Craniocervical Syndrome and MRI
I have a friend who practices on the south side of Tucson who does a lot of personal injury work and takes his own x-rays at this office. He regularly sends them out to a DACBR for a reading. My friend has had me do about ten DMX studies on his patients over the years, and on probably eight or nine of those studies, I have identified laterolisthesis of C1 on C2, which is indicative of alar and accessory ligament damage. The DACBR he has been using for his films has told him on a number of occasions that lateral overhang of C1 on C2 with lateral flexion (side bending) is a normal finding. If you have ever seen one of my alar-accessory ligament damage addendums, or if you have been to my seminar and seen my presentation on alar and accessory ligament damage, you know that I present compelling evidence from the literature which supports why I say what I do about these ligaments- that lateral overhang of C1 on C2 is definitely abnormal.
In fact, it’s not just my friend’s DACBR, it’s just about every radiologist, neurologist, and neurosurgeon I have had the occasion to speak with about this lateral instability at C1-C2, who considers it not worth mentioning. In fact, a couple of years ago, I took Arthur Croft’s series of four seminars in Newport Beach, CA, and when it came time to address alar ligament damage, he stated that he thought that some doctors (which I guess would include me) are just too hypersensitive about alar ligament damage. He said that he thought that cervical DMX studies were overused and over-read. I hadn’t been doing DMX studies for very long, and the main reason I went to his seminars was because he was The Man when it comes to whiplash, and I don’t think many people challenge Art Croft when it comes to the whole field of inquiry. Because I was still just learning, I didn’t say anything.
But I have learned a whole lot about the field of motion x-ray since then, and the fact of the matter is that he is wrong when it comes to the importance of alar and accessory ligament damage when it comes to car crash cases. Besides the fact that the literature is loaded with articles attesting to the problems associated with alar ligament damage, a new book just became available within the past month which makes the strongest statements I have ever seen about the nature of the alar ligament lesions, and also addresses solutions for the problem.
The book is entitled, The Craniocervical Syndrome and MRI, and is edited by Francis W. Smith, PhD, and Jay S. Dworkin, MD. Of particular interest to me is the second chapter because it was authored by Joel Franck, MD, the prominent Panama City, FL, neurosurgeon, who has come up with a minimally invasive (for surgery), novel way to repair the damage to the C1-C2 level. The chapter is entitled, “The Cranial Cervical Syndrome Defined: New Hope for Postwhiplash Migraine Headache Patients- Cervical Digital Motion X-Ray, FONAR Upright Weight-Bearing Multi-Position MRI and Minimally Invasive C1-C2 Transarticular Lag Screw Fixation Fusion.”
High points from the chapter:
- It is a retrospective study of 39 patients who sustained cervical whiplash injuries, and manifested the essential symptom of “postwhiplash migraine headaches” in association with neck pain. Most of the patients also exhibited other, seemingly unrelated symptoms including difficulty with concentrating and focusing, diminished memory, visual disturbances, tinnitus, ataxia, nausea and vomiting, autonomic disturbances, paresthesias, and weakness. Nearly all of the patients had been all over the country consulting with all types of providers, with no relief, only to be labeled as “dysfunctional,” “histrionic,” “malingering,” or “just plain nuts.” The average interval from the date of the car crash to the date of the surgery was 928 days.
- “The essential radiological feature of the cranial cervical syndrome (CCS) is lateral C1-C2 ligamentous instability,” which was detected on all patients using cervical DMX. Franck considered any laterolisthesis exceeding 2 mm. (as measured with DMX caliper software, which means that there is no adjustment for magnification) to be clinically significant. For four years now I have been seeing on a regular basis that this is a common occurrence as a result of the whiplash event.
- The average measured overhang for left lateral flexion was 4.62 mm., with a range of 0-8 mm., and for right lateral flexion was 4.6 mm., with a range of 0-7 mm.
- The upright FONAR MRI was used as a complement to the DMX findings by visualizing the two alar ligaments and the transverse ligament using proton density sequences so that ligamentous edema and overt tears, and Chiari type 0-1 syndrome, a pathology which has important implications for the clinical expression of CCS, could be demonstrated.
- 34 of the 39 patients underwent the positional MRI study and Dr. Franck found that 25 (73.5%) had verified alar ligament tears. 16 had transverse ligament tears (47%).
- The solution for the C1-C2 instability is a procedure which involves a combination of a 3-D CT scan interfaced with a computer via an infrared camera which senses the position of specialized metallic balls placed into the surgical wound and the surgeon’s instruments, and hence the position of the patient in the room, making perfect placement of two pedicle screws through the lateral masses of C2 and into the lateral masses of C1 possible, and thereby eliminating the instability. The technology is called STEALTH Navigation, and for more information on that, you really need to read the chapter. A 20 minute video of the highlights of one of his surgeries can be seen on YouTube- just do a search for “Joel Franck, MD,” and left click on the presentation he did at the Cranio-Cervical Symposium in 2012. The most impressive part of the video comes when he grabs the posterior tubercle of exposed atlas with a forceps and wiggles it show how unstable the segment is, and then, after the screws are in place, he grabs it again and tries to wiggle it, and can’t, because it is no longer loose.
- All 39 patients underwent the C1-C2 transarticular fixation fusion, and 12 of them also underwent suboccipital cranioectomies (for the Chiari malformation).
- Six weeks after the surgery, the headache intensity was reduced by 96%, the neck pain was reduced by 86%, and the radiculomyelopathic complaints were reduced by 89%. Come on- when have you heard of that degree of success with a surgery?
- Complications were very few, mainly along the lines of infection, all of which resolved with antibiotics.
Dr. Franck calls the headaches “postwhiplash migraines” because migraine headaches are vascular headaches. Because the vertebral arteries go just superior to the arch of C1 before entering the foramen magnum, the side to side movement of the atlas irritates the vertebral artery by inducing repeated stretching. He goes on to explain that the transient vertebral artery traction and compression may be causing the equivalent of transient ischemia to parts of the brainstem, cerebellum, and cerebral cortex. And with the stabilization of the C1-C2 motion segment, the repeated stretching of the vertebral arteries is eliminated immediately.
All but one of the patients involved in the study was injured in an auto crash. The one exception was a 49 year old female who had a lifelong history of common migraine headaches, with no history of trauma, who had undergone a C5-C6 fusion surgery previously (which provided no relief for her headaches), and originally underwent the cervical DMX study to evaluate the fusion. She was found on the study to have C1-C2 ligamentous instability, averaging 4.5 mm. bilaterally, and she requested that the transarticular fusion surgery be done. What’s really interesting about her case is that she also underwent the FONAR upright MRI study as well, and no evidence of alar or transverse ligament damage could be found. But four months after the surgery, she had no headaches, and near resolution of her neck pain. Previously, she was having two headaches daily, which she rated as 10 on a pain scale of 10. You can’t call that living- that’s called barely surviving.
There’s more to this, but if I write any more, I’ll just be copying Dr. Franck’s chapter for you. I wish Dr. Franck practiced here, as I have several patients whom I have not been able to persuade to go to Florida and end their pain. One of the things we know about pain is that the longer it persists, the harder it is to get rid of. In neurology, the law of facilitation tells us that the more often a message travels over a set of synapses, the easier it gets to propagate the signal. This applies not to just motor learning, but also to the transmission of pain messages. And we know that chronic pain can actually cause changes- permanent changes- in the central nervous system, so that even after a corrective procedure has been done, the pain might not go away. But the fact that for most of Dr. Franck’s patients, 928 days passed before they were fixed means that there is hope for those who have this problem. At this time, there are no neurosurgeons in our area who perform this type of surgery. If you have patients who have lateral instability at C1-C2, killer headaches, and neck pain that won’t quit, right now he is your best option. If a patient comes to you who has been everywhere else, spending thousands of dollars trying to find someone to help them, send them to Dr. Franck. It’ll be their last stop (I mean that in a good way).
Joel Franck, MD can be reached at the Bay Neurosurgical & Spinal Institute, 801 E. 6th St., Ste. 302, Panama City, FL 32401. The clinic phone number is (850)914-7040.