Cervical Instability in Children, Adolescents, and Teenagers
There is now an epidemic of unexplained disorders according in children, adolescents and teenagers. These medically unexplained and neurological symptoms including migraines, other headaches, neck pain, dizziness, light and sound sensitivity, vertigo, dizzineeess, dystonia, double vision, seizure disorder, impulsivity, anxiety, and emotional lability. These young people can a myriad of diagnoses including whiplash syndrome, basilar artery migraine, vertiginous seizures, post-traumatic dizziness, Meniere’s disease, delayed endolymphatic hydrops, syncope, unsteady gait, eustachian tube dysfunction, benign positional vertigo, juvenile rheumatoid arthritis, vestibular neuritis, psychological trauma, labyrinthine concussion, fibromyalgia, chemical sensitivity, anxiety disorder, depression, autoimmune disorders, attention deficit disorder, bruxism, epilepsy, leaky-gut, 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.
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.
Children’s necks are vulnerable to the devastating effects of cervical instability
There are significant differences that make an infant/children/adolescent’s neck vulnerable to becoming unstable compared to adults1,2,3:
|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?
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 the best treatment option for the majority of cases to stimulate the strengthening of overstretched ligaments. This is 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.
Cervical instability is increasing as cell phone and tablet usage increases among children
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.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.
Teenage boys on their cell phones while in the Hauser Neck Center office for a Digital Motion X-ray.
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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3. Stuart HC, Stevenson SS. In: Physical Growth and Development. 5th Edn. Nelson, editor. Mitchell-Nelson Textbook of Pediatrics; Philadelphia: 1950. 1959. Reprinted in Documents-Geigy, Scientific Tables.
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5. Fuchs S, et al. Cervical spine fractures sustained by young children in forward-facing car seats. Pediatrics August 1989;84(2):348-354.
6. Tokio K, et al. Groth of the cervical spine with special reference to its lordosis and mobility. Spine. 1996;21(18):2067-2073.
7. Heulke D. An overview of anatomical considerations of infants and children in the adult world of automobile safety design. Annu Proc Assoc Adv Automot Med. 1998;42:93–113.
8. Ogrenci A, Koban O. The effect of technological devices on cervical lordosis. Open Access Maced J Med Sci. 2018;6(3):467-471.
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10. Phuntsok R, Mazur MD. Development and initial evaluation of a finite element model of the pediatric craniocervical junction. J Neurosurg Pediatr. 2016;17(4):497-503.