As a practicing orthopedic physical therapist, I have seen multiple patients with the same complaint of chronic neck pain. They complain of neck pain that occurs after staying in the same position too long. “I need to move around or it will hurt” is a common comment. Also they tend to be serial self-manipulators which means that they are constantly popping their neck. These patients have cervical instability. Basically, this means that they have a lot of motion in the neck, but they do not have the strength to control it. The good news is that this is a treatable condition. Read on to learn about cervical instability and how to treat it. Let’s start with anatomy!
The spine
In order to understand cervical instability, you need to be familiar with the structure of the spine. The spine is made up of 33 vertebrae. The vertebrae are the bones of the spine. Each is stacked on top of one another to make a column. The spinal cord travels through the column with nerves exiting at each vertebral level. The first 7 vertebrae make up the cervical or neck region. The middle 12 vertebrae are the thoracic or mid back region. The next 5 vertebrae are the lumbar, which is also known as the low back. The next five make up the sacrum which is the triangular bone at the base of the spine. The sacral vertebrae are fused meaning they have grown together. The last 4 vertebrae are also fused. This is the coccyx or tailbone. The discs are in between the cervical, thoracic, and lumbar vertebrae. The sacrum and coccyx have grown together and have no space between the vertebrae for a disc.
The cervical spine
The cervical spine is made up of 7 unique vertebrae (spinal bones). It’s job is to support and soften loads to the head and neck while allowing movement. It also functions to protect the spinal cord. The cervical vertebrae are named C1 through C7. C1 is the first vertebrae below the skull and C7 is the last vertebrae of the cervical spine.
The first two vertebrae of the cervical spine are considered the upper cervical spine. They are different in shape and function than the other cervical vertebrae. C1 and the back of the skull (occiput) combine to form the atlanto-occipital joint. This joint allows for 1/3 of cervical flexion (looking down) and extension (looking up). C2 forms a joint with C1 called atlanto-axial joint. This joint is responsible for over half of the rotation (looking over your shoulder) of the cervical spine. This amount of mobility makes this area of the cervical spine vulnerable to instability.
The cervical spine has 8 cervical nerve roots. These nerve roots come off of the spinal cord and travel between the vertebrae at each level. The cervical nerves provide sensation and movement to our neck, shoulders, arms, and hands. Each nerve root innervates a different area of the body.
Along with the vertebrae, discs, and nerve roots, the cervical spine has many other structures which add stability and allow it to function smoothly. These include joints between the vertebrae which allow movement. Muscles, tendons, and ligaments add stability to the spine.
What is cervical instability?
Mechanical instability of the cervical spine refers to excessive motion at a joint or joints. The term laxity is also used because the instability is caused by lax or torn ligaments. Ligaments provide stability to a joint. If they are torn or not tight enough, the joint is allowed to move more. This additional movement requires more muscle strength to control since the ligamentous support is no longer there.
What are the symptoms of cervical instability?
Cervical instability has many symptoms. These include:
- Unable to stay in the same position for a prolonged period
- Fatigue and difficulty holding up head
- Need to self-manipulate or pop neck
- Neck feels unstable or shaky
- Sharp pain, especially with sudden movements
- Head feels heavy
- Neck can get stuck or locked up with movement
- Catching, clicking, or popping sensations
- Muscles feels stiff and tight
- Fear or apprehension with moving neck
- Temporarily improves with manipulation
- Feels better when lying down or when neck is supported
What causes cervical instability?
There are several different causes of cervical instability. These include:
- Trauma – This could be from a car accident, sports, fall, or other type of injury. It could be from one major incident or repetitive microtraumas. These incidents can cause damage and tearing to the ligaments that stabilize the cervical spine.
- Types of inflammatory arthritis – This includes rheumatoid arthritis, lupus, and ankylosing spondylitis. Unlike osteoarthritis, inflammatory arthritis is an autoimmune disorder. This type of arthritis will destroy healthy tissue which can lead to instability of the cervical spine. The most affected region of the cervical spine with inflammatory arthritis is the upper cervical spine and the mid cervical spine at C4-C5.
- Congenital conditions – This includes Downs Syndrome and Ehlers-Danlos. Usually people with these conditions do not become symptomatic before adulthood.
Special considerations
Cervical instability can be a very dangerous condition if there is displacement or dislocation of the vertebrae of the upper cervical spine. This can lead to compression of the spinal cord, brain stem, arteries, veins, and cerebrospinal fluid. The symptoms of this compression can be severe, including paralysis and respiratory failure. It is important to be under the care of a physician if you have had recent trauma to the neck or have a condition that could cause cervical instability.
Who should I see?
- Orthopedic spine specialist or neurosurgeon – You need to first get evaluated to determine the severity of the cervical instability. This will include imaging and a physical exam. Your doctor will discuss the findings and the plan of treatment.
- Physical therapy – Physical therapy plays a key role in stabilizing the cervical spine. Physical therapist can help strength, coordination, and mobility issues in the neck or other areas of the body. Treatment could include joint mobilization or manipulation, soft tissue mobilization, dry needling, stretching, strengthening, and postural education. Your PT should be able to help decrease your pain while helping to improve your mobility, posture, and strength.
What can I do?
- Aerobic – Performing low impact aerobic exercise is very beneficial for the spine. It increases the flow of nutrients and blood. Examples of low impact aerobic exercise include walking, swimming, and biking. If you don’t currently have an exercise program, then carefully work into one. You might begin by walking for 5 to 10 minutes a day and slowly work up to 30-60 minutes over several weeks or months. Be sure that whatever you choose does not exacerbate your symptoms.
- Ice – Ice can help decrease pain in the neck, shoulder, or upper back. Ice the painful area for 15 to 20 minutes at a time. I would recommend using an ice pack several times per day if the pain is constant or is preventing you from participating in an activity. Ice immediately after activity.
- Posture – Having forward rounded shoulders causes the chin to poke forward and the neck to forward flex. This takes the cervical spine out of it’s natural alignment. If the pectorals and biceps are tight, they will cause the shoulders to round. Below is a video showing how to stretch the pecs and biceps and also how to use a wall to check your posture.
- Strengthen and stretch the muscles around the cervical spine – Strengthening the deep neck flexors are vital in strengthening the neck and being able to maintain proper posture. The deep neck flexors are attached to the vertebrae and are the key stabilizers of the cervical spine. The upper trapezius and levator scapula are muscles that attach to the neck and shoulder. These muscles are commonly tight and can cause neck pain and headaches. Below is a video on how to strengthen the deep neck flexors and stretch the upper trapezius and levator scapula.
- Strengthen the scapular stabilizers – The scapular stabilizers are the muscles around the shoulder blade which help stabilize the shoulder joint while your arm is performing different activities. They are also very important in maintaining good posture. Activating these muscles will help properly align the thoracic spine which will help with proper posture of the cervical spine. The videos below review some strengthening exercises for the scapular stabilizers. Using loop resistance bands and resistance bands can increase strength and difficulty.
- Latex pillow – There has been research showing that an ergonomic latex pillow can help decrease neck pain. The pillow can support the spine and the head which can improve sleep and decreased pain.
In review
- The cervical spine is made up of 7 unique vertebrae (spinal bones).
- It’s job is to support and soften loads to the head and neck while allowing movement.
- The first two vertebrae of the cervical spine are considered the upper cervical spine.
- They are different in shape and function.
- They allow a large amount of motion and are vulnerable to instability.
- The cervical spine has 8 cervical nerve roots.
- Along with the vertebrae, discs, and nerve roots, the cervical spine has many other structures which allow it to smoothly function.
- Mechanical instability of the cervical spine refers to excessive motion at the joint.
- This is caused by lax or torn ligaments.
- Symptoms include pain with prolonged positions, need to “pop” the neck, stiffness, and tight muscles.
- Cervical instability has several different causes including
- Trauma
- Inflammatory arthritis
- Congenital conditions
- This can be a serious condition if there is displacement or dislocation of the cervical vertebrae
- You would need to see a neurosurgeon or an orthopedic spine specialist.
- Physical therapy plays a key role in stabilizing the cervical spine.
- There are things that you can do.
- Aerobic exercise
- Ice
- Posture
- Strengthen and stretch neck muscles
- Strengthen scapular stabilizers
- Latex pillow
As always, If you have questions about the content of this post or any other musculoskeletal questions, please e-mail me.
Additional resources
https://www.physio-pedia.com/Cervical_Instability
https://www.ncbi.nlm.nih.gov/books/NBK519563/