Treating the symptoms of atlantoaxial instability
Ross Hauser, MD
Atlantoaxial instability treatment and repair without surgery
In this article, we will examine our published research findings and the latest in medical research concerning atlantoaxial instability and the myriad of symptoms and challenges it creates for patients.
Atlantoaxial instability can be caused by many factors. Trauma injury, congenital defects (defects from birth), and arthritis. A commonality among these causes is the possibility and extent of cervical ligament damage. The focus of this article will therefore concentrate on the impact of cervical spine ligament injury and how addressing this injury can help alleviate pain and symptoms.
A patient will come into our clinics, they will describe a daily, emotional battle with the symptoms of “suspected” or “suspicious” atlantoaxial instability. They will tell us about:
- Neck pain and muscle spasms and a confusing diagnosis of Cervical dystonia or wryneck or Torticollis. In fact, your medical journey may have started one day when you went to the doctor because you had painful, involuntary muscle spasms in the neck and your head started rotating and tilting to one side as these spasms got worse.
- Jaw pain and a problem with subluxing or tilted mandibles. Many will be diagnosed with TMJ and be recommended to a lot of treatments that did not help them.
- Migraines and tension headaches accompanied by neck pain and the types of medications they have been prescribed.
- Losing their balance and unsteadiness on their feet.
- Vision is becoming a problem.
The patient will then related a long, confusing, frustrating medical history that including MRIs, CT Scans, Physical therapy and countless medications.
In some patients, an MRI will reveal that the Atlantoaxial joint between C1-C2 has subluxed or moved out of place. Some of these patients will reveal to us that they have been recommended for a cervical fusion surgery. Some patients will tell us that their doctors have recommended to wait on the surgery until “things get really bad.”
For some who did not have a positive MRI reading for Atlantoaxial joint subluxation, they will tell us that they have been recommended to counseling and for mental illness screening. They have been told it may be “all in your head.”
It is not all in your head, it is all in your neck – let’s get to some answers
Atlantoaxial instability is the abnormal, excessive movement of the joint between the atlas (C1) and axis (C2). This junction is a unique junction in the cervical spine as the C1 and C2 are not shaped like cervical vertebrae. They are more flattened so as to serve as a platform to hold the head up. The bundle of ligaments that support this joint are strong bands that provide strength and stability while allowing the flexibility of head movement and to allow unimpeded access (prevention of herniation or “pinch”) of blood vessels, nerves that travel through them to the brain and the spinal cord itself.
Understanding how the Atlas and its ligaments support your head and how damage to those ligaments causes the symptoms of neck pain, limited head and neck motion, and possibly sensory issues.
Above, we have a picture of the Greek mythological titan Atlas. Atlas was ordered by the king of the Greek gods Zeus, to hold the sky in the heavens (later the earth in the heavens as depicted in art). The C1 vertebra is therefore aptly named the Atlas as it holds the weight of your head as Atlas in mythology holds “the weight of the world.”
A little bit of pretending helps us understand the role of cervical ligaments in Atlantoaxial instability and how the weight of the world can damage our neck.
- Let’s pretend the globe in the picture to the left is your head.
- Atlas’s shoulders and torso are the C1 vertebra.
- If we pretend that his arms are the cervical ligaments that hold the globe in place on his shoulders and his legs are the cervical ligaments that hold him to the ground, we can see how damage to the arms and legs can make the earth (your head) fall and tilt and create the health challenges typical of Atlantoaxial instability. The ground we will pretend is the C2 axis vertebrae that the C1 atlas stands on.
If Atlas’s right arm is injured, the weight of the world will fall on the left hand. With this extra burden and stress, the left arm will eventually suffer fatigue, wear and tear, and weaken. With both arms injured and weakened the earth (your head) will wobble between the right and left arm.
If Atlas’s right leg is injured, he will shift his weight to his left leg. The earth will tilt towards his left leg. With this extra burden and stress, the left leg and left arm will eventually be injured. Atlas himself will wobble and have balance issues.
To fix Atlas’s problems, you need to fix his cervical ligaments. His supporting structures that keep the globe steady.
The scientific and anatomical explanation to supporting the weight of the head on the atlas
Above I describe in metaphorical terms cervical instability at C1-C2. Let’s be a little more medical in this description.
The C1 (atlas) and C2 (axis) articulation involves 3 separate joints (AA joints): two lateral flat horizontal oriented facet joints (one on each lateral mass) and the medial atlanto-dens joint. Let’s briefly discuss the image below.
What are we seeing in this image?
For many of the neurologic, vascular, psychiatric-like problems we see, there is an issue with possible compression of the brainstem / spinal cord. In the illustration below we see clearly that the brainstem and spinal cord slip neatly into the space provided by the proper alignment of the C1-C2 atlas/axis. The key here is a properly aligned C1-C2 .
What are we seeing in this image?
As mentioned, in the illustration above we see clearly that the brainstem and spinal cord slip neatly into the space provided by the proper alignment of the C1-C2 atlas/axis. The key here is a properly aligned C1-C2 . In this image below we see that the right posterior or to the rear malrotation of the C2. What this means is that the C2 is rotating to the right below the C1. This rotation shows cervical ligamentous or cervical ligament laxity. The problem is the cervical ligaments are not holding the C2 and C1 in proper alignment to each other.
What are we seeing in this image below? A wandering C1.
The basic understanding that this article is trying to present is that the brainstem and spinal cord slip neatly into the space provided by the proper alignment of the C1-C2 atlas/axis. In this image below we see a wandering C1 vertebrae. What this means is that the C1 is moving back and forth in an unnatural motion on the C2 and causing compression to the spinal cord, arteries, veins and nerves. This image here is the image generated by a digital motion x-ray (DMX).
The primary ligamentous support of the lateral or side facet joints of C1-C2 are the capsular ligaments; whereas the atlanto-dens joint is held together by the transverse ligament and its back-up the alar ligaments.
The C1-C2 atlantoaxial joint provides 50% of cervical spine rotational mobility as the arch of C1 rotates around the dens of C2. The The atlantoaxial joint when stable allows some flexion but
almost no lateral flexion. Lateral flexion in this joint is one of the hallmark signs of facet atlantoaxial instability (FAAI). In other words, you should not be able to touch your shoulder with your ear without moving your arm up to meet your head.
In the medical literature, generally atlantoaxial instability refers to the connection between the atlas and the dens of axis, which we refer to as dens atlantoaxial instability (DAAI). This is important because dens atlantoaxial instability is more of a surgical repair type lesion; whereas, facet atlantoaxial instability can more often be treated by conservative measures such as chiropractic care, physiotherapy and Prolotherapy.
Stability against anterior translation of the atlas (the C1 wandering over the C2) is by the capsular ligaments posterior (in the back) and the transverse ligament anteriorly (in the front). Capsular ligament injury of C1-C2 results in facet atlantoaxial instability whereas injury of the transverse and the alar ligament causes dens atlantoaxial instability. Injury to the atlantoaxial capsular ligaments causes a dramatic increase in lateral bending and axial rotation motion; whereas transverse ligament disruption significantly increases the anterior atlanto-dens interval. The anterior atlanto-dens interval is the horizontal distance between the C1-C2. The more distance, the more displacement, the more “wandering,” the more compression.
To fix your Atlantoaxial instability, you need to fix your cervical ligaments.
When ligaments are ignored, Occipitoaxial fusion becomes the treatment
Fixing the ligaments is usually not the first choice among more traditional doctors. Fusion surgery is. In the above picture, if we cemented Atlas’s feet to the ground do you think his knees and hips would suffer? When your C1-C2 cervical vertebrae are fused to limit atlantoaxial instability and related symptoms, the force and energy in your neck movements are going to be transferred to those vertebrae below the fusion. In many patients, all this accomplishes is transferring the atlantoaxial instability to the lower cervical vertebrae.
The following research highlights these problems:
In a study (July 2018) published in the Archives of Orthopaedic and Trauma Surgery, (1) doctors examined occipitoaxial fusion for atlantoaxial instability in non-rheumatoid arthritis.
Study findings: More than 1/3rd patients had complications after occipitoaxial fusion for atlantoaxial instability
- 41 patients underwent occipitoaxial fusion for atlantoaxial instability.
- Fifteen patients with postoperative adjacent segment disease. (Complications of pain and mobility)
- Twenty-six patients without postoperative adjacent segment disease.
- Fifteen patients with postoperative adjacent segment disease had a high incidence of sub axial subluxation (displacement of the vertebrae below the fusion) and swan neck deformity (extreme, unnatural curvature in the neck)
This type of surgery, with its high complication rate and similar procedures, may not even be necessary.
Cervical spine ligament weakness is why many cervical neck pain patients do not have a successful surgery.
Doctors at the University of Waterloo in Canada published research in the Spine Journal (2) where they were attempting to define a new clinical scoring system for patients with cervical neck instability. The scoring system would help identify the role of cervical ligaments in difficult to treat neck pain and instability.
This is what came out of this research:
- “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.”
- Our comment: The doctors understand that ligament laxity is a problem of stability and range of motion in the neck.
- 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.
- Our 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.
- 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.
- Our comment: Ligament laxity is a mystery and why cervical neck pain patients have a difficult time finding the right medical care.
Surgery, unless a life-threatening or extreme situation, should never be considered until the problems of the cervical ligaments are addressed.
Cervical ligament injury should be more widely viewed as a key, if not THE key, to atlantoaxial instability treatment
In a 2015 paper appearing in the Journal of Prolotherapy, our staff along with our co-writer Paul Fisher wrote that cervical ligament injury should be more widely viewed as a key, if not THE key, to chronic neck pain and various cervical neck related disorders including atlantoaxial instability treatment. In our opinion, in many patients, cervical ligament injury is underlying pathophysiology (the cause of) atlantoaxial instability and the primary cause of cervical myelopathy (disease).(3)
This was a continuation in the series of published research Caring Medical is producing on the problems of cervical instability including the 2014 article Chronic Neck Pain: Making the Connection Between Capsular Ligament Laxity and Cervical Instability led by Danielle Steilen.(4)
In that research, our team suggested that the cervical capsular ligaments are the main stabilizing structures of the facet joints in the cervical spine and that they are a major source of chronic neck pain. The instability these injuries create often reflects a state of instability in the cervical spine and is a symptom common to a number of conditions including disc herniation,
- cervical spondylosis,
- whiplash injury and whiplash associated disorder,
- postconcussion syndrome,
- vertebrobasilar insufficiency,
- and Craniocervical syndrome (aka Barré-Liéou syndrome).
In the upper cervical spine (C0-C2), this can cause a number of other symptoms including, but not limited to, nerve irritation and vertebrobasilar insufficiency with associated cervical vertigo, dizziness, tinnitus, facial pain, arm pain, and migraine headaches.
An overstressed transverse ligament may be the culprit to your myriad of symptoms
In June 2017, German researchers publishing in Zeitschrift für Orthopädie und Unfallchirurgie (Journal of Orthopedics and Trauma Surgery) also saw the connection of damaged cervical ligaments and chronic neck problems. Here is what they wrote:
- The odontoid process (the protruding bony process of the C2 (Axis)) and the transverse ligament are the most important structures stabilising the atlantoaxial complex.
- There is not a clear understanding of how injuries of these structures contribute towards neck instability and a potential narrowing of the spinal canal.
The German team set out to investigate in human cadaver studies, fracture and displacement of the odontoid process and ruptures and tears of the transverse ligament. After examination and compilation of date, the researchers concluded:
- “Our results demonstrate that a relevant constriction of the spinal canal may be due to isolated or combined injuries of the bone and the transverse ligament. Furthermore, our results show the importance of posttraumatic immobilization of the spine with a view to the role of the transverse ligament for stabilization of the atlantoaxial complex.”(5) (Neck collars and other devices).
The c2 vertebra is moving and causing basilar invagination
In March 2019, a team of neurosurgeons wrote in the medical journal World Neurosurgery, (6) about cervical instability and osteoarthritis. What they found was the degenerative condition of the cervical spine could result in hypermobility of the atlantoaxial segment (excessive rotation, possible subluxations) and cause overstress in the transverse ligament and the lateral atlantoaxial joints.
The surgeons noted: “These changes explain the pathogenesis of atlantoaxial dislocation and basilar invagination associated with osteoarthritis.”
In other words, the c2 vertebra is moving and causing basilar invagination, (reducing the size of the opening in the skull (the foramen magnum)) where the spinal cord passes into the brain. This excessive movement is caused by an overstressing (wear and tear) degeneration of the transverse ligament. This is causing the symptoms we alluded to earlier including balance issues, vision issues, headache, hearing issues, among others.
There is no gold standard for making the diagnosis of upper or lower cervical instability on clinical ground’s so it must be suspected so the right radiographic analysis can be made. A 2017 mini-review paper published in the Journal of Spine (7) offer common guidance in what to look for in patients with suspected upper cervical instability. These are many of the symptoms we see here in our patients and are symptoms you are likely yourself suffering from. Here is what the authors published:
“Diagnosis of Atlanto-axial instability is based upon careful history, a detailed neurological exam and imaging of the upper cervical spine. The most common clinical features are neck pain and suboccipital headache, with the caveats that headache is present in 50% of patients with EDS (doctors should look for Ehlers-Danlos Syndrome as a possible component of the patient’s challenges) and that moderate pain is a common occurrence for most EDS patients.
There may be symptoms referable to the vertebral artery blood flow, including visual changes, as well as headache associated with the vertebral artery itself. Syncopal (fainting or passing out) and presyncopal (the feeling that you are going to faint or pass out) events are frequent.
Other symptoms include dizziness, nausea, sometimes facial pain, dysphagia (difficulty in swallowing), choking, and respiratory issues. There is usually improvement with a neck brace. (Note: Please see our Caring Medical article: Cervical collars – why do they help some people and not others?).
Examination often demonstrates tenderness over C1-C2, altered mechanics of neck rotation, hyperreflexia, dysdiadochokinesia (dysdiadochokinesia is an inability to perform rapid alternative movements – for example, as used to test for dysdiadochokinesia, your ability to tap the palm of one hand with the fingers of the other and then flipping the palm over so the fingers can tap the back of the hand) , hypoesthesia (loss of sensation) to pinprick.
What this mini-review reveals are the challenges we see of a neurologic-like nature.
What the physical therapists say: MRI can confuse the issue.
The most common symptoms or physical or muscular manifestation of Atlanto-axial instability or upper cervical instability re muscle tension in the neck, headache, weakness in holding the head
up, relief of major symptoms with laying down or wearing a cervical collar and a clicking grinding or popping sensation in the neck. An inability to hold a self or chiropractic cervical adjustment is another sign.
Let’s start with a 2005 study in the medical journal Physical Therapy (8). Here physical therapists correlated the following symptoms with cervical instability: intolerance to prolonged static postures, fatigue and inability to hold head up, improvement in symptoms with external support (collar), frequent need for self-manipulation, feeling of instability, shaking or lack of control of head, episodes of acute attacks, sharp pain with sudden movements.
A few years later in 2009, a paper published in the Journal of manual and manipulative therapy (9) tried to address the challenges of matching a patient’s symptoms with what appeared on an MRI. The problems of accurate diagnosis were noted:
“Information gathered from the patient history, physical examination, and advanced testing augments the decision-making process and is proposed to improve the probability of diagnostic and prognostic accuracy. However, these findings may provide inconsistent results and can lead to errors in decision-making. The purpose of this study was to examine the relationship between common clinical complaints and specific findings on magnetic resonance imaging (MRI) in patients with chronic neck dysfunction.
- Forty-five participants (25 female), with an average age of 52, were evaluated by a neurosurgeon for complaints of symptoms related to the cervical spine. All participants answered a subjective questionnaire and received an MRI of the cervical spine.
- Evidence of spinal cord compression was significantly correlated to: anteroposterior canal diameter of less than or equal to 9 mm diminished subarachnoid fluid (Cerebrospinal Fluid in the subarachnoid space) around the cord.
- Report of loss of dexterity was significantly correlated with report of lower extremity clumsiness.
- In this study, no definitive relationships were found between the clinical complaints of neck pain, hand function, or clumsiness and specific MRI findings of spinal cord compression. Further research is needed to investigate the diagnostic utility of subjective complaints and their association with advanced testing.
What we had here in this study was a lock of consistency in interpretation in what the MRI seemed to suggest and what was wrong with the patients.
Of note was the fact that when there was less fluid around the spinal cord, symptoms could be correlated. The image of less fluid suggested spinal cord compression.
What are we seeing in this image? It is an image of less Cerebrospinal Fluid surrounding the spinal cord. It is an image suggesting spinal cord compression
In the image below we have three cross sections of an upper cervical spinal cord MRI.
- The first image or image A is considered normal as a white circle, representing cerebrospinal fluid, surrounds and protects the spinal cord.
- In image B we see a partial blockage of the cerebrospinal fluid being suggested by the narrower or diminished white ring posteriorly.
- In image C we we a complete blockage of the cerebrospinal fluid. The white ring no longer being visible.
Cervical instability can be difficult to diagnose. 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.
A December 2013 study brings us closer to 2021 by way that the same problems seen 8 years ago, are still problems today. Here is a paper from the journal Physical therapy. (10)
“Patients with neck pain, headache, torticollis, or neurological signs should be screened carefully for upper cervical spine instability, as these conditions are “red flags” for applying physical therapy interventions. However, little is known about the diagnostic accuracy of upper cervical spine instability tests.”
Surgery is often aimed at fixing the instability by fusing vertebral segments together.
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.
Investigating the role of Prolotherapy in the reduction of pain and symptoms associated with increased cervical intervertebral motion and ligament damage
In the above research, we have made the case that the complexity of your problems may be caused by cervical instability caused by weakened and damaged cervical spine ligaments. Now we will begin to make the case that your symptoms may be alleviated on a long-term more permanent basis with the use of Prolotherapy.
Prolotherapy is a regenerative injection technique that utilizes substances as simple as dextrose to repair and regenerate damaged ligaments.
In 2015, Caring Medical published findings in the European Journal of Preventive Medicine investigating the role of Prolotherapy in the reduction of pain and symptoms associated with increased cervical intervertebral motion, structural deformity and irritation of nerve roots.
Twenty-one study participants were selected from patients seen for the primary complaint of neck pain. Following a series of Prolotherapy injections, patient-reported assessments were measured using questionnaire data, including range of motion (ROM), crunching, stiffness, pain level, numbness, and exercise ability, between 1 and 39 months post-treatment (average = 24 months).
- Ninety-five percent of patients reported that Prolotherapy met their expectations in regard 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.(7)
If this article has helped you understand the problems of atlantoaxial instability and you would like to explore Prolotherapy as a possible remedy, ask for help and information from our specialists
References for this article
1 Wu X, Qi Y, Tan M, Yi P, Yang F, Tang X, Hao Q. Incidence and risk factors for adjacent segment degeneration following occipitoaxial fusion for atlantoaxial instability in non-rheumatoid arthritis. Archives of orthopaedic and trauma surgery. 2018 Jul 1;138(7):921-7. [Google Scholar]
2 Lasswell TL, Cronin DS, Medley JB, Rasoulinejad P. Incorporating ligament laxity in a finite element model for the upper cervical spine. The Spine Journal. 2017 Jun 30. [Google Scholar]
3 Hauser R, Steilen-Matias D, Fisher P. Upper cervical instability of traumatic origin treated with dextrose prolotherapy: a case report. Journal of Prolotherapy. 2015;7:e932-e935.
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 Meyer C, Bredow J, Heising E, Eysel P, Müller L, Stein G. Influence of Osseous and Ligamentous Injuries on the Stability of the Atlantoaxial Complex. Zeitschrift fur Orthopadie und Unfallchirurgie. 2017 Jun;155(3):318. [Google Scholar]
6 Wang HW, Ma LP, Yin YH, Yu XG, Meng CL. Biomechanical Rationale for the Development of Atlantoaxial Instability and Basilar Invagination in Patients with Occipitalization of the Atlas: A Finite Element Analysis. World neurosurgery. 2019 Mar 26. [Google Scholar]
7 Henderson Sr FC, Henderson Jr FC. Diagnosis of Atlantoaxial Instability Requires Clinical Suspicion to Drive the Radiological Investigation. J Spine 6: 364. doi: 10.4172/2165-7939.1000364. [Google Scholar]
8 Cook C, Brismée JM, Fleming R, Sizer Jr PS. Identifiers suggestive of clinical cervical spine instability: a Delphi study of physical therapists. Physical Therapy. 2005 Sep 1;85(9):895-906. [Google Scholar]
9 Coronado R, Hudson B, Sheets C, Roman M, Isaacs R, Mathers J, Cook C. Correlation of magnetic resonance imaging findings and reported symptoms in patients with chronic cervical dysfunction. Journal of Manual & Manipulative Therapy. 2009 Jul 1;17(3):148-53. [Google Scholar]
10 Hutting N, Scholten-Peeters GG, Vijverman V, Keesenberg MD, Verhagen AP. Diagnostic accuracy of upper cervical spine instability tests: a systematic review. Physical therapy. 2013 Dec 1;93(12):1686-95.
7 Hauser RA, 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. 2015;3(4):85-102. [Google Scholar]