Craniocervical Instability: Fact or Fiction

There has been a rising number of patients with concerns of craniocervical instability. Increased usage of craniocervical imaging in trauma cases and rising awareness of patients with connective tissue disorders like Ehler-Danlos make up a large number of the consults coming into my office.⁣
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Craniocervical instability is a condition where the ligaments holding the skull to the neck become injured, weakened, or disrupted causing the Upper Cervical vertebra to move excessively under the skull. ⁣
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Craniocervical instability can have wide ranges, but the amount of movement far exceeds what’s considered a chiropractic misalignment or subluxation.⁣
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In mild cases, injuries to alar or capsular ligaments can contribute to non-specific headache, neck pain, or dizziness symptoms, but it’s unclear how strong the correlation is to the instability vs other tissue injury.⁣
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Moderate cases can see larger instability measurements that with a clear relationship to cranial pain or cranial nerve symptoms during the unstable plane of motion, but there is no immediate threat to the brainstem or arteries.⁣
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In severe cases, the excess motion can cause pressure to the brainstem, spinal cord, or blood vessels in the neck and skull leading to life threatening injury or paralysis and surgical intervention is necessary.⁣
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Management is unclear and largely untested. Surgery is necessary in severe cases to prevent catastrophic injury or disability, but conservative management of mild and moderate instability is largely untested.⁣
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As a chiropractor, it’s important to recognize that these cases represent a population where manual techniques and manipulation are likely unsafe and contraindicated in these patients.⁣
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Case reports show that low force upper cervical techniques may be done safely for mild/moderate cases, but the instability may prevent lasting effects of correction. ⁣

There’s still a lot we don’t know about managing the gray areas of instability, so the best approach currently is to proceed with caution.