Atlantoaxial instability and the myriad of symptoms and challenges it creates for patients

Danielle R. Steilen, PA-C,, Ross Hauser, MD

In this article we will examine our published research findings in 2014 and 2015 and the latest in medical research  with two 2017 studies concerning atlantoaxial instability and the myriad of symptoms and challenges it creates for patients.

In a 2015 paper appearing in the Journal of Prolotherapy, we along with my co-writer Paul Fisher, 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 and dying vertebrae and cervical discs).(1)

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.(2)

In that research, our team suggested that the cervical capsular ligaments are the main stabilizing structures of the facet joints in the cervical spine and that they are a major source of chronic neck pain. The instability these injuries create often reflects a state of instability in the cervical spine and is a symptom common to a number of conditions including disc herniation, cervical spondylosis, whiplash injury and whiplash associated disorder, postconcussion syndrome, vertebrobasilar insufficiency, and Barré-Liéou syndrome.

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.2

Atlantoaxial instability

However, this hypothesis of ligaments being the underlying cause of chronic neck instability has little support in the medical community with respect to data correlating patient status with either repair-promoting treatments or documentation of regained stability. As we will see in the updated research below, cervical spine recommendations to treatment so often includes dangerous surgeries because the cervical neck problems are only seen by many health care providers as a disease of the vertebrae and discs, not the supporting structures including ligaments. New research is challenging this.

Atlanto-axial rotational instability
Atlanto-axial rotational instability. The atlas is shown in the rotated position on the axis.

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.”(3(Neck collars and other devices).

Ligament laxity is a mystery and why cervical neck pain patients have a difficult time finding the right medical care

In research we have cited in other articles on our website doctors at University of Waterloo in Canada published their research in the June 30, 2017 edition of the Spine Journal.(4) Here the role of cervical ligaments in difficult to treat neck pain and instability patients is explained within the context of trying to create a neck pain and range of motion scoring system that would help guide doctors in the treatment of the difficult to treat patient,

  • “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.

Above is a sample of the handful of research from our office, German researchers and Canadian researchers who recognize the problems of cervical ligament damage in helping patients with atlantoaxial instability. This research is dwarfed by the amount of papers which deal with seeking out better ways to perform Atlantoaxial instability to limit complications, long hospital stays, and unsatisfactory outcomes.

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.

We concluded that statistically significant reductions in pain and functionality, indicating the safety and viability of Prolotherapy for cervical spine instability.(6)

Axis - the most important bone in the cervical spine

If you have questions about Atlantoaxial instability, get help and information from Caring Medical

References for this article

1 Hauser R, Steilen-Matias D, Fisher P. Upper cervical instability of traumatic origin treated with dextrose prolotherapy: a case reportJournal of Prolotherapy. 2015;7:e932-e935.

2 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]

3 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]

4 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]

5 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