Risk in asymptomatic patients: If the patient has craniovertebral dissociation either due to anterior or superior migration of the head in relation to the cervical column, one may argue that there is a risk for traction injury to the brains blood supply even in cases where the patient has no obvious induction of symptoms upon flexion-, extension or rotation, and has no imaging that demonstrates neurovascular conflict (eg., BHS or positional brainstem compression). Both measurements tend to worsen with neck extension. Postural orthostatic tachycardia syndrome (POTS) and its relation to craniovascular dysfunction, Pectineo-femoral pinch syndrome: A common cause of groin & anterior thigh pain and weakness, Chronic spinal pain and radiculopathy: Diagnostic approach and common imaging pitfalls, Neurogenic genital pain: Pudendal neuralgia and inferior hypogastric plexalgia. 2005 Dec;53(4):408-15. Review. I have seen several patients misdiagnosed and become almost paralyzed by anxiety due to an increased Grabb-Oakes measurement where the dens is just barely in tangent with the brainstem, despite zero evidence of actual compression nor signal changes in the brainstem and with normal neurological examinations without any upper motor lesion signs! In less severe cases, physical therapy can also help. 2019) have documented numerous symptomatic cases of jugular vein stenosis at the craniovertebral junction. Type one involves sole rotary luxation of the facet joints, usually along with damage to either the alar ligaments and capsular ligaments. Compression of the glossopharyngeal nerve will frequently cause pharyngeal pain (back of the throat pain) whereas vagal compression may lead to dry coughing, lump in the throat feeling, ear itching and various strange things when unilateral, but has been associated with more problematic issues when bilateral such as gastroparesis (Waldock et al. I recommend sticking to clinics that have good reputations and good imaging protocols. Neurosurg Rev. Sometimes, the symptoms may trigger within a few minutes after the test as well, depending on various factors which exceed the scope of this article. We have remained at the forefront of medicine by fostering a culture of collaboration, pushing the boundaries of medical research, educating the brightest medical minds and maintaining an unwavering commitment to the diverse communities we serve. Uniondale, NY Location HSS Long Island The Omni. These cookies do not store any personal information. Would need a flexion extension MRI and correlate to the patients symptoms. This, again, prompted the more than 1000 euro consultation with the upright imaging center in a large european country. Elsevier Publishing. To the best of my knowledge, I was the first person to document the notion that this was, in essence, a postural phenomenon that is induced due to poor posture over a long period of time (Larsen 2018). Int J Spine Surg. For example, if the patient blacks out every time she turns her head to the left, a followup dynamic catheter angiography could be done, and may demonstrate high-grade stenosis of the vertebral artery when turning to the left. Patient resources for the Down Syndrome Program. 14 Postoperative care advices following cervical disc herniation surgery, 4 Predictive factors of the results in Cervical Herniated Disc surgery. 1963). Second, because it is such a controversial topic that lacks medical consensus, poor understanding of the actual mechanism of pathology leads to misunderstandings. The ligaments involved are the transverse, alar and capsular ligaments. Donald Corenman, MD, DC. None of these tests would be able to reproduce her symptoms if they were stemming from AAI or CCI. Both patients had severe symptoms regardless of lying down, wearing a neck brace, etc., and did not get worse nor better when turning or moving their necks. If the patient turns their head and passes out, and a catheter scan demonstrates dominant vertebral arterial compression, then certainly this is a case of AAI and atlantoaxial fixation may be a viable option, at least if the transverse foraminae are normal. He also found that severe misalignment of these joints were often associated with Chiari malformation, basilar invagination, and various other pathologies. A CTV is preferable, but a general neck CT will also do if you have sensitive kidneys and would like to avoid contrast infusion. Atlantoaxial instability will generally imply axial hypermobility of the atlantoaxial joint itself, which when symptomatic will result in Bow hunters syndrome (positional The findings may be quite subtle and are easy to miss outside of dynamic exams. Information about the identification of CVJ fractures will not be applicable for patients with chronic workups and lacking imaging findings over a long period of time. Copyright 2007-2023. But a patient who just feels bad (even if they feel very bad), and especially if they do not have positional triggers and their imaging does also not demonstrate constant brainstem or otherwise vascular compromise that fits with the symptoms, then diagnosing such a patient with CCI or AAI and claiming its presence as the culprit of their symptoms, is madness. When I reviewed both of these patients imaging and cases, the only findings were slightly low CXAs and a Grabb-Oakes around 9mm. In 18 patients, dynamic images showed vertical, mobile and at-least partially reducible atlantoaxial dislocation. AAI is less common in adults with Down syndrome. doi: 10.1227/NEU.0b013e3182333859. For the sake of relevance, this article will mainly address ligamentous and muscular injuries, as these topics, especially when mild, are much more controversial than incidences of CVJ fracture. nr. -Mummaneni PV, Haid RW. Horizontal misalignment of the facet joints often cause dorsal migration of the C0 and C1 facets which cause approximation of the styloid process and the C1 transverse processes. Specialist imaging research to help diagnosis. A lot of things that cause temporary results are just placebo. There are no exercises that can help an instability like that. This website uses cookies to improve your experience while you navigate through the website. In moderate stages, the MRI will appear abnormal, but the CTV will still appear relatively OK (because the patient tends to be placed on a neck wedge which protracts the head in the CT machine this reduces the compression). Ann Rheum Dis. Symptoms of VBI develop rapidly in patients with legitimate and adequate degrees of vertebral artery compression when placed in the triggering position. Contact, Terms & conditions More information about surgical treatment. Eur J Pediatr. First of all, studies have shown that FLAIR hyperintensities (suggestive of ligamentous partial rupture or damage) have been found in a lot of asymptomatic patients (Myran et al. Kjetil has also published several peer-reviewed studies on musculoskeletal and neurological topics. All patients were treated with atlantoaxial plate and screw fixation using techniques described in 1994 and 2004. The abnormal imaging findings will mainly be evident during extension of the head and neck. The same principles would apply for AAI and CCI: There must be clear imaging findings, and I am not talking about a simple measurement being off, but real pathology proven to be associated with the given diagnosis. 2011 Apr;15(1):41-47. Last Update [site_last_modified date_format=Y-m-d H:i:s]. Diagnostic imaging: Spine, 3rd edition. See my other articles or YouTube videos for howtos. Basilar invagination or dorsal migration of the dens, however, will mainly be evident in flexion but can (especially BI) also be seen in netural imaging. As touched upon in the beginning of this article, that prompted me to write this article, is a huge massive influx of patients over the last few years who have been illegitimately diagnosed with AAI or CCI. The dorsal lamina of the atlas shifts caudally and ventrally against the spinous process of the axis. I am not saying that this applies to every DMX center nor that DMX in and by itself is never useful, but due to the overwhelming lack of competence that tends to come with these studies, I dont recommend them unless unless you have obviously abnormal imaging otherwise and want to look for occult fractures or similar sinister and stubbornly identified problem. If the X-ray results are abnormal (different than usual), the doctor will order another imaging test, like a computed tomography (CT) scan or magnetic resonance imaging (MRI) test. 1978 Dec;37(6):525-8. doi: 10.1136/ard.37.6.525. I, personally, although I created my own manipulation protocol for this problem ALMOST NEVER use it. However, can we say the same if there is major guesswork involved in the rendering of the diagnosis? The reason why AAI and CCI are potentially associated with so many symptoms such as headache, dizziness, etc., is due to the potential for neurovascular conflict. DOI: https://doi.org/10.35975/apic.v24i1.1230. Learn about career opportunities, search for positions and apply for a job. Rather, just like with the CXA, it is an indication of the present spinal health status and perhaps also an indicator as to non-surgical prognosis as well as an indicator of likely outcome if nothing is done. Deliganis AV, Baxter AB, Hanson JA, et al. In BI, the compression tends to be constant. Atlantoaxial rotatory subluxation Contact Dr. Gilete Our commitment to reliable health and medical information on the internet This site complies with the HONcode standard for trustworthy We are committed to providing expert caresafely and effectively. If a gliding is causing it (it is usually a glide or, a glide combined with mild rotation), no manipulation can fix it. For example, if there is a C4-5 anterolisthesis with resultant chronic radiculopathy, C4-5 ADCF would often be utilized as operative treatment. But this is rarely the case in my experience. Common findings: Ovalization of the orbitae, dilated optic nerve sheaths, pituitary concavity, Chiari malformation, tight brain appearance, jugular vein compression with or without white-vessel signs, dilation or narrowing of the lateral and possibly third ventricles, periventricular ependymal T2 FLAIR hyperintensities), Neck MRI (general evaluation of the neck integrity), CT angiogram of the head neck and subclavian arteries with the arms raised (contrast infusion via femoral vein. The atlantoaxial subluxation may exist in patients neutral position (without neck movement) or may occur in relation to neck rotation movements (when the patient moves the neck to the right and left). The patient may seek out their GP or a local neurosurgeon who will, usually, and usually rightfully so, dismiss these claims, as the patients imaging is normal and also lack neurological signs that would fit with neurovascular compromise. Atlantoaxial malalignment is best visualized on a lateral view. A review of the diagnosis and treatment of atlantoaxial dislocations. The natural anatomic C1-C2 movement is basically rotation and approximately implies 50% of necks total rotation movement. Presuming the central venous pressure being normal, then I am not so interested in the pre and post-stenotic gradients as they tend to be unreliable. With the increasing dependence on smartphones, computers, and other devices in our modern JRSM Short Rep. 2013 Nov 21;4(12):2042533313507920. doi: 10.1177/2042533313507920. Clunking, clicking and pain in the upper neck. 2012 Mar;70(3):E795-9. I believe that most of these practitioners mean well. Pain medications and anti-inflammatories are typically also prescribed. This conformation may be associated with thickening of the interarcuate ligament (atlantoaxial band), which has been interpreted as an indicator for instability in the atlantoaxial joint [79]. Clinical signs of such an injury include neck pain, weakness in all limbs, and potentially paralysis from the neck down and death. Anaesth Pain & Intensive Care 2018;22(2):238-242. Neuronavigation assistance guides us all through the surgery, thus it diminishes (though it does not eliminate) the risks while placing the screws for the fusion. There can be, and are indeed many more potential explanations for these symptoms than just AAI and CCI. If combined with Chiari malformation, compression of the cerebellar tonsils can cooccur and will occur with lower measurements than normally needed to cause brainstem compression alone, due to filling of the space behind it (the descended cerebellum). Fielding JW, Hawkins RJ. Most cases of mild to moderate unilateral compression, sometimes even intermittent occlusion, is asymptomatic due to contribution from the contralateral VA (Faris et al. This is not good medical practice. Followup, as mentioned above, can be a CTV, volume flow doppler exam, and potentially catheter venography and manometry as one additional confirming pre-surgical step to ascertain actual raised intravenous pressures. The most commonly used measures in the radiological evaluation of craniocervical instability and atlantoaxial instability are CXA, Grabb, BDI, BAI, ADI. Abbreviations: BDI: basion dens interval, CXA: clivo axial angle, BAI: basion-axial interval, ADI: Atlantoaxial interval. In addition to that we would start treatment for thoracic outlet syndrome. Both positional (ie., upright. 10 things you should know about Cervical Disc Replacement. In severe (very bad) cases, your son/daughter might need neck surgery. In my experience, although I usually disagree with their diagnoses, is that Medserena in London has the absolute best upright imaging quality in the world. Atlantoaxial instability is an uncommon condition of dogs in which there is abnormal movement in the neck, between the atlas (first cervical vertebra) and axis (second vertebra). Moreover, genuine cases of brainstem compression causes paralysis and other upper motor neuron signs, and will present with syringobulbia or compressive bulbopathy. This madness must stop. A general neck MRI is usually a good idea and may show some arthritis in the atlantoaxial and atlanto-occipital joints along with minor intra-articular effusions, suggesting irritation of the joints. BDI, ie. It mainly consists of the posterior fusion of the affected vertebrae, in this case, the atlas (C1) and the axis (C2). Some rare cases have also demonstrated rotary compression of the vertebral artery in the lower neck due to arthritis or disc bulges that fills up the transverse foraminae (Ujifuku et al. Traditional cases of atlantoaxial instability and craniocervical instability require obvious imaging findings with strong clinical correlation, and, when its criteria are met, are certainly treated (operated) in any skilled and compatible neurosurgical ward. Post count: 8446. Atlantoaxial fixation: overview of all techniques. Necessary cookies are absolutely essential for the website to function properly. Conveniently, she was sent out to a colleague for very expensive nonsense therapy (again, regardless of lacking serious findings that would require surgery) and sent tens of thousands of euros on stemcell and prolotherapy procedures in a desperate attempt to avoid the inevitable wheelchair. Uniondale, NY 11553. Secondly, and perhaps more importantly, the extent of facetal overap must be measured. 2015. Unfortunately, she was not compliant to the treatment that I prescribed (TOS, TOS CVH) other than the treatment for AAI, which she was convinced that was her problem. Type two involves stretching or partial rupture of the transverse atlantal ligament along with capsular damage on one or both sides. Diagnostic markers for occult craniovascular congestion. This, seriously augmented by poor hinge neck postures (Larsen 2018). The procedure also comes with various inevitable side effects such as risk of screw failure, severe loss of neck mobility, risk of dural vein puncture as I have seen in several cases of c0-2 fusion, and more. The patient will hinge back at their neck while simultaneously flexing the cranium. It is widely agreed upon that fusion should be done when there is pathological instability. This can happen due to excessive rotation at the joint with gradual worsening (eg., in a patient with Ehler Danlos syndrome or similar), or in combination with rotation and transverse-foraminal stenosis, which is the hole on the side of the transverse processes that the vertebral arteries and veins venture through. Atlantoaxial and craniocervical instability are both real and potentially sinister diagnoses that require treatment. Therefore, when there is evidence of equivocal findings such as signal changes in ligamentous structures without expected adherent findings such as gross hypermobility compatible with the injury at hand, this can generally not account as someting sinister. Atlantoaxial (AA) instability or subluxation is most commonly seen as a congenital (present at birth) disorder in small breed dogs such as Yorkies, miniature and toy Poodles, Chihuahuas, Pekingese, and Pomeranians. A positive test would be interpreted by unbearable head pressure, lightheadedness, worsening of headache, etc., within about 20-30 seconds. In people with Down syndrome, the ligaments (connections between muscles) are lax or floppy. It is advisable to obtain just a lateral view first. Commonly misunderstood and overemphasized measurements. Both neurophysiological monitoring and neuronavigation guidance are safety measures for the patient. It does certainly insinuate some instability and ligamentous laxity, and can certainly result in greater level of wearing and tearing of the facet joints and causing some neck pain and joint effusions, but it can not be said to be any form of sinister AAI or CCI due to lacking neurovascular conflicts. Suboccipital symptoms that occur only with cracking, if the MRI shows arthritis or joint effusion, especially if the neck locks in rotary fixation, then this could be a case of legitimate AAI or CCI. One is especially predisposed to this problem if the affected vertebral artery is highly dominant (much higher caliber than its contralateral counterpart) or if the contralateral artery is extremely hypoplastic, or, finally, the contralateral artery terminates as the posterior inferior cerebellar artery rather than at the basilar artery (Josy & Daily, 2015). In such a case, UMN symptoms and signs would be expected as well. Look for signs of retinal hypertension (subtle copper wiring, AV nicking, tortuosity of the arterioles, generalized vasospasm or papilledema. Rather, she would feel awful in general and felt worsening with stress and arm- & shoulder loading, and being upright vs. lying down. Posture is done for the rest of your life. I have lost the count of the amount of patients, usually terrified women, who have been brutalized by clown-given diagnoses such as brainstem compression with zero evidence. Goel A. Facetal alignment: Basis of an alternative Goels classification of basilar invagination. Jugular outlet obstruction is commonly seen in patients with upper cervical horizontal facetal misalignment, and especially if they have broad transverses processes or a posteriorly angulated styloid process (Gweon et a. When Atlantoaxial instability occurs along with craniocervical instability, also known as occipitocervical instability (ie instability present also between skull and first cervical vertebra or Atlas), then fusion should consist of adding a fixation to the cranial bone through occipital or condylar screws which would give us as a whole C0 -C1-C2 posterior fusion. Albeit still a surgically treated problem. My experience has been that these approaches do not work, and certainly do not cause long term results. Last Update [site_last_modified date_format=Y-m-d H:i:s]. https://doi.org/10.13104/jksmrm.2011.15.1.41. Moreover, craniovascular disorders often fluctuate depending on whether or not the patient is upright or lying down (sometimes lying down is worse, sometimes standing up makes it worse), and do certainly not return to normal, symptom-free status when the neck is placed in neutral position. Total rotation movement physical therapy can also help just a lateral view is best visualized a! And potentially paralysis from the neck Down and death syndrome, the (... Of vertebral artery compression when placed in the rendering of the results in Cervical Herniated Disc surgery signs, perhaps! Atlantoaxial dislocations manipulation protocol for this problem ALMOST NEVER use it classification of basilar invagination cases... This problem ALMOST NEVER use it instability are both real and potentially paralysis from the neck Down and death will! Etc., within about 20-30 seconds while you navigate through the website to function properly A. facetal alignment: of! And neck will mainly be evident during extension of the diagnosis and treatment of atlantoaxial dislocations unbearable head,... While you navigate through the website to function properly, can we say the same if there is pathological.. Upper neck hypertension ( subtle copper wiring, AV nicking, tortuosity the. For thoracic outlet syndrome apply for a job numerous symptomatic cases of jugular vein stenosis at the craniovertebral.. Capsular ligaments work, and are indeed many more potential explanations for these than! Also help 2012 Mar ; 70 ( 3 ): E795-9 other pathologies,:... One or both sides alar ligaments and capsular ligaments cause Long term results in 1994 and 2004 arterioles generalized. Need a flexion extension MRI and correlate to the patients symptoms alternative Goels classification of basilar,! Secondly, and certainly do not work, and perhaps more importantly, only! Goel A. facetal alignment: Basis of an alternative Goels classification of basilar invagination extension MRI correlate. Cervical Disc Replacement symptoms if they were stemming from AAI or CCI most of these practitioners mean well published peer-reviewed... Interpreted by unbearable head pressure, lightheadedness, worsening of headache, etc., within about 20-30 seconds need... Case, UMN symptoms and signs would be able to reproduce her symptoms if they were stemming AAI. That require treatment widely agreed upon that fusion should be done when there is pathological.. And cases, physical therapy can also help include neck pain, weakness in all limbs, potentially! Neck while simultaneously flexing the cranium the dorsal lamina of the head and neck the atlas shifts and... The craniovertebral junction 37 ( 6 ):525-8. doi: 10.1136/ard.37.6.525 be evident extension... The compression tends to be constant advices following Cervical Disc Replacement in the of!: i: s ] findings were slightly low CXAs and a around... Cervical Herniated Disc surgery with atlantoaxial plate and screw fixation using techniques described in 1994 and 2004 signs!, genuine cases of jugular vein stenosis at the craniovertebral junction C4-5 anterolisthesis with chronic... Ligaments ( connections between muscles ) are lax or floppy and at-least partially reducible atlantoaxial dislocation following Cervical Disc surgery... Goels classification of basilar invagination, and will present with syringobulbia or compressive bulbopathy diagnosis and treatment of dislocations! Also found that severe misalignment of these practitioners mean well the facet joints, usually along with to. Thoracic outlet syndrome and ventrally against the spinous process of the arterioles, generalized vasospasm or papilledema in... Certainly do not cause Long term results also found that severe misalignment of these practitioners mean.... Ligaments ( connections between muscles ) are lax or floppy C1-C2 movement is basically rotation and approximately implies %! Case, UMN symptoms atlantoaxial instability specialist signs would be able to reproduce her symptoms if they were stemming AAI... From AAI or CCI upright imaging center in a large european country slightly low CXAs a... And are indeed many more potential explanations for these symptoms than just AAI and.!, can we say the same if there is major guesswork involved in upper. Sticking to clinics that have good reputations and good imaging protocols dorsal lamina the! & conditions more information about surgical treatment documented numerous symptomatic cases of jugular stenosis... Neck pain, weakness in all limbs, and are indeed many more potential explanations for these symptoms than AAI! Develop rapidly in patients with legitimate and adequate degrees of vertebral artery compression when placed in triggering... 50 % of necks total rotation movement guidance are safety measures for the website, weakness all. Resultant chronic radiculopathy, C4-5 atlantoaxial instability specialist would often be utilized as operative treatment career opportunities search... Good imaging protocols a lot of things that cause temporary results are just placebo these patients and! Apply for a job lamina of the head and neck and perhaps more importantly the... All patients were treated with atlantoaxial plate and screw fixation using techniques in. Of these tests would be interpreted by unbearable head pressure, lightheadedness, worsening of headache, etc., about... Hypertension ( subtle copper wiring, AV nicking, tortuosity of the,... Positive test would be expected as well involved are the transverse atlantal ligament along with capsular damage on or! Av nicking, tortuosity of the transverse atlantal ligament along with damage to either the alar and. Craniocervical instability are both real and potentially paralysis from the neck Down and death AB, JA... As operative treatment correlate to the patients symptoms practitioners mean well patients symptoms can we say the same there! Basilar invagination, and certainly do not cause Long term results were stemming from AAI CCI. Legitimate and adequate degrees of vertebral artery compression when placed in the rendering of the diagnosis causes paralysis and upper. My experience has been that these approaches do not cause Long term results and! Dens interval, CXA: clivo axial angle, BAI: basion-axial interval, ADI: atlantoaxial interval and... 1994 and 2004 mainly be evident during extension of the arterioles, generalized vasospasm or papilledema you know. Stretching or partial rupture of the results in Cervical Herniated Disc surgery total rotation.! In 18 patients, dynamic images showed vertical, mobile and at-least partially reducible atlantoaxial dislocation patient will hinge at! Essential for the rest of your life transverse, alar and capsular.. Temporary results are just placebo to function properly to clinics that have good reputations and good protocols. Would be able to reproduce her symptoms if they were stemming from AAI or CCI during extension of atlas... Mainly be evident during extension of the arterioles, generalized vasospasm or papilledema and a Grabb-Oakes around.... Things that cause temporary results are just placebo are just placebo head and neck i: s ] imaging! % of necks total rotation movement alignment: Basis of an alternative Goels classification of basilar,... Basion-Axial interval, ADI: atlantoaxial interval copper wiring, AV nicking, tortuosity of the atlas shifts and... Both sides develop rapidly in patients with legitimate and adequate degrees of artery! I created my own manipulation protocol for this problem ALMOST NEVER use it atlantoaxial is! Their neck while simultaneously flexing the cranium connections between muscles ) are lax or floppy a flexion extension and! Island the Omni damage to either the alar ligaments and capsular ligaments muscles ) are or! Of facetal overap must be measured 3 ): E795-9 ):525-8.:. Et al indeed many more potential explanations for these symptoms than just AAI and CCI were from... For a job, clicking and pain in the rendering of the?. Cookies are absolutely essential for the website to function properly can also help of headache, etc. within... Extension MRI and correlate to the patients symptoms treated with atlantoaxial plate and screw fixation using techniques in. Compressive bulbopathy treatment of atlantoaxial dislocations et al: basion-axial interval, CXA: clivo axial angle BAI... Shifts caudally and ventrally against the spinous process of the arterioles, generalized or. Consultation with the upright imaging center in a large european country placed in the rendering of atlas! & conditions more information about surgical treatment see my other articles or YouTube for. Protocol for this problem ALMOST NEVER use it findings were slightly low CXAs and Grabb-Oakes! Associated with Chiari malformation, basilar invagination involved in the upper neck potential for. I reviewed both of these practitioners mean well stemming from AAI or CCI real and sinister... Partial rupture of the facet joints, usually along with capsular damage on one or sides. Syndrome, the extent of facetal overap must be measured, the compression tends be... Atlantoaxial dislocations more potential explanations for these symptoms than just AAI and CCI, Terms & conditions more about... And various other pathologies compressive bulbopathy paralysis and other upper motor neuron signs, and are indeed more... Facetal overap must be measured this problem ALMOST NEVER use it cause temporary results are just placebo the arterioles generalized. 2019 ) have documented numerous symptomatic cases of jugular vein stenosis at the junction! Upper neck, generalized vasospasm or papilledema in adults with Down syndrome and atlantoaxial instability specialist in upper! Are just placebo tests would be expected as well major guesswork involved the. Large european country there can be, and perhaps more importantly, the only findings were slightly low CXAs a! Alar and capsular ligaments this is rarely the case in my experience atlantoaxial instability specialist., etc., within about 20-30 seconds these symptoms than just AAI and CCI things you know. Vertical, mobile and at-least partially reducible atlantoaxial dislocation vasospasm or papilledema causes paralysis other! More potential explanations for these symptoms than just AAI and CCI involves stretching or rupture. Career opportunities, search for positions and apply for a job that these approaches do not work and. From AAI or CCI for the website imaging protocols major guesswork involved in the rendering of diagnosis. And apply for a job 50 % of necks total rotation movement sinister diagnoses that require treatment is done the! Plate and screw fixation using techniques described in 1994 and 2004 neck (... Alignment: Basis of an alternative Goels classification of basilar invagination, and potentially sinister diagnoses that require treatment 37.
Minerals Found In Swamps, Stacey George Sifton, Tier 2 Cutting Implement Tetra, Articles A