How neck pain and cervical spine instability cause nausea, gastroparesis and other digestive problems
Ross Hauser, MD
Nausea due to neck pain, neck stiffness, and neck instability
When we see patients with problems of cervical spine instability, they usually present with many symptoms, not just one. These symptoms are not confined to neck pain, arm numbness, headaches, or the traditional symptoms of cervical spine instability or cervical radiculopathy, some of these symptoms these people describe can seem remote or unrelated to their neck problems, but they are not. These symptoms patients may discuss with us are the constant presence of nausea and/or gastroparesis or a problem with their stomach’s ability to empty itself of food. While many readers may not be familiar with the term gastroparesis, they are familiar with the symptoms they suffer from heartburn, vomiting, the sensation of being bloated, a constantly full stomach, and of course nausea.
In this article, we want to stress that nausea and digestive problems can be caused by many problems, however, many patients we see have nausea caused by cervical vertigo and cervicogenic dizziness and may have underlying problems with cervical instability and beyond. This includes compression of the brain stem
- In our article, Upper Cervical Instability and Compression of the Brainstem, we point out that the nausea center is right in the lower part of the brainstem. This causes many people to feel nauseated all the time and nobody can tell what’s causing it. These people have a history of seeing gastroenterologists and various gastrointestinal doctors and they would have no idea that the cause of this chronic nausea can be upper cervical instability.
- In some patients we see, we can trace their digestive problems to compression of the vagus nerve, which will be discussed below. In our article Cervical spine instability as a cause of your digestive disorders, we present the case of a particular patient, who over the course of years developed many symptoms that lead her to many specialists including, gastroenterologists, ENTs, neurologists, pain doctors, etc. She has had the gradual onset of ringing in the ears, tinnitus, migraines, fainting spells, loss of balance, speech issues, voice issues, and interesting to me is GERD or gastroesophageal reflux disease and other digestive problems.
Stomach function is vagus nerve dependent. To Digest food, the stomach needs normal vagus nerve input.
Many people we see have done and continue to do deep research on their own medical conditions. They, like you, were exploring other possibilities for their unresponsiveness to treatments. Some will explore research because they are not seeing eye-to-eye with their doctors over their treatments, or lack of wellness progress, or an overall lack of understanding of their situation and symptoms. Some will focus on the vagus nerve when they reach out to our center. Here are some sample emails. These emails have been edited for clarity.
My doctor seems to have never heard of the connection between digestive and motility disease and cervical spine instability.
I know I have craniocervical instability and vagus issues. When I asked my neuro-gastroenterologist about whether cervical fusion of the vertebrae could be an option for me, it seemed like he had never even heard about the connection between digestive and motility disease and cervical spine instability. For my gastroparesis, I was prescribed medications for constipation.
My doctors have not investigated my neck
Ten years ago I had C3-4-5 fused. At the time I had numbness and tingling and throat issues. About a year ago, the tingling returned and then I started to have significant digestive issues. I lost 25 pounds. I have been diagnosed with gastroparesis of an “unknown cause.” My doctors have not investigated my neck, although I have been begging for a cervical MRI. I am currently eating only puree foods, soft foods and trying to keep down what I can.
I have had cervical neck pain for a long time
I am suffering from chronic nausea and vomiting. I have had cervical neck pain for a long time. I have seen a gastroenterologist, psychiatrist, and psychologist, and I have had a PET scan, a CT scan of my stomach and abdomen, and a brain MRI. I was told nothing was found. I have neck instability and severe back pain upon waking. I’m dealing with motion-type sickness, waking up with nausea, and have had panic attacks that last for hours with major adrenaline surges. I have trouble sleeping and for this, I am being prescribed antidepressants. I’ve been to the ER so many times I’m on a list not to treat anything chronic and I have been classified as having drug-seeking behavior.
Neurologists say they don’t treat my symptoms.
I have trouble swallowing, barium swallow shows I have delayed swallowing. I have been diagnosed with gastroparesis and I also have difficulty breathing. My stomach feels tight and I feel like nothing ever digests. It makes me incredibly nauseous. I also have a burning sensation in the nerves near my esophagus/stomach. My issues eating have made me avoid food. Last year I lost 25 pounds and didn’t eat anything for days at a time. I’ve had two endoscopies that didn’t show anything except inflammation. I have a very stiff neck and arthritis. . . Doctors haven’t been able to help me . . . Neurologists say they don’t treat my symptoms.
Vagus nerve issues:
I have had chronic nausea. I have been diagnosed with gastroparesis and SIBO, which I have been treating, but the nausea has persisted without letup. I believe it could be a vagus nerve issue, but I’m not sure. Nothing relieves the nausea. I have lost 15 pounds since the nausea began. (Please see my article Small intestinal bacterial overgrowth and the Vagus Nerve. The problem of nerve compression.)
I have daily debilitating nausea.
I have daily debilitating nausea. I was diagnosed with gastroparesis a few months ago. Medications are not working. I am a long Covid-19 patient as well. My doctor thinks my Gastroparesis may be a result of Covid-related damage to my vagus nerve. I also had a three-level cervical fusion four years ago. Is the cervical fusion connected to my vagus nerve damage?
Six years ago, I had a neck surgery.
Six years ago, I had a neck surgery. About three months after that, I started vomiting non-stop. I went to the hospital. They did a gastric emptying study on me. After the results came in, they told me I have gastroparesis. Since then, I have been suffering very very much.
I was very recently diagnosed with gastroparesis.
I was very recently diagnosed with gastroparesis. I have been suffering with nausea for two years. I’ve been also experiencing tingling and numbness all over my body and face for the past five years. I had an MRI of my cervical spine. Everything came back normal. My doctors told me my only issue was the “straightening of the normal lordotic curvature of the cervical spine.” Is this what is causing my vagus nerve to not work properly?
I have disc herniation at my neck (C4-C5)
I have been suffering with neck issues for the last five years. I have disc herniation at my neck (C4-C5). I have developed ringing in my ears, gastroparesis symptoms, GERD, and any physical activity causing issues with acid reflux and breathing.
The causes of nausea. What are we seeing in this image?
As stated, there are many reasons and many investigations needed to understand the cause of someone’s nausea. In this article, we will go down the investigative route of cervical spine instability. In this illustration, we see that nausea can be caused by hormonal balance, food sensitivities, medications, overheating, and digestive problems such as small intestinal bowel overgrowth and structural gastrointestinal problems of the stomach and gall bladder.
But nausea can also find origins in:
- Increased tension (stretch) on the brain’s nausea center located in the medulla oblongata.
- Increased intracranial pressure (pseudotumor cerebri).
- Cerebrospinal leak.
- Cervicovagopathy. (Vagus nerve dysfunction)
- Orthostatic hypotension.
Below I will briefly describe these conditions.
The majority of patients are teenage girls and younger women: gastroparesis can be caused by vagus nerve injury in the neck
Many are told that the cause of the condition is psychological. They are examined for an eating disorder.
Gastroparesis is synonymous with delayed gastric emptying and it is becoming an epidemic among teenage girls and women in their twenties. In some patients, gastroparesis can be caused by vagus nerve injury in the neck. Often people are diagnosed with autoimmune disease, hysteria, or depression. Typically when no mechanical obstruction is found. Many are told that the cause of the condition is psychological. They are examined for an eating disorder.
Recently one person described swallowing difficulties that were made worse by something acutely shifting in their neck. They reported the neck issues were soon resolved with chiropractic visits but the swallowing difficulties continued.
Scans and testing revealed no obvious cause of their swallowing issues. However, this person was told that the x-ray they took revealed a lack of neck curvature. Further physical therapy and chiropractic adjustments did not help their swallowing difficulties.
Finally, a diagnosis of allergy and food sensitivity was given and this person’s doctors now tackled the problem as Eosinophilic Esophagitis. An overactive immune system reacts to food.
This person’s problems continued with weight loss, then a diagnosis of hypothyroidism which typically means you gain weight. This was followed by a diagnosis of adrenal fatigue (which could account for unexplained weight loss), Leaky gut syndrome, low stomach acid, and inadequate gut flora with yeast overgrowth.
This person tells that they are on a food elimination diet, a Low Fermentation Diet to combat small intestinal bacterial overgrowth, and are taking supplementation to help with nutritional deficiencies.
Is this a person we can help? Yes, if problems in the neck can be identified as causing disruption of the digestive cycle. Also, this will not be a quick fix. The road to recovery will be long and challenging. Some people will not be successful in their treatment. Many factors go into the cause of non-successful treatment.
Why does my neck pain make me nauseous? Nausea causes can be difficult to pinpoint
As stated above, nausea can be caused by many problems. Nausea is sometimes a problem buried so deep in the patient’s medical issues that a great deal of work may be required to find NOT THE SOURCE of nausea, but THE SOURCES of their nausea.
Listen to what we have heard from patients, these are possible sources of nausea. Possibly your causes of nausea.
- Nausea from anti-inflammatory medications. A patient will tell us about their long history of anti-inflammatory medication usage and their need for other medicines to counteract the gastrointestinal distress these anti-inflammatories cause.
- Autonomic Dysautonomia. The patient is seeing us because they have been diagnosed with problems of the autonomic nervous system which include nausea and vomiting.
- They have, among other problems, a diagnosis of Cricopharyngeal Dysfunction where they have issues with their esophagus being able to take in food and this causes acid reflux and nausea.
- They have been diagnosed with post-concussion syndrome and this has led to dizziness and the main culprit of their nausea. Which may or may not be true.
- The patient has been diagnosed with complications related to Ehlers-Danlos syndrome.
- The patient has been diagnosed with POTS (Postural orthostatic tachycardia syndrome) and their nausea may be coming from their fainting attacks and irregular heartbeat.
- The patient has been diagnosed with Mast Cell Activation Syndrome which is causing them problems of too much inflammation which is leading to symptoms of nausea and diarrhea.
This is just a small sampling of the problems our patients come to us for. The cause of nausea can be complicated.
Increased tension (stretch) on the medulla nausea center.
The medulla (that portion of the lower brain stem) houses the chemoreceptor trigger zone or the medulla nausea center. The chemoreceptor trigger zone which can cause nausea and vomiting can be thrown into chaos by injury, by stroke, or by something else that can cause neuron death and nervous system dysfunction. Chaos for the suffering means nearly untreatable vomiting and nausea. Recently a possible cause of this problem has been discussed by doctors. The compression of the ceratoid sheath and the veins and arteries of the neck.
What are we seeing in this image? Compression of the carotid sheath. A possible cause of nausea.
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.
We see many patients with this type of compression and the neurologic-like symptoms of nausea and vomiting. We are not the only specialists who see this and understand that this is not so rare of a phenomenon.
A 69-year-old woman presented with a 10-month history of intractable nausea and vomiting resulting in a 50-pound weight loss.
In 2015, doctors at the Department of Neurological Surgery, Saint Louis University wrote up, what they considered at the time, a very remarkable case of “Intractable vomiting caused by vertebral artery compressing the medulla.” This paper was not published in a gastroenterologist journal it was written in the Journal of Craniovertebral Junction and Spine. (1)
Here is the patient’s story and the learning points:
- A 69-year-old woman presented with a 10-month history of intractable nausea and vomiting resulting in a 50-pound weight loss.
- She had an extensive medical workup at multiple outside hospitals including a comprehensive gastrointestinal workup that showed celiac disease.
- Because of her weight loss, she had a gastrostomy tube inserted.
- The patient had previously been treated for breast cancer and had a mastectomy, and cholecystectomy to remove her gall bladder.
- During her evaluation by the gastroenterologists at the hospital, the diagnosis of celiac disease was confirmed, and she was also noted to have a duodenal ulcer ( a peptic or stomach ulcer.) She also had dizziness and diplopia (double vision).
- Magnetic resonance imaging/angiography (MRI/MRA) of the brain and neck and diagnostic four vessels cerebral angiogram were obtained to further evaluate her dizziness and double vision. The left vertebral artery angiogram revealed a tortuous left vertebral artery. This, along with dolichoectasia (stretching) of the vertebrobasilar arteries, resulted in compression of the medulla oblongata. Computed tomography angiography (CTA) also confirmed that the vertebral artery was pushing the medulla medially. The patient was offered a microvascular decompression (MVD) of the vertebral artery to attempt to decompress the brainstem and alleviate her intractable nausea and vomiting.
Explanatory notes: The patient had vertebrobasilar arteries that were stretched with caused a narrowing of the vessels. The vertebral artery was compressing the brain stem.
In this case, the patient had microvascular decompression. According to the doctors, “the postoperative course was uneventful, and the patient was kept in the hospital to transition her from gastrostomy tube feedings to regular oral feeding. The patient was discharged from the hospital without any antiemetic medication and was documented to have started gaining weight. At her 2-year postoperative visit, the patient had a non-focal neurologic exam without recurrence of her prior nausea or vomiting. She had also achieved a normal body mass index (BMI).
The doctors concluded: “This case demonstrated the importance of neurological investigations in the isolated intractable vomiting patient without a clear evidence of peripheral cause and including a central nervous system etiology on the differential, and the role of (decompression surgery) in achieving (a) cure.”
This paper was cited by an August 2022 paper published in the medical journal Life (2). In this paper a case history is presented to support looking for the rare condition of vertebral artery compression of the medulla and that it can be managed without surgery.
At our center we offer non-surgical methods of achieving “decompression” which is discussed below.
Nausea and gastroparesis caused by cervical spine instability and pressure on the vagus nerve (shorter video)
In this video Ross Hauser, MD describes the problems and symptoms of nausea and gastroparesis caused by cervical spine instability.
Summary transcriptions and explanatory notes:
- We are seeing many nauseated patients.
- A lot of these patients have seen gastroenterologists, they have had endoscopy performed and the result has revealed nothing.
- Some of these patients will ultimately get a diagnosis of gastroparesis which simply means that their stomach is not working.
At 0:54 of this video, Dr. Hauser refers to Vagus nerve compression and how this could cause gastroparesis.
Injury to the vagus nerve, the cause of nausea?
Before we discuss this illustration connecting the vagus nerve to the brain’s vomiting center and chemoreceptor trigger zone. Let’s look at some of the research connecting the vagus nerve to the vomiting center.
In December 2022, doctors at the Mayo Clinic, in Arizona examined the connection between migraines and gastroparesis in the journal Current Neurology and Neuroscience Reports. (3) They wrote: “There is evidence that gastroparesis, a gastrointestinal (GI) dysmotility disorder in which transit of gastric contents is delayed, can occur in the setting of migraine. . . There has been increasing recognition of the importance of the connection between the GI tract and the brain, and mounting evidence for the overlap in the pathophysiology of migraine and gastroparesis specifically. . . Noninvasive vagus nerve stimulation has been FDA-cleared for migraine treatment and is also being studied in gastroparesis. Dysfunction of the autonomic nervous system is a significant feature in the pathophysiology of gut motility and migraine, making treatments that modulate the vagus nerve attractive for future research.”
The connection between gastroparesis and migraine has been well understood and research goes back to the 1970s. In 2013 Dr. Henry Parkman of the Gastroenterology Section, Temple University School of Medicine wrote (4): “Evidence from pharmacokinetic (the study of drug interaction within the body) and gastric motor studies conducted over the past 40 years shows that delayed gastric emptying often occurs in migraine. . . The nature, causes, correlates, and consequences of gastric stasis in migraine are just beginning to be (understood); much further study is warranted. The data available to date show that gastric stasis in migraine appears to be clinically important. . . ”
Here we are making the broad connection between vagus nerve dysfunction and gastroparesis through a common symptomology surrounding migraines. But now let’s look at another study that directly correlates vagus nerve injury and gastroparesis caused by surgery.
In March 2020, doctors in Turkey wrote in the journal Medical Ultrasonography (5) about how neck surgery could injure the vagus nerve and how this could cause gastroparesis. The good news of this study was that this damage could be reversed. Here is the summary of the findings:
- During neck dissection (surgery to remove lymph nodes thought cancerous), the vagus nerve may be exposed to manipulation together with the common carotid artery and internal jugular vein.
- Previous studies suggested that postsurgical gastroparesis was caused by vagus nerve injury.
Using ultrasound, the Turkish doctors then evaluated Vagus nerve changes in patients with unilateral and bilateral neck surgery to establish if there is a relationship between postoperative findings of the vagus nerve and postsurgical gastroparesis.
- Seventeen patients in which 30 neck dissection (4 unilateral and 13 bilateral) were performed, were enrolled in the study.
- The vagus nerve’s area and diameter were measured preoperative (baseline), one week, and one month postoperative.
- The doctors noted: “Vagus nerve ultrasound clearly showed the transient dimensional changes of vagus nerve caused by manipulation in neck dissection, which may lead to temporary gastrointestinal symptoms due to reversible dysfunction of vagus nerve”
Let’s look at the image below, but first, provide some simple definitions.
- A receptor is part of the messenger system in the body. It is a structure that takes energy and converts it into electrical signals.
- 5-HT3 receptors, among their function, is to send messages regarding the secretion of fluids that assist normal GI function and messages to move “food down the line.”
- NK1 receptors are part of the vomiting process.
- Dopamine receptors also move food down the line and give signals for gastric emptying to occur.
- Serotonin is a GI hormone. It helps regulate the flow of acids and contractions of muscles that move food.
In the illustration below we see the vagus nerve at the center of this communication system.
We have two vagus nerves. One on the left side of the neck and the one on the right side of the neck. Among the many functions of the vagus nerve is that it provides 75% of the total input for the parasympathetic nervous system, aptly called the rest and digest system. The vagus nerve is responsible for managing our intestinal activity as well as managing the sphincter muscles in the gastrointestinal tract.
- Injury, compression, or damage to the vagus nerve is believed to be the main culprit in the diagnosis of gastroparesis.
- The vagus nerve supplies input to the stomach that helps manage your stomach muscles. If this input is compromised, in other words, the vagus nerve is sending bad or confusing messages to your stomach, your stomach muscles may not contract normally, and your stomach may not push food out into your small intestines.
- These confusing messages cause dysfunction in normal stomach acid secretion which means undigested food remains in your stomach longer than it should. This leads to the common symptoms of bloating, fullness, nausea, and finally when your stomach has had enough, the initiation of the vomiting response.
- Another problem is a pyloric valve that stays closed. This can lead to a problem of pyloric stenosis (thickening or blockage). The pyloric valve or pylorus is the valve that separates the stomach from the small intestine. Nerve inputs from the vagus nerve open and close this valve when it is time for the stomach to release the broken-down food into the small intestine.
The most important function of the vagus nerve is afferent, bringing information about the inner organs (most of them digestive) to the brain.
The most important function of the vagus nerve is afferent, bringing information about the inner organs (most of them digestive) to the brain. The gut has the largest surface toward the outer world and is therefore of particular importance. Peripheral nervous system innervation of the GI tract causes increases in bowel motility and glandular secretion. It also causes an increase in the dilation of blood vessels, but in contrast, the sympathetic activity (via the splanchnic nerves) leads to a reduction of intestinal activity and a reduction of blood flow to the gut, allowing a higher blood flow to the heart and the muscles when the individual faces existential stress.
In humans, the vagus nerve innervates the right two-thirds of the transverse colon, with parasympathetic innervation to the left third of the transverse colon (to the splenic flexure), descending colon, and the rectum innervation arising from the sacral parasympathetic nerves. The vagus nerve, however, could innervate all parts of the digestive tract in humans.
The digestive tract has its own intrinsic nervous system called the “gut-brain axis” through the enteric nervous system, composed of the outer myenteric plexus and inner submucosal plexus. Both plexuses have connections with the vagus nerve. The enteric nervous system is in control of the GI musculature and transmucosal fluid movements. The vagus nerve is so important for proper GI tract functioning; to that end, it should be noted that accumulating evidence suggests the brain-gut interaction is bidirectional via the vagus nerves. What this means is that there is a direct link between intestinal luminal contents (both good and bad) and the brain. The vagus nerve is the neurology highway for interoceptive awareness in the digestive tract between the microbiota gut and brain. The vagus nerve can take the gut information from microbiota metabolites and food metabolites and transfer it to the ANS and brain, where an integrated appropriate or inappropriate response occurs.
An April 2022 study in the journal Frontiers in Neuroscience (6) from the University of Adelaide suggests “the vagus nerve is crucial in the bidirectional communication between the gut and the brain. It is involved in the modulation of a variety of gut and brain functions. Human studies indicate that the descending vagal signaling from the brain is impaired in functional dyspepsia. Growing evidence indicates that the vagal signaling from gut to brain may also be altered, due to the alteration of a variety of gut signals identified in this disorder. The pathophysiological roles of vagal signaling in functional dyspepsia are still largely unknown, although some studies suggested it may contribute to reduced food intake and gastric motility, increased psychological disorders and pain sensation, nausea and vomiting.”
Stimulation of the vagus nerve can lead to an emptying of the stomach.
- Research note: There have been a considerable number of animal (rat) studies suggesting that stimulation of the vagus nerve can lead to an emptying of the stomach.
- One study published in 2018 in the journal Neurogastroenterology and Motility (7) suggested that vagus nerve stimulation electroceutical therapy could remedy gastric and emptying disorders that are poorly managed by pharmacological treatments and/or dietary changes.
- Another study, this time published in 2020 in the journal Neurogastroenterology and Motility (8) by the same researchers wrote that “Vagus nerve stimulation is an emerging bioelectronic therapy for regulating food intake and controlling gastric motility.” The researchers here found monophasic (consistent at the same level) Vagus nerve stimulation biased toward the afferent pathway (the sensation and nerve transmission being sent to the central nervous system and brain or the stimuli) is potentially more effective for facilitating occlusive contractions than that biased toward the efferent pathway (the brain or central nervous systems messages back to in this case, the digestive system).
We use many tools in our office to assess problems of vagus nerve compression and how to treat these problems to restore normal function without the need for a vagus nerve stimulator implant. Vagus nerve stimulation.
When my neck hurts, I want to vomit: Does a pinched Vagus nerve cause nausea? Does Vagus nerve stimulation help?
Let’s look more specifically at nerve networks. The vagus nerve mediates responses from the stomach and the small intestine closest to the stomach. Possibly the vagus nerve actually influences the entire small intestine, because of its influence on the celiac ganglion (The two celiac ganglia are the largest ganglia (nerve bundles) in the autonomic nervous system, and they innervate most of the digestive tract. They represent parts of the branches of the vagus nerve) and because the splanchnic nerves (which converge on the celiac ganglion) manages responses from the entire small intestine.
- The two celiac ganglia are the largest ganglia (nerve bundles) in the autonomic nervous system, and they innervate most of the digestive tract.
Abdominal irritants or toxins cause nausea and vomiting by activating emesis-related (vomiting process starting) afferents (the neurons sending messages back to the brain), called chemoreceptors. One of the substances the entero-endocrine cells (cells that produce and release hormones in response to stimuli) release is 5-hydroxytryptamine (5-HT, a serotonin precursor), and these precursors activate 5-HT3 (information transfer in the gastrointestinal tract) receptors on vagal afferents. When a person has food poisoning or receives chemotherapy, it causes an excessive amount of 5-HT to be released, inducing nausea and vomiting. Ondansetron (Zofran®) works by blocking 5-HT3 receptors. Increased activation of mechanosensitive vagal afferents following either gastrointestinal dysrhythmia or dysmotility (increase of gastric speed to 5-6 contractions/min. instead of a normal 3 contractions/min.) or an abnormal distention of the stomach, intestine, or biliary tract evokes nausea.
These afferents also respond to mucosal stroking, acid, alkali, hypertonic solutions, temperature, nutrient amounts, and irritants or toxins. Mechanoreceptors, also in the bowel wall, get activated by distension from the gastric antrum, such as occurs with overeating or overextension of the proximal small intestine by obstruction. These vagal-sensory nerves from the periphery terminate primarily in the nucleus of the solitary tract and area postrema. Vagal sectioning above the level of the heart causes an intractable vomiting syndrome and central cervical vagal stimulation inhibits vomiting.
Perhaps the best way to end this section is to note that the worst kind of vomiting is continuous vomiting. Cyclic vomiting syndrome is a disabling migraine variant manifesting as severe episodes of nausea and vomiting which is often refractory to many therapies. This condition is characterized by gastritis (inflammation of the stomach) and gastroparesis (decreased stomach motility), both of which occur with low vagal tone. It, therefore, makes sense that vagus nerve stimulation is being used successfully for cyclic vomiting syndrome and chronic nausea conditions such as intractable gastroparesis.
In some cases, our patients are recommended to use a vagus nerve stimulator between our Prolotherapy treatments. Prolotherapy treatments which are our main treatments are explained below in the research.
What are we seeing in this image?
Vagus nerve stimulators can stimulate the nucleus tractus solitarius. When food touches your mouth, your body begins sending chemical and mechanical messages to stimulate the gastrointestinal tract to prepare the digestive system for food intake. The vagal nerve conveys primary afferent information from the intestinal mucosa to the brain stem. Activation of vagal afferent fibers results in inhibition of food intake (Sends signals to tell you to stop overeating), gastric emptying, and stimulation of pancreatic secretion.
Vagus nerve stimulators can stimulate the nucleus tractus solitarius. What does this mean?
When food touches your mouth, your body begins sending chemical and mechanical messages to stimulate the gastrointestinal (GI) tract to prepare the digestive system for food intake. A good explanation of what happens next and the vagus nerve involvement is explained in this paper published in the journal Current Medicinal Chemistry. (9)
- The vagal nerve conveys primary afferent information from the intestinal mucosa to the brain stem. Activation of vagal afferent fibers results in inhibition of food intake (Sends signals to tell you to stop overeating), gastric emptying, and stimulation of pancreatic secretion. Afferent nerves terminating near the mucosa are in a position to monitor the composition of the luminal (large intestine, small intestine,) contents.
So this is what is going on with the vagus nerve:
- Monitors food intake to avoid overeating or gorging.
- Helps move food down the esophagus, into the stomach, and moves food out of the stomach and into the small intestines and ultimately the large intestines.
So where does the nucleus tractus solitarius come into play?
- The nucleus tractus solitarius are the first neurons to understand that eating is occurring and the first to help process digestion-related vagal afferent signals. Simply, addressing vagus nerve impairment addresses digestive problems from the moment food touches your mouth.
How disruptions in the vagus nerve cause digestive problems
- A decrease in vagus nerve input impacts the path of food from the esophagus to the stomach, through the digestive tract to the duodenum, the part of the small intestine that immediately connects to the stomach.
What are we seeing in this image?
The vagus nerve supplies input to the stomach that helps manage your stomach muscles. If this input is compromised, in other words, the vagus nerve is sending bad or confusing messages to your stomach, your stomach may not push food out into your small intestines. This means food remains in your stomach longer than it should. This leads to the common symptoms of bloating, fullness, nausea, and finally when your stomach has had enough, the initiation of the vomiting response. In this illustration, dysfunction of the pyloric sphincter between the stomach and the small intestines is isolated as a problem of vagus nerve compression or injury.
Cervical vagopathy – poor vagus function
Dr. Hauser describes the term cervical vagopathy. This relates to poor vagus function and it is seen as a precursor to illness and makes recovery from diseases difficult. Low vagus nerve function has four main manifestations on the human body that increase the risk for almost all human diseases: chronic inflammation, elevated oxidative stress, sympathetic dominance (a condition of feeling overwhelmed by burden which leads to stress and is fed by the adrenaline (fight-flight) action system, and coagulopathy (problems with blood clotting) which can lead to joint inflammation, joint swelling, and joint pain. Next is the treatment of this problem with Prolotherapy.
Digestion & the Vagus Nerve: Sphincter function and related symptoms affected by neck instability
Ross Hauser, MD discusses digestion and the vagus nerve as it relates to the sphincter function. In the histories of patients who we see in our center, they often feel like they hit a wall with regard to finding a resolution of symptoms or their digestion conditions because the focus has been too narrow. When looking at many digestive symptoms through the aspect of vagus nerve health, many times solutions can be found because the vagus nerve innervates many vital digestive organs. Thus, in our center, we find that patients who have digestive complaints as part of their constellation of symptoms that also point to vagus nerve impairment, the upper cervical area, and the cervical curve should be analyzed and examined to see if this could be the cause of the issues.
How cervical instability can cause chronic nausea – the relationship between nausea and the neck
One of the most common symptoms that our patients with cervical instability complain of is nausea. In this video, Ross Hauser, MD gives an overview of the mechanisms by which cervical instability causes nausea. In our experience, when a person’s neck stability and curve are restored, the nausea is typically resolved. Of course, there are many reasons for nausea, but the primary focus of this presentation is the relationship between nausea and the neck.
The research surrounding the vagus nerve and digestive disorders
The vagus nerve innervates almost every part of the digestive tract including the stomach, intestines, liver, gallbladder, and pancreas, along with the heart, lungs, and spleen. Low Heart Rate Variable (Please see my extensive article Can cervical spine instability cause cardiovascular-like attacks, heart palpitations, and blood pressure problems?) and sympathovagal imbalance (the state of functional imbalance between the sympathetic and vagal components of the Autonomic Nervous System. In sympathovagal imbalance, it is usually the sympathetic system that is hyperactive (contestant stress) and the parasympathetic system (rest system) is hypoactive is seen with almost every digestive disorder, including functional bowel disorders, inflammatory bowel disease, dysmotility disorders, gastroparesis, gluten sensitivity, and gastroesophageal reflux. Diarrhea, constipation, early satiety, swallowing difficulties, decreased or increased salivation, gastroparesis, fainting during toileting activities, dysfunctional gastric or intestinal motility, excessive gas, vomiting, and extreme nausea can signify gastrointestinal manifestations of autonomic dysfunction caused by cervical spine instability. Most of these issues stem from an increased intestinal permeability or gastrointestinal dysmotility.
Numerous studies have made a connection between sympathovagal imbalance and digestive disorders. In some of these studies, Heart Rate Variable is used to show low vagal tone.
In the journal Neurogastroenterology and Motility (10), it was noted: “Impairment in autonomic functions (increased sympathovagal balance) may play a role in hyperglycemia-induced dysrhythmias.” In the journal Obesity Surgery (11) researchers wrote: “Vagal nerve stimulation (VNS) has been reported to reduce body weight and improve sympathovagal imbalance in both basic and clinical studies.”
Also in the journal Neurogastroenterology and Motility (12), doctors wrote: “A low vagal tone, as assessed by heart rate variability, a marker of the sympathovagal balance, is observed in functional digestive disorders and inflammatory bowel diseases. To restore a normal vagal tone appears as a goal in such diseases.”
And in the journal Pain Management (13), it was noted that “Abdominal pain continues to be a major challenge and unmet need in clinical practice. Normalization of bidirectional gut-brain signaling has generated much interest as a therapeutic approach to treat chronic abdominal pain. Vagal nerve stimulation (VNS) is emerging as a potential non-pharmacologic strategy for the treatment of abdominal pain.”
The importance of not damaging the vagus nerve in pylorus-preserving gastrectomy
I want to use a study not to debate the use of pylorus-preserving gastrectomy, which may be a needed and necessary procedure for people with cancer, but to demonstrate a “newfound awareness,” of the role of the vagus nerve in digestion and the importance of not damaging or removing the vagus nerve during this surgery.
Some of you reading this article may have been recommended for this type of surgery because you are considered a very complicated non-cancer case and you are not responding to traditional treatments for the digestive and gastrointestinal distress you are suffering from. This surgery will remove part of your stomach. Pylorus-preserving gastrectomy means that the surgeons will leave behind that portion of your stomach with the pyloric valve intact. If the pyloric valve is removed, the food in the stomach will move too quickly into the small intestine and cause another problem, post-gastrectomy syndrome.
An October 2020 study (14) produced by gastrointestinal surgeons gave us this concern about nerve preservation:
“Function-preserving gastrectomy, especially pylorus-preserving gastrectomy, can improve the quality of life and has been widely recognized. With the development of surgical techniques and equipment, nerve preservation has become a new requirement in the era of “precision medicine”, but the preservation of the celiac branch of the vagal nerve remains controversial in gastric cancer surgery.
Current research has shown that the preservation of the celiac branch of the vagal nerve is safe and feasible in patients with early gastric cancer. Although controversial, nerve preservation may play a role in preventing gallstones, regulating gastric emptying, reducing dumping syndrome, alleviating chronic diarrhea, reducing gastroesophageal reflux, and inhibiting bile reflux.
The significance of the celiac branch of the vagal nerve in gastric cancer surgery is worth further attention and exploration to promote the development of function-preserving gastrectomy and improve the quality of life of patients.”
What is being said here?
Surgeons are discussing amongst themselves the controversial decision to preserve the celiac branch of the vagal nerve in gastric cancer surgery. Why is it controversial? It adds a layer to the already difficult and challenging procedure and it is unclear if it will help the patient. This is however not what we are debating in this article. This study is used to display that some surgeons recognize the important functions of the celiac branch of the vagal nerve and something should be done to preserve it when possible.
Those functions outlined above include:
- Preventing gallstones,
- regulating gastric emptying,
- reducing dumping syndrome,
- Dumping syndrome is described as “a condition that occurs in patients who have had gastric surgery. The alteration of gastrointestinal physiology produces undesired effects for the patient that results from the rapid movement of hyperosmolar chyme from the stomach into the small intestine.” (15)
- Alleviating chronic diarrhea,
- reducing gastroesophageal reflux,
- and inhibiting bile reflux.
Preserving, maintaining, and restoring the proper celiac branch of the vagal nerve function, is then seen as a means to alleviate many digestive and gastrointestinal problems.
Some patients with gastroparesis need surgery because their symptoms and problems are not related to the problems outlined above with cervical spine instability.
Over twenty years ago, surgeons wrestled with the best concept in the surgical management of gastroparesis. A paper published in the Journal of the Society of Laparoendoscopic Surgeons (16) noted: “Partial gastrectomy, gastroenterostomy, pyloromyotomy, pyloroplasty, and endoscopic dilatation have all been recommended with variable results.” How much has changed? Surgeons are still debating and comparing techniques with various results.
A September 2021 paper in the medical journal Medicine (17) compared the short-term outcomes surrounding the effectiveness and complication rate between different types of pyloromyotomy and gastric electrical stimulation in the treatment of gastroparesis. A pyloromyotomy is an incision in the wall of the pylorus to release pressure or blockage on the connection between the stomach and the small intestine.
- Three studies with 196 participants who received 4 interventions
- including single per-oral pyloromyotomy, single incision
- double per-oral pyloromyotomy,
- laparoscopic pyloromyotomy,
- and gastric electrical stimulation.
- Compared to single per-oral pyloromyotomy, double single per-oral pyloromyotomy achieved a better clinical response while laparoscopic pyloromyotomy and gastric electrical stimulation showed no difference.
- As for the recurrence and complication rates, only gastric electrical stimulation showed a borderline significance of recurrence in comparison to single per-oral pyloromyotomy.
Conclusions: “The results suggest that double per-oral pyloromyotomy demonstrated better clinical success with similar recurrence and complication rates. In addition, gastric electrical stimulation may result in more recurrence amongst these interventions.”
What if the vagus nerve is suspected of causing problems of gastroparesis? Is Vagotomy warranted?
Some people who contact us have a history of or have been recommended for a vagotomy to help ease the symptoms and look for a cure for gastroparesis. A vagotomy is a surgery that removes all or part of your vagus nerve. Vagotomy is focused on helping people with stomach ulcers. The idea is that by cutting the vagus nerve, (the vagus nerve controls stomach acid secretion) stomach acids and the problems of acid erosion in the digestive tract can be managed and ulcers can heal. This procedure is not commonly performed as doctors were more eager to provide alternatives to this surgery such as proton pump inhibitors.
We have seen many patients who have had numerous gastroenterologist visits, an endoscopy where “nothing was found,” and a diagnosis of gastroparesis. Simply, this person’s stomach is not working right. As mentioned above, the stomach is not contracting normally, and the proper amounts of stomach acid are not being released. The pyloric valve is not functioning, opening and closing, correctly.
- To get the brainstem and all the nerves working correctly one has to address and tighten the cervical ligaments in the back of the neck as well as get the cervical curve back to its normal lordotic configuration. The way we do this at Caring Medical is with Prolotherapy treatments.
Upper cervical instability affects the medulla and the area postrema
- Another way that cervical instability causes nausea is that the upper cervical instability affects the medulla.
The medulla, short for medulla oblongata, is part of the brainstem. The signals of the vagus nerves, in fact almost all of the nerves of the body have to travel through the medulla through various nerve pathways or tracts.
- Important in this discussion is that the medulla is the center for nausea and nausea control via the area postrema. Here is the connection: The area postrema is the area of the medulla that makes you vomit when you have toxins in your stomach or excessive nausea. This area connects to the nucleus tractus solitarii and other autonomic control centers in the brainstem. Everything is connected and interacts. Any one of these processes disturbed by cervical spine instability putting pressure on the vagus nerve or the brainstem or other related structures will cause the problems of nausea and gastroparesis.
- Anything that impacts the medulla of the brainstem, that area above the cervical spinal cord can give you nausea.
Addressing cervical spine instability with Prolotherapy injections:
We have published dozens of papers on Prolotherapy injections as a treatment in difficult-to-treat musculoskeletal disorders. Prolotherapy is an injection technique utilizing simple sugar or dextrose. We are going to refer to two of these studies as they relate to cervical instability and a myriad of related symptoms including problems of digestion and a sense of chronic nausea in relation to the brainstem. It should be pointed out that we suggest in our research that “Additional randomized clinical trials and more research into its (Prolotherapy) use will be needed to verify its potential to reverse ligament laxity and correct the attendant cervical instability.” Our research documents our experience with our patients.
In 2014, we published a comprehensive review of the problems related to weakened damaged cervical neck ligaments in The Open Orthopaedics Journal (18) We are honored that this research has been used in at least 6 other medical research papers by different authors exploring our treatments and findings and cited, according to Google Scholar, in more than 40 articles.
What we demonstrated in this study is that the cervical neck ligaments are the main stabilizing structures of the cervical facet joints in the cervical spine and have been implicated as a major source of chronic neck pain. Chronic neck pain often reflects a state of instability in the cervical spine and is a symptom common to a number of conditions, including disc herniation, cervical spondylosis, whiplash injury, whiplash-associated disorder, post-concussion syndrome, vertebrobasilar insufficiency, and Barré-Liéou syndrome. The obvious should be pointed out, many people who have been diagnosed with these problems also suffer from a variety of digestive problems and swallowing difficulties.
Cervical Spine Stability and Restoring Lordosis
The cervical spine has a natural curve. It acts as a spring or shock absorber for the head. When this curve is gone because of injury, Joint Hypermobility Syndrome, or degenerative cervical disc disease, not only are the arteries and nerves between the vertebrae not protected from the impact of walking or running or jumping, or a bumpy car ride, but they are subjected to compression from cervical spine instability caused by cervical ligaments that have also been damaged by injury or wear and tear and no longer hold the neck in correct alignment.
The digital motion X-ray is explained and demonstrated below. This is one of our tools for demonstrating cervical instability in real-time and motion.
- Digital Motion X-ray is a great tool to show instability at the C1-C2 Facet Joints
- The amount of misalignment or “overhang” between the C1-C2 demonstrates the degree of instability in the upper cervical spine.
- This is treated with Prolotherapy injections (explained below) to the posterior ligaments that can cause instability.
- At 0:40 of this video, a repeat DMX is shown to demonstrate the correction of this problem.
The challenges of cervical instability are many. Fixing cervical neck instability is not something that can be treated simply or easily, it takes a comprehensive non-surgical program to get the patient’s instability stabilized and the symptoms abated. We believe that if you have been going from clinician to clinician, practitioner to practitioner, doctor to doctor, there is a good likelihood that you have problems of cervical neck instability coming from weakness and damage to the cervical ligaments. Our treatments of Comprehensive dextrose Prolotherapy and in some cases Platelet Rich Plasma Prolotherapy can be an answer.
If this article has helped you understand the problems of nausea and gastroparesis and you would like to explore Prolotherapy as a possible remedy, ask for help and information from our specialists
Treating and repairing cervical instability with Prolotherapy: research papers
- Chronic Neck Pain: Making the Connection Between Capsular Ligament Laxity and Cervical Instability
- This paper was published in the European Journal of Preventive Medicine
- Steilen D, Hauser R, Woldin B, Sawyer S. Chronic neck pain: making the connection between capsular ligament laxity and cervical instability. The Open Orthopaedics Journal. 2014;8:326-345. [Google Scholar]
- The Biology of Prolotherapy and Its Application in Clinical Cervical Spine Instability and Chronic Neck Pain: A Retrospective Study
- This paper was published in the European Journal of Preventive Medicine
- Ross Hauser, MD, Steilen-Matias D, Gordin K. The biology of prolotherapy and its application in clinical cervical spine instability and chronic neck pain: a retrospective study. European Journal of Preventive Medicine. 2015;3(4):85-102. [Google Scholar]
- Non-Operative Treatment of Cervical Radiculopathy: A Three-Part Article from the Approach of a Physiatrist, Chiropractor, and Physical Therapists
- This paper was published in the Journal of Prolotherapy
- Ross Hauser, MD, Batson G, Ferrigno C. Non-operative treatment of cervical radiculopathy: a three-part article from the approach of a physiatrist, chiropractor, and physical therapists. Journal of Prolotherapy. 2009;1(4):217-231.
- Dextrose Prolotherapy for Unresolved Neck Pain
- This paper was published in Practical Pain Management
- Hauser R, Hauser M, Blakemore K. Dextrose Prolotherapy for unresolved neck pain. Practical Pain Management. 2007;7(8):58-69.
- Cervical Instability as a Cause of Barré-Liéou Syndrome and Definitive Treatment with Prolotherapy: A Case Series
- This paper was published in the European Journal of Preventive Medicine
- Hauser R, Steilen-Matias D, Sprague IS. Cervical instability as a cause of Barré-Liéou syndrome and definitive treatment with prolotherapy: a case series. European Journal of Preventive Medicine. 2015;3(5):155-166. [Google Scholar]
Summary and contact us. Can we help you? How do I know if I’m a good candidate?
One of our patients discusses her success with Prolotherapy and curve correction for her neck pain and instability that was causing nausea and digestive problems. Not all patients receive the same results.
We hope you found this article informative and that it helped answer many of the questions you may have surrounding Nausea due to neck pain, neck stiffness, and neck instability. 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.
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This article was updated May 16, 2023