What is PICL, Also Known as MALC Treatment?

PICL (Percutaneous Implantation of the CCJ Ligaments), more precisely referred to as MALC (Median Atlantoaxial Ligament Complex) treatment, is a regenerative procedure aimed at restoring the stability of cervical ligaments. This helps reduce pain and improve head–neck coordination in cases of Whiplash Associated Disorder (WAD) or Craniocervical Instability (CCI).

How Does This Regenerative Treatment Work?

The goal of regenerative medicine is to activate the body’s natural healing processes. During the procedure, biological substances such as platelet-rich plasma (PRP) or bone marrow concentrate (BMC) are used.

These promote:

  • New collagen formation
  • Strengthening of ligaments and joint capsules
  • Improved blood circulation and oxygen supply
  • Restoration of neck proprioception (sense of position and balance)

The overall aim is to restore cervical ligament stability, reduce pain, and improve head–neck coordination.

When is CCJ Regenerative Treatment Recommended?

  • Craniocervical instability (CCI)
  • Cervicogenic headache
  • Post-whiplash symptoms (WAD grade 1–3)
  • Chronic neck pain not responding to other treatments (in some cases, treating the lower cervical spine alone may be sufficient)

What Happens During the Procedure?

The procedure is minimally invasive and performed under imaging guidance (X-ray and ultrasound). The physician precisely targets unstable areas (such as the atlanto-occipital (AO) or atlantoaxial (AA) joints and ligament structures) using small amounts of PRP or BMC injections.

  • AO/AA joints and posterior ligaments: performed under sedation, in prone position, with X-ray guidance and contrast verification (DSA)
  • MALC (central ligaments): performed under general anesthesia, in supine position, via a transoral approach
  • Lower cervical joints: treated similarly with small-volume injections

After the procedure, mild soreness, muscle tension, or swelling may occur for a few days — this is a normal part of healing.

How Many Treatments Are Needed?

The number of treatments is individualized, but typically 2–4 sessions are sufficient.
A 4–6 week interval between treatments is recommended to allow tissue regeneration.

What Results Can Be Expected?

Pain and instability usually decrease gradually.
Most patients report significant improvement after 2–3 treatments, along with better daily function.
Long-term, the treatment may improve cervical stability and reduce the frequency of headaches and other symptoms.

What Does Science Say About This Procedure?

Interest in regenerative medicine is rapidly growing worldwide, and scientific evidence is increasing.

Numerous high-level (Level 1) clinical studies support the effectiveness of treatments such as BMC, PRP, and prolotherapy for joint conditions, especially knee osteoarthritis, and for tendinopathies (e.g., tennis elbow).

Level 1 evidence also supports BMC and PRP in treating lumbar spine disc and facet joint pain.

For the cervical spine, data are currently more limited, but case studies suggest promising results.

The transoral treatment of the C0–C1–C2 region has not yet been formally published in the literature and is considered experimental. However, at our clinic, Dr. Agnes Stogicza has been performing this procedure since 2010, providing extensive clinical experience despite limited published data.

Possible Side Effects

Common, Mild Symptoms:

  • Local tenderness, swelling, muscle pain
  • Sore throat (resolves within 24 hours)

Rare Side Effects:

  • Infection, bleeding, nerve involvement
  • Temporary dizziness or muscle spasm

Severe Complications (such as paralysis, stroke, death, seizures, or permanent neurological damage) have not been reported. Due to limited data, exact risk rates cannot yet be determined.

The procedure must only be performed by highly experienced specialists. Proper X-ray-guided needle placement, contrast imaging knowledge, and high-level anesthesia ensure patient safety.

General anesthesia is essential for the transoral approach, as it allows safe airway protection and precise needle placement.

How Should Patients Prepare?

  • A pre-treatment session with a cervical manual therapist is recommended
  • Avoid anti-inflammatory medications and steroids for 2 weeks prior
  • Smoking should be stopped (reduces effectiveness)
  • Do not drive on the day of the procedure — arrive with an escort
  • Do not eat for 6 hours before the procedure; water is allowed up to 2 hours prior

Aftercare and Lifestyle

After regenerative treatment, the following are recommended:

  • Start physiotherapy and neck stabilization exercises as advised (typically 6 weeks after treatment)
  • Protein-rich diet and vitamin C (500 mg/day)
  • Use warm or cold compresses for pain if needed