The diagnosis of cervicogenic dizziness is characterized by vertigo and balance disorders associated with the pathological morphology of the cervical spine in patients with neck pain. For orthopedic surgeons and vestibular rehabilitation specialists, diagnosing and treating adult patients with cervical spine dysfunction coupled with complaints of dizziness can be a challenge. The purpose of this article is to review the incidence, prevalence, and historical background and to present the pathophysiology underlying cervicogenic dizziness.
In addition, we propose diagnostic criteria for cervicogenic dizziness, assessment and treatment of vertigo. The diagnosis of cervicogenic dizziness depends on the symptoms of vertigo and balance disorders associated with neck pain, as well as the exclusion of other vestibular system disorders based on the patient’s medical history, physical examination and examination of the vestibular system. When cervicogenic dizziness is correctly diagnosed, the disease can be successfully treated with a combination of both manual therapy and vestibular rehabilitation. Based on the potentially serious etiology of the dizziness, the physical therapist must learn how to obtain a complete history in order to make clinical decisions about the appropriate placement of the patient or to refer the patient to another health professional.
Definition of cervicogenic dizziness: “nonspecific alterations in spatial positioning and balance disorders due to abnormal cervical afferent activity.” Because cervicogenic dizziness is not caused by vestibular dysfunction, true vertigo rarely occurs.
The most common cause of cervicogenic dizziness is hyperextension injury and is common in patients with cervical spine arthritis, cervical disc herniation, and head trauma. Ataxia, unstable gait and postural imbalance associated with neck pain, limited range of motion in the neck or headache are seen in the complaints of these patients.
Once diagnosed and appropriately treated, cervicogenic dizziness can reduce its symptoms, thereby improving the patient’s function.
Dizziness symptoms accompanied by cervical spine dysfunction are usually due to hyperflexion and extension of the cervical spine during a motor vehicle accident (whiplash injury). The primary symptom following a whiplash injury is neck pain, with reports of neck pain in as many as 62% to 100% of the patients studied in the initial evaluation. The other most common symptom was headache (primarily in the occipital region), with 66-87% of patients presenting with symptoms. Although dizziness, vertigo, and balance disorders are infrequent in the emergency room, they are present in 20-58% of patients with closed head trauma or whiplash-like injuries.
The differential diagnosis of patients with vertigo with cervical dysfunction should include vestibular system disorders. For example, vertigo caused by a neck injury may be caused by a vestibular system disorder, brain injury, or cervical spine.
Abnormalities include defects in smooth eye tracking movements, normal or diminished caloric vestibular reflexes, spontaneous positional nystagmus, and postural control deficits.
Cervicogenic dizziness may be caused by cervical whipple-like injury, other cervical spine dysfunction, or cervical muscle spasm.
Brown proposed that the neck has an important influence on balance function, and related experimental animal studies have been conducted for 150 years. Studies have shown that there is a clear association between the dorsal roots of the cervical spinal cord and vestibular neurons, with cervical receptors (such as proprioceptors and joint receptors) playing a role in hand-eye coordination, perceived balance, and postural adjustment. Because there is such a close relationship between cervical receptors and balance function, it is easier to understand that a neck injury or pathological change in the neck may cause vertigo or balance disorders.
Diagnostic criteria
Cervicogenic dizziness is a diagnosis of exclusion (i.e., the diagnosis is usually based on the exclusion of other competing diagnoses, such as vestibular disorders or central nervous system disorders). Cervicogenic dizziness is usually identified with a nystagmus test during neck torsion, or a head fixation body rotation maneuver. This test requires the patient to rotate the body below the head without moving the head, the theory being that the proprioceptors in the neck are stimulated while the inner ear structures remain stationary. If this test is positive, nystagmus can also be elicited. However, there is no confirmation that this test is specific for cervicogenic dizziness.
The lack of a clear specific test makes the diagnosis of cervicogenic dizziness more difficult. Therefore, the diagnosis of cervicogenic dizziness is.
(1) A close temporal correlation between neck pain and vertigo symptoms, including onset and precipitating events.
(2) History of previous neck injury or pathological changes in the cervical spine.
(3) Exclusion of other causes of vertigo. Taking a detailed history and performing a complete physical examination is quite important to exclude other etiologies of vertigo.
Conclusion
The diagnosis of cervicogenic dizziness is characterized by vertigo and balance disorders related to the pathological morphology of the cervical spine in patients with neck pain. Given the number and quality of currently published clinical trials, the literature on this topic is limited. The diagnosis of cervicogenic dizziness depends on the symptoms of vertigo and balance disorders associated with neck pain, as well as on the basis of the patient’s history, physical examination and examination of the vestibular system to exclude other vestibular system disorders. When cervicogenic dizziness is correctly diagnosed, we believe that the disease can be successfully cured with a combination of manipulative therapy and vestibular rehabilitation.
Manipulative therapy is recommended for the treatment of cervicogenic dizziness because it reduces spasm of the musculature of the neck and pain at the trigger point. The patient’s neck pain and balance problems can be improved with manual therapy, and vestibular rehabilitation helps improve the patient’s symptoms of vertigo. The patient’s home exercise program can include cervical mobility training and balance training, which can help improve the patient’s symptoms.
Based on our clinical experience, we recommend that patients with cervicogenic dizziness receive manipulation to reduce the susceptibility of cervical proprioceptors due to muscle spasm and trigger points, and balance training to improve vestibular and proprioceptive afferent activity during balance maintenance. In addition we recommended that the patient perform ocular gymnastics to improve the function of the vestibular oculomotor reflex. In order to adequately address all of the patient’s symptoms, it is clearly necessary for the patient to be treated by a rehabilitation specialist, an orthopedic specialist and a vestibular specialist together.