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Atlantoaxial degeneration with myriad of symptoms.

Hello everybody.

I recently had a cervical MRI which revealed the following:

Findings:
No C1-C2 dislocation identified. Moderate degeneration of the atlantoaxial joint noted however.
Normal vertebral height and alignment and marrow signal pattern.
No recent bony injury.
Mild upper thoracic spondylosis with anterior marginal osteophytes noted at T2-T3.
No sign of inflammatory spondyloarthropathy.
Normal craniocervical transition.
Small posterior disc bulge at C4-C5 however no evidence of neurological contact or compression.
No nerve root compression identified.
Normal neural foramina.
Normal spinal canal and thecal sac. No thecal sac compression or myelopathic change.
Paravertebral soft tissues are unremarkable.
CONCLUSION:
No C1-C2 dislocation identified. Moderate degeneration of the atlantoaxial joint noted however.
Small posterior disc bulge at C4-C5 however no evidence of neurological contact or compression.

Prior to this I started seeing a physiotherapist some 6 months ago and have had about 10 hours physio and more recently 3 chiropractic sessions. I sought help not due to pain, but because I had an apparent scoliosis when looking in the mirror. My right shoulder was winging and my range of motion was limited particularly in my neck where I would find myself moving my whole body as opposed to turning my head when looking left or right. Right trapezius was and is contracted, as pointed out my physio and GP. Several ECGs resting heart rate 100. My head was stuck to the left. After cervical/cranial work of physio I would experience dizziness, confusion, blurred vision, vertigo, anxiety and fainting when stretching my neck. After 10 hours physio my range of motion had improved, but my breathing, although remedied for a day or two after physio, was still limited in that I felt I could only fill half my lungs with air. Immense spinal pain after going for a run a few days after physio on my back. Anti-inflammatories helped massively.
Recent chiropractic care including C1-C2 adjustment and shock wave therapy of the shoulder socket. Now after stretching my neck I experience visual and, to a lesser extent, auditory disturbances, but not vertigo, fainting, anxiety or confusion. X-ray prior chiropractic care show atlantoaxial joint out of alignment to the right. There is now a constant mild occipital headache, which extends to the eyes and forehead. Plenty of crepitus in the atlantoaxial area, cervical and thoracic. When I tilt my head back I find my breathing is better in that I can take in a full breath of air. Heart rate is now within range.

History:

2 years ago motorcycle accident - came off at 15 mph and landing on my right side and rolling a few times sideways. Suspected bruised ribs, but never pain in the neck (this only happened after starting physio and chiropractic care).

7 years ago diagnosed with bipolar disorder and ADHD. Treatment of depression required extensive pharmacological treatment including citalopram, trazodone, seroquel, lamotrogine. The depression was tough to combat and despite not feeling depressed I cannot function even remotely as I once could in an academic sense. Until shortly before turning 18 I was a high achiever at school in the top 10 academically, but the latter part of my final year is when my troubles managing my academia started. The following year I dropped out of university after less than a month failing tests where I once accepted no less than an A. 3 further university attempts have all ended the same way despite being medicated in the latter 2.

I was born one of a triplet weighing in at 4 pounds (1.8kg). Born at 35 weeks after I induced labour. I was positioned below my siblings and it is postulated that I was put in a state of stress causing my brain to mature faster (IUGR never diagnosed, but I am certain I had growth restriction. My siblings where within normal weight). I was much smaller than them, but didn't require incubation as they did.

I went bungee jumping the same year the academic difficulties started.

5.9 in height, I have grown nearly two inches since chiropractic care.
77kg (170lbs)

Any theories on the cause and if you think fusion surgery of the C1-C2 vertebra is imminent? Also, what are the negatives of such an operation with specific reference to ROM, the risks and overall success rate?

4 Responses
Avatar universal
Please note I am 27 years old*
1081992 tn?1389903637
HI, Ryan. Let's try a diffent avenue of thinking other than about the degeneration, and focus for the moment on the bone cracking procedure.

"Adverse effects of spinal manipulation: a systematic review"  2007
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1905885/
"The most serious problems, which some experts now describe as ‘well-recognized’, are vertebral artery dissections due to intimal tearing as a result of over-stretching the artery during rotational manipulation. This seems to occur most commonly at the level of the atlantoaxial joint. Intimal injury can be followed by intramural bleeding or pseudoaneurysm formation, which can result in thrombosis, embolism or arterial spasm."

The vertebral arteries supply the brain, the intima is one layer of an artery, dissection in this setting means tearing by stretching via rotation, and pseudoaneurysm roughly means a bulge caused by a mass of blood that bled into a space.

What we'd need next is to know is if (1) your MRI would have seen any pseudoaneurysm, or otherwise is some special sequence or contrast or whatever else necessary?  (2) could a pseudoaneurysm in the vertebral artery cause your symptoms? I don't know those answers, but maybe somebody (ahem) will come along who knows MRI and also the relevant neck anatomy. It might help to post the section of your MRI report that tells the type of MRI that was done. Any arterial spasm would never be seen, of course, unless it was happening right during a scan.

Here's a nice diagram showing the tortuous route of that artery and therefore how stretching could occur:
https://sciencebasedmedicine.org/upper-neck-manipulation-caveats-for-patients-and-providers/
Though from that figure, I don't see how a pseudoaneurysm might press on a nerve - but that's just guessing. I also note the text, that "It is generally accepted that neck manipulation is most dangerous when there is thrust-type manipulation with rotation in the upper cervical area." Whatever 'thrust-type' means, and if you had that... All the other text there might be relevant, too.

Or maybe there was some nerve damage. Maybe your previous bike spill and the bungee thing had setup your anatomy (possible stiffness?) and thereby made you vulnerable, whereas most people aren't vulnerable - after all, these injuries are said to be quite rare.

So that's all a possible start to understanding.

Btw, you might already know that MDs and chiros can be like lions and hyenas, and each might say the other are the hyenas :)
2 Comments
Hi, Ken, many thanks for your reply.

The cervical manipulation was done about 3 weeks ago where my problems have existed for what I believe to be a matter of years. That's not to say, of course, that damage hasn't been done. The manipulation was gentle in nature and not the stereotypical idea one might have of a rapid twist of the neck, but being in such a delicate area who knows.  

I do have pain in the neck and upper back, which I've had for sometime (not sure if I actually stated that in my opening post), which I understand to be related to muscle contracture of the trapezius or at least in part due to this.

Many thanks!
I have no idea what's going on with you, but most of the time -- and this doesn't mean y0u, it means most of the time -- pain in the neck and back aren't due to any irregularities in the spinal column.  Everyone has them.  Usually, pain is muscular even when there are irregularities.  From your description nothing was found to be wrong with your spine other than some minor stuff that you'd find in most of us.  Now, I've been through this for a long time, my cervical spine is disappearing.  I've never personally had any success with chiropractors with the back or the neck, though I have had success with other things ironically, such as rib problems.  Some benefit from them and some don't.  Some are pretty rough, but most aren't, and most won't do anything that abrupt in the beginning of treatment.  They can be pretty good at diagnosis, though, such as pointing out that old auto accidents, and I had one who even told me how long ago the accident in question was, can cause inflammation that, if not addressed -- and doctors never ever address this, they only look for broken bones and internal injuries -- in some fashion will become chronic and start degrading not only the spine but posture and range of motion and muscle tension.  That doesn't explain, however, all the different things you're experiencing.  If you're going to get PT, get it from a physical therapist, not a chiro -- I made that mistake and haven't been able to go the gym since.  But I've also found that physical therapists aren't that great either -- obviously some are probably primo but we don't know who we're seeing when we see medical practitioners, really.  Good reviews usually indicate they were good a few years ago, not necessarily anymore.  Impossible to know.  Which is why I'd be very hesitant about surgery -- a very large portion of the opiate epidemic is from unnecessary or failed or just plain botched surgeries by orthopedic surgeons so unless it has to be done, don't do it.  But that doesn't say what to do, and if I could answer that, I would, but I can't.  Just keep trying.  But again, you're describing more than just pain, you're talking about visual disturbances and breathing problems and such so you need more evaluation, I think.  Keep the hope.
1081992 tn?1389903637
Good morning, Ryan.

"The cervical manipulation was done about 3 weeks ago where my problems have existed for what I believe to be a matter of years."

Right, but I'm dividing your narrative into before-and-after the chiro. You had certain symptoms before the chiropractor, of which many or most were correctly resolved by the chiro. But after the chiro, you have new symptoms: "Recent chiropractic care including C1-C2 adjustment... **Now** after stretching my neck I experience visual and, to a lesser extent, auditory disturbances... There is **now** a constant mild occipital headache, which extends to the eyes and forehead."

Intermingled in that paragraph were the symptoms that were relieved by the chiro: "vertigo, fainting, anxiety or confusion...  When I tilt my head back I find my breathing is better in that I can take in a full breath of air".

Am I not correct? There were symptoms which were caused by the subluxation. The chiro fixed the subluxation, so most of the old symptoms disappeared as intended -- but it's possible that the procedure introduced the new symptoms.


"The manipulation was gentle in nature and not the stereotypical idea one might have of a rapid twist of the neck..."
Well, that's a point but the speed or forcefulness might not matter as much as the range of any stretch that was applied, since a vessel is easy to damage. It's also possible, I suppose, that your previous accident resulted in lessened mobility of the other cervical joints, so that when twisting the neck mostly all of the force went to the atlantoaxial joint.  

"...but being in such a delicate area who knows."
Yep, and that second article I cited tells of how some believe that a chiro should never twist the neck - except that maybe some who explicitly specialize in neck manipulation might sometimes do so. I'd heard that myself at least a decade or so ago.

Btw. if you happen to have inflexible or overly flexible joints, that can be due to a connective tissue disorder which in turn might make you more vulnerable than average to spinal problems.













1 Comments
I have no doubt that bad chiros can cause problems, but when they adjust your neck they don't "twist" it, they very carefully place their hands underneath the neck and move it side to side and not all that much.  I don't know if this does anything positive, but I doubt it very often does anything all that negative, either, except in the sense that all medical professionals are bad at their jobs either all of the time, some of the time, or once in awhile just as everyone else is.  And they usually have no idea what's really wrong with us.  Medicine has a long long way to go before we can really tell what's going on exactly.  That's why I mentioned that, although chiros probably do things that go wrong, so do orthopedic surgeons and other doctors.  Just saying, it's not the type of medicine practiced as much as it is that medicine is more an art form than science, as scientifically we know much less than advertised, and the advertising is done to make money as much as it to inform.  So you keep looking until y0u find a professional in whatever form who's really really good at it and gets you the help and answers you need and we need all be careful about anything that might just cause more harm unless it's necessary.  Peace, all.
1081992 tn?1389903637
If Ryan indeed had zero neck rotation applied, that logically leaves at least three possibilities:
1- the onset of new symptoms after the chiro visit was pure concidence. That's always possible, but seems extremely unlikely.
2- the chiro caused direct harm via some unknown direct method of action.
3- the chiro visit caused harm via some strange indirect MOA, which kinda fits in with how Ryan experiences visual and auditory disturbances despite the fact that those nerves don't travel through the spine (they go straight to the brain or brainstem).

Any other possibilities?


Speculating on #3 above: in cervical vertigo, the nerve for balance also does not go through the spine. "There are a number of potential causes of cervical vertigo... [including] tearing of these arteries (dissection)... The dizziness is caused in these cases by a disruption of blood flow to the inner ear or to a lower brain region called the brain stem."
https://www.healthline.com/health/cervical-vertigo


This all is getting very complicated, but then if it was simple his docs would have solved it by now.
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