Cervical Instability
Normal Anatomy
• Normal stability of any joint is made of 2 aspects
– Static Stabilisers – osseous configuration, capsules and
ligaments
– Dynamic Stabilisers- muscle function through dynamic
ligament tension, force couples, joint compression
and/or neuromuscular control
• Approximately 50% of rotation occurs at C1/2
• Ligaments provide the primary source of stability
• Vast amount of neurological and vascular
structures
Atlantoaxial Joint
Transverse Ligament of the Atlas
Atlantoaxial Joint
Tectorial Membrane
Atlantoaxial Joint
Alar Ligament and Transverse Ligament
Pathophysiology
• Excessive movement at
the upper cervical spine
• Can be the result of
bony fracture,
ligamentous laxity or
rupture or
neuromuscular deficits
• Can result in pain,
neurological or vascular
compromise
Mechanism Of Injury
• Traumatic
– Whiplash
– Fractures, Dislocations
– Surgery
• Systemic
– Upper Respiratory
Infection
• Congenital
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Down Syndrome
RA
Os Odontoideum
Klippel-Feil Syndrome
Hypermobility Syndrome
Associated Pathologies
• Cervical Artery Dysfunction
• Cervical Myelopathy
• Cervicogenic Headaches
Subjective
• History of trauma or congenital/systemic
disease
• Neck pain
• Intolerance to prolonged positions
• Feeling need to support the head
• Sharp pain or catch with movements
Subjective
• Signs of neurological or vascular compromise
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Drop attacks
Facial or lip paraesthesia
Bilateral or quadrilateral symptoms
Nystagmus
Dizziness
Blurred vision
Metallic taste in mouth
Lump back of throat
Think neuro, think vascular, think cranial nerves, think
CNS
Objective
• Based on Subjective
History
• May not be appropriate
in some cases
• Start with cranial nerve
and BP testing
Objective
Serious (Static Stability)
• Reduced sensation
• Reduced power
• Reflex changes
• Cranial Nerve Changes
• Significant muscle spasm
• Reluctance to move
Non Serious (Neuromuscular)
• Sensorimotor changes
– Smooth Pursuit Neck Torsion
– Saccadic Eye Testing
– Joint Position Error
• Full range of movement
with painful stretching end
of range
• Painful catch/ unsmooth
movements
• Increased joint play
Special Tests
• Sharp Purser
– Sitting relocation of C1 on
C2
• Alar Ligament Testing
– Supine testing of rotation
and lateral flexion of Upper
Cx with fixation of C2
• Transverse ligament
Testing
– Supine with fingers around
patients head and between
occiput and C2. Lift head
and C1 anteriorly and hold
for 20-30 mins
Further Investigation
• MRI
• X-ray
• Open Mouth X-Ray
Management
• Referral to a specialist if signs of neurological
or vascular compromise
• Conservative management for those with
congenital or neuromuscular reasons for
instability
• Surgery nearly always for traumatic instability
Conservative - Management
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Sensorimotor rehabilitation
Cervical and scapular rehabilitation
Manual Therapy to Thoracic Spine
Acupuncture for pain relief
Surgical - Management
• Depends on pathology causing instability
References
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Lincoln (2000) Clinical Instability of the upper cervical spine. Manual Therapy
Olson and Joder (2001) Diagnosis and Treatment of Cervical Spine Clinical
Instability. JOSPT
Niere and Torney (2004) Clinicans’ perception of minor cervical instability. Manual
Therapy
Cook et al (2005) Identifiers suggestive of clinical cervical spine instability: A Delphi
study of physical therapists
Mintken et al (2008) Upper cervical ligament testing in a patient with Os
Odontoideum Presenting with Headaches. JOSPT
Mathers et al (2011) Occult Hypermobility of the Craniocervical Junction: A Case
Report and Review
Osmotherly and Rivett (2011) Knowledge and use of craniovertebral instability
testing by Australian physiotherapists
Osmotherly et al (2012) The anterior shear and distraction tests for craniocervical
instability. An evaluation using magnetic resonance imaging
Rebbeck and Liebert (2014) Clinical management of cranio-vertebral instability
after whiplash, when guidelines shoulder be adapted: A Case report