Hiccups, Neck Pain, and Vagus and Phrenic Nerve Injury

Ross Hauser, MD., Brian Hutcheson, DC

Many people contact our center to discuss the challenges they face with chronic cough, throat clearing, and hiccups. They may have a hiccup that comes every 5 to ten minutes. It disrupts their sleep, their ability to eat, their ability to talk. The hiccups are accompanied by cough and throat clearing as if something is stuck in their throat. Unfortunately, this is not the only symptoms they have. They may also have other neurological symptoms such as hearing and vision problems, dizziness and balance issues, radiating pain into the back, shoulders, and arms.

Chronic hiccups and coughs can be caused by many problems. In this article and video we will try to explain that in some people, the cause of their problems may be rooted in cervical spine instability and compression of the vagus and phrenic nerves.

Patients may need to undergo repeated examinations before reaching a diagnosis

Here is a brief, yet detailed understanding that doctors understand that a patient may have to take all these examinations, which for some people can take years until they find a true diagnosis of their problem. This is from a November 2020 paper, published in the European Journal of Internal Medicine (1). It may describe your medical journey.

“Cough is a physiological response to mechanical and chemical stimuli due to irritation of cough receptors located mainly in the epithelium (nerve tissues) of the upper and lower respiratory tracts, pericardium (the membrane that covers the heart), esophagus, diaphragm, and stomach. A complex reflex arc through the vagus, phrenic, and spinal motor nerves to the expiratory musculature (the muscles that help you exhale) generates an inspiratory (breathing in) and forced expiratory effort (breathing out)to clear the airways.

Under pathological (disease) conditions of known and unknown etiologies, the chronic refractory cough may become a major medical problem because patients may need to undergo repeated examinations before reaching a diagnosis, and/or try several treatments with sometimes poor symptom control, worsening their quality of life and increasing economic burden (the costs on the patients and healthcare).

We are going to look at a November 2020 study (2) in the medical journal Lung. What we are looking at is the importance of the phrenic nerve in respiratory function, or more simply the ability to breath correctly. Disruption to the diaphragm function can lead to not only breathing problems, but problems of chronic cough and chronic hiccups.

This study we are going to examine is from surgeons discussing the side-effects of cardiovascular surgery. Why this study? Because it gives us a great independent assessment of what happens when the phrenic nerve is injured. Such as in cardiovascular surgery and such as in cervical spine instability causing compression on the nerve.

Phrenic Nerve Injury and Diaphragmatic Dysfunction is the heading of this section of this study: Here are the learning points:

So that is one of the paths of the right and left-sided pairs of the phrenic nerve. It winds through C3-C5 and makes its way down towards the diaphragm.

The concern in this paper is when surgeons performing cardiac surgery they may cut or injure the phrenic nerve. What happens if this occurs?

Hiccups – Irritation of the phrenic nerve by way of the Vagus nerve

Explanatory notes and supportive research to this video are provided throughout this article.

Phrenic Nerve Injury and Diaphragm Dysfunction

If you have been from one specialist to another and been suggested to many tests to look for possible causes in gastrointestinal distress, thyroid function, the presence of tumors or cysts in your neck, diabetes, kidney disease, a response to medications, and many other possible culprits, you, like many others are likely upset that nothing can be found once all these possible causes are ruled out. Now what? This is a significant problem understood by doctors as well. Now what?

Here is a brief, yet detailed understanding that doctors understand that a patient may have to take all these examinations, which for some people can take years until they find a true diagnosis of their problem.

When the phrenic nerve is injured, half of your diaphragm does not work properly or at all

What happens when half your diaphragm does not function properly?

How cervical foraminal stenosis can impact the diaphragm.

Here we are illustrating a case study reported in the medical literature to help people, maybe like yourself, understand that neck problems can cause breathing problems. This is a case in the extreme of diaphragm paralysis, but again, the connection is clear the problems in this patient, specifically, diaphragm paralysis, came from impingement caused by cervical foraminal stenosis.

This case is reported in the September 2020 edition of the journal Review Medicine. (3)

Coughs, hiccups, voice, breathing, and phrenic nerve irritation

Coughs and hiccups are pretty common complaints in our office another common complaint is swallowing difficulties and that their food is getting stuck in their throat. Similarly, people who get diagnosed with gastroesophageal reflux. They have a problem with cough and they will go to a gastroenterologist and get treated for digestive distress. Other symptoms or problems that have manifested themselves will also be explored. Some people will move onto an examination by an ENT that will look at problems of speech because of dysfunction of the vocal cords.


A patient’s story of chronic, violent hiccups

The video below is the story of one of our patients, he will describe his journey of how years of violent hiccups were successfully treated.

NOTE: Like all medical procedures, our treatments can be very successful, they may also not be very successful. This patient’s story may not be typical. Unfortunately, we cannot guarantee the outcome of any treatment you receive.

This is the story of George, below the video is a summary transcript.

Hiccups following endoscopy 

I was told by four GI specialists that there is nothing wrong with me

I researched nerve damage and cervical spine problems

Treatments

George had Prolotherapy treatments and cervical spine curve correction treatments which are explained below.

Hiccups gone

This video was taken at the time of George’s fourth treatment.

Restoration of function. The ability to turn his head to the right

Continuing treatments

George achieved remarkable results, they are results unique to him. You may not get similar results. Please contact us so we can realistically assess your situation and challenges.


DMX of cervical neck instability and in this case a cause of hiccups

What are we seeing in these images?

These images belong to our patient George. They are his DMX images.

At our center, we use a Digital Motion X-ray machine. What this machine does is not take an x-ray picture, it takes an x-ray movie. First, let’s see what digital motion does. Click on the video to watch the DMX movie. This is one of our tools in demonstrating cervical instability in real-time and motion.

Image 1 What are we seeing in this image?

In a still image from the patient’s DMX we see:

We asked the patient to open his mouth and then bend his head to the side towards his shoulder (lateral bending). When you bend your head to the side the C1 and C2 vertebrae should remain in correct anatomical alignment. In many patients, we see this does not happen. The “significant abnormal translation of C1 on C2 with overhand bilaterally,” means that the C1 is sliding over the C2 and is out of position. Bilaterally of course means this happens when the patient bent his head towards his right shoulder and then bent his head towards his left shoulder.

A sliding C1 would demonstrate atlantoaxial instability or excessive motion or hypermobility at the junction between the atlas (C1) and axis (C2). This could lead to compression of the cranial nerves and the condition or symptom of chronic hiccups among the many neurological type symptoms suffers report.

Image 2 What are we seeing in this image? A loss and reversal of correct cervical lordosis. The natural curve of the cervical spine.

In a still image from the patient’s DMX we see:

The neural lateral projection is simply the “side view.” The side view gives us a chance to see the curve of the cervical spine.

Let’s briefly review the curves of the cervical spine

The curvatures of the neck

What are we seeing in this image?

In our practice, we see problems of cervical spine instability caused by damaged or weakened cervical spine ligaments. With ligament weakness or laxity, the cervical vertebrae move out of place and progress into problems of chronic pain and neurological symptoms by distorting the natural curve of the spine. This illustration demonstrates the progression from Lordotic to Military to Kyphotic to “S” shape curve.

In our practice we see problems of cervical spine instability caused by damaged or weakened cervical spine ligaments. With ligament weakness or laxity, the cervical vertebrae move out of place and progress into problems of chronic pain and neurological symptoms by distorting the natural curve of the spine. This illustration demonstrates the progression from Lordotic to Military to Kyphotic to "S" shape curve.

Here our patient is displaying the Kyphotic Curve, his neck is curved in the wrong way. His is getting a progressively worse “hunch neck.” Look at what is happening. Disc narrowing at C3-C4, C4-C5, C5-C6. When you have disc narrowing you will have bulging, herniated discs, and compression of the vital cranial nerves and cervical arteries and veins. Simply, the brain and spinal cord start sending each other garbled communications which can lead to neurological-type symptoms. The arteries and veins become constricted or crushed. Blood going to your head and out of the head can be impeded.

Image 3 What are we seeing in this image? C3, C4, and C5 foraminal stenosis. The C3, C4, and C5 roots help to form the phrenic nerves. The hiccup nerve. Stenosis is occurring around the hiccup nerve.

In a still image from the patient’s DMX we see:

The C3, C4, and C5 roots help to form the phrenic nerves. The hiccup nerve. The connection is made.

The problems of the vagus nerve, the laryngeal nerve, and the phrenic nerve. Why you may have the symptoms you do.

We are stopping here to take a closer look at the interaction between the laryngeal nerve and the phrenic nerve and why you may have been sent to an ENT and why your symptoms may include the previously mentioned difficulties in swallowing, hoarseness in voice, and the main focus of this article coughs, hiccups, and breathing dysfunction.

While later we will be exploring the role of the vagus nerve in your symptoms, we are now going to explore one of the vagus nerve’s branches, the laryngeal nerve. The laryngeal nerve is the “nerve of the voice box.”

When the laryngeal and phrenic nerve is injured or damaged

To demonstrate what happens to the laryngeal and phrenic nerve when they are injured or damaged, we are going to look at recommendations doctors are given of how to avoid this damage when offering a patient a stellate ganglion block or a nerve block. The side-effects of this injection mimic the symptoms we have seen in our patients with cervical spine instability.

This comes from the medical textbook Complications in Regional Anesthesia and Pain Medicine. Complications associated with stellate ganglion and lumbar sympathetic blocks. (4)

Hoarseness and, occasionally, respiratory stridor (a wheezing or grinding type noise with breathing).

A lump in their throats

So what is happening here other than you recognize the symptoms but you may have never had a nerve block in your throat. 

Doctors will give a stellate ganglion block injection to block pain sensation in the nerves surrounding the larynx. These injections are given to patients who are not responding to other treatments for their neck, head, shoulder, or arm pain and in some patients with angina type symptoms with or without the presence of cardiovascular disease.

What we are demonstrating here is that the laryngeal nerve and the phrenic nerve, when injured or suppressed, in this case, caused by the injection of a nerve block that inadvertently and temporarily shut down the nerve function, are similar to symptoms we see in cervical spine instability patients. The point and case are made clear.

What are we seeing in this illustration? The possible why of why you have symptoms.

Learning points:

When you have unresponsive symptoms “Follow the Neurology.”

The examples of unresponsive system and the connection to cervical spine instability and problems in the neck are problems that we feel can be solved in appropriate candidates for treatment if we “follow the neurology.” What does this mean? It means looking for compression or herniation of the cervical nerves that flow through and around the cervical spine.

When we follow the neurology (the nerves) we may find solutions to problems that are not responding to traditional medical care such as arrhythmias, stomach distress, and digestive disorders, chronic cough, vision and hearing problems, and other neurologic concerns.

Back to chronic cough and chronic hiccups

If we follow the neurology and look for nerve compression or herniation in solving the problems mentioned above including chronic cough and chronic hiccups, what are we looking for? Generally an understanding of the patient’s current condition. Are there suspected problems with the nerves and sensors in the pharynx (the throat,) the back of the neck, the esophagus? So then we would explore the path of the vagus nerve. As demonstrated above one branch of the vagus nerve, is the laryngeal nerve, whose disruption and the symptoms these disruptions can cause was explained above.

Further disruption of the vagus nerve impacts the Phrenic Nerve

To review: When a patient comes into our clinic for cervical spine instability issues and they describe the problems of respiratory dysfunction, chronic cough, and hiccups among a myriad of other problems, we look for compression of the vagus nerve. We have two vagus nerves. The one on the left side of the neck and the one on the right side of the neck. Let’s continue following the path of the vagus nerve and see how the disruption of this path may be leading to your symptoms.

The phrenic nerve is formed from cervical nerve roots III to V which involves cervical vertebrae number two (the axis) through C6. So any type of instability on this side of course could lead to a phrenic nerve problem.

Posterior view of upper cervical region

The phrenic nerve besides originating from the upper cervical spine also passes between the anterior scalene muscles (the side neck muscles at C3-C6 that control certain neck movements including flexion, chin to chest head down, ear touching shoulder) and middle scalene muscles of the C2-c7 region which also control ipsilateral lateral flexion of the neck, ear touching shoulder movement).

These muscles can get very tight and atrophied when you have any cervical instability, forward neck carriage, or a chronic problem with your neck. So your musculature could pinch down and cause a problem with that phrenic nerve.

Vagus Nerve stimulation and hiccups: A Case presented in the medical literature

Some of the patients we see and their symptoms and conditions they face would be seen, by other medical professionals as rare cases. Based on what we see, maybe these cases are not so rare. The medical literature is in some cases very deep in case histories of “rare and mysterious” causes for hiccups.

Here is a case presents in the Journal International Journal of Surgery Case Reports. (5) It was published in January 2021 by a team from the National Hospital for Neurology and Neurosurgery, Queen’s Square, London, UK. Here is what happened:

An 85-year-old gentleman

In this case, a Vagus nerve stimulator was surgically implanted because of the severity of the patient’s case.

Vagal nerve stimulation for intractable hiccups is not a panacea

A December 2018 case history presented in The International Journal of Neuroscience (6) warns doctors that Vagal nerve stimulation does not work for everyone. I will comment below after the case history review: Here are the suggested learning points of this case:

Case report:

“A 52-year-old man presented with multiple years of intractable hiccups. A workup revealed no identifiable etiology, and he had failed multiple medical therapies. A phrenic nerve block was attempted, which was not beneficial. Vagal maneuvers, specifically the induction of emesis (vomiting), did consistently provide transient relief of his symptoms, and, therefore, the decision was made to proceed with a trial of vagal nerve stimulation after review of the literature supported the therapy. Despite 8 months with multiple stimulation parameters, the patient did not have any significant benefit from vagal nerve stimulation.”

My comment: Vagal nerve stimulation will not help people if they have an underlying cause of cervical neck and spine instability that has not been addressed. If the vagus nerves are being stretched and compressed, stimulation may or may not help and the stimulation will not address the problem of nerve compression and stretching.

Vagus nerve problems or problems of vagal tone. What are we seeing in this image?

If you look at the illustration you will see where the Vagus nerve is closely related to the C1 – C2 – C3 vertebrae. While doctors usually discuss the vagus nerve in the singular sense, there are two vagus nerves, one on each side of the neck and in combination, they are referred to as the vagal nerves. This means that the degenerative damage in your neck can significantly impact the function of one or both vagus nerves. The one on the left side of your body and the one on the right side of your body.

If you look at the illustration above you will see where the Vagus nerve is closely related to the C1 – C2 – C3 vertebrae. While doctors usually discuss the vagus nerve in the singular sense, there are two vagus nerves, one on each side of the neck and in combination, they are referred to as the vagal nerves. This means that the degenerative damage in your neck can significantly impact the function of one or both vagus nerves. The one on the left side of your body and the one on the right side of your body.

Research on cervical instability and Prolotherapy treatments

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 some of this research as it relates to cervical instability and a myriad of related symptoms including the problems of cough, hiccups, and disruption of the diaphragm.

In our own research, our Caring Medical research team published a comprehensive review of the problems related to weakened damaged cervical neck ligaments. (7)

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 that 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 (such as cough, hiccups, and swallowing difficulties) 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 cough, hiccups, and swallowing difficulties type symptoms, cervical instability.

This patient is having C1-C2 areas treated. Ross Hauser, MD, is giving the injections.

In 2015 our research team published our finding in our paper “The biology of prolotherapy and its application in clinical cervical spine instability and chronic neck pain: a retrospective study.” This peer-review research was published in the European Journal of Preventive Medicine. (8)

Here we wrote: “In an effort to facilitate the diagnosis and treatment of clinical cervical spine instability and chronic neck pain, we investigated the role of proliferative injection Prolotherapy in the reduction of pain and recovery of constitutional and neurological symptoms associated with increased intervertebral motion, structural deformity and irritation of nerve roots. . . 95 percent of patients reported that Prolotherapy met their expectations in regards to pain relief and functionality.”

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.”

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 cough, hiccups, neck pain, and phrenic nerve injury. 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

References for this article:

1 Visca D, Beghè B, Fabbri LM, Papi A, Spanevello A. Management of chronic refractory cough in adults. European Journal of Internal Medicine. 2020 Sep 19:4616. [Google Scholar]
2 Tanner TG, Colvin MO. Pulmonary Complications of Cardiac Surgery. Lung. 2020 Nov 11:1-8. [Google Scholar]
3 Park HY, Kim KW, Ryu JH, Lim CR, Han SB, Lee JS. Cervical foraminal stenosis causing unilateral diaphragmatic paralysis without neurologic manifestation: A case report and review of the literature. Medicine. 2020 Sep 11;99(37). [Google Scholar]
4 Rauck RL, Rathmell JP. Complications associated with stellate ganglion and lumbar sympathetic blocks. Complications in Regional Anesthesia and Pain Medicine. 2012 Jul 18:246. [Google Scholar]
5 Tariq K, Das JM, Monaghan S, Miserocchi A, McEvoy A. A case report of Vagus nerve stimulation for intractable hiccups. International Journal of Surgery Case Reports. 2020 Dec 16.
6 Grewal SS, Adams AC, Van Gompel JJ. Vagal nerve stimulation for intractable hiccups is not a panacea: a case report and review of the literature. International Journal of Neuroscience. 2018 Dec 2;128(12):1114-7.  [Google Scholar]
7 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;8:326-345. [Google Scholar]
8 Ross Hauser, MD, Steilen-Matias D, Gordin K. The biology of prolotherapy and its application in clinical cervical spine instability and chronic neck pain: a retrospective study. European Journal of Preventive Medicine. 2015;3(4):85-102. [Google Scholar] 5215

This article was updated February 1, 2021

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