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. One of these symptoms patients may discuss with us is the constant presence of nausea and/or gastroparesis, 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, heartburn, vomiting, 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.
- Many patients we see have nausea caused by cervical vertigo and cervicogenic dizziness, but these people may also have underlying problems that we will describe below with digestive problems causing nausea, it may not only be their vertigo.
- Many patients we see have a problem with 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.
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 inetstinal bowel overgrowth and structural gastrointestinal problems of the stomach and gall bladder.
But nausea can also find origins in:
- Increased tension (stretch) on the medulla nausea center.
- Increased intracranial pressure (psedotumar cerebri)
- Cerebrospinal leak
- Orthostatic hypotension
Below I will briefly describe these conditions.
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 lead 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 by thrown into chaos by injury, by stroke, or by something else that can cause neuron death and nervous system dysfunction. Chaos for the suffer means nearly untreatable vomiting and nausea. Recently a possible cause from 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 phenomena.
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)
Hear is the patient’s story and the learning points:
- “Vertebral artery compressing the medulla and causing intractable vomiting has only been reported once previously. We report a case of a 69-year-old woman with intractable nausea and vomiting causing a 50 pound weight loss and who failed medical management and whose symptoms were completely reversed following microvascular decompression).”
- 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 which showed celiac disease.
- Because of her weight loss she had a gastrostomy tube inserted.
- The patient had previously been treated for breast cancer, had a mastectomy, and cholecystectomy to remove her gall bladder.
- During her evaluation by the gastroenterologists at our 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 vertebro-basilar 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 vertebro-basilar 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.”
At our center we offer non-surgical methods of achieving “decompression” this is discussed below.
When my neck hurts, I want to vomit: Does a pinched nerve cause nausea?
Nausea and gastroparesis caused by cervical spine instability
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 have 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?
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, 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.
- 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 (1) 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 (2) 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 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 stimulii) 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
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. (2)
- 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. Afferents nerves terminating near to 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, 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 the treatment of this problem with Prolotherapy.
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 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 to 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 (3) 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 researches have 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.” (4)
- Alleviating chronic diarrhea,
- reducing gastroesophageal reflux,
- and inhibiting bile reflux.
Preserving, maintaining, restoring the proper celiac branch of the vagal nerve function, is then seen as a means to alleviate many digestive and gastrointestinal problems.
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, 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 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 in 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 or the brainstem, that area above the cervical spinal cord that 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. (3) 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, and 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, 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 in 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 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?
We hope you found this article informative and 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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6 Hui C, Dhakal A, Bauza GJ. Dumping Syndrome. 2020 Nov 10. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan–. PMID: 29261889.
7 Steilen D, Hauser R, Woldin B, Sawyer S. Chronic neck pain: making the connection between capsular ligament laxity and cervical instability. The open orthopaedics journal. 2014;8:326. [Google Scholar]
This article was updated May 25, 2021