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:

Comparing high blood pressure to Intracranial hypertension

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)

 intracranial hypertension treatment options

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)


Cervical cause of intracranial hypertension


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.

Intracranial causes of intracranial hypertension

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.

Brain venous sinus outflow obstruction

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 Horrific Progression of Neck Degeneration with Unresolved Cervical Instability

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:

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:

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

I also suffer from many Gastrointestinal symptoms

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

Vision problems

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

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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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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