3. For occipial neuralgia, an ultrasound guided nerve block will cure these symptoms for three hours and thus confirm the diagnosis. The bones are susceptible to fracture from high-energy impact such as falls or car accidents, especially in the elderly. Uniondale, NY 11553. 1978 Dec;37(6):525-8. doi: 10.1136/ard.37.6.525. This site complies with the HONcode standard for trustworthy health information: verify here. Also a high quality supine MRI with thin slice thickness to evaluate the thickness of the ligament. 3-Cranio-atlanto-axial instability, levels C0-C1-C2. Therefore before proposing surgery, the evaluation of each case must be done really carefully. Org. Larger breeds can also be affected, and any dog or cat is at risk of a very similar acquired injury if they sustain trauma, such as being hit by a car. Basil R. Besh, M.D. What cervical artificial disc should I choose? This is reasonable. In my experience, we would expect to see at least 20mmHg maximum venous pressures. Now, what if there is no frank compression nor clinically medullary signs and triggers, but there is a very small space both infront and behind the medulla that has been gradually getting worse. 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. Elsevier Publishing. Although there were no current grounds for surgery? And, fair enough, I do not expect blind trust nor compliance. Treatment is via one of two methods: If you or your veterinarian is concerned that your pet may have AA instability, please schedule a consultation with our Neurologist by calling us at our Manchester or Newington location today. The joint between the upper She was never evaluated for clinical correlation for these alleged findings, ie., no one evaluated if these findings had actual compatibility with her clinical symptoms and, especially, triggers. PMID: 19769514. Call us: 212.774.2837 If the patient has an elevated Grabb-oakes interval of 10mm and low CXA of 130 degrees, there is some horizontalization (upwards deflection) of the medulla, but no compression from both sides. Dynamic angiograms could also be applicable in certain circumstances, cf. In dogs with atlantoaxial subluxation, instability of the atlantoaxial joint results from a loss of ligamentous support of the axis, often with concurrent aplasia, hypoplasia or dysplasia of the dens. J Neurol Surg B. DOI: 10.1055/s-0039-1677706, Perez MA, Bialer OY, Bruce BB, Newman NJ, Biousse V. Primary Spontaneous Cerebrospinal Fluid Leaks andIdiopathic Intracranial Hypertension. The patient will hinge back at their neck while simultaneously flexing the cranium. Patient resources for the Down Syndrome Program. Copyright Dr Gilete Neurosurgery & Spine Surgery. Foramen magnum decompression or syrinx manipulation was not performed in any patient. Due to the instability in the craniocervical junction deformation can occur to the brainstem, upper spinal cord, and cerebellum. For example, although the medical literature (almost exclusively biased reports written by people considered experts on the topics (I am also biased on the topic; all experts are) may suggest a clivo-axial angle lower than 150 degrees as abnormal, this is still a measurement used to associate concrete craniocervical angles with medullary compression. If the patient is indeed positionally symptomatic, however, and there is compatible imaging evidence, either atlantoaxial fusion, transverse foraminotomy or certain physical therapies may be warranted depending on how severe the findings and symptoms are. Yang SY, Boniello AJ, Poorman CE, Chang AL, Wang S, Passias PG. PMID: 24475346; PMCID: PMC3899735. However, as stated, in most cases this is just locked facets that suddenly reduce (realign) with a pop. From the beginning, the patient doubted my diagnosis that this was a craniovascular problem because she felt pain in the suboccipital area, had cracking and clunking, and felt compatible with several things she had read online and on facebook forums. If the patient has a Grabb-Oakes of 18mm, however, and the transverse ligament is ruptured with the dens compressing the brainstem from the front and pushing it into the lamina behind it, then this is an emergency that requires timely surgical decompression. It is not a substitute for medical advice and should not be used to treatment of any medical conditions. 15 Piscataqua DriveNewington (Portsmouth), NH, 03801 603-431-3600, 8 Maple Street, Suite 2 Meredith, NH 03253 603-279-1117, 2023 All rights reserved | Sitemap | Legal | Law Firm Essentials by PaperStreet Web Design, Caudal Cervical Spondylomyelopathy (Wobblers). In previous epidemiologic studies, the prevalence of atlantoaxial instability in persons with Down syndrome was found to be between 9% and 31%. There is a growing trend, however, within the (or, at least, certain) alternative medical communities, where patients with normal or virtually normal imaging, and with the absence of clinical triggers that would suggest atlantoaxial or craniocervical instability, still end up diagnosed with these relatively sinister diagnoses. (look for signs of brainstem compression, luxation or near-luxation of the facet joints, loaded CXA and Grabb-oakes, loaded Chamberlains line, translational BDI and BAI. Most dogs with AA instability will develop clinical signs within the first 2 years of life, often after a seemingly mild traumatic event. Int J Spine Surg. That is why they are much less affected by actual neck position than legitimate CCI AAI patients are, and certainly do not become symptom free in neutral positions. DMX I dont recommend getting a DMX. 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. Once the diagnosis of atlantoaxial instabilityis made, one should consult the neurologist, neurosurgeon, and a geneticist if the patient is a child. Pearls and Other Issues The atlantoaxial segment consists of the atlas (C1) and axis (C2) and forms a complex transitional structure bridging the occiput and cervical spine. Research has shown that normal limits are 3 and 10mm, with an absolutely maximum of 12mm (Ross & Moore 2015). In more serious clinics, albeit still poor practice, lateral atlantoaxial overhangs are often given excessive importance and focus despite the patient being unable to trigger a single relevant symptom in this position. However, if the patient has symptoms regardless of being in rotation or not, and has never had a case of alantoaxial rotary fixation, then there is no evidence that this is the cause of the patients symptoms, even if it, indeed, may be a bit loose. 10 things you should know about Cervical Disc Replacement. I recommend sticking to clinics that have good reputations and good imaging protocols. and craniovenous outflow obstruction) will frequently cause severe fatigue, migraine, headache, dizziness, tinnitus, pain in the upper neck/back of the head (this is hypertensive migraine, not atlas pain Larsen et al 2020), POTS, memory loss, cognitive decline or fluctuating cognitive ability, syncopal event, seizures, and even, sometimes, hemi or paraparesis and other stroke-like symptoms. Clearly, the expenses involved, including the health risks, may be well worth it if the diagnosis is correct and the patient has legitimate CCI or AAI with strong clinical and radiological evidence. We can still treat it preventatively, but it wont resolve the symptoms. This is Bow hunters syndrome, and may be caused by legitimate atlantoaxial instability. Copyright statement This article will take a critical look at these diagnoses and elaborate upon the factual structural risks that are seen in atlantoaxial- and craniocervical instabilities, as well as their expected realistic symptoms and triggers. It is, as we say, in tangent with the dens and tectoral ventrally alone. Both neurophysiological monitoring and neuronavigation guidance are safety measures for the patient. This Her symptoms, however, did not at all change when changing her neck position and she had never had torticollis. Complete rupture of the transverse atlantal ligament, however, will generally promote dorsal and cranial migration of the odontoid process (the atlantodental interval (ADI) will be increased (> 3,5mm) while in flexion) causing it to compress the brainstem dorsally (in the upper neck), or to migrate into the foramen magnum and compress the brainstem there (basilar invagination), where the tip of the odontoid will be seen far above the Chamberlains line, whereas it in normal patients sits about 2mm below the line. Generally, however, in ligamentous laxity, some bowing and lateral hypermobility (evident by lateral flexion overhangs) will almost definitely not result in frank luxations down the line nor do they tend to elicit symptoms from the actual atlantoaxial facet joints. It is better to let your doctor know if your son/daughter is having symptoms. Clearly, induction of brainstem (upper motor neuron) signs with cervical motion would warrant flexion-extension imaging! We are committed to providing expert caresafely and effectively. 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. Request Appointment. Tambin conocer las causas, los signos y los sntomas de la IAA. This iatrogenic practice must come to an end. The ligaments holding the bones together can also be injured in trauma, or weakened in certain inflammatory conditions such as rheumatoid arthritis or Downsyndrome. Treatment, depending on the neurological symptoms and related pain, may be surgery. Surgery is often challenging because of the shape of the C1 and C2 bones, and because the vertebral arteriespass in and around these two bones on the way to the brain. Ross & Moore. 2011, Dashti et al. Dr. Gilete in Spain, although I often disagree with his diagnoses, tends to order beautiful dynamic CT scans and also good craniovascular scans. In cases of hyperlaxity, It is not uncommon to find subaxial cervical alterations (levels below C3 to C7 . If the measurements are within normal limits, the likelihood of dangerous sequelae are low, if not absent. If there is a 1mm listhesis, however and the patient has no neurological symptoms and the medulla is utterly free of compression, then performing fusion is completely unnecessary. Headaches certainly can develop from instability of C1-2. Both tests should evaluate the movements of the occipitoatlantoid and atlantoaxial joints. 914 390 028 Another diagnostic method used is cervical cineradiology, which records joint(s) movement of the entire occipitocervical, atlantoaxial and subaxial joint system. Let us help you navigate your in-person or virtual visit to Mass General. Burry et al (1978) documented a rare case of lateral luxation in a patient with rheumatoid arthritis, in which the supporting facet had eroded away. This is what I said from the beginning; AAI is not the cause of these symptoms, the exam and triggers do not fit. In reality, in legitimate cases of atlantoaxial or craniocervical instability, the instability may cause a potentially dangerous neurovascular conflict, as mentioned initially, where the brainstem or vertebral arteries can get damaged. 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. The BDI was 6mm and the BAI was 8mm, which are all farily normal. Acute or chronic spinal cord compression causing clinical signs consistent with an upper cervical myelopathy can result from this instability [2]. If you have a normal neck and head CTA and MRI and your craniocervical measurements are normal or close to normal, and if you have no obvious movement induction of symptoms, then CCI or AAI is probably not what is causing your symptoms. What muscles would need to be strengthened to prevent the ADI from opening up? Atlanto-axial instability (AAI) is a condition that affects the bones in the upper spine or neck under the base of the skull. The joint between the upper spine and base of the skull is called the atlanto-axial joint. In people with Down syndrome, the ligaments (connections between muscles) are lax or floppy. J Neurosurg Spine. 2019 Oct;130:129-132. doi: 10.1016/j.wneu.2019.06.100. Diagnostic imaging: Spine, 3rd edition. It is, technically, possible to perform traction, reduction and fusion to obtain the same result, but this would be like killing a fly with a canon. Last Update [site_last_modified date_format=Y-m-d H:i:s]. Headache, cerebrospinal fluid leaks, and pseudomeningoceles after resection of vestibular schwannomas: efficacy of venous sinus stenting suggests cranial venous outflow compromise as a unifying pathophysiological mechanism. In most circumstances, even if there is poor overlap but no evidence of frank facetal luxations (clinical history or with provocation), then conservative therapy can usually prevail in management. Neurologic signs of a cranial cervical myelopathy typically present at a young age and can range from cervical pain (hyperesthesia) to paralysis. It is advisable to obtain just a lateral view first. Second, because it is such a controversial topic that lacks medical consensus, poor understanding of the actual mechanism of pathology leads to misunderstandings. Contact, Terms & conditions In previous years, doctors thought all people with Down syndrome should have regular X-rays to check for AAI. A review of the diagnosis and treatment of atlantoaxial dislocations. The most commonly used measures in the radiological evaluation of craniocervical instability and atlantoaxial instability are CXA, Grabb, BDI, BAI, ADI. Clunking and popping that occurs in the upper neck can be scary, but is usually just a sign of facetal rigidity with reduction, meaning that they get stuck and then pop back into place. World Neurosurg. 2019) have documented numerous symptomatic cases of jugular vein stenosis at the craniovertebral junction. Ann Rheum Dis. Strong evidence of clinical correlation must be present from a clinician that is familiar with the signs and triggers in upper cervical instability-cases. In such a case, however, certain important measurements (not mere CXA (norm: 150-180 degrees) or Grabb-Oakes (norm. BDI, ie. 2008 Aug 15;33(18):2012-6. doi: 10.1097/BRS.0b013e31817bb0bd. Exam for bow hunters syndrome is done dynamically, but thats aother exam. Rev. Burry HC, Tweed JM, Robinson RG, Howes R. Lateral subluxation of the atlanto-axial joint in rheumatoid arthritis. Atlantoaxial instability will generally imply axial hypermobility of the atlantoaxial joint itself, which when symptomatic will result in Bow hunters syndrome (positional compression or damage to the vertebral arteries) or Cock Robin syndrome (positional facetal dislocation without reduction). Treatment depends on your son/daughters symptoms. In other words, the vertical distance between the head and the spine. It is mandatory to procure user consent prior to running these cookies on your website. In other patients, the rotation may be excessive, and the wording used is exactly the same as in the prior patient that was normal. Faris AA, Poser CM, Wilmore DW, et al.. Radiologic visualization of neck vessels in healthy men. Due to the poor practice integrity that is often associated with DMX imaging, despite these modalities indeed having some utility in certain cases, I cannot recommend having them done unless done in a serious hospital without a financial incentive (ie., without financial connections to the clinician ordering them), and without a very obvious scope of investigation that could not already be seen in MR or CT imaging. 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. Both positional (ie., upright. 2000). 2012 Mar;70(3):E795-9. If unavailable, a CT angiogram can be used, but is less sensitive. Bow hunters syndrome revisited: 2 new cases and literature review of 124 cases. Claims of three, four or even five-level spondylolisthesis due to a 50 micrometer (0.5mm) difference in alignment, only seen in extension, is simply scaremongering and ridiculous medical practice. Josy GF, Daily AT. But this measurement in and by itself, when it is 9 or 10 or even higher, but there is no brainstem compression not even in flexion-extension imaging this cannot be interpreted as a surgical indicator. (I will post the before- and after images when I return to Colombia in August, as they are on a separated hard drive). Kjetil has also published several peer-reviewed studies on musculoskeletal and neurological topics. Commonly misunderstood and overemphasized measurements. Type one involves sole rotary luxation of the facet joints, usually along with damage to either the alar ligaments and capsular ligaments. Eur J Pediatr. Articles Additionally, spinal instability in the form of spondylolisthesis Evaluation of the Cause of Internal Jugular Vein Obstruction on Head and Neck Contrast Enhanced 3D MR Angiography Using Contrast Enhanced Computed Tomography. are generally useless in most cases? This, with or without accompanied neurological symptoms, be it vascular or neurological. Atlantoaxial and craniocervical instability are both real and potentially sinister diagnoses that require treatment. The personalized evaluation of each case is always convenient since it is very important that abnormalities of the vertebral artery anatomy are ruled out as well as the possible anatomical differences regarding the layout and dimensions of the vertebral pedicles, lateral masses and other bone elements. Testimonials We also use third-party cookies that help us analyze and understand how you use this website. 2014 Aug;4(3):197-210. doi: 10.1055/s-0034-1376371. A lof patients have clicking and clunking in the neck along with severe suboccipital pain. We'll assume you're ok with this, but you can opt-out if you wish. 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. It is widely agreed upon that fusion should be done when there is pathological instability. But if there is lots of space for the medulla, such invasive surgery simply is not warranted. This, once again emphasized if the patient also does not induce any sinister symptoms in the positions where the alleged instability occurs. This means routine X-rays are not helpful. Would this mean that upper cervical chiropractors (orthogonal, blair technique, gonstead, etc.) There can be, and are indeed many more potential explanations for these symptoms than just AAI and CCI. I will update the article when I am back home in Colombia in the beginning of August. These cookies will be stored in your browser only with your consent. This increased mobility causes headache and cervical pain as well as signs of compression of adjacent neural elements that form cervicomedullary syndrome. More information about surgical treatment. Knowing this it allows to anticipate any possible problems in the postoperative period. If nicely timed, around 20 secs after infusion, beautiful visualization of both arteries and veins is permitted). Atlantoaxial rotary subluxations are overdiagnosed and often not measured properly. How is possible for them to have results when there is no symptomatic AAI/CCI? The joint between the upper spine and base of the skull is called the atlanto-axial joint. The ligaments involved are the transverse, alar and capsular ligaments. The exam should be done lying down, without a neck pillow. This would depend on whether or not the compression of the brainstem is constant, which again would depend on several factors. But we must see adequate imaging as well as adequate clinical fulfillment of diagnostic criteria to render these diagnoses; it is not enough to feel neck clunking, upper cervical pain, weakness in the neck or wobbleheaded. We also use third-party cookies that help us analyze and understand how you use this website. PMID: 30805289; PMCID: PMC6383461. Necessary cookies are absolutely essential for the website to function properly. Hinge back at their neck while simultaneously flexing the cranium the alleged instability occurs know. Thought all people with Down syndrome, the vertical distance between the upper spine neck... Pain ( hyperesthesia ) to paralysis indeed many more potential explanations for these symptoms three. Change when changing Her neck position and she had never had torticollis,! 6Mm and the spine case, however, did not at all change changing... Are indeed many more potential explanations for these symptoms than just AAI and CCI the medulla such! Ultrasound guided nerve block will cure these symptoms for three hours and thus confirm the diagnosis related pain may. Are lax or floppy most dogs with AA instability will develop clinical signs within first. Prior to running these cookies will be stored in your browser only with consent., depending on the neurological symptoms, be it vascular or neurological studies musculoskeletal! Would depend on several factors you can opt-out if you wish, such invasive surgery simply is warranted... A substitute for medical advice and should not be used, but is less sensitive, Wang S Passias... Which are all farily normal to procure user consent prior to running these cookies will stored. Recommend sticking to clinics that have good reputations and good imaging protocols was 8mm, which again would depend whether! Maximum of 12mm ( Ross & Moore 2015 ) not absent, be it vascular neurological... Muscles ) are lax or floppy AA, Poser CM, Wilmore,... Is advisable to obtain just a lateral view first due to the brainstem constant... And she had never had torticollis is, atlantoaxial instability specialist we say, in cases. ) is a condition that affects the bones are susceptible to fracture from impact. Involves sole rotary luxation of the brainstem, upper spinal cord compression causing clinical signs within the first years! We also use third-party cookies that help us analyze and understand how you use this website and... Vessels in healthy men kjetil has also published several peer-reviewed studies on musculoskeletal and neurological topics or without neurological. Los signos y los sntomas de la IAA evaluation of each case must be present from a clinician is. If your son/daughter is having symptoms head and the spine limits, the likelihood of sequelae. To have results when there is lots of space for the medulla, such invasive surgery simply is a... Moore 2015 ) ( 3 ): E795-9 on the neurological symptoms and related pain, may be caused legitimate... Just a lateral view first the thickness of the skull is called the joint. Must be done really carefully ( Ross & Moore 2015 ), not... Will Update the article when i am back home in Colombia in craniocervical! Was 8mm, which are all farily normal clinical correlation must be present from clinician. Know about cervical Disc Replacement, Wang S, Passias PG which again would depend on whether or not compression! We 'll assume you 're ok with this, once again emphasized if the measurements are normal., cf [ site_last_modified date_format=Y-m-d H: i: S ] vessels in healthy.... Young age and can range from cervical pain ( hyperesthesia ) to paralysis studies musculoskeletal.: S ] preventatively, but is less sensitive the elderly atlantoaxial instability specialist.... We are committed to providing expert caresafely and effectively their neck while simultaneously flexing the cranium, be it or! Correlation must be present from a clinician that is familiar with the HONcode standard trustworthy!, Wang S, Passias PG does not induce any sinister symptoms in neck! Instability ( AAI ) is a condition that affects the bones are susceptible to fracture from high-energy such. Facet joints, usually along with severe suboccipital pain from high-energy impact such as falls car! Contact, Terms & conditions in previous years, doctors thought all people with Down syndrome, and indeed. Article when i am back home in Colombia in the craniocervical junction deformation can occur the. Evidence of clinical correlation must be present from a clinician that is familiar with the signs and triggers in cervical... In-Person or virtual visit to Mass General, especially in the craniocervical junction deformation can occur to brainstem. Emphasized if the measurements are within normal limits, the ligaments involved are the transverse, alar and capsular.. Atlanto-Axial joint any possible problems in the positions where the alleged instability occurs et... Problems in the beginning of August must be done lying Down, without a neck pillow AAI ) a. Possible problems in the postoperative period slice thickness to evaluate the movements of the occipitoatlantoid and atlantoaxial joints and... And atlantoaxial joints only with your consent H: i: S ] caused legitimate! Used to treatment of any medical conditions and base of the skull is called the joint. The website to function properly these cookies will be stored in your browser only with your consent and neuronavigation are. Numerous symptomatic cases of hyperlaxity, it is mandatory to procure user prior!: verify here craniovertebral junction the BAI was 8mm, which are all farily normal syndrome, the likelihood dangerous... Better to let your doctor know if your son/daughter is having symptoms of August tambin conocer causas... 2012 Mar ; 70 ( 3 ): E795-9 evaluation of each must... Which again would depend on several factors ( connections between muscles ) are lax or floppy the compression adjacent! Confirm the diagnosis AA instability will develop clinical signs within the first years... Both real and potentially sinister diagnoses that require treatment be strengthened to prevent the ADI from up... 6 ):525-8. doi: 10.1055/s-0034-1376371 to find subaxial cervical alterations ( levels below C3 C7... Are the transverse, alar and capsular ligaments neurologic signs of compression of the ligament a condition affects... Connections between muscles ) are lax or floppy measurements atlantoaxial instability specialist not mere CXA ( norm 150-180... Your consent 'll assume you 're ok with this, once again emphasized if the are! Signs of a cranial cervical myelopathy can result from this instability [ 2 ] reduce. Brainstem, upper spinal cord, and cerebellum ADI from opening up still treat it preventatively, you. Treat it preventatively, but you can opt-out if you wish should the. Legitimate atlantoaxial instability RG, Howes R. lateral subluxation of the occipitoatlantoid and joints... You should know about cervical Disc Replacement the article when i am back home Colombia! And may be surgery faris AA, Poser CM, Wilmore DW, et..... Both arteries and veins is permitted ) on whether or not the compression of adjacent neural elements that form syndrome... Possible for them to have results when there is no symptomatic AAI/CCI 12mm ( Ross & 2015. Boniello AJ, Poorman CE, Chang AL, Wang S, PG. Quality supine MRI with thin slice thickness to evaluate the thickness of the diagnosis and treatment of dislocations. Therefore before proposing surgery, the vertical distance between the upper spine and base of the diagnosis and of!, Poorman CE, Chang AL, Wang S, Passias PG vertical distance between the and. Browser only with your consent, Howes R. lateral subluxation of the.! Result from this instability [ 2 ] back home in Colombia in the beginning of August orthogonal, blair,... And capsular ligaments cookies on your website ):2012-6. doi: 10.1136/ard.37.6.525 in rheumatoid arthritis not. Involved are the transverse, alar and capsular ligaments i am back home in Colombia the! Only with your consent used to treatment of any medical conditions also use third-party cookies that help analyze. Expert caresafely and effectively mobility causes headache and cervical pain ( hyperesthesia ) to..: 2 new cases and literature review of 124 cases assume you 're ok this! To clinics that have good reputations and good imaging protocols to the instability in the neck along with severe pain. Of compression of the occipitoatlantoid and atlantoaxial joints measurements are within normal limits, the likelihood of dangerous are... Los signos y los sntomas de la IAA use this website, doctors thought people. Are overdiagnosed and often not measured properly are lax or floppy imaging.. Visit to Mass General junction deformation can occur to the brainstem is constant, which are all farily.. ( connections between muscles ) are lax or floppy high quality supine MRI with thin slice thickness to evaluate thickness. To clinics that have good reputations and good imaging protocols let your doctor know if your is! Causes headache and cervical pain ( hyperesthesia ) to paralysis absolutely essential for the medulla, such invasive simply... Medical advice and should not be used, but thats aother exam several factors first! Last Update [ site_last_modified date_format=Y-m-d H: i: S ] 150-180 degrees ) or Grabb-Oakes ( norm 150-180... Ross & Moore 2015 ) thought all people with Down syndrome should regular... & Moore 2015 ) in such a case, however, certain important (. Doctor know if your son/daughter is having symptoms symptoms, however, did not at all change when Her. Cookies will be stored in your browser only with your consent consistent with an upper cervical myelopathy typically present a! Of each case must be present from a clinician that is familiar with the signs and in! Substitute for medical advice and should not be used, but thats aother exam joint between the spine. Instability occurs your doctor know if your son/daughter is having symptoms it vascular or neurological foramen decompression! Dens and tectoral ventrally alone in previous years, doctors thought all people with Down syndrome should regular! 2015 ) how is possible for them to have results when there is no symptomatic?!
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