Skin Pain, Hot and Cold Skin: Are fixing upper cervical neck instability problems the missing treatment?

Ross Hauser, MD., Danielle R. Steilen-Matias, PA-C

Like many of the people we see, people who have symptoms of tactile allodynia or painful to the touch skin, skin sensations where one half of their body will feel hot and one half of their body will feel cold, rashes and problems of sweating, will have these symptoms among a “sea of symptoms,” that can include chest pain, GERD, ear and vision issues, and neck and joint pain.

These people have so many issues, sometimes they lose track of what is affecting them and their primary concern may change over the course of days and weeks. Where today they may have nausea and that is the main concern, their swallowing difficulties will worsen to the point that that is their main concern.

Problems of the skin, symptoms of the skin, or manifestations of the skin can be caused by many problems. The focus of this article will be for people who have already had the many tests to siolate causes that have not offered a clear cut diagnosis and treatment plan beyond symptom management. In this article we will look for the unknow cause of these skin manifestations in the upper cervical spine and how neck instability and pressure and disruption on the neurological nerve network that passes through the neck may be the missing diagnosis for some.

The symptoms, the diagnosis, and the medical journey. These are the stories we hear.

Many of the people that contact our office have been on a long medical journey, perhaps like yourself. Years of testing, years of trial and error medicine. The one thing that many of these people have acquired is a much thicker medical file. Here are some of the stories we hear.

Ehlers-Danlos syndrome, skin flushing, sweating

I have Ehlers-Danlos syndrome, the worse pain is in my neck, then shoulders and hips. I am told the problems in my lower legs, ankles and feet are being caused by peripheral neuropathy and I have a condition of polyneuropathy. My doctors suspect that my neck pain may be the cause of my migraines and headaches, blurred vision, eye pain, numbness and burning sensation in my face. Some of my other doctors think that the numbness and burning sensation in my face, the problems I have with sweating (hyperhidrosis), and skin flushing, my be a problem of  thoracic outlet syndrome since the skin flushing and redness is occurring mostly in my upper chest and shoulders. I have plateaued with all the treatments that are trying to manage my symptoms, I need something more.

Thoracic outlet syndrome, hot and cold, sweaty hands

My doctors tell me that my problems center around my diagnosis of Thoracic outlet syndrome. I have had a lot of surgeries. I had a scalenectomy thinking that would help with my nerve compression and symptoms. I have cervical instability C3-C7 and have been told that cervical fusion may be in order. Because the scalenectomy offered little help, I want to try to avoid the fusion. 

I have told my doctors that many of the symptoms I have including burning and tingling in my mouth, gag and chocking sensation, are related to the way I hold my head up. That is why they want to do a fusion. The symptoms that confuse my doctors the most is my ability, depending on how I stand, is to make my hands feel hot or cold, sweaty or dry, pale or red in color. They tell me that this is a neurology problem. I do not like having the sweaty palms.

Changes in skin color, cold hands.

My symptoms include tingling in mouth; pain and tingling from the neck through my hands, I have changes in skin temperature and color from white to red, a gag reflex or chocking sensation, choking sensations; pressure headaches. I have a history of shoulder surgeries and a cervical fusion. I cannot get help.

Strange sensations in the skin

In the video below with Ross Hauser, MD and Brian Hutcheson DC, a discussion chronic skin sensations that are pretty common symptoms and findings in cases of cervical instability. These include symptoms like abnormal temperature regulation over half of their body or certain areas that are hot or cold compared to the rest of the body as well as specific areas that are hypersensitive or numb compared to the rest of the body, and other odd skin sensations, including localized swelling, vibration, and severe itching that have not been resolved by other traditional treatments by a dermatologist, rheumatologist, neurologist, etc.

The stories above may be a familiar tale. One of the common characteristics that you may share with these story examples is that you are getting a lot or treatments that are only addressing the symptoms. So you may be on medications for gastrointestinal distress because your swallowing difficulties my be leading to digestive problems. Your problems with sweating may be being with medications. Your headaches may be being treated with medications, you may be on medications for dizziness, you may have had Botox injections, cortisone injections, topical creams, ointments, and a shopping bag filled with other things. But nothing you are doing is helping you.

Before we move on. Many of the problems we are describing here do respond very well to conservative and tradition treatments. Many times they will succeed at a high rate and to the patient’s satisfaction. These are not the people we see at our center. We see the people who are being symptom managed without great results. Again, we will focus this article on the problem of cervical spine instability as the underlying cause for many of these problems and the symptoms of strange sensations in the skin.

Explanatory and learning points from this video are highlighted and detailed below.

What are the strange sensations in the skin that we see at our center?

  • People have symptoms or concerns surrounding skin that feels hot or feels cold.
  • Some people report a vibration or a diagnosis of Paresthesia. They describe an abnormal sensation of the skin which can include the hot cold sensation, a tingling or numbness or “electric shock feeling,” that no one has been able to figure out the cause of.
  • Some people report pain or these symptoms occurring on just one side of their body.

The skin is a sensory organ it senses things

That the skin is reacting to some type of “bad,” neurological stimulus should not be surprising. That is what the skin does. It reacts. The skin’s reaction is a warning signal that something is not right or something is wrong. The skin is very clever, but the skin can also be confused. If you are reading this article your skin’s confusion can be in the relaying of messages from the skin, through the cervical spine into the brain. We are suggestion that there is a message interruption occurring in the neck being caused by cervical spine instability.

Senses disrupted

  • The skin senses hot, cold, sharp touch, soft touch, vibration.
    • It can also become confused because of underlying (in some unidentified) problems and start sending and receiving misinterpreted messages from the nerves.
    • These could be misinterpretation of temperature. One side of the body thinks its cold and heats up. That side of the body can also feel hot and try to cool down.
    • Parts of the body can have paresthesia and numbness or tingling because of these misinterpreted or confused nerve messages.
  • Side note: Restoring sensation
    • In some patients, to help them restore normal sensations, we have to “retrain the body.” Some patients are told to put warm or hot, cool or cold towels or items on their skin to “reboot,” the nerves. Soft touch like cotton, sharp touch like pop corn. For some people with peripheral neuropathy we may recommend they put their feet in a bowl of pop corn kernels.

A brief discussion on Complex Regional Pain Syndrome and the touch/pain sensation, changes in skin color and and temperature asymmetry

For a more detailed discussion please see our more extensive article –  Complex Regional Pain Syndrome (CRPS). In this article we will highlight a portion of that article as it relates to touch and pain sensitivity.

Many of the challenges patients with skin sensitivity to pain and temperature have many of the symptoms common in Complex Regional Pain Syndrome. These patients will also have a very heightened sensitivity to pain, especially the skin. A cool breeze will “burn,” on their exposed skin. Bed sheets will cause a similar pain sensation when they try to sleep. Updated information in the National Center for Biotechnology Information publication STAT PEARLS (1) offers this explanation and understanding of hyperesthesia and allodynia.

“The official International Association for the Study of Pain definition of allodynia at the time of this article is “pain due to a stimulus that does not normally provoke pain.” An example would be a light feather touch (that should only produce sensation) causing pain. Allodynia is different from hyperalgesia, which is an exaggerated response from a normally painful stimulus, although both can and often do co-exist. Both are types of neuropathic pain.

An example of the difference between allodynia and hyperalgesia on the physical exam would be softly rubbing a cotton-tipped swab against a patient’s skin. Lightly brushing a swab against the skin would cause a low-level stimulus, but should not elicit a pain response. A patient who experiences pain with a stimulus that should only cause sensation may have allodynia. If the clinician significantly increases the degree of pressure, some pain would be part of a normal response. A patient who feels an excessive amount of pain would be noted to have hyperalgesia.”

Patients may display the following problems:

  • vasomotor – reports of temperature asymmetry and/or skin color changes and/or skin color asymmetry.
    • This is the one-sided phenomena we see, one side of the body will be hot, the other side cold. One side of the body will display a pallor or pale appearance, the other side darker, more blush, and hot.
  • sudomotor/edema – reports of edema and/or sweating changes and/or sweating asymmetry.
  • motor/trophic – reports of decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (hair, nail, skin).

The problems of temperature asymmetry and cervical spine instability

In our nearly three decades in helping people with chronic pain, we have seen, from the start, that mysterious symptoms and missing diagnosis often plague people with upper cervical instability and compression of the brainstem. Solving the problem of a missing diagnosis of cervical spine issues causing these mysterious symptoms may be found in dysregulation of temperature control in the body.

Researchers as far back as 1998 published findings (2) on the value of infrared or thermovision image in pain syndromes associated with instability of the cervical segment of the spine.

In this study, 71 patients with cervical spine instability had high temperature readings of the neck and severe cervical hyperthermia (above normal temperature readings) when compared to healthy subjects.

When the doctors addressed the cervical spine problems through therapy and rehabilitation, they could see that high dynamic changes were occurring in the patient’s temperature readings. As rehabilitation programs helped correct the neck problems, temperature symmetry (normal regulation) in the neck returned and there was a reduction of cervical hyperthermia.

The results of the study tests point to the suitability of the thermovision testing in the evaluation of the effectiveness of rehabilitation procedures in patients with cervical segment of the spine. In other words, your cervical spine treatments are working if the patient’s temperature assymetry is correcting itself.

Where you are hot and cold could dictate where your cervical spine instability is

Here is a study (3) from 1999 that used thermal imaging to help assess possible locations neck that was causing arm pain. In this study researchers found that symptoms of a cool or warm sensation in the arm could be shown objectively by using of thermography with the detection of thermal change in the case of radiculopathy, including cervical disc herniation.

In other words, if you take the temperature of the arm, not only will temperature asymmetry, the different readings across the arm confirm a problem in the cervical spine, but the location of the problem temperatures in the arm may also give a clue to exactly where in the neck the problem was.

But this can be a tricky science, in 2020 researchers published these observations in the journal Medicine (4).

“In general, in digital infrared thermographic imaging of patients with unilateral (one sided) spinal radicular pain, the thermal pattern of the extremities of the side of (the degenerative disc lesions) shows hypothermia (cold skin) compared to the opposite, intact side.

However, sometimes, digital infrared thermographic imaging shows hyperthermia (hot skin) on the side of the lesion, and this variation can cause confusion.”

What the researchers did was try to explain this flip-flop in temperature asymmetry.

They compared the data of both hypothermia and hyperthermia patients to clarify the factors determining different thermal characteristics in spinal radiculopathy. Two hundred twenty four patients were divided into two groups:

A hypothermia group (180 patients) and a hyperthermia group (44 patients). Then they compared the various factors that could account for this.

They found: In patients with trauma history, acute phase of pain, and severe radicular pain, hyperthermia in digital infrared thermographic imaging is not unusual and careful interpretation of the digital infrared thermographic imaging results is necessary for proper diagnosis and treatment decisions in spinal radiculopathy.

In other words, in chronic neck pain people, hot and cold can go either way.

In chronic neck pain people, hot and cold can go either way

As we discussed above and demonstrated with independent research, understanding skin temperature can help us understand your symptoms and where these symptoms can be coming from. In other words, understanding skin temperature can help get to the underlying cause of your problems if are centered in your cervical spine and neck pain.

Checking for temperature at various points of the body

Checking for temperature at various points of the body.

  • Using an infrared detector, on each side of the body, can be an effective diagnostic way to find out what may be causing the skin sensation abnormalities we are discussing. Whether your skin is painful to the touch, itchy, has a sensation of vibration or numbness.

The clue that temperature dysfunction is being caused by cervical spine instability

Patient demonstration at 1:45 of the above video – the clue that temperature dysfunction is being caused by cervical spine instability.

  • In this patient we see that the the temperatures we recorded on the left side of the patient are much lower than the temperatures we recoded on the right side of the patient.
  • So here we have a clue that the patient’s problems are being caused something going on in the upper cervical spine. What is the clue? Because in this patient the temperature dysfunction is impacting the entire body.  If the problem was confined to the lower body, we would suspect that the problems could be coming either from the neck or the low back.
  • In this patient we suspect that something is irritating the left side of the upper cervical spine or maybe the lower brain stem. It is possibly a problem that has gone on for sometime because these type of temperature ranges from one side to the other typically occur over a period of time as the nerves get irritated. The more irritation long-term, the worse the problem as temperature regulation is compromised.

Why just one side? Why is it difficult to understand or diagnose?

  • We would typically encourage people to check their temperatures at various points on one side of the body against the other side to look for variations. This could help the person and even their health care providers understand that the underlying problem is one coming from the upper cervical spine.
  • It is very common for us to see people who have this one-sided body issue with skin sensations and off temperature ranges. These people have had many challenges getting any one to explain why one side of their body vibrates, one side of the body is cold or warm
  • When we see patients with temperature regulation problems, a weird vibratory sense, numbness on one-side, a dull or reduced touch sensation or a hypersensitive touch sensation, we will most likely suspect you have upper cervical instability.

No symptoms at rest or certain motion, all symptoms appear when you move your head to left or right, up or down.

  • When upper cervical instability is suspected, certain ranges of motion would make symptoms worse, certain positions of the head would create no symptoms. People usually know these positions very well and when their symptoms flare, holding their chin out for example or looking up may reduce their symptoms. Each person has a different “comfort,” “no symptom position.”
  • Generally people do understand that a position that they are in, whether sitting or standing, or any position, that is “not a good position,” for them will start creating symptoms. Symptoms for some may be immediately, for other a few minutes of gradual symptom development may occur.

For some the missing diagnosis for skin sensitivity issues is the cervical spine

  • The clues of upper cervical instability can be found in the symptoms of the skin. Hot skin, cold skin, sensitivity to touch, skin rashes on the skin. This may be the missing diagnosis and why people do not get the care they need.

This slide explains that all the nerves that go to your arm that go to your leg they have sympathetic nerves with them that are associated with blood vessels. When sympathetic system gets irritated that’s going to give you heat and cold sensation. The point is that any of these spinal nerves whether it’s in the leg the neck if they’re irritated it can irritate the sympathetic ganglion and vice-versa which can affect the skin

  • A lot of nerves in the skin they get sensitized once a nerve get sensitization or neurogenic inflammation,  so the person has just one area of the body all of a sudden it’s really sensitive to touch or they get localized swelling if you have any kind of crazy any sort of strange sensation of your skin vibration hot cold sensitivity to touch itching vibration of your skin you should get an evaluation by a digital motion x-ray (DMX) of your neck all the nerve tracts from the skin they go through the neck into the brain.

What are we seeing in this image?

A Digital Motion X-Ray or DMX is a tool we use to help understand a patient’s neck instability and how we may be able to help the patients with our treatments. In the illustration below a patient who suffered from upper cervical instability demonstrated hypermobility of the C1-C2. This hypermobility can result in common symptoms of neck pain, headaches, dizziness, vertigo, tinnitus, concentration difficulties, anxiety, skin flushes, hot skin, cold, skin, sensitivity to pain.

A Digital Motion X-Ray or DMX is a tool we use to help understand a patient' neck instability and how we may be able to help the patients with our treatments. In the illustration below a patient who suffered from upper cervical instability demonstrated hypermobility of the C1-C2. This hypermobility can result in common symptoms of neck pain, headaches, dizziness, vertigo, tinnitus, concentration difficulties, anxiety and other symptoms common in TMJ/TMD patients.

The treatment of cervical spine instability at the Hauser Neck Center – Research on cervical instability and Prolotherapy

In the above article, we suggest that many of the problems related to among other symptoms, skin sensations and temperature regulation  can be treated by addressing cervical spine instability in the neck. There are many ways to treat this problem. Our preferred choice is regenerative medicine injections that begin with Prolotherapy.

Caring Medical has 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. Our research documents our experience with our patients.

In 2015, our research team at Caring Medical published findings in the European Journal of Preventive Medicine investigating the role of Prolotherapy in the reduction of pain and symptoms associated with increased cervical intervertebral motion, structural deformity, and irritation of nerve roots. Irritation of nerve roots cause many of the symptoms and challanges our patients face.

Twenty-one study participants were selected from patients seen for the primary complaint of neck pain. Following a series of Prolotherapy injections, patient-reported assessments were measured using questionnaire data, including range of motion (ROM), crunching, stiffness, pain level, numbness, and exercise ability, between 1 and 39 months post-treatment (average = 24 months).

  • Ninety-five percent of patients reported that Prolotherapy met their expectations in regards to pain relief and functionality. Significant reductions in pain at rest, during normal activity, and during exercise were reported.
  • Eighty-six percent of patients reported overall sustained improvement, while 33 percent reported complete functional recovery.
  • Thirty-one percent of patients reported complete relief of all recorded symptoms. No adverse events were reported.

We concluded that statistically significant reductions in pain and functionality, indicating the safety and viability of Prolotherapy for cervical spine instability.(5)

In 2014, we published a comprehensive review of the problems related to weakened damaged cervical neck ligaments in The Open Orthopaedics Journal.(6) 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.

This is what we wrote in this paper: “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 are 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 (such as excessive sweating or inability to sweat and temperature dysregulation or other skin sensations mentioned in this article) or symptoms.”

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 many of the symptoms we mention above.

1 He Y, Kim PY. Allodynia. InStatPearls [Internet] 2019 Aug 17. StatPearls Publishing. [Google Scholar]
2 Jasiak-Tyrkalska B, Frańczuk B. Evaluation of thermovision images in pain syndrome associated with instability of the cervical segment of the spine. Przeglad Lekarski. 1998 Jan 1;55(5):246-9. [Google Scholar]
3. Zhang HY, Kim YS, Cho YE. Thermatomal changes in cervical disc herniations. Yonsei Medical Journal. 1999 Oct 1;40(5):401-12. [Google Scholar]
4. Park TY, Son S, Lim TG, Jeong T. Hyperthermia associated with spinal radiculopathy as determined by digital infrared thermographic imaging. Medicine. 2020 Mar 1;99(11):e19483. [Google Scholar]
5 Hauser RA, Steilen 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):155-66. [Google Scholar]
6 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]

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