Understanding Spinal Instability

Estimated reading time: 8 minutesI am often astounded by the choice of words and language that is used with patients about their spines. As therapists and clinicians, we need to be mindful of how we explain things to patients and clients so that we do not create fear, misunderstandings, or a sense of vulnerability.

Language can lead a patient to unnecessary worry, fear avoidance behaviors, and fear of injury. For example, being told that your spine is fragile or that you need to protect your spine at all costs is not a very helpful message.

Or ‘you have the spine of an 80-year-old’ in your 30’s. How about the good one about degenerative disc disease (DDD) – that your spine is wearing out? DDD is a normal part of aging – I have many clients with DDD, and they do not have any pain. The fact that it is called a disease makes it sound scary.

I would like to change the narrative around the spine – it is actually an incredibly strong structure that is designed to bear loads and transmit force. Of course, certain conditions and injuries, as discussed below, may need us to be cautious. However, we do not want to live in fear of hurting ourselves. But even injuries like disc herniations become ‘old and cold.’ They don’t have to be a limiting factor in our daily life.

Even with hypermobility and hEDS, the spine can be strong and resilient. Hypermobility does not equal instability. You can be hypermobile but still maintain control and stability of the spine. With appropriate movement practices, we can maintain a healthy spine and enjoy moving regularly.

The Anatomy of the Spine: The Basics

The spine or vertebral column is composed of 7 cervical vertebrae of the neck, 12 thoracic vertebrae of the upper back, 5 lumbar vertebrae in the lower back, 5 sacral vertebrae that are fused together to form the sacrum, and 4 coccygeal vertebrae that are fused together to form the coccyx. The 33 vertebrae each have a central canal that the spinal cord runs through (1). They increase in size the lower they are, because the weight they carry increases informedhealth).

The spine holds up the head, transfers the weight of the trunk and abdomen to the legs, protects the spinal cord, allows you to bend and twist, and helps you stand (1, 2).

The spine normally has three curves: a c C-shaped curve or lordosis at the neck, a small curve at the upper back in the opposite direction, and then another small lordosis at the lower back. These curves help with balance, act as a shock absorber, and protect the individual bones (2).

Between the body of the vertebrae are the spinal discs (not including the sacrum and coccyx). These discs allow the spine to move, rotate, bend, and act as shock absorbers. They compress and decompress as we move and put pressure on the spine. These discs naturally undergo degeneration and decrease in width with age (2).

Original: ArcadianVector: Pixelsquid🎱, Public domain, via Wikimedia Commons

What Is Spinal Instability?

Different types of clinicians may provide different answers for the definition of spinal instability. According to one review, physicians and surgeons require evidence of fracture or the migration of the vertebrae forward or backward on an X-ray with flexion and extension views which is called mechanical instability (3).

Others may define it as functional instability when there is an increase in spinal motion and a significant decrease in the spinal stabilizing system – so there is too much spinal motion for what the ligaments, muscles, and neurological system can control (3).

Identifying the Causes and Types of Spinal Instability

Spinal instability can occur due to ligament laxity (like that found in connective tissue disorders) and trauma (4, 5). There are multiple conditions associated with instability that can be found in people with hypermobility and EDS.

• Craniocervical instability (CCI) or Upper Cervical Instability (UCI) – when the ligaments that connect the skull and spine are lax.
  • When there is laxity between the skull and cervical vertebrae 1 (the atlas or C1) it is considered atlano-occipital instability (AA1) or CCI.
  • When it occurs at C1 or C2 (the axis), it is atlantoaxial instability (AAI). UCI is the term for both AOI/CCI and AAI – so instability at the first two vertebrae of the neck (6).
  • UCI is a term that encompasses both CCI and AAI.
• Lower cervical instability occurs below C2 and is often associated with spondylosis(see below) and degeneration of the intervertebral discs (5).
• Segmental Instability happens when vertebrae move more than normal. With flexion (bending forward) and extension, this increased movement can impact the spinal cord (4)
• Spondylosis is noninflammatory disc degeneration and often occurs after mild segmental instability or the vertebrae moving more than normal (4). But remember, disc degeneration is a normal part of aging.
• Kyphosis is when the upper back curves forward more than normal. In hypermobility, this is often seen as a result of cervical and thoracic instability. There is a loss of the normal curvature of the neck (cervical lordosis) and an increase in kyphosis, which can contribute to neck and chest pain (4).
• Pars defect refers to a stress fracture or defect in the pars interarticularis, a small segment of bone that connects the upper and lower facets of a vertebra.

Recognising Symptoms of Spinal Instability

Symptoms of segmental instability are likely related to the impact of spinal movement affecting the spinal cord and can present as things like (4):

• Pain and disability
• Sensory changes
  • Acute or chronic hypoesthesia (partial or total loss of sensation), hyperesthesia (increased sensitivity to sensory stimulation) paresthesia (“pins and needles” tingling, burning, numbness)
• Changes in reflexes

Please speak with your medical team if you are experiencing sensory changes, or if there is a marked increase in your symptoms. There can be many causes for some of these symptoms that they can rule out.

Symptoms of UCI (CCI/AAI/AOI) can vary based on severity and can present with musculoskeletal symptoms or neurological symptoms. Some of these include (6):

Musculoskeletal:

• Heavy bobble head feeling – bracing feels like it decreased symptoms
• Sub-occipital headaches
• Tinnitus
• Dizziness
• Neck tension and spasm
• Clicking of neck associated with movement
• Lump in throat, trouble swallowing

Neurological:

• Seizure like activity (non-epileptic seizures or pseudo seizures)
• Drop attack associated with neck movement (not dysautonomia)
• Facial tingling/numbness
• Vision changes
• Ataxia – poor coordination
• Dystonia – involuntary muscle contractions
• Symptoms of dysautonomia – especially if not responding to standard treatment
• Cognitive changes

You can find out more about UCI and management strategies specific to this type of spinal instability in our blog Understanding hypermobility in the neck.

Diagnostic Methods for Spinal Instability

In the literature, there is some controversy about how to diagnose spinal instability and whether imaging should be used, or indirect signs. Imaging does not always correlate with clinical findings (4).

A physical therapist or physiotherapist can examine you to determine if spinal instability may be playing a role in back pain. There are specific movement patterns they can clinically assess that point to spinal instability. This increased motion between vertebrae can result in altered movement patterns with forward bending and straightening (3).

Some of these signs include (3):

• A painful motion with forward bend or returning to upright
• A catch resulting in shaking, juddering, or sudden changes in speed of motion when moving the trunk
• Alterations in hip and spine rhythm when bending forward and straightening
• Gower’s sign – using the hands to climb on the thighs to return to upright from bending forward

Diagnostic approaches for UCI/CCI/AAI

According to Gensemer, et al.,  evaluation of spinal instability can be tricky because imaging is often done static and lying down, whereas hypermobility and instability are often more apparent with upright and dynamic imaging when gravity is at play (5). Dynamic MRI in an upright position is recommended by EDS specialists (4). There are published angles that are assessed with imaging.

Dr. Leslie Russek along with a group of EDS and UCI specialist physical therapists and rheumatologist recently published consensus guidelines for screening for and treating UCI. This paper contains a screening tool that can be used to assess for UCI based on clinical presentation. You can find it here

Movement Therapy Approaches for Spinal Instability

A movement approach like physical therapy is the first recommendation for managing spinal instability and back pain. Specifically, exercises aimed at improving control and coordination of the trunk muscles (3). It is recommended to work with physical therapists who are knowledgeable in ligament laxity to treat spinal instability (4).

In a 2017 study, researchers sought to see what effect an 8-week stabilization program would have on pain, postural stability, and muscle endurance of the trunk muscles in women with benign joint hypermobility syndrome (BJHS). This was before the publication of the 2017 diagnostic criteria and BJHS was defined as “an inherited connective tissue disorder with hypermobility in which musculoskeletal symptoms occur in the absence of a systematic rheumatologic disease (7).” The use of the terms BJHS and Joint hypermobility syndrome were discontinued and replaced with Hypermobility Spectrum Disorder (HSD) and hypermobile Ehlers-Danlos Syndrome (hEDS) (8).

• What they did: Women aged 18-30 with BJHS volunteered – there were strict exclusion criteria that excluded people with other connective tissue disorders, like Marfan Syndrome, EDS, and chronic illness.
• How they did it: Participants were randomly assigned to two groups – an 8-week stabilization exercise program (n=20) or a control group with no program (n=18). The exercise program was run by a physiotherapist 3 days a week with 10 minutes of warm-up, 25 minutes of stabilization exercises, and 5-10 minutes of cool-down including stretching.
• The Findings: They found with the 8-week program, participants had decreased pain intensity, improved endurance of the trunk muscles, and improved dynamic stability with eyes open (7).

This is a small study on a pretty homogenous group (women aged 18-30), so results cannot be vastly generalizable, but it does point to a potential role for stabilization exercises in hypermobility.

The Myth of Core Stability

There is also a narrative that a weak core makes your spine vulnerable. There has been so much focus on core stability that I did a video about this.

Concerning these comments about a “weak core” being the cause of so many spinal issues, Eyal Lederman states there were several assumptions made that research just cannot back up. For example, weak abdominal muscles lead to back pain, or that there is a unique group of core muscles that you can “activate” independently of the other muscles, or that the transversus abdominis muscle is more important for stabilization of the spine than the other muscles. The research just does not support these ideas (9).

We need to find balance through the whole structure, muscles do not act in isolation.

Tips for Supporting Spinal Instability

Here are some strategies I recommend for supporting spinal instability

• I always start with the breath as this brings awareness to alignment and areas of tightness and restrictions. Learning diaphragmatic breath can help with lumbar stability too.
• Proprioception training and awareness are key. Becoming aware of how we stand or sit. Do we stand in an optimal position or are we allowing gravity to pull us into a more flexed posture?
• Overall muscle and postural tone attained through whole body awareness and exercises.
• Start with supine stability exercises like knee rolls, knee drops, bridge, pelvic rolls, arm rolls, and so on. Here’s a great movement snack to get started.
• Work on control. This is why I advocate that it is not about the range of movement, but the control. If you’re hypermobile, we already know you probably have a big range of motion. So we don’t need to work on that, but we probably need to work on controlling it so that structural alignment can be maintained.
• Pain could cause compensatory movement patterns that put excess strain on certain areas. Remember the body takes the path of least resistance. If I have pain somewhere in my spine, I will probably restrict that area but that means the forces will go through fewer joints. These joints could become more unstable and inflamed. Working on pain management could help address this.
• Building up to standing exercises when ready. Gravity is going to challenge our stability, especially when upright. Doing specific standing exercises can help strengthen you in this position.
• Use braces or orthotics to help improve overall stability if you need them. The Body Braid has had great feedback from our community about its ability to support the spinal alignment.
• Address ergonomics. Invest in a good chair with lumbar support, or head support, and position computer screens at the right level so that the cervical spine is in a good alignment.

With appropriate exercise, spinal instability can be manageable. I work with many patients with cervical instability with great success and reduction in pain and neurological symptoms. Lumbar instability can be improved through suitable, gentle movements. We can start in a supine position whilst we improve control, awareness, and proprioception. The Zebra Club is a great place to work on breath, proprioception, control, and stability.

Here’s a quick little video on lumbar instability you may find helpful.

FAQ

Can an MRI show spinal instability?

Not in a passive MRI scan.  You would need to move during the scan – this is how cervical instability is diagnosed.  People are asked to do certain movements and the degree of instability can be measured and observed.

What does spinal instability feel like?

Everyone is going to experience symptoms differently. Common symptoms could be localized pain like the low back region, sharp pains with certain movements, or referred pain down the legs or arms if cervical instability. There may be spasms as the muscles try to stabilize the area. Some people feel weakness and a sense of giving way.

Does lumbar instability need surgery?

Surgery should always be the last option when all other avenues have been explored. Surgical intervention like spinal fusions may be necessary in severe cases when conservative medical approaches have not been successful.