Cervical instability: what to do when a cervical joint is unstable and has too much excursion?

Cervical instability is a condition characterised by the reduced ability of the cervical vertebrae to maintain their correct alignment, particularly under stress during neck movements. This instability can result in excessive movement of the vertebrae, causing pain, discomfort, and in severe cases, can impair nerve or spinal cord function.

Cervical spine instability and particularly atlanto-occipital and atlanto-axial instability, can be the result of various factors, including physical trauma such as whiplash or sports injuries, age-related degenerative processes, rheumatic diseases, neck surgery, or congenital conditions that affect the structure and function of the cervical vertebrae. Symptoms can vary from mild to severe and include neck pain, stiffness, restriction of movement, headaches, dizziness, cracking noises during neck movement, and in some cases, neurological symptoms such as tingling, weakness or altered sensation in the arms or legs.

The diagnosis of cervical instability requires a thorough evaluation that may include a physical examination, and imaging techniques such as radiography, magnetic resonance imaging, or computed tomography. These examinations assess the alignment of the vertebrae, the integrity of the ligaments and intervertebral discs, and the presence of any abnormalities or injuries.

In order to obtain an accurate diagnosis of cervical instability, it is crucial to acquire dynamic images, i.e. taking multiple shots while the head is positioned at various angles. This approach is essential; static images may not only be of limited use, but also potentially misleading, risking not revealing the actual instability. Furthermore, it is important to recognise that many radiologists may not have the experience or specific training required to adequately identify cervical spine instability, emphasising the need for specialised attention in this area.

Instability after a whiplash injury

Following a whiplash accident that has resulted in the stretching of the joint capsule and/or ligaments, the joint may show excessive laxity, i.e. the vertebrae involved may move more than normal relative to each other or the Atlas relative to the occiput, making the joint unstable during movement. This causes abnormal variable compression of the adjacent structures. Inappropriate cervical positions, maintained for a long time, can also induce adaptation and stretching of the ligaments and joint capsules.

This condition can be a contraindication to Atlas correction or at least impair the long-term results, as the vertebrae involved can easily return to an incorrect position.

In the following video you can see at minute 2:10 how during lateral flexion of the head, the spinous process of C2 rotates abnormally, while the Atlas tends to slide laterally, showing significant instability of the joint.

Joint instability is difficult to detect through static images. In other words, a single 'photograph' is not enough; rather, a 'video' taken during movement of the cervical spine is required. As a fallback, several static images captured in various positions of the joint can be taken. The examination shown in the video makes use of an X-ray machine called fluoroscopy or Digital Motion X-ray, which makes it possible to observe moving structures.

The insidiousness of joint tissue hyperlaxity

It is widely recognised that muscle strengthening helps to increase joint stability. However, in situations where tissues responsible for maintaining joint integrity, such as ligaments and capsules, do not provide adequate support, exercise may improperly stress the affected joints, further aggravating the condition. Therefore, when in doubt, it is crucial to thoroughly investigate whether there are unstable joints due to torn or excessively loose ligaments before starting with exercises.

Unfortunately, many radiologists are not adequately trained to accurately identify cervical instability, which requires the analysis of dynamic images or, alternatively, multiple static images obtained with the head in different positions, either by X-ray or MRI. As previously mentioned, joint instability is often not identifiable by single static images. If someone, relying solely on an image acquired in a single position of the head, were to diagnose cervical instability or, worse still, rule it out, it is crucial to recognise that there is a lack of competence.

Prolotherapy for joint instability

The term 'Prolotherapy' is derived from 'proliferation therapy', coined in the 1950s by Dr. George Hackett, an American orthopaedic surgeon.

Prolotherapy involves the infiltration of an irritant solution, such as dextrose, directly into the injured area in order to stimulate the tissue's natural self-healing process.

Dextrose triggers a local inflammatory response that induces a self-repair reaction with the formation of new connective tissue at the injection site. This process contributes to the reinforcement of damaged tissue, restoring joint stability and increasing the tensile strength of stabilising joint structures such as ligaments, tendons and joint capsules.

Prolotherapy is to be considered an effective, generally safe and side-effect-free method, which in many cases can avoid the need for surgery. If you suffer from general ligamentous laxity that cannot be traced back to an accident, then prolotherapy may be less effective, as the body produces little collagen and by inducing tissue inflammation, the production of new elastic tissue may be limited.

Collagen is an essential component for the strength and elasticity of connective tissues, and its adequate production is crucial for the repair and strengthening of ligaments. To increase collagen production, proper nutrient intake is crucial, and vitamin C plays a key role in this process. Vitamin C is not only a powerful antioxidant, but is also essential for collagen synthesis. For this reason, for those undergoing prolotherapy or wishing to improve the health of their connective tissues, it may be helpful to find out about the benefits of vitamin C and how to increase its intake through diet or supplements.

Prolotherapy, despite being a little-known treatment compared to other medical interventions such as surgery or the use of drugs, has gained attention for its effectiveness in treating certain musculoskeletal conditions, especially those related to ligament laxity. Its simplicity and relatively low cost may make it less visible in the landscape of more traditionally promoted treatment options, which often involve greater financial gains for the healthcare sector.

The use of ultrasound in prolotherapy offers a significant advantage by allowing the precise localisation of the treatment area. This non-invasive imaging method helps identify the exact spot for solution injection, increasing the effectiveness of treatment while reducing the risks associated with inaccurate injections. When performing prolotherapy on specific vertebrae such as the Atlas and Epistropheus, precision is crucial given the complexity and sensitivity of the cervical area.

Below is a video on how Prolotherapy on C1 is performed:

PICL: Percutaneous ligament implantation

The PICL procedure (Percutaneous Implantation of Cervical Ligaments) is an advanced, minimally invasive surgical technique focused on repairing damaged ligaments in the cervical region, particularly those that stabilise the joint between the occipital bone (C0), the Atlas (C1) and the Epistropheus (C2). This procedure is distinguished by its transoral approach, which allows direct access and treatment of the injured ligaments without the need for external fixators, which can significantly limit head mobility.

The PICL technique offers several advantages over traditional methods of cervical stabilisation, which often involve the use of bulky external devices and can lead to a long recovery period, as well as limiting the range of motion of the neck. With PICL, recovery tends to be faster and less painful, and the aim is to preserve or even improve the mobility of the cervical joint.

Due to its minimally invasive nature, PICL reduces the risk of infection and other post-operative complications associated with more invasive surgeries. It is important, however, that this procedure is performed by surgeons experienced in minimally invasive techniques and the management of cervical spine pathologies, as the cervical region is complex and requires extreme surgical precision to avoid damage to nerves or other vital structures.

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