Treatment of neck instability
Ross Hauser, MD
Treatment of neck instability – cervical spine instability
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.
- The surgery will help, the patient is told, because it will cut away the cervical vertebrae bone that is pressing on the nerves.
- The surgery will fuse the cervical vertebrae in place so the vertebrae do not shift out of place and press on the nerves again.
- Sometimes the cervical disc that has been flattened or herniated is also be replaced with an artificial implant.
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:
- Anterior Cervical Discectomy and Fusion | Does this surgery cause more cervical spine instability and deformity?
- Patients report problems with sexual function after cervical spine surgery
- Non-Surgical Cervical radiculopathy treatments
- Atlantoaxial instability | Cervical Fusion or Prolotherapy PRP Stem Cell treatment options
Surgical treatments for Cervical Instability – Disc, disc, disc may be 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,(1) 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.” After 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?
CREEP – 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 surgery that cuts away the cervical vertebrae bone that is pressing on the nerves – does not correct or prevent CREEP recurrence
- The surgery that will fuse the cervical vertebrae in place so the vertebrae do not shift out of place and press on the nerves again, MAY NOT be needed at all if CREEP can be repaired and prevented by the use of non-surgical regenerative medicine techniques.
- Regenerative medicine injection techniques such as H3 Prolotherapy explained below, work on the same understanding as fusion surgery, but with big differences.
- The regenerative injections repair the ligaments.
- The injections strengthen the ligaments’ ability to hold the vertebrae in its natural position. Which is what the fusion seeks to do.
- The big difference is that with fusion surgery you will lose a great amount of ability to turn your head from side to side and up and down. In Regenerative medicine injections the treatment repairs and allows for this natural movement of your head.
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
- Predicting physiological (normal) range of motion (ROM) using a finite element (FE) model (a numeric scoring system) of the upper cervical spine requires the incorporation of ligament laxity.
- COMMENT: The doctors understand that ligament laxity (CREEP) is a problem of stability and instability To come up with a scoring system to define the normal range of neck motion, you need to understand how loose ligaments are not normal.
Patients suffer from big problems caused by little damage to the ligaments
- The effect of ligament laxity can be observed only on a macro level of joint motion and is lost once ligaments have been dissected and preconditioned for experimental testing.
- COMMENT: It is hard on any level to accurately determine the amount of ligament damage to the amount of instability because even small injuries or damage, sometimes undetectable, cause big problems. This is what we call cervical ligament microinstability.
Patients suffer because Ligament laxity is a mystery
- As a result, although ligament laxity values are recognized to exist, specific values are not directly available in the literature for use in finite element models.
- COMMENT: Ligament laxity is a mystery, defining it within mathematical equations for the scoring system is difficult. This is why cervical neck pain patients have a difficult time finding the right medical care. Their conditions if based on degenerative ligament disease 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:
- Articular: pain and motion restriction in extension (moving head side to side back and forth)
- Myofascial: pain related to the muscles of the neck and shoulders
- Neural: related to nerve and muscle pain
- Central: related to possible narrowing of the spinal canal
- Sensorimotor control: Loss of physical function in the face and neck region.(2)
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
- Without addressing the cervical ligament laxity, CREEP, conditions that originate from joint instability can wreak havoc on a patient’s life in the form of chronic headaches, migraines, neck pain, TMJ syndrome, ear, and mouth pain, to name a few.
- There is also much overlap in the symptoms caused by cervical instability and CREEP, and especially upper cervical instability (C0-C2): cervicocranial syndrome, atlanto-axial instability, whiplash, post-concussion syndrome, and vertebrobasilar insufficiency.
- The ligaments that hold the cervical vertebrae in alignment can be damaged via a sudden trauma, such as whiplash or concussion as well. If you are suffering from whiplash please read this article next Whiplash and whiplash-associated disorders, please read this article if post-concussion syndrome is an issue for you.
Treating cervical ligaments – published research from Caring Medical
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.
- In the upper cervical spine (C0-C2), this can cause symptoms such as nerve irritation and vertebrobasilar insufficiency with associated vertigo, tinnitus, dizziness, facial pain, arm pain, and migraine headaches.
- 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.
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:
- 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.(5)
Questions about Cervical Neck Pain and Instability?
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]