Cervical Vertigo

Timothy C. Hain, MD

Last updated: 10/2012

What is Cervical Vertigo?

Vertigo or dizziness occasionally accompanies a neck injury. The precise incidence is controversial. Nevertheless, cervical vertigo is matter of considerable concern because of the high litigation-related costs of whiplash injuries.

When cervical vertigo is diagnosed, the usual symptoms are dizziness associated with neck movement. There should be no hearing symptoms or findings but there may be ear pain (otalgia).Yacovino (2012) has recently reviewed this topic.

What Causes Cervical Vertigo?

Physiologically, there are two well recognized potential causes of cervical vertigo:

  1. 1. Vascular compression. The vertebral arteries in the neck can be compressed by the vertebrae (which they traverse), or other structures. Arthritis, surgery or chiropractic manipulation are all possible causes. Common causes of vertebral dissection include major trauma (car accidents, blast-induced injuries, etc.) sports injuries, and chiropractic manipulation (Gottesman et al., 2012). Consequently, we recommend against chiropractic treatment of the neck that includes “snapping” or forceful manipulation.
  2. Abnormal sensory input from neck proprioceptors. Proprioceptors are nerves that sense movement and vibration. Sensory information from the neck is combined with vestibular and visual information to determine the position of the head on the neck, and space. Sensation from the neck may be unreliable or absent. This mechanism was investigated by DeJong and DeJong who injected local anesthetics into their own necks. Such injections caused unsteadiness and minor amounts of dizziness. It is possible that some individuals are more sensitive than others, and also that neck sensation affects other causes of vertigo (see below).

The neck interacts with other types of vertigo. Neck input may be used as sensory input to assist in stabilizing vision. This can be easily demonstrated by eliciting ocular nystagmus from vibration of the neck in individuals who are otherwise well compensated.

How is Cervical Vertigo Diagnosed?

Diagnosis is generally uncertain and frustrating. First, other entities need to be ruled out including inner ear disease, central vertigo, psychogenic vertigo (often including malingering when there are legal issues), and medical causes of vertigo. There should be no hearing symptoms or findings, but there may be ear pain (otalgia), as part of the ear is supplied by sensory afferents from the high cervical nerve roots. As cervical vertigo often follows a head injury; in this situation, the various causes of post-traumatic vertigo shoud be considered.

If cervical vertigo still seems likely after excluding reasonable alternatives, one next needs to look for positive confirmation. The “gold standard test” for vertebral artery disease is vertebral angiography. Because this is a risky procedure by itself, often it is decided not to proceed to this step. Ordinary magnetic resonance angiography (MRA) and vertebral doppler procedures are rarely abnormal, and sometimes are used as a screening procedure to decide whether vertebral angiography is necessary. A magnetic resonance imaging (MRI) scan of the neck and flexion-extension X-ray films of the neck are suggested in all cases.

Many patients who have vertigo in the context of neck disease have a BPPV type nystagmus on positional testing. This suggests that the neck afferents may interact strongly with vestibular inputs derived from the posterior canal.

How is Cervical Vertigo Treated?

Cervical vertigo is difficult to treat. If the underlying cause is identified, treating this may result in improvement of the vertigo. Treatment strategies are unconfirmed by large trials becasue this condition is rare. Patients with cervical vertigo that is thought to be due to abnormal proprioception may benefit from pain medication applied topically or orally (Michels 2007).

Case Example

An otherwise healthy man was involved in a severe auto accident. On awakening, he was dizzy and he developed severe neck pain over ensuing days. Evaluation in the hospital revealed a BPPV type positional nystagmus, which responded to physical treatment. He had persistent unsteadiness. After discharge from the hospital, on shaking his head forcefully to shake off some raindrops, he suddenly lost vision in one half of his visual field. Vision returned, but at that point a diagnosis of vertebral basilar compression was made. He continues to have unusual visual symptoms, attributed to poor circulation to the back of the brain.

References

  • Gottesman RF, Sharma P, Tobinson KA, Arnan M, Tsui M, et al. 2012. Clinical characteristics of symptomatic vertebral artery dissection: a systematic review. The neurologist 18:245-54.
  • Jongkees, L. B. (1969). “Cervical vertigo.” Laryngoscope 79(8): 1473-84.
  • Michels T, Lehmann N, Moebus S. Cervical vertigo-cervical pain: an alternative efficient treatment. J Comp Alt Med 13(5):513-18, 2007.
  • Norre, M. E. (1986). “Neurophysiology of vertigo with special reference to cervical vertigo. A review.” Acta Belgica – Medica Physica 9(3): 183-94.
  • Norre, M. E. (1987). “Cervical vertigo. Diagnostic and semiological problem with special emphasis upon “cervical nystagmus”.” Acta Oto-Rhino-Laryngologica Belgica 41(3): 436-52.
  • Yacovino DA. 2012 Cerrvical vertigo: myths, facts, and scientific evidence. Neurologia

 

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