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
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.
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.
Atlantoaxial Instability also known as Upper Cervical and C1-C2 Instability
A subset of those with cervical instability and chronic neck pain will have instability of their upper cervical spine, more specifically C1 and C2 (also known as the atlas (C1) and axis (C2). This atlanto-axial joint is what allows us to do the “no” motion with our head. It is the most mobile part of our spine; that and the fact that there is no intervertebral disc between the two bones increases its chance of developing instability. When the capsular ligaments are injured, they become “loose”, which causes excessive movement of the cervical vertebrae.
Published research from Caring Medical. : October 7, 2014 This is a full access article
Chronic Neck Pain: Making the Connection Between Capsular Ligament Laxity and Cervical Instability
from the The Open Orthopaedics Journal, 2014, 8, 326-345
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,
- postconcussion 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.
The cervical (neck) area is a very important and sensitive area of the body, as it protects the brain stem, provides rotational flexibility, and allows for other body functions to work properly. Damage to the C0, C1, or C2 vertebrae can cause many more problems than just pain in the neck. Their close proximity to the brain stem can lead to blocked neural signals and cause systematic problems throughout the body. The pain that shoots down your arm may stem from a problem that comes from damage to the C1 and C2 vertebrae.
Upper cervical instability is a more severe issue than many people realize. 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. However, this is not the case for those of us who are skilled in recognizing cervical joint instability.
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.
Diagnosis and Symptoms of Cervical Neck Pain and Instability of the Neck
Destabilization of the upper cervical area can lead to severe life-threatening neurological sequelae that include but are not limited to vertigo, post-whiplash concussion, tinnitus, drop attacks, vertigo dizziness, occipital neuralgia, and headaches. (migraine headaches).
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.
Treatment Options of Instability of the Neck
Traditional treatment of cervical instability includes temporarily treating the area using electrical stimulation, physical therapy, chiropractic adjustments, and even surgical fusion (if immediately necessary or severe of a case). All of these treatments will require a fair amount of visits and possibly the use of other treatments long term in order to keep the results they may give. A permanent solution to cervical instability, however, is comprehensive Hackett-Hemwall Prolotherapy.
Prolotherapy: A Non-Surgical Alternative to Instability of the Neck
How do we treat cervical radiculopathy at Caring Medical? Many people with a cervical radiculopathy diagnosis don’t truly have radiculopathy. Since we have a lot of people who come to Caring Medical who travel quite a distance, we need to ask questions about their symptoms to try and verify their condition before they embark on the trip. For instance, if the person has more arm pain then neck pain, it might be that the nerve roots in the neck truly are getting pinched, and there is a chance that they have true cervical radiculopathy.
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.1
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.1
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.
This video is going to demonstrate comprehensive Hackett-Hemwall Prolotherapy of the neck. Here you see me, Dr. Ross Hauser, marking out some landmarks relating to the neck. The midline mark is made so I know where the spinus processes are. We want to stay lateral to the midline, because the midline is where the spinal cord is. I am doing the superior and inferior nuchal ridge. This particular patient has extensivearthritis in their neck, severe neck pain, and clicking and grinding in the neck.
This is a very comprehensive procedure. Again, we are doing the superior and inferior nuchal ridge on the occiput, which is where a lot of muscles attach. A lot of people are very sensitive at these locations. Now I am doing the midline on the occiput. Typically, I would do this if someone was having significantheadaches, which this person is having. If a person has neck pain before or during the headache, that indicates that Prolotherapy will help resolve their headaches. This includes migraine headaches as well astension headaches. I am being very thorough on the occipital ridge, making sure that the whole occiput is treated.
Now we are going to do the lateral masses, so we are going to do the lateral transverse processes of C2 to C7. I am going down, doing each vertebra. Each vertebra is going to get four different injections. They are going to get injections on the right, left, on the facet joints, as well as the lateral masses or transverse processes. You can see that I am somewhat following the line that I drew from the mastoid process down to the spinous process of C7. Here I am doing the facet joints. The facet joints are located one finger breadth from the midline. This is another reason I drew the midline: so I can easily tell where the facet joints are. Prolotherapy of the neck is a very effective treatment for chronic neck pain, headaches, as well as neck instability.
There are lots of people who go to a chiropractor and need a lot of chiropractic care, but the vertebrae sublux or get out of alignment a day or two after the patient goes to the chiropractor. This means that they have joint instability. The best treatment for joint instability of the neck and anywhere else in the body I believe is Prolotherapy. By stimulating ligament repair, Prolotherapy can stabilize those joints. Thus, the muscles spasms stop, and the pain that the person is suffering from stops.
As you can see, this person is not sedated, and they are tolerating the procedure very well. If someone was having a lot of problems with the procedure, we could give them sedation; either oral pain medications or IV sedation. However, most people just “grin and bear it,” because even a thorough treatment like this is only going to take a few minutes. As you can see, it is done very safely, in the office. If you have had neck pain for five or ten years, then this is a simple price to pay to get rid of pain for the rest of your life, even though the procedure is a little bit painful. This person did extremely well, and tolerated the procedure very well.
1. 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.