Cervical Spine Realignment and restoring loss of cervical lordosis, Symptoms and treatments of spinal curvature problems

Ross A. Hauser, MD

For many patients we see, who have issues of chronic pain and neurological symptoms, they come into the first visit us with an understanding that something is wrong with the curve of their neck and spine. They also have an understanding that it is this curve problem, whether their spines curve inwards too much or that they lost the natural curvature of the spine that is a cause of their problems. But the curvature of the spine is a complex problem and many of our patients who come in have reduced their understanding of this problem, and rightfully so, to how it impacts their daily lives.

This article will present the case that cervical spine, upper cervical spine, and lower cervical spine instability may be an unexplored cause of your neurologic-like, vascular-like, and psychiatric-like conditions and symptoms. It is very likely that you are reading this article as a continuation of your research into your symptoms and conditions and you came here from other pages on this website or that you landed here because a doctor, in many cases a chiropractor, mentioned to you that you have C1-C2 instability or C3-C7 instability. That this cervical instability has caused you to lose the natural curve or LORDOSIS in your neck. Further, that you have started to comes to terms with the understanding that all the tests that you have had performed by neurologists and cardiologists and the prescriptions offered to you by psychiatrists have never offered a “grand unifying theory” or help in diagnosing what was really wrong with you.

To be clear, cervical instability MAY BE the cause of your symptoms and conditions. It may not be the ONLY cause. This article however will address cervical instability as the main culprit. We will see how cervical instability causes destructive joint motions to occur which can eventually injure the facet joints, cervical discs and other ligaments and structures that are vital to neck stability. We will see how ligament laxity can cause the loss of the natural curve of the cervical spine.

What are we seeing in this image?

In this image from a digital motion x-ray we can see how a reverse curve or “S” curve can lead to problems of the vertebrae banging against the back of the head, nerve impingement or pinching, and reducing blood flow into the brain. With these problems comes the long list of “unexplained” neurological symptoms the patient may suffer from.

Cervical lordosis is the anterior convexity or the rear curve of the cervical spine from the foramen magnum (the base of the skull) to the thoracic spine. Cervical lordosis is created by the wedge-shaped design of the vertebrae. Cervical lordosis is necessary to keep the spine balanced from the kyphosis in the thoracic region and enable forward gaze (head upright looking forward). It is important throughout life to maintain a stable cervical lordotic curve as it maximizes the spine’s ability to handle forces by maintaining global spinal alignment while having the head balanced on its supporting platform.

Cervical spines can easily be placed into 1 of 6 categories just from an upright lateral c-spine x-ray:

The caption states – the six types of cervical curves based on upright lateral c-spine x-ray.

• A: Normal “C” cervical lordosis: normal cervical curve with lordosis.
• B: Hypolordosis: loss of optimum curvature, but still lordotic
• C: Military: complete loss of lordosis resulting in a straight spine
• D: Hypokyphosis: “R” reversed curve, a slight flexed posture of the cervical curve.
• E: Degenerative hyperkyphosis: extreme reversal of cervical curve (sideways “V”).
• F: Sigmoidal “S”

In the image below we see hypolordosis the flattening of a curve in the spine.

Psychologic and emotional distress, weird symptoms and conditions

Many, many people contact us. They have stories and a medical history that have caused them psychological and emotional distress in that weird symptoms and conditions plague them almost to the point, as some described, that they are possessed or no longer in control of their body.

People will report a sudden and severe onset of symptoms such as tinnitus, chronic headache, vomiting, dizziness, unexplainable emotional and panic-like attacks, and the inability to truly describe what is going on “inside their head.” They may lose their balance and coordination and an inability to hold their head up. Despite these problems, some report to us that their ENT, their neurologist, their eye specialists, and the other doctors they saw, could not adequately explain the myriad of symptoms they had nor present a single strategy for treating them other than handling the symptoms one by one.

As mentioned above, one of their health care providers, a physical therapist, a chiropractor, or perhaps their neurologist recommended a cervical spine MRI. Their MRI reveals that the natural curve of the cervical spine has now straightened as in a military curve or is now curving in the wrong direction as in a situation of cervical lordosis to cervical kyphosis. For others, The MRI came back “unremarkable.” Yet persistent symptoms, pain, numbness, and the neurologic-like, vascular-like, and psychiatric-like conditions and symptoms continue.

Understanding a treatment path that restores cervical spine instability and cervical lordosis.

The cervical spine is a very complex area. The blood highway from the heart to the brain must travel through and around the vertebrae and bones of the neck, and also must the vast neurological networks and nervous systems which must also map out a path from brain to body through the cervical spine. If the cervical spine begins to become unstable, the cervical vertebrae will begin to float out of position and take with it the veins, arteries, and nerves. The veins and arteries become stretched and narrowed causing a stenosis-like situation of reduced blood flow. Some of the arteries and veins can become compressed and blood flow in and out of the brain becomes greatly diminished. For the nerves, not only do they get pinched, they too can become stretched causing distorting or confusing messages from the brain to body. This would lead to the onset of neurological type symptoms and a search of the brain for the cause of these problems when the problem may be in the neck.

What are we seeing in this image?

The complexity of the cervical spine and the neurology (nerve networking) and blood supply to the neck, face, and brain.

Lordosis to kyphosis – the role of cervical spine ligaments

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 and thus make 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 simple explanation to a complex series of problems is that to maintain upper and lower cervical spine stability, the cervical ligaments must keep the cervical facet joints from curving in the opposite direction. If the ligaments are weak, damaged, incapable of doing this job, the cervical spine muscles will try to help. This will pull on the muscle tendons, stretching them and overusing them. This will cause pain and spasms in the neck and continue the cascade towards instability. Eventually, the bones of the cervical spine jump in and start to form bone spurs and bone overgrowth leading to a stenosis situation.

What are we seeing in this image?

Look at these images below. When the patient looks down, there is a 6 mm (about 2/10ths of an inch) space between the C1-C2. There is room for some vessels and nerves to get through. When the same patient looks up, 0 mm or NO SPACE. Everything in between gets pinched. This is a classic representation we see in many of our patients. Worsening of symptoms with certain movements of the head. This is also a classic representation of cervical spine instability. The bones of the neck and cervical spine are “floating” around.

Treatments for cervical spine realignment – restoring the curve without surgery

When we start looking at the most recent research papers surrounding treatments for cervical spine realignment, we often find ourselves reading a lot of new research on cervical spine surgery procedures. Non-surgical treatments for cervical spine realignment are, for the most part, fewer and far between. There is a rush in medicine to surgically correct cervical spine abnormalities including the loss of the natural cervical spine curve. In our office, we rush more to non-surgical applications to help the patient with cervical spine instability and abnormal curvature of the spine. But what if you were told surgery should be strongly considered?

Researchers say fusion surgery should not be considered for some kyphosis patients

Let’s look at a recurrent theme in medical research: Controversy in the surgical repair of cervical kyphosis.

First, let’s look at a June 2020 study from the Mayo Clinic. (1) It is very likely that many of you reading this article will identify with what is being said here.

“Cervical kyphotic deformity can be quite debilitating. Most patients present with neck pain, but they can also present with radiculopathy, myelopathy, altered vertical gaze, swallowing problems, and even cosmetic issues (round back or hunchback) from the severe kyphotic deformity. After failing conservative management, surgery remains the only option for halting symptom progression.”

Once pain medications became the primary treatment, it was at this point that many received a surgical recommendation to multi-level fusion surgery.

Many of you reading this article will have already undergone conservative care options for cervical kyphosis. Typically this will include physical therapy and chiropractic care to try to improve your posture and/or muscle spasms. You may have been prescribed a neck brace or neck collar and ultimately pain medications. Once pain medications became the primary care, it was at this point that perhaps you received a surgical recommendation to multi-level fusion surgery.

For many people, cervical multi-fusion surgery can be very successful. In the Mayo Clinic study we are citing, an anterior-only (front) approach consisting of a four-level anterior cervical discectomy and fusion (ACDF) found that in a study of 20 patients, significant improvement or complete resolution of symptoms post-operatively occurred in all patients.” The conclusion of the study: “Four-level ACDF in carefully selected patients can be used to correct cervical alignment in patients presenting with symptomatic multi-level cervical stenosis with kyphosis.”

In some patients, fusion should be avoided as it is thought to lead to increased rates of adjacent segment degeneration

However, a March 2020 study in the Journal of Spine Surgery (2) with the title: “Sagittal alignment of the cervical spine: do we know enough for successful surgery?” suggested: “The relationship between sagittal cervical spine alignment and symptoms in patients prior to undergoing surgery remains imprecise, and the evidence for its influence on postoperative clinical outcomes is similarly mixed. It is generally accepted that in patients undergoing cervical fusion surgery for a variety of indications, fusion in kyphosis. . . should be avoided as it is thought to lead to increased rates of adjacent segment degeneration”

This research concludes: “Cervical sagittal balance is undoubtedly a vital concept that must be considered with surgery to the cervical spine. As it stands, however, our understanding of its exact role and impact is incomplete and primitive. Patients with pre-operative cervical kyphosis with sagittal imbalance are known to have worse outcomes post-operatively.”

This group of patients is more typical of the patients we see. In our office, we usually do not see excellent surgical candidates. The reason, obviously, is that most of these patients went onto surgery. Who we see are the patients who are not excellent candidates for surgery or people who are concerned with undergoing surgery and they are looking beyond simple chiropractic care, physical therapy, neck braces, and medications.

Cervical kyphosis in Ehlers-Danlos syndrome

We see many patients with Ehlers-Danlos syndrome. For these patients, there can be a great challenge in having a successful surgery.  A  paper in the American Journal of Medical Genetics summarizes the challenges some patients with hypermobility syndromes such as hEDS may face.

“The prevalence of cervical and thoracic segmental instability in the population of patients with hypermobility syndromes has not been well established. However, discopathy (degenerative disc disease) and early degenerative spondylotic disease (degenerative disease associated with aging)  in hEDS and classical type EDS are well established. EDS is characterized by segmental instability, kyphosis, and scoliosis. Spondylosis, defined by the presence of non‐inflammatory disc degeneration, is usually preceded by mild segmental instability. As a consequence of cervical and thoracic instability, and discopathy in EDS, there is loss of the normal cervical lordosis and an increasing kyphosis, rendering EDS patients prone to progressive myelopathy (compression of the spinal cord), and mechanical neck and chest pain. (3)

What are we seeing in this image?

A cervical venous system that makes its way to the brain. The brain drains primarily via the internal jugular and vertebral venous plexus. Most venous compression syndromes that lead to such things as brain fog, memory problems, intracranial hypertension, pseudotumor cerebri, dizziness, head pressure, eye pain, and decreased or blurry vision occur at the J3 segment (upper cervical area) of the internal jugular vein. The J3 segment can get impinge by anterior subluxation of the atlas, occipital-atlanto (C0-C1), and atlantoaxial instability (C1-C2) along with altered musculoskeletal biomechanics as occurs with forward head posture. Realigning and stabilizing the atlas while destroying the cervical lordotic curve resolves most venous compression syndromes, including venous hypertension, venous ischemia, and internal jugular venous obstruction and the symptoms with them.

Sagittal cervical spine alignment goals

This is a general section on the types of cervical spinal curvatures we routinely encounter. Here we briefly introduce the idea of cervical spine ligament weakness and damage, commonly referred to as cervical ligament laxity as a possible leading factor in curvature problems of the neck.

• The cervical spine should have lordotic curvature, it should be shaped like a C. The C shape keeps stress forces on the cervical spine at a minimum.
• When you have a cervical spine ligament injury, the ligaments cannot hold the C shape. The neck can progress to a Military curve, which is straight up and down. Eventually, the natural curve of the neck distorts and twists into a letter S. (See illustrations below).
• How do we reverse this?
  • We treat the injured ligaments with Prolotherapy injections, explained below, which will cause the ligaments to strengthen and tighten and provide cervical spine stability.

Cervical spine ligaments, are they the answer to neck curvature problems?

Cervical spine patients do a lot of research. Their health problems are so vast and sometimes so complex that research provides many patients a degree of comfort through understanding. In some of our very well-read patients, we can hear the arguments they have been given to proceed with surgery as the “only answer.” Again, for some patients, surgery is the only answer. But it is not always the case.

Here is something typical of what we hear in our consultations:

I was told I have a damaged alar ligament, laxity in other ligaments, muscle atrophy, which is obvious to me. This soft tissue damage in my neck cannot be repaired. My head “floats” on my craniovertebral junction. I can feel the upper vertebrae banging against the back of my head (the occiput bone). I was told that I must get a fusion.

In this video, DMX displays Prolotherapy before and after treatments

• In this video, we are using a Digital Motion X-Ray (DMX) to illustrate a complete resolution of a pinched nerve in the neck and accompanying symptoms of cervical radiculopathy.
• A before digital motion x-ray at 0:11
• At 0:18 the DMX reveals completely closed neural foramina and a partially closed neural foramina
• At 0:34 DXM three months later after this patient had received two Prolotherapy treatments
• At 0:46 the previously completely closed neural foramina are now opening more, releasing pressure on the nerve
• At 1:00 another DMX two months later and after this patient had received four Prolotherapy treatments
• At 1:14 the previously completely closed neural foramina are now opening normally during motion

• Once the Prolotherapy treatments strengthen the ligaments significantly enough to handle the force of cervical spine curve correction, we put weights on him
• The end result of the treatment at 1:00 a good cervical spine curve and we have not had to see the patient again.

Addressing the problems caused by cervical lordosis or loss of the natural cervical curve.

• Not only is tightening the ligaments with Prolotherapy injections important to help stabilize the neck but just as important is that we are addressing the problems caused by cervical lordosis or loss of the natural cervical curve.
• Helping a patient get the curve back in the neck is so important. Your head weighs 8 to 10 pounds, if your center of gravity (posture) is off even a small amount, the pressure on the neck increases, and degenerative problems accelerate.

Repairing the ligaments and curve for a long-term fix

The goal of our treatment is to repair and strengthen the cervical ligaments and get your head back in alignment with the shoulders in a normal posture. In some patients, using subtle cervical adjustments in conjunction with Prolotherapy, we can get the body to work and move correctly.

In this illustration, we see the before and after of neck curve corrections. Ligament laxity or looseness or damage, whether the cause is from trauma, genetic as in cases of Ehlers-Danlos syndrome, ultimately causes a kyphotic force on the cervical spine, stretching the posterior ligament complex of the neck. As can be seen in the x-rays of this image, patients with a whiplash injury, Joint Hypermobility Syndrome, and Ehlers-Danlos syndrome can have their cervical curve restored with Prolotherapy Injections and the use of head and chest weights, documented below.

Cervical Curve Correction

Through extensive research and patient data analysis, it became clear that in order for patients to obtain long-term cures (approximately 90% relief of symptoms) the re-establishment of some lordosis, (the natural cervical spinal curve) in their cervical spine is necessary. Once spinal stabilization was achieved with Prolotherapy and the normalization of cervical forces by restoring some lordosis, lasting relief of symptoms was highly probable.

In this video Ross Hauser, MD explains Caring Cervical Realignment Therapy aka “Curve Correction:”

• Caring Cervical Realignment Therapy is one of the therapies we use to correct abnormal cervical spine
• The cervical spine should have lordotic curvature, it should be shaped like a C. The C shape keeps stress forces on the cervical spine at a minimum.
• When you have a cervical spine ligament injury, the ligaments cannot hold the C shape. The neck can progress to a Military curve, it is straight up and down. Eventually, the natural curve of the neck distorts and twists into a letter S. (See illustrations above).
• At 1:07 of the video: How do we reverse this?
  • We treat the injured ligaments with Prolotherapy injections, which will cause the ligaments to strengthen and tighten and provide cervical spine stability.
  • At 1:24: Once the cervical spine is stabilized, then the neck can handle the weight forces of the Caring Cervical Realignment Therapy. Dr. Hauser explains.
  • 1:46 images of post-treatment correcting cervical spine curvature.

An individualized treatment protocol may include the following:

• A certain number of Prolotherapy visits to resolve the instability.
• An initial period of cervical immobilization with a cervical collar in order to limit neck forces while the ligaments regenerate.
• Rescanning every two-four visits to ensure the Prolotherapy is resolving the instability.
• When improved spinal stability is demonstrated, Curve Correction using cervical weights will be started. In some severe spinal curves, Curve Corrction using cervical weights is started immediately. Changing the spinal curve can take just minutes for some patients to several months in others.

The treatment regimen is continued until the person can do all desired activities with minimal symptoms and spinal curve kinematics (curve) are improved.

Cervical spine weights

Individualized cervical weight protocols are prescribed during Curve Correction. These weights help postural distortions by placing appropriate forces onto the neck to change alignment. The weights can include the use of anterior or posterior head weight and/or an anterior chest weight. The vector of force (the direction of the force or pull of the weights) is determined by the motion scanning and lateral x-rays. The more rigid the spine the more weight may be required and for a longer period of time. Many Caring Medical patients work up to using the weights 30 minutes per day but may start out with just one minute per day. Patients are instructed on the use of the weights and monitored by periodic x-rays/motion scans as well as symptom resolution to make sure the regime is successfully improving the patient’s cervical curve.

What are we seeing in this image?

Caring cervical realignment therapy weight protocol. A patient demonstrating an example of the anterior (front) chest weight that is worn like a necklace in the posterior (back) weight that is worn across the head and looks like an elf hat proper positioning of the weights using DMX guidance can put forces on the neck to regain proper lordotic curve this curve can become permanent by stretching by strengthening the capsular and posterior ligaments with Prolotherapy injections

The Prolotherapy injections demonstrated

This patient is having C1-C2 areas treated. Ross Hauser, MD, is giving the injections.

• The patient was experiencing vertigo, tinnitus, severe neck pain, migraines, and other problems based on C1-C2 instability.

Summary and contact us. Can we help you? How do I know if I’m a good candidate?

We hope you found this article informative and it helped answer many of the questions. Just like you, we want to make sure you are a good fit for our clinic prior to accepting your case. While our mission is to help as many people with chronic pain as we can, sadly, we cannot accept all cases. We have a multi-step process so our team can really get to know you and your case to ensure that it sounds like you are a good fit for the unique testing and treatments that we offer here.

Reach out to the Hauser Neck Center Patient Team here

References:

1 Ebot J, Foskey S, Domingo R, Nottmeier E. Kyphosis Correction in Patients Undergoing a Four-Level Anterior Cervical Discectomy and Fusion. Cureus. 2020 Jun 25;12(6):e8826. doi: 10.7759/cureus.8826. PMID: 32742839; PMCID: PMC7384706. [Google Scholar]
2 Teo AQ, Thomas AC, Hey HW. Sagittal alignment of the cervical spine: do we know enough for successful surgery?. Journal of Spine Surgery. 2020 Mar;6(1):124. [Google Scholar]
3 Henderson Sr FC, Austin C, Benzel E, Bolognese P, Ellenbogen R, Francomano CA, Ireton C, Klinge P, Koby M, Long D, Patel S. Neurological and spinal manifestations of the Ehlers–Danlos syndromes. In American Journal of Medical Genetics Part C: Seminars in Medical Genetics 2017 Mar (Vol. 175, No. 1, pp. 195-211). [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 Katz EA, Katz SB, Fedorchuk CA, Lightstone DF, Banach CJ, Podoll JD. Increase in cerebral blood flow indicated by increased cerebral arterial area and pixel intensity on brain magnetic resonance angiogram following correction of cervical lordosis. Brain circulation. 2019 Jan;5(1):19. [Google Scholar]
6 Bulut MD, Alpayci M, Şenköy E, Bora A, Yazmalar L, Yavuz A, Gülşen İ. Decreased vertebral artery hemodynamics in patients with loss of cervical lordosis. Medical science monitor: international medical journal of experimental and clinical research. 2016;22:495. [Google Scholar]

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• Surgery
• NSAIDs
• Cortisone Shots
• R.I.C.E.