Post-Traumatic Instability of the Cervical Spine

Ross Hauser, MD, Caring Medical Florida

Chronic Post-Traumatic Instability of the Cervical Spine: Persistent neck pain that develops into hearing, vision, and swallowing problems, dizziness, and chronic headaches.

We often see patients who have suffered from a significant injury to the neck, such as a whiplash injury or sports-related injury, who continue to have post-traumatic neck pain and instability despite many years of treatments following acute care. Acute care in some cases included immediate surgery following the injury. Some of these people have been told the root of their problem was that following their injury, they were not correctly diagnosed, correctly treated or in some cases, after the acute management phase of the injury, even believed that their pain was worsening. As is the case with many neck pain sufferers who doctors may dismiss symptoms as being all in the mind. You may be one of these people.

If you are indeed one of these people then you are already familiar with the treatments that did not work for you.

• Prolonged use of neck braces
• Regularly scheduled cortisone injections
• Alternating and rotating doses of pain medications
• Physical therapy
• Chiropractic care

For many people, these treatments can be very effective and helped them resume a good quality of life. These are typically not the people we see in our offices. We see the people for whom these treatments have failed and cervical fusion surgery is the “only,” available option. For some people, fusion surgery may be the only option and many people may have good results. These are also not the people we typically see in our office. We see the people who had post-traumatic neck pain, the failed conservative treatment, the fusion surgery, and now have the common complication of adjacent segment disease. So what do we do to help them? Let’s review the research and a case history so we can present an option.

Chronic Post-Traumatic Instability: The injured posterior ligamentous complex and the cervical intervertebral disc

In this section, I will briefly describe what is happening in your neck. Understanding the damage and weakness exhibited by the cervical neck ligaments can help understand why your past treatment may have not worked for you and what can be done to repair this damage with the goal of alleviating your symptoms.

Many patients we see who suffered a significant neck injury will typically not exhibit a singular symptom. They will exhibit multiple symptoms.

These include but are not limited to:

• Cervicogenic dizziness and problems of balance, spatial disorientation, accompanying neck pain, limited range of motion in the neck, and sometimes a headache. See also my article Vestibular migraine and spontaneous vertigo – Migraine Associated Vertigo.
• Tinnitus is caused by cervical neck ligament damage. We suspect cervical neck instability when the patient has been unresponsive to typical Tinnitus treatments.
• Swallowing difficulty. Cervical instability in the neck has been linked to swallowing difficulties, diagnosed as cervicogenic dysphagia.
• Blurred, double vision, and accompanying light sensitivity.

These symptoms can come from cervical spine ligament damage. This is demonstrated in the illustration below as a torn interspinous ligament; a thinned ligamentum flavum; torn capsular ligaments; and a torn posterior longitudinal ligament.

Post-Traumatic Instability of the Cervical Spine is rarely a problem of one isolated injury to a single structure in the neck. Damage to multiple ligament structures is more often the cause.

In this illustration post-traumatic instability of the cervical spine is rarely a problem of one isolated injury to a single structure in the neck. Damage to multiple ligament structures is more often the cause. These injuries are demonstrated here as a torn interspinous ligament; a thinned ligamentum flavum; torn capsular ligaments; and a torn posterior longitudinal ligament.

Understanding the posterior ligamentous complex and how damage to its components create chronic post-traumatic instability of the cervical spine

Posterior ligamentous complex damage was seen as responsible for an increased local range of motion (hypermobility) at the injured level C4-C5  by 77.2% and  C6-C7 by 190.7%

In a May 2020 study, (1) French and Canadian researchers looked at the injured posterior ligamentous complex and the cervical intervertebral disc and their roles in post-traumatic instability in the cervical spine.

The posterior ligamentous complex (the ligaments at the back of your neck and head) act to stabilize the cervical spinal column and prevent your head from hyper-flexion (your head bending too far forward with your chin buried into your chest), hyper-rotation, and translation (hypermobility where the ear may crash into the shoulder or your head snaps too far to the left or the right). In your research or discussions with your doctors, the posterior filamentous complex may also be referred to as the posterior tension band and it is called this in certain medical studies.

• The facet joint capsule. The facet joint capsule is an area of connective tissue that covers and closes the facet joint (the joint that connects two vertebrae together and allows proper spinal movement).
• The ligamentum flavum. The strong band of connective tissue prevents the cervical spine from bending too far forward.
• The interspinous ligament. The interspinous ligament is found at the back of the vertabrae, the bony protrusion called the spinous process on each side of the two vertabrae together.
• The supraspinous ligament. This ligament connects the C7 to the rest of the spine through the sacrum.

In this study, the researchers gave this assessment of post-traumatic instability in the cervical spine.

• “(the) Posterior ligamentous complex and intervertebral disc injuries are common cervical spine flexion-distraction injuries, but the residual stability following their disruption is (unknown).”
  • Simply, patients have symptoms of cervical spine instability after an injury or accident to the cervical spine and doctors are not sure if these injuries heal sufficiently enough in some patients to restore the natural stability of the neck

So what the researchers did was create a computer model to simulate the impact of certain injuries to the posterior ligamentous complex and intervertebral disc injuries and measure the consequences.

• Posterior ligamentous complex damage was seen as responsible for an increased local range of motion (hypermobility) at the injured level C4-C5  by 77.2% and  C6-C7 by 190.7%
• Complete disc rupture had the largest impact on C2-C3, increasing C2-C3 hypermobility by 181% and creating a large anteroposterior displacement of the C2-C3 segment. (The vertabrae have moved out of place and the patient is usually recommended a cervical spinal fusion). This is an injury that is also seen commonly and we can help many patients avoid this fusion surgery.

The conclusion of this study? “Stabilization appears important when managing patients with soft tissue injuries.”

It does not take much damage to the posterior ligamentous complex to send you into cervical spine instability problems

A study in the European Spine Journal (2) showed how significant the cervical spine stabilizers are and how significant injury can be in starting a cascade of degenerative neck disease. Here the researchers examined cadaver  C6-7 segments: supraspinous/interspinous ligaments; ligamenta flavum; facet capsules, and facet joints. A robot-based testing system performed repeated flexibility testing of flexion-extension, axial rotation, and lateral bending.

What they found was:

• The ligamenta flavum is mechanically important in the cervical spine; its injury could negatively impact load distribution. Damage to the facets in a flexion injury could lead to axial rotation or lateral bending hypermobility. (Your vertebrae are moving out of place and could herniate or pinch the nerves or impact the spinal cord this can cause a myriad of symptoms).

Damaged ligaments in the facet joint capsule

Above I noted that the facet joint capsule, implicated in the injured posterior ligamentous complex is an area of connective tissue that covers and closes the facet joint (the joint that connects two vertebrae together and allows proper spinal movement).

In 2014 headed by Danielle R. Steilen-Matias, PA-C, our Caring Medical team published these findings in The Open Orthopaedics Journal. (3)

When the capsular ligaments are injured, they become elongated (stretched out) and exhibit laxity (as with anything that is stretched out, the ligaments have now become loose). Loose ligaments cause and allow 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.

Capsular ligament laxity can occur instantaneously as a single macro trauma, such as a whiplash injury, or can develop slowly as cumulative microtraumas, such as those from repetitive forward or bent head postures. In either case, the cause of injury occurs through similar mechanisms, leading to capsular ligament laxity and excess motion of the facet joints, which often results in cervical instability.

So how does this impact you? A case history of a 47-year-old woman – headaches, chronic pain in the neck and upper limbs, and intermittent tingling in one arm. Treated with simple dextrose injections.

We published a case history in the Journal of Prolotherapy (4) of a 47-year-old woman. Her symptoms were headaches, chronic pain in the neck and upper limbs, and intermittent tingling in one arm. Her pain was made much worse when she moved her head. She had crunching and cracking sounds coming from the C0 – C2, and severe spasms and tenderness in the trapezius and paraspinal muscles.

The patient was treated with dextrose Prolotherapy at each of four visits over five months. Prolotherapy is a simple injection technique. We have documented its success in helping patients with cervical spine instability in the research articles listed below. A detailed explanation of Prolotherapy is given following the patient’s case history:

Case history notes:

• A 47-year-old female came into our clinic with a history of neck pain.
• The patient had been in two motor vehicle accidents (five years apart), in each of which she was rear-ended.
• The patient’s medical history included unsuccessful treatments or pain relief with NSAIDs, muscle relaxants, and physical therapy. Symptoms included pain in the upper limbs, headaches, muscle tenderness and spasm, sub-occipital pain and clicking, and intermittent tingling down her right arm. The pain was exacerbated by head movement.
• The patient also reported a decreased range of neck motion.
• Physical exam revealed straightening of cervical lordosis, decreased range of motion for extension, lateral flexion and rotation (bilaterally), crepitation at C0 – C2, and severe spasms and tenderness in the trapezius and paraspinal muscles. Muscle tenderness was most significant in the C0-C2 area. The sensorimotor exam was normal bilaterally.

Recommendations are given to the patient:

• The patient was given advice regarding posture and told to avoid high-velocity manipulation, self-manipulation, neck stretching exercises, and motions that cause crepitation or clicking.

Prolotherapy treatment

We will use this video to help you understand the 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.

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

In the case history we are exploring in the 47-year-old woman:

• Dextrose Prolotherapy was administered in the upper and lower cervical region at the initial visit, and three further treatments were provided 1, 2, and 4 months later (visits 2 – 4).
• Between visits 1 and 3, the patient also attended physical therapy sessions three times a week.
• Digital Motion X-ray (DMX – explained in the video below) was performed between visits 1 and 2. The DMX showed straightening of cervical lordosis and instability throughout the upper and lower cervical spine.
• At visit 2, the patient reported that tingling in the arm had abated and her neck crepitation had noticeably decreased (especially with neck rotation), but there was little change in pain intensity.
• At visit 3, she reported that she no longer had headaches. The pain had become more localized to the left side, particularly on a rapid rotation of the neck.
• At visit 4, the patient reported that pain intensity had decreased significantly, and there was now only an intermittent sensation of pressure in the upper cervical region. Crepitation had resolved completely and she had begun to exercise with a stationary bicycle. The patient expressed satisfaction with her progress (“95% improvement”).

In this video, DMX displays Prolotherapy before and after treatments that resolved problems of a pinched nerve in the cervical spine

• 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

In this video and explanatory notes, Ross Hauser, MD explains the various unresolved symptoms that you may be suffering from that can be traced to upper cervical spine instability. This is a good overview of our treatment program. Use this contact form with questions.

Treatment of Upper Cervical Instability with Prolotherapy

Ross Hauser, MD at Caring Medical Florida.  Notes of this video are below with time marks.

• For about 30 years I have been successfully treating upper cervical instability with Prolotherapy.

Tension on the spinal cord

(1:26 of video)

When a person has cervical instability, specifically upper cervical instability, there is a greater tension on the spinal cord. The spinal cord can pull on the brainstem. This pull or traction can cause all kinds of problems within the relay centers that are in the brainstem.

• For instance, the nausea center is in the brain stem, cervical instability may cause you to feel nauseated all the time.
• The brain stem is where blood pressure control and heart rate center are. Someone who has arrhythmias and nobody knows the cause of it can be from cervical instability. Please see our article – Heart Rate Variability.

The vertebral artery runs in the transverse foramen of the cervical vertebrae. If the cervical vertebrae are moving too much you can get compression of the artery that supplies about 1/3 of the brain with its blood.

Loss of blood flow to the brain

(At 2:22 of the video)

• Vertebrobasilar insufficiency – Drop Attacks, Bow Hunter Syndrome: The vertebral artery runs in the transverse foramen of the cervical vertebrae. If the cervical vertebrae are moving too much you can get compression of the artery that supplies about 1/3 of the blood to the brain.

Intracranial pressure (At 3:05 of the video)

• Upper cervical instability can also obstruct cerebral spinal fluid flow, increasing Intracranial pressure. There are a lot of people who constantly feel pressure in their heads. If you’re one of those people you may have upper cervical instability.

Vision problems

• When Intracranial pressure is increased you can get changes in your vision, you can get double vision or you can get graying of the vision. You can even see an image and you look away and you still see that image. There are all kinds of vision problems that are from upper cervical instability.

Trigeminal nerve and trigeminal neuralgia (4:45 of the video)

It is well known in neurology, that trigeminal neuralgia and even migraine headaches are because of irritation of the trigeminal nerve. It turns out that the cervical trigeminal nucleus in the spinal cord goes all the way down to C3 so upper cervical instability can affect this nucleus which can give you facial pain can give you trigeminal neuralgia can give you Cervical dystonia and spasmodic torticollis all kinds of cranial nerve symptoms.

Treating and repairing cervical instability with Prolotherapy: research papers

• Chronic Neck Pain: Making the Connection Between Capsular Ligament Laxity and Cervical Instability
  • This paper was published in the European Journal of Preventive Medicine
  • 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;8:326-345. [Google Scholar]
• The Biology of Prolotherapy and Its Application in Clinical Cervical Spine Instability and Chronic Neck Pain: A Retrospective Study
  • This paper was published in the European Journal of Preventive Medicine
  • Ross Hauser, MD, Steilen-Matias 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. 2015;3(4):85-102. [Google Scholar]
• Non-Operative Treatment of Cervical Radiculopathy: A Three-Part Article from the Approach of a Physiatrist, Chiropractor, and Physical Therapists
  • This paper was published in the Journal of Prolotherapy
  • Ross Hauser, MD, Batson G, Ferrigno C. Non-operative treatment of cervical radiculopathy: a three-part article from the approach of a physiatrist, chiropractor, and physical therapists. Journal of Prolotherapy. 2009;1(4):217-231.
• Dextrose Prolotherapy for Unresolved Neck Pain
  • This paper was published in Practical Pain Management
  • Hauser R, Hauser M, Blakemore K. Dextrose Prolotherapy for unresolved neck pain. Practical Pain Management. 2007;7(8):58-69.
• Cervical Instability as a Cause of Barré-Liéou Syndrome and Definitive Treatment with Prolotherapy: A Case Series
  • This paper was published in the European Journal of Preventive Medicine
  • Hauser R, Steilen-Matias D, Sprague IS. Cervical instability as a cause of Barré-Liéou syndrome and definitive treatment with prolotherapy: a case series. European Journal of Preventive Medicine. 2015;3(5):155-166. [Google Scholar]

If you have questions and would like to discuss your cervical spine issues with our staff you can get help and information from us.

1 Beauséjour MH, Petit Y, Hagen J, Arnoux PJ, Thiong JM, Wagnac E. Contribution of injured posterior ligamentous complex and intervertebral disc on post-traumatic instability at the cervical spine [published online ahead of print, 2020 May 28]. Comput Methods Biomech Biomed Engin. 2020;1-12. doi:10.1080/10255842.2020.1767776 [Google Scholar]
2 Hartman RA, Tisherman RE, Wang C, Bell KM, Lee JY, Sowa GA, Kang JD. The mechanical role of the posterior column components in the cervical spine. European Spine Journal. 2016 Jul 1;25(7):2129-38.[Google Scholar]
3 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]
4. Hauser R, Steilen-Matias D, Fisher P. Upper cervical instability of traumatic origin treated with dextrose prolotherapy: a case report. Journal of Prolotherapy. 2015;7:e932-e935.

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