Chronic Neck Pain | Cervical Neck Instability
Ross Hauser, MD discusses the problems of chronic neck pain and Cervical Neck Instability and treatment options including Prolotherapy, Stem Cell Therapy, and Platelet Rich Plasma Therapy.
Below are two published medical papers the first a case history and the second a medical study on treatment of chronic cervical neck instability.
Published Case History Neck Pain in a 47 year old woman
Here is a summary account of a case study we published in the Journal of Prolotherapy:
The patient is a 47 year-old-woman first treated in 2013. She had been in two car accidents, one in 2008 and one in 2013, both times rear ended. Because of symptoms the patients was treated with NSAIDS, muscle relaxants and physical therapy with unsatisfactory results.
- Pain in the upper limbs,
- muscle tenderness and spasm,
- chronic pain in the neck and clicking,
- and intermittent tingling down her right arm.
- Pain was exacerbated by head movement.
- The patient also reported decreased range of neck motion.
Physical exam revealed:
- straightening of cervical lordosis (curve in cerival spine),
- a decreased range of motion for extension, lateral flexion and rotation (bilaterally),
- crepitation at C0 – C2,
- and severe spasms and tenderness in the trapezius and paraspinal muscles.
- Muscle tenderness was most significant in the C0-C2 area.
The patient was given advice regarding posture and told to avoid high velocity manipulation, self manipulation, neck stretching exercises, and motions that cause crepitation or clicking.
Dextrose prolotherapy was administered in the upper and lower cervical region at initial visit, and three further treatments were provided 1, 2 and 4 months later (visits 2 – 4).
Between visits 1 and 3, the patient also attended physical therapy sessions three times a week.
Digital motion X-ray (DMX) was performed between visits 1 and 2. The DMX showed straightening of cervical lordosis and instability throughout the upper and lower cervical spine. Findings were indicative of capsular ligament damage at C1-C2. There was also significant anterolisthesis of C2 on C3 and of C3 on C4. Capsular ligament damage at C6-C7 was indicated by gapping of those facet joints. Facet hypertrophy was evident at right C4-C5
At visit 2, the patient reported that tingling in the arm had abated and her neck crepitation had noticeably decreased (especially with neck rotation), but there was little change in pain intensity.
At visit 3, she reported that she no longer had headaches. Pain had become more localized to the left side, particularly on rapid rotation of the neck.
At visit 4, the patient reported that pain intensity had decreased significantly, and there was now only an intermittent sensation of pressure in the upper cervical region. Crepitation had resolved completely and she had begun to exercise with a stationary bicycle. The patient expressed satisfaction with her progress (“95% improvement”).
Straightening of lordosis was still evident, but the offsets of the right and left lateral masses of C1 on C2 (during left and right rotation, respectively), were each reduced to 20%, representing a 33 – 50% decrease from initial values.
In absolute terms, atlas lateral shift decreased to 1.12 mm during left lateral bending (as compared to original measurement of 1.85 mm) and to 0.36 mm during right lateral bending (as compared to 0.72 mm). Measurements were performed by Spinal Kinetics. Some anterolisthesis was still noted at C2–C3 and C3-C4. Facet hypertrophy at C4-C5 was unchanged.
This case study is the first report describing dextrose prolotherapy and longitudinal imaging in a case of chronic neck pain with clinically and radiographically confirmed instability in the upper cervical region.
During the treatment course, the patient experienced progressive symptomatic relief, which began at one month of treatment and included at least partial alleviation of all reported symptoms. The patient showed functional gain, returning to exercise within four months. No adverse effect was observed. At five months after initiation of treatment, a 33 – 50 percent reduction in atlantoaxial offset was observed, providing evidence for improvement in stability.
It is not common practice to obtain follow-up imaging in cases where patient symptoms are successfully diminished with therapy. The radiologic improvement observed in this case, in the context of a treatment course potentially promoting ligamentous repair, is consistent with a pathogenetic linkage of ligament injury to traumatic chronic neck pain in the setting of upper cervical instability. Our findings are consistent with previous observational studies of prolotherapeutic treatment of cervical injury.
Research on 21 patients with cervical instability and chronic neck pain
In new research published in the European Journal of Preventive Medicine our Caring Medical research team presented the following findings
- Ninety-five percent of patients reported that Prolotherapy met their expectations in regards to pain relief and functionality. Significant reductions in pain at rest, during normal activity, and during exercise were reported.
- Eighty-six percent of patients reported overall sustained improvement, while 33 percent reported complete functional recovery.
- Thirty-one percent of patients reported complete relief of all recorded symptoms. No adverse events were reported.
We concluded that statistically significant reductions in pain and functionality, indicating the safety and viability of Prolotherapy for cervical spine instability.
Full article and reference:
Hauser R, Steilen D, Gordin K The Biology of Prolotherapy and Its Application in Clinical Cervical Spine Instability and Chronic Neck Pain: A Retrospective Study. European Journal of Preventive Medicine. Vol. 3, No. 4, 2015, pp. 85-102. doi: 10.11648/j.ejpm.20150304.11
We see a high number of patients with a myriad of symptoms related to cervical instability. The symptoms are usually extremely debilitating and the patient is often at the “end of their rope.” Having seen numerous physicians, having tried a multitude of therapies, and having experienced little to no improvement, clearly many of these patients feel abandoned by the medical community.
Some of these cervical instability and chronic neck pain patients also had instability of their upper cervical spine, more specifically C1 and C2 (also known as the atlas (C1) and axis (C2). causing symptoms related to dizziness, cervical vertigo, ringing in the ears, headache, and other challenges.
Because headache pain, duration, and frequency (cluster headaches) can be so severe, the first treatment most doctors will recommend is the medication treatment course.
According to research the most effective pharmacological treatment options for acute cluster attack include nasal or injection of sumatriptan, 100% oxygen, and intranasal zolmitriptan.
Dihydroergotamine injection. The above mentioned drugs are thought to work by reducing swelling of blood vessels around the brain and blocking the release of certain natural substances that cause pain.1
These drugs are the most effective pharmaceuticals for treating the symptoms of these types headaches according to the leading experts, but they are not the most effective treatment and certainly do not provide the patient a curative option.
Why do medical practitioners rush to prescribe drugs for Cervical Neck Instability?
Instability in the neck region, that is the ligaments, must play a role in headaches? Here is where the MRI now becomes a player.
Cervical instability can be difficult to diagnose for the average practitioner. This is largely due to the low reliability and validity of radiographic studies including functional (motion) radiographs and many clinical examination measures that are still under debate and are rather questionable. Unfortunately, there is often no correlation between the hypermobility or subluxation of the joint, clinical signs or symptoms, or neurological signs or symptoms. Sometimes there are no symptoms at all which further broadens the already very wide spectrum of possible diagnoses for cervical instability.
In one study, “healthy” volunteers who experienced no neck pain or headaches had MRI’s that showed so many things wrong that the investigators had to conclude that the MRI had “limited diagnostic value in patients with whiplash-associated disorders.” 2 So without an MRI to guide treatment, it is back to the pharmaceuticals as the only treatment option. Please see our companion articles failed back surgery risk factors – the MRI, and is my MRI accurate?
Physical therapists typically use the following to diagnose cervical instability:
- Intolerance to prolonged static postures
- Fatigue and inability to hold head up
- Better with external support, including hands or collar
- Frequent need for self-manipulation
- Feeling of instability, shaking, or lack of control
- Frequent episodes of acute attacks
- Sharp pain, possibly with sudden movements.
Surgical treatments for Cervical Instability: Screw Fixation – Cervical Fusion
When the patients no longer wish to be on a pharmaceutical treatment plan for their headaches and subsequent cervical neck problems, surgery, ie fusion or cervical decompression surgery is typically recommended.
Surgery is often aimed at fixing the instability by fusing vertebral segments together. In the case of C1-C2 instability, these two vertebrae are fused posteriorly to limit their amount of movement. However, it may limit motion so much that patients become completely unable to move that portion of their neck. In addition, fusion operations can accelerate the degeneration of adjacent vertebrae as the motion in the neck is distributed more on these tissues. For example, if you fuse the C1 and C2 vertebrae together, extra motion is placed on the remaining vertebrae during normal neck movement, accelerating the degeneration process and further contributing to chronic neck pain.
The rush to surgery is based on the immediate goals of the patients, that is the alleviation of pain. And spinal cervical fusion and decompression seems to offer a solution – short term. “(In our research) of patients with cervical radiculopathy, we found that surgery with physiotherapy resulted in a more rapid improvement during the first year after surgery, with significantly greater improvement in neck pain and global assessment scores compared to physiotherapy alone; but the differences between the groups decreased after two years. Structured physiotherapy should be tried before surgery is chosen.” 3 After two years, the same result between physical therapy and surgery was seen – no difference in outcome.
In our own published research, we documented that the use of conventional modalities for chronic neck pain remains debatable, most treatments have had limited success and despite providing temporary relief of symptoms, these treatments do not address the specific problems of healing and are not likely to offer long-term cures.4
In this research, our team led by Danielle Steilen, MMS, PA-C, noted that the capsular ligaments are the main stabilizing structures of the facet joints in the cervical spine and have been implicated as a major source of chronic neck pain. Such pain often reflects a state of instability in the cervical spine and is a symptom common to a number of conditions such as:
- disc herniation,
- cervical spondylosis,
- whiplash injury and whiplash associated disorder,
- post-concussion syndrome,
- vertebrobasilar insufficiency,
- and Barré-Liéou syndrome.
In the lower cervical spine (C3-C7), this can cause muscle spasms, crepitation, and/or paresthesia in addition to chronic neck pain. In either case, the presence of excessive motion between two adjacent cervical vertebrae and these associated symptoms is described as cervical instability.
We concluded that in many cases of chronic neck pain, the cause may be underlying joint instability and capsular ligament laxity. Furthermore, we contend that the use of comprehensive prolotherapy appears to be an effective treatment for chronic neck pain and cervical instability, especially when due to ligament laxity. The technique is safe and relatively non-invasive as well as efficacious in relieving chronic neck pain and its associated symptoms.
In our clinical and research observations, we have documented that Prolotherapy can offer answers for sufferers of cervical instability, as it treats the problem at its source. Prolotherapy to the various structures of the neck eliminates the instability and the sympathetic symptoms.
If a person has true cervical radiculopathy and they are not yet a patient then we may recommend an electromyogram. An EMG nerve conduction study is done at the hospital by a physician, a physical medicine and rehabilitation doctor, or a neurologist. This nerve conduction test checks to see if the nerve is getting pinched, much like an electrician tries to figure out whether there is a short in the electrical wire. The study gives us more clarity as to what is going on in the neck.
Cervical radiculopathy is a condition of nerve function disturbance resulting from the compression of the nerve roots near the cervical vertebrae. This disturbance can damage the nerve roots in the cervical area and cause pain and loss of sensation in different parts of the upper extremities, depending on the location of the damaged roots. Pain is the main symptom of cervical radiculopathy and is experienced spreading into the arm, neck, chest, upper back and shoulders. There may also be weakness, numbness, or tingling in these various areas. Sometimes there is a lack of coordination, especially in the hands.
Cervical radiculopathy is generally considered to result from pressure from a herniated disc, arthritis, or other injuries that increase pressure on these nerve roots. However, a 1998 study demonstrated that an exacerbation in radicular pain in patients with disc herniation and cervical arthritis was related more to provocative movements such as flexion, extension, and rotation, rather than to the size of the herniated disc. A neural foramen is the opening that allows the passage of spinal nerve roots to exit the spine. These various motions changed the foraminal size, nerve root motion, and cervical cord rotation. When arthritis or stenosis was present, the increased radicular pain was also related to movement of the cervical spine as it narrowed the foraminal opening.4
If the changes in foraminal size with motion cause an exacerbation in cervical radicular pain, it would follow that any instability in the cervical spine would exacerbate the radicular pain as well, since instability causes even more motion in the joint.
The foraminal size will change as an individual carries out their normal daily activities, bending and rotating the neck. During these activities the nerve root will get compressed intermittently as it exits the neural foramen. When the person assumes a different position, the nerve root contact may be relieved. In the study, movements such as flexion tended to relieve compression caused by stenosis, and extension tended to produce more symptoms.5
Positional narrowing of the foramina or degenerative issues leading to radicular pain is exacerbated by instability of the cervical spine. In our experience, the instability of the spine is caused from injury to the cervical ligaments. Ligaments are connective structures that connect bone to bone and aid in the stabilization of the cervical vertebrae.
Treating cervical instability by treating the cervical ligaments
“Since patients with traumatic cervical instability have few viable treatment options other than surgical fusion, cervical proliferant injections under C-Arm fluoroscope may be a viable treatment option.” 6
Prolotherapy under C-Arm fluoroscope for neck ligament injections
In our published study on Prolotherapy for neck pain, we followed 98 patients undergoing dextrose Prolotherapy treatment for unresolved neck pain. These patients reported neck pain for an average for 59 months. These patients saw an average of more than three physicians prior to being treated quarterly with Prolotherapy.
This population included patients who were told by their doctors that there were no other treatment options or that surgery was their only answer for their chronic pain.
- More than 83% of patients showed improvements in walking ability, exercise ability, anxiety, depression and overall disability with Prolotherapy.
- Ninety percent of patients who were on medications at the start of Prolotherapy were able reduce pain medication use by 50% or more. Additional pain management care was able to be lessened by 50% or more in 75% of cases with Prolotherapy.
- Ninety-eight percent of patients stated their pain was better with Prolotherapy.
- Ninety-seven percent of patients said Prolotherapy changed their life for the better. 7
The key to avoiding cervical spine surgery for instability, headaches, or radiating pain, is preventing the surgery and choosing conservative treatments. In our opinion Comprehensive Prolotherapy including the use of Platelet Rich Plasma Prolotherapy, Stem Cell Therapy, and Dextrose Prolotherapy with and without other growth factors offers a realistic chance to avoid surgery by strengthening the supportive ligaments and tendons of the cervical spine region, stabilizing the area and preventing further deterioration.
1. Becker WJ. Cluster Headache: Conventional Pharmacological Management. Headache. 2013 Jun 14. doi: 10.1111/head.12145. [Epub ahead of print]
2. Lummel N, Bitterling H, Kloetzer A, Zeif C, Brückmann H, Linn J. Value of “functional” magnetic resonance imaging in the diagnosis of ligamentous affection at the craniovertebral junction. Eur J Radiol. 2012 Nov;81(11):3435-40. doi: 10.1016/j.ejrad.2012.04.036. Epub 2012 Jul 2.
3. Engquist M, Löfgren H, Oberg B. Surgery Versus Non-Surgical Treatment for Cervical Radiculopathy: A prospective, randomized study comparing surgery plus physiotherapy with physiotherapy alone with a two year follow-up. Spine (Phila Pa 1976). 2013 Jun 17. [Epub ahead of print]
4. Steilen D, Hauser R, Woldin B, Sawyer S. Chronic neck pain: making the connection between capsular ligament laxity and cervical instability. Open Orthop J. 2014 Oct 1;8:326-45. doi: 10.2174/1874325001408010326. eCollection 2014.
5. Muhle C, Bischoff L, Weinert D, et al. Exacerbated Pain in Cervical Radiculopathy at Axial Rotation, Flexion, Extension, and Coupled Motions of the Cervical Spine. Investigative radiology, 1998;33(5): 279-288.
6. Centeno CJ, Elliott J, Elkins WL, Freeman M. Fluoroscopically guided cervical prolotherapy for instability with blinded pre and post radiographic reading. Pain Physician. 2005 Jan;8(1):67-72.
7. Hauser R, Hauser M. Dextrose Prolotherapy for Unresolved Neck Pain, Practical Pain Management, October 2007