How cervical spine instability disrupts blood flow into the brain and causes many neurological problems
Ross Hauser, MD
Over the many years of helping people with cervical spine problems, we have come across a myriad of symptoms that seemingly go beyond the orthopedic, musculoskeletal, and neuropathic pain problems commonly associated with cervical spine disorders, “herniated disc,’ and cervical radiculopathy. While many patients can understand that cervical neck instability can cause problems with pinched nerves and pain and numbness that can extend down into the hands or even into the feet, they can have a lesser understanding that their cervical spine instability also pinches on arteries and disrupts, impedes and retards blood flow into the brain.
We often receive emails or phone calls from people who have been on a long medical journey. They just tell one story of a problem with brain fog or memory or concentration difficulties. They tell a story of many challenges. These people stories go something like this:
Sometimes I feel like I do not get enough oxygen.
- I have had a constant problem on my left side. I have chronic left side of the head headaches, my left ear is “always stuffed,” and feels filled, I can’t hear and it hurts, I have left shoulder pain and arm pain, throat pain, brain fog, and dizziness. Sometimes I feel like I do not get enough oxygen.
More symptoms but my brain scan shows nothing. Yet I feel like I am suffocating.
- For many years I suffered from TMJ, then my TMJ was “spreading,” into other problems including tinnitus. Then the TMJ and tinnitus spread into problems with my eyesight and visual abnormalities, and dizziness, coordination and balance problems. I have concentration problems, memory problems and brain fog. It is if I live in an alternative universe. The list of my problems are much longer and are being made worse because all my brain scans show that there is nothing wrong with my brain. Yet I feel like I am suffocating.
How cervical spine instability pinches on arteries and disrupts, impedes, and retards blood flow into the brain.
This is one of the great challenges that face cervical spine or cervical neck instability patients. The understanding of what treatment may help them the best and the controversies and confusion that surround these treatments. For some cervical spine surgery is the only way, for others, non-surgical treatments may be best. But what about patients whose symptoms are at best difficult to understand or difficult to determine what is causing them?
In our office, almost all the people who have upper cervical spine instability, who come in for our non-surgical treatments, have an amazing amount of brain fog, the inability to concentrate, anxiety, and depression. These are not the typical things that doctors look for in the neck. Yet, on the point of depression, this is not a chemical depression that can be managed with antidepressants. This is a cervical spine structural depression causing altered blood flow to the brain causing an altered brain function.
A typical patient experience with altered blood flow to the brain suspected caused by suspected cervical spine – cervical neck instability:
We cite here from our article on Vertebrobasilar insufficiency – Hunter Bow Syndrome – Cervical neck instability a typical patient experience with altered blood flow to the brain suspected caused by suspected cervical spine / cervical neck instability:
Turning their head to one side or another will make the patient dizzy or blur their vision or cause ringing in the ears
“The patient will tell us that they finally went to get help because for a long time, sometimes or every time he/she turned his/her head they would get dizzy, lightheaded and sometimes have to grab onto something because they felt like they were going to faint.
During these episodes the patient would also experience fuzzy, blurry vision, ringing in the ears, and trouble with postural balance, even walking.
In more advanced situations and certainly more frightening to this patient is the “drop attack,” where they would suddenly and for seemingly no reason at all, fall to the ground and then get up as if nothing had happened a few seconds later. Of course to this patient “as if nothing happened,” is not what is going through their mind.
When they went to their primary care physician, the patient tells us, the doctor started to suspect that they, the patient, was having some sort of blockage of blood to the brain.
In the ruling out process, the physician started to look at atherosclerosis or hardening of the arteries. This problem would be suspected in patients who were older, had diabetes, high blood pressure or hypertension, smoked, were obese, or led a very poor lifestyle devoid of activity or exercise. Most likely if you were in this risk group you would have received a referral to a vascular surgeon so they could take a look. However, this group of patients can suffer both atherosclerosis and from vertebrobasilar insufficiency. In this group of patients, it would not take much by way of neck rotation compression to cut off blood flow to the brain in arteries that are internally clogged. Here surgeons may see more of an urgency to recommend a decompression surgery.
The problems and challenges these problems create for patients are very broad. We are going to narrowly focus on research and clinical observation on how reduced blood flow to the brain can be caused by cervical neck instability, and then, redirect you to pages throughout this site on the symptoms and manifestations of these problems and how we treat them.
Understanding blood flow to the brain in patients
The main advance in the understanding of blood flow to the structures in the brain, head, face, and neck including the cranial arteries has been in our opinion extracranial and transcranial doppler ultrasound, primarily because this can be done in a physician’s office by the physician or his trained staff. A problem is, is that these tests are done with the patient in a standard or static position.
Most patients know the exact head position that gives them the symptoms of dizziness, “lack of oxygen to the brain,” and related problems. I can tell you that head position is almost always when they are standing or sitting upright, not when they are lying down, as when these vascular tests are almost always done.
For many years, I ordered these tests and wanted the technician to perform the test in the patient’s “vulnerable to symptoms” position, not in the lying down position. Our patients would relay to us that, unfortunately, their tests were not done the way I ordered them primarily because the technician simply tells the patient that, “we don’t do the tests that way.”
Even when disruptions of blood flow were found on the test, the radiologist reading the test would call the test normal. Once when talking to a neurosurgeon colleague he explained “You have to learn to read the scans yourself. The radiologists don’t have experience in reading results from the craniocervical junction.” I was shocked actually when he told me this, but now I know it is true.
When cervical myelopathy patients lay prone – everything calms down – a test where you are laying down is probably not a good test if you are looking for active blood flow problems
When it gets bad, I lay down and things calm down for me.
Often people in their pre-patient interview will tell us that their brain fog and related problems reduce in severity if they lay down. Simply they say things like:
- I have neck pain, cognitive problems, insomnia, headache, dizziness, fatigue, and brain fog. When it gets bad, I lay down and things calm down for me. The problem is I am now spending days laying in bed.
In this one sentence, we can get a clue that this patient may be having problems with a diagnosis because of the way they are getting testing. As stated above, a test where you are laying down is probably not a good test if you are looking for active blood flow problems.
Anesthetized patients, when positioned prone, experience hypotension and reduction in cardiac output.
Look at this research from March 2019 published in the Indian Journal of Anesthesia.(1) It comes in part from the National Institute of Mental Health and Neurosciences in India.
Here are the summary points:
- Anesthetized patients, when positioned prone, experience hypotension and reduction in cardiac output.
- Associated autonomic dysfunction in cervical myelopathy patients predisposes them to hemodynamic (blood flow) changes.
- Thirty adult chronic cervical myelopathy patients, aged 18-65 years were observed for Heart rate, mean blood pressure, cardiac output, stroke volume, total peripheral resistance (the arteries resistance to blood flow), and stroke volume variation (“The change in the amount of blood ejected from the left ventricle into the aorta with each heartbeat.”)
Conclusion? Prone position and non-prone positions create a different blood flow.
- Cardiac output during the entire study period (prone position) remained stable
- Sixty percent of the patients experienced hypotension.
- At 15 and 20 minutes after prone positioning, mean blood pressure decreased, stroke volume increased (more blood pumped out of the hear), and heart rate and total peripheral resistance decreased. These changes were significant when compared to pre-prone position values. The number of levels of spinal cord compression positively correlated with the incidence of hypotension.
Conclusion? Prone position and non-prone positions create a different blood flow.
Whether it is flexion/extension cervical x-rays, open mouth lateral flexion x-rays, flexion/extension MRI’s, MRI’s with thin slices to examine the ligaments of the craniocervical junction or doppler ultrasound of the head and neck it is best to have the tests in house, that is the only way to guarantee that the exam was done exactly what the patient needs and interpreted correctly.
This is why our testing and treatment center is equipped with x-ray diagnostics with digital motion x-ray because the traditional scans missed so many instabilities.
Transcranial Doppler & Extracranial Doppler Ultrasound
For this and other reasons, we offer testing with Transcranial Doppler & Extracranial Doppler Ultrasound. For the full article on this testing please visit our page: Using Transcranial Doppler & Extracranial Doppler Ultrasound Testing at the Hauser Neck Center.
Here is a summary of that article and how this type of testing can show disruptions in blood flow to the brain and may help explain to patients why they feel that they are “not getting enough oxygen.”
- Transcranial doppler (TCD) can track real-time, moment-to-moment changes in blood flow to the brain. This allows for an assessment of blood flow changes to the brain and their impact of patient symptoms when the patient moves their head and creates changes in neck positioning. This includes monitoring the blood flow even while the patient walks in the office.
Understanding that blood flow may only be suppressed in certain positions of the neck
- If the blood flow is intermittently compromised, such as only when the neck is in certain positions, it will be difficult to catch and diagnose. To assess proper blood flow to the body’s most important nerves and nervous tissue (the brain), especially with head and neck motions, we perform transcranial doppler (TCD) and extracranial doppler (ECD) ultrasound examinations.
- It is through dynamic transcranial doppler (TCD) and extracranial doppler (ECD) ultrasound analysis that this decrease in blood supply can be documented with its root cause being compression of the arteries as they run through the cervical spine.
Pinpointing the position of the neck at the time of of worse brain fog and other neurological type symptoms
Commonly, a person’s history will clearly indicate that their symptoms/conditions occur when they are upright and/or while they were moving their neck, versus when they are lying flat. Any symptom that is worsened with a specific neck position or movement most likely is due to cervical instability or another neck issue. Even symptoms such as blurry vision, changes in vision, tinnitus, vertigo, poor balance, brain fog, dystonia, tremors, decreased memory, swallowing difficulty, hearing impairment, and ear fullness, as well as any type of cranial nerve issue, can be from cervical instability. One of the troubling similarities amongst the wide array of symptoms is how many patients tell us that no one else has been able to find the cause. This may be from their previously tasting’s inability to “test,” while the person is in normal daily activity. Like reaching above their head for something, turning their head to the side, or walking among other daily routines. The reason people tell us that their brain scans show nothing is that the scans are showing nothing while the patient is laying prone during their test.
Atlantoaxial instability: C1 and C2 hypermobility causes cervical spine instability and arterial compression
Atlantoaxial instability is the abnormal, excessive movement of the joint between the atlas (C1) and axis (C2). This junction is a unique junction in the cervical spine as the C1 and C2 are not shaped like cervical vertebrae. They are more flattened so as to serve as a platform to hold the head up. The bundle of ligaments that support this joint is strong bands that provide strength and stability while allowing the flexibility of head movement and to allow unimpeded access (prevention of herniation or “pinch”) of blood vessels that travel through them to the brain.
In a 2015 paper appearing in the Journal of Prolotherapy, (2) our research team wrote that cervical ligament injury should be more widely viewed as the underlying pathophysiology (the cause of) atlantoaxial instability and the primary cause of cervical myelopathy (disease) including the problems of Vertebrobasilar insufficiency.
The problems of Atlantoaxial instability are not problems that sit in isolation. A patient that suffers from Atlantoaxial instability will likely be seen to suffer from many problems as they all relate to upper cervical neck ligament damage and cervical instability. As demonstrated below this includes cervical subluxation, (misalignment of the cervical vertabrae). One of the causes of Vertebrobasilar insufficiency is this cervical mis-alignment and its “pinching,” or “herniation,” not of a disc, but of the arteries themselves as we suggested above. This creates the situation of ischemia (damage to the blood vessels).
The case for identifying loss of cervical lordosis as the cause of your symptoms
The cervical ligaments are strong bands of tissues that attach one cervical vertebra to another. In this role, the cervical ligaments become the primary stabilizers of the neck. When the cervical ligaments are healthy, your head movement is healthy, pain-free and non-damaging. The curve of your cervical spine is in correct anatomical alignment.
When the cervical spine ligaments are weakened, they cannot hold the cervical spine in proper alignment or in its proper anatomical curve. Your head begins to move in a destructive, degenerative manner on top of your neck. This is when cervical artery compression can occur.
In our 2014 research lead by Danielle R. Steilen-Matias, MMS, PA-C, published in The Open Orthopaedics Journal (2), we demonstrated that when the neck ligaments are injured, they become elongated and loose, which causes excessive movement of the cervical vertebrae. In the upper cervical spine (C0-C2), this can cause a number of other symptoms including, but not limited to, nerve irritation, vertebrobasilar insufficiency with associated vertigo and dizziness, tinnitus, facial pain, arm pain, and migraine headaches.
Treating and stabilizing the cervical ligaments can alleviate these problems by preventing excessive abnormal vertebrae movement, the development or advancing of cervical osteoarthritis, and the myriad of problematic symptoms they cause including nerve and arterial compression.
Through extensive research and patient data analysis, it became clear that in order for patients to obtain long-term cures (approximately 90% relief of symptoms) the re-establishment of some lordosis, (the natural cervical spinal curve) in their cervical spine is necessary. Once spinal stabilization is achieved and the normalization of cervical forces by restoring some lordosis, lasting relief of symptoms was highly probable.
Digital motion X-Ray C1 – C2
The digital motion x-ray is explained and demonstrated below
- Digital Motion X-ray is a great tool to show instability at the C1-C2 Facet Joints
- The amount of misalignment or “overhang” between the C1-C2 demonstrates the degree of instability in the upper cervical spine.
- This is treated with Prolotherapy injections to the posterior ligaments that can cause instability.
- At 0:40 of this video, a repeat DMX is shown to demonstrate the correction of this problem.
You can also visit this page on our site for more information Digital Motion X-ray (DMX)
We are going to go briefly outside of our own research and observation to present two independent studies. In our research that we will demonstrate below, we were able to get good outcomes with simple dextrose Prolotherapy injections that stimulated repair and restoration of the damaged cervical neck ligaments. This helped restore the normal anatomical alignment of head and neck. In this research below, we will explore proper alignment that came from chiropractic studies.
In 2019, published in the medical journal Brain Circulation,(3) Evan Katz, a private practitioner published the findings of his office in treating the Cervical lordosis of seven patients (five females and two males, 28–58 years). “The aim of this study is to evaluate cerebral blood flow changes on brain magnetic resonance angiogram (MRA) in patients with loss of cervical lordosis before and following correction of cervical lordosis.”
These are some of the study’s learning points:
- Loss of lordosis of the cervical spine is associated with decreased vertebral artery hemodynamics. “Vertebral arteries proceed superiorly, in the transverse foramen of each cervical vertebra and merge to form the single midline basilar artery” which continues to the circle of Willis and cerebral arteries. Based on this close anatomical relationship between the cervical spine, the vertebral arteries, and cerebral vasculature, we hypothesized that improvement in cervical hypolordosis increases collateral cerebral artery hemodynamics and circulation. This retrospective consecutive case series evaluates brain magnetic resonance angiogram (MRA) in patients with cervical hypolordosis before and following correction of cervical lordosis.
Note: The study cites a paper from Yuzuncu Yil University, Medical Faculty in Turkey published in the journal Medical Science Monitor.(4) In this study the research team suggests:
Because the loss of cervical lordosis leads to disrupted biomechanics, the natural lordotic curvature is considered to be an ideal posture for the cervical spine. The vertebral arteries proceed in the transverse foramen of each cervical vertebra. Considering that the vertebral arteries travel in close anatomical relationship to the cervical spine, we speculated that the loss of cervical lordosis may affect vertebral artery hemodynamics. . . the possible effects of loss of cervical lordosis on vertebral artery hemodynamics and their clinical outcomes are completely unknown. Because the vertebral arteries are the major source of blood supply to the cervical spinal cord and brain stem, the possible factors affecting these vessels warrant investigation.”
The study from Dr. Katz is one of the studies of further investigation. Following chiropractic adjustments he noted:
“This retrospective consecutive case series was performed to test the hypothesis that loss of cervical lordosis may be associated with the circle of Willis (the junction of several arteries at the base of the brain) and cerebral artery hemodynamics (More simply blood flow). The results of this case series revealed that the circle of Willis and cerebral artery parameters were significantly different between pre- and postcervical adjustments with preadjustment values showing lower values in comparison to postadjustment values. . .Our findings demonstrate preliminary evidence that loss of cervical lordosis may play a role in the development of changes related to the circle of Willis and cerebral artery hemodynamics and decreased blood flow in the brain.”
Non-surgical treatment – Cervical Spine Stability and Restoring Lordosis -Making a case for regeneration and repair of the spinal ligaments
The patient says when he turned his head to the right, he would lose control of all his muscles and he would “drop.”
Brad’s story is unique, it may not be typical of the patients we see. Brad with treated with Prolotherapy injections and neck curve correction techniques. Not everyone will achieve these results as results of treatment will vary.
We specifically want to highlight his case because he has some unusual strange sensations in his ear and breathing difficulties because of his problem with his contracting diaphragm.
Patient symptom list:
- Ringing in the ears and a sensation in his ears of hot wax. He also reported it was as if spiders were crawling in his ears.
- Severe dizziness. The patient describes that he would be in a car and then out of nowhere he would get dizziness and it would feel like the car was flipping end over end.
- Brain fog
- Contracting diaphragm
- Patient’s description at 1:32: “I would just be sitting or standing there, doesn’t matter which, and all of a sudden I couldn’t breathe. Finally I would take a big gasp of air and finally I would be able to breathe.”
- Swallowing difficulties: The saliva is his mouth would build up and it was as if he was drowning. This would cause panic attacks.
- The patient also reported when he turned his head to the right, he would lose control of all his muscles and he would “drop.”
Patient had these symptoms for 3 – 4 months. It started with a fall of of a ladder. Symptoms did not develop for months
- Patient fell off a ladder from a height of 12 feet. He hit a sink and his head snapped backed
- His symptoms started to develop four months after the fall
Because of the nature of his injury and ligament damage in his cervical spine, the patient underwent eight prolotherapy treatment sessions. Here is his description:
- The diaphragm problems went away after the 4th or 5th visit along with the swallowing difficulties.
In this section, we are going to talk about the realistic non-surgical options to the treatment of cervical spine instability and compressed cervical arteries and its related symptoms.
Research on cervical instability and Prolotherapy
Caring Medical has published dozens of papers on Prolotherapy injections as a treatment in difficult to treat musculoskeletal disorders. We are going to refer to two of these studies as they relate to cervical instability and a myriad of related symptoms including the problem of Vertebrobasilar insufficiency.
In our 2014 study mentioned earlier in this article, we published a comprehensive review of the problems related to weakened damaged cervical neck ligaments.
This is what we wrote: “To date, there is no consensus on the diagnosis of cervical spine instability or on traditional treatments that relieve chronic neck instability issues like those mentioned above. In such cases, patients often seek out alternative treatments for pain and symptom relief. Prolotherapy is one such treatment which is intended for acute and chronic musculoskeletal injuries, including those causing chronic neck pain related to underlying joint instability and ligament laxity. While these symptom classifications should be obvious signs of a patient in distress, the cause of the problems are not so obvious. Further and unfortunately, there is often no correlation between the hypermobility or subluxation of the vertebrae, clinical signs or symptoms, or neurological signs or symptoms. Sometimes there are no symptoms at all which further broadens the already very wide spectrum of possible diagnoses for cervical instability.”
What we demonstrated in this study is that the cervical neck ligaments are the main stabilizing structures of the cervical facet joints in the cervical spine and have been implicated as a major source of chronic neck pain and in the case of Vertebrobasilar insufficiency type symptoms, cervical instability.
Prolotherapy is referred to as a regenerative injection technique (RIT) because it is based on the premise that the regenerative/reparative healing process can rebuild and repair damaged soft tissue structures. It is a simple injection treatment that addresses very complex issues.
We propose that in many cases of chronic neck pain, the cause may be underlying joint instability due to capsular ligament laxity. Currently, curative treatment options for this type of cervical instability are inconclusive and inadequate. Based on clinical studies and experience with patients who have visited our chronic pain clinic with complaints of chronic neck pain, we contend that prolotherapy offers a potentially curative treatment option for chronic neck pain related to capsular ligament laxity and underlying cervical instability.”
A continuation of this discussion can be found in these articles on our website:
- Cervical Vertigo and Cervicogenic Dizziness
- Cervicogenic headaches – Migraines, tension headaches and cervical neck instability
- Cluster headache treatment – cervical ligament instability and the trigeminal and vagus nerves
- Occipital neuralgia and Suboccipital headache – C2 neuralgia treatments without nerve block or surgery
- Making the case for cervical instability as a cause of Tinnitus
- Cervical disc disease and difficulty swallowing – cervicogenic dysphagia
- Can Chronic fatigue syndrome and Myalgic encephalomyelitis be caused by cervical stenosis and cervical spine instability?
- Cervical dystonia and spasmodic torticollis treatment
- Chronic Neck Pain and Blurred Double Vision Problems – Is the answer in the neck ligaments?
Summary and contact us. Can we help you? How do I know if I’m a good candidate?
We hope you found this article informative and it helped answer many of the questions you may have surrounding how cervical spine instability disrupts blood flow into the brain and causes many neurological problems. Just like you, we want to make sure you are a good fit for our clinic prior to accepting your case. While our mission is to help as many people with chronic pain as we can, sadly, we cannot accept all cases. We have a multi-step process so our team can really get to know you and your case to ensure that it sounds like you are a good fit for the unique testing and treatments that we offer here.
References for this article:
1 Manohar N, Ramesh VJ, Radhakrishnan M, Chakraborti D. Haemodynamic changes during prone positioning in anaesthetised chronic cervical myelopathy patients. Indian journal of anaesthesia. 2019 Mar;63(3):212. [Google Scholar]
2 Hauser R, Steilen-Matias D, Fisher P. Upper cervical instability of traumatic origin treated with dextrose prolotherapy: a case report. Journal of Prolotherapy. 2015;7:e932-e935.
3 Steilen D, Hauser R, Woldin B, Sawyer S. Chronic neck pain: making the connection between capsular ligament laxity and cervical instability. The open orthopaedics journal. 2014;8:326. [Google Scholar]
4 Katz EA, Katz SB, Fedorchuk CA, Lightstone DF, Banach CJ, Podoll JD. Increase in cerebral blood flow indicated by increased cerebral arterial area and pixel intensity on brain magnetic resonance angiogram following correction of cervical lordosis. Brain circulation. 2019 Jan;5(1):19. [Google Scholar]
5 Bulut MD, Alpayci M, Şenköy E, Bora A, Yazmalar L, Yavuz A, Gülşen İ. Decreased vertebral artery hemodynamics in patients with loss of cervical lordosis. Medical science monitor: international medical journal of experimental and clinical research. 2016;22:495. [Google Scholar]