Alternative treatments for CCI+AAI - an overview

If you’re exploring alternative (non-fusion) treatments for Craniocervical Instability (CCI) and Atlantoaxial instability (AAI) here’s what you should keep in mind.

Important disclaimer: this is not medical advice. You should talk to a specialist familiar with CCI+AAI, especially because the condition is complex and treatments vary a lot depending on your exact anatomy, ligament involvement, symptoms, comorbidities (e.g., connective tissue disorders), etc.

What is CCI + AAI in brief

CCI+AAI refers to excessive movement (instability) between the skull base (occiput) and the upper cervical spine (C0–C1 for CCI, C1–C2 for AAI) due to ligamentous laxity or damage. This instability can lead to symptoms like headaches, dizziness, neck pain, neurological issues, autonomic dysfunction, etc.

Treatment “ladder” / categories

Many clinicians working in this space (alternative therapies) conceptualize treatment for CCI+AAI as moving from less invasive to more invasive, depending on severity, ligament involvement, response to initial treatments, etc.

Here are the broad categories:

1. Conservative / non-invasive treatments — posture correction, bracing, physical therapy, medication/symptom management (Read our post on this here)

2. Regenerative / injection-based therapies — for ligament repair or supplementation (e.g., prolotherapy, PRP, stem cell, etc.)

3. Invasive / surgical options — e.g., occipitocervical fusion in severe instability cases.

   
   

My focus here will be on the “alternative” treatments — especially the regenerative/injection therapies and how they are being used for CCI+AAI.

Alternative / Regenerative Treatments

Here are some of the main options, how they’re used, what evidence exists, and what caveats apply.

Prolotherapy

What it is: Injection of an irritant (often dextrose) into ligaments/tendons to provoke a mild inflammatory cascade, which in theory stimulates healing and strengthening of the ligaments.

Use in CCI+AAI: Some practitioners inject the posterior cervical ligaments (and joint capsules) in cases of CCI+AAI/upper cervical instability.

Evidence / considerations:

• It is a relatively older regenerative medicine technique with limited large-scale trials in CCI+AAI specifically.

• Because ligaments in the C0–C2 region are small, precision is very important.

• Some patients report improvement; others less so.

Caveats:

• If the instability is due to deep/“internal” ligaments (e.g., alar, transverse), posterior approaches may not reach them adequately. Prolotherapy might be insufficient in those cases.

• Injecting around the C0-C2 can be risky and require ultrasound guidance to be safe. Some providers only inject under C2 for this specific reason, which might provide limited results for CCI+AAI.

• As with all injections, risk of increased inflammation, transient worsening, and procedure‐related risks (especially in upper cervical spine) must be weighed.

Platelet-Rich Plasma (PRP)

What it is: Autologous blood centrifuged to concentrate platelets (growth factors) which are then injected into injured soft tissue/ligament/joint structures to promote healing.

Use in CCI+AAI:

• PRP may be injected into posterior ligaments, the posterior capsule of the C0–C1/C1–C2 joints, surrounding muscles, or facet joints.

• The goal is to strengthen / heal the lax ligaments and improve stability. 

Evidence / considerations:

• Evidence is emerging; there are case series and “proof of concept” but less in terms of large randomized controlled trials in CCI+AAI specifically.

• A case report described a complication of cervicogenic dizziness after PRP injection in cervical facets.

Caveats:

• Results may depend heavily on correct patient selection (which ligament(s) are involved) and correct targeting of the injection. If the key ligament is unreachable by the chosen injection site, benefit may be limited.

• Cost, access to experienced provider, and imaging/guidance quality matter a lot.

• Not covered by many insurances in many countries for CCI+AAI.

Stem Cell / Bone Marrow Cells / PICL (Percutaneous Implantation of CCJ Ligaments)

What it is: More advanced regenerative intervention — harvesting bone marrow (autologous) or other cell sources, and injecting stem/precursor cells into the damaged ligaments.

• The “PICL” procedure (Percutaneous Implantation of the CCJ Ligaments) specifically targets the anterior ligaments (e.g., alar and transverse ligaments) of the C0–C1–C2 complex.

Use in CCI+AAI:

• For patients whose instability involves anterior deep ligaments (where posterior injections may not reach), PICL is proposed as a “next step” before fusion by it's providers.

Evidence / considerations:

• Still considered investigational / higher risk. Many sources say that only a few centers internationally have performed many of these procedures.

• The complexity is high: e.g., injecting near vertebral arteries, airway access, fluoroscopic guidance, endoscopy, etc.  

Caveats:

• Because it’s new and fewer in number, long-term outcomes, potential complications, cost, and access are significant considerations.

• Requires very specialised expertise. Not every clinic offers it; travel may be needed

• PICL is often proposed as a cure for CCI+AAI. However this is misleading and patients need to be aware that no cure currently exists.

Key Questions / Considerations You Should Ask

Before undertaking any of these “alternative” treatments (especially the more advanced ones), important questions include:

• Diagnosis certainty & anatomy: Has your CCI+AAI been confirmed with appropriate imaging (e.g., dynamic motion x-rays, upright MRI, imaging that shows ligamentous laxity)?

• Which ligaments are damaged? Are we talking posterior capsule, alar ligaments, transverse ligaments, facet ligaments? Because that determines which treatment may work. For example, if the problem is in deep anterior ligaments, only injections that reach those (or PICL) may make sense.

• Provider experience: Especially for high-risk procedures (upper cervical injections, PICL) the provider’s volume and experience matters a lot.

• What’s the goal? Is the intention to avoid fusion entirely? Stabilize sufficiently so symptoms reduce? Improve quality of life?

• Risks vs benefits: Especially in upper cervical region, small error has greater risk (e.g., vertebral artery injury, spinal cord compression, infection).

• Cost / coverage / follow-up: Many of these therapies are not covered by insurance. Travel and long term follow-up may be necessary.

• Combination therapy: Often these regenerative/injection therapies are not stand-alone; they need to be combined with posture correction, neuromuscular re-education, avoiding over-strain, etc.

• Evidence base & realistic expectations: The literature is still limited for many of these in CCI+AAI. Some anecdotal and case series exist; however large trials are still limited.

Summary Table (Alternative treatments vs pros/cons)

Summary Table (Alternative treatments vs pros/cons)

Treatment	Pros	Cons / Limitations
Prolotherapy (ligament injection posterior)	Less invasive, stimulate healing, good for some posterior-capsule ligament deficiency	May not reach deeper/anterior ligaments; limited formal evidence; precision critical
PRP injections	Stimulate soft tissue healing, increasingly used, may improve symptoms	Requires imaging/precise targeting; cost; results variable; potential for transient worsening (see case)
Stem cell / PICL (anterior ligament injection)	Target deeper ligamentous instability that cannot be reached posteriorly; may avoid fusion	High cost; specialist procedure; fewer outcome data; higher risk; access limited
Surgical fusion	Definitive stabilisation in severe cases	Loss of motion; surgical risks; may be over-kill or necessary depending on severity

What the recent studies say (2023–2025): key points with sources

1. PRP in the cervical spine — a 2023 study/series reported cervical facet PRP is safe and feasible for chronic neck pain and whiplash-associated disorders; systematic reviews/meta-analyses for PRP in spinal/orthopedic conditions (2023–2025) show benefit for pain/function in many musculoskeletal uses but note heterogeneity in preparation and technique. That means PRP is plausible for symptom relief but results vary by how PRP is prepared and where it’s injected. Source, Source

2. PICL — clinic data but limited peer-review — the PICL procedure is actively performed at Centeno-Schultz and described in clinic literature and patient outcome reports; the clinic reports promising symptom reductions and ongoing data collection. Independent, peer-reviewed, multi-centre randomized controlled trials (RCTs) or large cohort publications specifically reporting PICL outcomes are still limited or pending. That makes PICL an experimental but promising option that requires careful patient selection and an experienced team. Source, Source

3. Bone-marrow / stem cell approaches — reviews from 2024–2025 indicate stem cell (BMC/adipose) therapies for spinal disorders are an active research area with safety and occasional benefit signals (e.g., in spinal cord injury and certain degenerative conditions), but the evidence for ligament regeneration at the craniocervical junction is not yet robust. More trials and standardized protocols are needed. Source, Source

4. Safety & technical complexity — upper cervical injections (alar/transverse region) are technically demanding (airway, vertebral artery proximity, need for endoscopic/fluoroscopic guidance, sterile bone-marrow handling). Many clinics emphasize specialized training and only offer PICL at select centres because of sterility/anesthesia/technical risk considerations. Source

5. Evidence gaps — for all these alternatives (prolotherapy, PRP, PICL, BMC), randomized, long-term comparison trials vs fusion or vs sham are scarce; much of the current literature is case series, clinic cohorts, or reviews of PRP in related indications rather than definitive RCTs for CCI+AAI. This leaves uncertainty about which patients will reliably benefit, how durable the results are, and what the complication rates are in larger populations. Source, Source

Chiropractic care and what it aims to do

Chiropractors focus on diagnosing and treating musculoskeletal problems, especially involving the spine, often using manual manipulation (adjustments) to restore alignment or reduce pain. In theory, for neck issues, the goal is to improve mobility, reduce muscle tension, and optimize biomechanics.

Why CCI/AAI are very different

CCI and AAI involve ligamentous instability at the upper cervical joints:

• C0–C1 (atlanto-occipital joint)

• C1–C2 (atlanto-axial joint)

These ligaments — especially the transverse, alar, and accessory ligaments — are critical for keeping the skull and upper spine stable around the brainstem.If they’re weakened or torn, even small movements can cause:

• Neural compression (brainstem, upper spinal cord)

• Vertebral artery compromise

• Worsening neurological or autonomic symptoms

So anything that increases movement or applies force in that area can potentially make the problem worse.

High-velocity manipulation (HVT) and risks

Traditional chiropractic neck adjustments often involve high-velocity, low-amplitude thrusts — quick, controlled rotations or extensions of the cervical spine.

In CCI or AAI, this type of manipulation is contraindicated because:

• It can further stretch or tear already lax ligaments.

• It can exacerbate instability.

• There’s a small but serious risk of vertebral artery dissection or neurologic injury even in people without instability — so the risk is amplified when the upper cervical ligaments are compromised.

Multiple case reports have documented neurological complications after cervical manipulation in patients later found to have instability.

Safer chiropractic or manual options (if any)

Some chiropractors with specialized training (for example, in upper cervical care, Atlas Orthogonal, or NUCCA) focus on non-force or low-force alignment techniques.These involve precise positioning, gentle pressure, or instrument-assisted methods rather than thrust manipulation.

However:

• Evidence supporting these techniques in true ligamentous CCI/AAI is very limited.

• Even gentle upper cervical techniques should only be attempted after diagnostic imaging (e.g., dynamic MRI and CT) confirms stability — and ideally under medical supervision (source)(source)

In cases of confirmed instability, most neurosurgeons and spine specialists advise against any manipulation near the craniocervical junction.

However some patients do swear by these types of upper cervical chiropractics, but this is purely anecdotal.

This concludes todays post. Please comment below if you have any thoughts, questions or anything to add.