How cervical spine instability disrupts blood flow into the brain
Ross Hauser, MD and Brian Hutcheson, DC
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.
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 confusions that surrounds 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. Great concern is.
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 a hardening of the arteries. This problem would be suspected in patients who were older, had diabetes, high blood pressure or hypertension, smoked, was 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 is 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 to you to pages throughout this site on the symptoms and manifestations of these problems and how we treat them.
Below is a two hour webinar presented by Ross Hauser, MD. on these and related challenges.
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 my 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 realy to us unfortunately their tests was not done the way I ordered them primarily because the technician advises us and the patient, “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 – now is probably not a good time to get a scan if you are looking for active blood flow problems
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 haemodynamic (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.”)
- 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. 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 offices are equipped with x-ray diagnostics with digital motion x-ray because the traditional scans missed so many instabilities.
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)
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.
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 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
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.
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, (5) 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).
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?
If this article has helped you understand the problems of cervical spine instability and cervical artery compression and you would like to explore Prolotherapy as a possible remedy, ask for help and information from our specialists
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 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]
3 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]
4 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]
5 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.