patients were treated since this article was published? What was their outcome? When will this become a Regenexx standard procedure?
    Thanks.

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    Chris Centeno says

    Michael,
    This is a very specialized procedure and it's not likely that it would be available at every Regenexx location even in the future. We've done around 40 to date, once we've done at least 100, we'll start planning on how best to proceed. There is a Clinical Trial Planned. It is a game changer for the right set of patients!

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    Carl Rachal says

    Do most medical insurance cover this treatment and how much does it cost?
    My son was injured by chiropractor his neck was hyper extended or overstretch back into 2012 he was 25 when the injury occurred is now 31 he has seen many doctors and massage therapist and has had mild relief. He cannot drive or tie his shoes by himself sit for long periods of time cannot turn his head up or down or to the side, he sleeps on a hard massagewith a thin padwith little relieve.he saw a doctor in Florida I A neorsurgeon and they recommend that his neck be defuse but that's gonna be the last treatment for us

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    Chris Centeno says

    Carl,
    So sorry to hear that! Unfortunately, no medical insurance covers this type of treatment yet. Cost depends on what's needed which can be very different case to case. Does your son have a current MRI?

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    HWS says

    Thank you very much for your article.
    In Germany we have problems to find medical experts who even know that a damage of the ligaments a: might happen, b: might cause such severe problems.
    This ignorance is followed not only by problems with insurances but leaves us alone with all the handicaps and pain and a condition that is getting worse year after year.

    I'd be very happy if you could support me with more information about the effects of hurt ligg. C0-C2.

    In my case, sth very hard & heavy fell on my head (I didn't expect and couldn't see it come, my head was turned to the right). One of my lig alar is too long now. I found literature about the structure of the fibres of ligg alar, that explains why the structure is special and what that means as a result of an accident with extension.

    Also interesting for patients might be a therapie with laserpointer. You can find more on the internet about it.
    Sry for my English mistakes.

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    Chris Centeno says

    HWS,

    We will be sending information as you requested. Laser therapy would not be recommended, as the goal is to tighten lax ligaments and or heal injured ones, and Laser therapy has the opposite effect.

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    ronaldo says

    Centeron says:

    73 from Canada Calgary - very interesting as have had unstable neck since rear ended in 2012 but from 2000 to 2012 NUCCA chiro kept my neck good one or two treatments for months on end - but since mva keeps coming out after Nucca or myself put back in such that now i do several to many times per day adjustments (not 100% sure if upper cervical only anymore but could be lower where worse wear down say C3 to C6). usual arthritis wear down some stenosis but not on spinal chord - physio is failure Prolo was failure and altho Osteopathic helped muscles and recently tried atlas profilix but after each treatment of all of these i have to put neck back in immediately after treatment, myself. lots of lots of headache and neck pain. So what exactly are u injecting in these treatments?
    Because i also suffer from fairly severe peripheral neuropathy and have had to refuse some procedure or xray type except plain mri because of the neurotoxic nature of the contrast dyes (also some antibiotics have made worse (original CIPN)) can i assume that i am not a candidate and never will be and just will have to slug it thru rest of life?
    That dynamic motion xray sounds interesting just for diagnosis - does it require contrast dye ? thank u

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    Chris Centeno says

    ronaldo,
    DMX can be very helpful in confirming cervical instability and does not use contrast. The criteria for Candidacy for the CCJ instability procedure is very strict because it is still an experiemental procedure with a higher degree of risk than other procedures. Therefore there is a list of exclusions and inclusions which need to be met to be considered. We keep patients safe by exposing them to the least invasive procedures first. Please see: https://www.regenexx.com/candidacy-for-ccj-instability-procedure/

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    Magdalen savory says

    Sorry to be a bit confused and it all makes a lot of sense but you didn't answer Ronaldo in that you don't say what is in the injection and you also don't make clear how it keeps and holds the c1 etc and facets in place as when you have tried every method bar surgery how is it strengthening the ligaments or is it just for pain relief

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    Chris Centeno says

    Magdalen,
    It's a same day stem cell procedure using the stem cells from a patient's own bone marrow, which strengthens and repairs the alar, tranverse and accessory ligaments, which are basically what holds your head onto your neck. It's an experimental procedure and such has very strict inclusion and exclusion criteria for Candidacy. Because of that, a very small percentage of people would be Candidates as failure of very specific previous procedures is required.

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    ronaldo says

    Just after my previous comment i noticed the link which was an update to this article and it had i believed on quick glance a list of treatment ingredients. However when i went back to this window it showed a different link and this morning it seems that the link changed again. Where is the update?

    also in my reading of your material it appears there are no contrast dyes in the DMX thing (which i understand is difficult to find such a protocal but please correct me if wrong) and where is back up for the conclusion that one gets automatically to a diagnoses of the ligaments without seeing them on the DMX - perhaps i am confused in my understanding here?; and you have said that you use contrast dye in the treatment...

    Cannot find the answer why there cannot be contrast dyes made that are more natural and certainly at least non-toxic and non neurotoxic materials unless there is no profit in it for the Pharmecutical companies if the science does not preclude?

    Thx Dr. Centeno

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    Chris Centeno says

    ronaldo,
    The diagnosis for CCJ instability requires a very, very extensive exam meeting the criteria and and procedures to exclude all other causes. No links have been removed. On the website, just put CCJ into the search section and all the articles will come up. www.regenexx.com

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    Yvonne says

    Very interesting and hopeful. I am just starting on this journey after 21 years of trying to ignore continuing problems and pain etc. Finally I was listened to thanks to a clever physiotherapist and had an MRI. I am now pretty much housebound, unstable, taste is very odd, visual problems since 2005 along with drop attacks and terrible pass out pain. I have learned that I have to maintain posture and not move my head (which wants to fall off) in certain ways to limit effects. Here in the UK we are going backwards regarding medical developments to do with the spine. At the same time our treatment of initial trauma is exceptional.

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    Chris Centeno says

    Yes, UK is going backwards on spine treatment. This is being run by a band of phyiotherapists trying to convince the NHS that any patient with chronic pain just needs a good lecture that their pain is all in their nerves and they're be fine. This insanity is called PNE for Pain neuroscience Education.

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    Shawna Thompson says

    I was involved in a mva and diagnosed with whiplash and concussion. It’s been a year and I still have pain that begins in the back (base) of my skull and radiates around into my face, tinnitus, vision disturbances, vertigo, balance issues, numbness and tingling in my left arm/hand, memory loss. I’ve neen treated by no less than 7 physicians and most are to the point now they’re convinced the pain is “all in your head”. So now sending me for therapy. Nobody believes I still have these symptoms. “You just don’t want to work”. No really I’d like my life back. How do I convince a dr to look for alar ligament problems?

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    Chris Centeno says

    Shawna,
    Unfortunately, this is not an issue many Drs are familiar with, know how to diagnose, or know how to treat safely. There is very strict criteria for our CCJ procedure detailed here: https://www.regenexx.com/candidacy-for-ccj-instability-procedure/ Treatment for this issue is done exclusively in CO. If after reading through the eligibility criteria, you'd like to see if you'd be a Candidate for this procedure, please let us know.

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    wendy emeny says

    Hi, I have the same issues as yourself. It makes one feel very alone, but you aren't alone.
    I and i'm sure others understand how you are feeling. I have multiple injuries and has been so difficult to understand where my symptoms are coming from. I have seen many health professionals. I went to a headache neck and jaw clinic and at the session I showed them a few MRI images I knew weren't right. She and the other senior agreed the alar ligament is torn.
    It feels so good to know and others to know your not crazy and making it up. So I recommend finding a physio who specializes in the neck. Check first if the will assess imaging. Or a sports physio who can read imaging. Or possibly find something on here you can show your doctor. Maybe you can say you would like to rule this out. I wish you the best of luck. This injurie is so debilitating. Not being able to socialize and do things normally is very depressing. One more thing I use a neck brace to hold my head up, just loosely. It helps with the muscle spasms and pain.

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    Bobby Barjasteh says

    Hi. I am hoping to maybe get a consultation with one of your specialists with necks after reading this article, I seem to match a lot of the described symptoms and would like to know more. I'm a 26 year old healthy competitive Olympic weightlifter and powerlifter and always put my body under physical stress, and I think something happened to my neck after skydiving two months ago as a result of being too heavy to jump and not being made aware of the risk for someone of my stature / physical condition. It was my first time skydiving as a heavy person in tandem (I weighed almost 240 lbs), and right away I felt something different about my body a few hours after landing, and have had severe neurological and physiological complications ever since, despite the fall itself seeming completely normal (no concussion or loss of consciousness or anything like that). I began to have muscle weakness and loss of sensation in my muscles (loss of proprioception, but not of position of my muscles, but rather how much effort I am putting in to lift things and the feeling of my muscles when they are engaged) which is especially noticeable when I try to participate in my sport as a lifter, increased muscle pain tolerance (a consequence of not being able to feel the muscles I imagine), as well as vision issues (dynamic visual acuity is bad) and vestibular/dizziness problems with head / neck motion, and I had other complications early on like change in food taste, nerve sensations down my arms, and loss of sensation of temperature/feeling on my skin in certain areas (most of the early stuff has resolved but the vision and loss of muscle feeling / numbness and weakness issues have persisted). I have been doing vestibular therapy which has helped maybe a little bit with the dizziness but the fundamental issues are still there, and after doing some manual therapy with my neck today, my vestibular therapist showed me that my neck has all sorts of strange things going on - muscle weaknesses and tightness that shouldn't be there, my head when lying supine is also tilted to the right when I am in a neutral position, and other weird things. There is also clicking in my neck when I turn my head left and right or diagonally, and I have had whiplash-like symptoms on and off with soreness and pain in the neck, although much of the pain is gone now, I still have residual pain and stiffness and it feels like my head is always too 'heavy' in addition to having a constant pressure-like sensation at the base of my skull where my head and neck meet (not a traditional headache). I've seen two neurologists and an orthopaedic, and no one has any idea what is wrong with me (I have had a brain MRI with contrast, and a regular supine cervical MRI but nothing unusual stuck out to them). But I know something is wrong as my whole body has been affected and it isn't in my head, I have been struggling to do my normal activities and am otherwise an extremely healthy individual with lots of energy. So something is up. I just started chiropractic treatment and I will investigate if upper cervical manipulation can help - I suspect it will provide some sort of temporary relief/improvement of symptoms. But in the meantime I was also hoping to speak to someone, in a consultation perhaps, on what I could do to help diagnose the suspected instability (i.e. digital motion X-Ray as suggested in the blog post, or maybe dynamic MRI or upper cervical MRI), and options for treatments. Sorry for the long message but as you can see, I am a particularly strange case and was hoping to speak to a professional like Dr. Centeno after reading this blog post and seeing if he or someone similar could help me. I live in Minnesota, and I see there is an affiliate office in Shakopee which isn't far from me, so that could be a decent starting place. Anyway, hope this message makes sense and I hope to speak to someone soon. Thank you very much for your time and considerations.

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    Chris Centeno says

    Bobby,
    All potential CCJ patients are evaluated and treated at the Centeno-Schultz Clinic in Broomfield, Colorado. To begin the Candidacy Evaluation with Dr. Centeno, please submit the Candidate form here: https://centenoschultz.com/ and please let us know when you submit it.

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    About the Author

    Chris Centeno

    Christopher J. Centeno, M.D. is an international expert and specialist in regenerative medicine and the clinical use of mesenchymal stem cells in orthopedics. He is board certified in physical medicine as well as rehabilitation and in pain management through The American Board of Physical Medicine and Rehabilitation.…

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