Cervical Subluxation

What is Cervical Subluxation?

Spinal cord injury can cause multiple neurological issues and put a massive strain on the healthcare system, particularly in countries with lower income levels. Around 80% of patients with spinal cord injuries are men, and almost 60% of those affected are aged between 16 and 30 years old. Interestingly, up to 60% of the people with these injuries remain unemployed after the incident.

A significant portion of traumatic injuries to the neck, or cervical area of the spine, are subluxations. Simply put, this condition involves one of the bones in your spine slipping in relation to the bones next to it. This can result from damage to the ligaments supporting your spine, with the risk becoming notably higher for spinal cord injuries when the facets, or small joints connecting the bones of your spine, are dislocated or “jump” out of place. Partial displacement or loss of contact between the joint surfaces is referred to as subluxation, while facet dislocation happens when there is complete loss of contact. These types of damage can cause more risk of nerve injury.

The cervical spine consists of seven separate bones, each with their own roles. C1, the first bone, also known as the atlas, interacts with the skull to enable head movement, such as nodding. The second bone, aptly named the axis or C2, stands out due to a protrusion called the dens, which allows your head to rotate. The remaining bones, from C3 to C7, are what you may conceptualize as typical spinal bones with processes that help in supporting and stabilizing the neck. In between each set of these bones is a disc made of fibrous material and a jelly-like substance that cushions and allows flexibility in your spine.

The cervical spine is divided into the upper part (C1, C2), allowing head rotation, and the lower part (C3 to C7) that facilitates bending and extending movements.

The spinal cord, protected by these vertebrae, helps transmit sensory and motor signals between the brain and the body. Nerves in the neck, numbered C1 to C8, handle feeling and movement in the upper body. Each nerve leaves the spine through small openings between the bones. Sensory fibers in these nerves bring information like touch, pressure, and temperature from your upper body back to the brain, while motor fibers send signals from the brain to the muscles.

Importantly, these nerves each have their own specific roles. The C1 nerve, for example, helps with head movement, while nerves C2 through C4 contribute to a bundle of nerves known as the cervical plexus. The nerves from C5 to T1 are part of the brachial plexus, acting on muscles and providing feeling in the upper limbs.

Another essential component of the cervical spine is the vertebral arteries that supply blood to the brain. These arteries are susceptible to trauma-induced injury. The spine is also held together by a plethora of ligaments and discs that prevent it from moving excessively. The job of facet joints is to allow the spine to move smoothly, but these can also be affected by a spinal cord injury.

What Causes Cervical Subluxation?

Cervical subluxation, which is a displacement or misalignment of the neck vertebrae, often happens due to car accidents or falls. The jolting movements in these kinds of accidents or a direct hit to the neck can cause the neck bones to move out of place.

Certain medical conditions can also make a person more likely to experience cervical subluxation, including:

* Rheumatoid arthritis, an autoimmune disease that causes joint inflammation.
* Down syndrome, a genetic disorder.
* Mucopolysaccharidoses, especially Morquio disease, a group of metabolic disorders.
* Grisel syndrome, a condition that results in abnormal neck mobility.
* Previous neck surgery or radiation.
* Dystonia, a disorder characterized by involuntary muscle contractions.
* Marfan syndrome, a genetic disorder affecting the body’s connective tissue.

It’s been found that up to 50% of people with a severe form of rheumatoid arthritis also experience cervical subluxation. Disorders like Down syndrome and Marfan syndrome can cause issues with connective tissue, which makes the ligaments in the spine looser and more likely to become injured.

Risk Factors and Frequency for Cervical Subluxation

Cervical spinal injury (CSI), or neck injury, is found in about 3.7% of all trauma patients. It’s slightly more common in patients who are unable to be evaluated, with a 7.7% occurrence rate. Alarmingly, about 42% of these neck injuries are unstable, meaning they’re severe and require immediate care.

In the general population, there are 15 to 40 new cases of spinal cord injury for every million people each year. Over half of these are neck injuries, and of those, about half show either one-sided or two-sided displacement of the spine, known as subluxations. More common than subluxations is facet dislocation, a type of spinal injury that frequently happens between the C5 and C7 spinal regions. In North America, about 150,000 new cases of neck injury are reported each year, mostly due to car accidents.

• Every year about 15 to 40 new cases of spinal cord injury are reported per million people.
• More than half of these are neck injuries.
• Approximately half of these cases present with subluxations – displacement on one or both sides of the spine.
• Facet dislocation is more common than subluxation, especially in the C5 to C7 regions.
• The majority of these injuries in North America, about 150,000 cases per year, are from road accidents.

A ten-year Australian study found that the typical cervical subluxation patients were 40-year-old manual laborers. More than half of these patients had one or both sides of a joint in their neck dislocated. The study also showed it was more common in men, with a ratio of 4 men to each woman who had a traumatic neck injury. The most common cause in younger patients was high-speed car accidents, while low-speed falls were more common in older adults. The C6 to C7 spinal region constituted 38.5% of cases, and almost 9 out of 10 patients presented with tetraplegia – paralysis of all four limbs. Nearly 60% of patients also had a facet fracture. The vast majority, 81.3%, had either a grade A or B ASIA neurological status, meaning they had significant or complete loss of sensory and motor function.

• In a ten-year Australian study, the typical cervical subluxation patients were 40-year-old manual laborers.
• The ratio of men to women with traumatic neck injury was 4:1.
• Around 56.2% of patients had unilateral or bilateral facet dislocations.
• The majority of injuries in younger patients were from high-speed car accidents, while older adults saw more injuries from low-speed falls.
• The most common affected spinal region was C6 to C7, with tetraplegia (limbs paralysis) present in 87% of these cases.
• Almost 60% of patients had a concurrent facet fracture.
• 81.3% of patients had a grade A or B ASIA neurological status, indicating severe or complete sensory and motor loss.

Signs and Symptoms of Cervical Subluxation

Managing a cervical subluxation, or a partial dislocation in the neck, often starts with a primary survey. This is where medical professionals check your airway, your breathing, and your circulation. This is particularly important when most cases come from sudden injuries. Any patients who are unconscious need immediate help following the Advanced Trauma Life Support guidelines. A stiff neck brace is used to steady the neck and protect it from further harm during the evaluation and stabilization process. After the patient is confirmed to be stable, medical professionals thoroughly check for additional serious injuries.

People with cervical subluxation often have a history of neck injuries. This could be from car crashes, falls, sports-related accidents, or direct hits to the neck. You may hear a patient complain about sudden neck pain, stiffness, or discomfort after their accident. Depending on how severe and where the subluxation is, other signs could be feeling numb, tingly, or weak in the arms or hands.

Patients may also recount specific ways their injury took place, such as their neck extending or flexing too much. This can lead to the vertebrae misaligning. A loss of consciousness or a change in mental status at the time of the injury could also indicate a traumatic brain injury. Some patients may have previous neck injuries or medical conditions that make their necks more susceptible to instability. These could be degenerative disk disease, osteoarthritis, or birth defects of the cervical spine.

Other relevant medical information may include allergies, current prescriptions, underlying health conditions (like diabetes or a weakened immune system), and history of clotting, nerve, heart, and lung conditions.

A lot of patients with cervical subluxation also have other injuries, so a complete physical examination is necessary. Monitoring the cardiorespiratory status continuously is important for determining the need for resuscitation. The extremities should also be examined for potential injuries that need immobilization. Any wounds on the head, neck, and limbs should be immediately sterilized, and bleeding needs to be controlled.

The neurological assessment should be completed according to the American Spinal Injury Association guidelines. Briefly, these include:

• ASIA A: Complete loss of motor and sensory function
• ASIA B: Incomplete injury with feeling preserved but total paralysis
• ASIA C: Incomplete injury with some motor function preserved below the injury level; less than half the muscles have a Medical Research Council grade of 3
• ASIA D: Incomplete injury with some motor function preserved below the injury level; at least half the muscles have a Medical Research Council grade of 3
• ASIA E: Normal motor and sensory function

Potential indicators of cervical subluxation include neck pain, arm pain and weakness, and spinal cord injury. A twisted neck with neck spasm is a common sign of spinal joint rotatory subluxation. Patients might also experience other symptoms, like abnormal postures, muscle spasms in the neck, and changes in skull shape.

Testing for Cervical Subluxation

If you’ve experienced a significant injury, your healthcare professional will first ensure you’re stable before evaluating the extent of your damage. They’ll use recognized protocols and scoring systems to assess potential spinal cord injury. These assessments include evaluating your nerve function and checking for damage to ligaments and blood vessels.

Imaging tests, such as x-rays, are key to understanding more about the injury. Special precautions are followed during imaging to prevent further injury, and tests are performed if you have neck pain, if you’re not fully conscious, under the influence of drugs or alcohol, have new nervous system problems, or other serious injuries.

Bone imaging can provide crucial information about any injuries you have sustained. X-rays can help medical professionals identify and locate spinal injuries and rule out fractures. They are often the only imaging method available in remote areas.

Through a series of x-ray projections, doctors can detect issues such as asymmetry, abnormal shapes, or signs of instability. Dynamic x-ray (x-ray done in various positions) is important to rule out subtle instability which could harm your spine if not treated properly. However, this type of x-ray might be limited due to pain and muscle spasms. It can also risk increasing neural damage.

Doctors also use other imaging techniques such as computed tomography (CT) scans to get a more detailed view of your bones. This can help in diagnosing conditions like locked facets, evaluating injuries to the blood vessels of the spine, and to confirm spine structure for surgical fixation.

The severity of cervical subluxation (partial dislocation of vertebrae) can be graded in terms of percentage of misalignment and visual signs. CT scans may also show certain suggestive signs of facet dislocation for better understanding of the injury.

Magnetic resonance imaging (MRI) is another imaging technique that helps to identify the type of spinal cord injury and assess the health of the ligaments. It can also help in planning surgical approach and predicting the chance of nerve recovery. In some cases, a MRI may reveal a fluid-filled cavity within the spinal cord in patients with initially missed low-grade dislocations.

In some cases, health professionals may also use a procedure called vertebral artery angiography. This procedure helps to examine the arteries in the neck that lead to the brain. This is mainly done when fractures extend to the specific part of the vertebral column which contains the vertebral artery or there’s a high-grade dislocation.

Treatment Options for Cervical Subluxation

Traumatic neck subluxations, a type of injury where the neck joints become dislocated, can vary in severity. They are broken down into three main categories: facet subluxation, which is a dislocation of the joints; unilateral facet dislocation or facet fracture and dislocation, which is dislocation or fracture of the joints on one side of the neck; and bilateral facet dislocations, which involve both sides of the neck.

If there’s a minor fracture or the joints are separated by less than 1 mm, a neck brace may be enough to manage the injury. However, if the joints are displaced, or the ligaments connecting the bones are damaged, surgery will likely be needed.

The objective of any course of treatment is to put the joints and bones back into their proper place as quickly as possible in a safe environment. This should ideally happen within four hours of the injury to help improve the chances of recovery. Skull traction, a method that uses weighted tools to straighten the neck, is commonly used. The weight is gradually increased and adjustments are guided by x-rays and periodic assessments of the patient’s neurological health.

Depending on the patient’s situation and the success of the treatment, three scenarios could take place: emergence of a new neurological issue necessitating immediate reduction of traction and urgent MRI and open reduction; the need for urgent MRI and open reduction if traction fails to achieve the needed reduction; or success of the reduction, in which case the traction is maintained, a hard collar applied, and subsequent MRI and surgical plans are made.

Surgeons usually have several choices for the approach to surgery, including anterior (front), posterior (back), or a combination of the two. The chosen approach depends on several factors including the extent of the injury, the presence of a traumatic disk herniation, and the dislocation’s reducibility, among other factors. Specific surgical plans also depend on patient characteristics, neurological status, extent of spinal slipping, and the expertise of the medical team.

Timing of surgery is important. If the dislocation of the cervical spine isn’t improving or the patient’s neurological condition is getting worse, surgery will likely be required urgently. The optimal time for surgery is within 24 hours of the injury to maximize potential neurological improvement, assuming other conditions such as disc herniations are not present.

The determination of whether an anterior or posterior surgical approach is appropriate often relies on where the compression exists. For example, if the injury has only impacted the ligaments at the back of the spine, a posterior approach would make sense. However, adopting the anterior approach often involves less blood loss and operating time.

Lastly, the management of neck subluxations also depends on the duration after the injury took place. For injuries within one week, non-surgical management like using a soft neck collar, pain medication, and physical therapy could be attempted. But for injuries that extend beyond a month, more invasive treatments are usually required, including traction therapy, immobilization, or possibly surgery.

What else can Cervical Subluxation be?

Pseudosubluxation is a term you might hear when doctors are looking at problems with the neck spine. It’s typically linked to a missing part of the neck spine called a cervical pedicle. To identify if pseudosubluxation is present, doctors use something called the Swischuk line.

Here’s how it works: a line is drawn from the front edge of the back arch of the first cervical vertebrae (C1) to the same spot on the third cervical vertebrae (C3). If the Swischuk line ends up being 2 mm or more behind the front edge of the second cervical vertebrae (C2), then it suggests that there is a problematic forward shift happening.

What to expect with Cervical Subluxation

Cervical subluxation, or a slight misalignment of the cervical spine (neck), can significantly lower a person’s quality of life and ability to function. Observations show that individuals with a completely dislocated facet (joints in the spine), when compared to their age group, are about seven times more likely to suffer from spinal cord injuries. In studies examining those with fractures or dislocations, nearly all (93.5%) resulted in tetraplegia, a condition resulting in partial or total loss of use of all four limbs and torso, usually due to spinal damage or disease.

Nearly half (44%) of these patients also experience another concurrent injury, the most common of which is a lung contusion or bruise. Over one in five (21.3%) of these patients experience at least one complication while in the hospital, the most common of which is a lung infection. Risks such as hospital-acquired pneumonia and pressure ulcers, which are sores that develop from prolonged pressure on the skin, can possibly result in permanent disability or death, especially among those with severe neurological impairments.

Many patients with poor neurological status depend entirely on caregivers for their day-to-day activities. Moreover, as many as 30% of these patients are at risk of being readmitted to the hospital due to various complications.

Regrettably, cervical subluxation can sometimes be overlooked, or the diagnosis may be delayed. This happens in about 5% to 20% of cases. It is also five times more likely to be missed compared to similar conditions affecting the thoracolumbar spine, which is the lower part of the spine. About 25% of patients show signs of disrupted disc and herniation, a condition where the soft center of a spinal disc pushes through a crack in the tougher exterior casing. An MRI scan revealing just a 1% increase in spinal cord compression can almost triple the risk of a spinal cord injury.

Open surgical correction is needed in about 26% of patients with cervical subluxation, at a rate of 3.7 surgeries per 100,000 people per year. No significant difference was found between surgery through the front (anterior approach) or back (posterior approach) in terms of improving neurological function. However, surgery from the front often results in less pain after surgery, fewer wound-related complications, and a better rate of successful spinal fusion, which is a process that joins together two or more vertebrae.

While prolonged, single-stage combined surgery can be stressful for the patient, it’s noteworthy that the mortality rate in cervical subluxation patients has decreased by 62% from 1993 to 2014. The overall death rate within 90 days after surgery was 7.1% in one study.

Possible Complications When Diagnosed with Cervical Subluxation

Cervical subluxation, or the dislocation of the neck, can cause several immediate complications:

• Neurological issues such as quadriplegia (total paralysis), quadriparesis (partial paralysis), central cord syndrome, and crisscross paralysis.
• Injury to the phrenic nerve at the C3-C5 level of the spine.
• Vertebral artery injury between C2-C6 levels of the spine.
• Spinal cord injury, such as compression, cutting, or bruising.
• Additional complications related to spinal cord injuries, like pneumonia, pressure sores, deep vein thrombosis, urinary tract infections, muscle wastage, and muscle stiffening or spasms. Roughly 84% of patients with injuries from C1 to C4 and 60% of people with injuries from C5 to C8 commonly experience respiratory problems.

The mortality rate for individuals with spinal cord injuries is nearly three times the average. Prolonged external blockage or immobilization risks worsening the severity of the condition. Moreover, there’s an increased risk of pneumonia, osteomyelitis (bone infection), sepsis (body-wide infection), deep vein thrombosis (blood clot in a deep vein), acute kidney injury, aspiration pneumonitis (lung inflamation from inhaled foreign substances), and acute respiratory distress syndrome.

Other complications include surgery site bleeding, cerebrospinal fluid leaks, recurrent laryngeal nerve damage, injury to the vertebral artery, graft rejection, increase in fluid in the spinal cord due to reperfusion (normal blood flow restored), and spinal cord herniation.

Late complications include:

• Infection at the surgical site.
• Tracheoesophageal fistula (abnormal connection between the trachea and esophagus).
• Implant failure.
• Pseudoarthrosis (non-healing of a broken bone).
• Adjacent segment disease (disease of the spinal cord adjacent to a treated area).
• Kyphotic deformity (excessive outward curvature of the spine).
• Nonunion (permanent failure of healing).

These conditions significantly disrupt normal life, creating physical, economic, social, and emotional challenges for caregivers. High treatment and rehabilitation costs, combined with lost productivity, pose a substantial challenge for individuals, families, and society.

Recovery from Cervical Subluxation

Recovery from an injury often involves the following steps:

• Ensuring the body’s structure is stable and fixed promptly.
• Focusing on keeping your spinal cord working as it should.
• Getting you moving again as soon as possible and starting well-planned recovery programs.
• Quickly putting patient care plans in place to prevent other problems from occurring.
• Working towards the patient’s survival, recovery, and getting them back to functioning as best they can.

When it comes to a neck injury called ‘cervical subluxation,’ the recovery strategies involve a variety of steps. This could include physical and occupational therapy to boost your strength, increase your mobility, and help you become more independent.

You might also use assistive devices, like braces or crutches, to help support you. Pain management techniques can help control any discomfort you’re feeling. Also, ‘neuromuscular reeducation’ is a way to improve the way you move and decrease the chances of another injury.

Education, home exercise programs, and functional training are also key parts of recovery. These strategies are tailored to each patient’s unique needs and are done with the support of a rehabilitation team made up of different health professionals.

Preventing Cervical Subluxation

Primary prevention is all about taking steps to stop a condition from occurring in the first place. In this case, it’s all about preventing injuries to your neck, specifically cervical subluxation, which is a kind of dislocation or misalignment in the neck. Some of the ways to prevent this kind of injury include carrying out educational campaigns to make people aware of the risks associated with such activities as unsafe driving and playing sports without the correct techniques. Trying to increase safety by using protective gear during activities that carry a high risk and ensuring that your workplace has been set up in a way that helps to look after your neck can also reduce the chance of ending up with cervical subluxation. Additionally, keeping your spine healthy by regular exercise, maintaining the correct posture, and avoiding neck-straining behaviors can contribute to these prevention efforts.

Secondary prevention focuses on three key areas:

* Quickly reducing and decompressing the spine and setting it in its correct place.
* Starting graded physiotherapy as soon as possible to help restore any lost neurological function.
* Stopping any further complications from happening.

In addition, carers should lend a helping hand to patients who have severe deficits in their daily activities. The plan to manage the patient’s condition should be customized to address both the patient and the carer’s needs.