Ross Hauser, MD

People contact our office with unusual and distressing skin symptoms: skin that hurts when lightly touched, burning or tingling, unexplained itching, abnormal sweating, flushing, or one side of the body feeling hotter or colder than the other. These symptoms may occur alongside neck pain, headaches, dizziness, brain fog, swallowing difficulty, visual disturbances, gastroesophageal reflux, chest discomfort, or joint pain.

When symptoms are numerous, the patient’s greatest concern may change from day to day. Nausea may dominate one week; swallowing difficulty, facial burning, or temperature asymmetry may become the main problem the next. Many patients have undergone years of testing and symptom-directed treatment without receiving one diagnosis that explains everything.

 

Skin pain and temperature changes have many possible causes. They may result from dermatologic disease, infection, vascular disorders, medication effects, endocrine or metabolic disease, peripheral neuropathy, small-fiber neuropathy, complex regional pain syndrome (CRPS), spinal nerve-root irritation, spinal cord disease, or altered pain processing in the central nervous system. Sudden one-sided numbness, weakness, facial droop, speech difficulty, severe headache, or loss of coordination requires emergency evaluation.

This article focuses on a narrower question: after common and urgent causes have been investigated, could cervical instability or cervical nerve irritation contribute to abnormal sensory and autonomic symptoms in a subset of patients? Our clinical experience and research support asking this question, but they do not establish cervical instability as the cause of every unexplained skin symptom.

The skin is both a sensory and an autonomic organ

The skin detects light touch, pressure, vibration, pain, itch, heat, and cold. Small sensory nerve fibers—primarily thinly myelinated A-delta fibers and unmyelinated C fibers—help transmit pain and temperature signals. Autonomic fibers regulate sweating, the narrowing and widening of small blood vessels, and other functions that affect skin color and temperature.

This helps explain why a neurologic or autonomic disorder may be experienced as burning, electric shocks, pins and needles, painful cold, unexplained warmth, numbness, flushing, or abnormal sweating even when the skin itself appears structurally normal.

Allodynia is pain caused by a stimulus that does not normally provoke pain, such as clothing, a bedsheet, or a light breeze. Hyperalgesia is an exaggerated response to a stimulus that is normally painful. Paresthesia refers to abnormal sensations such as tingling, prickling, buzzing, or “electric” feelings. These terms describe the experience; they do not identify its cause.

Central sensitization can also amplify sensory signals. In this process, pain-processing pathways become more responsive, allowing normal or mildly uncomfortable input to be perceived as disproportionately painful. This is another reason that the severity of allodynia may not correlate neatly with findings on conventional imaging. (1)

Other diagnoses

Small-fiber neuropathy

Small-fiber neuropathy (SFN) can cause burning pain, tingling, painful sensitivity, impaired temperature sensation, altered sweating, gastrointestinal or cardiovascular autonomic symptoms, and sometimes normal routine nerve-conduction studies. Because standard electromyography and nerve-conduction testing primarily assess larger fibers, normal results do not rule out SFN.

A 2026 evidence-based review from the American Association of Neuromuscular and Electrodiagnostic Medicine (2) concluded that skin biopsy measuring intraepidermal nerve-fiber density is the most validated direct diagnostic test for SFN. Quantitative sensory testing, corneal confocal microscopy, and autonomic testing may provide additional information. Testing should be interpreted within the clinical picture and accompanied by evaluation for potentially treatable causes. 

Ehlers-Danlos syndrome and small-fiber dysfunction

Many patients we see have Ehlers-Danlos syndrome or hypermobility spectrum disorder. Their burning pain, temperature disturbance, sweating changes, and other autonomic symptoms should not automatically be attributed to cervical instability.

Skin-biopsy and autonomic studies have documented small-fiber abnormalities in some people with hypermobile Ehlers-Danlos syndrome (hEDS). A prospective study of 31 patients with hEDS found evidence of generalized small-fiber neuropathy and autonomic involvement compared with healthy controls. (3) More recent 2026 research reported similar intraepidermal nerve-fiber loss in hEDS and another comparison group, with greater autonomic-fiber loss in the hEDS group. These findings provide a direct alternative or coexisting explanation for sensory and sweating symptoms. (4)

Complex regional pain syndrome

CRPS most commonly develops in a limb after injury or surgery. It may involve continuing pain disproportionate to the inciting event, allodynia or hyperalgesia, swelling, temperature or color asymmetry, abnormal sweating, weakness, limited motion, tremor, and changes in hair, skin, or nails.

CRPS is diagnosed clinically using the Budapest criteria. Thermography or autonomic testing may provide supportive data, but there is no single imaging or laboratory test that confirms the diagnosis. A patient must have the required pattern of symptoms and observed signs, and no other diagnosis should better explain the presentation. (5)

For a broader discussion, see our article on Complex Regional Pain Syndrome.

How the cervical spine may affect sensation and skin temperature

Cervical nerve-root irritation can cause pain, numbness, tingling, or altered sensation in a corresponding region of the shoulder, arm, or hand. The sympathetic nervous system also influences blood-vessel tone and sweating. Irritation within a spinal segment may therefore be accompanied by measurable skin-temperature differences, although the direction and pattern are not consistent enough to identify the painful structure by themselves.

An older study of 71 patients with cervical instability reported abnormal cervical thermal patterns and changes during rehabilitation. (6) Another study found that thermal changes in the arm could accompany cervical disc herniation. (7) These investigations suggest that thermography can document physiologic asymmetry, but both were small, older studies and do not prove that a thermal pattern diagnoses cervical instability or predicts treatment response.

A 2020 study illustrates why thermal findings require caution. Among 224 patients with unilateral spinal radicular pain, most showed cooler skin on the symptomatic side, but a smaller group showed warmer skin. Trauma history, acute pain, and severe radicular pain were associated with hyperthermia. Both hot and cold patterns can occur, and neither pattern identifies the cause without a complete clinical evaluation. (8)

Thermography can be a noninvasive adjunct for documenting temperature differences, but it should not be used alone to diagnose cervical instability, CRPS, neuropathy, or the source of pain. A single reading can be influenced by room temperature, acclimatization, medications, recent activity, vascular disease, and measurement technique.

Symptoms change predictably when they rotate, flex, extend, or hold the neck

Some patients tell us that their symptoms change predictably when they rotate, flex, extend, or hold the neck in a sustained position. They may have a “comfort position” in which burning, pressure, dizziness, or temperature sensations lessen. Reproducible positional symptoms can be an important clinical clue, but they are not proof of instability.

At Caring Medical, we evaluate whether cervical ligament injury, excessive vertebral motion, nerve-root irritation, altered cervical sensorimotor input, or compression of structures near the upper cervical spine may contribute to the patient’s symptom pattern. This evaluation begins with history and physical examination—not imaging alone.

Depending on the presentation, appropriate testing may include neurologic and vascular examinations, standard radiographs, MRI or CT, electrodiagnostic studies, autonomic testing, skin biopsy, laboratory evaluation, or referral to dermatology, neurology, rheumatology, vascular medicine, or pain medicine. Dynamic imaging may be considered in selected patients when symptoms and examination raise a specific question about abnormal motion.

For more information, see our discussions of upper cervical instability and the brainstem, excessive sweating and cervical instability, and digital motion X-ray.

Our research: cervical structure and autonomic pathways

Our newer research explores how cervical structure and instability might affect structures traveling through the neck. The vagus nerves and internal jugular veins lie within the carotid sheaths immediately anterior and lateral to the cervical spine. Sympathetic pathways also course through the neck. We propose that cervical dysstructure or abnormal motion could affect these structures in selected patients and contribute to a broader cluster of neurologic or autonomic symptoms.

In a 2025 hypothesis paper, we described “cervicovagopathy”—a proposed condition in which cervical instability or dysstructure may contribute to vagus nerve dysfunction. This provides an anatomic and physiologic framework for further study, but it does not prove that vagus nerve compression causes allodynia, flushing, or temperature asymmetry. (9)

In 2026, our research group published a retrospective, cross-sectional study of 227 young adults evaluated at an outpatient neck center for persistent brain-based symptoms. The cohort had high rates of abnormal cervical structural findings, reduced internal jugular vein and vagus nerve cross-sectional areas, and elevated optic nerve sheath diameters. The internal jugular vein area at C1 increased significantly while patients lay on a cervical orthotic compared with lying supine.

These findings demonstrate measurable, sometimes position-dependent associations among cervical structure, carotid-sheath contents, and markers proposed to reflect altered cranial outflow. However, the study involved a selected clinic population, lacked a healthy control group, and was not designed to study skin pain or prove causation. It is preliminary observational evidence supporting prospective controlled research. (10)

A separate 2026 retrospective study of 84 patients with hEDS documented frequent co-occurrence of forward-head posture, reduced cervical curve, ligamentous cervical instability, and reduced internal jugular vein and vagus nerve cross-sectional measurements. This does not establish that these cervical findings caused the patients’ skin symptoms. It supports investigating the interaction between connective-tissue laxity, cervical mechanics, and autonomic complaints in future controlled studies. (11)

What are we seeing on digital motion X-ray?

A digital motion X-ray (DMX), or videofluoroscopy, records cervical motion rather than producing only a stationary image. In selected cases, it may help demonstrate translation or abnormal motion that is not visible on a neutral radiograph.

In the image below, the intended finding is hypermobility at C1-C2. Such a finding may be relevant when it correlates with the mechanism of injury, physical examination, and reproducible symptoms. It should not be used to conclude that cervical instability is responsible for every accompanying symptom.

Treatment at the Hauser Neck Center

Treatment depends on the diagnosis. A patient with small-fiber neuropathy, CRPS, vascular disease, a dermatologic disorder, or spinal cord compression requires care directed toward that condition. When examination and imaging support painful cervical ligament injury or instability, treatment may include activity modification, targeted rehabilitation, posture and curve considerations, bracing when appropriate, or regenerative injection treatment.

Our preferred injection treatment for selected ligament injuries is Prolotherapy, which uses an irritant solution—commonly dextrose—with the goal of stimulating a reparative response at injured connective tissue.

In 2015, Hauser, Steilen, and Sprague reported a case series of 21 patients treated with Prolotherapy for chronic neck pain and radiographically identified cervical instability. Patients reported improvements in pain and function at follow-up. Because this was a small, uncontrolled case series based largely on patient-reported outcomes, it cannot determine how Prolotherapy compares with placebo, rehabilitation, surgery, or the natural course of symptoms. It also did not specifically test allodynia or temperature dysregulation. (12)

Our 2014 narrative review discussed the biomechanical role of cervical capsular ligaments and the proposed relationship between ligament laxity, excessive motion, and chronic neck pain. It provides a rationale for further study of ligament-focused treatment but is not a randomized clinical trial. (13)

Summary: finding the right explanation for unusual skin symptoms

Painful skin, hot or cold sensations, color changes, abnormal sweating, numbness, and vibration sensations are real symptoms with a broad differential diagnosis. They should not automatically be labeled as cervical instability. Small-fiber neuropathy, CRPS, radiculopathy, vascular disease, dermatologic illness, metabolic disease, medication effects, and central sensitization may produce similar complaints and must be considered.

For some patients—especially those with substantial neck pain, trauma, connective-tissue laxity, or reproducible positional symptoms—the cervical spine may be one contributing part of a more complex problem. Our clinical work and recent research suggest that cervical mechanics and nearby autonomic and vascular structures deserve further investigation. The present evidence demonstrates associations and plausible mechanisms, not universal causation.

The goal of a careful evaluation is not to force every symptom into one diagnosis. It is to determine which findings are clinically meaningful, identify conditions that require other specialists or urgent care, and decide whether treatment directed at documented cervical injury is reasonable.

If you would like us to review your case, our team uses a multistep process to determine whether your history, symptoms, and imaging suggest that you may be an appropriate candidate for evaluation at the Hauser Neck Center.

References

1 Volcheck MM, Graham SM, Fleming KC, Mohabbat AB, Luedtke CA. Central sensitization, chronic pain, and other symptoms: better understanding, better management. Cleveland Clinic Journal of Medicine. 2023;90(4):245-254. [Google Scholar]

2 Katzberg HD, So Y, Brannagan T, et al. Diagnostic and screening laboratory tests in the assessment of patients with small fiber neuropathy: an evidence-based review—report of the American Association of Neuromuscular and Electrodiagnostic Medicine Small Fiber Neuropathy Task Force. Muscle & Nerve. 2026;73(6):952-960. [Google Scholar]

3 Igharo D, Thiel JC, Rolke R, et al. Skin biopsy reveals generalized small fibre neuropathy in hypermobile Ehlers-Danlos syndromes. European Journal of Neurology. 2023;30(3):719-728. [Google Scholar]

4 Dell’Aversana D, Provitera V, Trinchillo A, et al. Distinct sensory and autonomic involvement in hypermobile Ehlers-Danlos syndrome compared with idiopathic small fiber neuropathy: a multimodal study. Scientific Reports. 2026. Online ahead of print. [Google Scholar]

5 Harden RN, Bruehl S, Perez RSGM, et al. Validation of proposed diagnostic criteria (the “Budapest Criteria”) for complex regional pain syndrome. Pain. 2010;150(2):268-274. [Google Scholar]

6 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;55(5):246-249. [Google Scholar]

7 Zhang HY, Kim YS, Cho YE. Thermatomal changes in cervical disc herniations. Yonsei Medical Journal. 1999;40(5):401-412. [Google Scholar]

8 Park TY, Son S, Lim TG, Jeong T. Hyperthermia associated with spinal radiculopathy as determined by digital infrared thermographic imaging. Medicine (Baltimore). 2020;99(11). [Google Scholar]

9 Hauser RA, Matias D, Rawlings BR. Cervicovagopathy: ligamentous cervical instability and dysstructure as a potential etiology for vagus nerve dysfunction in the cause of human symptoms and diseases. Frontiers in Neurology. 2025;16:1572863. [Google Scholar]

10 Hauser RA, Griffiths M, Watterson A, Matias D, Steilen C, Rawlings BR. Brain-based symptoms reported in young adults evaluated for cervical spine etiology: a retrospective, cross-sectional clinical study with preliminary data on over 200 patients. Frontiers in Neurology. 2026;17:1749266. [Google Scholar]

11 Hauser RA, Griffiths M, Watterson A, Matias D, Rawlings BR. Characterizing initial cervical spine and neurovascular findings in 84 consecutive patients with hypermobile Ehlers-Danlos syndrome: a retrospective study. Journal of Clinical Medicine. 2026;15(6):2212. [Google Scholar]

12 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):155-166. [Google Scholar]

13 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]