Cervical vertigo is the most common clinical syndrome. It is not a specific disease name, but refers to a kind of central vertigo caused by insufficient blood supply to the vertebral artery due to certain causes, and the so-called “certain causes” are most common in cervical spondylosis, so in general, “cervical vertigo” is used to refer to vertigo caused by cervical spondylosis. With the aging of the population, the incidence of this disorder is increasing, and it has received widespread attention from the medical community at home and abroad.
What is vertigo? Vertigo is a general term for dizziness and lightheadedness, and is characterized by blurred vision, blurred vision and darkness, and dizziness is characterized by spinning vision or inability to stand up as if the sky is spinning. Today, I will mainly discuss cervicogenic vertigo.
Chapter 1: Pathogenesis and causes of cervicogenic vertigo
Section I. Relationship between cervicogenic vertigo and vertebral artery
1. Mechanically compressed pathogenic mechanism
1.1 Cervical vertebral osteophytes and displacement
This kind of change is caused by the involvement of the 2nd segment of vertebral artery.
With the growth of age, the bone density gradually decreases and the function of vertebral body gradually degenerates. The main manifestation is the appearance of hyperplasia, or bone spurs, on the anterior and posterior edges of the vertebral body and the hook and cone joints. Bone spurs are very common in middle-aged and elderly people, and gradually aggravate with age, where the hook-cone joint is the main site of bone spur formation in cervical spondylosis, especially the 4th and 5th cervical vertebrae are the most serious. When the intervertebral disc degenerates and thins, the hook vertebra is close to the superior vertebral body, at which time the stress at the hook prominence approximates the contact point and becomes a stress concentration area, and its stress level is higher than any part of the vertebral body, which easily causes degenerative hyperplasia and stimulation of the vertebral artery or sympathetic nerve, causing vertigo.
When hyperplasia, loosening, and dislocation of the hook vertebral joint spreads to the upper and lower transverse foramina on both sides, resulting in axial or lateral displacement, it can stimulate or compress the vertebral artery, causing spasm, stenosis, or folding changes, resulting in obstruction of vertebral artery blood flow. Bone flab around the transverse foramen can directly compress the vertebral artery.
1.2 Effect of cervical flexion changes on vertebrobasilar artery blood flow velocity in patients with cervical spondylosis
Prolonged low head position can cause chronic stress injury to the cervical musculature. Over time, the static and even dynamic balance of the cervical spine becomes dysfunctional, and the anterior arch of the neck disappears or becomes retroflexed. The loss of the proper curvature of the cervical curve changes the intravascular blood flow pathway of the vertebral artery and even causes turbulence formation. Since the vertebral artery is connected to the surrounding fibrous tissue and is relatively fixed, the change in the cervical curve also increases the possibility of stimulation of the sympathetic plexus around the vertebral artery, resulting in spasm of the vertebral artery and impaired blood flow.
1.3 Effect of cervical spine activity on the vertebral artery
The movement of the cervical spine is large, and changes in flexion and extension and rotation of the cervical spine inevitably lead to changes in the posterior joints between the vertebrae, the hook vertebral joints and the sliding of the intervertebral disc to make corresponding changes in spatial position, causing a decrease in blood flow to the vertebral artery on one side. Normal people do not experience symptoms because of the compensatory effect of the vertebral artery on the other side. In pathological state, vertigo is induced or aggravated because the vertebral artery on the other side cannot make the corresponding compensation.
2. Vascular and hemodynamic changes of vertebral artery
Endothelial cell damage of vertebral artery can cause local thrombosis and fibrosis, reduce vascular compliance and compensatory ability, and make the brainstem, cerebellum, temporal lobe underneath and occipital lobe medial cortex in relative ischemia and hypoxia, if vertebral artery is slightly stimulated or compressed, it can affect the vestibular system of brainstem through a series of neurohumoral reactions and induce vertigo symptoms.
3.Body fluid factor
The clinical symptoms of cervical vertigo are correlated with the indicators of blood rheology. The change of whole blood viscosity value and other indicators of blood rheology is one of the main reasons for the attack of this disease.
4. Cervical disc degeneration and lower cervical spine instability
Clinical investigation found that cervical instability is the main cause of cervical vertigo in young patients. Among 45 patients with cervical instability, 67% combined with cervical vertigo, and 27 patients (9O%) were <40 years old [3]. The abnormal position relationship between vertebrae under physiological load in the cervical spine causes the vertebrae to move back and forth with head and neck activities, causing the second segment of VA to be stretched and distorted, which, together with the stimulation of sympathetic plexus and sinus vertebral nerve around VA, causes VA spasm. Repeated stimulation of the dura mater, nerve roots and sympathetic nerves around VA through neurovascular reaction during cervical activity by the protruding disc can also cause reflex vertigo, or direct compression of the cervical medullary segment of the vestibular spinal cord bundle by the protruding disc_5)
Section 2: Relationship between cervicogenic vertigo and the upper cervical spine
The upper cervical spine includes atlantoaxial, pivotal and atlanto-occipital joints, which are the most prone to injury and strain because they carry the weight of the head and head movement. The vertebral artery is also curved at nearly right angles above the superior orifice of the atlantoaxial foramen and is fixed in the atlanto-occipital vertebral artery groove by the posterior atlanto-occipital membrane. These structural features determine that the living space of this segment of the vertebral artery is extremely limited, and when the neck movement, especially rotational movement, this segment of the vertebral artery is easily affected, especially when various factors cause a significant increase in atlantoaxial instability, which can lead to narrowing or even obstruction of the vertebral artery. Atlantoaxial joint instability caused by congenital developmental abnormalities, inflammation and trauma can cause VA to be squeezed, pulled, twisted and stimulated, resulting in vertigo syndrome.
1.Atlanto-occipital joint lesion
2.Atlantoaxial joint lesion
2.1 Fracture or dislocation of atlantoaxial spine
2.2 Ligament injury
2.3 Congenital malformation.
2.4 Cervical and upper respiratory tract infections.
3. cervical artery sulcus ring
Section 3 Relationship to adjacent nerves
Irritation of the cervical nerve roots is often cited as a cause of pain. Many studies have concluded that the posterior branch of the cervical nerve is a common cause of head and neck pain and shoulder and upper extremity involvement pain, in which disorders of the synovial joints innervated by the articular branch of the lateral branch of the posterior cervical nerve are considered to be one of the main sources of neck and shoulder pain. When neck pain persists, spasm occurs in the neck muscles, and the spastic muscles exacerbate the compression of the posterior cervical nerve roots, producing a vicious cycle. These pains can stimulate sympathetic nerves through fiber connections between sensory and sympathetic nodes, and when these stimuli reach a certain threshold, they induce sympathetic excitation, which in turn constricts the vertebral artery and vertigo occurs.
In patients with occipital major nerve entrapment, in addition to headache as the main complaint, most of them are accompanied by dizziness, and the symptoms are often aggravated by conditions such as cold and flu, cold weather, and humidity, but fewer of them have obvious vertigo symptoms.
Section 4 Relationship with sympathetic and spinal nerves
Cervical lesions, whether in soft tissues or bony joints, inside or outside the spinal canal, can cause sympathetic nerve stimulation and dysfunction, causing spasmodic constriction of the vertebral artery through the vertebral plexus and insufficient blood supply to the vertebral a basilar artery. This eventually leads to vestibular vagus ischemia and produces vertigo symptoms.
Section V. Relationship with soft tissues of the neck
In recent years, vertigo caused by soft tissue lesions in the neck, including neck muscles, ligaments and tendons, has become more and more important. Most patients with soft tissue lesions in the neck have vertigo as a symptom of complaint in addition to neck pain. Patients with cervicogenic vertigo generally have a persistent and chronic dizziness and vertigo, and the appearance and aggravation of symptoms are not associated with changes in head position, but can be aggravated after weather changes or cold.
Chapter 2 Diagnosis and differential diagnosis
Section I. History of non-cervicogenic vertigo
Vertigo can be caused by a variety of causes.
1. systemic diseases, such as hypotension, hypertension, cerebral hypoxia, hypoglycemia, intracranial occupancy, endocrine disorder, hypo- or hyperthyroidism.
2. Vestibular systemic diseases, such as Meniere’s syndrome, which can be accompanied by tinnitus and deafness.
3.After trauma, such as skull base fracture, intracranial hematoma, intracranial hypertension.
4.Drug poisoning, such as gentamicin, caramycin after injection.
5.Other, such as hysteria.
Section 2 Medical history
Patients often have a history of seizures commonly after middle age, usually more than 40 years old. Patients may have sensory head rotation related, but the onset may be earlier in those with congenital malformations such as atlantoaxial sulcus ring, atlantoaxial subluxation or instability.
Section 2 Physical examination
Cervicogenic vertigo is combined with cervical spine lesions, which can irritate or compress the vertebral artery, or compress the near spinal cord or nerve roots. The examination should be performed in accordance with the usual examination, whether there is dullness or hypersensitivity of sensation in the extremities, which nerve root of vinegar is damaged by the sensory loss area, whether there are lamellar or striated sensory loss areas on the body surface, and whether the reflexes are dull, absent or hyperactive. In general, the reflexes are hyperreflexic in upper motor neuron damage and absent or dull in lower motor neuron damage. High muscle tone is a sign of damage to the pyramidal fasciculus and can be hyperreflexic, positive for patellar clonus and ankle clonus. Hoffman’s sign may be positive. Neck compression test and dorsal plexus pull test can be positive for examination, and pain or increased reflex pain can be found on examination. Turning the neck test is positive, this is related to the atlantoaxial intervertebral misalignment during turning the neck, stimulating the compression of the vertebral artery.
Section 4: x-ray examination
The cervical spine should be photographed in orthogonal, open, lateral, lateral extension, and double oblique positions.
The orthogonal open position can show whether the relationship between the lateral block of the atlantoaxial spine and the dentate process of the atlantoaxial spine is symmetrical, whether there is a small, isolated bone block, or even whether there is a dentate process, dentate fracture or deformity.
Section V. CT examination
It can mainly check whether the relationship of atlanto-axial spine is normal, whether there is subluxation, whether the transverse foramen is symmetrical on CT, etc.
Section 6 MRI examination
In this examination, the soft tissues are shown clearly than the bone, and the disc degeneration, disc herniation, edema or degeneration of the compressed spinal cord, and intravertebral canal occupancy can be examined, and the vertebral artery examination can be shown without imaging. There are two methods: 1 specifically showing the vertebral artery and carotid artery 2 showing the vertebral artery while seeing the cervical spine orthogonally.
Section VII pulsed Doppler examination
Section VIII Differential diagnosis
To differentiate from 1 sulcus ring syndrome 2 atlantoaxial intervertebral instability or subluxation 3 hooked vertebral joint hyperplasia 4 subclavian artery reflux syndrome
Chapter 3 Treatment
There are two categories of surgical treatment and non-surgical treatment
Part I Non-surgical treatment
Section 1 Braking
Cervicogenic vertigo is characterized by vertigo during movement, so braking can reduce or avoid vertigo
(1) Plaster neck brace
(2) Support protection, such as collar, neck brace and inflatable collar. Both collar and neck brace can protect cervical spine by braking, reduce the wear and tear of nerves, reduce the traumatic reaction of intervertebral joints, and help the tissue edema to subside and consolidate the therapeutic effect to prevent recurrence, but long-term application of neck brace and collar can cause muscle atrophy and joint stiffness of neck and back, which is not beneficial but harmful, so the wearing time should not be too long.
Section 2: Traction
The method of cervical traction Generally, the cervical pillow traction belt is used for cervical traction.
(1) posture: the position can be taken sitting or lying, for convenience, more stable sitting position, so that the neck from the longitudinal axis of the trunk forward about 10 °-3O °, to avoid over-extension. The patient is required to fully relax the neck, shoulder and the whole torso muscles. The traction position should be comfortable for the patient, and should be adjusted as appropriate if there is discomfort. In the vertebral artery type patients, the anterior tilt angle should be small, and in the spinal cord type cervical spondylosis patients should take a nearly vertical posture, avoiding forward flexion traction.
(2) Traction weight and duration: the commonly used traction weight varies greatly, from 1/10 to 1/5 of the patient’s own body weight, mostly with 6-7 kg, with a smaller weight at the beginning to facilitate patient adaptation. At the end of each traction, the patient should have an obvious feeling of neck stretching, but no special discomfort, if this feeling is not obvious, the weight should be increased as appropriate. The duration of each traction is usually 20-30 minutes. The traction weight and duration can be made in different combinations, generally the duration is shorter when the traction weight is larger and longer when the traction weight is smaller.
(3) Traction frequency and course of treatment: generally traction 1-2 times a day, there are also 3 times a day, 10-20 days for a course of treatment, can continue for several courses of treatment until the basic elimination of symptoms.
(4) If traction in sitting position is not effective, or if the patient has heavy symptoms or is too weak to sit, traction in supine position can be used. After 2 hours of continuous traction, rest for 15 minutes, then traction again, the total time of traction can be 1O-14 hours per day.
(5) Intermittent traction can be performed by using electric traction apparatus, which is considered to be beneficial for relaxing muscles and improving local blood circulation. Generally, traction for 2 minutes, relax or reduce the traction weight for 1 minute, repeatedly for about half an hour.
Section 3: Sealing treatment
Localized compression of the vertebral artery can be treated with procaine injection, or planetary ganglion block if the exact location of the compression or irritation of the vertebral artery is not diagnosed.
Section 4: Tui na massage and acupuncture
1.Role and indications
Chinese medicine believes that cervical spondylosis is caused by long-term strain on the neck, loss of harmony of qi and blood, combined with external wind and cold, blocking the meridians and collaterals.
2.Methods
Cervical spondylosis massage techniques should be a combination of rigid and soft, do not be rough, commonly used techniques such as.
In the back of the neck repeatedly make palm kneading, tan method and one finger Zen pushing method, then in the neck and shoulder of the Governor, hand three Yang meridian part of the Yu points such as Fengchi, Fengfu, shoulder within the Yu, shoulder well, Tianzong, lack of basin points for point, pressure or take method, and then in the oblique muscles and scapular muscles to perform flicking method. In case of nerve root type, the main points of shoulder, elbow and hand should be included in the treatment; in case of vertebral artery type, the head and face points such as Baihui and Sun should be included. Next, rotational wrenching technique is used. Finally, wiping, tapping and clapping are used to end the treatment.
Acupuncture can use warm acupuncture pinch points, Fengchi, Dazhi, dizzy hearing area, and also Fengchi plus vertigo points plus electric acupuncture
Section V. Physiotherapy
Physiotherapy can improve local blood circulation, relax spastic muscles, relieve symptoms, eliminate edema and congestion of nerves caused by lesion stimulation, and improve blood circulation to relieve symptoms. High frequency (microwave, ultra-short wave), low and medium frequency electrotherapy (such as TENS, intermittent electrotherapy, computerized medium frequency), ultrasound, magnetic therapy, interference current therapy, ion introduction, introduction of drugs, etc., as well as hydrotherapy, spa therapy, etc. can be used as methods. These therapies can improve local blood circulation, strengthen tissue supply and nutrition, reduce inter-tissue exudation, and promote the dissipation and elimination of pain-causing substances.
Section 6: Drug treatment
Although there are many drugs for treating vertigo, there are not many drugs for treating cervicogenic vertigo, and it is recommended to take co danshin tablets, and the internal use of Chinese medicine needs dialectical treatment
Section 7 Stimulation therapy or relaxation therapy
A small acupuncture therapy
Generally choose the attachment point of tendon bone in spastic muscle, commonly there is collar muscle spasm, its attachment area is in the inferior occipital collar line, in this area, hard striated spastic tendon is examined, and there is tenderness and pressure pain, this area can be chosen as the entry point, and the needle is plucked away after routine disinfection. After stripping, inject prednisone and procaine in appropriate amounts.
II Soft tissue release surgery
Part II Surgical treatment
First Atlantoaxial sulcus atlantiotomy
Second posterior atlantoaxial fusion
Third occipitocervical fusion myoatlantoaxial posterior arch resection
Hook arthrodesis myotransverse foraminotomy
Chapter 4 Health care and rehabilitation
Section I. Maintaining good posture in life and work
Section II Avoiding trauma
Section III Choice of occupation
Section IV health care traction pillow
Pillow and sleep: the center of the pillow should be slightly concave, the height of 12 – 16cm, the neck should be pillowed on the pillow, can not be suspended, so that the head to keep slightly back. Those who are accustomed to side lying position, should make the pillow with the shoulder height. When sleeping, do not lie down and read, and do not put your hands above your head for a long time.
Section 5: Cervical spine health exercise