Introduction: Numerous post-traumatic whiplash migraine headache patients remain unsuccessfully treated, with chronic pain, disability, and huge medical expenses. Anatomical correlation of this complex with C1-C2 lateral ligamentous instability and alar/transverse ligament injury is now possible using digital video-fluoroscopy (DMX) and positional MRI. Utilizing the STEALTHSTATION and O-Arm, we afford these patients a unique methodology of C1-C2 stabilization.

Methods: These patients undergo open-mouth Odontoid Digital Motion X-ray (DMX). With lateral instability exceeding 3 mm, patients obtain lateral tilt pMRI sequences for alar/transverse ligament injury analysis. Patients subsequently undergo minimally invasive transarticular lag-screw fixation fusion utilizing the STEALTHSTATION and O-Arm.

Results: 25 whiplash injury patients from 5 states and Canada, with a mean age of 35, and an average C1-C2 lateral overhang of >4.5 mm, measured utilizing DMX, were treated. Alar/transverse ligament injuries were identified in 81% of pMRI cases, with 20% having combined injuries. All patients had disabling migraine headaches and neck pain. There was an overall 100% reduction in headaches and neck pain, with an average follow-up of 6.1 months. 84% of patients had radiculo-myelopathic symptoms pre-operatively with a 94% reduction postop and 65% of patients had radiculo-myelopathic signs pre -op with a 100% reduction post-op. Successful alignment and fusion was achieved in 100% of patients. Average hospitalization was 1.2 days. Post-op complications included two superficial wound infections

Conclusions: Utilizing DMX and pMRI, we have identified a new syndrome of post-whiplash intractable migraine headaches correlated with lateral C1-C2 ligamentous instability. Without effective treatment, this disabling condition results in huge costs in lost income and fruitless medical expense. These new diagnostic modalities, and the significant advance in image guided surgery combining the STEALTH and O-Arm systems, has facilitated a minimally invasive C1-C2 fusion methodology. The results have been dramatic with resolution of these disabling headaches, often with return to employment or school.

Patient Care: This research affords a definitive solution to treat post whiplash intractable migraine headaches thereby facilitating patients returning to gainful employment, improving their overall quality of life and greatly reducing the socioeconomic costs associated with this syndrome.

Learning Objectives: 1- Identify the syndrome of post-traumatic cervical whiplash induced migraine headaches and their relationship to lateral C1-C2 ligamentous instability 2- Understand the modalities of DMX and pMRI 3- Comprehend the minimally invasive technique of trans-articular lag screw fixation/fusion with STEALTH/O -Arm.

References: Krakenes J, Kaale BR: Magnetic Resonance imaging assessment of craniovertebral ligaments and membranes after whiplash trauma. Spine 2006, 31(24): 2820-2826. Roy, S., Hol, PK, Laerum, AT, Tillung, T.: Pitfalls of MRI of alar ligament. Neuroradiology 2004, 46 (5): 392-398.