Case Series on Using Bone Marrow Concentrate for Alar Ligament Injuries

The primary objective of this study is to evaluate the clinical outcomes for patient who are
treated with with bone marrow concentrate (BMC) using an anterior approach through the
posterior oropharynx for treating alar and transverse ligament injuries as part of their
clinical care. The case series will observe pre and post-treatment subject-reported clinical
outcomes. Secondary objectives include evaluation of post-treatment complications, adverse
events, re-injections, and surgical intervention, change in use of pain medications, and
changes on post treatment imaging.

The treatment consists of patients undergoing a bone marrow aspiration of approximately 30-60
cc. Platelet rich plasma (PRP) and platelet lysate (PL) will be derived from the bone marrow
aspirate and later mixed with the bone marrow cell layer. While under anesthesia, the
injectate is then injected under fluoroscopy into the area in need of treatment using an
anterior approach through the posterior oropharynx.

One of the challenges of treating the upper cervical ligaments through injection is that they
can't be accessed from the posterior due to obstruction from the cervical spinal cord. The
investigator's group has developed an injection technique using an anterior approach through
the posterior oropharynx, which allows direct access to the ligaments for injection. The goal
of this study is to evaluate the effectiveness of this procedure in CCJ instability patients.

Inclusion Criteria:

- 1) Voluntary signature of the IRB approved Informed Consent, 2) Skeletally mature Male
or Female ages 18 to 65 3) Disabling symptoms of headache, dizziness, neck pain, or
other neuro-musculoskeletal symptoms, that based on physical exam or diagnostic blocks
is attributable to the upper cervical spine for >12 months 4) Symptoms exacerbated by
activity and relieved by rest 5) Failed all conservative care 6) Hasn't responded
long-term to:

1. C0-C3 facet injections

2. Upper cervical prolotherapy or PRP into the posterior stabilizing ligaments
(nuchal, supraspinous, interspinous ligaments) 7) Considered a likely cervical
fusion candidate 8) Imaging (one of the three)

1. Upper cervical MRI showing decreased signal in alar, transverse, PAOM, AAOM, or
Tectorial membrane

2. DMX showing 2 mm or greater lateral overhang of C1 on C2 in lateral bending open
mouth view or a V shaped ADI in flexion of increased ADI in flexion

3. Upper cervical rotatory CT that shows excessive C0-C1 rotation 9) Exam is c/w
upper cervical injury (i.e. tenderness along upper cervical facet joints and/or
musculature/skull base, good anesthetic block response (>50% pain relief) to
C0-C3 intra-articular facet injections, proprioceptive difficulties) 10) Is
independent, ambulatory, and can comply with all post-operative evaluations and
visits 11) Patient states strong desire to avoid surgery

Exclusion Criteria:

- 1) Unable to tolerate injections due to central sensitization (i.e. significant
intolerance to manual therapy such as massage, activity such as physical therapy, or
an exaggerated pain response to prior injection therapy)

2) Previous neck surgery that has caused chronic neck pain or radiculopathy 3) Prior
epidural or other milligram dose steroid injection in any area or other neck injection
therapy within the past 6 months 4) Physical infirmity that is incompatible with the
procedure and/or anesthesia required for same 5) Unable to tolerate the injection
position 6) Abnormal anatomy seen on MRI imaging that would make the procedure higher
risk (e.g. congenital atlanto-axial fusion, atlas assimilation, upper cervical
fracture or surgical fusion)

7) Inflammatory or auto-immune based pathology (e.g., rheumatoid arthritis, systemic
lupus erythematosus, psoriatic arthritis, polymyalgia, polymyositis, gout, pseudo
gout) 8) Quinolone or Statin induced myopathy/tendinopathy

9) Condition represents a worker's compensation case 10) Currently involved in a
health-related litigation procedure 11) Is pregnant 12) Bleeding disorders 13)
Currently taking anticoagulant or immunosuppressive medication 14) Allergy or
intolerance to study medication 15) Use of and significant physical dependence on a
chronic opioid (>20 mg oxycodone equivalent per day) 16) Documented history of drug
abuse within six months of treatment 17) Any other condition, that in the opinion of
the investigator, that would preclude the patient from enrollment