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Backward Slip of C2 over C3 (C2–C3 Retrolisthesis)

Dr. Lisa S. Apfel MD - Spine and Neurosurgery Dr. Lisa S. Apfel MD - Spine and Neurosurgery
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Degenerative Bones, Joints, and Spine Care (A - Z)

A backward slip of the second cervical vertebra (C2) over the third cervical vertebra (C3), medically called C2–C3 retrolisthesis, is a condition in which C2 shifts slightly backward relative to C3. This misalignment can irritate joints, nerves, and supporting tissues, leading to pain and dysfunction. Below is a comprehensive, evidence-based look at this condition in plain English, organized into clear sections for readability, visibility, and accessibility.

A retrolisthesis occurs when one vertebra moves backward on the one below it. At the C2–C3 level, even a small backward shift (often just a few millimeters) can strain neck structures. Retrolisthesis is graded by how far the vertebra has shifted:

  • Grade I: up to 25% of the vertebral width

  • Grade II: 26–50%

  • Grade III: 51–75%

  • Grade IV: 76–100%

Most C2–C3 retrolistheses are low-grade (I or II) but can still cause notable symptoms.

Anatomy of the C2–C3 Segment

Structure & Location

  • C2 (Axis): The second cervical vertebra, distinguished by its tooth-like odontoid process (dens) that pivots with C1 (atlas).

  • C3: The third cervical vertebra, with a more typical vertebral body and spinous process.

Origin & Insertion of Supporting Muscles

Key muscles attaching around C2–C3 include:

  1. Rectus capitis posterior minor

    • Origin: Posterior tubercle of C1

    • Insertion: Medial occipital bone

  2. Obliquus capitis inferior

    • Origin: Spinous process of C2

    • Insertion: Transverse process of C1

  3. Longus colli

    • Origin: Anterior tubercles of C3–C5

    • Insertion: Bodies of C2–C4 and transverse processes of C5–C6

Blood Supply

  • Vertebral arteries pass through the transverse foramina of C1–C6, supplying the cervical spine and brainstem.

  • Ascending cervical arteries (branches of the thyrocervical trunk) supply muscles and vertebral bodies.

Nerve Supply

  • C3 spinal nerve exits between C2 and C3, providing sensation to the back of the head and upper neck (via the greater occipital nerve from C2) and motor fibers to local muscles.

Functions of the C2–C3 Segment

  1. Support: Carries the head’s weight.

  2. Mobility: Allows flexion/extension and slight rotation.

  3. Protection: Shields the spinal cord and exiting nerve roots.

  4. Load Distribution: Shares forces during movement.

  5. Shock Absorption: Intervertebral disc cushions impacts.

  6. Proprioception: Joint receptors provide balance and position sense.

Types of Retrolisthesis at C2–C3

  1. Functional: Due to muscle spasm or ligament laxity, often reversible.

  2. Degenerative: From disc wear, osteoarthritis, or facet joint breakdown.

  3. Traumatic: Following trauma or sudden forced movements.

  4. Pathologic: Caused by tumors, infections, or bone disease weakening structures.

  5. Post-surgical: After cervical surgery altering alignment.

Common Causes

  1. Age-related disc degeneration

  2. Osteoarthritis of facet joints

  3. Whiplash injury

  4. Repetitive neck strain (e.g., poor posture)

  5. Rheumatoid arthritis

  6. Congenital vertebral anomalies

  7. Spinal infections (e.g., discitis)

  8. Spinal tumors

  9. Metabolic bone disease (e.g., osteoporosis)

  10. Post-surgical changes

  11. Ligamentous laxity

  12. Disc herniation causing segment instability

  13. Autoimmune conditions (e.g., ankylosing spondylitis)

  14. Facet joint cysts

  15. Down syndrome (associated ligament laxity)

  16. Spinal fractures

  17. Spondylolysis at C2–C3

  18. Chronic corticosteroid use (weakens connective tissue)

  19. Intra-articular hemorrhage from minor trauma

  20. Heavy manual labor with repeated cervical loading

Symptoms

  1. Neck pain (localized at C2–C3)

  2. Stiffness in the upper neck

  3. Headaches (occipital region)

  4. Reduced range of motion (turning or tilting)

  5. Muscle spasm in upper trapezius/neck

  6. Tenderness over C2–C3

  7. Radiating pain into shoulders

  8. Numbness in the back of scalp

  9. Tingling in upper shoulders

  10. Weakness in neck flexors or extensors

  11. Balance problems (rare)

  12. Clicking or “popping” sounds with movement

  13. Pain aggravated by extension (looking up)

  14. Difficulty swallowing (rare, if severe)

  15. Visual disturbances (very rare, via cervical vertigo)

  16. Fatigue of neck muscles after minimal activity

  17. Pain at night, disrupting sleep

  18. Referred pain to the jaw or face

  19. Reduced grip strength (via C3 nerve involvement)

  20. Psychological distress due to chronic pain

Diagnostic Tests

  1. Plain X-rays (lateral view with flexion/extension)

  2. Magnetic Resonance Imaging (MRI) for soft tissues

  3. Computed Tomography (CT) for bone detail

  4. Flexion-extension radiographs

  5. Bone scan (to detect infection or tumor)

  6. Electromyography (EMG)/Nerve conduction study

  7. Ultrasound (for muscle/facet evaluation)

  8. Discography (disc pain source)

  9. Facet joint injection (diagnostic block)

  10. Provocative maneuvers (Spurling’s test)

  11. Digital motion X-ray (dynamic imaging)

  12. CT myelogram (spinal canal imaging)

  13. Blood tests (inflammatory markers, infection)

  14. Rheumatology panel (for autoimmune causes)

  15. DEXA scan (for osteoporosis)

  16. PET-CT (for malignancy evaluation)

  17. Cervical traction trial (to assess relief)

  18. Gait and balance assessment

  19. Jaw-thrust maneuver (for swallowing issues)

  20. Pain pressure threshold testing

Non-Pharmacological Treatments

  1. Heat therapy (moist hot packs)

  2. Cold therapy (ice packs)

  3. Manual therapy by a trained physical therapist

  4. Gentle cervical traction devices

  5. Cervical stabilization exercises

  6. Deep neck flexor strengthening

  7. Postural correction training

  8. Ergonomic workstation adjustments

  9. Trigger point release massage

  10. Myofascial release

  11. Ultrasound therapy

  12. Transcutaneous electrical nerve stimulation (TENS)

  13. Acupuncture

  14. Chiropractic manipulation (low-force techniques)

  15. Pilates-based neck exercises

  16. Yoga for neck flexibility

  17. Alexander Technique (postural re-education)

  18. Biofeedback for muscle relaxation

  19. Activity modification (avoiding aggravating positions)

  20. Cervical collars (soft, short-term use)

  21. Prolotherapy injections (for ligament support)

  22. Kinesiology taping

  23. Balance training

  24. Breathing exercises (to reduce muscle tension)

  25. Hydrotherapy (warm pool exercises)

  26. Cognitive behavioral therapy (for chronic pain)

  27. Mindfulness meditation

  28. Ergonomic sleep pillows (cervical support)

  29. Nutritional counseling (to support tissue health)

  30. Spinal decompression therapy (mechanical)

 Drugs (Simple Table)

Drug Name Class Typical Dose Timing Common Side Effects
Ibuprofen NSAID 200–400 mg every 6 h With meals GI upset, headache
Naproxen NSAID 250–500 mg twice daily Morning & night Indigestion, dizziness
Diclofenac NSAID 50 mg three times daily With food Liver enzyme elevation
Celecoxib COX-2 inhibitor 100–200 mg daily Any time Edema, hypertension
Acetaminophen Analgesic 500–1000 mg every 6 h As needed Liver toxicity (high dose)
Ketorolac NSAID 10 mg every 4–6 h Up to 5 days Renal impairment
Gabapentin Antineuralgic 300 mg at bedtime Bedtime start Drowsiness, dizziness
Amitriptyline TCA antidepressant 10–25 mg at bedtime Bedtime Dry mouth, sedation
Cyclobenzaprine Muscle relaxant 5–10 mg up to 3× daily Bed & morning Drowsiness, dry mouth
Tizanidine Muscle relaxant 2–4 mg up to 3× daily Throughout day Hypotension, weakness
Prednisone Corticosteroid 5–10 mg daily taper Morning (to mimic cortisol) Weight gain, insomnia
Diazepam Benzodiazepine 2–5 mg up to 3× daily Bed & day Drowsiness, dependence
Duloxetine SNRI 30 mg daily Morning Nausea, dry mouth
Methocarbamol Muscle relaxant 1500 mg four times daily Daytime Dizziness, sedation
Baclofen Muscle relaxant 5 mg three times daily Daytime Weakness, sedation
Trolamine salicylate Topical NSAID Apply QID As needed Skin irritation
Lidocaine patch Topical anesthetic One patch for 12 h on Daytime Local skin reaction
Tramadol Opioid-like analgesic 50–100 mg every 4–6 h As needed Nausea, constipation
Oxycodone Opioid analgesic 5–10 mg every 4–6 h As needed Sedation, respiratory depression
Meloxicam NSAID 7.5 mg daily With food GI upset, edema

Dietary Supplements

Supplement Dosage Function Mechanism
Glucosamine 1500 mg daily Joint support Stimulates cartilage repair
Chondroitin 1200 mg daily Cartilage health Inhibits cartilage-degrading enzymes
Omega-3 fatty acids 1000 mg EPA/DHA daily Anti-inflammatory Reduces pro-inflammatory eicosanoids
Turmeric (curcumin) 500 mg twice daily Anti-inflammatory NF-κB pathway inhibition
Vitamin D3 1000–2000 IU daily Bone and muscle health Promotes calcium absorption
Magnesium 300 mg daily Muscle relaxation Calcium channel regulation
Collagen peptides 10 g daily Connective tissue support Provides amino acids for collagen synthesis
MSM (methylsulfonylmethane) 1000 mg twice daily Joint mobility Sulfur donor for connective tissue
Boswellia serrata 300 mg twice daily Anti-inflammatory 5-LOX enzyme inhibition
Vitamin C 500 mg daily Antioxidant support Collagen synthesis cofactor

Surgical Options

  1. Anterior cervical discectomy and fusion (ACDF) at C2–C3

  2. Posterior cervical fusion

  3. Laminectomy (removal of the lamina)

  4. Foraminotomy (widening nerve exit)

  5. Disc replacement (arthroplasty)

  6. Posterior cervical decompression

  7. Lateral mass screw fixation

  8. Occipitocervical fusion (if instability extends)

  9. Minimally invasive microdiscectomy

  10. Cervical osteotomy (correction of alignment)

Prevention Strategies

  1. Maintain good posture (neutral spine)

  2. Ergonomic workstations (monitor at eye level)

  3. Regular neck-strengthening exercises

  4. Avoid prolonged forward head posture

  5. Use cervical support pillow

  6. Take frequent movement breaks

  7. Use safe lifting techniques

  8. Stay hydrated (disc health)

  9. Maintain healthy weight (reduces spinal load)

  10. Stop smoking (improves bone health)

When to See a Doctor

  • Severe neck pain that doesn’t improve after 1–2 weeks of home care

  • Neurological signs, such as weakness, tingling, or numbness in arms or hands

  • Loss of bladder/bowel control (emergency)

  • Fever with neck pain (possible infection)

  • Significant trauma preceding symptoms

  • Difficulty swallowing or breathing

Frequently Asked Questions

  1. What exactly is retrolisthesis?

    • It’s when one vertebra shifts backward relative to the one below.

  2. How is C2–C3 retrolisthesis diagnosed?

    • Via neck X-rays (including flexion/extension), MRI, or CT scans.

  3. Can a small backward slip cause big symptoms?

    • Yes, even a 2–3 mm shift can irritate nerves and joints.

  4. Is surgery always needed?

    • No. Most cases improve with conservative treatments.

  5. How long does recovery take?

    • With non-surgical care, 6–12 weeks; post-surgery can be 3–6 months.

  6. Can physical therapy help?

    • Yes, targeted exercises and manual therapy often relieve pain.

  7. Are braces useful?

    • Soft collars can help short-term, but long-term use is discouraged.

  8. What activities worsen it?

    • Prolonged neck extension (looking up), heavy lifting, poor posture.

  9. Can retrolisthesis lead to spinal cord injury?

    • Rarely; only in severe shifts or if left untreated with worsening instability.

  10. Is retrolisthesis reversible?

  • Functional retrolisthesis often improves with therapy; degenerative may not fully reverse.

  1. Do I need to avoid exercise?

  • No, but modify high-impact or heavy loading exercises until cleared by a professional.

  1. What lifestyle changes help?

  • Posture correction, ergonomic adjustments, regular breaks, healthy diet.

  1. Can supplements really help joint health?

  • Some (like glucosamine, omega-3) support tissue health and reduce inflammation.

  1. How can I prevent recurrence?

  • Ongoing posture awareness, neck strengthening, and ergonomic habits.

  1. When is follow-up imaging necessary?

  • If symptoms worsen or don’t improve after 8–12 weeks of treatment.

Disclaimer: Each person’s journey is unique, treatment plan, life style, food habit, hormonal condition, immune system, chronic disease condition, geological location, weather and previous medical  history is also unique. So always seek the best advice from a qualified medical professional or health care provider before trying any treatments to ensure to find out the best plan for you. This guide is for general information and educational purposes only. Regular check-ups and awareness can help to manage and prevent complications associated with these diseases conditions. If you or someone are suffering from this disease condition bookmark this website or share with someone who might find it useful! Boost your knowledge and stay ahead in your health journey. We always try to ensure that the content is regularly updated to reflect the latest medical research and treatment options. Thank you for giving your valuable time to read the article.

The article is written by Team Rxharun and reviewed by the Rx Editorial Board Members

Last Updated: May 06, 2025.

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References

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