Cervical neck instability | Regenerative medicine and Prolotherapy for chronic neck pain

Cervical Neck Pain | Cervical Neck Instability

Ross Hauser, MD

In our practice, we continue to see a large number of patients with a myriad of symptoms related to cervical neck instability including severe pain, problems of balance, headaches, and loss of mobility. These people are often confused, many times frightened by recommendations to complicated cervical neck surgeries they don’t understand.

Many of these people have been told that their problem is a problem of degenerative cervical disc disease. After years of prolonged pain and conservative care options such as chiropractic, massage, physical therapy, anti-inflammatories, pain medications, cortisone injections, and cervical epidurals that eventually fail, the only recourse, these people are told, is neck surgery.

Neck surgery when all else has failed. But did “all else” include regenerative medicine injections?

Surgical recommendations are described in a way that seemingly makes sense as the only solution to degenerative disc disease.

But if these surgical options make so much sense, why were they not offered in the first place? The answer to that question is explained in the following articles:

Surgical treatments for Cervical Instability – Disc, disc, disc maybe wrong, wrong, wrong

In medicine, there are universally accepted equations. When pain cannot be controlled using conservative treatments including physical therapy, chiropractic, and pain medications, there has to be a surgical recommendation. 

In neck and spine surgery, doctors focus on degenerative disc disease and its treatment,   anterior cervical discectomy and fusion and cervical decompression surgery to remove whole or part of the cervical vertebrae to allow space on compressed nerves and to fix the instability by fusing vertebral segments together. In the case of C1-C2 instability, these two vertebrae are fused posteriorly (behind) to limit their amount of movement.  The goal is to limit pressure on the nerves.

However, it may limit motion to such an extent 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.

After two years, the same result between physical therapy and surgery was seen – no difference in the outcome.

The rush to surgery is based on the immediate goals of the patients, that is the alleviation of pain. Spinal cervical fusion and decompression seem to offer a solution – short term. This is supported in the medical literature. In one study in the medical journal Spine, patients with cervical radiculopathy, treated with surgery and physiotherapy resulted in a more rapid patient improvement during the first year after surgery, with significantly greater improvement in neck pain and global assessment scores compared to physiotherapy alone.

However, the differences between the groups decreased after two years. In this paper where surgery was touted as being so successful – the researchers concluded: “Structured physiotherapy should be tried before surgery is chosen.”(1After two years, the same result between physical therapy and surgery was seen – no difference in the outcome.

Neck surgery when all else has failed. But did “all else” include a discussion with the patient that this may not be a disc problem at all but that their cervical ligaments need to be repaired?


cervical degenerative ligament diseaseCREEP – cervical degenerative ligament disease – why neck surgery fails

Some of the most debilitating conditions attributed to problems in the neck are those due to cervical instability caused ligament laxity. What does this mean? It means that surgery may not address the problems you are experiencing in your neck.

When spinal ligaments are exposed to continued compression or stress, they “Creep.” Creep is a medical condition that results from the deformity or elongation of the ligaments that hold the cervical spinal vertebrae in place. This is cervical neck instability.

The concept of ligament laxity or cervical neck instability being caused by ligament damage is not so simple for doctors to understand. This may be why patients with neck problems walk around for years without hope or optimism that their problems can be solved.

An amazing study came out of the University of Waterloo in Canada and was published in the November 2017 edition of the Spine Journal.(1) Briefly here was the problem and the goal of the study:

Loose ligaments are not normal

Patients suffer from big problems caused by little damage to the ligaments

Patients suffer because Ligament laxity is a mystery

Patients suffer because cervical ligament laxity is a mystery


Identifying what is happening in the cervical spine, why ligaments are not even thought of

Physical therapists in Belgium wrote in the medical journal Manual Therapy, “Classifying nonspecific neck pain patients into subgroups based on clinical characteristics might lead to more comprehensive diagnoses and can guide effective management.” The subgroups were:

While these symptom classifications should be obvious signs of a patient in distress, the cause of the problems are not so obvious.

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 (excessive movement of the vertebrae), 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 from the Department of Neuroradiology at the University of Munich, “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.” Why? because MRI cannot show the problems of the cervical ligaments. (3)

Treating cervical ligament instability and its symptoms

Cervical instability conditions symptoms overlap

The regenerative medicine injection treatment for cervical spine instability

Treating cervical ligaments – published research from Caring Medical

In 2014 headed by Danielle R. Steilen-Matias, PA-C, our Caring Medical team published these findings in The Open Orthopaedics Journal.(4)

The capsular ligaments (the ligaments of the joint capsule) 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.

When the capsular ligaments are injured, they become elongated and exhibit laxity, which causes excessive movement of the cervical vertebrae.

Therefore, we propose that in many cases of chronic neck pain, the cause may be underlying joint instability due to capsular ligament laxity. Furthermore, we contend that the use of comprehensive 3H 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.

Stabilizing the unstable neck – the case for treating ligaments with Prolotherapy

Back to our 2014 research headed by Danielle R. Steilen-Matias, PA-C, published in The Open Orthopaedics Journal. Here we outline that the problems of the cervical neck are not always problems of degenerative disc disease but problems of degenerative ligament disease. This explains why traditional treatments focused on the discs will not be successful in the long-term.

The use of conventional modalities for chronic neck pain remains debatable, primarily because most treatments have had limited success. We conducted a review of the literature published up to December 2013 on the diagnostic and treatment modalities of disorders related to chronic neck pain and concluded that, 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.

The objectives of this study are to provide an overview of chronic neck pain as it relates to cervical instability, to describe the anatomical features of the cervical spine and the impact of capsular ligament laxity, to discuss the disorders causing chronic neck pain and their current treatments, and lastly, to present Prolotherapy as a viable treatment option that heals injured ligaments, restores stability to the spine, and resolves chronic neck pain.

There are a number of treatment modalities for the management of chronic neck pain and cervical instability, including injection therapy, nerve blocks, mobilization, manipulation, alternative medicine, behavioral therapy, fusion, and pharmacologic agents such as NSAIDs and opiates. However, these treatments do not address stabilizing the cervical spine or healing ligament injuries, and thus, do not offer long-term curative options. In fact, cortisone injections are known to inhibit, rather than promote healing.

Research on 21 patients with cervical instability and chronic neck pain

In our research published in the European Journal of Preventive Medicine we presented the following findings:

We concluded that statistically significant reductions in pain and functionality, indicating the safety and viability of Prolotherapy for cervical spine instability.(5)

Prolotherapy Specialists Cervical Neck Pain and Instability

Questions about Cervical Neck Pain and Instability?

Get help and information from our Caring Medical Staff

References

1. 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.  [Google Scholar]
2. Dewitte V, Peersman W, Danneels L, Bouche K, Roets A, Cagnie B. Subjective and clinical assessment criteria suggestive for five clinical patterns discernible in nonspecific neck pain patients. A Delphi-survey of clinical experts. Man Ther. 2016 Jul 21;26:87-96. doi: 10.1016/j.math.2016.07.005. [Google Scholar]
3. 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 [Google Scholar]
4 Steilen D, Hauser R, Woldin B, Sawyer S. Chronic neck pain: making the connection between capsular ligament laxity and cervical instability. The open orthopaedics journal. 2014;8:326.  [Google Scholar]
5 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.20150304.112396 [Google Scholar]


 

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