Cervical spine instability: symptoms and treatment

In accordance with the ICD, degenerative-dystrophic diseases of the spine (DDSD) in medicine are understood as a broad group of pathologies of osteochondral tissue, which often cause chronic pain and gradual destruction of the spinal column. Such changes, sometimes with disabling consequences, include: intervertebral hernias, protrusions, osteochondrosis, spondylolisthesis, long-term consequences of spinal fractures and injuries.

Degenerative diseases of the spine may not bother the patient until a certain point, so they are most often “incidental findings” on CT or MRI. However, over time, the situation worsens - stenosis leads to narrowing of the intervertebral foramina and spinal canal, osteoporosis - to increased fragility and degeneration of the vertebrae, osteophytes and hernias - to neuralgia.

Contrary to popular stereotypes, degenerative spinal diseases are not only common in older patients and adults (median age 40 years), but can also be detected in younger patients. Some common DDSDs, such as Schmorl's hernia, do not affect the patient's quality of life and do not require special treatment or surgery. However, their timely diagnosis will help the patient adjust their lifestyle (change motor habits, add exercise therapy, conservative treatment procedures) and thus prevent possible complications.

In this article we will tell you what other diseases belong to the group of DDSD, how they manifest themselves, and what to do if this diagnosis appears in the CT report?

General information

What is instability of the C3-C4 cervical vertebrae? Instability of the cervical spine is a condition in which the vertebrae of the cervical spine are unable to maintain the correct anatomical position and, at the same time, the range of motion is greater than the physiological norm (pathological mobility). Spinal instability is a fairly common phenomenon and most of this pathology occurs in the cervical spine, which is due to its high activity and load (tilting/turning the head). As a result, against the background of increased mobility of the vertebrae, various structures suffer: the ligamentous apparatus, roots, spinal cord, vertebral arteries, which take part in the blood supply to the spinal cord.

Features of the structure and function of the cervical spine

Atlas (C1) and axis (C2) - the first/second cervical vertebrae connect the base of the skull with the spinal column (atlantoaxial-occipital complex). At the same time, the Atlas has a specific structure (there is no vertebral body), and on its upper surface there are concave articular processes connected to the condyles of the occipital bone. The axis has a body that passes into the odontoid process, which, protruding upward, articulates with the surface of the anterior arch of Atlas (Fig. below).

The first and second vertebrae form three joints: one between the arch of the atlas and the odontoid process of the axis and two paired ones between C1 and C2, which are functionally combined into a combined joint, providing about half of the movements in the cervical region.

Rotational/axial loads in this region occur on the intervertebral discs of the vertebral body. They are responsible for axial pressure, shock load and maintaining the vertical position of the human body. The load on the spine is distributed by the nucleus pulposus . Intervertebral joints located in the articular capsules do not bear axial load. Important importance is given to the ligamentous apparatus, which fixes the intervertebral discs/vertebrae to each other and determines the range of motion of the spine.

The biomechanics of movements in the cervical spine occurs around three axes:

Flexion/extension around the transverse axis.
Circular movements around the longitudinal axis.
Lateral bends around the sagittal axis.

Other features of the cervical spine include the narrowness of the spinal canal, the weakness of the muscular corset of this area, and a well-branched neurovascular network, which, with instability of the cervical spine, contributes to the development of neurological symptoms.

The spinal column combines the properties of mobility and stability:

Mobility is determined primarily by the structural features of the vertebrae, mechanical strength and size of the vertebral structures and intervertebral disc.
The leading element in stabilizing the spine is the fibrous/pulpous nucleus ligament of the intervertebral disc and the capsule of the intervertebral joints. The stability of the vertebrate is ensured by the stability of all its segments and protects it from deformation under conditions of physiological stress.

Of particular importance is the fact that cervical pathologies often accompany serious consequences, in particular paresis/paralysis of the upper limbs. Advanced instability can provoke cerebral circulatory disorders, respiratory failure, and impaired vision/hearing. Therefore, treatment of this pathology must begin as early as possible.

Diagnostics

If unpleasant symptoms appear, you should consult a neurologist. Diagnostic measures are performed in 2 stages.

First, the doctor collects anamnesis, asks the patient about the course of the disease, how long ago the first symptoms appeared. Examines the patient's neck. But with vertebral instability, there are almost no external manifestations.

The doctor pays attention to the position of the head. If it is inclined towards one of the shoulders, a diagnosis of neurogenic torticollis is made. The neurologist may feel subtle changes by palpating the affected area. He may see excessive muscle spasms predominantly on one side (opposite to which the head is tilted).

Changes in vision may be visible - the palpebral fissure narrows, the pupil becomes smaller, and the position of the eyeball may change. This indicates that the optic nerves are being pinched. Because of this, the patient experiences vision problems.

After this, instrumental diagnostics are prescribed. It includes the following methods:

X-ray. Pictures of the neck are taken in several projections. First, the head is tilted forward and the doctor takes a photo. Then the procedure is repeated, but with the head thrown back. If there is a suspicion of subluxation of the cervical vertebrae, an x-ray is taken through the mouth.
MRI. This is a more accurate study. Helps determine the exact localization of the pathological process; pinched nerves are clearly visible.
Ultrasound. During this procedure, the doctor determines the condition of the arteries that run through the spine. Ultrasound also helps to find out whether there are disturbances in the outflow of venous blood. This procedure is very important for making a diagnosis, so it is carried out in the exact order.

If there is instability of the cervical vertebrae c3 c4, it is very important to consult a doctor in a timely manner. Timely diagnosis will speed up the treatment process and increase the chances of a full recovery.

Pathogenesis

The pathogenesis of instability of the cervical spine is based on several anatomical anomalies:

destruction of the disc/disturbance of its structure, which contributes to the appearance of excessive translational movement in the posterior (dorsolateral) direction;
the inability of the disc to perform the function of stabilization and transfer of the center of gravity to neighboring structures (discs, ligaments);
increase in the neutral zone;
formation of a center of pathological movement (rotation around the longitudinal axis).

Classification

There are several types of instability of the cervical spine.

Post-traumatic instability. The most common type. Is a consequence:

Providing obstetric assistance during childbirth (application of forceps, squeezing out the baby).
Injuries (road accidents, sports injuries, falls from a height) in the form of dislocations / fractures of the vertebrae, resulting from compression, flexion/extension, flexion-rotation mechanisms of injury. Complications in the form of post-traumatic instability develop in 10-15% of cases of vertebral fractures/dislocations, and unstable is the segment of the spine in which the height of the intervertebral discs is reduced, the disc is damaged or the ligaments are torn. As a rule, with post-traumatic instability, severe spinal/radicular symptoms develop.

Degenerative instability . Develops with osteochondrosis of the spine due to the disintegration of the fibrous ring/fragmentation of the disc tissue, which reduces its ability to fixate. The cause may be both a violation of the metabolism of cartilage tissue and a violation of the statics of the spine. When a load is placed on a degenerative disc of the spine, pathological mobility is formed, often with displacement of the vertebrae (degenerative spondylolisthesis). Displacement of the vertebra contributes to overload of the posterior supporting complex, which gradually leads to the development of degenerative spondyloarthrosis. In most cases, this type of instability occurs at the C3–C4, C4–C5, or C5–C6 vertebral levels.

Dysplastic instability.

Develops as a consequence of dysplastic syndrome. Manifestations of dysplasia include changes in the structure of collagen fibers, narrowing of the intervertebral disc, incorrect position of the nucleus pulposus, wedge-shaped vertebral bodies, and disruption of the integrity of the endplates. This contributes to the development of disruption of the mechanical properties of the disc, the relationship between the fibrous ring and the nucleus pulposus, which reduces the rigidity of fixation of the vertebrae, and can occur at all levels of the cervical spine (C1-C7).

Signs of dysplasia can be found in various structures of the spinal column - in the vertebral body, intervertebral disc/joints, and spinal ligaments. This kind of instability is caused mainly by congenital inferiority of the intervertebral disc, less often by asymmetry of the intervertebral joints, changes in the position/size of the articular facets, and underdevelopment of the articular processes.

Postoperative instability.

It is a consequence of surgical interventions in which it is necessary to remove/resect facets, significantly disrupting the integrity of the supporting complexes and ligamentous apparatus, which leads to a significant increase in the load on the vertebrae/intervertebral joints.

It is customary to distinguish several stages of instability:

The first stage is mechanical (pathological mobility develops at the level of the destabilized spinal motion segment). It is often not detected x-ray. Develops mainly at a young age (up to 20 years). It manifests itself as pain in the neck near the spine, less often as radicular pain.
The second stage is neurological, accompanied by damage to the spinal structures and has pronounced neurological symptoms. Develops in people 20-60 years old.
The third stage is combined (manifestations of the first and second stages are present simultaneously). It develops mainly in people over 60 years of age.

Vertebral instability

It is not uncommon for your back to hurt after working at a computer for a long time or standing for a long time. There can be quite a few reasons. And one of them (by the way, common) is vertebral instability.

Vertebral instability is excessive movement of the vertebrae relative to each other. Often instability entails many unpleasant symptoms similar to other diseases.

Causes of instability

Instability most often develops in the cervical and lumbar spine, as these sections have significant mobility. When moving, the vertebrae move along a certain trajectory, held by muscles and ligaments. If the muscles and ligaments do not hold the vertebrae tightly enough, pathological slipping of the vertebrae occurs. Most often, the causes of weakness of muscles and ligaments are the anatomical characteristics of a particular person (congenital weakness of the ligamentous apparatus). There are also external signs - usually these are people with a long neck and smoothed curves of the spine, often with a thin build.

Often the cause of instability is a back injury. For example, with a sharp hyperextension, unsuccessful landing after a jump, etc. Another reason is degenerative-dystrophic processes, in other words, osteochondrosis.

Instability that developed after surgery is also distinguished. When removing herniated intervertebral discs, it is often necessary to remove parts of the vertebrae. Changes in the shape of the vertebra, as well as the relative position of the vertebrae after surgery, can lead to excessive mobility.

Constant work at the computer in an uncomfortable position, or if the workplace is not arranged correctly, can provoke an exacerbation of symptoms.

Symptoms of instability

A typical patient with excessive mobility in the cervical spine complains of headaches, neck pain, dizziness, swelling of the face after waking up, a feeling of confusion in the head, and poor sleep. Very often, these complaints appear or intensify after being in a stationary position for a long time. For example, when propping your head with one hand while sitting or lying on your side or stomach, when falling asleep on an uncomfortable pillow or in an uncomfortable position.

Read also: Treatment of disc herniation: is surgery necessary?

Instability in the lumbar region is manifested by back pain during prolonged walking or when lifting heavy objects. The pain may radiate to the legs and intensify when bending over. Quite often, such patients say that after sessions of “preventive massage” their back pain sharply increased and dizziness appeared.

Why instability is dangerous

Excessive mobility of the vertebrae may be an additional factor in the formation of osteophytes - bone growths on the vertebrae. This is due to the fact that with vertebral instability, normal anatomical interactions between bone structures, ligaments, and muscles are disrupted. Conditions are created when the body weight begins to be incorrectly distributed along the axis of the spine. Subsequently, osteophytes can cause restriction of spinal movements and compression of nerve roots.

In the cervical spine, instability can lead to irritation of the nerve plexuses of the vertebral arteries, which in turn leads to the development of dizziness and other reflex vascular manifestations.

How to make a diagnosis

The diagnosis is usually made by a neurologist. The presence of instability can be assumed based on the patient’s complaints. Experienced doctors can, by palpation, determine at what level there is pathological mobility. Very often, excessive mobility is accompanied by local muscle tension, which sometimes leads to reflex muscle spasm and limitation of spinal movements.

To confirm the diagnosis, an X-ray of the spine of interest is performed with functional tests (additional images - flexion and extension). The photographs may show not a smooth, as normal, but a step-like displacement of the vertebrae. The radiologist describes the amount of this displacement in millimeters. If the displacement is more than 3 mm, instability is indicated.

Additional information about excessive mobility in the cervical spine is provided by ultrasound examination of the neck vessels with functional tests (tests with head rotation - possible compression of the vessel is examined when the head is turned).

How to treat

Treatment of excessive mobility is carried out depending on the cause of instability and the severity of complaints. They use medication, physiotherapy, acupuncture, and manual therapy. In most cases, the exacerbation of instability can be relieved within a few days. Massage during an exacerbation is prescribed with caution. If sessions are still carried out, they try to avoid exposure to areas with instability.

Sometimes the help of a neurosurgeon is necessary. Most often, surgery is performed if instability develops as a result of a vertebral fracture (for example, after an injury, as a result of an infectious, oncological process) or in case of combination with a disc herniation. Instability is eliminated by installing metal structures that fix the vertebrae above and below.

Cervical and lumbar corsets are widely used, which provide stabilization of moving areas, especially during exacerbations. Wearing a corset can reduce muscle tension and, accordingly, reduce pain and reflex vascular reactions (for example, dizziness). Often, wearing a corset very quickly relieves the main complaints.

Physical therapy (especially post-isometric relaxation methods) and proper organization of the workplace are important. Postisometric relaxation is aimed at strengthening muscles and ligaments, normalizing muscle tone. The exercises are simple and quite effective when performed regularly.

Be healthy!

Maria Meshcherina

Photo istockphoto.com

Causes

The main causes of instability of the cervical spine include:

dysplasia .
Spinal injuries involving the cervical spine (domestic, road, birth, sports).
Anomalies of spinal structures.
Disorders of bone tissue mineralization processes.
Osteochondrosis in the cervical region.
Degenerative changes in the vertebral discs ( hernias / protrusions ).
Involvement of bone tissue in the infectious process ( osteomyelitis / tuberculosis ).
Systemic inflammatory diseases ( systemic lupus erythematosus / rheumatoid arthritis ).
Spine operations (ligaments, discs, facets).

Symptoms

Symptoms of cervical spine instability can vary significantly depending on the severity of the instability. The main manifestations of instability of the cervical vertebrae are:

Pain syndrome, including headache . Appears mainly against the background of physical activity or immediately after it, as well as during prolonged stay in an uncomfortable position (sitting with the head tilted down/in front, flexion/extension of the head).
Muscle symptoms. It manifests itself as a feeling of fatigue, tension in the neck muscles.
Neurological focal symptoms. Characterized by numbness/weakness of the upper extremities, shooting pains, and pain on palpation of paravertebral points.
Vestibulo-cochlear disorders. Dizziness , tinnitus, less often - visual disturbances. Appear when the vertebral artery is compressed.
Hypertension syndrome. Increased intracranial / blood pressure , which increases dizziness and headache.
Sleep disorders. It is observed against the background of chronic pain. Feeling of constant discomfort, inability to sleep, interrupted sleep.
Spinal deformity. Changes in the shape of the neck (increased kyphosis).

Also common manifestations of instability include decreased muscle tone in the neck, soreness of the skin, numbness, weakness in the limbs, and less commonly, arrows.

Osteochondrosis in the thoracic region

Osteochondrosis of the thoracic spine according to ICD 10 is exhibited under the number M 42.14. This lesion is more dangerous than the previous version - the movements of the head, neck and upper limb are impaired. Here the symptoms are easily confused with pneumonia or bronchitis - in most cases, patients complain of pain from the respiratory system.

The clinical picture of thoracic osteochondrosis is as follows:

Chest pain - the severity varies from person to person, but most patients report tingling or burning.
Increased pain when raising your arms or making sudden movements to the side.
There is an aching pulsation in the chest, which radiates to the collarbone, shoulder blade, arm and stomach.

Common causes of damage to the thoracic region are protrusions (bulging of the articular disc), bone growths, or narrowing of the distance between adjacent vertebrae.

Osteochondrosis of the thoracic spine requires mandatory examination and treatment, as there is a risk of developing disability in old age.

Tests and diagnostics

The diagnosis is made based on:

Collecting complaints and studying the history of the disease (characteristics of the pain syndrome, localization, presence of concomitant symptoms - dizziness, headache, unsteadiness while walking, etc.).
Neurological examination data (soreness of the cervical muscles/paravertebral points of the spine, range of motion of the spinal joints/condition of the muscular corset, presence of radiating pain, sensory disturbances, etc.).
X-ray examination/CT/MRI of the cervical spine. Allows you to determine the condition of the bone structures of the spine, the width of the spinal canal, and the displacement of the vertebrae.

Consequences and complications

The most common complications of cervical spine instability are:

Vertebral artery syndrome (compression of the vertebral artery), which may be accompanied by the appearance of cerebral/vestibular symptoms ( dizziness , headache , noise effects). In cases of acute compression, an acute attack may develop, manifested by severe dizziness with nausea / vomiting , and loss of coordination. When the vertebral artery is compressed over a long period of time, it can lead to chronic impairment of spinal/cerebral circulation.
Severe pain syndrome , often becoming chronic due to weakening of muscle tone.
Disorder of sensitivity/motor function due to compression of the nerves located in the intermuscular spaces.
Spinal stenosis . Clinically manifested by paralysis/paresis of the upper and lower extremities

Spinal stenosis

Stenosis is a pathological narrowing of the spinal canal caused by hyperplasia of bone tissue, tumor growth, and the entry of fragments of osteochondral fragments during injury into the space occupied by the roots of the spinal cord or nerve fibers, which leads to their compression. Spinal stenosis manifests itself as pain with neuralgic symptoms. The most common complaint is back pain, which increases with walking and decreases with sitting (flexing the spine). An accompanying symptom is most often numbness and weakness of the legs, pain of a “shooting” nature. The latter is typical for lesions of the lumbosacral segment.

List of sources

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Neck pain: differential diagnosis and basic approaches to treatment / Shostak N.A., Pravdyuk N.G. // General Medicine - 2009 - No. 2.
Mumentaler Marco. Differential diagnosis in neurology. Guide to the assessment, classification and differential diagnosis of neurological symptoms / Marco Mumenthaler, Claudio Basseti, Christoph Detwiler; lane with him. – 3rd ed. – M.: MEDpress-inform, 2012. – 360 p.
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