Navigating Anterior Pannus in PICL and CCI: Key Considerations for Patients and Providers
Craniocervical instability (CCI) is a complex condition that demands highly individualized treatment decisions, especially when considering regenerative interventions like PICL (Percutaneous Implantation of the Cervical Ligaments) versus surgical stabilization.
One of the key questions emerging in this space is whether the presence of an anterior pannus—a thickening of soft tissue that can contribute to both anterior and posterior compression—should be considered a contraindication for PICL.
With experts like Dr. Chris Centeno, Dr. Rowan Paul, and Dr. Fraser Henderson weighing in on the role of regenerative medicine versus surgical intervention, patient selection criteria for PICL are still evolving.
This article breaks down:
✔ The significance of anterior pannus in CCI treatment planning
✔ Current research on PICL outcomes, including Dr. Centeno’s RCT results
✔ The latest innovations in motion-preserving CCI surgery
✔ Key questions patients and providers should ask when deciding between PICL and surgery
Whether you’re a patient exploring treatment options or a provider refining best practices, this guide provides evidence-based insights to help navigate the evolving landscape of CCI, PICL, and anterior pannus considerations.
For additional guidance on treatment for MCAS and EDS, see here and here.
Understanding Anterior Pannus in Craniocervical Instability (CCI)
Craniocervical instability (CCI) presents unique challenges, requiring highly individualized evaluation before choosing between regenerative medicine interventions like PICL (Percutaneous Implantation of the Cervical Ligaments) and surgical stabilization.
One of the key questions that arises is whether the presence of an anterior pannus and both anterior and posterior compression should influence PICL candidacy. While regenerative approaches have shown promise, surgical innovations—including skull-fusion-sparing techniques—are also advancing, making the decision-making process more nuanced.
As a patient advocate, I work closely with top physicians in regenerative and surgical interventions for CCI, and my goal is to ensure patients and providers have access to the most accurate, up-to-date information when weighing these complex options.
Case Study: Sarah’s Experience (Name Changed for Privacy)
Sarah, a patient with documented craniocervical instability, sought guidance on whether PICL or surgical stabilization would be the best option. She consulted multiple specialists, and interpretations of her imaging varied:
- Three doctors noted that she had an anterior pannus with both anterior and posterior compression on her scans.*
- Dr. Chris Centeno, who has been tracking response patterns, did not mention the anterior pannus in his assessment.
- Dr. Rowan Paul carefully reviewed her case but did not make a definitive call on contraindications, recognizing the complexity of the decision.
- Another provider raised concerns that an anterior injection could cause swelling in the pannus, potentially worsening compression.
- Sarah has now transferred DOs and is deciding between PICL therapy and surgery, likely with a nationally regarded and closely located provider, who specializes in cutting edge motion preserving techniques she has a scheduled first upcoming consult with.
- Sarah understands that PICL may provide a step in the right direction, regardless of whether she ultimately needs surgical stabilization, and that if she is a candidate it may improve her long term outcome.
- Dr. Fraser Henderson, a pioneer in skull-fusion-sparing CCI surgery at Metropolitan Neurosurgery, has reviewed records and consulted but has not examined her in person.
This case highlights a critical question:
Should an anterior pannus be considered a contraindication for PICL?
There is no universal consensus, and ongoing case tracking is essential to refining best practice. Dr. Fraser Henderson and Dr. Chris Centeno weighed in on significance of pannus to help provide guidance.
PICL Outcomes: What the Research Says
Dr. Chris Centeno’s PICL Randomized Controlled Trial (RCT) reports that 70% of patients who received PICL did not proceed to surgical intervention. However, it’s essential to examine the context and applicability of this figure:
✅ Time Frame Considerations – The duration over which this 70% metric is measured is not explicitly defined.
✅ Highly Selective Inclusion Criteria – The trial’s patient selection process was strict, meaning real-world application may vary.
✅ Evolving Understanding of Contraindications – There is ongoing debate regarding whether an anterior pannus should guide treatment selection for PICL.
- note: not all methods of injecting the alar ligament have equal safety profiles. I am aware of another provider, whose process may be less safe for injection under these circumstances. Just because one method or injector is likely safe, doesn’t mean all injectors and all methods may be likely safe.
✅ Surgical vs. Regenerative Pathways – Some providers suggest that visible vertebral slippage on static imaging may indicate a need for more robust stabilization, favoring surgical intervention over regenerative options in certain cases.
For both patients and referring physicians, it’s important to recognize that PICL is at the cutting edge of regenerative medicine, and continued tracking of patient outcomes will help refine selection criteria.
Patients should be educated that PICL is not only viewed as a stand-alone procedure, but may also support less drastic secondary surgical interventions and stabilization of skull-fusion-sparing surgical options.
The role of PICL in both surgical and non surgical cases must be understood and training programs must be established to meet the growing need of MCAS patients, particularly after COVID, which increased the incidence of clinically recognized MCAS.
The Role of Consulting Experts Like Dr. Rowan Paul & Dr. Fraser Henderson
Dr. Rowan Paul: Advancing Regenerative Ehlers-Danlos Treatment
Dr. Rowan Paul is a world-class expert in regenerative orthopedic and musculoskeletal repair, with extensive experience treating:
✔ Olympic athletes
✔ Professional ballerinas, who frequently have hypermobility and Ehlers-Danlos syndrome (EDS)
✔ Elite sports professionals
Now highly specialized in Ehlers-Danlos repair, Dr. Paul is studying deeply in joint, ligament, and fascia repair, refining regenerative approaches in his specialty. His expertise spans hands, feet, and whole-body biomechanical optimization, and he collaborates with leading specialists worldwide to push the field forward.
While he did not make a definitive call on whether this anterior pannus is a contraindication for PICL, his measured and research-driven approach ensures that patient outcomes remain the top priority.
Dr. Fraser Henderson: Skull-Fusion-Sparing Surgery
For cases where regenerative medicine may not be the optimal path, Dr. Fraser Henderson, a pioneer at Metropolitan Neurosurgery, has developed advanced CCI surgical techniques that can, in some cases, avoid full skull fusion.
His approach provides:
✔ Stabilization with maximal motion preservation and reduced pressure on C1
✔ Minimization of long-term surgical complications where possible
✔ A strong alternative for patients with complex anterior/posterior compression
Dr. Fraser Henderson emphasizes that anterior pannus is often overdiagnosed in EDS patients and is significantly more common in rheumatoid arthritis (RA) than in hypermobility-related CCI. In Sarah, there is a history of JRA, Juvenile Rheumatoid Arthritis. While mild stenosis at C1 is present in flexion, there is no indication of severe CCI, and PICL remains a viable option. Importantly, he notes that PICL does not contribute to pannus growth behind the odontoid, particularly in the case of a smaller pannus, suggesting that regenerative approaches remain a viable consideration in patients like Sarah. He recommends consulting Dr. Chris Centeno to further explore PICL as a treatment option.
Many doctors follow a three-session cycle for serious injuries (sometimes following up BMAC or other stem cell therapies with PRP, PRF, or PRGF)—firstly, as soon as possible after the injury, followed by a second session after a few weeks, and a third after a few months. However, Dr. Chris Centeno notes that PICL procedures require at least three months between BMAC harvesting sessions. While other experts may vary in their protocols, patients considering PICL should plan for a minimum 3+ month gap after their last BMAC procedure to ensure proper timing and optimal outcomes.
For Patients: Making an Informed Decision
If you’re considering PICL, surgery, or alternative treatments, here are key questions to ask your provider:
1️⃣ Does an anterior pannus impact my candidacy for PICL?
2️⃣ What are the risks of anterior injection swelling in my specific case?
3️⃣ How do you determine whether posterior ligament treatment alone is sufficient?
4️⃣ Are there long-term success rates for PICL in patients with both anterior and posterior compression?
Taking the time to ask the right questions can ensure that your decision is informed by both clinical reasoning and real-world outcomes.
For Providers: Enhancing Patient Selection & Education
PICL represents a groundbreaking innovation in regenerative medicine, and ongoing collaboration between providers is key to optimizing patient selection. As more data emerges, physicians can improve outcomes by:
✔ Defining clearer contraindications – Ensuring standardized guidance on whether an anterior pannus affects PICL candidacy.
✔ Encouraging multidisciplinary collaboration – Bridging the gap between regenerative medicine, neurosurgery, and radiology.
✔ Standardizing patient education – Providing clearer decision-making tools for both physicians and patients.
✔ Tracking long-term PICL outcomes – Contributing to the refinement of selection criteria based on real-world results.
By working together, regenerative medicine and surgical teams can create a more effective, patient-centered approach to CCI treatment.
For more information and step-by-step guidance on treatment for MCAS and EDS, see here and here.
*a previous version noted three neurosurgeons: one of the practitioners is listed as a neurosurgeon on google, but is not boarded in neurosurgery and is not practicing neurosurgery.
Disclaimer:
The information provided herein is for informational purposes only and is not intended to serve as medical advice, diagnosis, or treatment. It is not a substitute for professional medical care. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition or treatment. The authors and publishers do not assume any responsibility or liability for any direct or indirect consequences resulting from the use or misuse of this information.
