Ross Hauser, MD
We see many adult and adolescent patients with cervical spine instability. Among the many problems and challenges that these people have is cervical spine instability causing developing or worsening cervical scoliosis.
What causes the curvature of the spine in scoliosis?
Many patients are no longer looking for a cause of their scoliosis, they are looking for a solution. Many patients, in fact, do relate to us that their problem of cervical scoliosis treatments up until this point was a search for what caused it and for finding and applying a diagnosis to that cause. Some of these people have become familiar with the term “idiopathic scoliosis,” meaning scoliosis with an unknown cause that started out of nowhere. In this article, we will present one possible answer that is often overlooked or in fact, not even looked for. Cervical ligament weakness and laxity. A somewhat simple answer to the complexity of cervical scoliosis.
- Is cervical scoliosis really a ligament problem? In the adult patent, the cause of their scoliosis problem can be traced to more obvious causes such as a post-traumatic injury, whiplash, or a “broken neck,” or damage caused by neck surgery. However, scoliosis can also be caused by degenerative disc disease of the cervical spine.
While this is a general article about cervical scoliosis and how it impacts adolescents and adults, we will discuss non-surgical options when surgery is presented to the patient as the “only” option. For some people, surgery will be the only option, but that is for some people, not all.
Cervical Scoliosis is more than the curvature of the cervical spine and angles
Many of the patients we see talk about Cobb angles and other degrees of curvature to their cervical spine, first and foremost. For some, this is the way they were taught to speak about their scoliosis by their doctors. While the problems of curvature are at the root cause of these people’s problems, one thing that is not discussed initially is what is scoliosis doing to them or you?
Often, after we hear about the amount of curvature, a patient will finally tell us about the symptoms they are having:
“I have a lot of headaches, problems with memory, hearing issues and sometimes it is difficult for me to speak. I have also developed TMJ and wear a night splint. Nothing has really helped me. Eventually or sooner I will get surgery to correct the scoliosis. It has risks but it is hard to live with this.”
“My neck is tight and is spasm all the time. It gets difficult to turn my head one way or the other. I was sent to physical therapy and given a series of exercises to perform. Really not helping, I have various massage devices, rubber balls, tennis balls, that help a little, I do some yoga. Sometimes I think I am wasting my time and I should ask for surgery.”
“I am on a waiting list for surgery. I have a pinched nerve in my neck that is causing me significant pain in my left arm and into my left hand and fingers. If I could get the surgery today I would, is there anything else I can do?”
This is just a small portion of what we hear from patients about their day-to-day experiences. Some of these patients are even surprised we asked about their symptoms because they are so used to talking angles and degrees of curvature.
Adolescent idiopathic scoliosis, thoracic hypokyphosis, cervical kyphosis
A September 2023 study (1) from doctors at Children’s Orthopaedic Center, Children’s Hospital Los Angeles. and the Department of Orthopaedics, Cedars-Sinai Medical Center investigated the incidence of cervical degenerative disc disease in patients with adolescent idiopathic scoliosis, prior to surgical intervention.
The doctors noted that adolescent idiopathic scoliosis is often associated with thoracic hypokyphosis and compensatory cervical kyphosis. In adults, cervical kyphosis is associated with degenerative disc disease. Although cervical kyphosis has been reported in up to 60% adolescent idiopathic scoliosis patients, the association with cervical degenerative disc disease has not been reported.
In this study, eighty consecutive patients were included (average age 14 years old). Increasing cervical kyphosis (c-shaped spine pushing vertebrae backwards) was significantly correlated to decreasing thoracic kyphosis (straight back syndrome or loss of natural curve) and increasing major curve magnitude at the neck.
- Forty-five patients (56%) had the presence of degenerative disc disease (grades 2-4) with a average cervical kyphosis of 11.1 degrees.
- More cervical kyphosis was associated with more severe cervical degenerative disc disease
- Nine patients had ventral cord effacement (cord herniation).
The doctors concluded: “Cervical kyphosis was significantly associated with increasing severity of cervical degenerative disc disease in patients with adolescent idiopathic scoliosis. Patients with evidence of ventral cord effacement had the largest degree of cervical kyphosis.
Adult Patients With Adolescent Idiopathic Scoliosis – Outcome of Surgery
We do see many patients who have had cervical surgery for their cervical spine deformities whose outcomes had less than the desired results. We also see many patients considering adult cervical deformity surgery.
Surgery is a treatment that should be given great and careful consideration. Many people do very well with surgery. Some do not. Those who do well should be monitored because they can develop degenerative disc disease of the cervical spine.
In June 2020, surgeons from around the United States and from some of our nation’s leading Neurosurgery centers including the University of Virginia Health System, Duke University, the Hospital for Special Surgery, the University of California Davis, and New York University (NYU) Hospital for Joint Diseases among many others published this report in the medical journal Spine. (2) Here are the summary highlights.
- The objective of the study was to examine factors influencing cervical alignment after corrective surgery for adult patients with adolescent idiopathic scoliosis.
- Two years following surgery, adult patients were examined who developed adolescent idiopathic scoliosis following posterior corrective surgery for the thoracic or lumbar major curve.
- More than half of the patients with baseline cervical spine deformity still had their cervical malalignment postoperatively. Because cervical spine deformity has the potential to lead to cervical degeneration, careful follow-up observation is necessary for these young patients.
These are some of the patients we see in our office. The patient had a successful surgery initially and then cervical spine degenerative disease began to progress. What would cause this? In some people, it is damaged and loose cervical spine ligaments. I will explain below.
There are many causes for the development of scoliosis, perhaps one of the simplest, overlooked, and easier to treat problems is a problem of weak, damaged, overstretched cervical spine ligaments.
For many patients we see, they report to us that they have tried many methods of neck curvature correction. Many went through months and months of physical therapy, not trying to reverse the problem, but simply try to stop their cervical scoliosis from getting worse. Equally, many have been under the care of chiropractors for many years seeking the same outcome of lessening progression.
There are many causes for the development of scoliosis, perhaps one of the simplest, overlooked, and easier to treat problems is a problem of weak, damaged, overstretched cervical spine ligaments that are not holding the vertebrae in their natural position.
In common language, scoliosis means that the spine is crooked. The spine is held together by the same thing that holds all the bones together, ligaments.
In common language, scoliosis means that the spine is crooked. The spine is held together by the same thing that holds all the bones together, ligaments. The patient often experiences pain at the site where the spine curves. At the apex of this curve, the ligaments are being stretched with scoliosis, and localized ligament weakness is one of the etiological bases for it. Traditional treatments for scoliosis, especially during adolescence, include observation, bracing, and surgery. Observation of a crooked spine does not sound very helpful, bracing has been shown to decrease the progression of mild scoliosis, and surgery involves placing rods into the spine. Surgery is generally utilized for severe scoliosis when bracing has failed to stop the progression.
Chronic atlantoaxial instability leading to scoliosis
The medical literature is filled with “curious,” or “unusual cases,” when it comes to cervical scoliosis. We present some of these case histories to demonstrate what we see here in our office is seen in other offices around the world. We simply do not find these cases to be curious because we see so many.
Here is an example of a case published in the journal World Neurosurgery. (3) This is from August 2020. It is the story of an 11-year-old girl.
- “An 11- year old girl presented with the major symptom of progressively worsening dorsal kyphoscoliosis.”
- (Note: Many of you reading this article know what kyphoscoliosis is because you or a loved one have been diagnosed with it.
- Kyphoscoliosis is an abnormal curvature of the spine. In the neck, this is cervical kyphoscoliosis, dorsal means “upper.” As the word kyphoscoliosis itself suggests: kyphoscoliosis is a combination of kyphosis (the abnormal spinal curve that leads to a hunchback shape) and the word scoliosis. The sideways curvature of the spine. So kyphoscoliosis is the combined abnormal curvature of the spine twisting in the hunch back shape and the sideways shape at the same time. When this happens in the cervical spine this can lead to many problems ranging from syringomyelia, pulmonary hypertension kyphoscoliosis, weakness or paralysis, and other neurological issues.
Dynamic imaging revealed atlantoaxial instability
- In this 11-year-old girl, in addition to dorsal kyphoscoliosis, examinations revealed multiple craniovertebral and cervical spinal musculoskeletal abnormalities, Chiari formation, and syringomyelia. Dynamic imaging revealed atlantoaxial instability.
- Atlantoaxial stabilization (in this case achieved with cervical surgery, below we will explain how this may be achieved without surgery) resulted in rapid improvement in dorsal kyphoscoliosis, regression of tonsillar herniation, and resolution of the syrinx. The experience with the case showcases wide-ranged spinal consequences as a result of chronic atlantoaxial instability.
In our article Atlantoaxial instability treatment and repair without surgery, I describe Atlantoaxial instability as 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 is strong bands that provide strength and stability while allowing the flexibility of head movement and allow unimpeded access (prevention of herniation or “pinch”) of blood vessels that travel through them to the brain.
While atlantoaxial instability can be caused by many factors. Trauma injury, congenital defects (defects from birth), and arthritis. The focus of this article concentrated on the impact of cervical spine ligament injury and how addressing this injury could help stabilize the cervical spine and address the challenges of cervical spine deformity such as scoliosis.
In this video Ross Hauser, MD explains how cervical scoliosis can develop from cervical spine and neck instability
Here is a summary transcript:
- At 0:30 seconds of the video: A discussion of the impact of weak cervical neck ligaments on the development of scoliosis.
In this illustration, we are using the springs as a visual image to help understand the natural movement of a spinal ligament.
- In flection, bending your head forward with your chin moving towards your chest we see that the spring is stretched to accommodate that movement
- In extension, this would be with your chin pointed upwards in the air, we see that the spring is compressed.
- In lateral flexion, you are moving your head with your ear moving towards your shoulder. You get both ligament motions.
Damage or weakness to these ligaments will cause the vertebrae to move out of place and could result in problems of the curvature of the spine including scoliosis.
- At 1:00 of the video, Dr. Hauser is demonstrating the motion of the neck and how this motion impacts cervical spine and neck instability. In the illustration below, the extension and flexion motion of the neck demonstrates the stretching of the ligaments. When the ligaments are constantly overstretched, such as in the face down smartphone position or other repetitive motions where the chin is moving towards the chest, the ligament structure is weakened and scoliosis can be one outcome.
Malrotation of C2
In the image below we can see the start of cervical spine problems that could lead to many problems including the degenerative cascade leading to scoliosis.
Prolotherapy injections for Atlantoaxial instability in developing scoliosis
In 2015, Caring Medical published findings in the European Journal of Preventive Medicine (3) 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. We concluded that statistically significant reductions in pain and functionality, indicating the safety and viability of Prolotherapy for cervical spine instability.
A continuation of this discussion can be found in these articles on our website:
- Cervical Vertigo and Cervicogenic Dizziness
- Cervicogenic headaches – Migraines, tension headaches, and cervical neck instability
- Cluster headache treatment – cervical ligament instability and the trigeminal and vagus nerves
- Occipital neuralgia and Suboccipital headache – C2 neuralgia treatments without nerve block or surgery
- Making the case for cervical instability as a cause of Tinnitus
- Cervical disc disease and difficulty swallowing – cervicogenic dysphagia
- Can Chronic fatigue syndrome and Myalgic encephalomyelitis be caused by cervical stenosis and cervical spine instability?
- Cervical dystonia and spasmodic torticollis treatment
- Chronic Neck Pain and Blurred Double Vision Problems – Is the answer in the neck ligaments?
If this article has helped you understand the problems of cervical spine instability and cervical scoliosis and you would like to explore Prolotherapy as a possible remedy, ask for help and information from our specialists
1 Lin A, Skaggs DL, Andras LM, Tolo V, Tamrazi B, Illingworth KD. Increasing Cervical Kyphosis Correlates With Cervical Degenerative Disc Disease in Patients With Adolescent Idiopathic Scoliosis. Spine. [Google Scholar]
2 Smith JS, Buell TJ, Shaffrey CI, Kim HJ, Klineberg E, Protopsaltis T, Passias P, Mundis GM, Eastlack R, Deviren V, Kelly MP. Prospective multicenter assessment of complication rates associated with adult cervical deformity surgery in 133 patients with minimum 1-year follow-up. Journal of Neurosurgery: Spine. 2020 Jun 19;1(aop):1-3. [Google Scholar]
3 Goel A, Biswas C, Shah A, Darji H, Bhambere S, Hawaldar A. Atlantoaxial instability as a cause of Craniovertebral and cervical spinal alterations and dorsal kyphoscoliosis-a case report. World Neurosurgery. 2020 Aug 8. [Google Scholar]
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