Cervical artificial disc replacement complications

Ross Hauser, MD.

Cervical artificial disc replacement complications

In this article, we will discuss the challenges patients may face after cervical artificial disc replacement.

We generally see three types of patients when the subject is artificial disc replacement surgery.

Many people have had successful cervical artificial disc replacement surgery and are happy people. These are typically not the patients that seek our help.

“I had two consultations for surgery”

This is the type of story patients share with us. They tell us about cortisone injections in the neck as a last attempt to avoid surgery following many months or years of typical home remedies including stretching, yoga, and traction. Someone pushing forward with these remedies and treatments has hope that these therapies will help them avoid surgery in the near future. There is a clear desire on these people’s parts to avoid surgery and they have not reached the stage of “I am just getting the surgery and will try to be done with this.” They will also tell us multi-segment degenerative disc disease and cervical disc bulging, maybe from C3 – C7 or C2 – C5. They tell us about the surgeon who reviewed their MRI and that doctor’s suggestion to surgery because of developing bone spurs. Then they will tell us about a second opinion they got.

We will now focus on artificial cervical disc replacement.

Artificial Disc Replacement – Who is it best for? Who is not a candidate?

In a cervical artificial disc replacement surgery, the herniated or damaged disc between the vertebrae is removed. As opposed to a fusion surgery where bone and graft are inserted into the void created by the disc removal and then the vertebrae of the cervical spine are held together with rods and screws, the artificial disc replacement surgery inserts a ball and socket joint apparatus. The idea is that this ball and joint can do the job of a natural disc by maintaining disc height and preventing the vertebrae from rubbing against each other, reduce compression on the nerves, and maintain mobility in the cervical spine and a proper range of motion.

As a lesser procedure to bone graft, surgeons hope that they can complete the procedure within 2 hours, have the patient go home the next day, and have them return to a normal lifestyle within 2 months.

The benefits of spinal fusion in discussions between surgeons are

However,

Many people have successful surgery – here are some outcomes

A January 2021 study in the Global Spine Journal (1) examined the outcomes of 3,350 people who had elective primary Anterior Cervical Disc Arthroplasty surgery between  2008 – 2017.

But is this reflective of a successful procedure? Let’s look at more research.

Cervical disc replacement may not recreate the normal range of cervical spine motion. This may cause problems down the road.

As we will see in the research below, one of the given benefits discussed with surgical candidates of cervical disc replacement is a better range of motion in the neck compared to the traditional fusion. We will explore just how much better it is or is not in the surgical studies we are presenting here.

One of the problems that patients seek to solve with a cervical disc replacement is the abnormal motion that they are already suffering from in their neck that is causing them many challenges. They have hope that surgery will remedy this problem. For some people, this may be a false hope.

What are we seeing in this image?

Below we see an image of a neck with a series of disc replacements. As we note in the image caption: Artificial joint replacement parts, of in the case of this article, artificial discs, are stiff and rigid. In the supportive research noted in this image, these stiff and rigid parts are up to 500 times stronger than osteoarthritic cartilage. While the disc replacement is much stronger than the remaining natural structures, this imbalance can cause a structural breakdown in the neck. Maybe not enough to warrant a revision surgery, but a significant impact to neck pain and structure just the same.

The imbalance of artificial components and surviving elements in the neck can cause daily joint forces to be transmitted to these weaker areas of the periarticular (the soft tissue surrounding the cervical spine) structures. This can cause the accelerated breakdown of this soft tissue and lead to neck pain and neck instability.

Below we see an image of a neck with a series of disc replacements. As we note in the image caption: Artificial joint replacement parts, of in the case of this article, artificial discs, are stiff and rigid. In the supportive research noted in this image, these stiff and rigid parts are up to 500 times stronger than osteoarthritic cartilage. While the disc replacement is much stronger than the remaining natural structures, this imbalance can cause structural breakdown in the neck. Maybe not enough to warrant a revision surgery, but a significant impact to neck pain and structure just the same.

A September 2019 study in the journal World Neurosurgery (2) suggests that “simply understanding ranges of motion (ROMs) does not capture the quality of normal cervical motion.”

In other words, cervical disc replacement may not recreate a normal range of cervical spine motion. Remember, this comes from surgical research, it is the surgeons themselves expressing these concerns and represents the challenges some find with artificial cervical disc replacement. This research is discussed further below.

Before we go further, let’s understand again that there are many people who get a great benefit from a cervical artificial disc replacement surgery. There are a lot of people who do well with the “hybrid” surgery of anterior cervical discectomy with fusion plus cervical artificial disc replacement surgery when multiple areas of the cervical spine are causing them pain. The people who have successful surgery are, however, not typically the patients that we see in our office. But we do see a lot post-surgery:

Generally, people who have had a successful cervical artificial disc replacement surgery will report problem situations like this:

Or,

A weakness in their ability to “hold their head up.”

The reason that these people come to our office is that they are exploring regenerative medicine treatments that may help them avoid further surgery by strengthening their cervical spine by way of addressing cervical ligament damage and weakness. We will discuss this below. They may also be in our office looking for ways to strengthen their cervical spine even after successful surgery but they feel something is not right. In some of these patients, they recognize a weakness in their ability to “hold their head up.”

In this video, Ross Hauser explains how even after disc replacement surgery, cervical spine instability is not only present but has been made worse.

Again, let’s point out that many people get significant benefits from cervical disc replacement. These are the people we do not see in our office. We see the people who had disc replacement and continued or worsening problems.

A summary transcript and explanatory notes are below the video.

I’m seeing a lot more disc replacement patients with continued neck problems

The belief is that disc replacement can provide stability as well as a more natural motion. For some people, this did not work out.

At 1:10 of the video, Dr. Hauser shows on a Digital Motion X-Ray (DMX) how one patient continued to suffer from cervical spine instability 

What is Dr. Hauser demonstrating with the tongue depressor?

In the video, (1:40) the patient with the disc replacement is moving their head forward. The DMX image is stopped so the cervical spine instability can be demonstrated.

DMX image of what Dr. Hauser is showing with the tongue depressor: (Note the bottom vertebrae, that is where the disc replacement is)

The person in this DMX image did not have the disc replacement that long ago. So the cervical spine instability see at C2 C3 C4 C5 C6 has probably been there for some time. This is why disc replacement at C6 did not help their neck problems at C2-C5


Neck pain after C5-C6 disc replacement surgery
An introductory video discussion with Ross Hauser, MD

In this video, Ross Hauser, MD, explains pain after disc replacement surgery. These are the learning points:


A comparison of surgical techniques – fusion vs. disc replacement – is about motion

If you have been recommended to a disc replacement fusion surgery, one of the main aspects of this recommendation is your need to have some type of movement in your neck and that you are a candidate for this type of surgery.

We are going to explore a June 2020 study from the Department of Neurosurgery, Medical College of Wisconsin. It was published in the Journal of the Mechanical Behavior of Biomedical Materials. (3) Let’s let the surgeons explain the differences and comparisons between anterior cervical discectomy and fusion and cervical disc arthroplasty or replacement:

“Surgical treatment for spinal disorders, such as cervical disc herniation and spondylosis, includes the removal of the intervertebral disc and replacement of biological or artificial materials. In the former case, a bone graft is used to fill the space, and this conventional procedure is termed anterior cervical discectomy and fusion. The latter surgery is termed artificial disc replacement or cervical disc arthroplasty. Surgeries are most commonly performed at one or two levels.”

Range of motion and anterior and posterior load sharing

The question that these researchers were asking in this study was to determine the external (range of motion, ROM) and internal (anterior and posterior load sharing) responses of the spines with one-level and two-level surgeries in both models (anterior cervical discectomy and fusion and cervical disc arthroplasty/replacement).

“Results for both one-level and two-level surgeries showed that anterior cervical discectomy and fusion decreases range of motion at the index level (the surgery segments or levels), while cervical disc arthroplasty/replacement increase motions compared to the intact normal spine.

The ROM, anterior column load (pressure on the front-facing part of the cervical vertebrae), and  posterior column load (pressure on the rear part of the cervical vertebrae) increased at both adjacent levels for the anterior cervical discectomy and fusion while cervical disc arthroplasty/replacement showed a decrease.”

Suspected facet joint disease after surgery

“Although two-level surgeries resulted in increased these biomechanical variables, greater changes to adjacent segment biomechanics in anterior cervical discectomy and fusion may accelerate adjacent segment disease. Decreased ROM and lower load sharing in cervical disc arthroplasty/replacement may limit adjacent segment effects such as accelerated degeneration. Their increased posterior load sharing, however, may need additional attention for patients with suspected facet joint disease.”

So to recap. The benefit of cervical disc arthroplasty/replacement surgery is a better range of motion and less risk of Cervical adjacent segment disease, as compared to traditional cervical spine fusion. However, the cervical disc arthroplasty/replacement surgery may accelerate facet joint disease. Let’s again refer to the research above. “Cervical disc replacement may not recreate a normal range of cervical spine motion.” Just having more range of motion is not beneficial if it is creating a hypermobile situation that is causing the development of osteoarthritis and bone spurs.

How cervical surgery positively or perhaps negatively affects a patient is done via a comparison of surgical techniques

We are going to return now to the 2019  research we cited above and the discussion of how cervical surgery positively or perhaps negatively affects a patient is via comparison of surgical techniques. This is demonstrated with a September 2019 study in the journal World Neurosurgery (2).  Here the researchers “evaluated clinical and radiologic results as well as biomechanical changes after anterior cervical discectomy and fusion, cervical disc replacement, and posterior cervical foraminotomy. (a minimally invasive surgical procedure performed from the back) and/or discectomy in individuals with unilateral single-level cervical radiculopathy.

RESULTS:

Comparatively:

Yet within the medical community is a debate between what is considered successful cervical artificial disc replacement, when cervical artificial disc replacement should be chosen over anterior cervical discectomy with fusion, and when patients should reconsider the surgical recommendation.

If you can make the neck move more naturally, the better the chance treatment will have in achieving success.

One of the controversial issues surrounding cervical neck surgery is the movement and range of motion, or lack thereof, of the cervical spine following neck surgery. Even in artificial disc surgery, there is a question as to how much, natural movement can be restored. In the above research and research below, a key benefit is the improved range of motion with the disc replacement.

“The complications after total disc replacement surgery are thought to be caused by inadequate natural movement restoration.”

In research from the Department of Orthopedic Surgery, Newton-Wellesley Hospital/Harvard Medical School, published in the Journal of Orthopaedic Translation, July 2019, (4) doctors wrote: “The subaxial cervical spine (C3, C4, C5, C6, C7) is the most mobile region of the cervical spine, allowing positioning of the head in a multitude of positions for various activities of daily living. As the discs degenerate, the relationship between alteration in kinematics (natural motion), resting alignment, and symptom development are not clear.”

(Explanatory note: As cervical degenerative disease occurs, it is not clear what causes the development of the person’s pain challenges or what causes one person to have symptoms of cervical spine degenerative disease and why another person with a similar degenerative disease will have no symptoms.)

Again, what the research suggests is that:

Returning to the research:

The researchers of this study concluded that: “the subaxial cervical intervertebral center of rotation (the place where the vertebra anchors itself to support rotation) and range of motions were segment level- and neck motion-dependent. (Each vertebra had its own unique rotation and motions and fusing or replacing one or multiple segments will impact other non-surgical treated segments). This may help to improve the artificial disc design as well as a surgical technique by which the neck functional motion is restored following the cervical arthroplasty.”

In other words, there is a concern that cervical spine disc replacement surgery does not restore the normal motion of the cervical spine in some patients and that this lack of normal motion can cause post-surgical complications and complaints. Doctors should look for ways to make the neck move more naturally. If they can, the better the chance the surgery, or any treatment will have in achieving better success.

Surgeons ask: “Are Controversial Issues in Cervical Total Disc Replacement Resolved or Unresolved?”

In the February 2018 issue of the Asian Spine Journal, (5) Neurologists in Korea published these findings in their paper: Are Controversial Issues in Cervical Total Disc Replacement Resolved or Unresolved?: A Review of Literature and Recent Updates.

Here are the summary findings and learning points:

Complications in neck surgery.

It is likely that you are like many people. You want someone experienced in the challenges you are facing to help you. This would be especially true in choosing a surgeon. Many people do ask their surgeon, “how many of these surgeries have you done?” It is human nature to feel better when the surgeon reports more rather than less.

A February 2021 study published in the Surgical Neurology International (6) examined the experience of cervical spine surgery as being a factor in reduced complication rates. What the study found was the experience of the surgeon did not matter. This study is here in this article not to question the surgeon’s experience, but because it gives the most recent list of complications and rates. The complications were examined for anterior cervical discectomy without fusion, anterior cervical discectomy and fusion, and anterior cervical disc arthroplasty and noted as:

  1. Dysphagia (swallowing difficulties).
  2. Dysphonia (difficulty speaking)
  3. Unintended durotomy (puncture of dura matter).
  4. Hyposthenia (extreme neck weakness)
  5. Hypoesthesia (Strange sensations to the sense of touch, numbness)
  6. Hematoma
  7. Horner’s syndrome (constriction of the pupil caused by injury to the facial nerves)

Heterotopic ossification- the growth of bone in the tendons, muscles, and soft tissue after cervical disc replacement

Heterotopic ossification is the unnatural formation of bone in the tendons, muscles, and other soft tissue. Speculation in the medical community that the acquired form of heterotopic ossification can occur when a muscle is injured. Muscle is injured during surgery. Let’s look at the research:

Doctors wrote in the journal Medicine – (7)

What causes this?

Doctors at the Spine Institute of Louisiana wrote in a June 2018 study in the International Journal of Spine Surgery (8) that it is difficult to understand why Heterotopic ossification happens.

We would like to point out that possible causation is adjacent-level degeneration and possible problems with the cervical neck sagittal alignment. The cervical spine’s natural alignment or curve.

The neck just decided to fuse itself following a disc replacement

Spontaneous fusion is considered a somewhat rare phenomenon following a cervical disc replacement. But it happens. The point that we stress in our patients is that the neck is always trying to stabilize itself. One way it does this is by the formation of bone spurs. Here in this patient, a patient who had cervical disc replacement, his neck decided that the disc replacement was not providing enough stability so the neck fused over it.

Let’s take a look at a case history presented in June 2020 in the Journal of Pain Research (9) by the attending physicians of a patient whose neck decided to fuse itself.

A 63-year-old man presented the case authors with a 6-month history of progressive neck pain and developed left C-7 radiculopathy 4 years ago. Magnetic resonance imaging revealed disc herniation at the C6–C7 levels resulting in compression of the left C-7 nerve root.

The patient underwent cervical disc replacement at the C6–C7 levels. He failed to follow-up regularly as recommended postoperatively because he was completely free from the pain in his neck and left upper limb.

Four years later, he was readmitted with a 2-month history of occasional neck stiffness. Plain radiographs indicated complete radiographic fusion of the C6–C7 levels with trabecular bone bridging surrounding the cervical disc prosthesis, and dynamic imaging showed no motion.

He was seen at regular follow-up visits for up to 60 months without special treatment, as his symptoms of neck stiffness were minor and his symptom has not worsened since then.

Here again, we have a successful cervical disc replacement. The patient developed fusion lost range of motion but had no significant pain. His body decided to just fuse itself and save him from another procedure.

In this video, Danielle R. Steilen-Matias, MMS, PA-C explains the challenges of adjacent segment disease

Summary transcript

A case presented

Cervical spinal alignment and curvature after disc replacement surgery

Let’s point out again that people have good success with cervical disc replacement. In some instances, documented in the studies we will cite below, the disc replacement helped restore, in part, the natural alignment of the neck. In others, the artificial disc caused an unnatural curve and alignment in the neck that caused complications.

This is the progression of cervical neck instability. The neck has a natural “backward C” shape. Cervical instability causes a normal lordotic curve to end up as an “S” or “Snake” curve, or cervical dysstructure.

The Horrific Progression of Neck Degeneration with Unresolved Cervical Instability

While people have good success with cervical disc replacement, in some instances, documented in the studies we will cite in this article, the disc replacement helped restore, in part, the natural alignment of the neck. In others, the artificial disc caused an unnatural curve and alignment in the neck that caused complications. This image help-s documented the type of changes that can occur in the cervical spine.

In the European Spine Journal (10), medical university researchers in Italy researchers examined alignment at the cervical spine in patients following cervical disc replacement surgery.

Here is what they wrote:

“The alignment at the cervical spine has been considered a determinant of degeneration at the adjacent disc, but this issue in cervical disc replacement surgery is poorly explored and discussed in this patient population. The aim of this systematic review is to compare anterior cervical fusion and total disc replacement in terms of preservation of the overall cervical alignment and complications.”

“In most of the retrieved studies, a tendency towards a more postoperative kyphotic alignment in total disc replacement was reported. The reported mean (average) complication rate was 12.5 % (0% in some research up to 66.2 % in other research). Complications associated with cervical prosthesis included heterotopic ossification, device migration, mechanical instability, failure, implant removal, operations, and revision.

“Even though cervical disc arthroplasty (replacement) leads to similar outcomes compared to arthrodesis (fusion) in the middle term follow-up, no evidence of the superiority of cervical total disc replacement is available up to date. We understand that the overall cervical alignment after total disc replacement tends towards the loss of lordosis, but only longer follow-up can determine its influence on the clinical results.”


The importance of the cervical spine curve in alleviating pain

Surgical treatments for Cervical Instability – the disc may not be the problem causing pain, loss of cervical curvature, and loss or range of motion

In our practice, we see many patients, not only with neck pain and radiating pain into the back, shoulders, arms, and hands but also with a myriad of symptoms related to cervical neck problems that doctors feel an artificial disc may help remedy, those related to degenerative cervical disc disease including problems of pinched nerves.

cervical degenerative ligament disease

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.

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 by 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 spine instability.

Range of motion issues are in the ligaments

A study came out of the University of Waterloo in Canada and was published in the November 2017 edition of the Spine Journal. (11) 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


In this video, a demonstration of treatment is given

Prolotherapy is referred to as a regenerative injection technique (RIT) because it is based on the premise that the regenerative healing process can rebuild and repair damaged soft tissue structures. It is a simple injection treatment that addresses very complex issues.

This video jumps to 1:05 where the actual treatment begins.

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

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. (12)

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 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. (13)

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 you may have surrounding your neck pain. 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.

Please visit the Hauser Neck Center Patient Candidate Form

References

1 Lee NJ, Joaquim AF, Boddapati V, Mathew J, Park P, Kim JS, Sardar ZM, Lehman RA, Riew KD. Revision Anterior Cervical Disc Arthroplasty: A National Analysis of the Associated Indications, Procedures, and Postoperative Outcomes. Global Spine Journal. 2021 Jan 19:2192568220979140. [Google Scholar]
2
Lin GX, Rui G, Sharma S, Kotheeranurak V, Suen TK, Kim JS. Does the Neck Pain, Function, or Range of Motion Differ After Anterior Cervical Fusion, Cervical Disc Replacement, and Posterior Cervical Foraminotomy?. World neurosurgery. 2019 Sep 1;129:e485-93. [Google Scholar]
3 Purushothaman Y, Yoganandan N, Jebasselan D, Choi H, Baisden J. External and internal responses of cervical artificial disc replacement, and anterior cervical discectomy and fusion: A finite element modeling study. Journal of the Mechanical Behavior of Biomedical Materials. 2020 Mar 22:103735. [Google Scholar]
4 Yu Y, Li JS, Guo T, Lang Z, Kang JD, Cheng L, Li G, Cha TD. Normal intervertebral segment rotation of the subaxial cervical spine: An in vivo study of dynamic neck motions. Journal of Orthopaedic Translation. 2019 Jan 21. [Google Scholar]
5 Park CK, Ryu KS. Are Controversial Issues in Cervical Total Disc Replacement Resolved or Unresolved?: A Review of Literature and Recent Updates. Asian spine journal. 2018 Feb;12(1):178. [Google Scholar]
6 Zekaj E, Iess G, Servello D. Anterior cervical spine surgical complications: Safety comparison between teacher and student. Surgical Neurology International. 2021;12. [Google Scholar]
7 Kong L, Ma Q, Meng F, Cao J, Yu K, Shen Y. The prevalence of heterotopic ossification among patients after cervical artificial disc replacement: a systematic review and meta-analysis. Medicine. 2017 Jun;96(24). [Google Scholar]
8 Nunley PD, Cavanaugh DA, Kerr EJ, Utter PA, Campbell PG, Frank KA, Marshall KE, Stone MB. Heterotopic ossification after cervical total disc replacement at 7 years—prevalence, progression, clinical implications, and risk factors. International journal of spine surgery. 2018 Jun 1;12(3):352-61. [Google Scholar]
9 Ge CY, Wang J, Zhang BF, Hui H, Shan LQ, Zhao QP, Hao DJ. Spontaneous Fusion After Cervical Disc Arthroplasty: A Case Report and Literature Review. Journal of pain research. 2020;13:771. [Google Scholar]
10 Di Martino A, Papalia R, Albo E, Cortesi L, Denaro L, Denaro V. Cervical spine alignment in disc arthroplasty: should we change our perspective?. European Spine Journal. 2015 Nov 1;24(7):810-25.
11 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 Nov 1;17(11):1755-64. [Google Scholar]
12 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]
13 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]

This article was updated February 22, 2021

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