Dynamic Structural Medicine Ross Hauser MD Review of Treatments for Cervical Spine Instability
Ross Hauser, MD
A coordinated and balanced effort between the musculoskeletal, neurologic, and vascular systems is required to maintain a healthy upright posture. It is underappreciated how subtle changes in spinal curvature, posture, and stability affect this delicate balance.
Dynamic Structural Medicine
Body mechanics in health and disease is an integral part of medical specialties such as orthopedic surgery, physical medicine and rehabilitation, neurology, as well as osteopathic and chiropractic medicine. It involves how the human frame moves in three-dimensional space and its effect on joint and neurological structures, as well as organ systems and their functions. A more modern term to describe this field is “dynamic structural medicine,” defined as how human structure influences health and disease. The term “dynamic” embodies the constant state of change that occurs in the human body to maintain homeostasis in various postures, positions, and motions.
The caption of this image reads: Dynamic Structural Medicine: Bony alignment, spinal curves and postures, as well as joint instability are the pillars of dynamic structural medicine. The effects of normal structural alignment and stability and the effects of malalignments, dysfunctional curves and joint instability explain the structural cause of human health and disease. Below the image is the explanatory concepts of Dynamic Structural Medicine.
The concept that subtle changes in cervical and spinal curvature, posture, and stability can impact and create problems that are neurologic, cardiovascular, gastroenterology, immunologic, and endocrine-like in nature.
Without normal spinal alignment and movement, neurologic structures that travel through the neck are at risk. Once alignment, curve, or stability are compromised, the body starts making compensatory changes down the spinal kinetic chain, with changes typically progressing from the neck down. This was demonstrated in a September 2019 paper in the European Spine Journal (1) which travel down the spine from C0-to pelvic incidence. See my article Treatments for leg length discrepancy, pelvic tilt, pelvic incidence-lumbar lordosis mismatch, and walking difficulties for more understanding.
Compared to people with normal lordotic curves, those with kyphosis note greater incidence of neck pain and scoliosis, disc herniations that are more severe, increased incidence of spinal stenosis with and without myelopathy, and spinal cord tensions associated with elevated intramedullary pressures.(2, 3, 4, 5).
The image below shows degenerative kyphosis of cervical spine. In the left side pabnel at lateral x-ray. In the right side panel the same x-ray with the red line marking diffuse degenerative disease with bone spur. This is advanced cervical dysstructure or “degenerative broken neck structure.” The result is spinal cord tension.
It is well known that spinal flexion-extension movements can have dramatic effects on the spinal canal dimensions, spinal cord and spinal nerve root movements, and even cervical ventral epidural pressures.(6, 7) Missed dynamic cervical spine instability is associated with spinal cord compression, most commonly at the C5-C6 segment and cervical segments with greater disc bulge, more severe disc degeneration, greater angular motion, segmental kyphosis, and developmental stenosis.(8)
Static and dynamic digital motion x-rays help determine which of the 3 variables (alignment, curve, and/or stability) are involved in a person’s pathology, but typically one needs motion to show instability. This is demonstrated in the image below.
The image reads:
3 keys to structural health
1. Proper position of vertebrae.
2. Optimal spinal curves.
3. Spine stability.
By taking static and motion x-rays in the various neck planes, a picture of a person’s 3-D cervical anatomy can be found. The primary structural lesion is identified as causing the person’s symptoms, and then the correct therapeutic remedy is applied.
In cases of forward head posture or poor cervical curve in the absence of instability, restoration of the curve is crucial for overall health. Forward head posture is associated with a decline in cervical sensorimotor control and autonomic dysfunction, which gets better with restoration or improvement of cervical lordotic curve. (9, 10) Now let’s examine the structural diagnoses discussed above.
While ligamentous cervical instability can start with humble beginnings such as subtle ligament lengthening with forward head posture from excessive computer work or cellphone usage, causing a dull neck aching, if left unchecked it can progress to neurocatastrophic consequences as the cervical supporting structures are broken (a condition known as cervical dysstructure) and the carotid sheath and/or spinal cord and the fluids contained within get compressed, torqued, and stretched. The two most common mechanisms by which severe symptoms arise are venolymphatic drainage compression (lymph drainage), leading to intracranial hypertension and alterations of brain function, and cervicovagopathy (cervical-induced vagus nerve injury or signal interference), causing dysautonomia and systemic inflammation, both of which lead to dysfunctional body homeostasis.
Disorders including whiplash-associated conditions, post-concussion syndrome, migraine headaches, vertigo, Meniere’s disease, tinnitus, dizziness, subluxations, degenerative disc disease (DDD), postural tachycardia syndrome, brain fog, radiculopathy, and many others can have at their etiological root ligamentous cervical instability. As ligamentous cervical instability is a progressive disorder, if left untreated it can lead to serious conditions and symptoms, including cardiac arrythmias and drop attacks, visual loss, cerebral and spinal cord atrophy, unrelenting fatigue, mast cell activation syndrome, dystonic storms, and serious digestive issues with life-threatening weight loss. The most common spinal instability involves the spine’s most mobile segment, the atlantoaxial joint (C1-2), whose pathophysiology may unlock the cause and solution to neurodegenerative conditions, including Alzheimer’s dementia.
Neck Reconstruction Therapy
A cervical spine that is “fit” has proper dynamic cervical anatomy, which involves 3 primary parameters: alignment, curve, and stability. Ligamentous cervical injury can result in misalignment (subluxation), curve deformation, and instability. In many ways, they are a continuum of the progressive nature of ligamentous cervical instability, so treatment is directed at each part of triad.
Caring Cervical Realignment Therapy (CCRT) or what we call “Curve Correction” combines these treatments to help re-establish normal biomechanics and encourage restoration of cervical lordosis.
Cervical curve correction often consists of utilizing patient-specific weights in a standing or weight-bearing position. Under x-ray guidance, specific chest and/or head weights are used to determine the best method of cervical curve correction. Other therapeutic components of the curve correction program include specific chiropractic adjustments (Dynamic Orthoneurological Correction), a Denneroll (chiropractic neck wedge), specific exercises, and of course, proper ergonomics while working. Cervical curve correction therapies optimize curvature and positioning, thereby helping to stabilize the spine. Because there is a significant correlation between increasing forward head posture and increasing neck pain and disability, treatment is imperative.
We are seeing a significant rise in the population where people have C1 sliding forward off of C2 likely due to car accidents, being on our phones all day, and our technology use. So we have changed the way that we adjust the C1 with the times. Very often, perhaps 80 – 90 % of the time, I find that I’m moving the C1 from the front to the back in order to bring it into a place of integrity.
Manual therapy and cervical exercise
A lot of research shows that one of the most important parts of performing cervical traction is maintaining the cervical lordosis during performing traction. This is something to consider, Performing traction may not always be the best therapy for patients and if they do have a lot of instability you would want to be careful with doing a lot of traction because you don’t want to expose too much motion to an area that’s already moving too much.
A January 2021 study in the International Journal of Environmental Research and Public Health (11) suggested that addition of one C0-C1 and C2-C3 manual therapy session to cervical exercise can immediately improve flexion-rotation test and cervical range of motion and reduce pain intensity in chronic neck pain patients.
The controversies surrounding which patients would benefit from traction or manipulation and who would not was shown in a December 2020 study in the journal Musculoskeletal Science & Practice. (12) The researchers here wrote that “understanding the 3D-kinematics of the upper cervical spine during manual mobilization is essential for clinical examination and therapy. Some information about rotational motion is available in the research but translational components (the movements during flexion-extension and axial rotation) are often ignored, complicating the understanding of the complex inter-segmental motions.
The researchers in this cadaver study found that 3D displacement was larger at C1-C2 during axial rotation, and Atlanto-occipital flexion displayed the greatest variability in the C0 trajectory. During a right rotation, the left C1 facet moved mainly forward, and the right C1 facet moved backward. During a left rotation, the left C1 facet moved backward, while the right C1 facet moved forward. During passive spinal motion, there is an important variability in the magnitude and trajectory of joints’ displacement.
Dynamic Orthoneurological Correction
Specific spinal manipulations (or adjustments) are the basis for much of the chiropractic profession. In Dynamic ortho neurological correction, we watch the movement of the bones under the Digital Motion X-Ray and then we do palpation and then try to correct the bone’s position and get them back into a better alignment.
In the image below we see a high-riding (cowboy) atlas. The cowboy atlas is riding so high in the cervical spine that there appears no space for the vertebral artery or C1 nerve root (what the arrow is pointing at). The combination of dynamic ortho-neurological adjustments, curve correction, and Prolotherapy to the various areas of cervical instability will improve the C1 space and reduce symptoms.
Prolotherapy is referred to as a regenerative injection technique that is used to stimulate repair of injured soft tissues, including ligaments. Our definition of Prolotherapy: proliferative injections onto the bone at ligament attachments that strengthen ligaments to resolve joint instability. Ligamentous tissue in particular is often slow to heal on its own due to a lack of blood supply, which explains why people can develop chronic cervical instability that worsens over time. Prolotherapy to the cervical spine involves injecting an irritating solution (often dextrose) at ligament and tendon attachment sites that creates a mild inflammatory response, initiating the body’s natural healing cascade targeted at poorly vascularized tissue.
Prolotherapy to the cervical spine is best done comprehensively, which means that multiple ligament and tendon attachments are addressed at each cervical level of instability.
Demonstration of Prolotherapy treatment
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.
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