1. Cervical Instability

2. 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

3. Atlantoaxial Joint Transverse Ligament of the Atlas

4. Atlantoaxial Joint Tectorial Membrane

5. Atlantoaxial Joint Alar Ligament and Transverse Ligament

6. 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

7. Mechanism Of Injury Traumatic Systemic Congenital Whiplash
Fractures, Dislocations
Surgery
Systemic
Upper Respiratory Infection
Congenital
Down Syndrome RA
Os Odontoideum
Klippel-Feil Syndrome
Hypermobility Syndrome

8. Associated Pathologies
Cervical Artery Dysfunction
Cervical Myelopathy
Cervicogenic Headaches

9. 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

10. Subjective Signs of neurological or vascular compromise 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

11. Objective Based on Subjective History
May not be appropriate in some cases
Start with cranial nerve and BP testing

12. Objective Serious (Static Stability) Non Serious (Neuromuscular)
Reduced sensation
Reduced power
Reflex changes
Cranial Nerve Changes
Significant muscle spasm
Reluctance to move
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

13. Special Tests Sharp Purser Alar Ligament Testing
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 mins

14. Further Investigation
MRI
X-ray
Open Mouth X-Ray

15. 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

16. Conservative - Management
Sensorimotor rehabilitation
Cervical and scapular rehabilitation
Manual Therapy to Thoracic Spine
Acupuncture for pain relief

17. Surgical - Management
Depends on pathology causing instability

18. References
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