Cervical spine compression causes internal jugular vein stenosis

Ross Hauser, MD

While cervical spine and neck instability offers us a good explanation as to the causes of these symptoms, cervical spine and neck instability can also be an umbrella term to describe many factors. You may have C0-C1 instability, causing some of these symptoms. You may have problems from C3-C7 fusion causing segmental changes in your cervical spine which cause symptoms. You may have compression of any one or all of the cervical nerves. You may have carotid artery compression. You may also have internal jugular vein stenosis. You may also have a combination of some, many, or all these problems depending on the severity of your neck instability.

We know you may be reading this article for two main reasons. You have been searching for possible answers to your symptoms because no one can find out why you have them, or, an enlightened clinician suspects that your jugular vein has something to do with it and he/she ordered a Jugular Vein Doppler Ultrasound or jugular venography to take pictures of your jugular vein and its branches. They suspect or want to rule out a clog or a narrowing of the vein is causing circulatory issues. If Eagle syndrome has been suggested to you, please see our article: Eagle syndrome and the diagnosis of stylohyoid complex syndrome, for a more detailed understanding of jugular vein compression caused by a hypermobile or elongated styloid bone.

Internal jugular vein stenosis

We have been helping people with “mystery symptoms” and “mystery diagnosis” for approaching three decades. When we sit in the examination room with new patients, even after a careful screening process to assess their candidacy for the treatments we offer, we still sometimes get the look of confusion in patient’s eyes when we suggest a problem that has not been suggested to them before. Sometimes such is the case with internal jugular vein stenosis.

Here is an example: A patient has just completed real-time testing at our center. Real-time meaning we know the results as the test is being performed, this is explained further below. We will sit with the patient and their spouse or partner and then tell them that we believe many of their symptoms are coming from compression of their jugular vein, the compression is being caused by pressure from the cervical vertebrae or a problem with the styloid process at the base of the skull and possible carotid artery syndrome. (We are going to discuss this further below).

The patient and the spouse will look at me, our staff, and our associates and on occasion say: “How come no one else figured this out? No one has even said jugular vein to us.” Sometimes the patient and their spouse will feel a sense of enlightenment, it makes sense. Sometimes we have to explain further because these people have been on a long medical journey, they have already had numerous diagnoses, numerous treatments, nothing has worked for them. Honestly, sometimes these people think, “great another diagnosis,” add it to the pile.

What are we seeing in this image? Internal Jugular Vein Stenosis induced by the C1 transverse mass

Here we have neuroimaging features of the right Internal Jugular Vein Stenosis induced by the C1 transverse mass. Sagittal or side view (A); Axial view (horizontal plane) and D reconstructive (D) CTV images revealing the right transverse mass of C1 compression on the right Internal Jugular Vein. Magnetic resonance venography (C) revealing the right IJV-J3 segment stenosis accompanied by substantially abnormal collateral veins.

This image comes from a paper published in January 2020 in the journal CNS neuroscience and therapeutics. (1) In this paper doctors, moreso, neurologists, describe a condition of “cervical spondylotic internal jugular venous compression syndrome.”

This is what they wrote: “Although traditional cervical spondylosis including radiculopathy, myelopathy, axial neck pain and vertebral artery insufficiency has been frequently reported in the literature (medical research), studies focusing on cervical spondylosis‐induced venous outflow disturbance are still lacking. In our clinical practice, we have noticed that a large percentage of Internal Jugular Vein Stenosis patients display with osseous (bone) impingement or compression, with the first cervical vertebra (atlas, C1) being the major contributor. As the Internal Jugular Vein passes over the anterior (front) aspect of the transverse process of C1 and once the cervical vertebral structure changes, this Internal Jugular Vein segment is likely to be compressed. Given that, we bring forward a novel concept: “cervical spondylotic internal jugular venous compression syndrome,” to depict the clinical presentations and imaging features in patients with this issue.

The following was noted in these patients:

Nonfocal neurological symptoms like headache, head noise, tinnitus, and visual impairment are tightly correlated to unilateral or bilateral internal jugular vein syndrome.

So why this diagnosis?

For many, it is because the symptoms they, you, suffer from are not responding to the other diagnoses and treatments and internal jugular vein stenosis is usually not at the top of anyone’s list to check for unless there is also the frequency of blackouts, mini-strokes, cognitive difficulties, and amnesia.

So when other doctors write up case histories of the patients they see with internal jugular vein stenosis and publish it in the medical literature, we get excited. We get excited for the people who contact us because not only do we see these problems related to internal jugular vein stenosis and these other doctors are seeing the problem. The medical community is recognizing that this can be a cause of your symptoms. There is a degree of hope in that statement.

Overcrowding in the carotid triangle and the carotid sheath. A cause of internal jugular vein stenosis

There are many keywords in this article. The two main keywords are instability and compression. It is our belief that many of the mystery neurologic symptoms and conditions people suffer from can be traced to cervical spine instability and compression of the vital arteries, nerves, and veins in the neck.

As you may already be aware from your previous examinations, the neck is filled with triangles. Let’s briefly understand their functions and how it relates to your symptoms.

Are my triangles my problem?

After reading this little section you may be wondering to yourself, are my triangles “off,” Is this why I have thyroid issues? Is this why my spit does not drain? These are questions to ask a medical provider. The possible connections are there.

Compression of the carotid triangle – The muscles

A number of important structures related to symptoms and conditions of cervical spine instability run through the carotid triangle of the neck.

The carotid triangle is formed by three muscles

Compression and symptoms related to muscle dysfunction

If there are spasms, dysfunctions, instability with any of the muscles, you can see the consequence especially on the acts of eating, chewing, swallowing, and saliva buildup, etc. The next question is, why are these muscles in spasm? What is causing them to spasm and compress the nerves, arteries, and veins? Further, as these muscles are tensing what are they doing to the internal jugular vein, the carotid artery, and the cranial nerves?

Compression in the carotid triangle – The cranial nerves

As mentioned above, the carotid sheath is a wrapping of connective tissue or fascia that surrounds the vascular vessels of the neck. It also surrounds the cranial nerves. This is all one neat roll-up of arteries, veins, and nerves. It is also a very tight and compact roll-up packed into this protective tube. But the protective tube can only protect so far. Cervical instability can lead to compression of this tube and all the components within it. This can lead to an impact on the cervical nerves and conditions and symptoms thought to be neurologic in nature.

The cranial nerves within the triangle are:

So here again, compression of the carotid triangle and the carotid sheath impacts the muscles and nerves that pass through the carotid triangle or are squeezed into the carotid sheath. This compression of these structures can lead to or are the possible reasons for your symptoms and conditions. Now let’s talk about the jugular vein and the arteries.

Compression in the carotid triangle – the arteries and veins

For every artery, there is a corresponding vein. The arteries bring fresh, well-oxygenated blood, the veins take the oxygen-depleted blood to the lungs to expel the carbon monoxide and refresh the blood with oxygen.

The largest artery is the carotid artery. There is a carotid artery on your left and right side of your head and neck. The blood flows from the heart through the neck to the brain. In the carotid triangle and neck, the carotid artery split into two branches to facilitate this blood distribution. The external carotid artery supplies blood to the neck and face, the carotid artery moves the blood to the brain. Some of the larger branches of this complex plumbing network include:

Ground zero: The carotid triangle and the internal jugular vein – When it’s a drainage problem

When it comes to your head and neck, the internal jugular vein is the drainage system. When oxygen-rich blood is delivered to the brain, the oxygen-poor blood must drain out. Blockage of this drainage system leads to oxygen-poor blood back up in the brain.

The veins that surround the cervical vertebrae

Let’s explore a September 2020 study in the journal Frontiers in Neurology (2) on understanding diagnosis and diagnostic testing of Chronic Cerebrospinal Venous Insufficiency. Here are the learning points of this research:

“As an indispensable part of the cerebral venous system, the extracranial cerebrospinal venous system is not fully recognized. This study aimed to analyze the clinical classification and imaging characteristics of chronic cerebrospinal venous insufficiency (CCSVI) quantitatively (higher quality research).”

Explanatory note: The extracranial cerebrospinal venous system includes:

Let’s point out that this is a September 2020 study that acknowledges current medical understanding of the “extracranial cerebrospinal venous system is not fully recognized.”

In this study, 128 patients were diagnosed with chronic cerebrospinal venous insufficiency (CCSVI) by jugular ultrasound and contrast-enhanced magnetic resonance venography (CE-MRV). For the patients with possible extraluminal compression (drainage from the brain and head are being compromised by another source), tests for internal jugular venous stenosis were performed.

Conclusions: “A multimodal diagnostic system is necessary to improve the diagnostic accuracy of chronic cerebrospinal venous insufficiency (CCSVI). The vertebral venous system is an important collateral circulation for CCSVI, which may be a promising indicator for evaluating Internal jugular vein stenosis degree.” Below we will discuss various testing strategies.

Chronic cerebrospinal venous insufficiency

In this section, a brief summary of symptoms and conditions of Chronic Cerebrospinal Venous Insufficiency outside of a primary diagnosis of Multiple Sclerosis, Alzheimer’s Disease, and Parkinson’s Disease are discussed. At our center we do not treat these diseases, we treat craniocervical instability, upper cervical spine instability, cervical spine instability, or problems related to neck pain and loss of cervical spine curvature that may share common symptoms and characteristics of neurological-like and vascular-like disorders such as those just mentioned.

Common symptoms, a common confusion

We are often contacted by people who had symptoms of Multiple Sclerosis but a brain MRI ruled MS out. This however left the patient and their neurologist at a loss as to what may be causing the person’s MS-like symptoms and conditions. Craniocervical Instability, upper cervical spine instability, cervical spine instability, and Multiple Sclerosis share the following challenges.  This of course is a general guide, in both Multiple Sclerosis and cervical spine instability, the symptoms and conditions can vary greatly and appear more or less severe in people.

Fatigue

Vision problems

Swallowing difficulties

Temperature dysregulation

As noted in a detailed paper in the Journal of applied physiology (x), people with a diagnosis of MS may suffer from problems of heat sensitivity, central regulation of body temperature; and thermoregulatory effector responses (the ability to maintain a core body temperature). These are the same challenges people not diagnosed with MS but have cervical instability suffer from as well. Please see my articles:

Dysesthesias or “abnormal sensations”

Some MS patients share a common characteristic with cervical spine instability patients in that they sense “weird” or “strange” sensations beyond numbness and tingling or electric shock sensation in their skin.

Some of the common characteristics a cervical spine instability patient may experience:

Bowel – digestive disorders 

Some of the common characteristics a cervical spine instability patient may experience conditions related to poor digestion. Please see my articles:

Bladder problems

Some of the common characteristics of a cervical spine instability patient may experience conditions related to urinary problems including the need to urinate more frequently and urgently which may ultimately lead to a loss of bladder control and urge incontinence problems.

Cognitive difficulties, depression, and anxiety

These conditions and problems are of course and unfortunately very common in all people who suffer from chronic medical conditions. We will discuss these challenges later in this article.

Chronic Cerebrospinal Venous Insufficiency: Breaking away from a Multiple Sclerosis only type condition

Chronic Cerebrospinal Venous Insufficiency is exactly what it sounds like. You have a chronic problem moving cerebrospinal fluid out of the brain via the venous or vein network.

A 2019 study in the journal Reviews on Recent Clinical Trials (3) examined the Chronic Cerebrospinal Venous Insufficiency and its relationship with Multiple Sclerosis and found that this condition could be prevalent in other disorders. Here is what the researchers wrote:

“About 10 years ago, the so-called chronic cerebrospinal venous insufficiency syndrome was discovered. This clinical entity, which is associated with extracranial venous abnormalities that impair venous outflow from the brain, was initially found exclusively in multiple sclerosis patients. Currently, we know that such venous lesions can also be revealed in other neurological pathologies, including Alzheimer’s and Parkinson’s diseases. Although the direct causative role of chronic cerebrospinal venous insufficiency in these neurological diseases still remains elusive, in this paper, we suggest that perhaps abnormal venous drainage of the brain affects the functioning of the glymphatic system (the waste clearance system of the central nervous system) which in turn results in the accumulation of pathological proteins in the cerebral tissue (such as β-synuclein, β-amyloid, and α-synuclein) and triggers the venous outflow from the cranial cavity and circulation of the cerebrospinal fluid in the settings of neurodegenerative disease.”

In this paper, there is an identification with the brain being unable to drain wastes and that these accumulated wastes would lead to degenerative disorders. We find here similarities in our cervical spine instability patients. We will discuss this important concept shortly.


Internal jugular vein gets compressed by anterior subluxation of C1 and C0-C1 instability

As mentioned earlier in this article and discussed further in our article on Eagle Syndrome, compression of the internal jugular vein can come from many sources beyond the more researched styloid process. Dr. Enrico Nastro Siniscalchi, maxillofacial surgery and assistant professor at the University of Messina took it one step further and more in agreement with what we have seen in our patients. Basically, the styloid process does not have to be that elongated or even display the type of angulation or measurement deviations discussed in the previously mentioned study. A normal size styloid process can cause arterial compression if there is cervical spine instability. Even in the presence of a styloid process of normal length, lateral (side) and medial (middle) deviations can occur, in fact, a normal styloid process can cause compression of vessels and nerves. (4)

This is alluded to in a paper and case history published in the journal Vascular Medicine. (5) Here the doctors reported on a case of internal jugular vein thrombosis (blood clot) possibly related to internal jugular vein compression between the styloid process and the first cervical vertebra (C1) transverse process. To support this hypothesis, the doctors performed a radiological assessment of the internal jugular vein and examined its relationship with the styloid process and C1 transverse process in 34 control patients. Their results showed a strong correlation between internal jugular vein diameter and styloid process-C1 transverse process distance. Compared to control subjects, our patient had a short styloid process-C1 transverse process distance, which suggests its involvement in internal jugular vein thrombosis.

The researchers found this so extraordinary that they thought to suggest that this is a new venous entrapment syndrome. We call it cervical spine instability.


How does venous obstruction (jugular vein stenosis) occur in a neck? An explanation of cervical spine and neck instability

Upper cervical instability is a primary focus of the Hauser Neck Center at Caring Medical Florida. Every day we are making discoveries in patients who have bizarre and disabling neurological symptoms that have gone undiagnosed or unresolved by their local primary care doctors or even other well-known specialty clinics.

What are we seeing in this image?

A cervical venous system that makes its way to the brain.

The brain drains primarily via the internal jugular and vertebral venous plexus. Most venous compression syndromes that lead to such things as brain fog, memory problems, intracranial hypertension, pseudotumor cerebri, dizziness, head pressure, eye pain, and decreased or blurry vision occur at the J3 segment (upper cervical area) of the internal jugular vein. The J3 segment can get impinge by anterior subluxation of the atlas, occipital-atlanto (C0-C1), and atlantoaxial instability (C1-C2) along with altered musculoskeletal biomechanics as occurs with forward head posture. Realigning and stabilizing the atlas while destroying the cervical lordotic curve resolves most venous compression syndromes, including venous hypertension, venous ischemia, and internal jugular venous obstruction and the symptoms with them.

Over the many years of helping people with cervical spine problems, we have come across a myriad of symptoms that seemingly go beyond the orthopedic, musculoskeletal, and neuropathic pain problems commonly associated with cervical spine disorders, “herniated disc,’ and cervical radiculopathy. While many patients can understand that cervical neck instability can cause problems with pinched nerves and pain and numbness that can extend down into the hands or even into the feet, they can have a lesser understanding that their cervical spine instability also pinches on arteries and the veins in the neck and disrupts, impedes and retards blood flow into the brain and the drainage of this blood and other fluids that can cause intracranial pressure and the symptoms we described above and those we will describe below.

My doctors are telling me I am not draining

Pseudotumor cerebri

Pseudotumor cerebri is brain tumor-like symptoms, but it is not a tumor. Like all these symptoms we have described and you may suffer from, there is confusion when any one symptom or condition is treated in isolation. For example:

I have been suffering from many symptoms. My last diagnosis is pseudotumor cerebri. I have headaches, neck pain, crunching, cracking neck, light sensitivity, dizziness, pressure in the head, pressure behind the eyes, altered heart rate, blood pressure problems.

My doctors are telling me I am not draining. I have a buildup of cerebrospinal fluid. It is not draining right. I do have the symptoms and I do have head pressure but I do not think the way I am being treated is correct for me. I am not overweight yet they treat me like I have high blood pressure and diabetes. So now they want me to take diuretics, I am on fluid restrictions, and salt restrictions. They tell me if this does not work I should consider a spinal tap to “level off,” my fluid levels. Maybe stents or a decompression surgery if all this does not help. I do not feel like I am on the right track.

None of this person’s doctors have recommended cervical spine instability until the end-stage treatments of stents and decompression surgery.

Transient monocular blindness a problem of drainage

This is a symptom we see commonly reported in people seeking our treatments. These people, possibly like yourself will report that suddenly, without warning, they will not be able to see out of one eye. They are blind in that eye. Within a short time, the vision returns. I picked this symptom to focus on because it is one that is more specific to internal jugular vein stenosis.

I have been diagnosed with Idiopathic intracranial hypertension. I have seen many, many specialists. I have had countless tests, countless scans. “Everything,” shows nothing. I keep telling my doctors that all my symptoms go away when I am laying down, when I am laying down for my scans I am not surprised “They show nothing.”  When I am standing I cannot breathe, I blackout,  I have vision problems, and have a diagnosis of transient monocular blindness.

Like the example story above, Transient monocular blindness is a “mystery symptoms,” among many “mystery symptoms.” Its causes can be many, its causes can be internal jugular vein compression.

A paper published in the journal BioMed Central Neurology (6) tried to identify why people have this temporary blindness. Here are the summary learning points of this paper

Medication for jugular vein compression

In August 2019, a paper published in The Journal of International Medical Research (7) described the cases of two 61-year-old women for whom they identified jugular vein compression, caused by a tortuous internal carotid artery compression, as the culprit in their health problems. The use of the word “tortuous” describes that the carotid artery has “altered its course,” it is wandering around in the carotid sheath and triangle and crowding the jugular and nerves.

The first case: Explanatory notes and summary:

The second case: Explanatory notes and summary:

Comment: The source of these two women’s problems were attributed to the jugular vein being compressed on both sides of their neck by the carotid arteries. The only treatments they were offered were medications for the symptoms. Based on the results, some of the symptoms were lessened but the problems remained. The problem was identified, treatments that could help more were not.

Stenting

For some people, stenting will be a successful procedure or at least a successful enough procedure to allow normal blood flow to resume through the jugular veins. This could alleviate symptoms until a more long-term solution can be arrived at. However, when there is compression from the lateral masses of the C1 or cervical instability from C0-C2, elongated styloid bone, or hyoid bone, stenting alone, in many cases, will provide good relief and in some cases make the patient’s situation worse. First, let’s talk about when stenting would work.

A February 2018 study in the European Journal of Neurology (8) looked for the answer to idiopathic intracranial hypertension in internal jugular vein stenosis. What they were especially looking for was when brain scans revealed nothing or as the researchers put it “the absence of intracranial abnormalities.” The focus here is what was going on inside the brain.

Extracranial venous abnormalities: When the problem is not inside the brain but in the cervical spine, this is where stents are going to be a problem.

The people who have success with stents opening up the jugular vein are not the people we see. We see the people who have stents in their blood vessels that did not help and for some put them in a worse situation. We are not the only center to see this.

Here is a June 2018 study published in the journal CNS Neuroscience and Therapeutics. (9) In this paper, as opposed to intracranial abnormalities, they are going to explore “Extracranial venous abnormalities.” Problems coming from outside the brain. Explanatory notes are added in italics.

“Extracranial venous abnormalities, especially jugular venous outflow disturbance, were originally viewed as nonpathological (treatable, solvable) phenomena due to a lack of realization and exploration of their feature and clinical significance.”

(Basically, jugular venous outflow disturbance was thought to be easily treatable using stents. However, and as we shall see, when the stents failed, doctors realized that they did not realize how complicated jugular venous outflow disturbance could be. It was just not a “plumbing problem of a clogged vein.”)

“The etiology and pathogenesis are still unclear, (for many, where their jugular vein blood flow problems are coming from, is still unclear) whereas a couple of causal factors (causal factors are causes that would not be normally considered in a traditional setting)  have been conjectured.

The clinical presentation of this condition is highly variable, ranging from insidious (gradual onset with no symptoms) to symptomatic, such as headaches, dizziness, pulsatile tinnitus, visual impairment, sleep disturbance, and neck discomfort or pain. Standard diagnostic criteria are not available, and current diagnosis largely depends on a combinatory use of imaging modalities.

Although few types of research have been conducted to gain an evidence‐based therapeutic approach, several recent advances indicate that intravenous angioplasty (balloon angioplasty) in combination with stenting implantation may be a safe and efficient way to restore normal blood circulation, alleviate the discomfort symptoms, and enhance patients’ quality of life.

In addition, surgical removal of structures (this would be cervical vertebrae decompression) that constrain the internal jugular vein may serve as an alternative or adjunctive management when endovascular (the balloon angioplasty and stents) intervention is not feasible.”

Finally:

“Extrinsic (from the outside) compression of the internal jugular vein secondary to the osseous and muscular origins (such as the styloid process, the posterior belly of the digastric muscle, and the transverse process of an adjacent vertebra) has been found in a set of unselected patients who underwent computed tomography angiography (CTA). However, some of the internal jugular vein stenosis may not be taken as pathological considering no evidence of abnormal collateral (secondary) formation.

Patients may display central venous hypertension‐associated symptoms when this impingement either occurs bilaterally or affects the dominant internal jugular vein. Surgical resection of culprit structures is gradually emerging as the choice of treatment. Among patients with identified extrinsic impingement of the internal jugular vein between the styloid process and the lateral mass of the cervical vertebra at the C1 segment, venous stenting alone was deemed ineffective given the compressive nature and delayed stenting complications were also recorded.”

And this is what we see

Can you stent a stretched-out vein? When vein narrowing is caused by a stretched out vein

What are we seeing in this image?

A blue balloon is used to demonstrate stenosis of a different kind. The stretched out or elongated vein stenosis. This is stenosis caused by cervical spine instability and a loss of the natural cervical spine curve. Look at the blue balloon in its normal resting state on the left. Note how much wider it is than the eleven inches, a stretched-out version of itself on the right. The stretched-out version of itself has less inner space for the blood to drain.

In the video below Ross Hauser, MD, and Brian Hutcheson, DC discuss the various symptoms related to intracranial pressure. At 3:30 of the video, Dr. Hauser discusses the problem of a stretched-out vein.

A balloon demonstration of a stretched vein

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.

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.

Posture-induced changes

At our center, a major factor in deciding a course of treatment is understanding the dynamics of symptom alleviation and severity by the position of the patient’s head in real-time. During the examination we have the patient rotate their heads to all the positions they can manage and monitor symptom changes. Sometimes head rotations in our examination rooms can bring upon very dramatic and immediate symptoms. We are replicating the patient’s real-life experience so we can make the best assessment of treatments.

You probably understand the importance of this more than your doctors. You know that if you turn for head to the left and look down, your ears may fill up. You know that if you look to the right and look up you may become instantly dizzy. You know that if you look down a lot your hands may tingle, you may get bloated. These are examples of how the different positions of your head can make symptoms better or worse. So shouldn’t your tests be taken while you move your head through these various positions?

Unfortunately, many doctors can only rely on static images. The patient lays on a table and has an MRI. Hold still, don’t move. Of course, the image that is taken reflects only the head and neck in that position, not the other positions the patient may be able to achieve and the positions that make their symptoms worse.

Transcranial doppler (TCD) and extracranial Doppler (ECD)

Above I mentioned transcranial doppler (TCD) and extracranial Doppler (ECD) ultrasound. We utilize a Transcranial Doppler (TCD) to track real-time changes in blood flow to the brain. What we hope to see is how, when you move your head into certain positions, this impacts your blood flow into your brain. If blood flow is compromised through compression/stenosis, so will neurologic function. The end result will be your symptoms. Symptoms and diagnoses such as dizziness, lightheadedness, fainting (drop attacks), imbalance, dysarthria (slurred speech), facial dropping, transient ischemic attacks (weakness or sensory deficits on one side of body/face that resolve completely within an hour), as well as strokes (weakness or sensory deficits on one side of the body/face that last greater than one hour) imply a loss of circulation to the brain or other vital nervous tissue. Patients may complain of “weird” symptoms such as a swishing sound in their ear, numb tongue, numb lips, visual distortions, poor balance, and other symptoms that come and go.

If your blood flow to your brain is intermittently compromised, such as only when the neck is in certain positions, it will be difficult for static imaging to capture the films that your doctors are using to diagnose and plan treatment.

A typical patient’s medical history with static testing

We will often see patients whose medical histories will give obvious testament to the fact that when they move their head one way or another they have symptoms and challenges that were just outlined above. The patient tells us that their symptoms occur when they are upright and/or while they were moving their neck, versus when they are lying flat. Many people tell us that to alleviate their symptoms, they go and lay down. This is also the position that they take their MRIs or MRVs. This is one explanation as to why diagnosis can be difficult or the test results “show nothing.”

Atlantoaxial instability: C1 and C2 hypermobility causes cervical spine instability and artery, vein, and nerve compression

Atlantoaxial instability is the abnormal, excessive movement of the joint between the atlas (C1) and axis (C2). This junction is a unique junction in the cervical spine as the C1 and C2 are not shaped like cervical vertebrae. They are more flattened so as to serve as a platform to hold the head up. The bundle of ligaments that support this joint is strong bands that provide strength and stability while allowing the flexibility of head movement and allow unimpeded access (prevention of herniation or “pinch”) of blood vessels that travel through them to the brain.

In a 2015 paper appearing in the Journal of Prolotherapy(10) our research team wrote that cervical ligament injury should be more widely viewed as the underlying pathophysiology (the cause of) atlantoaxial instability and the primary cause of cervical myelopathy (disease) including the problems I have written about in this article.

The problems of Atlantoaxial instability are not problems that sit in isolation. A patient that suffers from Atlantoaxial instability will likely be seen to suffer from many problems as they all relate to upper cervical neck ligament damage and cervical instability. As demonstrated below this includes cervical subluxation, (misalignment of the cervical vertebrae). One of the causes of Internal jugular vein stenosis is this cervical misalignment and its “pinching,” or “herniation,” not of a disc, but of the arteries and veins. This creates the situation of ischemia (damage to the blood vessels) or in the case of this article internal jugular vein ischemia.

The case for identifying loss of cervical lordosis as the cause of your symptoms

The cervical ligaments are strong bands of tissues that attach one cervical vertebra to another. In this role, the cervical ligaments become the primary stabilizers of the neck. When the cervical ligaments are healthy, your head movement is healthy, pain-free, and non-damaging. The curve of your cervical spine is in correct anatomical alignment.

When the cervical spine ligaments are weakened, they cannot hold the cervical spine in proper alignment or in its proper anatomical curve. Your head begins to move in a destructive, degenerative manner on top of your neck. This is when cervical artery and jugular vein compression can occur.

In our 2014 research lead by Danielle R. Steilen-Matias, MMS, PA-C, published in The Open Orthopaedics Journal (11), we demonstrated that when the neck ligaments are injured, they become elongated and loose, which causes excessive movement of the cervical vertebrae. In the upper cervical spine (C0-C2), this can cause a number of other symptoms including, but not limited to, nerve irritation, vertebrobasilar insufficiency with associated vertigo and dizzinesstinnitus, facial pain, arm pain, migraine headaches, and jugular vein compression.

Treating and stabilizing the cervical ligaments can alleviate these problems by preventing excessive abnormal vertebrae movement, the development or advancing of cervical osteoarthritis, and the myriad of problematic symptoms they cause including nerve, vein, and arterial compression.

Through extensive research and patient data analysis, it became clear that in order for patients to obtain long-term cures (approximately 90% relief of symptoms) the re-establishment of some lordosis, (the natural cervical spinal curve) in their cervical spine is necessary. Once spinal stabilization is achieved and the normalization of cervical forces by restoring some lordosis, lasting relief of symptoms was highly probable.

The Horrific Progression of Neck Degeneration with Unresolved Cervical Instability

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.

Non-surgical treatment – Cervical Spine Stability and Restoring Lordosis -Making a case for regeneration and repair of the spinal ligaments


Cervical instability on DMX

Research on cervical instability and Prolotherapy

Caring Medical has published dozens of papers on Prolotherapy injections as a treatment in difficult-to-treat musculoskeletal disorders. We are going to refer to two of these studies as they relate to cervical instability and a myriad of related symptoms including the problems spoken of in this article.

We are going to go briefly outside of our own research and observation to present two independent studies. In our research that we will demonstrate below, we were able to get good outcomes with simple dextrose Prolotherapy injections that stimulated repair and restoration of the damaged cervical neck ligaments. This helped restore the normal anatomical alignment of the head and neck. In this research below, we will explore the proper alignment that came from chiropractic studies.

In 2019, published in the medical journal Brain Circulation,(12) Evan Katz, a private practitioner published the findings of his office in treating the Cervical lordosis of seven patients (five females and two males, 28–58 years). “The aim of this study is to evaluate cerebral blood flow changes on brain magnetic resonance angiogram (MRA) in patients with loss of cervical lordosis before and following correction of cervical lordosis.”

These are some of the study’s learning points:

  • Loss of lordosis of the cervical spine is associated with decreased vertebral artery hemodynamics. “Vertebral arteries proceed superiorly, in the transverse foramen of each cervical vertebra and merge to form the single midline basilar artery” which continues to the circle of Willis and cerebral arteries. Based on this close anatomical relationship between the cervical spine, the vertebral arteries, and cerebral vasculature, we hypothesized that improvement in cervical hyperlordosis increases collateral cerebral artery hemodynamics and circulation. This retrospective consecutive case series evaluates brain magnetic resonance angiogram (MRA) in patients with cervical hyperlordosis before and following correction of cervical lordosis.

Note: The study cites a paper from Yuzuncu Yil University, Medical Faculty in Turkey published in the journal Medical Science Monitor. (13) In this study the research team suggests:

Because the loss of cervical lordosis leads to disrupted biomechanics, the natural lordotic curvature is considered to be an ideal posture for the cervical spine. The vertebral arteries proceed in the transverse foramen of each cervical vertebra. Considering that the vertebral arteries travel in close anatomical relationship to the cervical spine, we speculated that the loss of cervical lordosis may affect vertebral artery hemodynamics. . . the possible effects of loss of cervical lordosis on vertebral artery hemodynamics and their clinical outcomes are completely unknown. Because the vertebral arteries are the major source of blood supply to the cervical spinal cord and brain stem, the possible factors affecting these vessels warrant investigation.”

The study from Dr. Katz is one of the studies of further investigation. Following chiropractic adjustments he noted:

“This retrospective consecutive case series was performed to test the hypothesis that loss of cervical lordosis may be associated with the circle of Willis (the junction of several arteries at the base of the brain) and cerebral artery hemodynamics (More simply blood flow). The results of this case series revealed that the circle of Willis and cerebral artery parameters were significantly different between pre-and-post cervical adjustments with preadjustment values showing lower values in comparison to post-adjustment values. .  .Our findings demonstrate preliminary evidence that loss of cervical lordosis may play a role in the development of changes related to the circle of Willis and cerebral artery hemodynamics and decreased blood flow in the brain.”

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 the challenges that internal jugular vein stenosis may be causing you. 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

1 Ding JY, Zhou D, Pan LQ, Ya JY, Liu C, Yan F, Fan CQ, Ding YC, Ji XM, Meng R. Cervical spondylotic internal jugular venous compression syndrome. CNS neuroscience & therapeutics. 2020 Jan;26(1):47-54. [Google Scholar]
2 Wang Z, Ding J, Bai C, Ding Y, Ji X, Meng R. Clinical Classification and Collateral Circulation in Chronic Cerebrospinal Venous Insufficiency. Frontiers in Neurology. 2020;11. [Google Scholar]
3 Simka M, Skuła M. Potential involvement of impaired venous outflow from the brain in neurodegeneration: Lessons learned from the research on chronic cerebrospinal venous insufficiency. Reviews on recent clinical trials. 2019 Dec 1;14(4):235-6. [Google Scholar]
4 Siniscalchi EN. Dynamic imaging in suspected Eagle syndrome. European Archives of Oto-Rhino-Laryngology. 2020 Jan 1;277(1):307-. [Google Scholar]
5 Pokeerbux MR, Delmaire C, Morell-dubois S, Demondion X, Lambert M. Styloidogenic compression of the internal jugular vein, a new venous entrapment syndrome?. Vascular Medicine. 2020 Mar 18:1358863X20902842. [Google Scholar]
6 Cheng CY, Chang FC, Chao AC, Chung CP, Hu HH. Internal jugular venous abnormalities in transient monocular blindness. BMC neurology. 2013 Dec;13(1):1-6. [Google Scholar]
7 Li M, Su C, Fan C, Chan CC, Bai C, Meng R. Internal jugular vein stenosis induced by tortuous internal carotid artery compression: two case reports and literature review. Journal of International Medical Research. 2019 Aug;47(8):3926-33. [Google Scholar]
8 Zhou D, Meng R, Zhang X, Guo L, Li S, Wu W, Duan J, Song H, Ding Y, Ji X. Intracranial hypertension induced by internal jugular vein stenosis can be resolved by stenting. European journal of neurology. 2018 Feb;25(2):365-e13. [Google Scholar]
9 Zhou D, Ding JY, Ya JY, Pan LQ, Yan F, Yang Q, Ding YC, Ji XM, Meng R. Understanding jugular venous outflow disturbance. CNS neuroscience & therapeutics. 2018 Jun;24(6):473-82. [Google Scholar]
10 Hauser R, Steilen-Matias D, Fisher P. Upper cervical instability of traumatic origin treated with dextrose prolotherapy: a case report. Journal of Prolotherapy. 2015;7:e932-e935.
11 Steilen D, Hauser R, Woldin B, Sawyer S. Chronic neck pain: making the connection between capsular ligament laxity and cervical instability. The open orthopaedics journal. 2014;8:326. [Google Scholar]
12 Katz EA, Katz SB, Fedorchuk CA, Lightstone DF, Banach CJ, Podoll JD. Increase in cerebral blood flow indicated by increased cerebral arterial area and pixel intensity on brain magnetic resonance angiogram following correction of cervical lordosis. Brain circulation. 2019 Jan;5(1):19. [Google Scholar]
13  Bulut MD, Alpayci M, Şenköy E, Bora A, Yazmalar L, Yavuz A, Gülşen İ. Decreased vertebral artery hemodynamics in patients with loss of cervical lordosis. Medical science monitor: international medical journal of experimental and clinical research. 2016;22:495. [Google Scholar]

This article was updated on March 23, 2021

 

 

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