Unraveling Cervical Instability: Symptoms, Causes, and Solutions | E8

In this episode Dr. Ayla Wolf dives deep into cervical instability, a condition that often gets overlooked but can have significant effects on daily life. Understanding its symptoms, diagnostic challenges, and treatment options can empower listeners to seek the help they need.

• Explanation of cervical instability and its causes, highlighting four types of cervical instability 
• Discussion of the wide range of symptoms associated with cervical instability, including neurological effects 
• Overview of diagnostic testing processes, including advanced imaging techniques 
• Examination of treatment options, including physical therapy, prolotherapy and platelet injections
• Emphasis on the importance of neck strengthening and postural awareness 
• Call to action for listeners to learn more and take care of their neck health

Blog Post: Upper Cervical Instability After Head Trauma: https://www.lifeafterimpact.com/post/upper-cervical-instability-following-head-trauma

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Chapters

• 0:00 Introduction to Cervical Instability
• 46:28 Symptoms of Cervical Instability
• 1:56:02 Diagnostic Testing for Cervical Instability
• 7:31:54 Treatment Options Available
• 17:01:30 The Importance of Neck Strengthening
• 22:46:55 Key Takeaways and Looking Forward

Transcript

Ayla Wolf: 0:00

A forward shifted C1 vertebrae can place strain on the surrounding structures, leading to chronic symptoms. And this fourth category is actually the one that I think is going to be the cause of a lot more incidence of ligament laxity and upper cervical instability here in the future, given the fact that, as a society, so many people are spending much of the day looking down and with a forward head posture as they're staring at laptops and tablets and phones.

Sophia Bouwens: 0:37

Welcome to the Life After Impact podcast, where we do a deep dive into all things concussion and brain injury related. We talk about all the different symptoms that can follow a brain injury, different testing methods, different types of specialists out there and different therapies available. I'm Sophia Bowens, I'm here with Dr Ayla Wolf and we will be your guide to living your best life after impact be your guide to living your best life after impact.

Ayla Wolf: 1:13

Welcome to Episode 8 of Life After Impact, the concussion recovery podcast, where we break down complex topics relevant to people suffering from post-concussion syndrome. I'm Dr Ayla Wolf, and today we're diving deep into a condition that often flies under the radar but can have profound effects on people's lives. We are talking about cervical instability, and particularly upper cervical instability, because trauma to the head and neck can cause cervical instability. This is a particularly important topic for our listeners. If you've ever experienced chronic neck pain, dizziness, occipital headaches and otherwise unexplained neurological symptoms, then this episode might be worth listening to for you. We'll explore what cervical instability is, why it happens, what symptoms it causes, types of specialized diagnostics that exist and what treatment options are available, and then also talk a little bit about why this condition is likely going to be more common than it has been in the past. So let's get started. So what is cervical instability? Cervical instability occurs when the ligaments in the neck fail to properly support the cervical spine, leading to excessive movement between the vertebrae. This instability can put stress on the spinal cord, the nerves and the blood vessels, causing a pretty wide variety of potential neurological as well as musculoskeletal symptoms. There was a really great study that was published where they discussed four basic or distinct patterns of cervical instability that they came up with based off of the data on 8,000 digital motion x-rays and if you're not familiar with what a digital motion x-ray is, we will talk about that here in a minute when we get into diagnostics. But I think that this categorization of these patterns is extremely helpful. The first category they described is severe generalized instability, and this is often due to some kind of underlying hypermobility disorder, like Ehlers-Danlos syndrome, for example, and it is much more common in females and can lead to widespread joint instability, including the cervical spine. So this is not a case of just an upper cervical instability. This is where the joint instability can affect any joint, including the upper cervical spine as well as the lower cervical spine.

Ayla Wolf: 3:48

Then the second category is instability around a fusion site, and this can occur either above or below a surgical fusion or a degenerative fusion. So at times when there is degenerative disc disease, you can actually have a natural fusion of vertebrae, and when one part of the spine becomes very rigid, what this can lead to is excessive movement in the areas either above or below the area that's fused. Now I have my L3 and L4 vertebrae fused due to a bad snowboarding accident and even my neurosurgeon at the time said after my surgery that it was going to be very important for me to do yoga for the rest of my life, essentially to maintain as much mobility throughout my entire spine as possible so that I don't put excessive amounts of stress on the joints immediately above and below that fusion. So I thought it was pretty cool when a neurosurgeon is telling me to do yoga and it just points to this concept around the fact that when one part of the spine is fused it is going to completely change the dynamics of the rest of the spine and potentially put excessive stress on certain joints and certain discs. So what? This is the second category.

Ayla Wolf: 5:08

The third category is severe upper cervical instability due to trauma like a concussion or a brain injury. So traumatic events such as car accidents, whiplash injuries, head trauma all of these can result in ligament laxity, and particularly in the atlantooccipital joint, which is right where the skull meets the spine, and then the C1-C2 joint. So that is the third group. The fourth group is a loss of normal cervical curvature and anterior positioning of C1, that first cervical vertebrae, the natural curve of the neck is crucial for stability. The neck essentially acts like a spring wire that provides cushioning to the head and the normal curvature is essential for that action. A forward shifted C1 vertebrae can place strain on the surrounding structures, leading to chronic symptoms. Strain on the surrounding structures leading to chronic symptoms and this fourth category is actually the one that I think is going to be the cause of a lot more incidence of ligament laxity and upper cervical instability here in the future, given the fact that, as a society, so many people are spending much of the day looking down and with a forward head posture as they're staring at laptops and tablets and phones, especially all of these young kids who have all of their parents constantly yelling at them to correct their posture.

Ayla Wolf: 6:47

So one of the reasons why I wanted to do a podcast episode specifically on cervical instability is for this very reason that more and more people are losing their normal cervical curvature and in some cases, when they have this anterior shift of that first cervical vertebrae, it can actually put pressure on the carotid sheath in the neck, which is where we have our vagus nerve and our jugular vein, and in doing so, this can actually affect blood flow to the brain and it can affect vagal nerve function, which has all kinds of consequences as a downstream effect, and we'll get into a lot of the possible neurological symptoms that can arise from cervical instability. But this is something that is important to be aware of. Just a few weeks ago I was actually visiting one of my local chiropractors and when I brought up the topic of a loss of cervical curvature, his response was that about 85% of his patients have a loss of cervical curvature and at this point that was almost becoming so normal for him. And I think that just goes to show you just how common this loss of cervical curvature has become as a result of what we do all day long as far as working in front of computer screens and, like I I said, on laptops and looking at phones, and the fact that we are always looking down. And while this may be common, that doesn't necessarily mean that it's normal or that it's okay, and in some cases it can really actually lead to a lot of problems. So let's talk about the symptoms of cervical instability.

Ayla Wolf: 8:30

People with cervical instability often report a wide range of symptoms, many of which are neurological. People can have chronic headaches or a chronic sense of head pressure and that is often located in the back of the head. They definitely complain of neck pain and at times it can be quite debilitating. Definitely complain of neck pain and at times it can be quite debilitating. People can actually have facial pain or a pulling sensation within parts of their face or even their mouth. They can have tingling or numbness in the face or the side of the head or the scalp. They often complain of dizziness, lightheadedness or possibly vertigo, and then they can experience difficulty swallowing or choking. People can have changes in voice strength. They can experience nausea, as well as visual disturbances, things like blurry vision, tunnel vision or even visual auras, and that's usually in much more severe cases of cervical instability and specifically upper cervical instability.

Ayla Wolf: 9:35

Other more severe symptoms can include even sleep apnea, which can be caused by compression on brainstem structures that affect those nerves and nuclei that regulate breathing. And the instability can also cause altered positioning of the airway and dysfunction of the muscles involved in breathing, leading to airway obstruction during sleep. There can even be cognitive symptoms due to alterations in blood flow to the brain and then hearing changes. Cervical instability can affect blood flow to the nerves. The cochlear and vestibular nerves need the correct blood flow to function and if you have compression of the nerves or compromised blood flow to those nerves, then this can actually lead to tinnitus, hearing loss or a sensation of fullness in the ear. So dysfunction of the upper cervical spine can actually alter functions of the eustachian tube and that can lead to that type of ear pressure and then difficulty with sound modulation. So, as you can imagine, these types of neurological symptoms that cause changes in brain function and cognitive functions hearing, breathing these are usually seen primarily in these more severe cases of upper cervical instability.

Ayla Wolf: 12:01

As you can imagine, if people are suffering from so many different neurological symptoms, those symptoms could easily be misdiagnosed as many other things, whether that is migraines or vestibular disorders and even anxiety. Sometimes people are, you know, their symptoms are kind of swept under the rug or not considered serious, and so they are just labeled as having anxiety, and this can lead to a lot of frustration and obviously a delay in proper treatment when there isn't a proper diagnosis. So let's talk about diagnostic testing for cervical instability. Accurate diagnosis is crucial for identifying cervical instability and in determining the appropriate treatment. Here's the problem. However, healthcare as a whole is not on the same page when it comes to cervical instability, for some providers it is not even on their radar. For others, there may be a basic level of awareness of severe cases of instability from severe trauma or a generalized joint instability due to hypermobility disorders. It is actually not very easy to find experts in cervical instability, and this is why there's also confusion and disagreement around the methods in order to assess it. So when this type of disagreement and lack of standard protocols exists, the people who suffer the most are the patients who are just trying to get to the bottom of their symptoms, to understand what is going on and what can be done about it. So let's talk about some of the tests that do exist and then some of the treatment options I had mentioned earlier.

Ayla Wolf: 13:49

The digital motion x-ray, and this is a dynamic imaging technique that captures real-time movement of the cervical spine to identify instability. Unlike a typical x-ray, which is just one image, a digital motion x-ray, which is also sometimes called a dynamic motion x-ray, or DMX for short, is actually taking about 15 images per second, and so you can really get a much better sense. When you're taking that many images in rapid succession and with somebody moving their head into different positions, you can really capture the amount of movement that is happening of those vertebrae, and so, unlike any other device, these digital motion x-rays are actually very effective at capturing excessive amounts of movement of the cervical spine. The problem is not very many people have them, and so they are hard to find, or it's hard to locate a clinic that offers it.

Ayla Wolf: 14:51

The next option, which might be easier to find but still has some problems associated with it, is what's called a standing MRI. Well, oftentimes, if you are laying down for an MRI, you're not going to capture cervical instability. However, there are standing MRIs that are set up in order to be able to do that. The problem that I've seen with some of my patients that have had that is that the radiology report gets sent out and then, when it comes back, the doctors that ordered the MRI don't actually know how to interpret them. So a standing MRI can help to assess things like ligament laxity, any kind of spinal cord compression, and then there may also be the need to do some type of vertebral artery testing to assess blood flow in the vertebral basilar system, to see if there are any arteries that are being compressed as a result of these types of injuries. Other clinics may offer flexion extension x-rays, which are standard x-rays, but they're taken with different neck positions in an attempt to look at this excessive motion happening between the vertebrae.

Ayla Wolf: 16:05

Once cervical instability is diagnosed, and specifically upper cervical instability, in a very, very small percentage of cases that are highly severe they may actually require surgery, but in most instances what is recommended is a combination of physical therapy and neck strengthening in order to help strengthen the deep neck muscles that can compensate for the ligament laxity, and there are a lot of specialty devices out there specifically for neck strengthening, and so in this case, it would also be important to seek out a clinic whether it's a physical therapy clinic or a specific chiropractic clinic where they actually specialize in cervical instability and have the right types of equipment and neck strengthening devices that are useful for this type of treatment. And then there are specific types of chiropractic care that specialize in gentle adjustments to realign the upper cervical spine and improve stability. So not all chiropractic is the same. There are many, many different types of chiropractic care out there, different types of adjusting techniques, and so there are certain disciplines within the chiropractic profession that really focus on the upper cervical spine and are trained to address cervical instability, and then the other therapy that could be quite helpful is prolotherapy, and this can include either the injection of a dextrose solution or a person's own platelets, and this is called PRP, or platelet rich plasma and prolotherapy. The idea is that you are injecting a solution into the attachment sites for these ligaments, where they attach to the bone, and this creates a mild inflammatory response that stimulates fibroblast activity to increase the tensile strength of the ligaments and over time this can improve the load bearing capacity of these cervical ligaments to make the neck more stable. In some cases, if prolotherapy with saline isn't cutting it, the PRP is a little bit stronger and it's in effect, and how that is done is that your own blood is taken out of you, the platelets are spun in a centrifuge and then those platelets are injected back into these specific sites. So the PRP is a little bit more expensive than the prolotherapy, but it is a little bit stronger in its effects.

Ayla Wolf: 18:47

We've mentioned in past episodes the importance of neck strengthening for people that have had concussions, and I think it's important when it comes to the topic of just generalized cervical instability or loss of cervical curvature, of recovery, and the research has also suggested that it can be preventative of future concussions, especially for people in certain sports like soccer, for example, and so I think it's really important to be able to find some kind of provider whether that is a physical therapist or a chiropractor that has some specialty in neck strengthening and many of the exercises that are out there can easily be done at home, but it's important that you're doing them correctly. One of the reasons why I wanted to talk about cervical instability is because so much of the concussion research is done kind of in a vacuum, so to speak, where they're not talking about pre existing conditions, and the reality is that I have worked with many patients who have had more than one concussion. I've had people that have been in three or more car accidents, and so they actually have had three concussions and three different whiplash injuries that have caused ligament laxity. I've worked with people that have Ehlers-Danlos syndrome or people that have had lupus, for example, which can affect the joints and the connective tissue, that have then gone on to have concussions and develop a worsening of ligament laxity and cervical instability. And so part of this podcast is really emphasizing the fact that concussions don't occur in vacuums. They occur in people that often have pre existing issues that they're dealing with, and so it's important to recognize how some of these pre existing issues can actually set people up for a situation where they might develop a ligament laxity or a cervical instability that can drive even symptoms that mimic dysautonomia in terms of changes in, say, heart rate or heart rhythm or heart palpitations, the cognitive symptoms, the changes in hearing, the headaches, migraines, vertigo. There's a lot of symptoms that can come on if somebody has severe upper cervical instability, and the point of this whole podcast is trying to highlight all the different things that need to be tested and looked at so that people aren't spending years and years suffering without having the right tests or the most accurate diagnosis.

Ayla Wolf: 21:30

In many cases, cervical instability is complex, but it is treatable, and through a combination of things like prolotherapy or platelet injections, in conjunction with neck strengthening programs and postural restoration techniques, people can get relief from these symptoms. The most crucial thing is to seek out some type of specialist who has a deep understanding of this condition and can offer these types of specific treatments In general, I think it's also important for anybody who spends a lot of time with their head down and with a forward head posture as they are looking at phones or laptops to recognize the long-term impacts this can have on the cervical spine in terms of a loss of cervical curvature, and that over time that can lead to ligament laxity, which can cause problems in the future. So for anybody who is spending a lot of time with their head down and jutted forward, this is a good reminder to engage in some kind of neck strengthening program and to also work on stretching the neck and adjusting their posture as much as they can throughout the day. For more information on cervical instability, you can check out lifeafterimpactcom, and we have a recent blog post that talks about cervical instability, along with a list of the research papers that we referenced in the making of this episode. In upcoming episodes we will be diving into aspects of dysautonomia and bringing you interviews with different specialists in the field of concussion recovery.

Ayla Wolf: 23:19

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