A craniocervical instability case that two years of conventional imaging missed.
The Patient
A woman in her 30s arrived at our Tarzana clinic after two years of chronic neck pain and positional dizziness. Specific head movements reliably reproduced her symptoms. She had been evaluated multiple times. She had been told, repeatedly, that nothing was wrong.
Her prior imaging supported that conclusion. A supine MRI showed a 2-3mm disc bulge at C5-6. Everything else read as unremarkable. No instability flagged. No structural explanation for the severity or persistence of her presentation.
She self-referred to us because she had run out of options.
What Static Imaging Showed — And What It Couldn’t
Conventional imaging is built around a specific question: what does the spine look like at rest? MRI captures soft tissue in exquisite detail. CT and standard X-ray document osseous anatomy with precision. For pathology that is structurally present in a static position, this workup is appropriate and often definitive.
But craniocervical instability frequently isn’t structurally present at rest. It is a motion-dependent finding. The atlantoaxial and atlanto-occipital joints can appear congruent on a supine MRI and still demonstrate aberrant tracking the moment the patient moves into the position that reproduces their symptoms.
This is the diagnostic gap that has historically left post-traumatic patients in limbo: symptoms inconsistent with imaging, repeated reassurance that nothing is wrong, and no clear next step.
What DDR Captured
Dynamic Digital Radiography (DDR) captures motion radiography at up to 15 frames per second, at low radiation dose, across full functional range of motion. The patient is upright. The patient moves. The imaging captures what the joint actually does under load — not what it looks like when it’s still.
On this patient’s DDR study, the findings were unambiguous:
- Lateral overhang of C1 on C2 during active lateral flexion
- Aberrant atlantoaxial tracking during flexion-extension
Neither finding was visible on her prior supine MRI. Both were obvious the moment the patient reproduced the movements that caused her symptoms.
The Question Each Modality Answers
The distinction matters clinically:
- Static imaging asks: What does the spine look like at rest?
- DDR asks: What does the spine do when the patient reproduces the movement that causes their symptoms?
For post-traumatic craniocervical instability, those are not the same question. A patient can have a completely unremarkable MRI and a clinically significant motion-based finding on DDR. The two modalities are complementary, not redundant.
Where This Patient Is Now
Following her DDR workup, she is under evaluation with a neurospine specialist. For the first time in two years, her imaging matches her symptoms — and her care team has objective documentation to build a treatment plan around.
When to Consider Motion Imaging
DDR is not a first-line study for every neck pain presentation. It earns its place in the workup when:
- A patient has persistent post-MVA or post-traumatic symptoms that don’t correlate with their static imaging
- The clinical picture includes positional dizziness, headaches, or autonomic findings without a structural explanation
- The patient describes symptoms that are reliably reproduced by specific movements — but those movements aren’t captured by supine imaging
- A surgical or medico-legal workup requires objective documentation of motion-based instability
For patients in this category, DDR may visualize what their workup has missed.
A Note on Our Approach at Jawmatrix
At Jawmatrix, we evaluate the craniomandibular and cervical systems as one continuum. Cervical instability frequently presents with downstream symptoms that look like TMJ dysfunction — and TMJ presentations frequently have a cervical driver that goes unidentified in conventional workups.
Cases like this one underscore why we look at the whole upper quarter rather than treating the jaw and the cervical spine as separate problems.
For Referring Providers
Dynamic Digital Radiography is offered at our Tarzana facility — California’s only DDR center. Referrals and imaging inquiries: digitaldynamicxray.com | info@digitaldynamicxray.com | 747-309-1600.
For Patients
If you have a TMJ, jaw, or cervical pain presentation that has not been adequately explained by prior workups, we offer comprehensive evaluations at our Tarzana clinic.
Dr. Maggie Pezeshkian, DC, BSDH, CKTP is the founder of Jawmatrix and operates California’s only Dynamic Digital Radiography center in Tarzana.