Chronic neck pain: making the connection between capsular ligament laxity and cervical instability

Abstract

The use of conventional modalities for chronic neck pain remains debatable, primarily because most treatments have had limited success. We conducted a review of the literature published up to December 2013 on the diagnostic and treatment modalities of disorders related to chronic neck pain and concluded that, 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. The objectives of this narrative review are to provide an overview of chronic neck pain as it relates to cervical instability, to describe the anatomical features of the cervical spine and the impact of capsular ligament laxity, to discuss the disorders causing chronic neck pain and their current treatments, and lastly, to present prolotherapy as a viable treatment option that heals injured ligaments, restores stability to the spine, and resolves chronic neck pain. 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. Chronic neck pain often reflects a state of instability in the cervical spine and is a symptom common to a number of conditions described herein, including disc herniation, cervical spondylosis, whiplash injury and whiplash associated disorder, postconcussion syndrome, vertebrobasilar insufficiency, and Barré-Liéou syndrome. When the capsular ligaments are injured, they become elongated and exhibit laxity, which causes excessive movement of the cervical vertebrae. 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 vertigo, tinnitus, dizziness, facial pain, arm pain, and migraine headaches. 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. Therefore, we propose that in many cases of chronic neck pain, the cause may be underlying joint instability due to capsular ligament laxity. Currently, curative treatment options for this type of cervical instability are inconclusive and inadequate. Based on clinical studies and experience with patients who have visited our chronic pain clinic with complaints of chronic neck pain, we contend that prolotherapy offers a potentially curative treatment option for chronic neck pain related to capsular ligament laxity and underlying cervical instability.

Keywords: Atlanto-axial joint; Barré- Liéou syndrome; C1-C2 facet joint; capsular ligament laxity; cervical instability; cervical radiculopathy; chronic neck pain; facet joints; post-concussion syndrome; prolotherapy; spondylosis; vertebrobasilar insufficiency; whiplash..

Fig. (1)

Atlanto-axial rotational instability. The atlas is shown in the rotated position on the axis. The pivot is the eccentrically placed odontoid process. In rotation, the wall of the vertebral foramen of Cl decreases the opening of the spinal canal between Cl and C2. This can potentially cause migraine headaches, C2 nerve root impingement, dizziness, vertebrobasilar insufficiency, 'drop attacks; neck-tongue syndrome, Barré-Liéou syndrome, severe neck pain, and tinnitus.

Fig. (2)

Typical Z (zygapophyseal/ facet) joint. Each facet joint has articular cartilage, the synovium where synovial fluid is produced, and a meniscus.

Fig. (3)

Ligament laxity and creep. When ligaments are under a constant stress, they display creep behavior. Creep refers to a time-dependent increase in strain and causes ligaments to "stretch out" over time.

Fig. (4)

Cervical spinal motion continuum and role of prolotherapy. When minor or moderate spinal instability occurs, treatment with prolotherapy may be of benefit in alleviating symptoms and restoring normal cervical joint function.

Fig. (5)

3D CT scan of upper cervical spine. C1-C2 instability can easily be seen in the patient, as 70% of C1 articular facet is subluxed posteriorly (arrow) on C2 facet when the patient rotates his head (turns head to the left then the right).

Fig. (6)

Digital motion X-ray demonstrating multi-level cervical instability. Neural foraminal narrowing is shown at two levels during lateral extension versus lateral flexion.

Fig. (7)

Cervical OA: The 3 phases of the degenerative cascade.  Used with permission from: Kramer WC, et al. Pathogenetic mechanisms of posttraumatic osteoarthritis: opportunities for early intervention. Int J Clin Exp Me d. 2011; 4(4): 285-298.

Fig. (8)

Overlap in chronic symptomology between atlanto-axial instability, whiplash associated disorder, post-concussion syndrome, vertebrobasilar insufficiency, and Barré-Liéou syndrome. There is considerable overlap in symptoms amongst these conditions, possibly because they all appear to be due to cervical instability. 1. Meadows J, Armijo-Olivo S, Magee D. Cervical Spine. Orthopedic Physical Assessment. 5 ed: Saunders Elsevier; 2008: 17-44. 2. Leddy J, Sandhu H, Sodhi V, Baker J, Wilier B. Rehabilitation of concussion and post-concussion syndrome. Sports Health. 2012; 4(2): 147-154. 3. Boake C, McCauley SR, Levin HS, et al. Diagnostic criteria for postconcussional syndrome after mild to moderate traumatic brain injury. J Neuropsychiatry Clin Neurosci. 2005; 17: 350-356. 4. Swinkels RA, Oostendorp RA. Upper cervical instability: fact or fiction. J Manip Physiol Ther. 1996; 19(3): 185-194. 5. Tamura T. Cranial symptoms after cervical injury. Aetiology and treatment of the BarrÉ-LiÉou Syndrome. J Bone Joint Surg Br. 1989; 71 B: 282-287. 6. Chen HB, Yang KH, Wang ZG. Biomechanics of whiplash injury. Chin J Traumata/. 2009; 12(5): 305-314. 7. Endo K, lchimaru K, Komagata M, Yamamoto K. Cervical vertigo and dizziness after whiplash injury. fur Spine J. 2006; 15: 886-890. 8. Pearce J. BarrÉ-LiÉou "syndrome". J Neural Neurosurg Psychol 2004; 75(2). •Also based on the evaluation and treatment of thousands of patients at Caring Medical and Rehabilitation Services in Oak Park, IL over a 20 year period.

Fig. (9)

Stress-strain curve for ligaments and tendons. Ligaments can withstand forces and revert back to their original position up to Point C. At this point, prolotherapy treatment may succeed in tightening the tissue. Once the force continues past Point C. the ligament becomes permanently elongated or stressed.

Fig. (10)

The biology of prolotherapy.