Cervical Spine Instability, fluid build up and intracranial hypertension.

Ross Hauser, MD

We see many patients who have a serious health challenge in having intracranial hypertension. In many of these people, intracranial hypertension was not initially thought of as a problem as their doctors instead tackled the symptoms that these people were facing. Symptoms included dizziness, headache, vision problems such as sensitivity to light where exaggerated pupillary hippus dilating and constricting which can cause problems with light sensitivity and the pupil fails to respond correctly to light sources. These people also faced symptoms and diagnosis of Tinnitus or ringing in the ears, neck pain, and tremors.

These are the types of people we see at our clinic. Layers of symptoms, no real underlying possible diagnosis. Maybe an understanding of the problem of intracranial hypertension? But missing a diagnosis of the root cause, cervical spine instability.

Increased intracranial pressure for no apparent reason

If one considers just one condition as an example of how cervical spine instability can be misdiagnosed, let’s look at pseudotumor cerebri, or idiopathic intracranial hypertension, which is increased intracranial pressure for no apparent reason. The condition causes moderate to severe headaches that often originate behind the eye and are worse with eye movements because the condition can cause swelling in the optic nerve and even blindness. Ringing in the ears that pulses in time with your heartbeat (pulsatile tinnitus), nausea, vomiting or dizziness are common symptoms. Of course neck, shoulder, and back pain are common and many have other visual symptoms including blurred or dimmed vision, photopsia or seeing light flashes, again because of the optic nerve swelling. (6).  The condition is serious as it can cause permanent optic nerve damage and even blindness, and the traditional treatments of spinal fluid shunts and optic nerve sheath fenestration (operation to reduce swelling on optic nerve) never explain why the cerebrospinal pressure is high. Anyone who has unexplained vision changes should consider upper cervical instability as a cause.

Stories of these people, maybe your story follow a familiar descriptive path and they go like this:

One day I was laying down relaxing. Suddenly I noticed that my heart was racing and beating hard enough that I could hear my heart beat in my ears. I then had the sensation of fluid, like running water in my ears. I went to the doctor who recommended I seek more specialized care. I start with an ENT who ordered a full range of scans and imaging studies. Everything came back normal.

My symptoms continued to worsen. I developed headaches, I hear fluid running in my head and into my ears. More tests were ordered and nothing shows up that “can be treated.” Sometimes when I try to stand I feel a fluid buildup and pressure rushing into my head, I get dizzy, have weakness in my body, I hear popping sounds coming from my ears and my nostrils as well as experience twitching throughout my body. The ENT stated that he thinks it might be neurological and so I was referred to a neurologist. In my appointment with the neurologist he suggests that he thinks the issues might be spontaneous intracranial hypertension.

Once a problem of intracranial hypertension or a  build-up of pressure around the brain was discovered, a myriad of tests and treatments were tried. Once obvious causes such as head injury or stroke were ruled out, initial testing may have looked for causes in blood clots, infection, and tumors. Once tests ruled those out as causes your diagnosis of intracranial hypertension, you then got an updated diagnosis of idiopathic intracranial hypertension, which means no one knows why you have intracranial hypertension.

Video learning points:

• Intracranial hypertension is a newer term to describe pseudotumor cerebri.
• Pseudotumor cerebri can be explained as a diagnosis that describes symptoms that mimics those of brain tumor. “Pseudotumor” means “fake tumor” when you add cerebri it becomes “fake brain tumor.”
• The shared symptoms of Pseudotumor cerebri and brain tumor or lesion is :
  • nausea, poor eating
  • loss of vision
  • tinnitus
  • headaches
  • neck pain or stiffness
  • cognitive difficulties
• As will be explained throughout this article, intracranial hypertension is a high pressure within the skull that can be caused cerebrospinal fluid buildup (CSF).

Comparing high blood pressure to Intracranial hypertension

• The number one killer is cardiovascular disease which is related to high blood pressure. The same can be said of the brain. The number one reason that brain tissue dies is intracranial hypertension.
• At our center we see young people in their 30s with changes on their brain MRIs that look like the changes a 75 year old would have with onset dementia. Why? How? One explanation is that these younger people live the face down lifestyle. Always looking down at cell phones or other electronic devices.

An summary explanation of this table is given below

From Monro-Kellie 2.0: The dynamic vascular and venous pathophysiological components of intracranial pressure. (3)

Venous cause of intracranial hypertension

Orthostatic (drop in blood pressure) / hydrostatic (In neurosurgical patients, when you raise your head) the hydrostatic pressure plays an important role in cerebral perfusion (drives oxygen to the brain), transcapillary fluid movements (helps drain the brain and regulate pressure) and venous air embolism (transporting out carbon dioxide.) (4)

Treatments:

• Avoid hypoxia (drop in oxygen levels in the blood).
• Elevate head.
• Avoid abdominal compression.

Cervical cause of intracranial hypertension

Treatments:

• Avoid neck vein compression (e.g. with collars) and maintain in neutral position or position where dominant jugular is optimized.
• Avoid “double chin” which compresses jugular.

Intracranial causes of intracranial hypertension – the transverse sinus

In the image below we see how the brain drains. The transverse sinus drains out into the internal jugular.

• Looks for dominance in transverse sinus drainage.
  • In a November 2021 paper (5) examining 33 patients, bilateral venous drainage dysfunction was found in 30 (90.9%) patients. But there were no differences in clinical symptoms between the two groups. The most common case is hypoplasia (one side is smaller than the other).
• In patients with suspected cervical spine instability, the cause of poor drainage of the transverse sinus is not so much of a cause of left or right side sinus size but rather a compression of the internal jugular vein. This is depicted in the image below.

Brain venous sinus outflow obstruction. This condition is called venous dysgemia which can lead to intracranial hypertension and result in brain cortex hypoperfusion (reduced blood flow) fusion and resultant cortex hypoperfusion (reduced blood flow to brain) and  brain cell death or brain atrophy.

Cervical spine ligaments as a cause of intracranial hypertension

The word ligamentous refers to ligaments. Ligaments are the strong connective bands in our bodies that hold bone to bone. Cervical ligaments hold vertebrae to vertebrae and prevent the vertebrae from wandering out of place. When a vertebrae wanders out of place it can cause spinal cord compression, nerve compression, vein compression, and arterial compression leading to a myriad of neurologic-like, psychiatric-type, and vascular-type disorders. In this article, our focus will be on how Ligamentous Cervical Instability or a “loose” neck with wandering vertebrae cause the problems associated with intracranial hypertension.

Brief explanation of the role of cervical ligaments

Caption reads: How heavy is your head? For every inch of forward head posture, the force of the spine increases by an additional 10-12 pounds. A forward head posture causes a slow strecthing of the posterior neck ligaments which is a phenomenon known as ligament creep.

• The face down lifestyle is the act of stressing muscles while using phones, tablets, and computers causing stretching of the posterior cervical ligaments.
• Repetition of these activities leads to the gradual loss of cervical lordosis, the normal slight curve in the cervical vertebrae of a healthy neck. The normal curve allows for comfortable neck movement.
• The body then increases tension in the muscles to limit excessive forward movement of the cervical vertebrae and protect nerve tissues.
• When tension to protect the neck structure becomes insufficient, the upper cervical vertebrae C1 to C2 in relation to the lower cervical vertebrae C3 to C7, the force of the head weight forward in relation to the neck curve past the  plumb line accelerates posterior cervical ligament demise.
• Excessive persistent cervical ligament stretch and forward displacement of forces causes reversal of cervical curve kyphosis.
• In order to keep the head facing forward the upper cervical vertebrae C1 and C2 have to hyperextend.
• Hyperextension of the cervical vertebrae leads to a significant S curve when the spine has both a lordotic and kyphotic curve, this becomes the most difficult of neck curve corrections.

Cervical instability is a progressive disorder causing a normal lordotic curve to end up as an “S” or “Snake” curve with crippling degeneration.

I have had all possible medical tests to rule out problems with my endocrine system, gastrointestinal system, autoimmune system, cardiovascular system.

Idiopathic intracranial hypertension symptoms are very wide-ranging which makes a proper diagnosis difficult.

So what doctors look for are patients who are:

• overweight or obese
• have hormone problems  stemming from the adrenals or thyroid
• have problems with medications or a combination of medications causing increased blood pressure
• have anemia or lack of red blood cells or conversely, the patient is making too many red blood cells
• autoimmune disorders
• have headaches
• have vision problems
• coordination problems

Tests are ordered to look for problems with the eyes, CT or MRI of the brain, and a spinal tap to check for high pressure in the cerebral spinal fluid surrounding your brain and spinal cord.

Once these tests are performed you may be given a treatment plan that includes weight loss, a review or reduction or repurposing of the medications you are on, you may be given medications to reduce the production of cerebrospinal fluid, steroids, routine spinal taps to remove excess fluid buildup.

Finally, when all these things do not work, a suggestion to surgery to plant a drainage tube may be recommended or surgery to help relieve pressure on your eyes. These of course are risky surgeries.

For many people, these treatments may have worked wonderfully. These are not the people that are contacting our office. We see the people that continue to have these symptoms and challenges despite years of treatment. So what is it that we can offer them? The possibility of a missing diagnosis. For some of these patients, not all, there is a problem of cervical spine instability causing a problem of cerebral spinal fluid drainage and buildup.

Looking for meaningful relief of my symptoms, my doctors and I agreed to explore the problems I was having in my neck

When someone gets the barrage of tests described above, it is easy to understand their confusion and concern as one possibility for the medical ailments follows another to the point of being overwhelmed by the diagnosis. Some people, collapse under the weight of these symptoms and diagnosis. Here is a sample story that takes us away from intracranial hypertension and then brings us back to it as a possible landing point for the ground zero diagnosis, how this person’s problems may have started with upper cervical spine instability.

This story was edited for reading flow:

I was diagnosed with Myalgic encephalomyelitis/chronic fatigue syndrome. However, the diagnosis did not help me as my doctors were still at a loss to provide any type of meaningful treatments for me. For more information on this subject please see our article: Can Chronic fatigue syndrome and Myalgic encephalomyelitis be caused by cervical stenosis and cervical spine instability?

Looking for meaningful relief of my symptoms, my doctors and I agreed to explore the problems I was having in my neck that were causing pain and functional limitations. After many tests, I was finally diagnosed with problems related to my cervical spine and brain stem compression. At this point I was diagnosed with:

• Craniocervical Instability
• Atlantoaxial Instability
• CSF leak
• Intracranial hypertension
• Basilar invagination
• Chiari malformation

Despite these diagnoses, the doctors are still concentrating on my symptoms. This includes a diagnosis of:

• Post–exertional malaise. I am exhausted even after the smallest activity and it is prolonged fatigue.
• POTS and Dysautonomia
• Cardiovascular-type symptoms of heart palpitation, increased heart rate. (We cover this problem extensively in our article Can cervical spine instability cause heart palpitations and blood pressure problems?)
• Dizziness and vertigo
• Shortness of Breath and breathing difficulties
• Intolerance of temperature, inability to regulate my body temperature. (Please see  our article Thermoregulatory instability – Neck pain and inability to maintain consistent body temperature.)
• Sweating problems. (Please see our article Excessive Sweating – Hyperhidrosis. Is upper cervical instability the missing treatment?)

I also suffer from many Gastrointestinal symptoms

• I have extreme difficulty digesting even the smallest amount of foo0ds. It seems like I have to exert all my body energy to eat and digest food.
  • Please see our articles:
  • Cervical spine instability as a cause of your digestive disorders;
  • How neck pain and cervical spine instability cause nausea, gastroparesis and other digestive problems;
  • Neurologic, digestive, cardiac, and bladder disorders: Some of the symptoms of Autonomic nervous system dysfunction and treatment options;
• I have gas, terrible flatulence, and bloating.

The focus is now on Intracranial Hypertension and Ligamentous Cervical Instability

Let’s explore the problems a person like this faces because if you are reading this article it is very likely that you or a loved one has been diagnosed with intracranial hypertension and that some of your doctors may suspect that there is compression happening in your cervical spine causing it. But like the story above, you suffer from more than just a CSF leak or intracranial hypertension, you may be dealing with similar challenges like those you just read about, an overwhelming cascade of symptoms and conditions.

Did it all start with Intracranial Hypertension? If so, how did the Intracranial Hypertension start?

Ligamentous Cervical Instability, especially ligamentous upper cervical instability, is often the missing structural cause and/or co-morbidity for many chronic disabling symptoms and diagnoses. As the cervical instability and/or breakdown of the cervical curve (called cervical dysstructure) progresses it can impair venolymphatic, cerebrospinal, and/or carotid/vertebral fluid flow into and out of the brain resulting in brain and systemic disorders because of increased intracranial (brain) pressure, breakdown of the blood-brain barrier and/or brain ischemia which inhibit proper brain function.

Case histories presented in the medical literature – Plugging the leak caused by atlantoaxial subluxation

In many people we see, they think that their symptoms are so bad that they must be a unique case. While yes, everyone is unique and the complexity of their symptoms have developed from a unique milieu of challenges that may be emanating from their cervical spine, these people need to be shown that they are not alone in suffering from this “avalanche of symptoms” and there are many ways they can be helped. Let’s now explore the research.

Here is a case history presented in March 2021 (1) by the Department of Neurology, Iwate Prefectural Central Hospital in Japan. The title of this paper is: “Spontaneous intracranial hypotension complicated by atlantoaxial subluxation: a case report.”

Here is the story:

A 54-year-old woman presented at the hospital with headache and posterior neck pain, which worsened when standing or in the sitting position and improved when in the supine position. A diagnosis of rheumatoid arthritis was made at the age of 33 years, and the patient has been taking methotrexate (explanatory note: Methotrexate may be prescribed as a rheumatoid arthritis treatment. It is thought to be able to help symptoms by decreasing the activity of the immune system) and methylprednisolone (corticosteroid anti-inflammatory).

Cervical MRI and magnetic resonance myelography showed the appearance of CSF leakage, resulting in a diagnosis of spontaneous intracranial hypotension. A diagnosis of atlantoaxial subluxation was also made based on the abnormal anterior position of the atlas (C1) in the cervical X-ray image.

The CSF leakage corresponded with the atlantoaxial subluxation region, which indicated that spontaneous intracranial hypotension was caused by the compression of the dura mater. These symptoms were improved following treatment with the intravenous drip of the extracellular fluids, and she was discharged from the hospital on day 25. The disruption of the dura matter induced by atlantoaxial subluxation is a rare complication but is worth considering when determining the etiology of spontaneous intracranial hypotension.

Cervical Spine Instability, Vein blockage, fluid build-up, and intracranial hypertension.

Blurry vision, eye pain, eye pressure, light sensitivity and other vision problems, along with symptoms above among the more troubling and disabling symptoms that are often due to cervical spine instability. An summary and explanatory notes of this video can be found here at: Blurry vision, light sensitivity, brain fog, increased ocular pressure and cervical Instability.

How does venous obstruction occur in a neck? 

We are finding and doing outcome research on is the problem of what’s causing the cerebrospinal fluid flow to accumulate and cause pressure inside the head to be elevated is a venous obstruction (vein blockage) so how does venous obstruction occur in a neck? One reason is that the vein is getting stretched out in the neck. How? One way is that the patient’s head is moving forward on their shoulders. When the head is in this position, the veins get pulled on and stretched out. This narrows the veins. A narrowed vein has less room for blood and fluid to flow in, this narrowing caused by cervical spine instability, which leads the head forward is characteristic of the problems faced with stenosis.

The main danger of brain venous congestion is that it increases intracranial pressure, this pressure is then transmitted to the brain’s arteries, which then increases blood flow to ensure adequate oxygenation of the brain. If the blood vessels cannot respond because of their obstruction in the neck, then brain ischemia can ensue.

The brain’s blood vessels may initially be able to respond via autoregulation (increases in blood vessel diameter in the brain) for a time, but if the cervical/brain venous congestion continues because of cervical dysstructure and cervical instability, the increased intracranial pressure will eventually damage the brain neurons, and ultimately, the brain tissue itself.

While the most common cause of arterial or venous obstruction in patients seen at Caring Medical is narrowing caused by cervical instability, it can also be from autonomic nervous dysfunction. Autonomic nervous dysfunction or dysautonomia can cause detrimental changes in the arterial blood flow to the brain or venous blood flow out.

Loss of blood flow to the brain

• Vertebrobasilar insufficiency – Drop Attacks, Bow Hunter Syndrome: The vertebral artery runs in the transverse foramen of the cervical vertebrae. If the cervical vertebrae are moving too much you can get compression of the artery that supplies about 1/3 of the blood to the brain.
• The vertebral artery supplies the brainstem and the cerebellum so Vertebrobasilar insufficiency can cause drop attacks, dizziness, impairments of the cranial nerves, balance problems.
• Please see our article Using Transcranial Doppler & Extracranial Doppler Ultrasound Testing at the Hauser Neck Center. Transcranial doppler (TCD) ultrasound provides real-time measurements of the blood flow in the arteries that go to the brain.

Vision problems

• When Intracranial pressure is increased you can get changes in your vision, you can get double vision or you can get graying of the vision. You can even see an image and you look away and you still see that image. There are all kinds of vision problems that are from upper cervical instability.
• If you have vision issues and nobody can help identify the problem I suggest an examination for upper cervical instability.

A September 2020 study in the Journal of Neuro-Ophthalmology (1) noted that abnormal forces around the optic nerve head due to orbital diseases, intracranial hypertension, and glaucoma are associated with alterations of the optic nerve head shape. Elevated cerebral and ophthalmic venous pressure can contribute to stress and strain on the optic nerve head and peripapillary retina.

You can’t clear your head

• When cerebral spinal fluid flow is disrupted, it’s almost it’s as if the brain becomes a toxic toilet. You need normal cerebral spinal fluid flow to be normal to flush all the toxins and all the waste products from all the activity of the brain out. If there is impeded flow you will suffer the problems of not being able to focus or remember. You feel like a brain fog has surrounded you. This can be caused by upper cervical instability.

In our article: How cervical spine instability disrupts blood flow into the brain, we discuss 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. 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. For more information, please continue with the article: How cervical spine instability disrupts blood flow into the brain

Summary and contact us. Can we help you? How do I know if I’m a good candidate?

When one understands the anatomy at the craniocervical junction, it is easy to see how upper cervical instability could cause a blockage of cerebrospinal fluid or arterial flow and/or venous drainage causing neurologic insult. Even if it is just the Cerebrospinal fluid that is increased, eventually this will lead to an increase in intracranial hypertension which can cause reduced blood flow to the nervous tissue in the brain and spinal cord, potentially causing damage. When cerebrospinal fluid flow is slowed, the brain fluid becomes toxic and that also over time can cause neurologic injury. Any of the neurological tracts or spinal segments can be affected when the normal arterial, venous and/or cerebrospinal fluid flow is disrupted. If severe enough, the gray matter of the central nervous system can even be permanently damaged. Therefore, anyone with unusual neurological symptoms that go undiagnosed or unexplained by traditional medical means should consider a motion scan of the cervical spine looking for instability. Cervical instability is very reversible cause of many neurological symptoms and syndromes.

We invite you to continue your research with our article Dynamic Structural Medicine Ross Hauser MD Review of Treatments for Cervical Spine Instability where a discussion is offered on the absence of normal spinal alignment and movement causing neurologic structures that travel through the neck to be put at risk and causing the conditions and symptoms described above. This article offers testing and diagnostic assessment explanations.

We hope you found this article informative and it helped answer many of the questions you may have surrounding the problems of Cervical Spine Instability, Vein blockage, fluid build up and intracranial hypertension. 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.

Please visit the Hauser Neck Center Patient Candidate Form

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References:

1 Yamazaki N, Ryosuke D, Yamaguchi E, Takahashi K, Takahashi H, Kikuchi T. Spontaneous intracranial hypotension complicated by atlantoaxial subluxation: a case report. Rinsho Shinkeigaku= Clinical Neurology. 2021 Feb 23. [Google Scholar]
2 Kupersmith MJ, Sibony PA. Retinal and Optic Nerve Deformations Due to Orbital Versus Intracranial Venous Hypertension. J Neuroophthalmol. 2020 Sep 11. doi: 10.1097/WNO.0000000000001074. Epub ahead of print. PMID: 32956232. [Google Scholar]
3 Wilson MH. Monro-Kellie 2.0: The dynamic vascular and venous pathophysiological components of intracranial pressure. Journal of Cerebral Blood Flow & Metabolism. 2016 Aug;36(8):1338-50. [Google Scholar]
4 Hans P. Hydrostatic pressure and neurosurgical pathology. InAnnales Francaises D’anesthesie et de Reanimation 1994 Jan 1 (Vol. 13, No. 1, pp. 123-126). [Google Scholar]
5 Tian Y, Zhang Z, Jing J, Dong K, Mo D, Wang Y. Anatomic Variation of the Lateral Sinus in Patients With Idiopathic Intracranial Hypertension: Delineation With Black-Blood Contrast-Enhanced MRI. Frontiers in Neurology. 2021;12. [Google Scholar]
6 Ibrahim YA, Mironov O, Deif A, Mangla R, Almast J. Idiopathic intracranial hypertension: diagnostic accuracy of the transverse dural venous sinus attenuation on CT scans. The Neuroradiology Journal. 2014 Dec;27(6):665-70. [Google Scholar]

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• Surgery
• NSAIDs
• Cortisone Shots
• R.I.C.E.