Cervical Instability

Anatomy

Normal stability of joint made of 2 components
Static stabilisers
Osseous configuration, joint capsules, ligaments, other non-contractile structures
Dynamic stabilisers
Muscle function through
Dynamic ligament tension
Force couples
Joint compression
Neuromuscular control
Vast amount of neurological and vascular structures
Approximately 50% of rotation occurs at C1/2
Ligaments provide primary source of stability in upper cervical region (see Anatomy, Joint Orientation and Arthrokinematics Teaching Pack)

Pathology

Dysfunction in one or more of the above static or dynamic stabilisers can reduce stability of a joint
Dysfunction of the static stabilisers potentially more serious consequences
Dysfunction can be result of bony fracture, ligamentous laxity or rupture, neuromuscular deficits, anatomical anomalies
Increased accessory or physiological movements can cause increased stress of various surrounding structures (soft tissue, joint, vascular or neurological structures)
Majority time this is none serious, resulting in pain only
Increased movement at the upper cervical spine can have potentially serious consequences due to large presence of vascular and neurological structures. This is rare.

Mechanism of Injury

Traumatic

Whiplash
Fractures
Dislocations
Surgery

Systemic

Upper Respiratory Infection

Congenital

Down Syndrome
RA
Os Odontoideum
Klippel Feil Syndrome
Hypermobility Syndrome

Insidious

Postural
Muscular imbalance
Degenerative disc disease/ spondylosis

Associated Pathologies

Cervical Artery Dysfunction
Cervical Myelopathy
Cervicogenic Headaches
Degenerative Disc Disease/Spondylosis

Examination

Upper Cervical Instability

Subjective

History of trauma or congenital/systematic disease
Neck Pain
Intolerance to prolonged positions
Feeling need to support the head
Sharp pain of catch with movements
Signs of neurological or vascular compromise
Cranial nerves
Drop attached
Facial or lip paraesthesia
Bilateral or quadrilateral symptoms
Nystagmus
Metallic taste in mouth
Lump back of throat

Objective

Reduced sensation
Reduced power
Reflex changes
Cranial nerve changes
Significant muscle spasm
Reluctance to move
Order examination to cause no harm
Diagnostic medical work UP
Blood Pressure
Cranial Nerve Testing
Active ROM
Passive ROM
Refer on as soon as serious pathology is suspected, do not complete the examination
Refer on if you do not possess the clinical skills to perform relevant examinations

Special Tests

Possess poor sensitivity and specificity
Sharp Purser
Alar Ligament Testing
Transverse Ligament Testing

Further Investigation

MRI
X-RAY
Open Mouth X –Ray

Generalised None Serious Instability

Subjective

Insidious onset
Neck Pain
Headaches
Intolerance to prolonged positions
Feeling need to support the head
Sharp pain of catch with movements

Objective

Full range of movement with painful stretching end of range
Painful catch/unsmooth movements
Increased joint play
Poor scapular and cervical muscular strength
Sensorimotor changes
Smooth Pursuit neck torsion
Saccadic eye testing
Joint position error

Further Investigation

MRI to rule out serious pathology

Management

Dependent on severity
Upper cervical instability/serious instability with neurological and/or vascular compromise referral to a specialist is indicated
Conservative management for neuromuscular reasons for instability and congenital reasons that have been cleared by a specialist
Surgery nearly always indicated for traumatic instability

Conservative

Cervical and scapular strengthening
Sensorimotor rehabilitation
Acupuncture for pain relief
Manual therapy to thoracic spine

Plan B

Dependent on underlying pathology

References

(Cattrysse et al., 1997, Swinkels et al., 1996, Lincoln, 2000, Olson and Joder, 2001, Piovesan et al., 2003, Niere and Torney, 2004, Cook et al., 2005, Kaale et al., 2008, Mintken et al., 2008, Mathers et al., 2011, Osmotherly and Rivett, 2011, Osmotherly et al., 2012, Hutting et al., 2013, Rebbeck and Liebert, 2014, Rushton et al., 2014)

Cattrysse, E., Swinkels, R. A. H. M., Oostendorp, R. A. B. and Duquet, W. (1997) 'Upper cervical instability: are clinical tests reliable?', Manual Therapy, 2(2), pp. 91-97.

Cook, C., Brismee, J. M., Fleming, R. and Sizer, P. S., Jr. (2005) 'Identifiers suggestive of clinical cervical spine instability: a Delphi study of physical therapists', Phys Ther, 85(9), pp. 895-906.

Hutting, N., Scholten-Peeters, G. G. M., Vijverman, V., Keesenberg, M. D. M. and Verhagen, A. P. (2013) 'Diagnostic Accuracy of Upper Cervical Spine Instability Tests: A Systematic Review', Physical Therapy, 93(12), pp. 1686-1695.

Kaale, B. R., Krakenes, J., Albrektsen, G. and Wester, K. (2008) 'Clinical assessment techniques for detecting ligament and membrane injuries in the upper cervical spine region—A comparison with MRI results', Manual Therapy, 13(5), pp. 397-403.

Lincoln, J. (2000) 'Case report. Clinical instability of the upper cervical spine', Man Ther, 5(1), pp. 41-6.

Mathers, K. S., Schneider, M. and Timko, M. (2011) 'Occult hypermobility of the craniocervical junction: a case report and review', J Orthop Sports Phys Ther, 41(6), pp. 444-57.

Mintken, P. E., Metrick, L. and Flynn, T. W. (2008) 'Upper cervical ligament testing in a patient with os odontoideum presenting with headaches', J Orthop Sports Phys Ther, 38(8), pp. 465-75.

Niere, K. R. and Torney, S. K. (2004) 'Clinicians' perceptions of minor cervical instability', Man Ther, 9(3), pp. 144-50.

Olson, K. A. and Joder, D. (2001) 'Diagnosis and treatment of cervical spine clinical instability', J Orthop Sports Phys Ther, 31(4), pp. 194-206.

Osmotherly, P. G. and Rivett, D. A. (2011) 'Knowledge and use of craniovertebral instability testing by Australian physiotherapists', Man Ther, 16(4), pp. 357-63.

Osmotherly, P. G., Rivett, D. A. and Rowe, L. J. (2012) 'The anterior shear and distraction tests for craniocervical instability. An evaluation using magnetic resonance imaging', Man Ther, 17(5), pp. 416-21.

Piovesan, E. J., Kowacs, P. A. and Oshinsky, M. L. (2003) 'Convergence of cervical and trigeminal sensory afferents', Curr Pain Headache Rep, 7(5), pp. 377-83.

Rebbeck, T. and Liebert, A. (2014) 'Clinical management of cranio-vertebral instability after whiplash, when guidelines should be adapted: a case report', Man Ther, 19(6), pp. 618-21.

Rushton, A., Rivett, D., Carlesso, L., Flynn, T., Hing, W. and Kerry, R. (2014) 'International framework for examination of the cervical region for potential of Cervical Arterial Dysfunction prior to Orthopaedic Manual Therapy intervention', Man Ther, 19(3), pp. 222-8.

Swinkels, R., Beeton, K. and Alltree, J. (1996) 'Pathogenesis of upper cervical instability', Manual Therapy, 1(3), pp. 127-132.