[smg91]

#28454

First, thank you for moderating this site. For the past couple of weeks I have read and learned a lot! All doctors should care so much!

My daughter, now sixteen, has been suffering from 24/7 migraine-like headaches (with vertigo, double vision and mild nausea, light and sound sensitivity). The pain started behind her eyes and now stretches over her forehead along the centerline. Vertigo and double vision used to be intermittent brought on by physical activity, but now they are constant. She was treated for years by the same neurologist for Chronic Migraine (so a host of ineffective drugs, IV cocktails, DHE, etc.) and only Botox was found effective. She became resistant to Botox two years ago (doesn’t even quell muscle movement). Second opinion from the Cleveland Clinic was New Daily Persistent Headache given its 24/7 nature greater than 3 months in duration with a rapid onset (after an acute inflammatory infection) that she can remember.

This lead me to Dr. Todd Rozen’s work who found that many of his NDPH patients were hypermobile, and over 90% had some form of cervical spine issue that had been undiagnosed. We learned my daughter is hypermobile and her upright MRI found high grade lesions in five key static stabilizers of the CCJ, “the constellation of findings consistent with sequela of hyperextension/flexion/hypermobility stress of the craniovertebral junction.” A re-review of her earliest MRI shows key lesions and evidence of spinal degeneration when she was twelve. While the MRI didn’t point to significant instability, we had a DMX performed recently (and I have read about your concerns regarding this technology) and it was very revealing. She has now been diagnosed with Spinal Instability (M53.2X1 and M53.2X2) and Cervicalgia (M54.2).

In the past year she developed a stabbing pain in her cheek (at first once sided, but then both sides), numbness and tingling in her arms and fingers, balance and coordination difficulties and chronic early gastric emptying. Could these new symptoms be related to the degeneration in her lower spine? Given her physical de-conditioning PT has been recommended, and some suggest it for her injury as well, but I have concerns that this might be more damaging than beneficial. Any suggestions or thoughts?

A summary of the MRI and DMX findings are:
1) attenuation of several of the key elements of the ligamentous and membranous static stabilization mechanisms of the cervico-occipital junction
– hyperintense signal in bilateral alar ligaments greater than two thirds, consistent with high-grade lesions of the alar ligaments bilaterally
– thinning and disruption of the tectorial membrane bilaterally
– thinning and disruption of the transverse ligament bilaterally
– myo-dural bridge dural defect in the PAOM/dura matter complex
2) non-union of the posterior arch and significant lateral tilt, rotation and hypermobility of C1
3) significant lateral translation of C1 on C2 with an overhang bilaterally up to 6.3mm on left bending, 5.3mm on right bending; substantially greater bilateral overhang on lateral bending with chin protruded
4) significant asymmetry bilaterally of the lateral atlanto dens interval (LADI) between left and right bending
5) anterolisthesis C2-3 (4.4mm), C3-4 (3.3mm), C4-5 (3.6mm), C5-6 (2.7mm), C6-7 (2.7mm)
6) retrolisthesis C3-4 (2.1mm), and C4-5 (3.6mm)
7) bilateral gapping of the facet joints C5-7
8) bilateral intervertebral foraminal encroachment of the facet joints C3-5 (severe left and mild to moderate right)
9) disc protrusions C3-7 indenting the thecal sac with close proximity to the spinal cord at C3-4
10) ligamentum flavum hypertrophy with mild facet joint arthropathy, narrowing the posterior aspect of the spinal canal and contacting the spinal cord at C3-4
11) straightening of cervical lordosis

Again, thank you for your time.
S

[Donald Corenman, MD, DC]

#28456

You have to be very careful when using Motion MRI findings due to poor resolution and image quality. DMX (motion X-rays) can be over-interpreted leading to diagnoses that are not necessarily accurate. I understand your dilemma with your daughter and I would look for answers like you are currently searching.

The data for implicating the upper cervical ligaments is limited and the only solution at the present time (if the diagnosis is accurate which I am not suggesting) is fusion of Occiput-C2 which takes 50% of your daughter’s neck motion away. You can put her in a restrictive collar for a week or so and if her symptoms improve significantly, this does give some minor credence to some type of cervical instability causing your daughter’s symptoms. What if you had her undergo this surgery and your daughter’s headaches are no better but she is now worse off due to loss of neck motion?

Dr. Corenman

PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
 
Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.

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