Foremost Symptom – "Pressure Headaches" Cranio-Cervical Syndrome (CCS) Symptomatology and Its Origin in Prior Trauma to the Neck Foremost Symptom – "Pressure Headaches" Severe Headaches – most frequently described by the patient as "severe pressure headaches" or as "migraines" Headaches described as "sub-occipital neck pain" in the "back of the neck" at the base of the skull. "Neck pain" that is frequently position dependent (e.g. "skull forward", "skull backward", "turning of the head", etc.) "Neck pain" described as "knife stabbing" or "pins and needle stabbing at the base of the skull" Headaches occurring randomly throughout the day but frequently generated by a change of head position (e.g. moving of the head from the recumbent to the upright position) Headaches accompanied by tinnitus and visual disturbances such as "blurred vision", "tunnel vision", "double vision", "kaleidoscopic vision", nystagmus "Pressure headaches" accompanied by dementia and loss of cognitive skills”  

Additional Symptoms Encountered: Accompanying "Pressure Headaches" to Varying Degree: "drop attacks" "dizziness" "loss of balance" "numbness of legs" "difficulty walking" "paroxysmal vertigo" "sudden dropping of things from hands" "loss of color vision" "loss of motor skills in the lower extremities and potential wheel chair confinement" "numbness and tingling" in the legs and feet "vertigo on standing and walking" "Numbness and loss of motor control in the upper extremities"  

Sagittal MRI of a normal cervical spine 1. Normal apical ligament 2. Anterior occipitoatlantal membrane 3. Anterior atlantoaxial membrane 4. Anterior longitudinal ligament 5. Tectorial membrane 6. Dural reflection 7. Posterior occipitoatlantal membrane 8. Posterior atlantoaxial membrane 9. Nuchal ligament 10. Flaval ligaments 11. Area of interspinous ligaments 12. Supraspinous ligament Sagittal MRI of a normal cervical spine

Sagittal MRI of a clinically unstable cervical spine 1. Intact portions of anterior occipitoatlantal membrane 2. Torn portions of anterior occipitoatlantal membrane 3. Anterior arch of C1 4. Intact anterior atlantoaxial membrane 5. Prevertebral edema or hemorrhage 6. Torn tectorial membrane 7. Torn posterior occipitoatlantal membrane 8. Torn posterior atlantoaxial membrane 9. Intact dural reflection 10. Intact nuchal ligament Sagittal MRI of a clinically unstable cervical spine

Vertebral-Basilar Circulation Overview of Major Regions Supplied ! upper cervical spinal cord ! brainstem and cerebellum ! most but not all of the thalamus and hypothalamus ! cortex and deep white matter of the posterior medial parietal lobes, and medial and inferior temporal and occipital lobes (including the posterior hippocampus) ! posterior part of the corpus callosum (splenium) The vertebral arteries usually arise from the subclavian arteries. They ascend through the upper cervical transverse foramina, turn medially along the upper surface of the atlas, pierce the dura to enter the subarachnoid space and ascend into the cranial cavity via the foramen magnum. The vertebral arteries run alongside the medulla, giving rise to branches that participate in supplying the cervical spinal cord as well as the brainstem. They end by fusing to form the basilar artery.

Vertebral-basilar branches supply the following key functional areas: Brainstem Region Medial Structures Dorsolateral Structures Rostral Midbrain *CST and CBT in cerebral peduncle Superior cerebellar peduncle Oculomotor nucleus / nerve Medial longitudinal fasciculus Reticular formation Mid-Pons Medial longitudinal fasciculus Middle cerebellar peduncle Reticular formation Trigeminal sensory and CST and CBT motor nuclei / nerve Spinothalamic tract Caudal Pons Abducens nucleus / CNVI Facial motor nucleus / CNVII Motor fibers of CNVII Middle cerebellar peduncle PPRF (lateral gaze center) Descending tract/nucleus of V CST and CBT Spinothalamic tract Medial lemniscus Vestibular and Cochlear nuclei CN VIII Rostral medulla Hypoglossal nucleus / CNXII Nucleus ambiguus CST CNIX and CNX axons Medial lemniscus Descending tract/nucleus of V Vestibular nuclei *CST = corticospinal tract; CBT = corticobulbar tract Inferior cerebellar peduncle