Craniocervical Instability
If you have been told you might have craniocervical instability, you have probably already read a great deal, seen more than one specialist, and heard conflicting opinions. That is common. CCI is a real but difficult diagnosis: symptoms overlap with many other conditions, imaging findings are not always straightforward, and treatment evidence is still developing. At Essential Sports + Spine Solutions in Columbus, Dr. Nikhil Verma, MD, a board-certified Physical Medicine & Rehabilitation physician with fellowship training in interventional spine and sports medicine, starts where good care should start: a careful, unhurried evaluation. Our goal is to help you understand what your imaging and exam actually show, what is and is not known, and which options are reasonable for you, including when surgical consultation is the right next step.
Craniocervical Instability (CCI) FAQs
Craniocervical instability usually develops when the ligaments connecting the skull to the top two vertebrae are stretched or weakened. Reported causes include whiplash and other neck trauma, hypermobile Ehlers-Danlos syndrome and other connective tissue disorders, rheumatoid arthritis, certain congenital anomalies, and prior surgery. In many patients, more than one factor contributes, and sometimes no clear cause is found.
Common symptoms include headache at the base of the skull, neck pain, a heavy-head sensation, dizziness, imbalance, visual or hearing disturbances, fatigue, and brain fog, often worse when upright and better lying down. None of these is specific to CCI. Weakness, trouble walking, swallowing difficulty, or fainting with head movement need urgent medical evaluation.
No single test confirms CCI. Diagnosis combines a detailed history, a neurological and upper cervical exam, and careful review of imaging, which may include flexion-extension X-rays, upright or motion MRI, CT, or digital motion X-ray. Measurements are interpreted alongside symptoms and exam findings, because borderline numbers alone do not establish the diagnosis.
For selected patients without neurological red flags or severe structural instability, non-surgical care may help. This usually starts with specialized physical therapy, activity changes, and addressing contributing factors. Image-guided regenerative injections may be considered when rehabilitation is not enough. Patients with significant instability or brainstem or spinal cord compression should see a spine surgeon.
Prolotherapy and PRP are thought to trigger a controlled healing response that may strengthen lax ligaments and joint capsules, improving support and reducing pain. Evidence for CCI is limited to case reports, case series, and related studies; no completed controlled trials exist. Some patients improve, others do not, and results cannot be guaranteed.
Yes. We evaluate patients with hypermobile Ehlers-Danlos syndrome and other hypermobility disorders. Because ligament laxity in these conditions is widespread, we set realistic goals, emphasize stabilization-focused rehabilitation, approach injections conservatively, and coordinate with your other specialists. Any regenerative treatment is discussed only after a thorough evaluation, with clear expectations about the limited evidence.
Your first visit is a dedicated consultation, not a procedure visit. Dr. Verma reviews your history and prior treatments, performs a focused neurological and upper cervical exam, and goes through your actual imaging with you, not just the report. You leave with a clear explanation of the findings, what further imaging (if any) would change the plan, and your options, from rehabilitation to referral.
Generally, no. Regenerative injections such as PRP and prolotherapy for craniocervical instability are usually not covered by insurance and are paid out of pocket. Costs depend on the treatment plan and are reviewed with you in full after your evaluation, before anything is scheduled, so there are no surprises.
What Is Craniocervical Instability?
The craniocervical junction is where the skull (occiput) meets the first two vertebrae of the neck, the atlas (C1) and the axis (C2). Unlike the rest of the spine, this region has no discs. Its stability depends almost entirely on ligaments and joint capsules, including the alar ligaments, the transverse ligament, the tectorial membrane, the atlanto-occipital membranes, and the capsules of the C0-C1 and C1-C2 joints, supported by the deep suboccipital muscles.
Craniocervical instability (CCI) describes excessive or abnormal motion between the skull and the upper cervical spine when these stabilizers are insufficient. A related term, atlantoaxial instability (AAI), refers to excess motion specifically between C1 and C2. Because the brainstem, upper spinal cord, vertebral arteries, and several cranial nerves pass through this small space, abnormal motion here may contribute to symptoms well beyond neck pain.
Reported causes include trauma such as whiplash or a fall, connective tissue disorders such as hypermobile Ehlers-Danlos syndrome (hEDS), inflammatory arthritis such as rheumatoid arthritis, certain congenital anomalies, prior surgery, and in some cases repetitive strain. Severity ranges widely, from subtle ligament laxity to structural instability that requires surgical stabilization. Telling these apart is the central job of the evaluation.
Common Symptoms of Upper Cervical Instability
Symptoms vary from person to person and none are specific to CCI on their own. Patients commonly report:
- Headache at the base of the skull, often worse with upright posture or prolonged sitting
- Neck pain, a feeling that the head is “too heavy,” or a need to hold or brace the head
- Dizziness, lightheadedness, or imbalance, especially with head movement
- Visual disturbances, ringing in the ears, or a sense of pressure in the head
- Clicking, grinding, or a sense of the neck “slipping” or locking
- Fatigue, brain fog, or difficulty concentrating
- Symptoms that improve when lying down and worsen when upright
Some symptoms need prompt attention rather than a routine visit. Seek urgent care for sudden weakness or numbness, difficulty walking, clumsy hands, loss of bowel or bladder control, trouble swallowing or speaking, fainting or sudden falls with head movement, or any new severe headache. These can signal pressure on the brainstem, spinal cord, or blood vessels, and they call for urgent imaging and surgical evaluation.
How CCI Is Evaluated
There is no single test that confirms or rules out CCI. Measurement thresholds vary between studies, standard lying-down MRI can miss instability that appears only when upright or moving, and a borderline measurement does not necessarily explain symptoms. For that reason, Dr. Verma treats diagnosis as a process of putting several pieces together rather than relying on one number.
Detailed history. We review the onset of symptoms, any injury or event, prior treatments and how you responded, connective tissue and hypermobility history, autonomic symptoms such as POTS, and what makes symptoms better or worse.
Focused physical and neurological examination. This includes a full neurological exam looking for signs of spinal cord or brainstem involvement, assessment of upper cervical and suboccipital tenderness, segmental motion, posture, and deep neck flexor and scapular control. Upper cervical ligament stress tests are performed selectively and gently, because they have limited accuracy and are not appropriate for everyone.
Imaging review. Dr. Verma personally reviews your images, not just the radiology report. Depending on your history, this may include cervical X-rays with flexion-extension views, upright or flexion-extension MRI, CT, rotational CT for suspected C1-C2 rotational instability, or digital motion X-ray (DMX). Commonly reported measurements include the clivo-axial angle, the Grabb-Oakes measurement, the basion-dens interval, the atlanto-dental interval, and C1-C2 lateral overhang. We interpret these with their known limitations in mind and correlate them with your exam.
Diagnostic blocks, when appropriate. For some patients, a carefully performed, image-guided diagnostic injection into an upper cervical joint can help clarify whether that joint is a meaningful pain source before any longer-term treatment is considered.
Knowing when to refer. If imaging or exam suggests significant structural instability, brainstem or cord compression, or progressive neurological signs, we coordinate referral to a spine surgeon or neurosurgeon experienced in craniocervical disorders. Non-surgical care is not the right path for every patient, and we will tell you plainly when we think it is not.
Non-Surgical Options Considered for Selected Patients
For patients without red-flag findings or surgical-level instability, a stepwise, non-surgical plan may be reasonable. The foundation is rehabilitation, not injections.
Specialized physical therapy. Targeted training of the deep neck flexors and suboccipital stabilizers, scapular and postural control, graded exposure to movement, and vestibular and oculomotor rehabilitation when dizziness or visual symptoms are present. Aggressive manipulation of the upper neck is avoided.
Activity and ergonomic changes. Workstation setup, sleep positioning, screen height, and load management to reduce sustained strain on the upper neck.
Bracing, used sparingly. A soft or rigid collar may be used short term during flares or after procedures, not as a long-term solution, since prolonged bracing can weaken the muscles that help stabilize the neck.
Addressing contributing factors. Sleep, nutrition, autonomic symptoms, and, in hypermobility, coordination with other specialists involved in your care.
Image-guided regenerative injections, for selected patients. When symptoms persist despite well-executed rehabilitation and the evaluation points to an accessible ligament or joint source, Dr. Verma may discuss prolotherapy or platelet-rich plasma (PRP). These injections are intended to stimulate a repair response in lax or injured ligaments and joint capsules, with the goal of improving support and reducing pain. Upper cervical injections are performed under fluoroscopic (live X-ray) guidance, with ultrasound used where it adds value, because the vertebral arteries and spinal cord lie close to the target structures. Treatment typically focuses on structures that can be reached safely from behind, such as the upper cervical joint capsules and the posterior supporting ligaments. The deepest stabilizers, the alar and transverse ligaments, cannot be safely reached from behind; a specialized approach through the back of the throat is being studied at a small number of centers and is not offered at our practice.
What the research shows, and does not show. We want you to have an accurate picture. There are no completed randomized controlled trials of PRP or prolotherapy for craniocervical instability. Supporting evidence currently consists of case reports, case series, and related studies, including an early study by Centeno and colleagues using blinded flexion-extension X-ray readings after fluoroscopically guided cervical prolotherapy, and a 2026 case report by Jones, Ierulli, Williams, and Pitts describing regenerative treatment of CCI. A randomized, sham-controlled trial of bone marrow concentrate for alar and transverse ligament injury is registered but has not reported results. These findings are encouraging enough to justify careful use in selected patients, but they do not establish that these treatments work reliably for CCI. Results vary, more than one treatment session is often needed, and some patients do not improve. Regenerative injections for this condition are generally not covered by insurance.
What to Expect at Your Evaluation
Before your visit, we ask you to send all prior imaging on disc or by secure link, not only the reports, along with relevant records and a list of treatments you have tried. Upright or motion imaging, if you have it, is especially helpful.
Your first visit is a dedicated consultation, not a procedure visit. Dr. Verma will review your history in detail, perform a focused examination, and go through your imaging with you on screen. You will leave with a clear explanation of what the findings suggest, how confident we can be, what additional imaging or testing (if any) would change the plan, and a set of options ranging from rehabilitation to referral. If a regenerative procedure is discussed, we will cover the rationale, the limits of the evidence, risks, cost, and the rehabilitation plan that goes with it. No procedure is performed at the first visit.
Request a CCI Evaluation in Columbus
If you are living with symptoms that may come from the upper neck and want a careful, honest second look, we would be glad to help. Call Essential Sports + Spine Solutions at 614-626-8707 or request a consultation online. Please have your imaging available so we can make the most of your visit.
This page is for general education and is not a substitute for individual medical advice. Treatment decisions are made after an in-person evaluation.
- Jones HE, Ierulli JA, Williams C, Pitts J. The Treatment of Craniocervical Instability Using Regenerative Medicine Therapies: A Case Report. Cureus. 2026 (published Jul 28, 2026). doi:10.7759/cureus.113501
- NCT03517761: Single-blinded RCT of bone marrow concentrate for alar, accessory, and transverse ligament injuries (Regenexx); recruiting, no results posted
- Centeno CJ et al. Fluoroscopically guided cervical prolotherapy for instability with blinded pre and post radiographic reading. Pain Physician. 2005;8(1):67-72. PMID 16850045.