Post-cervical fusion migraines and neck pain

In this video presentation, Ross Hauser, MD reviews a digital motion X-ray of a post-cervical fusion patient.

The patient chosen for this demonstration is a 26-year-old who suffers from Ehlers-Danlos Syndrome, a disorder that causes excessive hypermobility in joints including the cervical spine. To fix this problem, the patient had undergone a cervical spine fusion.

In the five years since the patient has suffered from “unbelievable amounts” of neck pain and migraine headaches. In this video, Dr. Hauser will offer options for fusion surgery and treatment for post-fusion pain. Some people get great benefits from cervical fusion surgery. These are not the people we see in our clinics. We see people like this patient whose case is now demonstrated.

At 0:36 Dr. Hauser explores the patient’s DMX. A digital motion x-ray.

Dr. Hauser explains that what he is looking for is when the patient bends forward or backward, do the vertebrae stay together or move apart? In other words, how stable or unstable is the cervical spine?
In this still photo (At 1:17 of the video), Dr. Hauser shows the problems above the clearly seen fusion at C4-C5-C6.

The patient chosen for this demonstration is a 26-year-old who suffers from Ehlers-Danlos Syndrome, a disorder that causes excessive hypermobility in joints including the cervical spine. To fix this problem, the patient had undergone a cervical spine fusion. In this still photo from the video, Dr. Hauser shows the problems above the clearly seen fusion at C4-C5-C6

At 1:20 of the video: Dr. Hauser shows that this person, above their fusion, has significant instability or movement at the C2-C3 and this is causing their symptoms, including not only the migraines but significant muscle cramping and spasm.

At 1:50 of this video: Dr. Hauser explains that to view the instability at the C1-C2 facet joint area, the DMX takes a view of the patient, face to face with the mouth open. The motion that we want to capture is the flex motion, left to right. This will reveal instability and the amount of instability at the C1-C2 area.

Digital motion X-Ray C1 – C2

This is a video of another patient that we are using to demonstrate instability in the C1-C2 as it has a good explanation of the procedure and shows the “motion,” of the x-ray.

Digital Motion X-ray is a great tool to show instability at the C1-C2 Facet Joints
The amount of misalignment or “overhang” between the C1-C2 demonstrates the degree of instability in the upper cervical spine.
This is treated with Prolotherapy injections (explained below) to the posterior ligaments that can cause instability.
At 0:40 of this video, a repeat DMX is shown to demonstrate correction of this problem.

At 2:19 of the video, Dr. Hauser demonstrates that the alignment at C1-C2 is off as demonstrated by the amount of overhang between the C1-C2 vertebrae when the patient moves their head to the left and then again when the patient moves their head to the right.

I chose this particular digital motion x-ray to demonstrate that this person had a C4-C6 fusion and that they had worsening instability at C1-C3 and they also had instability at C6-C7. This problem is one we see very often, adjacent segment disease. Fortunately, this particular patient’s prognosis for recovery is excellent.

Caring Medical research on alternatives to Discectomy and Fusion

In our practice, we continue to see a large number of patients with a myriad of symptoms related to cervical neck instability including severe pain, problems of balance, headaches, and loss of mobility. These people are often confused, many times frightened by recommendations to complicated cervical neck surgeries they don’t understand.

Many of these people have been told that their problem is a problem of degenerative cervical disc disease. After years of prolonged pain and conservative care options such as chiropractic, massage, physical therapy, anti-inflammatories, pain medications, cortisone injections, and cervical epidurals that eventually fail the only recourse, these people are told, is neck surgery.

Surgical recommendations are described in a way to the patient that seemingly makes sense as the only solution to their problems.

The surgery will help, the patient is told because it will cut away the cervical vertebrae bone that is pressing on the nerves
The surgery will fuse the cervical vertebrae in place so the vertebrae do not shift out of place and press on the nerves again.
The cervical disc that has been flattened or herniated is replaced with an artificial implant or bone from the pelvis.

Surgical recommendation for degenerative disc disease may not address the patient’s real problems – cervical neck ligament damage

In neck and spine surgery, doctors focus on degenerative disc disease and its treatment, anterior cervical discectomy and fusion, and cervical decompression surgery to remove whole or part of the cervical vertebrae to allow space on compressed nerves and to fix the instability by fusing vertebral segments together. In the case of C1-C2 instability, these two vertebrae are fused posteriorly (behind) to limit their amount of movement. The goal is to limit pressure on the nerves.

However, it may limit motion to such an extent 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.

In 2014 headed by Danielle R. Steilen-Matias, PA-C, we published these findings in The Open Orthopaedics Journal. (1)

The cervical capsular ligaments 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, 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.

In the upper cervical spine (C0-C2), this can cause symptoms such as nerve irritation and vertebrobasilar insufficiency with associated vertigo, tinnitus, dizziness, facial pain, arm pain, and migraine headaches.
In the lower cervical spine (C3-C7), this can cause muscle spasms, crepitation, and/or paresthesia in addition to chronic neck pain.
In either case, the presence of excessive motion between two adjacent cervical vertebrae and these associated symptoms is described as cervical instability.

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.

Prolotherapy is an injection technique utilizing simple sugar or dextrose.

Stabilizing the unstable neck – degenerative disc disease vs. degenerative ligament disease

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.

In another of our published research studies, in the European Journal of Preventive Medicine, (2) we presented the following findings:

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, indicate the safety and viability of Prolotherapy for cervical spine instability.

1 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]
2 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]