Cervical Vertigo | Cervicogenic Dizziness
Ross Hauser, MD
In this article Ross Hauser, MD discusses the diagnosis and treatment of cervical vertigo and chronic dizziness associated with neck movement. Here we present research on when neck pain causes dizziness and headaches and treatment options.
Controversy surrounding a diagnosis of cervical vertigo
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 a new study, which details in depth, screening procedures that exclude possible causes of dizziness.
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.
This is the 2000 research 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 suffers 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 orthopaedic and vestibular (inner ear and brain) rehabilitation specialists.(1)
- Note: In addition to dizziness, patients with vestibular disorders can also experience vision problems, and problems related to disequilibrium and dizziness such as nausea. This may lead to diagnosis of an inner ear disorder.
Half way between 2000 and today, a 2009 study appeared in the Annals of physical and rehabilitation medicine from research doctors in Tunisa. They 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 the cervical instability as 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 headache was 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 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 signalling in the body’s unconscious or involuntary movements – pressure on the nerves) and neck movement limitations. Headache was also more frequent in these patients.(2)
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. (The neck is trying to restrict its own movement in much a same way a cervical collar works to prevent pain and symptoms of unstable vertebrae).
The connection between dizziness and degenerative disc disease in our aging population
A second 2009 study by often cited researcher Setsuko Morinaka M.D, of the Department of Otorhinolaryngology, Kobe Japanpost Hospital 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.(3)
Diagnostic testing for neck instability in looking for a dizziness cause
In September 2017, doctors at Duke University published research in the Archives of physiotherapy. (4) 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 a 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.(5) 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: 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 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.(6)
Vertigo treatment with Prolotherapy
Prolotherapy is an injection technique that stimulates repair of unstable, torn, or damaged ligaments. When ligaments are unstable, they allow for excessive movement of the bones, 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. Prolotherapy to the weakened, injured or lax ligaments involved is offered to stabilize these ligaments and connective tissue. This is described in the videos below:
Danielle Steilen-Matias, PA-C | Katherine Worsnick, PA-C | Ross Hauser, MD | David Woznica, MD
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