Six weeks of occipital headaches with occipital numbness and significant neck motion restriction accompanied by gait clumsiness best suggests which diagnosis?

• A. Atlas fracture
• B. Upper cervical ligamentous instability
• C. Cervical myelopathy
• D. VBI

Answer: (B)

Occipital headaches with numbness in the occipital region, along with marked neck motion restriction and a gait disturbance, point to instability at the atlas–axis region causing dynamic irritation of upper cervical structures. When the ligaments supporting the craniovertebral junction are lax or damaged, the atlas can move abnormally on the dens, especially with neck movement, leading to irritation of the suboccipital nerves and the cervicomedullary junction. This produces occipital headaches and occipital sensory changes, while the instability and pain limit neck motion and can yield gait clumsiness from cervical cord or brainstem involvement.

An atlas fracture would be expected after a high-energy trauma with an acute, severe presentation, not a subacute six-week history. Cervical myelopathy from multilevel degeneration tends to present with broader UMN signs (hyperreflexia, hand dexterity issues) and would not as specifically explain occipital headaches and numbness. Vertebral basilar insufficiency typically presents with dizziness, vertigo, or syncope related to vertebrobasilar flow changes with head position, rather than the combination of occipital sensory symptoms plus neck stiffness and gait clumsiness.