Differential diagnosis and treatment of cervical vertigo
I. Concept.
Vertigo is a spatial illusion of the body, which is the result of spinning, swaying and tilting of external objects and oneself, and can be accompanied by nystagmus, balance disorder, nausea, vomiting, cold sweat, pallor and other vegetative symptoms. It is a kind of motor hallucination, which is often referred to as “spinning”; the etiology is caused by vestibular nervous system lesions.
2. Pseudovertigo (dizziness): dizziness, dizziness, heavy head, light head and unstable feeling of shaking, no illusion of motion such as rotation and shaking of visual objects, no eye fluttering, not caused by vestibular nervous system lesions. Kong Qingquan, Department of Orthopedics and Spine Surgery, West China Hospital
3, dizziness: often manifested as a persistent dullness of the mind without a sense of clarity, mostly accompanied by head weight, dullness, headache, forgetfulness, weakness and other neurological or chronic somatic disease symptoms, aggravated by exertion. It is caused by neurasthenia or chronic somatic diseases, etc.
4, syncope: sudden, transient loss of consciousness, accompanied by fainting. Consciousness is restored within a short time after fainting, and there is usually no eye tremor. It is caused by multiple causes of transient low blood pressure, slow heartbeat, and transient cerebral ischemia.
Mechanisms of vertigo;
It is caused by lesions of the vestibular nervous system.
1. The vestibular nervous system includes: the end receptors of the vagus in the inner ear, the jugular crest of the semicircular canal, the ellipsoid bursa, the balloon spot, the vestibular nerve and the vestibular nucleus.
2.The vestibular nervous system has six pathways: vestibulo-ocular pathway, vestibulospinal pathway, vestibular reticular pathway, vestibular cerebellar pathway, vestibular vegetative pathway and vestibular cortical pathway. The bilateral vestibular nervous system is coordinated and synchronized. If a lesion occurs on one side, it can cause vertigo.
Vestibulo-vegetative pathway, vestibular reticular pathway: vestibular nerve → reticular formation → vasomotor center of medullary reticular formation + dorsal nucleus of vagus nerve → causes vertigo, nausea, vomiting, cold sweat, pale face and other vegetative symptoms.
Vestibular oculomotor pathway: vestibular nucleus → medial longitudinal tract of brainstem → each oculomotor nucleus connection: oculomotor tremor appears in case of lesion.
Vestibulocerebellar pathway: vestibular nucleus → vestibulocerebellar tract → anterior horn of the spinal cord: ataxia, balance instability and muscle tone changes.
Vestibulospinal pathway: vestibular nucleus → lateral vestibulospinal tract → anterior horn of spinal cord
The main clinical manifestations include one or more of the following
1. Self-rotation, swaying, tilting and other errors
2. Nystagmus
3, nausea, vomiting, cold sweat, pale face and other vegetative symptoms
4. Unstable balance and ataxia
5.Types of vertigo
(1) True vertigo (peripheral, vestibular peripheral): mostly accompanied by obvious nausea, vomiting and other vegetative symptoms; short duration, tens of seconds to several hours, rarely more than days or weeks. Mostly seen in vestibular peripheral lesions .
(2) Pseudovertigo (central, cerebral): symptoms are milder, accompanied by obscure vegetative symptoms; the duration is longer, up to several months. Most often seen in brain and eye disorders
IV. Vestibular function test.
The vestibular nervous system is an important system for spatial orientation and balance maintenance, and its abnormal function is one of the important causes of vertigo. The examination and evaluation of vestibular function is an important tool to diagnose vertigo and evaluate the effect of treatment.
1. Vestibular nystagmography (ENG) or video nystagmography is commonly used to check vestibular function by objectively quantifying the vestibular ocular reflex (VOR), but it mainly reflects the horizontal semicircular canal function, therefore, it is limited to reflect vestibular function only by VOR. Therefore, only the VOR reflects the vestibular function with certain limitations.
2, postural stability test: including Romberg test, reinforced Romberg test (also known as Mann test), single-leg upright test, etc. are also still widely used in clinical practice, for these clinical tests, in addition to determining whether the patient has tilted, there are timing methods, that is, recording the specific time the patient maintains uprightness in these balance tests.
(1) When the human body is in an upright static posture, although it is maintained immobile, the body actually keeps swaying around its own balance point, which is beyond the control of self-consciousness, and is called physiological postural swaying.
(2) The maintenance of postural balance relies on the synergy of vestibular, visual and proprioceptive systems. The visual system stabilizes the visual environment; the proprioceptive system provides information on muscle tone and the relationship between various body parts by receptors such as muscle shuttles, joints, and tendons to maintain joint position and muscle tone; the vestibular system senses static head position and linear acceleration by the balloon and ellipsoidal bursa, and angular acceleration by the potbelly crest. Various information through the complex integration mechanism of the central system, through the vestibular spinal cord lateral tract innervate the trunk limb muscles, called vestibulospinal reflex (VSR); and the vestibular spinal cord medial tract downstream fibers to affect the vagal tension impulses to the cervical muscles, called vestibulocervical reflex. The final eye position maintains clear vision and regulates related skeletal muscle tone to maintain head position and correct posture.
The postural stability test is a test of the functional state of the human postural control system, which is a system of three inputs and one output. The three sensory inputs are vision, proprioception and vestibular sensation, and the output is body sway.
V. The causes of vertigo include
1.Otogenic (Meniere, vestibular neuritis, etc.)
2.Ocular origin
3, intracranial tumor, traumatic brain injury, cerebellar lesions (cerebellar stroke, thrombosis), insufficient blood supply to the vertebral basilar artery (TIA)
4.Multiple sclerosis, cervical spine disorders, cervical spine whipping injury
5, motion sickness (motion sickness)
6, endocrine disorders (hypothyroidism)
7.Other
Cervical vertigo
1.Definition: Cervical vertigo refers to the syndrome caused by cervical spondylosis, mainly vertigo and sympathetic symptoms. Cervical spondylosis refers to cervical disc degeneration itself and its secondary changes that stimulate or compress the adjacent tissues and cause various symptoms and signs.
2. Mechanism: There are many theories about the pathogenesis of cervical vertigo at home and abroad, including four types
A. The theory of insufficient blood supply of vertebral artery
B. Sympathetic nerve theory
C. Cervical medullary injury theory
D. proprioceptive theory
3. Diagnostic criteria.
(1) Symptoms of episodic vertebrobasilar insufficiency associated with head and neck activity: such as headache, dizziness, visual disturbance, tinnitus, and positive neck turn test.
(2) Neck symptoms: muscle spasm, stiffness and pain in the neck, limitation of movement, pressure pain, sometimes numbness and pain in the upper limbs, positive sign of pull test.
(3) With symptoms of autonomic dysfunction: nausea, vomiting, sweating, chest tightness, palpitations.
(4) Severe cases may present with episodic sudden collapse, which usually occurs when the head is tilted back, lateral flexion or rotation. There is usually no loss of consciousness at the time of collapse, which is relieved by a change in position and with the reset of the neck position.
(5) Concomitant symptoms: A series of signs and symptoms of brainstem ischemia may be present simultaneously.
(6) X-ray manifestations: asymmetry on both sides of the atlanto-axial and atlanto-dental joints, skewed vertebral spine, vertebral hyperplasia, narrowing of the vertebral space, deformation of the hook vertebral joint, calcification of ligaments, and formation of bone bridges are common.
VII. Comprehensive clinical examination of vertigo patients
If necessary, hearing examination, vestibular function examination, fundus examination, cerebrospinal fluid examination, cranial or cervical spine X-ray, electrocardiogram, electroencephalogram and cranial CT scan should be done to find out the cause of vertigo.
Physical examination: Before physical examination, the focus should be on the medical history. When the history is unclear, special attention should be paid to the patient’s vital signs, cardiovascular system, ear (including the outer, middle or inner ear) and neurological examination.
(1) Blood pressure: Observe for upright hypotension.
(ii) Note whether the patient has hyperventilation or nervousness, which is usually associated with psychogenic dizziness.
③Pay attention to whether the patient has arrhythmias and any murmur in the neck.
④Detailed hearing examination should be done to note the presence of otitis media and whether the hearing is normal.
⑤ Do a detailed neurological examination.
⑥When benign paroxysmal vertigo is suspected, the Dix-Hallpick maneuver can be performed by having the subject lie on his back with his head over the edge of the bed, keeping it 30° below the bed level and turning it 30° to 45° to the left or right, then having the subject sit up and ask him to turn his head to the side and look at his forehead. The test taker holds the subject’s head with both hands, pushes back and quickly changes the subject from a sitting position to the above mentioned position. There is a resting period, sometimes up to 5-6 s, before the subject responds, and if the response is positive, the subject will become dizzy, close his eyes, scream, and try to sit up. The subject should be reassured and remain in this position. The subject will also experience rotational nystagmus (which may last 2-10 s), with the nystagmus rotating in the direction of the lower ear. The symptoms may gradually decrease afterwards. However, when the subject sits up, dizziness and nystagmus (in the opposite direction) may also occur. Repeated examinations may cause fatigue.
(7) Dizziness and light-headedness after prolonged standing may be associated with cardiovascular disease.
(8) Visual acuity examination.
Laboratory tests
① Head imaging: MRI is better than computed tomography if needed. It can help to rule out if the patient has lesions in the anterior cranial fossa (MRI is more sensitive to small lesions in the anterior cranial fossa).
(ii) Biochemical tests: Hypoglycemia, hypothyroidism, anemia, renal failure and vitamin B12 deficiency may be the cause of dizziness.
Electrooculography can help determine the presence of vestibular lesions, especially in older patients.
Doppler ultrasonography of the basilar system of the neck is useful to rule out subclavian artery piracy syndrome, and it can also help us to distinguish whether vascular or osteoarthritic disease is the cause of neck dizziness.
⑤Electrocardiogram should be considered in case of arrhythmia.
(6) Cardiac ultrasound can be done if cardiovascular system problems cause insufficient cardiac output.
VIII. Treatment of vertigo
1.Treatment of the cause of vertigo: After the cause of vertigo is clearly identified, treatment should be given to the cause of vertigo, which is the root of the problem.
2.Antihistamines, such as multiplying dizziness; Mineran, H1 receptor agonist, H3 receptor antagonist; anticholinergic drugs, such as 65422; nerve regulating agents, such as glutathione, aspergillus militaris tablets, etc. can be given.
3.Improve brain and inner ear microcirculation drugs, such as: soda solution intravenous drip, oral Cipro, Minestrone, Niacin and Ducoxib.
4.If necessary, diuretics can be used, such as dihydrocoumarol, mannitol, etc., to treat vagal edema.
5, physical exercise therapy: long time repeated stimulation, training can make the vestibular response to enhance the adaptability, such as: dancers, pilots training methods can make some vertigo patients’ symptoms or balance disorders get better.