CERVICAL INSTABILITY

The Definition of Cervical Instability

When the ligaments that connect your spinal cord to your skull become loose, you have cervical instability. For instance, the top two cervical vertebrae allow additional movement of the head because of “lax ligaments,” which can cause the symptoms outlined in the first paragraph of this page.  Also, ligament laxity refers to the loosening of ligaments that connect bones. Furthermore, this condition might go beyond the neck and affect the entire body or simply some other sections of it.

You may have noticed a friend bend their finger in an unusual manner. This is most likely caused by ligament laxity, which leads to other joints moving or bending more than they should. Your friend’s finger ligaments are lax and allow for a broader range of motion. An abnormal range of motion in your neck can indicate Cervical instability and other genetic connective tissue diseases can induce ligament laxity. In addition, ligaments at the following two joints can cause this disease:

1. Atlanto-occipital joint
2. Atlanto-axial joint

There are other terms that also describe Cervical instability.

What Causes Cervical Instability?

The bones and cartilage that make up your neck and backbone wear down with age. These changes might include:

• Dehydrated discs:

Between the bones of your spine, discs serve as cushions. Most people’s spinal discs begin to dry out and shrink around the age of 40 and generate:

• Bone spurs:

As a result of disc degradation, the spine will make additional bone. It occurs as a result of an attempt to strengthen the spine. These bone spurs might squeeze the spinal cord and nerve roots and cause:

• Stiff ligaments:

Ligaments join bones together. Your spinal ligaments stiffen as you become older, making your neck less flexible and in certain cases causing:

• Trauma:

A car collision, for example, might cause trauma to the cervical spine. Micro-injuries and repeated trauma can also cause:

• Rheumatoid arthritis (RA):

Rheumatoid arthritis and other disorders can cause problems to the cervical spine.

Symptoms of Cervical Instability?

Neck pain is becoming more common as we use smartphones, laptops, and other technologies that become available.

Also, neck, head, and shoulder pain might appear perfectly bland and have a clear cause in many cases, but for certain men and women, a severe condition lurks beneath the surface. For those that have cervical vertebrae that can move beyond their normal range of motion, they can develop cervical instability. Then, the cervical spine can no longer support the head or allow the patient to flex, twist, and turn their head fully — without pain.

Because the signs of cervical instability often seem confusing, knowing the exact reason for your pain requires a doctor’s skill. A proper diagnosis becomes essential for receiving the right treatment and relief from severe symptoms. In most cases, a doctor is the only person who can find the source of neck pain. When it comes to finding the origin of your pain and seeking treatment, doctors look for symptoms to determine whether you have cervical spine instability. Among them are:

• Inability to hold one’s head erect for long periods of time
• Pain in the upper neck, towards the skull
• Shoulder pain that was referred
• Head feels heavy
• Neck muscles that are tight or stiff
• Tenderness
• Headaches
• Neck/head trembling or unsteadiness
• Dizziness/imbalance

If there are other symptoms like shooting pain or numbness, there may be nerve compression or a larger issue. These symptoms are critical to note, as they can indicate a more severe underlying condition that requires immediate medical attention.

Pathophysiology of Cervical Instability

The cervical spine is composed of seven vertebrae (C1-C7), supported by a complex system of ligaments, muscles, and intervertebral discs. Cervical instability can arise from several pathological processes:

• Trauma: Accidents such as whiplash, falls, or blunt force injuries can disrupt ligaments and lead to instability.
• Degenerative Changes: Age-related conditions such as osteoarthritis, disc degeneration, or spondylolisthesis can weaken the spine’s support structures.
• Congenital Conditions: Conditions like Ehlers-Danlos syndrome, Marfan syndrome, or Down syndrome can affect connective tissue integrity, leading to laxity in the cervical spine.
• Inflammatory Conditions: Rheumatoid arthritis can erode ligaments and joints in the cervical spine, leading to atlantoaxial instability.

Understanding the underlying pathology is essential for accurate diagnosis and treatment planning.

Clinical Presentation

Patients with cervical instability may present with a wide range of symptoms, including:

• Neck pain: A primary symptom, which may be localized or radiate to the shoulders and upper back.
• Headaches: Often cervicogenic in nature, these headaches are caused by dysfunction in the upper cervical spine.
• Dizziness or vertigo: Resulting from abnormal movement of the cervical vertebrae affecting blood flow to the brain or the vestibular system.
• Neurological Symptoms: Numbness, tingling, or weakness in the arms or hands due to nerve root compression.
• Gait Disturbances: Instability in walking can occur if the spinal cord is compressed.

Given the non-specific nature of these symptoms, clinicians must carefully assess patient history and perform a thorough physical examination.

Diagnostic Approach

Patient History

The diagnostic process begins with a detailed history, focusing on:

• Symptom Onset and Progression: Was there a traumatic event? Are symptoms worsening over time?
• Previous Injuries or Surgeries: A history of neck trauma or cervical surgery can increase the risk of instability.
• Associated Symptoms: Dizziness, headaches, or neurological signs such as radiculopathy or myelopathy must be noted.
• Risk Factors: Age, congenital disorders, or connective tissue diseases can predispose patients to cervical instability.

A thorough history can provide clues about the underlying cause and help guide further diagnostic steps.

Physical Examination

The physical examination aims to identify signs of instability, nerve compression, or other cervical pathologies. Key components include:

• Range of Motion Testing: Excessive or painful range of motion, particularly with flexion and extension, can indicate instability. The clinician may observe abnormal movement or crepitus during motion.
• Neurological Examination: Testing for motor strength, sensory deficits, and deep tendon reflexes is crucial to identify any radiculopathy or myelopathy.
• Palpation: Tenderness over the cervical spine, muscle spasm, or misalignment can suggest instability.
• Special Tests: Specific clinical maneuvers can help diagnose cervical instability:
• Sharp-Purser Test: Used to assess the integrity of the transverse ligament of the atlas (C1) by observing for excessive movement during gentle forward pressure on the forehead.
• Alar Ligament Stress Test: Evaluates the alar ligament by laterally bending or rotating the head and checking for abnormal movement.
• Spurling’s Test: Assesses for cervical radiculopathy by compressing the cervical spine and reproducing radicular symptoms.
• Cervical Flexion-Rotation Test: Helps to assess upper cervical spine dysfunction, especially in cases with headaches or dizziness.

Imaging Modalities

Imaging is a critical component in the diagnosis of cervical instability, providing objective evidence of abnormal movement or structural damage. Common imaging modalities include:

X-rays

Standard X-rays are often the first imaging study ordered. Specific views, such as lateral, anteroposterior, and open-mouth odontoid, can reveal:

• Alignment: Abnormal alignment or curvature of the cervical spine (e.g., spondylolisthesis).
• Bone integrity: Fractures or degenerative changes.
• Flexion-Extension Views: Dynamic X-rays taken while the patient flexes and extends their neck can reveal excessive movement between vertebrae, a hallmark of instability.

Magnetic Resonance Imaging (MRI)

MRI provides detailed images of the soft tissues, including discs, ligaments, and the spinal cord. It is particularly useful for:

• Ligamentous Injury: MRI can show tears or degeneration of the ligaments supporting the cervical spine.
• Nerve or Spinal Cord Compression: Herniated discs, bone spurs, or excessive movement can compress the spinal cord or nerve roots.
• Myelomalacia: This refers to spinal cord damage that may result from chronic instability.

Computed Tomography (CT)

CT scans offer high-resolution images of the bony structures and are often used when fractures or congenital malformations are suspected. They can also help assess for:

• Atlantoaxial Instability: CT is often preferred for visualizing the C1-C2 vertebrae.

Dynamic Fluoroscopy

Fluoroscopy provides real-time X-ray imaging, which can be used to assess cervical spine movement during functional tasks, offering a more dynamic assessment of instability compared to static imaging.

Diagnostic Criteria

Several radiographic and clinical criteria have been proposed for diagnosing cervical instability, including:

• Translation of Vertebrae: Movement of one vertebra relative to another by more than 3.5 mm during flexion-extension X-rays is considered abnormal.
• Angulation: An angulation greater than 11 degrees between two adjacent vertebrae during flexion-extension is suggestive of instability.
• Loss of Cervical Lordosis: Abnormal curvature, including reversal or excessive straightening of the normal cervical lordosis, can indicate underlying instability.
• Spinal Cord Involvement: MRI showing cord compression or myelomalacia raises concerns for severe instability.

Adjunctive Testing

In some cases, additional diagnostic tests may be useful:

• Electromyography (EMG) and Nerve Conduction Studies (NCS): These tests can assess nerve function and help identify radiculopathy caused by cervical instability.
• Vestibular Testing: Dizziness or vertigo in cervical instability patients may necessitate vestibular function testing, particularly if vertebrobasilar insufficiency is suspected.

Challenges in Diagnosis

Diagnosing cervical instability can be challenging due to the variability in symptoms, the often subtle radiographic findings, and the overlap with other cervical spine conditions. Furthermore, in patients with connective tissue disorders like Ehlers-Danlos syndrome, traditional imaging may not fully capture the extent of ligamentous laxity. Therefore, clinicians must use a combination of clinical judgment, imaging, and functional testing to make a definitive diagnosis.

Conclusion

Cervical instability is a complex condition that requires a thorough diagnostic approach. By combining a detailed patient history, careful physical examination, advanced imaging techniques, and functional tests, healthcare providers can accurately diagnose this condition. Early detection is crucial to prevent further damage to the cervical spine and the potential for neurological complications. Future research should focus on refining diagnostic criteria and developing more sensitive imaging techniques, particularly for patients with ligamentous laxity or occult instability.

Treating Cervical Instability

If you’re having any of the above symptoms and suspect they’re connected to cervical instability, seeing a trained spine doctor becomes one of the most important things you can do. For this disease, there are five recommended treatments:

• Surgery
• Physical therapy
• Strengthening exercises
• Prolotherapy
• Chiropractic

For cervical instability therapy, the above five treatments appear as the most popular.

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Rest and Anti-inflammatory Medication

Rest and anti-inflammatory medication will usually resolve the problem. However, if there are other symptoms like shooting pain or numbness, there may be nerve compression or a larger issue. In such cases, more advanced treatments might be necessary.

Surgery

Unless your disease appears severe, doctors do not advise surgery. However, surgery will control the life-altering symptoms of cervical instability in the most severe patients and stop the pain in the upper spine. Also, the following identifies the most used surgical therapy options:

• Cervical fusion spine surgery
• Halifax clamp
• Along with the lateral mass of the atlas vertebra and the pedicle of the axis vertebra, doctors use screw-rod constructions.
• Posterior wiring

When minor problems appear, Cervical spine fusion will halt cervical instability. Upon receiving surgery, patients with pain and moderate cervical myelopathy achieve the best outcome for this disease. Because surgery is invasive and costly, our doctors always begin with treatments like physical therapy.

Physical Therapy

Physical therapy works well to treat cervical instability, and we normally advise patients to undergo physical therapy for excellent outcomes. Also, the following depicts what physical therapy entails:

• Strengthening exercises
• Posture education
• Joint mobilization
• Soft tissue mobilization
• Spinal manipulation
• Proprioception exercises

Depending on the degree of your cervical instability and if you had surgery before this, you may or may not need to wear a brace or cervical collar. According to a two-year follow-up research study, surgery improves patient outcomes after one year. After two years, however, physical therapy was not better than surgery in terms of relieving symptoms. To put it another way, surgery becomes a quick fix for this condition and it reduces pain.

Strengthening Exercises

Before doing these exercises to aid with cervical instability, always see your doctor or physical therapist. To prevent and cure this disease, the following are five exercise examples:

• Chin tucks help your posture and neck joints by stretching and strengthening them. Thus, the most typical exercise for improving cervical stability is chin tucks.
• To strengthen the neck region, mix workouts with an active range of motion. In order to learn workouts, view YouTube videos.
• The joints and muscles of the upper cervical spine can also become strengthened by rotating the neck gently and carefully.
• Neck motions such as yes and no assist to stretch the muscles and joints in the neck. So, nod your head gently up and down for the yes action and shake your head gently from left to right for a no motion.
• The pressure on the spine gets reduced by maintaining good posture. Accordingly, spend as much time as possible practicing proper posture. With each passing day, you should maintain proper posture.
• Any workout or movement that causes you pain should be stopped. If you’re in pain, take it easy, and don’t push yourself any farther.

Prolotherapy

This is a relatively recent option for cervical instability that has few negative effects. Prolotherapy is an injection procedure used to strengthen and mend broken joints and ligaments by stimulating the body’s natural healing processes. For example, it’s designed to treat acute and chronic problems, such as cervical instability, which causes chronic neck pain due to underlying joint instability and ligament laxity. By receiving these injections, patients with this disease might avoid surgery. On the other hand, this treatment has yet to show that it produces long-term results in every patient. Therefore, many patients seek both chiropractic and physical therapy after these treatments fail to provide long-term pain relief.

Chiropractic

Chiropractors address, treat, and help people with headaches, poor posture, and spinal problems, all of which have been linked to this disease. Furthermore, cervical instability, joint diseases, and other issues can respond favorably to spinal chiropractic treatment. When conducted by a highly experienced chiropractor, spinal manipulation appears as a safe but not always effective therapy for patients with this disease.

How to Prevent Cervical Instability

For persons with connective tissue diseases, our doctors recommend the following:

• Make regular appointments with your doctor
• Every day, do one minute of chin tucks.
• Every day, work on your posture.
• Avoid events that may cause whiplash or other spinal injuries.

There are Appointments Available for Neck Conditions at the Southwest Scoliosis and Spine Institute

In-person appointments are quickly available for treating cervical instability. You can easily make an appointment and consult with a doctor either through a physical visit to one of our three offices depending on your convenience and preference.

In-Person Appointments

• Immediate Care: Book same-day or next-day appointments to get immediate relief.
• Comprehensive Diagnosis: A face-to-face consultation allows for a thorough physical examination and a personalized treatment plan.

Both options ensure you receive expert care tailored to your needs. Choose the one that best fits your lifestyle and comfort level.

In conclusion, to stay in excellent health, everyone should follow these guidelines — especially those with connective tissue problems or neck or spine problems.  At the Southwest Scoliosis and Spine Institute, with offices in Dallas, Plano, and Frisco, Texas, we encourage people to get checked early on for neck pain.  In the majority of cases, our doctors will not find a serious condition, but in certain cases, early detection and treatment can have a positive effect on enjoying future decades of a wonderful life — pain-free. So pick up the phone today and give us a call.

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National Institute of Health: Cervical Instability