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:
- The left and right phrenic nerves originate from C3, C4, and C5 within the cervical spine, moving caudally (to the rear and) within the thorax (where the lungs and diaphragm are).
- Eventually, these nerves pierce the two diaphragmatic domes, relaying sensory and motor innervation. (The nerve impulses that control the diaphragm and from whose sensations coughs and hiccups come).
- The phrenic nerves are key components to maintain successful independent respiratory function.
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?
- “Surgical injury typically causes complete unilateral (one side) suspension of diaphragmatic function, commonly while the surgeon dissects near the internal thoracic artery”
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?
- Reduced breathing capabilities and spasm because the injured phrenic nerve is sending confusing or improper signals, or not getting any message through to the diaphragm to relax or contract.
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)
- Unilateral diaphragmatic paralysis due to cervical spondylosis has rarely been reported. We present the first case of unilateral diaphragmatic paralysis without radicular pain or motor weakness due to cervical foraminal stenosis and a review of the related literature.
- Patient concerns: A 59-year-old man presented with dyspnea and fever. His chest radiograph revealed right hemidiaphragmatic paralysis.
- The differential diagnosis of phrenic nerve palsy excluded mediastinal and neurodegenerative diseases. Imaging studies showed right foraminal stenosis caused by cervical spondylosis at C3-4 and C4-5.
- The patient underwent foraminotomy at C3-4 and C4-5 on the right side. The operative findings revealed a severe compression of the C4 root.
- At 3 months postoperatively, the unilateral diaphragmatic paralysis and dyspnea were recovered.
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.
- My name is George, I’m 62 years old.
- About six years ago I had a whiplash accident. A little bit before that I came down with a condition of ulcerative colitis, a lot of bleeding diarrhea, and I couldn’t eat or drink.
- I was treated for these problems, my doctors did not know what caused it.
Hiccups following endoscopy
- They did an endoscopy on me with a colonoscopy and when the endoscopy scope was removed from my throat I was in violent hiccups. That was the beginning of five to six years of my problem with hiccups.
- Doctors did not know what was causing these hiccups and I was becoming very frustrated with it.
I was told by four GI specialists that there is nothing wrong with me
- I went to four different gastrointestinal specialists and all they wanted to do was endoscopies and colonoscopies and that was it. When nothing came back from these tests I was told there is nothing wrong with me and they would simply let me go without helping me in any way.
- I suffered from these hiccups 24 hours a day, it was hard to sleep and my situation became desperate.
I researched nerve damage and cervical spine problems
- I am a dentist so I started looking through textbooks I start looking on the internet to see what could possibly be causing this.
- I came across nerve damage.
- Then I started looking for what would cause nerve damage. I started to find stories of people, like me who had a whiplash injury from an accident.
- I happen to come across a video by Dr. Hauser and I started looking at that more intently and I saw some reviews of patients who had ulcerative colitis and were tremendously helped by having their neck treated.
- This started to make sense to me. My problem appeared to be coming from my cervical vertebrae. Something in my neck was damaged and this was did something to my vagus nerve. Since the vagus nerve controls your entire digestive tract and your diaphragm and the phrenic nerve is also in this area I thought I was finding the answers.
George had Prolotherapy treatments and cervical spine curve correction treatments which are explained below.
- I started treatments with a doctor who was trained by Dr. Hauser in Prolotherapy. The suggestion was I travel the four hours to see Dr. Hauser himself because of the complexity of my case.
- With every treatment, I had everything was getting better and better. Every time I was treated, for the month in between treatments my neck stability was changing, my different symptoms were changing.
This video was taken at the time of George’s fourth treatment.
- I am getting my fourth treatment today. The hiccups are completely gone.
- I also had intense headaches coming from behind my neck. These would be “10 out of 10” type headaches that would happen twice a month and last for about five days.
- Other doctors told me to get rid of these headaches they would have to cauterize a nerve and this procedure would have to be done every three months. With the realignment of my neck and the cervical vertebrae, the treatments (Prolotherapy and cervical spine adjustments and correction) took the pressure off that nerve and I have absolutely no pain anymore.
Restoration of function. The ability to turn his head to the right
- I can turn my neck to the right. From one of the whiplash accidents I had when I was in the military, I could never really turn my head to the right. But since it was not causing me any pain I never had it treated.
- After the treatments I got, for the first time in 25 years, I can turn my head to the right and left.
- I have no pain in my neck, my neck feels like a tree trunk it is very solid. I never realized how weak my neck was. I’d say about 95% of my symptoms have gone away. I still get these little burps from my diaphragm but I am happy if this is all there is and it stays this way. But I want to get the final treatments.
- I understood that this was not a one-time treatment. It takes time, you gradually get better. I am glad I did it.
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.
- Digital Motion X-ray can be an effective 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 (explained below) to the posterior ligaments that can cause instability.
- At 0:40 of this video, a repeat DMX is shown to demonstrate correction of this problem.
Image 1 What are we seeing in this image?
In a still image from the patient’s DMX we see:
- Motion in the A-P open mouth lateral bending projection: There is a significant abnormal translation of C1 on C2 with overhand bilaterally. What does this mean?
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 neutral lateral projection shows the reversal of the cervical lordosis. There is a disc narrowing at C3-C4, C4-C5, C5-C6. What does this mean?
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.
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 motion in the oblique extension projection is restricted There is intervertebral foraminal encroachment of the facet joint at C3-C4 and C4-C5 on the right. What does this mean?
- We ask the patient to move in extension (chin up) or flexion (chin down) position. In a traditional MRI the patient points their chin up, a picture is taken. Then they point their chin down, another picture is taken. In a DMX image, a movie captures the chin up and the range of motion through the chin down phase. Extension to flexion.
- When our patient looked down, with his chin as close to his chest as he could get it we he gets foraminal encroachment of the facet joint at C3-C4 and C4-C5 on the right. What does this mean? Simply in this position, foraminal stenosis. Stenosis means something is being crushed or impinged.
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).
- “Recurrent laryngeal and phrenic nerve blocks are frequent side effects of a stellate ganglion block. They occur from the local anesthetic injection that spills from the area of the ganglion. Because diffusion of the drug is required to obtain a satisfactory block, it can be expected that these nerves will often be temporarily blocked. Symptoms of a recurrent laryngeal nerve block include hoarseness and, occasionally, respiratory stridor (a wheezing or grinding type noise with breathing).”
A lump in their throats
- “Patients often complain of difficulty in getting their breath and the sensation of 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.
- The vagus nerves supply “nerve communications” with the larynx.
- Proper, non-disruptive nerve input allows for good swallowing and speech. Disruptive nerve inputs impact swallowing and speech
- Further symptoms of poor vagus functioning, called vagopathy or vagal tone, affecting the larynx can be chronic cough, hoarseness, and as we will see below the contribution to chronic hiccup.
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.
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:
- In “Medical refractory (difficult) cases even indulge in unconventional therapies such as hypnosis, massages, and acupuncture. Surgical intervention, although undertaken very rarely, predominantly revolves around phrenic nerve crushing, blockade, or pacing. A novel surgical strategy is emerging in the form of Vagus nerve stimulator (VNS) placement with three cases cited in the literature to date with varying degrees of success. Here the authors report a case of VNS placement for intractable hiccups with partial success.”
An 85-year-old gentleman
- An 85-year-old gentleman with a 9-year history of intractable hiccups secondary to pneumonia came to our hospital. The hiccups were symptomatic causing anorexia, insomnia, irritability, depression, exhaustion, muscle wasting, and weight loss. The patient underwent countless medical evaluations. All examinations and investigations yielded normal results. The patient underwent aggressive pharmacotherapy, home remedies, and unconventional therapies for intractable hiccups but to no avail. He also underwent left phrenic nerve blocking and resection without therapeutic success. The patient presented to our hospital and the decision for Vagus nerve stimulator insertion was taken for compassionate reasons considering patient morbidity. The patient demonstrated significant improvement in his symptoms following Vagus nerve stimulator insertion.
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:
- “This is a case report and review of the literature regarding the use of vagal nerve stimulators for intractable hiccups. Specifically, this report highlights a case where this therapy was not effective, as two prior case reports have reported positive results.”
“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.
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.
- The patient was experiencing vertigo, tinnitus, severe neck pain, migraines, and other problems based on C1-C2 instability.
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?
References for this article:
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This article was updated February 1, 2021