Symptoms and misdiagnosis of cervical Instability in children, adolescents, and teenagers
Ross Hauser MD.
There is now an epidemic of unexplained disorders according in children, adolescents and teenagers. As our youngsters spend more time bent over texting on smartphones, hunched over a computer or reading, they are slowly stretching the ligaments in their necks. It is almost unheard of today to see a normal cervical lordotic curve ; even pre-adolescent children have straight curves because of all the looking down they do while playing games on their smartphones or tablets.
Cervical instability is increasing as cell phone and tablet usage increases among children
Back in 2006, before the true explosion of cell phones, tablets and other devices that put children and adolescents into a head down lifestyle, doctors at the University of Wisconsin (11) wrote about nontraumatic upper cervical spine instability in children. This paper appeared in The Journal of the American Academy of Orthopaedic Surgeons. “Nontraumatic upper cervical spine instability can result from abnormal development of osseous or ligamentous structures or from gradually increasing ligamentous laxity associated with connective tissue disorders. Such instability can lead to compression of the spinal cord during movement of the cervical spine.” Face down lifestyle has not been developed as a concern. According to Pew researchers, 3% of Americans owned a tablet in 2010. In 2021 53% of Americans did. There is no significant data on smart phone usage prior to 2011.
Nearly all children, adolescents, or teenagers whom I’ve seen for neck pain conditions in recent years state that they spend multiple hours each day using smartphones, computer games, and tablets. What most parents don’t realize is that kids were made to look up, not down. Increased time spent in neck flexion on tech devices has negative consequences for the cervical lordotic curve. The researchers of a 2018 paper wrote: “The use of computing devices, especially mobile telephones, and the increase in the flexion of the cervical spine indicate that cervical vertebral problems will increase even in younger people in future.”(8) A young person is supposed to be looking up increasing the muscular strength in their posterior neck which increases their cervical lordotic curve. This curve then increases throughout grade school (adolescents) as kids look up at their teachers. Once in high school, the curve is supposed to be maintained again as students look up at teachers. Unfortunately, children continually look down on computers and tablets to do their schoolwork and during playtime after school. The net result is complete destabilization of the young person’s neck because their ligaments become stretched out. A child has a big head in relation to the neck, thus, a large weighty head is resting on a little weak neck.
A child has a big head in relation to the neck, thus, a large weighty head is resting on a little weak neck.
The chronic loss of the lordotic curve occurs because the ligaments in the neck are stretched out. The long-term danger of this is that the forces on the facet joints and discs in the neck to hold the head up are substantially increased making these areas more vulnerable to injury during whiplash or other neck forces. The loss of the cervical curve can occur acutely after a whiplash, but when the curve is lost long-term, its primary cause is ligament injury.
A DMX is an x-ray that sees the neck and head in motion. It is basically an x-ray movie. In the image below we can see various neck problems recorded in children and teens who suffer from a large myriad of symptoms.
The first image shows cervical spine curve deformities. Lordotic curve is natural curve. The others are not.
In the image below we have a:
- 16 year old female who has a kyphotic curve, in essence her neck is curving backwards. That increases pull on the nerves and vital blood vessels. In the flexion image, looking downward, we see her vertebrae have wandered out of natural alignment and she has symptoms consistent with cervical instability.
- An 8 year old boy with the straight military curve. This is an unnatural curve and could cause symptoms of swallowing problems, breathing problems, spinal cord compression, heavy head or inability to lift their heads, and more described below. In the flexion image, looking downward, we see his vertebrae have also wandered out of natural alignment and cervical instability is present
These medically unexplained and neurological symptoms including:
- migraines, other headaches,
- neck pain,
- light sensitivity,
- sound sensitivity,
- cervical dystonia,
- double vision,
- seizure disorder,
- impulsivity, anxiety, and emotional lability. (Please see my article Dissociation, Anxiety, Personality Disorders and Depression – Uncontrolled emotion in cervical spine instability patients for more information on the emotional aspects).
These young people can a myriad of diagnoses including whiplash syndrome, basilar artery migraine, vertiginous seizures seizures or vertiginous epilepsy initiated by a symptom of vertigo, post-traumatic dizziness, Meniere’s disease, delayed endolymphatic hydrops structural problem in the inner ear causing increased pressure), syncope, unsteady gait, eustachian tube dysfunction (chronic sinusitis), benign positional vertigo, juvenile rheumatoid arthritis, vestibular neuritis, psychological trauma, labyrinthine concussion (damage caused to the inner ear by physical trauma), fibromyalgia, chemical sensitivity, anxiety disorder, depression, autoimmune disorders, attention deficit disorder, bruxism (teeth grinding), leaky gut syndrome, and growing pains. Rarely does receiving the diagnosis go along with an explanation of what is causing or worsening the condition and how the child might go about resolving the condition altogether.
Increased health problems in children due to face-down lifestyle causing cervical instability
In the video below: Ross Hauser, MD discusses the huge increase in children being seen in medical offices for conditions normally associated with adults and seniors. In our offices, patients usually come in after being seen by a dozen or more specialists who have offered nothing but medications and limiting/discontinuing the child’s activities.
This has included students having to completely quit school, sports, and even doing simple activities like shopping. Many kids are brought to us in a rather debilitated state and at their wits end about what is making them worse, leading to scary instances of fainting, extreme weight loss, and other conditions mentioned in the video.
One of the most critical contributing factors that we have seen in the majority of these cases is undiagnosed cervical instability. This is often caused by cell phone addiction and the face-down lifestyle. Dr. Hauser makes a plea to parents of children with mysterious or painful health conditions to pay attention to how much screentime their child gets, and if they are spending a lot of their day looking down at cell phones/tablets. This face-down position may be contributing to their declining health by putting too much tension on their cervical curve, and thus, spinal cord, vagus nerve, and other vital structures in their neck.
We are able to take on and help many children in these instances. Though not all are good candidates for our clinics, we hope that this video may provide a point of reference or a turning point in your child’s case to help guide you to someone who can help by considering a motion examination of their cervical spine.
Many diagnoses can share symptoms such as extreme neck pain, headaches, dizziness, vertigo, migraines, seizures, dystonia, and sensitivity to light, touch, or sound. In the cases that have presented at Caring Medical over the years, we find that the best potential solutions begin with determining if there is a connection between the nervous system malfunction and cervical neck destabilization. What we have found is that most of these children have cervical instability (a structural cause) and the resultant dysautonomia, vertebrobasilar insufficiency (transient occlusion of the vertebral artery in the neck), vagus neuropathy, and spinal cord stretch tension that comes with it.
Why young children are very prone to cervical dysstructure (neck structure that is out of alignment) and cervical neck instability – Children’s necks are vulnerable to the devastating effects of cervical instability
An explanation and summary of this image is given below:
The image above notes:
- The larger head / small body problem all children face. By age two the brain has reached 75% of adult size but the body has only reached 30% of its adult size.
- Children have slender necks and neck muscles that strain to support the weight of the head.
- The neck bones, that is the cervical vertebrae have not reach maturation to be called bones yet, they are more cartilage like in structure.
- The facet joints that connect the vertebrae to each other have not fully developed nor has the natural spinal curvature. This puts pressure on teh neck structures.
As they cause musculoskeletal problems, the higher the time children consume in front of digital devices and the more they use it in wrong posture; the more the complaints about pain are.
There are significant differences that make an infant/children/adolescent’s neck vulnerable to becoming unstable compared to adults.(1,2,3)
|Brain size (% body weight)||25%||5%|
|Head length to body length at birth||25%||14%|
70% of the adult brain weight is achieved at 18 months, 80% at 3 years and 90% at 5-8 years and 95% at the 10th year.
|Head/neck length to body length ratio||50-65%||25%|
In summary, children have large, heavy heads that are to be balanced on small bodies (and thus necks).
The necks in children/pre-teens are more vulnerable to injury than adults. In children, the articular facets are shallower and oriented in a more horizontal direction, and the fulcrum for flexion is higher than in adults. Using dynamic cervical spine radiographs (similar to digital motion x-ray) the fulcrum (place of maximum movement) for flexion is at C2-C3 in infants and young children, at c3=c4 at about the age of 4 or 6, and at C4-6 in adults.4 In one study, an interesting summary of neck structure in children sustaining injuries was described as (1) A heavy head on a small body results in high torques being applied to the neck and consequently, high susceptibility to flexion-extension injuries, (2) The lax ligaments that allows a significant degree of spinal mobility (anterior subluxation of up to 4.0 mm at C2-3 or C3-4 may occur as a normal variant), (3) The cervical musculature is not fully developed in the infant allowing for unchecked distracting and displacement forces, (4) The facet joints at C1 and C3 are nearly horizontal for the first several years of life allowing for subluxations at relatively little force, (5) Immature uncovertebral joints of the C2 to C4 levels may not withstand flexion-rotation forces (6) The fulcrum of cervical movement is located higher in young children (C2-3 level than in adults (C5-6).5
Cervical muscles are also not as well-developed. Ligaments in children compared to adults have less fibroblast (cells that make ligaments) density, ultimately causing less collagen to be made in the ligaments, and the ligament collagen fibrils to be thinner and weaker. The peak forces to injure a ligament or tendon in a child can be 25% of that of an adult. The combination of a large heavy head on a small neck and body, lack of bony articular support, weak neck muscles, and the inherent flexibility of children’s joints (and ligaments) put children’s cervical ligaments at risk.
While ligaments stiffen or strengthen as children get older, cervical ligament injuries are almost inevitable with the increase in fast-moving competitive sports activities and resultant head/neck traumas, combined with the assault the posterior cervical ligaments receive as children spend most of their childhood looking down at electronic devices.
Why is this structural cause not found earlier?
In our office, we use Digital Motion X-ray, DMX to watch the spine while the person is moving to analyze the movement of the structures in the neck.
Kids are super bendy because their soft tissues, including ligaments, are extra flexible. As “normal” children get older, their ligament laxity improves, and in turn, joint stability also improves. By the time most boys graduate high school, they have tight ligaments and stable joints. Compared to their male counterparts, females have more lax ligaments and looser joints. While joint hypermobility and resultant instability can afflict children with pain, when it occurs in the neck, the consequences can be severe. Children are especially vulnerable to cervical neck ligament injuries which can result in cervical spinal instability because they have a large head mass, ligamentous laxity, articular facets that are small and horizontally angled, and immature neck musculature.6,7 Because most pediatricians do not recognize the signs of cervical instability, the ligamentous damage in children’s necks goes unnoticed.
Additionally, modern testing for pediatric cervical spine instability is often inadequate as the MRI or vascular (MRA or CT angiogram) testing is done with the child supine or laying flat. To adequately assess looseness in the cervical spine the child must be upright and moving during testing. How can you know what is happening in the neck if you are not simulating real-life actions? At the Hauser Neck Center, cervical instability is assessed by Digital Motion X-ray (DMX)and vascular testing by extracranial and transcranial doppler. These procedures are done while the child is upright and moving their head and neck.
A young boy going through the flexion and extension head movements during a Digital Motion X-ray.
Once cervical instability is found, Prolotherapy is a treatment option for the majority of cases to stimulate the strengthening of overstretched ligaments. This is maybe a preferable option to fusing vertebrae surgically at such an early age. Surgical fusion would fuse two or three vertebrae at a time when the vertebrae are supposed to be free to grow as the child is growing! Cervical fusion operations are limited for the most severe extreme cases of childhood cervical spine instability.
In the above mini DMX, this 16 year-old is already exhibiting a straightening of the cervical spine and other structural abnormalities even though he is not yet symptomatic. He attends an Apple distinguished school which means that every student has an iPad. The schools are moving toward using these for most lessons and all homework. Kids are in class looking down at tablets versus looking up at the teacher.
Neck stabilization in young people is so important
Early in infancy, a baby can raise his head while lying prone and the cervical (neck) curve first occurs in the womb but then becomes stabled as the infant can sit and then crawl with their head up. Humans have their normal cervical lordotic curve even in the mother’s womb at 9.5 weeks.9 This lordotic curve is enhanced as a neonate looks up at their mother during breastfeeding and everything else they do. As a child crawls, it is increasing its cervical lordotic curve.
For a normal cervical lordotic curve (as well as the other spinal curves) to develop in a child, the child must be looking up, which is the posture that develops strong posterior cervical muscles, which are needed (along with strong posterior cervical ligaments) to maintain the cervical spinal lordotic curve. It is this curve that allows the spinal cord and important nerve structures including the sympathetic ganglion, vagus nerves, cranial nerves, spinal nerves, brainstem and even the brain to be under the least amount of tension. When a young person loses their lordotic curve, the crucial nerve centers, including the nodose ganglion (cell center) of the vagus nerve, cervical spinal cord, other cranial nerves (cranial nerves 7-12), and brainstem undergo dysfunctional neural dynamics.
As the supportive structures of the cervical spine are destroyed, a condition occurs that I have termed cervical dysstructure, causing tension, compression, impingement and/or other damaging forces on the spinal cord, cranial nerves, and brain stem. The upper cervical spine in a child or adolescent is especially vulnerable to injury. It only takes 10% of the force that it would in an adult to injure the upper cervical ligaments in a child.10 As nervous tissue cells called neurons are destroyed, nerve transmission is blocked or goes haywire.
In summary, it is paramount to limit a child’s screen time and time looking down at a phone. Posture is important during the growing years. For their long-term health, parents need to tell children (or nag, if necessary!) the same recommendation that your parents likely said to you: Sit up straight. Mind your posture!
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