And the Answer is. . .Occipitalization and Basilar invagination Both these conditions can lead to a variety of neurologic symptoms, and it is essential for chiropractors to recognize them prior to chiropractic manipulative therapy. Occipitalization is a congenital condition where the C1 vertebral level is either completely or partially fused with the base of the skull (occiput). Primarily the condition will limit cervical range of motion, however other symptoms may include:
  • Neck pain and stiffness
  • Headaches
  • Radicular pain
  • Neurologic symptoms secondary to spinal cord or nerve root compression
Basilar invagination is where the odontoid process is abnormally elevated into the foramen magnum, where the brainstem exits the cranial cavity. This may be assessed by using Chamberlain or McRae lines of mensuration. This condition can be either a congenital abnormality (as is likely the case here, given the patients age), however it may also be acquired from bone softening diseases such as rheumatoid arthritis, Paget disease or osteogenesis imperfecta.
Individuals with this condition may present with:
  • Headaches, neck pain and stiffness
  • Gait abnormalities
  • Difficulty swallowing
  • Bowel and bladder disturbances
Identification of this is crucial as there is inherently decreased space in the foramen magnum prior to CMT. This may additionally may be seen with a Chiari malformation, syrinx, and/or hydrocephalus. Either of these conditions should be followed up with MR imaging of the brain or cervical spine to further assess the extent of soft tissue complications/association. Typically, consultation with an orthopedic or neurosurgeon is warranted to address any neurologic symptoms/complications. This a T2 weighted MRI of another patient (rID: 92777) where they also have occipitalization along with cephalic migration of the odontoid process (C2). This is resulting in severe compression as seen by the tapered indentation of the brain stem and internal hyperintensity (bright signal).