In this article we will examine our published research findings and the latest in medical research concerning atlantoaxial instability and the myriad of symptoms and challenges it creates for patients.
Atlantoaxial instability can be caused by many factors. Trauma injury, congenital defects (defects from birth), and arthritis. The focus of this article will mainly concentrate on cervical ligament injury and the instability this injury causes.
Atlantoaxial instability is the abnormal, excessive movement of the joint between the atlas (C1) and axis (C2). This junction is a unique junction in the cervical spine as the C1 and C2 are not shaped like cervical vertebrae. They are more flattened so as to serve as a platform to hold the head up. This bundle of ligaments are string bands that provide strength and stability while allowing the flexibility of head movement and to allow unimpeded access of blood vessels that travel through them to the brain.
Understanding how the Atlas and its ligaments support your head and how damage to those ligaments cause the symptoms of neck pain, limited head and neck motion, and possibly sensory issues.
To the left, we have a picture of the Greek mythological titan Atlas. Atlas was ordered by the king of the Greek gods Zeus, to hold the sky in the heavens (later the earth in the heavens as depicted in art). The C1 vertebrae is therefore aptly named the Atlas as it holds the weight of your head as Atlas in mythology holds “the weight of the world.”
A little bit of pretending helps us understand the role of cervical ligaments in Atlantoaxial instability and how the weight of the world can damage our neck.
- Let’s pretend the globe in the picture to the left is your head.
- Atlas’s shoulders and torso are the C1 vertebrae
- If we pretend that his arms are the cervical ligaments that hold the globe in place on his shoulders and his legs are the cervical ligaments that hold him to the ground, we can see how damage to the arms and legs can make the earth (your head) fall and tilt and create the health challenges typical of Atlantoaxial instability. The ground we will pretend is the the C2 axis vertebrae that the C1 atlas stands on.
If Atlas’s right arm is injured, the weight of the world will fall on the left hand. With this extra burden and stress, the left arm will eventually suffer fatigue, wear and tear, and weaken. With both arms injured and weakened the earth will wobble between the right and left arm.
If Atlas’s right leg is injured, he will shift his weight to his left leg. The earth will tilt towards his left leg. With this extra burden and stress, the left leg and left arm will eventually be injured. Atlas himself will wobble.
To fix Atlas’s problems, you need to fix his cervical ligaments his supporting structures, in our pretend example the cervical ligaments are his arms and legs. Then he can hold the earth, your head, in place.
To fix your Atlantoaxial instability, you need to fix your cervical ligaments.
When ligaments are ignored, Occipitoaxial fusion becomes the treatment
Fixing the ligaments is usually not the first choice among more traditional doctors. Fusion surgery is. In the above picture, if we cemented Atlas’s feet to the ground do you think his knees and hips would suffer? When your C1-C2 cervical vertebrae are fused to limit atlantoaxial instability and related symptoms, the force and energy in your neck movements are going to be transferred to those vertebrae below the fusion. In many patients all this accomplishes is a transfer the problems of atlantoaxial instability to the lower cervical vertebrae.
The following research highlights these problems:
In a new study (July 2018) published in the Archives of orthopaedic and trauma surgery examined occipitoaxial fusion for atlantoaxial instability in non-rheumatoid arthritis.
Study findings: More than 1/3rd patients had complications after occipitoaxial fusion for atlantoaxial instability
- 41 patients underwent occipitoaxial fusion for atlantoaxial instability.
- Fifteen patients with postoperative adjacent segment disease. (Complications of pain and mobility)
- Twenty-six patients without postoperative adjacent segment disease.
- Fifteen patients with postoperative adjacent segment disease had high incidence of subaxial subluxation (displacement of the vertebrae below the fusion) and swan neck deformity (extreme, unnatural curvature in the neck) (1)
This type of surgery, with its high complication rate and similar procedures may not even be necessary.
Cervical spine ligament weakness is why many cervical neck pain patients do not have successful surgery.
Doctors at University of Waterloo in Canada published research in the Spine Journal (2) where they were attempting to define a new clinical scoring system for patients with cervical neck instability. The scoring system would help identify the role of cervical ligaments in difficult to treat neck pain and instability.
This is what came out of this research:
- “Predicting physiological (normal) range of motion (ROM) using a finite element (FE) model (a numeric scoring system) of the upper cervical spine requires the incorporation of ligament laxity.”
- Our comment: The doctors understand that ligament laxity is a problem of stability and range of motion in the neck.
- The effect of ligament laxity can be observed only on a macro level of joint motion and is lost once ligaments have been dissected and preconditioned for experimental testing.
- Our comment: It is hard on any level to accurately determine the amount of ligament damage to the amount of instability because even small injuries or damage, sometimes undetectable, cause big problems.
- As a result, although ligament laxity values are recognized to exist, specific values are not directly available in the literature for use in finite element models.
- Our comment: Ligament laxity is a mystery and why cervical neck pain patients have a difficult time finding the right medical care.
Surgery, unless a life threatening or extreme situation, should never be considered until the problems of the cervical ligaments are addressed.
Cervical ligament injury should be more widely viewed as a key, if not THE key, to chronic neck pain
In a 2015 paper appearing in the Journal of Prolotherapy, researchers wrote that cervical ligament injury should be more widely viewed as a key, if not THE key, to chronic neck pain. In our opinion, in many patients, cervical ligament injury is underlying pathophysiology (the cause of) atlantoaxial instability and the primary cause of cervical myelopathy (disease).(3)
This was a continuation in the series of published research Caring Medical Regenerative Medicine Clinics is producing on the problems of cervical instability including the 2014 article Chronic Neck Pain: Making the Connection Between Capsular Ligament Laxity and Cervical Instability lead by Danielle Steilen.(4)
In the upper cervical spine (C0-C2), this can cause a number of other symptoms including, but not limited to, nerve irritation and vertebrobasilar insufficiency with associated cervical vertigo, dizziness, tinnitus, facial pain, arm pain, and migraine headaches.
In June 2017, German researchers publishing in Zeitschrift für Orthopädie und Unfallchirurgie (Journal of Orthopedics and Trauma Surgery) also saw the connection of damaged cervical ligaments and chronic neck problems. Here is what they wrote:
- The odontoid process (the protruding bony process of the C2 (Axis)) and the transverse ligament are the most important structures stabilising the atlantoaxial complex.
- There is not a clear understanding how injuries of these structures contribute towards neck instability and a potential narrowing of the spinal canal.
The German team set out to investigate in human cadaver studies, fracture and displacement of the odontoid process and ruptures and tears of the transverse ligament. After examination and compilation of date, the researchers conclused:
- “Our results demonstrate that a relevant constriction of the spinal canal may be due to isolated or combined injuries of the bone and the transverse ligament. Furthermore, our results show the importance of posttraumatic immobilization of the spine with a view to the role of the transverse ligament for stabilization of the atlantoaxial complex.”(5) (Neck collars and other devices).
Prolotherapy injections for Atlantoaxial instability
In 2015, Caring Medical and Rehabilitation Services published findings in the European Journal of Preventive Medicine investigating the role of Prolotherapy in the reduction of pain and symptoms associated with increased cervical intervertebral motion, structural deformity and irritation of nerve roots.
Twenty-one study participants were selected from patients seen for the primary complaint of neck pain. Following a series of Prolotherapy injections patient reported assessments were measured using questionnaire data, including range of motion (ROM), crunching, stiffness, pain level, numbness, and exercise ability, between 1 and 39 months post-treatment (average = 24 months).
- 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.
The study concluded that statistically significant reductions in pain and functionality, indicating the safety and viability of Prolotherapy for cervical spine instability.(6)
References for this article
1 Wu X, Qi Y, Tan M, Yi P, Yang F, Tang X, Hao Q. Incidence and risk factors for adjacent segment degeneration following occipitoaxial fusion for atlantoaxial instability in non-rheumatoid arthritis. Archives of orthopaedic and trauma surgery. 2018 Jul 1;138(7):921-7. [Google Scholar]
2 Lasswell TL, Cronin DS, Medley JB, Rasoulinejad P. Incorporating ligament laxity in a finite element model for the upper cervical spine. The Spine Journal. 2017 Jun 30. [Google Scholar]
3 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.
4 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]
5 Meyer C, Bredow J, Heising E, Eysel P, Müller L, Stein G. Influence of Osseous and Ligamentous Injuries on the Stability of the Atlantoaxial Complex. Zeitschrift fur Orthopadie und Unfallchirurgie. 2017 Jun;155(3):318. [Google Scholar]
6 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