Ross Hauser, MD
In this article, we will discuss the problems of cervical angina. If you are reading this article you are probably aware that the issues you are having in your cervical spine and neck are causing nerve root compression leading to chest pains that mimic a cardiovascular event. It is important to realize that this may only be one possible explanation as to why seemingly healthy individuals, having been checked out by their cardiologist, have cardiovascular-type symptoms with seemingly no explanation.
This article is part of a series of articles on cervical spine and neck instability causing “cardiovascular,” events. Please see the companion article: Can cervical spine instability cause heart palpitations and blood pressure problems? For more information.
Cervical Angina and a long list of other symptoms you also suffer from. Do they all come from the neck?
Like many problems that come from cervical spine and neck instability, cervical angina or chest pain can be considered controversial or a mystery ailment. It is also not a symptom that develops in isolation. Cervical angina is typically accompanied by many coexisting problems related to the neck.
Listen to some of the problems that others like you have shared with us:
Chest pain and cracking noises in the neck
- I have many concerns. I have been having chest pains, shortness of breath, and palpitations. I have had full cardiac workups and my heart is strong and healthy. I started to suspect cervical angina because suddenly I developed crunching and cracking sounds in my neck that were not there before and I am starting to have pain in my shoulders and down my arms. Worse, I started to have swallowing issues accompanied by loud cracks in my neck.
Bulging discs, anxiety, and chest pain
- I have done a lot of research over the years trying to find any information that may help me understand what is wrong with me. I have angina attacks, frequent chest pain, and tightness that when I described it at first to my doctor, these concerns sent me immediately for a cardiovascular examination and more tests and blood work than I can remember taking. When “nothing,” was found I was sent to a physiatrist so I could get the “good,” anxiety medications to control my palpitations. Eventually, neck pain sent me to a chiropractor who suggested that I had degenerative disc disease in my neck and that I had bulging discs from C3-C7. The manipulation seems to have lessened my angina attacks but they still come and go.
Chest pains, POTS, dizziness, and other problems
- I have had neck problems for a long-time. Many of the problems I have already been traced to problems my neck instability is causing. I have been managing C4-C7 degenerative disc disease and cervical stenosis mostly between C6-C7. I have Postural Orthostatic Tachycardia Syndrome (POTS), with the classic symptoms of palpitations, lightheadedness, and dizziness that mimic cardiovascular disease. A cardiovascular workup ruled out heart problems. But with my other issues, namely tinnitus, vision problems, and worsening neck pain, I am being told to consider cervical fusion by the orthopedist.
I am wearing a heart monitor and I do not think it will find anything wrong
- I have been having many problems. Headaches, dizziness, neck, and chest pains. I have been to so many specialists. An orthopedist says I do not have enough damage in my neck to justify surgery at this point but I can get cortisone until it does not work anymore. I went to an ENT for dizziness and headaches. They suggested a follow-up with a cardiologist to “rule out everything.” That is why I have a heart monitor now.
The mystery of Cervical Angina and Pseudoangina. Chest pains from the neck
A patient will come in, they will say something like this: I have bulging discs C4-C7. I know that my chest pain is coming from my neck. My doctor tells me if I have the same type of chest pain that I have been having, I should simply find a quiet place to rest and avoid caffeine.
The idea that neck problems can cause “pseudo angina” is not a new one. A 1929 case history was presented in the Journal of the American Medical Association in 1934 (1). The patient was confined to bed because of a “bad heart.” However, after further examination, it was found he suffered from cervical spine osteoarthritis. When the patient was given head traction, the chest pains cleared up.
A 1997 paper in the American Academy of Family Physicians (2) by Dr. Patricia Wells of Scottsdale Memorial Hospital offered this explanation that your chest pain is from cervical spine instability.
“Cervical angina is defined as pseudo angina that resembles true cardiac angina but originates from a cervical discopathy with nerve root compression. This condition, which is also referred to as pseudo angina, most commonly results from compression of the C7 nerve root. Several simple findings from the history and the physical examination help make the diagnosis, which can then be confirmed with magnetic resonance imaging and/or discography. Coexisting coronary artery disease must always be ruled out. Treatment includes intermittent cervical traction, physical therapy, nonsteroidal anti-inflammatory drugs, and muscle relaxants. If these measures fall to alleviate the patient’s pain, referral to a spine surgeon may be indicated.”
Now for many people, these recommendations may bring great relief. For some, cervical spinal surgery may be very successful. These are not the people we see at our center. We see the people who do not want the surgery or worse, had the cervical fusion with resulting complications. Please see our article Cervical adjacent segment disease: Risks and complications following cervical fusion, for more information.
It is not just the chest pain, it is the years of accompanying symptoms. More mysteries, “not well explained.”
In August 2006, researchers wrote in the medical journal Spinal Cord, (3) called Cervical Angina: “a seemingly still neglected symptom of cervical spine disorder.” They wrote: Among the multitude of symptoms of cervical spine disorders, cervical angina may be miscellaneous, but it must be always recognized in clinical practice. In addition, the symptoms tend to be misidentified more frequently in elderly individuals because of the increased incidence of coronary artery diseases. The symptom is rather easily recognizable when the patient presents with neurological signs of spinal cord compromise, however, actually frequently, it appears to be a missing problem without careful examination. Many investigators have described details of this status but it appears still neglected in the routine clinical practice.
In 2015, doctors and neurosurgeons at Saint Vincent Hospital in Worcester Massachusetts wrote in the medical journal The Neurohospitalist (4)
“Cervical angina often presents with anterior chest pain and has been described as sharp, achy, or crushing in quality. Some patients may even experience relief with nitroglycerin. Symptoms may be present at rest or exacerbated by physical activity. Associated neck pain, stiffness, headaches, and shoulder, or arm pain may be present. Up to 50% to 60% of patients experience autonomic symptoms (dyspnea (difficulty breathing), (see our article on Cervical Vertigo and Cervicogenic Dizziness), nausea (see our article on Nausea and gastroparesis caused by cervical spine instability), diaphoresis (heavy and unusual sweating), pallor (being pale), fatigue (see our article Can Chronic fatigue syndrome and Myalgic encephalomyelitis be caused by cervical stenosis and cervical spine instability?), diplopia (double vision), and headaches), but the mechanism is not well explained.
“Physicians and spine surgeons alike should raise awareness of this unusual condition for diagnosis and treatment.”
The uncertainty about a diagnosis of cervical angina continues to be documented, 24 years after the 1997 paper cited above comes an August 2021 paper published by spinal surgeons in the Asian Spine Journal. (5)
“Cervical angina has been defined as chest pain that resembles true cardiac angina but originates from the disorders of the cervical spine. Thus, physicians and spine surgeons alike should raise awareness of this unusual condition for diagnosis and treatment. Particularly when neurologic signs and symptoms are present, there should be a strong suspicion for cervical angina in any patient with inadequately explained noncardiac chest pain.”
The process of elimination to come to a diagnosis of cervical angina
“Cervical angina can be diagnosed with negative cardiac workups, positive neurologic examination, and cervical radiographic findings (herniated disk, spinal cord compression, or foraminal encroachment). However, the mechanisms of pain production in cervical angina remain unclear.”
Where is the pain coming from?
“Previous studies attributed the pain to cervical nerve root compression, cervical sympathetic afferent fibers, referred pain, or lesions of the posterior horn of the spinal cord. Conservative treatments, which include neck collar fixation, head traction, and nonsteroidal anti-inflammatory drugs, have been determined to be successful in most patients with cervical angina.”
When all treatments fail, cervical fusion can help angina-like symptoms
“But when conservative treatment fails, anterior cervical surgery with complete decompression of the spinal cord and/or nerve root has been identified to effectively relieve cervical angina symptoms.”
Let’s stop here to explain some points. You may have already performed your own research as we find that people who suffer from symptoms like those above have done extensive reading on the internet. We will do a short summary and a video presentation with Ross Hauser, MD.
Summary learning points of this video
- There are a lot of people who have unexplained symptoms: They go to a cardiologist or several cardiologists and other doctors and no one seems to know the cause of their heart problems. We find that in a lot of these cases, the person is suffering from cervical instability, especially upper cervical instability.
- The sensory nerves that tell the brain what’s going on, moment to moment, in regard to heart rate and blood pressure are carried by the vagus nerve and the glossopharyngeal nerve. If the messages that these sensory nerves need to deliver to the brain are blocked or impaired, the heart symptoms described can develop.
At 1:00 of the video, Dr. Hauser refers to this image to describe the impact of compression of the vagus nerve and the glossopharyngeal nerve on heart rate and blood pressure
This image describes the impact of compression of the vagus nerve and the glossopharyngeal nerve on heart rate and blood pressure.
- Many of the vagus nerve sensory fibers that regulate blood pressure are in the carotid artery and the glossopharyngeal nerve fibers. The nerves are part of a network that carries impulses to the brain that tells the brain what is going on with heart rate and blood pressure from moment to moment.
- For example, if your blood pressure is going low you need this network to alert the adrenaline system or the sympathetic nervous system to regulate your blood pressure.
At 2:00 of the video – When a person has cervical instability, especially upper cervical instability
- When a person has cervical instability, especially upper cervical instability it can impact the vagus nerve and the glossopharyngeal nerve. The vagus nerve and the glossopharyngeal nerve run in the carotid sheath, the connective tissue that encapsulates the vascular compartments of the neck. This runs right along the anterior body of the cervical vertebrae, especially C1-C2.
At 2:20 of the video, the close proximity of the vagus nerve, the glossopharyngeal nerve, and the spinal accessory nerve to the C1-C2 vertebrae is demonstrated in this image
This image displays the close proximity of the vagus nerve, the glossopharyngeal nerve, and the spinal accessory nerve to the C1-C2 vertebrae. This proximity makes compression of these nerves common in cervical spine instability.
A November 2022 case report in the Journal of medical cases (6), describes the case of a 56-year-old man who suffered from chest pain and chronic neck pain for 2 years. He also had developed numbness in his right third and fourth fingers for 6 months. His chest pains were not associated with palpitation, orthopnea (breathing difficulties when laying down flat), or pedal edema (swollen feet). He did have hyperglycemia and was being treated for type 2 diabetes using glucose-lowering drugs. The cause of his chest pain remained unknown.
Following a second opinion from an orthopedist, the patient was diagnosed with cervical radiculopathy and was treated with analgesics and physical therapy. Because the treatments had only provided temporary pain relief, he sought chiropractic care for pain relief. Cervical radiographs revealed degenerative spondylosis with right C5/C6 neuroforaminal stenoses and bilateral C6/C7 neuroforaminal stenoses. It was believed he suffered from cervical spondylotic radiculopathy associated with cervicogenic angina was made. Chiropractic procedures, including cervical manipulation, instrumented soft tissue mobilization, and motorized intermittent neck traction, were performed two to three times per week. After 3 months, the patient reported that the chest pain, neck pain, and radicular symptoms had completely resolved.
Anterior Cervical Discectomy and Fusion for Cervical Angina
In April 2021 doctors offered this summary in the journal Clinical Spine Surgery (7) for comparing Anterior Cervical Discectomy and Fusion vs conservative treatment for Cervical Angina. The conservative treatment methods are described below.
Here are the learning points of this paper:
- “Cervical angina is typically characterized by intolerable and paroxysmal angina-like precordial pain (sudden attacks of chest pain that can mimic heart attack), which is caused by cervical disk degeneration in patients without definitive cardiovascular abnormalities. Diagnosis is either delayed or neglected because of its various clinical manifestations. Whether conservative or surgical treatment is appropriate remains controversial because of the lack of comparative studies.”
In this study, 163 patients with cervical angina with advanced chest pain, tightness, or palpitation were retrospectively studied.
- Twenty-three patients underwent Anterior Cervical Discectomy and Fusion, and the other 140 patients were treated non-surgically by medication, physical therapy, collar immobilization, or stellate ganglion block.
- The average age of the patients was 50 years, and most of them were females.
- The average follow-up was 25.5 months.
- Patients that had the fusion showed improvements in angina-like symptoms.
- During an average 2-year follow-up, good or excellent results were obtained in 78.2% of surgical patients and 35% of nonsurgical patients.
Conclusions: “Compared with conservative therapy, surgical treatment with ACDF for cervical angina provided better and more consistent relief from angina-like symptoms and overall sympathetic symptoms.”
In the conservative care treatments studied in this paper, a mainstay treatment, Prolotherapy was not examined. So let’s examine this treatment below.
A December 2020 study in the Journal of Neurosurgery. Spine. (8) assessed patients with cervical angina and found:
- Cervical herniation (72.6%) accounted for the majority of cervical angina cases, and surgical interventions (84.4%) predominated over physical therapy (13.0%) and medical management strategies (9.1%). Every patient assessed at follow-up reported relief from symptoms related to cervical angina.
What this study shows us is that angina and cardiovascular-like symptoms can come from cervical spine instability. In 78% of patients, improvement was seen after fusion surgery, and 35% of patients in the non-surgical group achieved similar improvements.
Research on cervical instability and Prolotherapy treatments. A possible solution to the problems and challenges created by cervical spine instability is seen as cardiovascular in nature.
Caring Medical has published dozens of papers on Prolotherapy injections as a treatment for difficult-to-treat musculoskeletal disorders. We are going to refer to one of these studies as they relate to cervical instability and a myriad of related symptoms including the problem of a racing heartbeat, heart rate variability, and high blood pressure.
In our 2014 study, (9) we published a comprehensive review of the problems related to weakened damaged cervical neck ligaments.
This is what we wrote:
“There are a number of treatment modalities for the management of chronic neck pain and cervical instability, including injection therapy, nerve blocks, mobilization, manipulation, alternative medicine, behavioral therapy, fusion, and pharmacologic agents such as NSAIDs and opiates. However, these treatments do not address stabilizing the cervical spine or healing ligament injuries, and thus, do not offer long-term curative options.
To date, there is no consensus on the diagnosis of cervical spine instability or on traditional treatments that relieve chronic neck instability issues like those mentioned above. In such cases, patients often seek out alternative treatments for pain and symptom relief. Prolotherapy is one such treatment that is intended for acute and chronic musculoskeletal injuries, including those causing chronic neck pain related to underlying joint instability and ligament laxity. While these symptom classifications should be obvious signs of a patient in distress, the cause of the problems is not so obvious. Further and unfortunately, there is often no correlation between the hypermobility or subluxation of the vertebrae, clinical signs or symptoms, or neurological signs or symptoms. Sometimes there are no symptoms at all which further broadens the already very wide spectrum of possible diagnoses for cervical instability.”
What we demonstrated in this study is that the cervical neck ligaments are the main stabilizing structures of the cervical facet joints in the cervical spine and have been implicated as a major source of chronic neck pain and in the case of chest pains, racing heartbeat, heart rate variability, and high blood pressure, caused by cervical spine instability.
Prolotherapy is an injection of simple dextrose into the unstable cervical spine. The concept is that these injections will strengthen the cervical ligaments thereby providing a stronger or more stable connection between the cervical vertebrae.
In our practice, we continue to see a large number of patients with a myriad of symptoms, like those described above, related to cervical neck instability. These people are often confused, many times frightened by recommendations to complicated cervical neck surgeries they don’t understand.
Many of these people have been told that their problem is a problem of degenerative cervical disc disease. After years of prolonged pain and conservative care options such as chiropractic, massage, physical therapy, anti-inflammatories, pain medications, cortisone injections, and cervical epidurals that eventually fail the only recourse, these people are told, is neck surgery.
Summary and contact us. Can we help you? How do I know if I’m a good candidate?
If you are like many of the patients we see, you have been chasing a diagnosis and treatment that works for years. For you, who had coexisting coronary artery disease ruled out, maybe wearing cervical neck collars, getting cervical traction, physical therapy, nonsteroidal anti-inflammatory drugs, and muscle relaxants, and perhaps waiting for surgery, you are probably exploring another way. This may be where Prolotherapy may be of benefit.
In our nearly three decades of helping patients with problems related to the cervical spine, we have seen these symptoms and treatment failures many times. In our own peer-reviewed published studies we have been able to document cervical neck ligament damage as a possible cause of many symptoms including a group of symptoms thought cardiovascular in nature.
We hope you found this article informative and that it helped answer many of the questions you may have surrounding Cervical angina. 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.
References for this article:
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This article was reviewed and updated April 8, 2023