Symptoms and conditions of cervical spine compression causing internal jugular vein stenosis
Ross Hauser, MD
Symptoms and conditions of cervical spine compression causing internal jugular vein stenosis. 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 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:
- Patients with unexplained nonfocal (not a nerve problem) neurological dysfunctions display cerebral venous outflow disturbance in relation to the atlas (C1) compression of the superior segment of the internal jugular vein.
- This included symptoms and conditions of transient monocular blindness, Ménière disease, Alzheimer’s disease, idiopathic intracranial hypertension (please see our article Cervical Spine Instability, Vein blockage, fluid build up, and intracranial hypertension), and multiple sclerosis.
- Decreased cerebral perfusion (blood flow to the brain – see our article Dynamic Analysis of Blood Flow Measurements to the Brain, Brainstem, Cervical Spinal Cord, and Cranial Nerves), cerebral microvascular structures impairment (This is the network where arteries and veins connect by way of the arterioles (the part of the artery that leads to the capillaries), capillaries (that connect the arterioles to the venules), and venules (which bring the connection to the vein)), impaired cerebrospinal fluid (CSF) dynamics, and elevated intracranial pressure may be the underlining mechanisms of internal jugular vein‐induced brain structural and functional disorders.
Nonfocal neurological symptoms like headache, head noise, tinnitus, and visual impairment are tightly correlated to unilateral or bilateral internal jugular vein syndrome.
- This study saw many of the things we see: That some 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.
In this video:
Ross Hauser, MD discusses some of the common symptoms and conditions associated with intracranial hypertension from internal jugular vein compression, as well as methods we use to determine if this is likely what is causing a patient’s symptoms. We see many patients with intracranial hypertension who come to our center because they have a constellation of symptoms like head pressure, brain fog, eye pain, glaucoma, vision problems, and many others that indicate the root cause may involve their internal jugular vein being compressed in the upper cervical spine.
Most of you who are watching a video on intracranial hypertension and internal jugular vein compression are probably doing it because nobody’s figured out the cause of your problem. To discover something you need to know what you’re looking for so if your doctor doesn’t look for drainage of the brain problem you’re not going to find what may be the primary cause of the patient’s problem.
Even to figure out whether a person’s internal jugular vein is getting compressed you have to have a high degree of suspicion that this is in fact occurring. The first thing you need to know is that the drainage of the brain all goes through the neck. Most of the drainage that goes through the neck drains through the veins and some of the brain drains through the lymph system. That’s why when we do ultrasounds of people’s necks we often find that there’s lymphadenopathy, enlarged lymph nodes not from infection but engorgement from basically “brain poop.” Something (compression) is also stopping the drainage of the lymph nodes.
Brain waste products or “Brain poop”
Brain poop is my terminology to describe the waste products of all the neuron (nerve) activity in the brain. Imagine there are a billion neurons in the brain that are active. There is a lot of waste products.
Let’s stop here for some further explanation of this idea of ‘brain poop.” All cells including the nerve cells produce waste products. Neurons are high energy, high fuel consuming, high by-product producing cells. In other words, they produce a lot of waste. You will recognize some of the waste products the neurons produce, the beta-amyloid and tau proteins implicated as a possible cause of Alzheimer’s disease.
What are we seeing in this image? You need to flush the brain to get rid of neuron poop. The brain functions as a toilet to get rid of its poop.
This may be a whimsical way to metaphorically present this serious problem, but over the last few years, this analogy has developed resonance in our patients as a simple to the point understanding of their challenges.
The neurons, as described above, are big consumers of food fuel to create energy. Simply anything that eats a lot usually poops a lot. The brain naturally flushes this poop out with Cerebrospinal fluid (CSF). If for whatever reason, the toilet tank does not fill, the toilet tank does not flush into the brain, the toilet clogs and causes overflow, the poop does not move out of the brain.
As stated in the captions of these images. Obstruction of the arteries and veins, both into and out of the brain, from cervical instability and wandering vertebrae compressing these vital structures, will ultimately result in an accumulation of Cerebrospinal fluid (CSF) in various parts of the brain including the frontal lobe. The neuron’s own waste will ultimately suffocate and drown them. This is one explanation for severe brain fog and mental decline in people with upper and lower cervical instability.
The majority of this drainage is through the internal jugular vein. This is why we emphasize the internal jugular vein. In the image below you can see how much thicker the internal jugular vein is from the other veins. It is the “big drainage pipe.”
Let’s look at what happens when you have internal jugular vein compression and how can you document it.
This discussion is at 2:35 of the video:
What are we seeing in this image? The causes of internal jugular vein compression
Let’s explain this image further:
We see the internal jugular vein (in blue) passing through the hole of the skull called the jugular foramen which is very close to the atlas and the occiput at the base of the skull.
We also see that the internal jugular vein right in front of the lateral mass of the C1. So if you have a forward head posture, the atlas is going to wander forward and it can compress the Carotid artery or the jugular vein. In patients, we see the number one cause of internal jugular vein compression is the lateral mass of the C1.
What are we seeing in this image?
We are seeing the upright ultrasound scan of the internal jugular vein (A) Right side (B) Left side. The “graying out” on the left internal jugular vein is occurring because of a very slow blood flow. A condition caused by cervical instability from damaged ligaments causing a slowing of the fluid flows in an out of the brain through the jugular veins.
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.
- The main triangle is the anterior triangle and the anterior triangle is divided into four other triangles. We are going to focus on the anterior triangle and the carotid triangle, but here is a brief understanding of the other triangles.
- The submental triangle lies under your chin. It contains the submental lymph nodes which are part of the mouth floor drainage system. The floor of the submental triangle is formed by the mylohyoid muscle. The mylohyoid muscle forms the floor of the oral cavity connecting the mandible to the hyoid bone (the tongue bone) in front of the C3 vertebrae.
- The submandibular triangle lies under your jaw. In the submandibular triangle, you will find the submandibular gland (the second largest of your three salivary glands), and the drainage system lymph nodes. You will also find that the facial artery and the facial vein pass through this triangle. The facial vein drains into the internal jugular vein.
- The muscular triangle lies lower than the other triangles, there is a question of whether to call this a triangle at all as its borders contain four sides. But look at what lays inside it:
- the pharynx that connects the mouth and esophagus,
- the thyroid gland,
- the parathyroid glands,
- and the infrahyoid muscles which in part help hold the hyoid bone (the tongue bone) in place.
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
- The sternocleidomastoid muscle. This muscle moves your head to the chin to chest (down) and chin (up) in sky positions. It rotates your head to the left and right and the motion of putting your right ear on your right shoulder and left ear on your left shoulder. Dysfunction of this muscle can cause compression on the carotid triangle during any of these motions.
- The superior belly of the omohyoid muscle. The omohyoid muscle, which is divided into two parts the superior belly being one, is responsible for many functions, the two we would like to highlight here are its role in normal swallowing (it restores breathing after the swallow) and its responsibility to the carotid sheath. The carotid sheath is the connective tissue, the fascia that surrounds the vascular vessels of the neck. The omohyoid muscle pulls back on the fascia to allow normal or low pressure in the internal jugular vein so blood flow is normalized with the brain.
- The posterior belly of the digastric muscle with the stylohyoideus. The digastric muscle opens your mouth. The stylohyoideus moves your tongue.
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:
- The facial nerve [CN VII or Cranial Nerve 7] is involved in the movements of the face including facial expressions. It is also involved in taste and tear production.
- The glossopharyngeal nerve [CN IX or Cranial Nerve 9], (helps control speaking, speech, swallowing, saliva, taste sensation, among other functions).
- The vagus nerve [CN X or Cranial Nerve 10], the vagus nerve does so many things, we have numerous articles on the vagus nerve’s impact on digestion, involvement with SIBO, Nausea, and gastroparesis, urinary incontinence, cervical angina, and so much more.
- The accessory nerve [CN XI or Cranial Nerve 11] controls the movements of certain neck and shoulder muscles.
- and the hypoglossal nerve [CN XII or Cranial Nerve 12] which controls almost all the muscles involved in the movement of the tongue.
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:
- The superior thyroid artery which in addition to supplying the thyroid gland with its blood, supplies the larynx.
- Disruption in this blood distribution can mean thyroid, speech, and swallowing difficulties.
- The superior thyroid vein drains the blood from the thyroid gland and the larynx down the internal jugular vein.
- The lingual artery and its branches bring blood to the back of the tongue, and the areas at the back of the throat including the palatoglossal arch, lingual tonsil, soft palate, and epiglottis.
- Disruption in this blood distribution can mean speech and swallowing difficulties.
- The lingual vein helps drain the blood to the back of the tongue, and the areas at the back of the throat including the palatoglossal arch, lingual tonsil, soft palate, and epiglottis down the internal jugular vein.
- The sublingual artery supplies the sublingual gland (salivary gland), the genioglossus (tongue muscle), the geniohyoid (a muscle that moves food down the throat and assists with breathing), the mylohyoid (the floor of the oral cavity), and the mandible.
- Disruption in this blood distribution means swallowing difficulties, chewing problems, saliva problems). Within its branches is the sublingual artery that supplies blood to the tip and body of the tongue.
- The sublingual vein drains the tongue, the sublingual gland, the geniohyoid (a muscle that moves food down the throat and assists with breathing), the mylohyoid (the floor of the oral cavity), and the mandible ultimately down the internal jugular vein.
- The facial artery supplies blood to all of the face and portions of the mouth.
- Disruption in this blood distribution can mean facial drooping, speech problems, vision problems, as well as other neuralgic type symptoms.
- The facial vein drains the blood from the face and portions of the mouth, down the internal jugular vein.
- The occipital artery brings blood to the scalp and muscles in the back and neck as well as the sternocleidomastoid muscles, the muscles that help rotate your head from side to side.
- Disruption in this blood distribution can mean neck pain, spasms, headaches, torticollis or cervical dystonia, nausea, tinnitus, and vertigo.
- The occipital vein drains the blood from the scalp and muscles in the back and neck into both the external jugular vein and the internal jugular vein.
- The ascending pharyngeal artery supplies blood to the pharynx.
- Disruption in this blood distribution can mean swallowing difficulties, chewing problems, food transit problems from the mouth to the esophagus).
- The pharyngeal vein helps drain the blood to the pharynx, down the internal jugular vein.
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:
- The external jugular vein on each side of the neck. The external jugular vein drains blood from the head, face, and parts of the shoulder area around the scapular.
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.
- The causes of extraluminal compression induced Internal jugular vein stenosis included:
- Osseous compression (Bones are compressing on the internal jugular) (78.95%),
- Carotid artery (24.21%), (Note the carotid artery itself is compressing the jugular vein).
- Sternocleidomastoid muscle (5.79%). Note: This muscle moves your head to the chin to chest (down) and chin (up) in sky positions. It rotates your head to the left and right and the motion of putting your right ear on your right shoulder and left ear on your left shoulder. Dysfunction of this muscle can cause compression on the carotid triangle during any of these motions and as seen in this research can be a cause of internal jugular vein stenosis
- swollen lymph node (1.05%),
- and unknown reasons (5.26%)
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.
- Chronic fatigue. Many people who reach out to us have a diagnosis of Myalgic encephalomyelitis (muscle pain from nerve inflammation) or Chronic Fatigue Syndrome. Fatigue in these people is part of a complex medical history. Sometimes this is diagnosed as Fibromyalgia.
- If you have been suffering from vision problems related to neck instability, you know that these problems can come with different impairments. MS patients and cervical neck instability patients can share problems of:
- Loss of vision in one eye. Symptoms of Transient monocular blindness – Amaurosis fugax – Transient visual loss. You suffer from a temporary loss, or a slow fading out to gray, in the vision of one of your eyes.
- Nystagmus – Oscillopsia type symptoms where you have a vision problem where you see things that bounce, jump or appear to be in some type of motion when in fact these objects are not moving at all.
- Blurred or Double Vision Problems
- Cervical spine nerve compression can be an “unseen” cause of swallowing difficulties.
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:
- Thermoregulatory instability – Neck pain and inability to maintain consistent body temperature
- Excessive Sweating – Hyperhidrosis. Is upper cervical instability the missing treatment?
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:
- Tactile hallucinations and Formication: Strange skin sensations
- Brachioradial Pruritis – Neuropathic itch
Bowel – digestive disorders
Some of the common characteristics of a cervical spine instability patient may experience conditions related to poor digestion. Please see my articles:
- How neck pain and cervical spine instability cause nausea, gastroparesis, and other digestive problems
- Cervical spine instability as a cause of your digestive disorders
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.
- Neurologic, digestive, cardiac, and bladder disorders: Some of the symptoms of Autonomic nervous system dysfunction and treatment options.
- Cervical spine problems, Vagus nerve compression, as cause urinary incontinence
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
Please see my companion article Chronic Cerebrospinal Venous Insufficiency and neurologic-like problems.
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 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 symptom,” 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
- The origin of transient monocular blindness in patients without carotid stenosis (traditionally thought of as cardiovascular disease) has been linked to ocular venous hypertension (poor drainage of the fluid inside the eye), increased retrobulbar vascular resistance (the blood vessels resistance to high/low blood pressure flow), sustained retinal venule dilatation (changes in the diameter and length of the retinal vessels typically associated with diabetes) and higher frequency of jugular venous reflux. (The valves of the jugular vein don’t function properly, leading to a backflow of blood through the valves).
- The researchers of this study found that transient monocular blindness patients suffered from significantly more moderate or severe internal jugular vein stenosis compression/stenosis which could impair cerebral venous outflow. Their results provide evidence supporting that the cerebral venous outflow abnormality is one of the etiologies of transient monocular blindness.
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:
- A 61-year-old woman presented with an 11-year history of dryness and a feeling of high pressure in both eyes accompanied by headache. She reported that her headache had worsened approximately 2 weeks previously, especially in the right temporal region, with neck discomfort and insomnia.
- Contrast-enhanced MRV (MR venography) of the neck showed segmental stenosis in the bilateral (both sides of her neck) jugular vein due to compression of the adjacent internal carotid arteries.
- The patient was treated with intravenous (Xueshuantong – patented traditional Chinese medicine), oral aspirin, oral atorvastatin (used to treat angina, stroke, heart attack, and blood vessel problems), oral probucol (for coronary artery disease). The medications helped reduce her symptoms.
The second case: Explanatory notes and summary:
- A 61-year-old woman presented with a 10-year history of intermittent headache, especially in the left temporal region, and bilateral high-frequency tinnitus. Four months before presentation, these symptoms had worsened and become accompanied by insomnia. She had no history of medications.
- Contrast-enhanced MRV (MR venography) of the neck showed focal stenosis of the jugular vein on both sides of her neck due to compression of the adjacent internal carotid arteries.
- The patient was treated with intravenous ginaton (a Ginkgo Biloba extract, oral betahistine (for vertigo type symptoms), and oral estazolam (for impaired memory and coordination). Her symptoms were partially resolved.
Comment: The source of these two women’s problems was 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.
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.
- Fifteen patients with internal jugular vein stenosis had stents put in.
- Blood flow normalized, symptoms of headache, tinnitus, papilledema (swelling of the optic nerve), and increased intracranial pressure were significantly relieved at a two-week follow-up.
- At one year, the headache disappeared in 14 out of 15 patients (93.3%), visual impairments were recovered in 10 of 12 patients (83.3%) and tinnitus resolved in 10 out of 11 patients (90.9%).
- The researchers concluded: “Stenting seems to be a promising option to address the issue of intracranial hypertension from the etiological (what is causing it) level, particularly after medical treatment failure.” Typically the medication route.
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.”
“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
- We see people where stents failed.
- We see people with cervical instability, especially C0-C2 instability, causing compression of venous outflow (which can be documented by transcranial doppler (TCD) and extracranial Doppler (ECD) ultrasound examinations). The internal jugular vein is almost always compressed at J3 because of issues from occipital C0-2 including subluxations and instability.
- We see people with cervical kyphosis (excessive spinal curvature) especially with hyperextension of C1. This can cause venous compression of the internal jugular vein at the J3 segment.
- In many candidates, we can avoid surgery.
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.
- Ross Hauser, MD: We are finding and doing outcome research on is the problem of what’s causing the cerebrospinal fluid flow to accumulate and cause pressure inside the head to be elevated is a venous obstruction (vein blockage) so how does venous obstruction occur in a neck? One way is stenosis because of an elongated stretched-out vein.
A balloon demonstration of a stretched vein
- At 3:30 of the above video: the vein is represented by a balloon. When the balloon is stretched to 9 inches it has more space for the blood to flow than when it is stretched to 11 inches. A narrowing occurs. The more stretching of the vein the less space is contained within the vein for the blood flow and for drainage of fluids that need to be moved out of the brain.
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.
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.
- To assess proper blood flow to the body’s most important nerves and nervous tissue (the brain), especially with head and neck motions, the Hauser Neck Center at Caring Medical Florida performs transcranial doppler (TCD) and extracranial Doppler (ECD) ultrasound examinations. A more detailed article on these tests can be found here: Using Transcranial Doppler & Extracranial Doppler Ultrasound Testing at the Hauser Neck Center.
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 dizziness, tinnitus, 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.
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This article was updated on May 10, 2021