A Review of Prolotherapy injections for Craniocervical instability with Ross Hauser, MD
Ross Hauser, MD reviews Prolotherapy injections for Craniocervical instability. The basis of this video is to help answer many of the questions we receive in regard to the challenges of upper cervical instability. In this video Dr. Hauser answers the common questions:
- What is Craniocervical instability?
- Do you treat C0-C1?
- When do you use guidance for treatment?
- Why don’t you use guidance for every injection?
Below the video are explanatory notes.
Fluoroscopic and radiological imaging
At 0:35 of the video: Dr. Hauser discusses the Turner mini-arm smart C. The Smart-C is a small, full-capability mini C-arm. It is a battery-operated system, that allows us to perform full fluoroscopic and radiological imaging.
This is a convenient unit with a very small almost no radiation exposure. We use this unit to help our patients with upper cervical instability.
At 1:10 of the video: A discussion of craniocervical instability.
- Craniocervical instability is when the head, is not being supported and held in place by the upper cervical vertebrae boney attachments. The head and the neck are not stable. In other words, when the person goes about their daily activities, the ligaments, those soft tissues that hold the vertabrae of the cervical spine together, are not doing that job and are not supporting the vertebrae. The neck bones are then moving and wandering in destructive ways and can cause the development of bone spurs and osteoarthritis.
The “neck hinges” have loose screws: What are we seeing in this image?
The progressive nature of an injured cervical ligament and loose screw of a door hinge. When the head and neck are not stable they wander off alignment. These malalignment forces on the ligament or the screw (as we are using in this example) are not removed, the problem will progress to adjacent ligaments and screws eventually causing ligamentous cervical instability and a “loose neck hinge.” Chronic ligament injuries “loose screws” do not heal on their own. The ligament needs to be treated (Using Prolotherapy discussed below)
The vertebrae of the cervical spine and all the joints in the body have a little bit of play. The ligaments are strong rubber band-like attachments that can stretch a little, but when the ligaments are weak, they become loose screws and the neck joint “hinges” do not hold the cabinet doors in place. The cabinet doors, like the vertebrae, start banging against each other and cause destructive wear and tear at the point where the door panels meet.
When the ligaments in the upper neck, specifically the capsular ligaments, the main stabilizing structures of the facet joints in the cervical spine that are implicated as a major source of chronic neck pain, get stretched out specifically at C1-C2, and the person goes through the motions of their head the bones float and wander into positions and areas that they are not supposed to. I call that destructive bone movement or destructive joint movement. This can cause bulging discs and herniations and nerves, jugular vein, and carotid artery compression.
Specifically, because the vagus nerve and the jugular vein basically sit on top of the vertebrae, when the vertebrae move in positions that they are not supposed to move in, it can damage the vagus nerve or it can impair or block nerve transmission.
At 2:45 of the video
The caption of this image reads Cervical instability-induced vagus nerve compression. Left: Rotation and smashing of the vagus nerve on one side. The right side panel is the view from the bottom of the skull up.
Condition severity scale caused by cervical instability
The caption reads: When cervical instability causes blood flow ischemia to the brain and impairs the homeostatic system (autonomic nervous system ANS) of the body, the medical condition can be extremely serious.
This compression can cause blood flow into the brain, and, out of the brain to be affected and compromised. Once fluid flow into the brain is compromised and nerve communications into the brain are compromised, people will develop the various neurologic-like, cardiovascular-like, and psychiatric-like symptoms typical of this problem.
Injections with and without x-ray guidance and ultrasound guidance
A doctor who has a lot of experience giving injections can learn through experience how to give injections safely and effectively without x-ray guidance or ultrasound guidance. I have been providing Prolotherapy treatments for 30 years. The first half of my career, the first 15 years of offering treatments, I did not use guidance. Many people would ask, “well how would you know what to do or where to inject?”
In the mid-1990’s I worked at Loretto Hospital in Chicago. I was the director of the pain clinic there. They had a C-arm for injection guidance. I did many different types of injections under C-arm and over time I started to learn where was the proper places to insert the needle. The key point here is that the more time it took to give the injections, that is with the guidance, the more the patient would be charged.
When a doctor does Prolotherapy in the neck and uses imaging for every single injection, the treatment will cost a lot more. A doctor who takes five times as long to do the injections will charge significantly more. So, at the start of my career, I wanted to make the treatment as affordable as possible by using my knowledge and experience and by learning how to give injections without guidance.
I would use guidance in upper cervical spine injections because we need to know where the vertebral artery is. When I first treat a patient I use ultrasound guidance, not x-ray guidance because I have to see where the vertebral artery is.
Knowing the location of the vertebral artery because it wanders
The vertebral artery wanders. In the image below the caption reads: The Hauser wandering vertebral artery between the atlas (C1) and the axis (C2). Altanto-axial (C1-C2) instability can cause vertebral artery compression when the vertebral artery goes lower in the back of the neck because of cervical instability and cervical dysstructure or a broken neck structure.
In the image below a low-lying vertebral artery is shown on the right with a black arrow. This Hauser wandering artery makes the artery more prone to compression between the atlas (C1) and the axis (C2), especially with extension.
The injections are primarily periarticular – meaning around the vertebrae, not into the discs or spinal canal areas. Periarticular injections are given where the ligaments attach to the bone. The emphasis is on the outside of the joint versus the inside of a joint. A small amount of the injectable goes into the inside of the joint. Why the outside of the joint? The pain and cervical instability are caused in many people by loose or lax ligaments and that is what we are treating, the ligaments attach on the outside of the joint.
Cone Beam CT Scan
At our center, for new patients, we will perform a Cone CT Scan and a Digital Motion X-ray so we have 3-D views of the patient’s head and neck.
We have a very extensive article Upright Cone Beam Computed Tomography (UCBCT) at The Hauser Neck Center that explains this technology. Here is a summary:
Upright cone-beam computed tomography (UCBCT) is a radiographic imaging method that creates three-dimensional imaging of the bony structures of the head (cranium), neck (cervical spine), and facial bones; joints in these areas; as well as the dentoalveolar (teeth/gum) structures, nasal/oral-pharyngeal airway, and neurovascular structures and canals.
Cervical Digital Motion X-ray (C-DMX)
Cervical Digital Motion X-ray (C-DMX) – This modality is essentially a video-fluoroscopic x-ray movie of the spine in motion. The procedure is completed with a device resembling a conventional C-arm. However, far less radiation is utilized than theoretically would be emitted with a conventional C-arm, due to the use of digital processing technology.
Please see my article Ross Hauser, MD. Reviews of Diagnostic Imaging Technology for Cervical Spine Instability.
Dr. Hauser explains the injections given without guidance
The video starts at the 10:35 point where the treatment begins.
Summary and contact us. Can we help you? How do I know if I’m a good candidate?
We hope you found this article informative and it helped answer many of the questions you may have surrounding Craniocervical Instability, upper cervical spine instability, cervical spine instability, or simply problems related to neck pain. Just like you, we want to make sure you are a good fit for our clinic prior to accepting your case. While our mission is to help as many people with chronic pain as we can, sadly, we cannot accept all cases. We have a multi-step process so our team can really get to know you and your case to ensure that it sounds like you are a good fit for the unique testing and treatments that we offer here.