Upper cervical instability and compression of the brain stem

Ross Hauser, MD

Upper cervical instability and compression of the brain stem

Upper cervical instability is a primary focus of the Hauser Neck Center at Caring Medical Florida. Every day we are making discoveries in patients who have bizarre and disabling neurological symptoms that have gone undiagnosed or unresolved by their local primary care doctors or even other well-known specialty clinics. In this video, Ross Hauser, MD discusses how upper cervical instability impacts the brain stem and leads to many of the symptoms that we help in our clinic, as well as our approach to resolving the issue without surgery or a lifetime of medication.

In this article we briefly review, compression of the brain stem symptoms of dizziness, fainting, blurred vision, visual and auditory disturbances, flushing, sweating, tearing of the eyes, runny nose, vertigo, numbness and tingling, and difficulty swallowing or talking, and drop attacks.

Hi, my name is Dr. Ross Hauser, welcome to Caring Medical, Florida.

I’m going to talk about how upper cervical instability can affect the brain stem.

As you may be aware, the spinal cord enters the brain through the foramen magnum, the hole in the base of the skull. Once through, the brainstem connects with the brain. This does not always occur. Sometimes, the brainstem does not make it all the way through the foramen magnum. The brainstem may end its journey to the brain in the cervical spine, short of the foramen magnum opening.

This is one reason that the brain stem can be affected by upper cervical instability.

  • Research note: A January 2018 study in the journal Neurosurgical Review (1). Wrote of the “growing recognition of the kyphotic clivo-axial angle (a deformity in the curvature of the neck) as an index of risk of brainstem deformity and craniocervical instability.” They note that the kyphotic clivo-axial angle “is a useful sentinel to alert the radiologist and surgeon to the possibility of brainstem deformity or instability.”
  • In Caring Medical Florida, assessing the curvature of the neck is a main component of our treatment plan and is explained below.

Another thing that can happen is cervical instability can cut off the blood supply to the brainstem which is the vertebral artery.

In my article, Vertebrobasilar insufficiency, I discuss the complexity and challenges of cervical neck instability treatment which we find fully displayed in the controversies and confusions surrounding the diagnosis of vertebrobasilar insufficiency, also called vertebrobasilar artery insufficiency or Bow Hunter Syndrome. Here patients may suffer from symptoms include dizziness, fainting, blurred vision, visual and auditory disturbances, flushing, sweating, tearing of the eyes, runny nose, vertigo, numbness and tingling, and difficulty swallowing or talking, and drop attacks. Please refer to that article for a review of current research.

In this illustration the vertebral artery is clearly seen weaving its way through C1-C2. If the C1-C2 are moving and hypermobile, they could press on and compress the vertebral artery. This could cause the sensation of lightheadedness and feeling faint.

In this illustration the vertebral artery is clearly seen weaving its way through C1-C2. If the C1-C2 are moving and hypermobile, they could press on and compress the vertebral artery. This could cause the sensation of lightheadedness and feeling faint. This is seen in the x-ray below.

In this x-ray, when the patient looks down, a 6 mm space opens between the C1-c2. When the patient looks up, 0 mm, no space. Everything between those two surfaces is compressed.

In this x-ray, when the patient looks down, a 6 mm space opens between the C1-c2. When the patient looks up, 0 mm, no space. Everything between those two surfaces is compressed.

Transcranial Doppler to test blood flow

Video at (1:05) in Caring Medical Florida, we document the blood flow of the vertebral artery with Transcranial Doppler. So our ultrasound machines can measure blood flow to the vertebral artery and then we can move a person through a range of motion to see if the blood supply goes down (is reduced). Please see our article Using Transcranial Doppler & Extracranial Doppler Ultrasound Testing at the Hauser Neck Center for further information and explanations.

We document the blood flow of the vertebral artery with Transcranial Doppler. So our ultrasound machines can measure blood flow to the vertebral artery and then we can move a person through a range of motion to see if the blood supply goes down

We document the blood flow of the vertebral artery with Transcranial Doppler. So our ultrasound machines can measure blood flow to the vertebral artery and then we can move a person through a range of motion to see if the blood supply goes down

(Video at 1:35 ) The lower part of the brainstem is called the medulla oblongata and is where Cranial Nerve X or the Vagus Nerve, Cranial Nerve IX or the glossopharyngeal nerve,  Cranial Nerve XI or the spinal accessory nerve and Cranial Nerve XII or the hypoglossal nerve all originate.

Upper cervical instability, by causing a decrease in neurologic function of the lower part of the brainstem can affect the nerves.

Symptoms may be seen as:

(Video at 2:23 ) A connection to constant nausea

  • Interesting too is that the nausea center is right in the lower part of the brainstem.  It is amazing how many people feel nauseated all the time and nobody can tell what’s causing it. These patients 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. Please see our article Cervical spine instability as a cause of your digestive disorders for further discussion on this problem.

(Video at 2:45 ) Heart palpitations and arrhythmias

  • What’s kind of interesting to me too is how many of my patients who once they get their upper cervical instability resolved, their heart palpitations and their arrhythmias go away. This is not to say that all heart palpitations and arrhythmias, but the lower part of the brainstem is what controls basically heart rate and blood pressure so somebody who’s having tachycardia all of a sudden and then it goes away and then they go to the cardiologist and they can’t really figure out what it is, it could be that the person is just having upper cervical instability affecting the center in the brainstem that controls heart rate and blood pressure. Please see my article Heart racing, heart rate variability, and high blood pressure. A cervical spine problem?

(Video at 3:35) Respiratory rate

  • The lower part of the brainstem also affects respiratory rate. There are a lot of people that all of a sudden feel panicky, on the verge of panic attacks.  They start breathing really hard or they have shortness of breath and they don’t know why. It could be that upper cervical instability is decreasing the function of the brainstem.

The Curve of the Cervical Spine

(Video at 4:05) The cervical curve

The Horrific Progression of Neck Degeneration with Unresolved Cervical Instability. Cervical instability is a progressive disorder causing a normal lordotic curve to end up as an “S” or “Snake” curve with crippling degeneration.

The Horrific Progression of Neck Degeneration with Unresolved Cervical Instability. Cervical instability is a progressive disorder causing a normal lordotic curve to end up as an “S” or “Snake” curve with crippling degeneration.

  • The cervical instability from ligament injury causes the cervical spine curve to change, from a normal “C” curve to the opposite, a reversal of the curve. See the progression illustration below.
  • This curve reversal causes stretching on the spinal cord, the cervical spine, with its now unnatural curve, is yanking and pulling on the brain stem and the whole brain. That traction, or pull on the brain stem, can also affect brainstem as well have cranial nerve function.
  • To get the brainstem and all the nerves working correctly one has to address and tighten the ligaments in the back of the neck as well as get the cervical curve back to its normal lordotic configuration.

"S" cervical curve. Cervical spine instability from cervical ligaments can cause hypermobility of the cervical vertabrae. This leads to a loss of the natural curve or lordosis and eventual cervical kyphosis and an "S" curve.

“S” cervical curve. Cervical spine instability from cervical ligaments can cause hypermobility of the cervical vertebrae. This leads to a loss of the natural curve or lordosis and eventual cervical kyphosis and an “S” curve.

Treatment Prolotherapy

  • To get the brainstem and all the nerves working correctly one has to address and tighten the 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.

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 those mentioned above 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.(2) 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 disorderpost-concussion syndrome, vertebrobasilar insufficiency, and Barré-Liéou syndrome.

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 cervical spine has a natural curve. It acts as a spring or shock absorber for the head. When this curve is gone, injury, Joint Hypermobility Syndrome, or degenerative cervical disc disease

The cervical spine has a natural curve. It acts as a spring or shock absorber for the head. When this curve is gone, injury, Joint Hypermobility Syndrome, or degenerative cervical disc disease

Digital motion X-Ray C1 – C2

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 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.

Summary and discussion

In this article and video summary we see that cervical spine instability can have a terrible impact on the quality of life in patients where brain stem compression is occurring. This is not a new problem. Neck instability and the symptoms I describe above have been linked together for a long time. In 1998 doctors at the Department of Neurosurgery, University of California, San Francisco reported on a strange case (3) of a 41 year old women, post-surgery who had flexion-induced compression (every time she pointed her chin down towards her chest) of the upper cervical spinal cord causing symptoms of brainstem compromise in the absence of radiographic evidence of osseous instability. (Nothing was showing up on MRI and there was no calcification of the soft tissue). Still, the patient experienced postsurgical instability with dynamic compression by the C3 vertebral body, which caused brainstem compromise. The patient was then sent to a more comprehensive second surgery to fix this problem. A little over two years after this second surgery the patient was reported asymptomatic.

The point to this research was to make fellow surgeons aware that following a C3 decompression surgery, with continued patient symptoms and no obvious reason for it, surgeons should look for cervical spine instability causing pressure on the brainstem. The patient in this case study had a subsequent C2 – C6 fusion.

This study is demonstrated to highlight that more than 20 years later, unknown problems of upper cervical instability continue to confuse patients and doctors. The patients we see in our offices still suffer from many of the same problems whether these symptoms resulted post-surgical or they have not had surgery yet without radiological evidence that something is wrong with them.

If this article has helped you understand the problems of cervical instability and you would like to explore Prolotherapy as a possible remedy, ask for help and information from our specialists

1 Henderson FC, Wilson WA, Mark AS, Koby M. Utility of the clivo-axial angle in assessing brainstem deformity: pilot study and literature review. Neurosurgical review. 2018 Jan 1;41(1):149-63. [Google Scholar]
2 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]
3 Rosenberg WS, Salame KS, Shumrick KV, Tew JM Jr. Compression of the upper cervical spinal cord causing symptoms of brainstem compromise. A case report. Spine (Phila Pa 1976). 1998;23(13):1497-1500. doi:10.1097/00007632-199807010-00013 [Google Scholar]

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