Cervical Anterolisthesis at the C2–C3

Anatomy of the C2–C3 Region
Types of Anterolisthesis
Causes
Symptoms
Diagnostic Tests
Non-Pharmacological Treatments
Pharmacological Treatments (Drugs)
Surgical Options
Prevention Strategies
When to See a Doctor
Frequently Asked Questions

Cervical anterolisthesis at C2 over C3 occurs when the second cervical vertebra (axis) slips forward relative to the third cervical vertebra (C3). This forward slip can compress nerves or the spinal cord, leading to pain or neurologic symptoms. Radiopaedia

Anatomy of the C2–C3 Region

Structure and Location

The axis (C2) is the second cervical vertebra, unique for its odontoid process (dens), which projects upward to form a pivot joint with the atlas (C1). C3 is a typical cervical vertebra with a small body, bifid spinous process, and transverse foramina for the vertebral arteries. Together, C2–C3 lie in the upper part of the neck, just below the skull base. RadiopaediaKenhub

Origin and Insertion of Key Ligaments

Alar ligaments originate on the sides of the dens of C2 and insert on the medial aspects of the occipital condyles, stabilizing axial rotation. Kenhub
Apical ligament connects the tip of the dens to the anterior margin of the foramen magnum, helping guard against excessive flexion. Kenhub
Anterior longitudinal ligament spans from the base of the skull to the sacrum along the anterior vertebral bodies, restraining hyperextension. Kenhub
Posterior longitudinal ligament runs within the spinal canal on the posterior aspects of vertebral bodies from C2 to the sacrum, limiting hyperflexion. Kenhub

Blood Supply

The vertebral arteries ascend through the transverse foramina of C1–C6, delivering blood to the cervical spinal cord and brainstem. Muscular branches from the vertebral, ascending pharyngeal, and inferior thyroid arteries supply the prevertebral muscles and ligaments in this region. Physio-pediaNCBI

Nerve Supply

The C2 and C3 spinal nerves exit above and below their respective pedicles. The dorsal rami of C2 supply the suboccipital region, while the ventral rami contribute to the cervical plexus (C1–C4), innervating anterior neck muscles and skin. TeachMeAnatomy

Functions

The C2–C3 segment of the cervical spine serves to:

Support the head’s weight, maintaining lordotic curvature.
Protect the spinal cord and nerve roots.
Enable motion: flexion, extension, lateral flexion, and rotation.
Transmit blood via the vertebral arteries.
Serve as attachment for muscles and ligaments.
Absorb shock during head and neck movements. NCBIRadiopaedia

Types of Anterolisthesis

By Grade (Myerding Classification):
- Grade I: < 25% slip
- Grade II: 25–50% slip
- Grade III: 50–75% slip
- Grade IV: 75–100% slip
- Spondyloptosis: > 100% slip Spine Info
By Etiology:
- Degenerative (age-related wear)
- Isthmic (pars interarticularis defect)
- Traumatic (fracture)
- Dysplastic (congenital malformation)
- Pathologic (tumor or infection)
- Iatrogenic (post-surgical) Wikipedia

Causes

Degenerative Disc Disease
Discs between C2 and C3 dry out and lose height with age, reducing stability and allowing forward slip. Cleveland Clinic
Facet Joint Degeneration
Wear of the C2–C3 facet joints (“doorstops” of the spine) diminishes their locking ability, permitting anterolisthesis. Nature
Isthmic Spondylolisthesis
A stress fracture in the pars interarticularis of C2 may allow forward slippage over C3. Wikipedia
Traumatic Injury
High-energy hyperflexion injuries can fracture C2 structures (e.g., hangman’s fracture), leading to slip. Radiopaedia
Congenital Dysplasia
Birth defects in vertebral formation or ligamentous laxity can predispose to early slip. Wikipedia
Rheumatoid Arthritis
Chronically inflamed ligaments and joints at C2–C3 loosen support, enabling displacement. Kenhub
Metastatic Tumors
Cancer spread to vertebral bodies weakens bone, permitting collapse and forward slip. Wikipedia
Spinal Infection (Osteomyelitis/Discitis)
Infection erodes vertebral endplates and disc, destabilizing the segment. Wikipedia
Osteoporosis
Reduced bone density at C2 or C3 increases fracture risk and slippage. Wikipedia
Paget’s Disease of Bone
Abnormal bone remodeling weakens vertebrae, predisposing to slip. Wikipedia
Ankylosing Spondylitis
Fusion of facet joints above and below C2 can redirect stresses, causing slip at adjacent segments. Wikipedia
Diffuse Idiopathic Skeletal Hyperostosis (DISH)
Excessive ligament calcification stiffens nearby segments, stressing C2–C3. Wikipedia
Ossification of the Posterior Longitudinal Ligament (OPLL)
Posterior longitudinal ligament thickens, compressing and shifting vertebrae. Wikipedia
Idiopathic Ligamentous Laxity
Generalized laxity (e.g., Ehlers–Danlos syndrome) allows excessive vertebral movement. Wikipedia
Down Syndrome
Atlantoaxial instability in Down syndrome increases risk of slip at C2–C3. Wikipedia
Iatrogenic Injury
Excessive bone removal during cervical surgery can destabilize C2–C3. Wikipedia
Radiation Therapy
Radiation-induced bone weakening may lead to vertebral collapse and slip. Wikipedia
Hyperparathyroidism
Excess PTH weakens bone, increasing fracture and slip risk. Wikipedia
Mechanical Overload
Chronic heavy lifting or contact sports stress C2–C3, leading to micro-injuries and slip. Wikipedia
Uncovertebral Joint Hypertrophy
Enlargement of uncovertebral (Luschka) joints can narrow the canal and shift vertebrae. Verywell Health

Symptoms

Neck Pain: Aching or sharp pain localized to C2–C3. Cleveland Clinic
Stiffness: Difficulty turning or bending the neck. Mayo Clinic
Muscle Spasms: Involuntary contractions of neck muscles. OrthoInfo
Radicular Arm Pain: Shooting pain radiating down the shoulders or arms. St. Elizabeth Healthcare
Paresthesia: Numbness or tingling in the arms, hands, or fingers. OrthoInfo
Weakness: Reduced strength in arm or hand muscles. Vitalis Physiotherapy
Headache: Occipital headaches from upper cervical nerve irritation. OrthoInfo
Grinding Sensation: “Crepitus” when moving the neck. OrthoInfo
Limited Range of Motion: Reduced flexion, extension, or rotation. Cleveland Clinic
Balance Issues: Unsteady gait if spinal cord is compressed. OrthoInfo
Clumsiness: Difficulty with fine motor tasks (buttons, writing). OrthoInfo
Hyperreflexia: Exaggerated reflexes below the injury level. PMC
Babinski Sign: Upgoing plantar reflex indicates myelopathy. PMC
Lhermitte’s Sign: Electric shock–like sensation on neck flexion. PMC
Bladder or Bowel Dysfunction: Urgency, incontinence in severe cord compression. PMC
Dizziness: Vertebral artery compression can cause lightheadedness. Physio-pedia
Visual Disturbances: Rarely from vertebrobasilar insufficiency. Physio-pedia
Ear Fullness or Tinnitus: From cervicogenic causes. OrthoInfo
Sleep Disturbance: Pain interfering with sleep position. Cleveland Clinic
Fatigue: Chronic pain leading to exhaustion. Cleveland Clinic

Diagnostic Tests

Plain X-ray (Lateral View): Visualizes slip and grade. Radiopaedia
Flexion-Extension X-rays: Assesses dynamic instability. Radiopaedia
Magnetic Resonance Imaging (MRI): Evaluates cord compression and soft tissues. Radiopaedia
Computed Tomography (CT): Detailed bony anatomy and fracture lines. Radiopaedia
CT Myelography: Enhanced canal imaging if MRI contraindicated. Radiopaedia
Electromyography (EMG) and Nerve Conduction Studies: Detect nerve root irritation. AAFP
Somatosensory Evoked Potentials (SSEPs): Tests spinal cord conduction. AAFP
Motor Evoked Potentials (MEPs): Assesses corticospinal tract integrity. AAFP
Bone Scan: Identifies stress fractures or infection. PMC
Blood Tests: ESR, CRP for inflammatory or infective causes. NCBI
Rheumatoid Factor / Anti-CCP: In suspected RA. Kenhub
HLA-B27: In suspected ankylosing spondylitis. Kenhub
CT Angiography: If vertebral artery involvement suspected. Physio-pedia
Dynamic CT: Quantifies slip during motion. Radiopaedia
Ultrasound of Vertebral Artery: Doppler flow assessment. Physio-pedia
Plain Radiograph (AP View): For coronal alignment. Radiopaedia
Flexion-Extension MRI: Dynamic cord compression. Radiopaedia
Myelography with CT: Canal patency if MRI not available. Radiopaedia
CT-Guided Biopsy: For suspected neoplasm or infection. Wikipedia
Dual-Energy X-ray Absorptiometry (DEXA): For bone density. PMC

Non-Pharmacological Treatments

Physical Therapy: Strengthening and stabilization exercises. Mayo Clinic
Cervical Traction: Temporary relief by unloading the spine. Mayo Clinic
Soft Cervical Collar: Short-term immobilization. Medscape
Rigid Orthoses (e.g., Philadelphia Collar): For severe instability. Medscape
Heat Therapy: Muscle relaxation and pain control.
Cold Therapy: Reducing acute inflammation.
Massage: Myofascial release to ease spasms. AAFP
Chiropractic Mobilization: Gentle joint mobilizations if no instability. AAFP
Acupuncture: Pain modulation through needle stimulation.
Yoga: Promotes flexibility and posture.
Pilates: Core stabilization and control.
Postural Training: Ergonomic education for daily activities. Patient Care at NYU Langone Health
Ergonomic Adjustments: Desk setup and lifting techniques.
Stretching Exercises: Improve flexibility of neck muscles. AAFP
Aerobic Exercise: Low-impact cardio (walking, swimming).
Transcutaneous Electrical Nerve Stimulation (TENS): Pain relief via electrical currents. NCBI
Ultrasound Therapy: Deep heat to soft tissues. PMC
Low-Level Laser Therapy: Tissue healing and analgesia. PMC
Spinal Decompression: Mechanical unloading in a clinic setting.
Kinesio Taping: Proprioceptive support for muscles.
Biofeedback: Training to reduce muscle tension.
Relaxation Techniques: Stress reduction to ease pain.
Mindfulness Meditation: Chronic pain management.
Tai Chi: Gentle movements for balance and strength.
Ergonomic Pillows and Mattresses: Optimal cervical support during sleep.
Weight Management: Reducing load on spine.
Smoking Cessation: Improves bone health and healing.
Patient Education: Understanding condition and self-management. Patient Care at NYU Langone Health
Activity Modification: Avoiding aggravating movements. Patient Care at NYU Langone Health
Ergonomic Tools: Cervical pillows, seat supports.

Pharmacological Treatments (Drugs)

Ibuprofen (NSAID) – first-line for inflammation and pain. Mayo Clinic
Naproxen (NSAID) – longer-acting anti-inflammatory. Mayo Clinic
Diclofenac (NSAID) – potent COX inhibitor.
Celecoxib (COX-2 inhibitor) – less GI irritation.
Meloxicam (NSAID) – selective COX-2.
Indomethacin (NSAID) – used in acute flair.
Acetaminophen – mild analgesic without anti-inflammatory effect.
Cyclobenzaprine – muscle relaxant for spasm relief.
Tizanidine – central α2-agonist muscle relaxant. Medscape
Gabapentin – for neuropathic pain. PubMed
Pregabalin – similar to gabapentin. PubMed
Duloxetine – SNRI for chronic pain. PubMed
Tramadol – weak opioid for moderate pain.
Codeine – low-potency opioid.
Prednisone – short-course oral steroid for inflammation. Mayo Clinic
Epidural Steroid Injection – targeted anti-inflammatory. NCBI
Facet Joint Injection – for facet-mediated pain. NCBI
Medial Branch Block – diagnostic and therapeutic for facet pain. NCBI
Lidocaine Patch – topical local anesthetic.
Capsaicin Cream – depletes substance P for pain relief. PMC

Surgical Options

Anterior Cervical Discectomy and Fusion (ACDF) – removes disc and fuses C2–C3 to restore alignment. PMC
Anterior Cervical Corpectomy and Fusion – for more extensive decompression. PMC
Posterior Cervical Laminectomy – decompresses spinal cord via posterior approach. PMC
Posterior Cervical Fusion (Occiput–C3) – stabilizes unstable segments. PMC
Laminoplasty – expands spinal canal while preserving motion. PMC
Foraminotomy – enlarges nerve root exit holes. PMC
Artificial Cervical Disc Replacement – maintains motion at C2–C3. PMC
Posterior Instrumented Fusion – rods/screws fixate vertebrae. PMC
Minimally Invasive Endoscopic Decompression – less tissue disruption. PMC
Combined Anterior–Posterior Approach – for severe deformity and instability. PMC

Prevention Strategies

Maintain Good Posture – keeps cervical spine aligned.
Ergonomic Workstation – screen at eye level, supportive chair.
Neck Strengthening Exercises – build muscle support around C2–C3. AAFP
Regular Stretching – maintain flexibility. AAFP
Proper Lifting Techniques – avoid sudden neck flexion under load.
Weight Management – reduces mechanical stress.
Avoid High-Risk Sports Without Protection – reduce trauma risk. Verywell Health
Stop Smoking – improves bone health and tissue repair.
Stay Active – low-impact aerobic exercise keeps spine healthy.
Early Treatment of Neck Pain – prevents chronic instability. Patient Care at NYU Langone Health

When to See a Doctor

Persistent or Worsening Neck Pain lasting > 4 weeks.
Neurological Signs: numbness, weakness, or reflex changes.
Myelopathic Symptoms: balance problems, bladder or bowel dysfunction.
Severe Trauma to the neck.
Systemic Signs: fever, weight loss, night sweats (infection or malignancy). Mayo Clinic

Frequently Asked Questions

What exactly is cervical anterolisthesis?
Anterior slip of one vertebra (C2) over another (C3), which can compress nerves or the spinal cord. Radiopaedia
How is it diagnosed?
Through X-rays (lateral and flexion–extension), MRI for cord evaluation, and CT for bony detail. RadiopaediaRadiopaedia
Can it heal on its own?
Low-grade slips (Grade I) may stabilize with conservative care; higher grades often need surgery. Spine Info
What non-surgical treatments help most?
Physical therapy, cervical traction, posture correction, NSAIDs, and sometimes brace use. Mayo ClinicMedscape
When is surgery recommended?
If there’s progressive neurologic deficit, intractable pain despite ≥ 3 months of conservative care, or severe instability.
What are the risks of surgery?
Infection, bleeding, nerve injury, fusion failure, and adjacent segment degeneration. PMC
Can exercise worsen anterolisthesis?
Improper high-impact or flexion-based exercises can aggravate slip; guided PT is safer. AAFP
Is it hereditary?
Some congenital forms (dysplastic/dysfunctional facets) may run in families. Wikipedia
Will it progress over time?
Degenerative slips may worsen; monitoring with periodic imaging is essential.
Are there long-term complications?
Chronic pain, myelopathy, loss of function, and risk of falls or cord injury. PMC
How long is recovery after surgery?
Fusion procedures often require 3–6 months for solid bone union; full activity may take up to a year. PMC
Can children get this condition?
Physiologic “pseudosubluxation” of C2 on C3 is common in children < 7 years and usually harmless. Radiopaedia
Does weight affect it?
Excess weight increases mechanical load on the cervical spine, accelerating degeneration.
Can posture correct it?
Good ergonomics and postural exercises can reduce symptoms but cannot reverse established slippage. AAFP
Is fusion always necessary?
Not for low-grade slips without neurologic signs; many patients do well with conservative care. Spine Info

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

Last Updated: May 06, 2025.

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