Cervical instability is a medical condition in which loose ligaments in your upper cervical spine may lead to neuronal damage and a large list of adverse symptoms.

If you have cervical instability, you may be experiencing migraines, vertigo, or nausea. Fortunately, this condition is treatable, though not curable.

Let’s talk about the symptoms, causes, treatments, diagnosis, and prevention of cervical instability — one step at a time.

What is cervical instability?

Cervical instability occurs when the ligaments in between your spinal cord and skull are loose. These “lax ligaments” allow for excessive movement of the top two cervical vertebrae, which may result in many symptoms, such as headaches, fainting, or even memory loss.

Ligament laxity is a state in which ligaments that attach bone to bone are loose. Also called ligamentous laxity, this condition often causes chronic pain. It can affect the whole body, or only specific parts.

You may have seen a friend hyperextend their finger, seemingly unnaturally. This is probably due to ligament laxity causing joint hypermobility syndrome. The ligaments connecting the bones in your friend’s finger are loose and allow for more range of motion.

This abnormal range of motion in your neck area can trigger cervical instability.

Ligament laxity may be caused by genetic connective tissue disorders, such as Ehlers-Danlos Syndrome or Marfan Syndrome.

There are 2 joints at which the ligaments may be loose, leading to cervical instability:

  1. Atlanto-occipital joint
  2. Atlanto-axial joint

Cervical instability is also known as:

  • Craniocervical instability
  • Craniovertebral instability
  • Clinical instability of the cervical spine
  • Cervical neck instability
  • Cervical spine instability
  • Atlantoaxial instability

Cervical Instability Symptoms

Symptoms of cervical instability:

Diagnosing Cervical Instability

How do you test cervical instability? Here are 4 testing methods for cervical instability:

  1. Upright MRI (AKA magnetic resonance imaging)
  2. Supine MRI (laying on your back)
  3. CT scan (AKA computerized tomography)
  4. Digital x-ray

It is worth mentioning that, although MRIs are the most common diagnostic testing method for cervical instability, a 2012 scientific investigation found that MRIs had “limited diagnostic value in patients with whiplash-associated disorders” such as cervical instability.

Here are some measurements doctors will look for to diagnose cervical instability:

  • Clivo-Axial Angle less than or equal to 135 degrees
  • Grabb-Oakes measurement greater than or equal to 9 mm
  • Harris measurement greater than 12mm
  • Any spinal subluxation

Causes of Cervical Instability

Craniocervical instability is caused by ligament laxity between the skull and the top two vertebrae (the atlas and the axis). This allows excessive movement and leads to a long list of physical and neurological symptoms.

These factors can cause ligament laxity and result in cervical instability:

Cervical Instability Treatments

How do you fix cervical instability? There are 4 standard treatments for cervical instability:

  1. Chiropractic
  2. Surgery
  3. Physical therapy
  4. Strengthening exercises
  5. Prolotherapy

There is no consensus on the best cervical instability treatment, but these 5 methods are supported by the most scientific evidence.

1. Chiropractic

Chiropractic care is a common and effective treatment for headaches, poor posture, and spinal misalignments — all of which are connected to cervical instability.

Upper cervical chiropractic care may correct cervical instability.

2020 study says: “Spinal chiropractic manipulative therapy can be used to correct cervical instability,” joint disorders, dislocations of cervical vertebrae, and much more.

Spinal manipulation is a safe and effective therapy when performed by a highly qualified chiropractor, even in special needs patients.

Here at Denver Upper Cervical Chiropractic, we have successfully treated cervical instability patients countless times. Gentle adjustments of the upper spine are critical to recovering from cervical instability. Click here to learn more about our practice.

2. Surgery

Does cervical instability require surgery? You do not need surgery for cervical instability unless your instability has gotten out of control. In the most severe cases, surgery may be necessary to manage the life-changing symptoms of advanced cervical instability.

Most surgical treatments aim to correct dysfunction of the craniocervical junction, where the skull meets the upper spine.

The most common surgical treatment options include:

  1. Cervical fusion spine surgery
  2. Halifax clamp
  3. Screw-rod constructs along the atlas vertebra lateral mass and axis vertebra pedicle (or the axis spinous process if the axis pedicle is inaccessible)
  4. Transarticular screws
  5. Posterior sublaminar wiring

Cervical spine fusion, in particular, may be performed when slight subluxations are detected but before migration of the odontoid process to prevent the progression of cervical instability. Unfortunately, some surgery patients find they can no longer move that part of their neck.

Medscape explains that when it comes to surgery for cervical instability, “optimal results have been obtained in patients with severe pain and mild myelopathy.”

However, more conservative treatments for cervical instability, such as chiropractic care or physical therapy, may also be effective. Since surgery is invasive and expensive, it may be wise to try more conservative treatments first.

3. Physical Therapy

Physical therapy is a very effective treatment option for cervical instability. We often recommend patients do PT alongside chiropractic care for the best recover outcomes.

What does physical therapy for cervical instability involve?

  • Strengthening exercises
  • Posture education
  • Joint mobilization (Click here to watch a video of what joint mobilization will look like.)
  • Soft tissue mobilization
  • Spinal manipulation
  • Proprioception exercises

You may or may not need to wear a brace or cervical collar, depending on the severity of your cervical instability, and whether you had surgery beforehand.

According to a two-year follow up study, surgery improved patient outcomes better after one year. But physical therapy was insignificantly different from surgery at improving symptoms after two years.

In other words, surgery is a short-term strategy to offer immediate back pain relief. Physical therapy improves symptoms in the long-term.

4. Strengthening Exercises

Always consult your doctor or physical therapist before trying these strengthening exercises to help with cervical instability.

5 examples of strengthening exercises that may treat or prevent cervical instability are:

  1. Chin tucks stretch and strengthen your posture and neck joints. Chin tucks are the most common strengthening exercise used to improve cervical instability.
  2. Isometric exercises can be combined with active range of motion to strengthen the neck area. Click here for a video demonstration by a physical therapist.
  3. Rotating the neck slowly and methodically also strengthens the joints and muscles around the upper cervical spine.
  4. Yes and no neck motions help stretch the muscles and joints around the neck. A yes motion is nodding your head up and down, slowly. A no motion is shaking your head left and right, slowly.
  5. Practicing good posture reduces pressure put on the spine. Practice good posture for as long as you can each day. You should be able to comfortably exercise good posture for longer and longer with each passing day.

Discontinue any exercise or movement that triggers pain. Feeling pain is a sign you should rest and not push yourself further.

5. Prolotherapy

Prolotherapy is a relatively new treatment option for patients with cervical instability, often with no adverse side effects.

Prolotherapy is a regenerative injection technique that aims to stimulate the body’s natural healing processes to strengthen and repair injured joints and ligaments.

It is “intended for acute and chronic musculoskeletal injuries, including those causing chronic neck pain related to underlying joint instability and ligament laxity,” such as cervical instability.

A 2007 case series showed that prolotherapy consistently improved neck pain in whiplash patients.

Stem cell prolotherapy is also a burgeoning treatment for ligament repair.

Prolotherapy injections offer cervical instability patients an alternative to surgery.

But, prolotherapy has yet to prove if it can offer permanent and repeatable treatment results. Many patients seek out combination chiropractic and physical therapy after undergoing prolotherapy treatment that didn’t provide lasting pain relief. 

How to Prevent Cervical Instability

Cervical instability is common in people with connective tissue disorders. Individuals at a higher risk, like Ehlers-Danlos syndrome, will need to actively prevent cervical instability.

To prevent cervical instability:

  • Regularly visit your chiropractor
  • Do chin tucks for one minute, every day
  • Practice good posture every day
  • Avoid situations associated with whiplash or other trauma to the spine

Everyone should follow these tips for good overall health, but particularly individuals with connective tissue disorders or malformations of the neck or spine.

Prognosis & Long-Term Outlook

Cervical instability is somewhat rare, but it is likely underdiagnosed. For example, connective tissue disorders that can trigger cervical instability affect at least 1 in 5,000 people worldwide.

If you are experiencing any symptoms of cervical instability, contact your doctor or chiropractor right away.

This is a manageable disorder, but only with high-quality treatment, such as physical therapy or chiropractic adjustments.

Click here today to make your appointment at Denver Upper Cervical Chiropractic. Here, we empower patients to take part in their whole person healing, and we want to help YOU with your cervical instability.

  1. Tominaga, Y., Maak, T. G., Ivancic, P. C., Panjabi, M. M., & Cunningham, B. W. (2006). Head-turned rear impact causing dynamic cervical intervertebral foramen narrowing: implications for ganglion and nerve root injury. Journal of neurosurgery: Spine4(5), 380-387. Full text: http://www.danmurphydc.com/wordpress/wp-content/uploads/archive/2006/Article_22-06.tominaga.pdf
  2. Lummel, N., Bitterling, H., Kloetzer, A., Zeif, C., Brückmann, H., & Linn, J. (2012). Value of “functional” magnetic resonance imaging in the diagnosis of ligamentous affection at the craniovertebral junction. European Journal of Radiology81(11), 3435-3440. Abstract: https://pubmed.ncbi.nlm.nih.gov/22762971/
  3. Rebbeck, T., & Liebert, A. (2014). Clinical management of craniovertebral instability after whiplash, when guidelines should be adapted: A case report. Manual therapy19(6), 618-621. Abstract: https://pubmed.ncbi.nlm.nih.gov/24560490/
  4. Fan, S. T. (2018). Clinical observation on cervical chiropractic for cervical spondylosis of vertebral artery type. Journal of Acupuncture and Tuina Science16(2), 115-119. Abstract: https://link.springer.com/article/10.1007/s11726-018-1034-2
  5. Wang, Y., Xu, M., & Shi, Y. (2020). Efficacy of spinal chiropractic manipulative therapy for adjusting the relationship between cervical facet joints to treat headache caused by acute mountain sickness. Journal of International Medical Research48(1), 0300060519898005. Full text: https://journals.sagepub.com/doi/full/10.1177/0300060519898005
  6. Dyck, V. G. (1981). Upper cervical instability in Down’s syndrome: a case report. The Journal of the Canadian Chiropractic Association25(2), 67. Full text: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2484266/pdf/jcca00090-0029.pdf
  7. Agarwal, A. K., Peppelman, W. C., Kraus, D. R., Pollock, B. H., Stolzer, B. L., Eisenbeis, C. H., & Donaldson, W. F. (1992). Recurrence of cervical spine instability in rheumatoid arthritis following previous fusion: can disease progression be prevented by early surgery?. Journal of rheumatology19(9), 1364-1370. Abstract: https://pubmed.ncbi.nlm.nih.gov/1433002/
  8. Maniker, A. H., Schulger, M., & Duran, H. L. (1995). Halifax clamps: efficacy and complications in posterior cervical stabilization. Surgical neurology43(2), 140-146. Abstract: https://pubmed.ncbi.nlm.nih.gov/7892658/
  9. Yuan, B., Zhou, S., Chen, X., Wang, Z., Liu, W., & Jia, L. (2017). Gallie technique versus atlantoaxial screw-rod constructs in the treatment of atlantoaxial sagittal instability: a retrospective study of 49 patients. Journal of Orthopaedic Surgery and Research12(1), 105. Full text: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5504836/
  10. Huang, K. Y., Lin, R. M., & Fang, J. J. (2016). A novel method of C1–C2 transarticular screw insertion for symptomatic atlantoaxial instability using a customized guiding block: A case report and a technical note. Medicine95(43). Full text: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5089091/
  11. Chang, H., Park, J. B., Choi, B. W., Kang, J. W., & Chun, Y. S. (2019). Posterior Sublaminar Wiring and/or Transarticular Screw Fixation for Reducible Atlantoaxial Instability Secondary to Symptomatic Os Odontoideum: A Neglected Technique?. Asian spine journal13(2), 233. Full text: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6454275/
  12. Young, B. A., & Ross, M. D. (2009). Neck pain and headaches in a patient after a fall. Journal of Orthopaedic & Sports Physical Therapy39(5), 418-418. Full text: https://www.jospt.org/doi/full/10.2519/jospt.2009.0405
  13. Engquist, M., Löfgren, H., Öberg, B., Holtz, A., Peolsson, A., Söderlund, A., … & Lind, B. (2013). Surgery versus nonsurgical treatment of cervical radiculopathy: a prospective, randomized study comparing surgery plus physiotherapy with physiotherapy alone with a 2-year follow-up. Spine38(20), 1715-1722. Full text: https://www.diva-portal.org/smash/get/diva2:656650/FULLTEXT01.pdf
  14. Steilen, D., Hauser, R., Woldin, B., & Sawyer, S. (2014). Chronic neck pain: making the connection between capsular ligament laxity and cervical instability. The open orthopaedics journal8, 326. Full text: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4200875/
  15. Hauser, R. A., Steilen, D., & Gordin, K. (2015). The Biology of Prolotherapy and Its Application in Clinical Cervical Spine Instability and Chronic Neck Pain: A Retrospective Study. European Journal of Preventive Medicine3(4), 85-102. Full text: https://www.researchgate.net/profile/Ross_Hauser2/publication/281131818_The_Biology_of_Prolotherapy_and_Its_Application_in_Clinical_Cervical_Spine_Instability_and_Chronic_Neck_Pain_A_Retrospective_Study/links/57b46ab708ae19a365fae7b3.pdf
  16. Hooper, R. A., Frizzell, J. B., & Faris, P. (2007). Case Series on Chronic Whiplash-Related Neck Pain Treated with Intra-articular Zygapophysial Joint Regeneration Injection Therapy. Pain Physician10(2), 313. Full text: https://stemcellarts.com/wp-content/uploads/2013/03/Prolotherapy-NeckPain-Chronic-Whiplash.pdf
  17. Alderman, D., Alexander, R. W., Harris, G. R., & Astourian, P. C. (2011). Stem cell prolotherapy in regenerative medicine: background, theory and protocols. J Prolother3(3), 689-708. Full text: http://journalofprolotherapy.com/stem-cell-prolotherapy-in-regenerative-medicine-background-theory-and-protocols/
  18. Centeno, C. J., Elliott, J., Elkins, W. L., & Freeman, M. (2005). Fluoroscopically guided cervical prolotherapy for instability with blinded pre and post radiographic reading. Pain Physician8(1), 67-72. Full text: https://www.painphysicianjournal.com/current/pdf?article=Njg%3D&journal=22