Cervical Vertigo and Cervicogenic Dizziness – Neck pain and dizziness
Ross Hauser, MD
For many people with neck pain and symptoms of vertigo and dizziness, common sense and their own awareness of their daily quality of life suggest to them that the many symptoms they have must be interconnected. There can be no other explanation. Yet for many of these people, their symptoms are divided up and distributed among specialists to be given individual focus. Digestive problems and nutritional disorders are sent to the gastroenterologist, cardiovascular-like problems are sent to the heart specialist, balance and dizziness issues are sent to the ENT and then possibly a neurologist. Rarely do these specialists talk to each other, rarely is there a “master plan” or grand unifying attempt to get these patients into a treatment program that addresses them as a whole.
It is for this reason that we will often get an email asking “Can a pinched nerve in the neck cause vertigo?” This email may be coming from someone who has battled many symptoms for many years and it is through their own research or an appointment with an enlightened physical therapist, chiropractor, or doctor that the idea that a pinched nerve in their neck may be their “ground zero” for the cause of many of their symptoms. This may describe you, you may be on this article because you are searching for support material to validate or dismiss this idea of a pinched nerve in the neck causing among other things, cervical vertigo, dizziness, and balance issues.
What are then going to discuss in this article?
- The diagnosis and treatment of cervical vertigo and chronic dizziness are associated with neck movement. Or more commonly for some, a diagnosis of Benign Paroxysmal Positional Vertigo and worsening of its symptoms.
- We present research on when neck pain causes dizziness and possible conservative treatment options.
Neck pain and dizzy spells
Like many of the problems we treat at our center, the problems of vertigo and dizziness are usually not problems that are isolated. The person who suffers from these disorders will usually, almost always suffer from many problems, and they will all be related to each other. Here are some examples:
When I turn my head I get dizzy.
- I have dizziness and ear pain and fullness. It happens when I look down or move my head forward to get a closer look at something. On other occasions, when I turn my head, I get a sudden dizzy spell. Sometimes after the dizziness goes away I get a long-lasting headache.
After the car accident.
- I was involved in a whiplash-type car accident. Not only do I get dizzy spells but I get heart palpitations and my blood pressure feels like it is going through the roof. (See our article Prolotherapy treatments for chronic neck pain after an automobile accident | Case review of three patients.)
There was no “event,” that triggered this.
- I have been dealing with my dizziness and other problems for a few years now. There was no “event,” that triggered this, I have always been active in sports and have taken my fair share of knocks to the head. I had been to the chiropractor a couple of times to get my neck and back cracked. I found these treatments helped me with the chronic nagging pain I often get from a job that requires me to sit all day.
No one wants to believe me because an MRI of my head doesn’t show anything.
- I have had problems with dizziness and balance for almost ten years now. No one wants to believe me because an MRI of my head doesn’t show anything. When I complained about neck pain, another MRI “did not show enough,” to justify surgery. I do have migraines and not hearing problems, but problems with noise sensitivity. Since I have an “ear problem,” now I am being sent for vestibular rehabilitation to focus on my ear as being the cause of the dizziness. I told my doctor that is not what I think it is. They think I am crazy.
I am arguing with my doctor that he is recommending me to get surgery that I do not need
- I have been going from one specialist to the next. It started with dizziness and then it became dizziness with tinnitus. Then it became dizziness, tinnitus, worse hearing, and now vision problems. The thing is in all the MRIs I have been getting, my neck one shows herniated discs from C3-C7 and some problems at C1-C2. My doctor is telling me that he thinks all my problems will go away with a cervical fusion. I think it will make my problems worse.
Now it is more than just dizziness – new symptoms
- One day I was at home getting ready to leave for work when suddenly everything started to spin. I had simply bent over to grab my bag. I fell over. I was able to call for help and I was taken to the emergency room by ambulance. Scans of my head revealed no abnormalities or problems. The attending physician thought this to be a temporary problem. I was given a prescription for Meclizine and as soon as my dizziness cleared. I was sent home.
Over the next few months and years, I had occasional dizziness, sometimes severe enough to send me for emergency care and an emergency room x-ray of my head and neck. All the doctors could tell me was that they suspected some type of post-traumatic concussion syndrome or whiplash-related disorders. At the last emergency room visit, it was recommended to me that I get “more aggressive,” with seeking out what was wrong with me.
I now began the more aggressive course of action that started with physical therapy. At PT, my therapist recommended that I go back to the doctor and get a referral for an ENT specialist, a neurologist, and a cardiovascular specialist. Let’s “rule out what is not wrong with you.”
Doctors too are looking for answers, including the relationship between neck pain and dizziness.
Above we read about people and their stories. Their stories contain fear and confusion and sometimes conflicting ideas with their doctors as to what is wrong with them. Doctors too are looking for answers, including the relationship between neck pain and dizziness.
Let’s look at an April 2020 study from the Department of Otorhinolaryngology and Head and Neck Surgery, Haukeland University Hospital, in Norway. The paper was published in the journal Physiotherapy Research International. (1)
In this paper, the researchers wanted to know if dizziness severity and degree differed between patients who only suffered from dizziness and patients who suffered from dizziness and neck pain. In other words, how did neck pain contribute to dizziness as compared to people with dizziness without neck pain?
Here are the summary learning points:
- The patients in this study with dizziness and neck pain were recruited from an ear-nose-throat department and a spine clinic.
- They were divided into three groups:
- patients with dizziness only (100 patients),
- patients with dizziness as their primary complaint and additional neck pain (138 patients) and finally,
- patients with neck pain as their primary complaint accompanied by additional dizziness (55 patients).
- The patients filled in questionnaires regarding their symptom quality, time-course, triggers of dizziness, and the Vertigo Symptom Scale Short Form. The physical examination included Cervical Range of Motion, American College of Rheumatology (ACR) Tender Points, Cervical Pressure Pain Thresholds, and Global Physiotherapy Examination 52-Flexibility (this test, considered controversial by some, measures Posture, Respiration, Movement, Muscle function, and stretchy skin characteristics.)
- Both neck pain groups were more likely to have a gradual onset of dizziness symptoms, more light-headedness, visual disturbances, autonomic/anxiety symptoms, decreased cervical range of motion, decreased neck and shoulder flexibility, and increased number of ACR tender points compared with patients with dizziness alone.
- The group having dizziness as their primary complaint and also reporting neck pain had the highest symptom severity and tended to report rocking vertigo and increased neck tenderness.
- The group with neck pain as their primary complaint was more likely to report headaches.
Conclusion: Neck pain is associated with certain dizziness characteristics, increased severity of dizziness, and increased physical impairment when compared with dizzy patients without neck pain.
So what can one do with information like this? Simply explore cervical spine instability as the cause of headache if neck pain is present.
You have likely been asked the key questions numerous times: How often do you get dizzy? Do you get dizzy when you look up? Look down? All around?
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 sudden head movements?
- How long does the dizziness last?
- Have you ever fallen because of dizziness?
- Do you get nausea, do you vomit?
- 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.
Your doctor may have offered you a diagnosis of benign paroxysmal positional vertigo or BPPV with a somewhat reassuring tone that your dizziness, loss of balance, sometimes nausea, sometimes vomiting is something that can be managed, may go away on itself, and this will be more of a nuisance than anything. That is why it is called “Benign.”
For some people, it may end at just that, a nuisance. These are usually not the people that come into our offices. We see the people whose symptoms have progressed to include double vision or sight problems and other challenges. These are related below.
“After all the lab tests, I was still dizzy”
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 started looking for other doctors to help them. When they are sitting in our clinic they will often tell us, “after all the tests, I was still dizzy and worse, there seemed to be no plan to help me.”
Further, 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 detail in-depth, screening procedures that exclude possible causes of dizziness.
The controversy surrounding a diagnosis of cervical vertigo and why no one has been able to help you
Sometimes a patient will tell us that they went to a specialist and they were told that there is no such thing as cervical vertigo. Pursuing this diagnosis was not helpful. Above we examined one study that tried to make a connection between neck pain and dizziness. Let’s look at another.
A June 2019 study (2) offered these statements:
- “The existence of cervical vertigo is still a question under debate. The basic hypothesis of the disease is that the abnormalities of the neck cause dizziness.”
- “The most common symptoms of cervical vertigo are cervical pain or discomfort, imbalance or dizziness, and limitation of cervical movement”
- “When diagnosing cervical vertigo, we always face the following difficulties: there is no diagnostic method specific to the disease, pathognomic (obvious symptoms that point to cervical vertigo) clinical elements are unavailable, no clear therapeutic recommendation exists. The diagnosis of the disease requires the exclusion of alternatives, but the possibility of the existence of psychogenic (a sense of hypochondria) vertigo causes further difficulties for the clinicians. Regarding the treatment, the combination of manual therapies and vestibular rehabilitation seems to be the most effective. “
It should be pointed out that despite the confusion and the controversy, manual therapies, treatments that address the cervical spine, and physical therapy seem to be the best answers.
“Cervical Vertigo–Reality or Fiction?” Two studies 23 years apart, ask the same exact question.
The title of this 2019 research study is: “Cervical Vertigo–Reality or Fiction?”
In 1996, 23 years earlier, a research study (3) also had the same exact title: “Cervical Vertigo–Reality or Fiction?” The answer to the question, in 23 years, had still not been sufficiently answered.
In this 1996 study, Professor Thomas Brandt of the Department of Neurology at the University of Munich offered this assessment:
“Neck afferents (nerves) not only assist the coordination of eye, head, and body, but they also affect spatial orientation and control of posture. This implies that stimulation of, or lesions (damage) in, these structures can produce cervical vertigo. . . Neurological, vestibular, and psychosomatic disorders must first be excluded before the dizziness and unsteadiness in cervical pain syndromes can be attributed to a cervical origin. To date, however, the syndrome remains only a theoretical possibility awaiting a reliable clinical test to demonstrate its independent existence.”
Just like your medical journey, the research journey of doctors trying to understand the cause of your dizziness and the origins of cervical vertigo is also a long one.
An introduction to our treatment philosophy with Ross Hauser, MD.
We know that you have probably done extensive research on the internet for the treatment of your dizziness and balance issues and you have read many, many articles. Before we move into the clinical and research observations, many new studies from within the last year, let’s have Dr. Hauser present a short summary.
Summary learning points of this video
- There are a lot of people who have unexplained dizziness, balance problems, and other symptoms.
- We find that in a lot of these cases, the person is suffering from cervical instability especially upper cervical instability.
- The sensory nerves that tell the brain what’s going on, moment to moment, in regard to heart rate and blood pressure are carried by the vagus nerve and the glossopharyngeal nerve. If the messages that these sensory nerves need to deliver to the brain are blocked or impaired, the heart symptoms described can develop.
At 1:00 of the video, Dr. Hauser refers to this image to describe the impact of compression of the vagus nerve and the glossopharyngeal nerve on heart rate and blood pressure
This image describes the impact of compression of the vagus nerve and the glossopharyngeal nerve on heart rate and blood pressure
- Many of the vagus nerve sensory fibers that regulate blood pressure are in the carotid artery and the glossopharyngeal nerve fibers. The nerves are part of a network that carries impulses to the brain that tells the brain what is going on with heart rate and blood pressure moment to moment.
- For example, if your blood pressure is going low you need this network to alert the adrenaline system or the sympathetic nervous system to regulate your blood pressure.
At 2:00 of the video – When a person has cervical instability especially upper cervical instability
- When a person has cervical instability especially upper cervical instability it can impact the vagus nerve and the glossopharyngeal nerve. The vagus nerve and the glossopharyngeal nerve run in the carotid sheath, the connective tissue that encapsulates the vascular compartments of the neck. This runs right along the anterior body of the cervical vertebrae especially C1-C2.
At 2:20 of the video, the close proximity of the vagus nerve, the glossopharyngeal nerve, and the spinal accessory nerve to the C1-C2 vertebrae is demonstrated with this image
This image displays the close proximity of the vagus nerve, the glossopharyngeal nerve, and the spinal accessory nerve to the C1-C2 vertebrae. This proximity makes compression of these nerves common in cervical spine instability.
- When a person has cervical instability those nerves can get compressed and they can get stretched. Some of the nerve impulses can be blocked. When this happens you could get tachycardia that comes and goes. If you move your head in a certain direction all of a sudden you could get tachycardia or lightheartedness because your brain isn’t getting the right sensory input because there are problems in the nerve conduction of the vagus nerve and the glossopharyngeal nerve.
Brief introduction of Prolotherapy as a treatment for this problem
At 3:00 of the video: We document the cervical instability by scanning with a Digital Motion X-Ray (explained below) and when instability in the C1-C2 region is found, we then tighten the stretched-out ligaments with Prolotherapy. These injections are typically given once a month. It causes a tightening of the ligaments and once the cervical spine is made stable again the nerve sensors through the vagus nerve and the glossopharyngeal nerve start working correctly and the arrhythmias go away.
Back in 1998, the connection between cervical neck pain and dizziness was not only not understood, but it was rarely studied. Doctors began to study the cervical spine as a cause of dizziness.
When we started our regenerative medicine practice back in 1993, one of the phenomena we studied in neck pain patients was, why did they have dizziness. So for us, treating the neck for problems of dizziness, balance, healing problems, is not a new phenomenon. But at the time was certainly something debated. Does neck instability cause dizziness?
The connection to cervical neck pain and dizziness was not only not understood, but it was also rarely studied.
In 1998, just over 22 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. (4) 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:
- 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.”
People with neck pain have worse dizziness, people with dizziness have worse neck pain. This should be studied
Let’s look at an April 2020 paper which examined the connection between neck pain and dizziness. This paper was published in the journal Physiotherapy Research International (5) and comes to us from the Norwegian National Advisory Unit on Vestibular Disorders, Department of Otorhinolaryngology, and Head and Neck Surgery, Haukeland University Hospital. Here are the learning points. Remember these are doctors educating other doctors on the relationship between dizziness and neck pain.
- “Many patients suffer from concurrent neck pain and dizziness. The aim of this study was to describe the clinical symptoms and physical findings in patients with concurrent neck pain and dizziness and to examine whether they differ from patients with dizziness alone.”
- Consecutive patients with dizziness and neck pain were recruited from an ear-nose-throat department and a spine clinic.
- They were divided into three groups:
- One hundred patients with dizziness only
- One hundred and thirty-eight patients with dizziness as their primary complaint and additional neck pain and finally,
- Fifty-five patients with neck pain as their primary complaint accompanied by additional dizziness
- The patients filled in questionnaires regarding their symptom quality, time-course, triggers of dizziness, and the Vertigo Symptom Scale Short Form. The physical examination included Cervical Range of Motion, American College of Rheumatology (ACR) Tender Points, Cervical Pressure Pain Thresholds, and Global Physiotherapy Examination 52-Flexibility. (Many of you have probably had these tests and if you look at the name of the tests they describe what the doctors are looking for: Range of motion, tender points, pain scales.)
- Both neck pain groups were more likely to have a gradual onset of dizziness symptoms, more light-headedness, visual disturbances, autonomic/anxiety symptoms, decreased cervical range of motion, decreased neck and shoulder flexibility, and increased number of ACR (American College of Rheumatology) tender points compared with patients with dizziness alone.
- The group having dizziness as their primary complaint and also reporting neck pain had the highest symptom severity and tended to report rocking vertigo and increased neck tenderness. The group with neck pain as their primary complaint was more likely to report headaches.
Conclusion: “Neck pain is associated with certain dizziness characteristics, increased severity of dizziness and increased physical impairment when compared with dizzy patients without neck pain.”
“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 abnormal or excessive motion whereas MRI, CT scan, and static x-rays do not.
“Let’s rule out what is not wrong with you.”
Above we told the story of a patient who had many symptoms. The aggressive plan to help her was to rule out what is not wrong with her.
Finding the source of dizziness is a matter of exclusion. It is a process of elimination – The Tests
In September 2017, doctors at Duke University published research in the Archives of Physiotherapy. (6) 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.”
Here are some of the tests they reviewed for patients cervical vertigo and cervicogenic dizziness and brief reasoning behind them:
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 is 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 later 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: Chronic Neck Pain: Making the Connection Between Capsular Ligament Laxity and Cervical Instability lead by Danielle Steilen-Matias.(7) 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.
As we were ruling out possible causes for my dizziness, more and more symptoms developed
If you are like the people with a similar story to that above, your medical journey may have continued like this:
- The dizziness was becoming more frequent and longer in duration. All along I had neck pain, this is why I was going to the chiropractor, but now I was having more symptoms. I started having jaw pain and was told I had TMJ. Along with the more frequent dizziness cam more frequent headaches. They did not develop into migraines although I was warned they could. Mostly I was told I had tension headaches. I also started to have a ringing in my ears.
At some point, my physical therapist confirmed with my doctors, and finally, something began to make sense. Were all these problems in my neck? Did I have cervical neck instability?
Another story: Here is a patient on video. Patricia’s story is one we commonly see. The results she achieved may not be typical for everyone. Complex cases typically require more than one treatment. Not everyone has successful outcomes. Here is the transcript to read:
My problems began after I fell. I tripped over a curb and fell. After the fall I started having problems with dizziness, being unstable, my ears were ringing. I started getting a lot of head pain, muscle spasms, and pain between my eyes.
I’ve now had one dose of Prolotherapy, my symptoms are so much better. Prior to the prolotherapy, I was sort of a prisoner in my own house because of my dizziness and lack of balance, and the pain that I was in.
I was pretty much a couch surfer and in bed and I had to cancel a lot of activities that I had signed up for I wasn’t able to take my dog for a walk. My life really changed. I had Prolotherapy 3 weeks ago and pretty much all of my symptoms have been alleviated and I’m very thankful for that because I don’t have to stay home all the time because I’m in pain and the prolotherapy from Dr. Hauser has been very very helpful.
The Prolotherapy was given in my c-spine about 3 weeks ago and my symptoms, my energy level, everything is really improved since then.
Since posting this video we were asked questions about this type of Prolotherapy treatment for these symptoms
- Which levels of the cervical spine were treated?
- The whole cervical spine typically needs to be treated in these cases of dizziness, loss of balance, tinnitus, because almost always there is instability at C1-C2. It is a critical area for these hearing and visual functions, and so a lot of these neurological symptoms are typically related to the upper cervical area needing treatment.
- In the video, the patient says “dose,” what are the dose or number of injections?
- The number of shots varies depending on the case, and where the spinal attachments need to be treated, approximately 30-50 injections during a single treatment can be expected. The average number of treatments needed is usually 3-8 treatments, approximately 1 month apart. This would be a more realistic expectation.
So why is the connection between 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 (8) 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. (9) 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 (10) 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.
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 (11) 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 a myth.
In this research, the doctors investigated the effect of cervical spondylosis on the 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 significantly 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 the 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 cervical spine 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,(12) 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?
- With 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 what you want? Can this ligament be repaired to not send pain signals and cause dizziness? The answer is for many people, yes.
Brain fog, breathing and swallowing difficulty, dizziness, tinnitus
Brad’s story will resonate with many of you. He will describe the same symptoms and combination of symptoms that many of our patients suffer with when they first see us.
Brad’s story is unique, it may not be typical of the patients we see. Brad with treated with Prolotherapy injections and neck curve correction techniques. Not everyone will achieve these results as the results of treatment will vary.
We specifically want to highlight his case because he has some unusual strange sensations in his ear and breathing difficulties because of his problem with his contracting diaphragm.
Patient symptom list:
- Ringing in the ears and a sensation in his ears of hot wax. He also reported it was as if spiders were crawling in his ears.
- Severe dizziness. The patient describes that he would be in a car and then out of nowhere he would get dizziness and it would feel like the car was flipping end over end.
- Brain fog
- Contracting diaphragm
- Patient’s description at 1:32: “I would just be sitting or standing there, doesn’t matter which, and all of a sudden I couldn’t breathe. Finally, I would take a big gasp of air, and finally, I would be able to breathe.
- Swallowing difficulties: The saliva in his mouth would build up and it was as if he was drowning. This would cause panic attacks.
- The patient also reported when he turned his head to the right, he would lose control of all his muscles and he would “drop.”
The patient had these symptoms for 3 – 4 months. It started with a fall off a ladder. Symptoms did not develop for months
- The patient fell off a ladder from a height of 12 feet. He hit a sink and his head snapped backed
- His symptoms started to develop four months after the fall
Because of the nature of his injury and ligament damage in his cervical spine, the patient underwent eight prolotherapy treatment sessions. Here is his description:
- After the eight sessions, the patient reports “almost everything is gone.” A slight ringing in the ears remains but is diminishing.
- The patient did not realize how bad his brain fog was. On his first visit, he had difficulty filling out paperwork. On his last visit he realized filling out the paperwork was “super easy.” It was then he realized the extent of his brain fog.
- The diaphragm problems went away after the 4th or 5th visit along with the swallowing difficulties.
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 results.
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. (13). 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 in 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 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.
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 (14) (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 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 is the same. How we increase blood flow to the brain has some similarities 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 position and keeping it in place by strengthening the supportive cervical ligaments. See below.
The bottom line of 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.
Looking at a muscular cause for this is confusing to researchers because there does not appear to be consistent answers. What did the physical therapists find?
As like yourself, many people with neck problems and systems of dizziness, after extensive testing, are often sent for exercise or physical therapy to strengthen the neck. For some, there must be a muscle component whether it is atrophy or thickening/swelling.
In July 2020 in the Journal of Physical Therapy Science (15), a group of physical therapists looked at the muscles of their patients who suffered from cervical vertigo. They compared these patient’s muscles with the cervical spine muscles of people who did not have cervical issues or cervical vertigo. What were they looking for and what did they find? Let’s let them answer.
“Cervical vertigo as a common complaint is associated with some musculoskeletal disorders. However, to date, ultrasonographical parameters of cervical muscles in patients with cervical vertigo have not been investigated. (Guidelines to help other health care professionals zero in on the muscles as a possible cause of the patient’s dizziness.) (The researcher’s study) was conducted to investigate the size of cervical muscles in patients with cervical vertigo compared to healthy controls.”
Thicknesses of cervical flexor (If you have been going to physical therapy, these names should be familiar to you: the longus colli, longus capitus, rectus capitus, and longus cervicus muscles) and extensor muscles (the deep muscles, the semispinalis cervicis, and multifidus) were evaluated through ultrasonography and results were compared between the patients and healthy controls.
Results showed that the thickness of the longus Colli muscle (the muscle that helps you look down) was significantly different between the patients and healthy controls. According to the findings of the study, the size of longus colli muscle is likely to be associated with the etiology of cervical vertigo.”
What does this mean?
The researchers noted: “As the cervical instability may cause abnormal afferent signals (messages between the brain and spinal cord) to the central nervous system and consequently vertigo feeling, the higher thickness of Longus Colli may be a compensatory mechanism in the patients with cervical vertigo.”
In other words, the muscle is thicker because it is trying to do a job it is not intended to do, the job of the cervical ligaments and keep the vertebrae in place.
In this image, we see a depiction of a muscle spasm in the back of the neck. Why the muscle spasms, or why it gets thicker is a response to cervical spine ligament injury. The muscle is trying to hold things together to prevent the nerve or cervical arteries from being impinged.
These researchers did cite another study that you may find of interest because it is something we see in many patients. The inability of the head to return to a normal posture position following certain movements because the vertebrae are not where they should be. They are not lined up correctly. This would lead to muscle thickening. This study comes from the Journal of Rehabilitation Medicine. (16) It deals with whiplash victims and dizziness.
“Dizziness and/or unsteadiness are common symptoms of chronic whiplash-associated disorders. This study aimed to report the characteristics of these symptoms and determine whether there was any relationship to cervical joint position error. Joint position error, the accuracy to return to the natural head posture following extension and rotation, was measured in 102 subjects with persistent whiplash-associated disorder and 44 control subjects. . . The results (of this study) indicated that subjects with whiplash-associated disorders had significantly greater joint position errors than control subjects.”
The researchers noted:
“Within the whiplash group, those with dizziness had greater joint position errors than those without dizziness following (head) rotation (to the right or left) and a higher neck pain index (score). . . Cervical mechanoreceptor dysfunction (simply the sensors in the neck that transmits information based on touch, pressure, stretching, and motion) is a likely cause of dizziness in whiplash-associated disorder.”
So what do we have here and what does it mean to you? Something is pressing on your nerves and arteries causing a dizzy situation.
Possibly that injury such as whiplash or degenerative disease or diseases possibly hEDS (Ehlers-Danlos Syndrome) has caused cervical spine instability. A thicker Longus Colli muscle may offer the clue necessary to help isolate cervical spine instability as opposed to other causes for your dizziness. The thicker muscle may indicate that the cervical spine ligaments are weak, your cervical vertebra is out of place, and something is pressing on your nerves and arteries causing a dizzy situation.
Regenerative Medicine Injections | Caring Cervical Realignment Therapy
Prolotherapy is an injection technique that stimulates the repair of unstable, torn, or damaged ligaments. When the cervical ligaments are unstable, they allow for excessive movement of the vertebrae, 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.
Non-surgical treatment – Cervical Spine Stability and Restoring Lordosis -Making a case for regeneration and repair of the spinal ligaments
Above we spoke about the vertebrae not being in the right place and this is caused by cervical spine ligament laxity or damage. The muscles of the neck may then spasm and thicken as a result of the muscle trying to do a job it was really not intended to do. Hold the cervical vertebrae in place. We also spoke about people who suffer dizziness when they move their heads a certain way.
Look at these images below. When the patient looks down, there is a 6 mm (about 2/10ths of an inch) space between the C1-C2. There is room for some vessels and nerves to get through. When the same patient looks up, 0 mm or NO SPACE. Everything in between gets pinched.
In this section, we are going to talk about the realistic non-surgical options for the treatment of cervical spine instability and compressed cervical arteries and their related symptoms.
Digital motion X-ray showing C1-C2
This is another of our videos, it gives a clearer view of C1-C2 instability in another patient.
Here are some brief explanatory notes. The video is only 1 minute in length.
- 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. How much space there is between the C1 and C2 on certain neck movements.
- 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.
Treating cervical ligaments – published research from Caring Medical
Caring Medical has published dozens of papers on Prolotherapy injections as a treatment in difficult to treat musculoskeletal disorders including problems created by neck instability. Above, we discussed our 2014 research headed by Danielle R. Steilen-Matias, PA-C, (7) 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.
Actual Prolotherapy treatment
This video jumps to 1:05 where the actual treatment begins.
This patient is having C1-C2 areas treated. Ross Hauser, MD, is giving the injections.
Caring Cervical Realignment Therapy (CCRT)
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 connects 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.
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.
Treatments for cervical spine realignment – restoring the curve without surgery
When we start looking at the most recent research papers surrounding treatments for cervical spine realignment, we often find ourselves reading a lot of new research on cervical spine surgery procedures. Non-surgical treatments for cervical spine realignment are, for the most part, fewer and far between. There is a rush in medicine to surgically correct cervical spine abnormalities including the loss of the natural cervical spine curve. In our office, we rush more to non-surgical applications to help the patient with cervical spine instability and abnormal curvature of the spine. But what if you were told surgery should be strongly considered?
A February 2017 study in the European Journal of Physical and Rehabilitation Medicine (17) 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 lead greater and longer-lasting improved function.
In this video, Ross Hauser, MD, and Brian Hutcheson, DC describe a case of restoring cervical spinal curve and alleviation of symptoms.
Summary and contact us. Can we help you? How do I know if I’m a good candidate?
We hope you found this article informative and it helped answer many of the questions you may have surrounding Cervical Vertigo and Cervicogenic Dizziness. Just like you, we want to make sure you are a good fit for our clinic prior to accepting your case. While our mission is to help as many people with chronic pain as we can, sadly, we cannot accept all cases. We have a multi-step process so our team can really get to know you and your case to ensure that it sounds like you are a good fit for the unique testing and treatments that we offer here.
Brian Hutcheson, DC | Ross Hauser, MD | Danielle Steilen-Matias, PA-C
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This article was updated July 6, 2021