I think patients with cranio-cervical instability (CCI) deserve my explanation as to why I have decided to withdraw the CCI treatment from my armoury. There are several reason that led me to this uneasy decision. Let me discuss them below:
- In the UK we currently have a very limited diagnostic options. Sadly Prof. Smith passed away earlier this year and in my opinion he was the best. His reports were like no other, competent, explanatory and thorough. I feel that what I see now is of much lower quality. Moreover, there are no DMX scanning available in the UK (and in Europe as far as I know).
- The above has put me in a very difficult position as it has never been my intention to become CCI expert. And I am not the one. As you might have heard me saying during the consultations, my treatment is generic: no matter what is the pathology I can only do some localised injections. So, I don’t feel I am and I will be competent enough to diagnose CCI.
- We would all agree that there are many various causes of the instability. Probably the worst is the one attributed to the hypermobility. This condition in turn is commonly caused by genetic factors and the outcome of localised treatment(s) is very poor and in my opinion serious risks of these treatments outweigh considerably mediocre results.
- The aforementioned risks should not be taken lightly. They can be grave, including para/tetraplegia and death. And I fully recognise that a desperate patient who has been suffering for months or years would agree to anything what could potentially give some relief. But I think it is the role of responsible doctor to assess the risk more objectively. In my humble opinion, the risks of the upper cervical injections often outweigh the benefits as mentioned above.
- In medicine what we do is , or at least should be, based on evidence. There are various levels of evidence: from pretty weak, such as specialist’s opinion (yes, it counts as a weak evidence…) to robust one such as meta-analysis. And in between sits many more, such as randomised trials and so on. Sadly, to my knowledge, there is no evidence that regenerative medicine works for CCI. It doesn’t mean that the regenerative medicine doesn’t work for CCI. It means exactly what it means: there is no evidence. I personally think that the lack of evidence is caused by many factors, such as difficult study design, difficult outcome assessments, very few clinicians involved in these treatments, cost of the studies and probably many more.
- I try to be a responsible clinician. And as such I simply can’t jump on the high risk treatment with no robust evidence of its effectiveness. I also accept that other clinicians, perhaps with much more experience, would take a different view. It is their right as is mine to differ in opinion.
I hope the above will explain my decision and will meet your understanding.
To summarise in a more optimistic tone, I am still happy to treat patients whose instability has been caused by trauma, such as whiplash and where there is a clear target for injection. I think that here the results are potentially better and might outweigh the risks. The final decision, however, is always made based on patient’s history and clinical examination. It is also important to realise that upper cervical spine injection is not a remedy for all symptoms, neither is it a “quick fix”.
Thank you for reading.
Dr ZM Kirkor