Can neck problems cause vertigo? Cervical Vertigo and Cervicogenic Dizziness
Ross Hauser, MD | Caring Medical Regenerative Medicine Clinics, Fort Myers, Florida
David N. Woznica, MD | Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
Danielle R. Steilen-Matias, MMS, PA-C | Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
In this article we discuss:
- The diagnosis and treatment of cervical vertigo and chronic dizziness associated with neck movement.
- We present research on when neck pain causes dizziness and possible conservative treatment options.
- We will also include research and evaluation on regenerative medicine injections including Prolotherapy.
Neck pain and dizzy spells
If you are reading this article it is likely that you have seen many health care providers with problems of neck pain and dizziness. It is also very likely that you are still looking for an answer, any answer to why your problem persists.
You have likely been asked the key questions numerous times:
- How often does the dizziness occur?
- Is there anything that triggers the dizziness, such as suddenly head movements?
- How long does the dizziness last?
- Have you ever fallen because of the dizziness?
- Do you get nausea?
- Do you get dizzy when you look up? Look down? All around?
You may also be tired of answering these same questions because no one has seemed to help you.
So why did I have all these lab tests?
Often a patient will tell us that they had a myriad of lab tests looking for the source of their frequent, occasional, or most of the time dizziness. At the end of these tests the patient, sitting in our clinic will tell us, “after all the tests, I was still dizzy.”
The controversy surrounding a diagnosis of cervical vertigo and why no one has been able to help you
The controversy surrounding a diagnosis of cervical vertigo stems from confusion and comparison with other symptoms related to whiplash related injuries and inner ear disorders. Below we will review studies, which details in-depth, screening procedures that exclude possible causes of dizziness.
Just like your medical journey, the research journey of doctors trying to understand the cause of your dizziness is also a long one.
A remarkable statement in the 1998 paper may be your answer to your dizziness – why has no one discussed this with you?
In 1998, just over 20 years ago, the connection to cervical neck pain and dizziness was not only not understood, but it was also rarely studied.
Listen to what German researchers wrote back then in the European Spine Journal. (1) This research is important today as it is often used as a starting point of the cervical neck/dizziness connection debate: In this research, treating cervical neck instability made vertigo go away.
The research paper begins:
“To our knowledge, quantitative studies on the significance of disorders of the upper cervical spine as a cause of vertigo or impaired hearing do not exist.”
To test their hypothesis that upper cervical disorders caused dizziness, the German doctors examined the cervical spines of 50 patients who presented with symptoms of dizziness. Prior to the orthopaedic examination, causes of vertigo relating to the field of ENT and neurology had been ruled out.
- The patients were treated with physical therapy and were available for 3 months of follow-up.
- Thirty-one patients, group A, were diagnosed with dysfunctions of the upper cervical spine.
- In group A dysfunctions were found at level:
- C1 in 14 cases,
- at level C2 in 6 cases and
- at level C3 in 4 cases.
- In seven cases more than one upper cervical spine motion segment was affected. Dysfunctions were treated and resolved with mobilizing and manipulative techniques of manual medicine.
- In group A dysfunctions were found at level:
- Nineteen patients, group B, did not show signs of dysfunction.
- Regardless of cervical spine findings seen at the initial visit, group A and B patients received intensive outpatient physical therapy.
- At the final 3-month follow-up,
- 24 patients of group A (77.4%) reported an improvement of their chief symptom and 5 patients were completely free of vertigo.
- Improvement of vertigo was recorded in 5 group B patients (26.3%); however, nobody in group B was free of symptoms.
The researchers concluded that “functional examination of motion segments of the upper cervical spine is important in diagnosing and treating vertigo, because a non-resolved dysfunction of the upper cervical spine was a common cause of long-lasting dizziness in our population.”
“Functional examination of motion segments of the upper cervical spine is important in diagnosing and treating vertigo.”
Why do we find this one sentence so remarkable? Because this one line may be the answer for many of you reading this article. Let’s explain.
The researchers suggest that you must examine the motion segments of the upper neck because it is the unresolved (non treated) vertebral segments that are causing the problems. In our 26+ years of service in treating cervical neck disorders, we have found that many patients who come through our doors do not have an accurate diagnosis or assessment of their situation.
As you can see in the video below, DMX is a motion picture of the bones while a person is moving. It is a dynamic diagnostic tool, versus a static one. The scan is produced in real-time, while the person is moving his/her neck. Pain typically occurs with motion. By being able to see the bones in motion, DMX picks up the abnormal or excessive motion whereas MRI, CT scan and static x-rays do not.
So why is the connection of cervical neck dysfunction and dizziness still controversial?
In this research from 2000, we can demonstrate that coming up on two decades later, the problem of Cervical Vertigo and Cervicogenic Dizziness still presents problems for health providers in identifying and treating these problems and as you know FIRST HAND, problems that cannot be identified in patients ARE OFTEN DISMISSED.
Here is the 2000 research (2) from the Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, appearing in the Journal of Orthopaedic & Sports Physical Therapy:
- The diagnosis of cervicogenic dizziness can be made if the patients suffer from dizziness and dysequilibrium that appears to come from neck pain caused by cervical disc disease and degenerative arthritis.
- The treatment of an individual presenting with cervical spine dysfunction and associated dizziness complaints can be a challenging experience to orthopedic and vestibular (inner ear and brain) rehabilitation specialists.
Dizziness, headaches and neck pain come together. Is it a pinched nerve?
Halfway between 2000 and today, a 2009 study appeared in the Annals of Physical and Rehabilitation Medicine. (3) Here medical university researchers in Tunisia wanted to examine balance disorders in chronic neck pain patients suffering from vertigo and balance instability.
Ninety-two patients having suffered from chronic neck pain for at least 3 months were enrolled in the present study. Patients with a history of neck trauma or ear, nose and throat, ophthalmological or neurological abnormalities were excluded so as to be able to focus on cervical instability as the cause.
The patients were divided into three groups:
- a group of 32 patients with neck pain and vertigo (Group 1)
- a group of 30 patients with chronic neck pain but no vertigo (Group 2)
- and a group of 30 healthy controls.
Findings in the groups
- Osteoarthritis was found in 75% of the group of 32 patients with neck pain and vertigo (Group 1).
- Osteoarthritis was found in 70% of the subjects with chronic neck pain but no vertigo (Group 2).
- Neck-related headaches were more frequently in patients with neck pain and vertigo (65.5% versus 40%)
- Restricted neck movement was more frequent in patients with neck pain and vertigo.
- Balance abnormalities were found more frequently in patients with neck pain and vertigo.
The doctors also noted that the study evidenced abnormal static and dynamic balance parameters in chronic neck pain patients with vertigo. These disorders can be explained by impaired cervical proprioception (a disruption in nerve signaling in the body’s unconscious or involuntary movements – pressure on the nerves) and neck movement limitations. Headaches were also more frequent in these patients.
So here we have one of many studies that are now connecting the problems of dizziness, imbalance, and headache to problems of cervical neck instability as attested to by pinched nerves and restricted range of motion in the neck.
In other words: The neck is trying to restrict its own movement in much the same way a cervical collar works to prevent pain and symptoms of unstable vertebrae.
The connection between dizziness, cervical instability and degenerative disc disease in our aging population – is dizziness a problem of degenerative disc disease in the neck?
A second 2009 study by often cited researcher Setsuko Morinaka M.D, of the Department of Otorhinolaryngology, Kobe Japanpost Hospital (4) examined patients over 66 and younger than 65.
In his study, Dr. Morinaka analyzed the frequency of musculoskeletal diseases in patients with cervical vertigo, as well as the relations of neck tenderness, psychiatric symptoms, and autonomic abnormalities (other symptoms beyond dizziness including irregular heartbeat after exercise, blood pressure drop, fainting, et al.) with pain and age.
One hundred and seventy-six patients with cervical vertigo were analyzed.
- Musculoskeletal diseases were very common (present in 86%).
- Older patients reporting pain:
- neck tenderness and orthostatic hypotension (blood pressure drop) were significantly more frequent than in the 65 or younger group.
- Dr. Morinaka concluded musculoskeletal diseases (degenerative disc disease in the cervical spine) played a role in cervical vertigo in patients older than 66.
Finding the source of dizziness is a matter of exclusion. It is a process of elimination
In September 2017, doctors at Duke University published research in the Archives of physiotherapy. (5) Here is the introductory paragraph:
“Cervicogenic dizziness is a clinical syndrome characterized by the presence of dizziness and associated neck pain. There are no definitive clinical or laboratory tests for Cervicogenic dizziness and therefore Cervicogenic dizziness is a diagnosis of exclusion.
It can be difficult for healthcare professionals to differentiate Cervicogenic dizziness from other vestibular, medical and vascular disorders that cause dizziness, requiring a high level of skill and a thorough understanding of the proper tests and measures to accurately rule in or rule out competing diagnoses.
Consequently, the purpose of this paper is to provide a systematic diagnostic approach to enable healthcare providers to accurately diagnose Cervicogenic dizziness. . . and provide steps to exclude diagnoses that can present with symptoms similar to those seen in Cervicogenic dizziness, including central and peripheral vestibular disorders, vestibular migraine, labyrinthine concussion, cervical arterial dysfunction, and whiplash associated disorder.”
The Duke researchers were very comprehensive. Here are some of the tests they reviewed for patients in chronic condition and brief reasoning behind them:
- Alar Ligament Test – Manual examination – to assess the integrity of the alar ligaments and upper cervical stability
- Sharp Purser Test – Manual examination – to assess the integrity of the transverse ligament/
upper cervical spine instability
- Cervical Facet Joint Dysfunction is tested by Manual Spinal Examination. Providers here are looking for pain generators in the facet joints.
- Cervical Facet Joint Mediated Pain – Palpation for Segmental Tenderness. Providers here are looking into spasms.
- Cervical Arterial Dysfunction (CAD) – CAD testing involves neck rotation and extension with a stationary body, causing decreased blood flow in the vertebrobasilar arteries with rotation alone and internal carotid arteries with combined extension and rotation. CAD testing requires cervical extension and rotation passive range of motion that is within normal limits.
- Head Thrust Test – a manual examination in which the movement of the patient’s eyes are monitored as they are fixed on the health care provider giving the test.
- Cervical Neck Torsion Test – a manual examination in which the movement of the patient’s eyes are monitored as they follow a mobile object side to side
- Cervical Relocation Test – this is a test that is often reviewed in the literature and is subject matter for a latter independent article on our site. Simply this test gauges the patient’s ability to return their head to a “neutral” position after movement.
- Dix-Hallpike to test for benign paroxysmal positional vertigo and episodes of dizziness and a sensation of spinning with certain head movements. benign paroxysmal positional vertigo.
Let’s point out again that the Duke team suggests that diagnosis is difficult and is sort of like peeling an onion, there are many layers that need to be peeled away, Cervicogenic dizziness is a diagnosis of exclusion.
In research published by Caring Medical and Rehabilitation Services: Chronic Neck Pain: Making the Connection Between Capsular Ligament Laxity and Cervical Instability lead by Danielle Steilen-Matias.(6) Our team also suggested that the diagnosis of chronic neck pain due to cervical instability is particularly challenging. In most cases, diagnostic tools for detecting cervical instability have been inconsistent and lack specificity and are therefore inadequate. A better understanding of the pathogenesis of cervical instability may better enable practitioners to recognize and treat the condition more effectively. For instance, when cervical instability is related to injury of soft tissue (eg, ligaments) alone and not fracture, the treatment modality should be one that stimulates the involved soft tissue to regenerate and repair itself.
Degenerative disc disease in the cervical spine, cervical spondylosis: Damaged cervical ligaments as a cause of dizziness – the loss of blood flow to the brain
Is Vertigo is associated with advanced degenerative changes in patients with cervical spondylosis? That is the title of a 2011 paper published in the medical journal Clinical Rheumatology (7) by doctors at Mansoura University in Egypt.
Here are the learning points of their research.
- Vascular risk factors for stroke, dementia, dizziness, loss of balance are thought to be caused by a blood clot or from narrowing of the arteries that supply the brainstem with blood.
- These risk factors are common findings in elderly
- Cervical spondylosis (Degenerative cervical disc disease) is also common in this age group BUT ITS CAUSE as vertigo is sometimes considered as a myth.
In this research, the doctors investigated the effect of cervical spondylosis on blood flow velocity in vertebral arteries during cervical rotation and to identify the possible association of vertigo with the decreased blood flow velocity during head rotation in these patients.
- A significantly higher prevalence of cervical spondylosis was found among patients complaining of vertigo than those in a group of patients with cervical spondylosis without vertigo group (71.4% vs. 32.9%, respectively). COMMENT: More degeneration more dizziness).
- Cervical spondylosis patients with vertigo had statistically significant lower blood flow parameters (into the brain) with contralateral head rotation in the left and right vertebral arteries than cervical spondylosis patients without vertigo and controls.
- The decreased vertebral artery blood flow that occurs with cervical rotation can be observed in patients with cervical spondylosis.
- In patients with high-grade cervical spondylosis with more extensive osteophyte formation, the decreased blood flow becomes prominent and symptomatic presenting as vertigo.
Dizziness and pain may be a call from your ligaments asking you for help
The cervical ligaments are strong bands of tissues that attach one cervical vertebra to another. In this role, the cervical ligaments become the primary stabilizers of the neck. When the cervical ligaments are healthy, your head movement is healthy, pain free and non-damaging. When the ligaments are suffering from degenerative wear and tear or excessive looseness or laxity that prevents the ligaments from holding the vertebrae together, the ligaments lose their ability to control proper motion of your head. The head begins to move in a destructive, degenerative manner on top of your neck. When this occurs the cervical neck ligaments cry out and you feel pain and you can develop the symptoms of cervical vertigo and dizziness.
- Most of the nerve endings that trigger neck pain are located in the ligaments.
- When a patient comes into our clinics with a cervical neck pain and symptoms already outlined in this article, we are attuned to the fact that the actual pain is stemming from the nerve endings in the ligaments.
- So we listen to what the neck is telling us:
- There is a problem with stretched out or damaged ligaments.
In the journal, Medical Hypothesis,(8) researchers and clinicians made a connection that the loss of flexibility of the posterior longitudinal ligament in the neck, was a compounding factor to cervical dizziness.
Here are the learning points of this study and what the doctors were looking for in the treatment of cervical disorders, such as vertigo, headache, and dizziness.
- Some patients were helped by undergoing routine anterior cervical decompression and fusion plus posterior longitudinal ligament (PLL) resection. The removal of the ligament in the neck region.
- If the ligaments are so important, why remove any part of a ligament? Because in this study, the doctors hypothesized that the sympathetic nerve innervations (nerve signals or messages) in the cervical posterior longitudinal ligament may be the cause of vertigo.
So what does this mean to you?
- In fusion surgery, doctors recommend the removal of the posterior longitudinal ligament because if you leave it behind, it can cause dizziness post fusion. How? Because it is still damaged and still sending pain signals that disrupt the nerves and cause dizziness.
- If you have a fusion, the rods and screws replace the ligament and ligaments of the neck as the main neck stabilizer.
But what if fusion is not want you want? Can this ligament be repaired to not send pain signals as cause dizziness?
- The answer is for many people, yes.
Cervical Vertigo Treatment options
There are many treatment options for the management of chronic neck pain and cervical vertigo. That you are reading this article is an indication that you may have tried many of these treatments with limited or no result.
These treatments may have included:
- Cortisone injection.
- Cortisone injection is typically given in patient complaints of neck pain when inflammation is suspected. It is usually not offered as a treatment directly for cervical dizziness. There is very little research to support cortisone injections in vertigo patients.
- Nerve blocks to assist with dizziness and neck pain.
- A May 2018 study from the Department of Neurosurgery, University of Ulm, Germany was published in the journal Pain Physician.(7). Here we should point out that this study was found to be favorable to nerve blocks as a short-term help.
- One-hundred seventy-eight patients were included in this study.
- One-hundred eleven patients (62.4%) experienced a significant improvement of vertigo.
- In 47 patients (26.4%), no information about the vertigo was available at follow-up; these patients were assumed to have no improvement (worst-case scenario). Altogether 67 patients (37.6%) had a negative result.
- The median relief of the vertigo was 2 months.
- Also note: Nine patients with a whiplash injury in their medical history were also tested. They experienced a lower success rate.
- A May 2018 study from the Department of Neurosurgery, University of Ulm, Germany was published in the journal Pain Physician.(7). Here we should point out that this study was found to be favorable to nerve blocks as a short-term help.
The bottom line is that 2/3rd’s of patients experienced dizziness relief for two months with a nerve block.
The hunt for muscle pain, muscle spasms, and weakened neck muscles as the cause of dizziness
- Chiropractic manipulation and physical therapy
- For the purpose of this article, we will address both of these treatment modalities as in essence they both seek the same goal. Treating cervical vertigo by putting the cervical spine back into proper anatomical alignment and both may use intermittent traction and/or cervical collars.
- We should point out here that the goal of our treatments with regenerative medicine injections of dextrose and possibly blood platelets taken from the patient as the same. Putting the cervical spine back where it belongs. We may use intermittent traction and/or cervical collars. However, our treatments differ significantly as we seek more of a curative effect in a short window of treatments and not prolonged care.
- In chiropractic manipulation and physical therapy, there is an expectation the chiropractic will manipulate the cervical spine back into place and that physical therapy will strengthen the muscles of the cervical neck region to provide support.
- These treatments typically do not provide a long term answer as we will see below because they must rely on strong cervical ligaments and strong cervical tendons. If you are reading this article we would have to guess that your cervical ligaments and cervical tendons are weak and strength compromised.
Treatments surrounding blood flow
- In the study above, we had a discussion about improving blood flow into the brain. There are theories surrounding how blood flow, or lack of it, to the brain causes dizziness.
- Acupuncture has been studied as a remedy for increasing blood flow.
- In the Chinese medical publication Zhongguo Zhen Jiu (9) (Chinese acupuncture & moxibustion (moxibustion is the burning dried mugwort on particular points on the body)), a Chinese team of researchers compared different methods of acupuncture to observe the differences in the clinical therapeutic effects on cervical spondylosis and cervical vertigo symptoms.
- The researchers observed the peak systolic blood flow velocity of the vertebral artery and the basilar artery, cervical vertigo symptoms and functional assessment scales during the testing.
- They found after 12 treatments over 2 weeks of modified bilateral acupuncture effectively regulates the blood supply of the vertebral basilar artery and improves the cerebral circulation in short term results.
- We should point out here that the goal of our treatments with regenerative medicine injections of dextrose and possibly blood platelets taken from the patient as the same. How we increase blood flow to the brain has some similiarity to acupuncture, however, our treatments differ significantly as we seek more of a curative effect. We find that in some patients blood flow to the brain can be restored on a more long-term basis by restoring the cervical spine to its natural anatomical postition and keeping it in place by strengthening the supportive cervical ligaments. See below.
The bottom line on this research is that these treatments may have a good short-term benefit, however, long-term is more typically the patient goal. This is achieved by addressing the stabilizing of the cervical spine and healing ligament injuries.
Regenerative Medicine Injections | Caring Cervical Realignment Therapy
Prolotherapy is an injection technique that stimulates repair of unstable, torn, or damaged ligaments. When the cervical ligaments are unstable, they allow for excessive movement of the vertabrae, which can then restrict blood flow to the brain, pinch on nerves (a pinched nerve causing vertigo), and cause other symptoms associated with joint instability, including cervical instability.
Treating cervical ligaments – published research from Caring Medical
Above, we discussed our 2014 research headed by Danielle R. Steilen-Matias, PA-C, We also noted that when the cervical ligaments are injured, they become stretched out and loose. This allows for excessive abnormal movement of the cervical vertebrae.
- In the upper cervical spine (C0-C2), this can cause symptoms such as nerve irritation and vertebrobasilar insufficiency with associated vertigo, tinnitus, dizziness, facial pain, arm pain, and migraine headaches.
Treating and stabilizing the cervical ligaments can alleviate the problems of cervical vertigo by preventing excessive abnormal vertebrae movement, the development or advancing of cervical osteoarthritis, and the myriad of problematic symptoms they cause.
An introduction to the treatment is best observed in the video below. A patients with cervical neck instability is treated with Prolotherapy using a Digital Motion X-ray machine.
Caring Cervical Realignment Therapy (CCRT) was developed by Ross Hauser, M.D. after decades of treating patients with neck disorders, including cervical instability and degenerative disc disease
As we discussed in reviewing the research above, our goal is to provide long-term solutions to the problems and symptoms of chronic neck pain and instability such as headaches, dizziness, vertigo, lightheadedness, imbalance and a host of other symptoms attributed to neck injuries.
Caring Cervical Realignment Therapy combines individualized protocols to objectively document spinal instability, strengthen weakened ligament tissue that connect vertebrae, and re-establish normal biomechanics and encourage the restoration of lordosis. This is our treatment method of moving towards putting a patient’s cervical spine back into place.
For many years, Dr. Hauser and the Prolotherapists at Caring Medical have had tremendous success in treating patients who were suffering from chronic neck pain. Though most of the cases were already failures in the traditional pain management system, Dr. Hauser’s team was able to help the majority of these tough pain cases.
Through extensive research and patient data analysis, it became clear that in order for patients to obtain long-term cures (approximately 90% relief of symptoms) the re-establishment of some lordosis, (the natural cervical spinal curve) in their cervical spine is necessary. Once spinal stabilization was achieved with Prolotherapy and the normalization of cervical forces by restoring some lordosis, lasting relief of symptoms was highly probable.
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.
A February 2017 study in the European Journal of Physical and Rehabilitation Medicine (10) investigated the immediate and long-term effects of a 1-year multimodal (multi-treatment) program, with the addition of cervical lordosis restoration and anterior head translation (Forward Head Posture) correction, on the severity of dizziness, disability, cervicocephalic kinesthetic sensibility (proper head orientation), and cervical pain in patients with cervicogenic dizziness.
Patients were divided into two groups, both groups received therapy and exercise programs, one group received a cervical neck traction device. At 10 weeks, the group analysis showed equal improvements in dizziness outcome measures, pain intensity, and head repositioning accuracy, the severity of dizziness, dizziness frequency, and neck pain.
At 1-year follow-up, the between-group analysis identified statistically significant differences for all of the measured variables including anterior head translation, cervical lordosis, the severity of dizziness, dizziness frequency, and neck pain, indicating greater improvements in the traction group. The results lead the researchers to conclude that “appropriate physical therapy rehabilitation for cervicogenic dizziness should include structural rehabilitation (traction) of the cervical spine (lordosis and head posture correction), as it might to lead greater and longer-lasting improved function.
If this article has helped you understand the problems of cervical vertigo and you would like to explore Prolotherapy as a possible remedy, ask for help and information from our specialists
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