Ross Hauser, MD discusses the problems of chronic neck pain and Cervical Neck Instability and the treatment options including Prolotherapy, Stem Cell Therapy, and Platelet Rich Plasma Therapy.
Cervical Neck Instability
In our practice, we continue to see a high number of patients with a myriad of symptoms related to cervical instability. The symptoms are usually extremely debilitating and the patient is often describes themselves at the “end of their rope.”
They have seen numerous physicians, tried a multitude of therapies, and experienced little to no improvement. A feeling of abandonment by the medical community is a common complaint.
Treating patients before neck fusion surgery
We like to see patients before the cervical neck fusion surgery when the problems of a failed surgery compound a pre-existing problem. Unfortunately we do not always see the patient first and see them after a cage, screws, and other fusion materials are already in place and the pain remains.
On diagnosis we see some pre-surgery patients with instability of their upper cervical spine, more specifically C1 and C2 (also known as the atlas (C1) and axis (C2). causing symptoms related to dizziness, cervical vertigo, ringing in the ears, headache, neck stiffness and neck instability and other challenges.
Why do medical practitioners rush to prescribe drugs for Cervical Neck Instability? Because of difficulty in diagnosing the problem and to try to delay surgery
Neck instability is a difficult problem to treat. The rush to utilize drug management stems from a desire to control symptoms. In the case of headache, because headache pain, duration, and frequency (cluster headaches) can be so severe, the first treatment most doctors will recommend is the medication treatment course.
According to research the most effective pharmacological treatment options for acute cluster attack include nasal or injection of sumatriptan, 100% oxygen, zolmitriptan, and Dihydroergotamine injection.
The above mentioned drugs are thought to work by reducing swelling of blood vessels around the brain and block the release of certain natural substances that cause pain.1
Understanding the symptoms, understanding the diagnosis
Physical therapists in Belgium wrote in the medical journal Manual Therapy, “Classifying nonspecific neck pain patients into subgroups based on clinical characteristics might lead to more comprehensive diagnoses and can guide effective management.” The subgroups were:
Articular: pain and motion restriction in extension (moving head side to side back and forth)
Myofascial: pain related to the muscles of the neck and shoulders
Neural: related to nerve and muscle pain
Central: related to possible narrowing of spinal canal
Sensorimotor control: Loss of physical function in the face and neck region.2
While these symptom classifications should be obvious signs of a patient in distress, the cause of the problems are not so obvious.
Cervical instability can be difficult to diagnose for the average practitioner. This is largely due to the low reliability and validity of radiographic studies including functional (motion) radiographs and many clinical examination measures that are still under debate and are rather questionable.
Unfortunately, there is often no correlation between the hypermobility or subluxation of the joint (excessive movement of the vertebrae), clinical signs or symptoms, or neurological signs or symptoms. Sometimes there are no symptoms at all which further broadens the already very wide spectrum of possible diagnoses for cervical instability.
In one study, “healthy” volunteers who experienced no neck pain or headaches had MRI’s that showed so many things wrong that the investigators had to conclude that the MRI had “limited diagnostic value in patients with whiplash-associated disorders.” 3
So without an MRI to guide treatment, it is back to the pharmaceuticals as the only treatment option to delay or keep the patient comfortable until a surgical date can be made. Please see our companion articles failed back surgery risk factors – the MRI, and is my MRI accurate?
Physical therapists typically use the following to diagnose cervical instability:
Intolerance to prolonged static postures
Fatigue and inability to hold head up
Better with external support, including hands or neck collar
Frequent need for self-manipulation
Feeling of instability, shaking, or lack of control
Frequent episodes of sharp, acute pain.
The problem of cervical radiculopathy – pinched nerves
The difficulty to diagnosis cervical neck pain origins can be seen in the discussion and myriad of symptoms circulating around the diagnosis of cervical radiculopathy.
Cervical radiculopathy is a condition of nerve function disturbance resulting from the compression of the nerve roots near the cervical vertebrae. This disturbance can damage the nerve roots in the cervical area and cause pain and loss of sensation in different parts of the upper extremities, depending on the location of the damaged roots.
Pain is the main symptom of cervical radiculopathy and is experienced spreading into the arm, neck, chest, upper back and shoulders. There may also be weakness, numbness, or tingling in these various areas. Sometimes there is a lack of coordination, especially in the hands.
Cervical radiculopathy is generally considered to result from pressure from a herniated disc, arthritis, or other injuries that increase pressure on these nerve roots. However, a 1998 study demonstrated that an exacerbation in radicular pain in patients with disc herniation and cervical arthritis was related more to provocative movements such as flexion, extension, and rotation, rather than to the size of the herniated disc.
A neural foramen is the opening that allows the passage of spinal nerve roots to exit the spine. These various motions changed the foraminal size, nerve root motion, and cervical cord rotation. When arthritis or stenosis was present, the increased radicular pain was also related to movement of the cervical spine as it narrowed the foraminal opening.4
If the changes in foraminal size with motion cause an exacerbation in cervical radicular pain, it would follow that any instability in the cervical spine would exacerbate the radicular pain as well, since instability causes even more motion in the joint. The foraminal size will change as an individual carries out their normal daily activities, bending and rotating the neck. During these activities the nerve root will get compressed intermittently as it exits the neural foramen. When the person assumes a different position, the nerve root contact may be relieved. In the study, movements such as flexion tended to relieve compression caused by stenosis, and extension tended to produce more symptoms.4
Positional narrowing of the foramina or degenerative issues leading to radicular pain is exacerbated by instability of the cervical spine.
In our experience, the instability of the spine is caused from injury to the cervical ligaments. Ligaments are connective structures that connect bone to bone and aid in the stabilization of the cervical vertebrae.
Surgical treatments for Cervical Instability: Screw Fixation – Cervical Fusion
In medicine there are universally accepted equations. When pain cannot be controlled using conservative treatments including physical therapy, chiropractic, and pain medications, there has to be a surgical recommendation.
In neck and spine surgery, doctors focus on giving the nerves room by removing or shaving down bone. Below you will see that it is not always the nerves but the cervical ligaments causing the problem and that ligament injection therapy such as Prolotherapy is a much less invasive way of treating the problem than cervical neck surgery.
As mentioned, when the patient no longer wishes to be on a pharmaceutical treatment plan for their headaches and subsequent cervical disc disease and neck problems, surgery, i.e., anterior cervical discectomy and fusion and cervical decompression surgery to remove whole or part of the cervical vertebrae to allow space on compressed nerves will be recommended.
Surgery is often aimed at fixing 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.
For example, if you fuse the C1 and C2 vertebrae together, extra motion is placed on the remaining vertebrae during normal neck movement, accelerating the degeneration process and further contributing to chronic neck pain.
The rush to surgery is based on the immediate goals of the patients, that is the alleviation of pain. Spinal cervical fusion and decompression seems to offer a solution – short term.
This is supported in the medical literature. In one study, patients with cervical radiculopathy, treated with surgery and physiotherapy resulted in a more rapid improvement in the patients during the first year after surgery, with significantly greater improvement in neck pain and global assessment scores compared to physiotherapy alone.
However the differences between the groups decreased after two years. In this paper where surgery was touted as being so successful – the researchers concluded: “Structured physiotherapy should be tried before surgery is chosen.”5 After two years, the same result between physical therapy and surgery was seen – no difference in outcome.
In a more detailed look at the above cited study, these doctors writing in the medical journal Spine looked at the factors affecting the outcome of surgical versus nonsurgical treatment of cervical radiculopathy.
They wanted to analyze factors that may influence the outcome of anterior cervical decompression and fusion (ACDF) followed by physiotherapy versus physiotherapy alone for treatment of patients with cervical radiculopathy.
They wrote that an understanding of patient-related factors affecting the outcome of cervical surgery is important for preoperative patient selection.
Sixty patients with cervical radiculopathy were randomized into two groups: One group had the surgery and the physiotherapy, one group had the physiotherapy alone.
The people who had the surgery had favorable outcome if
They had neck pain of 12 months or less
arm pain of 12 months or less
were women
high levels of anxiety due to neck/arm pain
The doctors report that there were no factors that positively influenced a favorable outcome in the physiotherapy alone group.5
This is why we see many patients who had a cervical spinal fusion include symptoms reflective of cervical adjacent segment pathology (CASP). This means that they are having pain from the cervical spine, above and below the original fusion. Some have recommended to them a revision surgery that includes more include fusion, laminoplasty and disc arthroplasty.
In a recent study, surgeons question whether the muscle attachments at C2 and C7 are important to keep in Laminoplasty, many think they reduce post-surgical pain, others think there is not enough evidence to “spare” the muscle attachments. 6
Recently, medical research warned doctors and patients that as surgeons began to increase their recommendations to cervical surgery, the number of failed procedures and the number of cervical neck surgeries would increase with it. 7
This is confirmed by the amount of new research studies on screw placement and fusion technique alternatives.
Because of the complex anatomy of the cranio-cervical junction, it remains challenging to insert atlantoaxial pedicle screw precisely and safely.8
In a discussion of using a cage or plate to stabilize the neck fusion surgery. Thirty-six (36) patients underwent fusion, 31 had “reasonable” outcomes, five failed.9
Cervical instability and Cervical Spondylosis
Cervical Spondylosis is an umbrella term used to describe degenerative changes in the cervical spine. It typically begins with repetitive actions “over use injury,” that results in sprains (ligament damage) and rotational strains or compressive forces to the spine. This causes injury to the cervical facet joints which in turn can jeopardize the natural function of the the cervical ligaments and cervical facet joint pain. Further degeneration can lead to abnormal motion in the cervical spine and cartilage break down.
In our own published research, we documented that the use of conventional modalities for chronic neck pain remains debatable, most treatments have had limited success and despite providing temporary relief of symptoms, these treatments do not address the specific problems of healing and are not likely to offer long-term cures.10
In this research, our team led by Danielle Steilen-Matias, MMS, PA-C, noted that the 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 and whiplash associated disorder,
post-concussion syndrome,
vertebrobasilar insufficiency,
and Barré-Liéou syndrome.
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.
We concluded that in many cases of chronic neck pain, the cause may be underlying joint instability and 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.
In our clinical and research observations, we have documented that Prolotherapy can offer answers for sufferers of cervical instability, as it treats the problem at its source. Prolotherapy to the various structures of the neck eliminates the instability and the sympathetic symptoms.
Medical research validating the use of Prolotherapy, from simple dextrose injections to stem cell injections is not new. There is almost 55 years of research supporting the use of Prolotherapy for problems of the neck and head.11
Published Case History Neck Pain in a 47 year old woman
Our own and independent research also confirms research on the effectiveness of Prolotherapy in cases of whiplash.12,13 Caring Medical doctors and medical staff found that conventional therapy for unresolved neck pain such as pain killers, non-steroidal anti-inflammatory drugs, anti-depressant medications, epidural or other steroid shots, trigger point injections, surgical treatments that range from disc replacements to fusions, the results of such therapies often left the patients with residual pain.
Here is a summary account of a case study we published in the Journal of Prolotherapy:
The patient is a 47 year-old-woman first treated in 2013. She had been in two car accidents, one in 2008 and one in 2013, both times rear ended. Because of symptoms the patients was treated with NSAIDS, muscle relaxants and physical therapy with unsatisfactory results.
Patient Symptoms
Pain in the upper limbs,
headaches,
muscle tenderness and spasm,
chronic pain in the neck and clicking,
and intermittent tingling down her right arm.
Pain was exacerbated by head movement.
The patient also reported decreased range of neck motion.
Physical exam revealed:
straightening of cervical lordosis (curve in cervical spine),
a 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 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.
Dextrose prolotherapy was administered in the upper and lower cervical region at 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) was performed between visits 1 and 2. The DMX showed straightening of cervical lordosis and instability throughout the upper and lower cervical spine. Findings were indicative of capsular ligament damage at C1-C2. There was also significant anterolisthesis of C2 on C3 and of C3 on C4. Capsular ligament damage at C6-C7 was indicated by gapping of those facet joints. Facet hypertrophy was evident at right C4-C5
Second treatment
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.
Third treatment
At visit 3, she reported that she no longer had headaches. Pain had become more localized to the left side, particularly on rapid rotation of the neck.
Fourth treatment
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”).
Follow-up DMX
Straightening of lordosis was still evident, but the offsets of the right and left lateral masses of C1 on C2 (during left and right rotation, respectively), were each reduced to 20%, representing a 33 – 50% decrease from initial values.
In absolute terms, atlas lateral shift decreased to 1.12 mm during left lateral bending (as compared to original measurement of 1.85 mm) and to 0.36 mm during right lateral bending (as compared to 0.72 mm). Measurements were performed by Spinal Kinetics. Some anterolisthesis was still noted at C2–C3 and C3-C4. Facet hypertrophy at C4-C5 was unchanged.
This case study is the first report describing dextrose prolotherapy and longitudinal imaging in a case of chronic neck pain with clinically and radiographically confirmed instability in the upper cervical region.
During the treatment course, the patient experienced progressive symptomatic relief, which began at one month of treatment and included at least partial alleviation of all reported symptoms. The patient showed functional gain, returning to exercise within four months. No adverse effect was observed. At five months after initiation of treatment, a 33 – 50 percent reduction in atlantoaxial offset was observed, providing evidence for improvement in stability.
It is not common practice to obtain follow-up imaging in cases where patient symptoms are successfully diminished with therapy. The radiologic improvement observed in this case, in the context of a treatment course potentially promoting ligamentous repair, is consistent with a pathogenetic linkage of ligament injury to traumatic chronic neck pain in the setting of upper cervical instability. Our findings are consistent with previous observational studies of prolotherapeutic treatment of cervical injury.
Research on 21 patients with cervical instability and chronic neck pain
In our research published in the European Journal of Preventive Medicine we presented the following findings:
Ninety-five percent of patients reported that Prolotherapy met their expectations in regards 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, indicating the safety and viability of Prolotherapy for cervical spine instability.
Full article and reference:
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.20150304.11
The key to avoiding cervical spine surgery for instability, headaches, or radiating pain, is preventing the surgery and choosing conservative treatments. In our opinion Comprehensive Prolotherapy including the use of Platelet Rich Plasma Prolotherapy, Stem Cell Therapy, and Dextrose Prolotherapy with and without other growth factors offers a realistic chance to avoid surgery by strengthening the supportive ligaments and tendons of the cervical spine region, stabilizing the area and preventing further deterioration.
References
1. Becker WJ. Cluster Headache: Conventional Pharmacological Management. Headache. 2013 Jun 14. doi: 10.1111/head.12145. [Epub ahead of print]
2. Dewitte V, Peersman W, Danneels L, Bouche K, Roets A, Cagnie B. Subjective and clinical assessment criteria suggestive for five clinical patterns discernible in nonspecific neck pain patients. A Delphi-survey of clinical experts. Man Ther. 2016 Jul 21;26:87-96. doi: 10.1016/j.math.2016.07.005. [Epub ahead of print]
3. Lummel N, Bitterling H, Kloetzer A, Zeif C, Brückmann H, Linn J. Value of “functional” magnetic resonance imaging in the diagnosis of ligamentous affection at the craniovertebral junction. Eur J Radiol. 2012 Nov;81(11):3435-40. doi: 10.1016/j.ejrad.2012.04.036. Epub 2012 Jul 2
4. Muhle C, Bischoff L, Weinert D, et al. Exacerbated Pain in Cervical Radiculopathy at Axial Rotation, Flexion, Extension, and Coupled Motions of the Cervical Spine. Investigative radiology, 1998;33(5): 279-288.
5. Engquist M, Löfgren H, Oberg B. Surgery Versus Non-Surgical Treatment for Cervical Radiculopathy: A prospective, randomized study comparing surgery plus physiotherapy with physiotherapy alone with a two year follow-up. Spine (Phila Pa 1976). 2013 Jun 17. [Epub ahead of print]
6. Riew KD, Raich AL, Dettori JR, Heller JG. Neck Pain Following Cervical Laminoplasty: Does Preservation of the C2 Muscle Attachments and/or C7 Matter? Evid Based Spine Care J. 2013 Apr;4(1):42-53.
7. Helgeson MD, Albert TJ. Surgery for Failed Cervical Spine Reconstruction. Spine (Phila Pa 1976). 2011 Nov 8.
8. Jiang L, Dong L, Tan M, Yang F, Yi P, Tang X. Accuracy assessment of atlantoaxial pedicle screws assisted by a novel drill guide template. Arch Orthop Trauma Surg. 2016 Nov;136(11):1483-1490.
9. Seo DK, Kim MK, Choi SJ, Sohn JY, Kim YK, Jeong EK, Ha JK, Kim CH, Park JH. Can an Anchored Cage be Substituted for an Anterior Cervical Plate and Screw for Single-Level Anterior Cervical Fusion Surgery?: Prediction of Poor Candidates Through a Review of Early Clinical and Radiologic Outcomes. Clin Spine Surg. 2016 Oct 19.
10. Steilen D, Hauser R, Woldin B, Sawyer S. Chronic neck pain: making the connection between capsular ligament laxity and cervical instability. Open Orthop J. 2014 Oct 1;8:326-45. doi: 10.2174/1874325001408010326. eCollection 2014.
11. Hackett, et al. Prolotherapy for headache. Pain in the head and neck, and neuritis. Headache. 1962 Apr;2:20-8.
12. Hooper RA, Frizzell JB, Faris P. Case series on chronic whiplash related neck pain treated with intraarticular zygapophysial joint regeneration injection therapy.Pain Physician. 2007 Mar;10(2):313-8.
13. Hauser R, Hauser M. Dextrose Prolotherapy for Unresolved Neck Pain, Practical Pain Management, October 2007