Vertigo is a kind of motion illusion produced by spatial disorientation of the human body. Cervicogenic vertigo is the vertigo syndrome caused by factors of cervical origin. It is characterized by sudden onset of transient vertigo when the head and neck move (flexion and extension, rotation) and is relieved by correction of the neck disorder. It is common in middle-aged and elderly people. Cervicogenic vertigo is a common clinical condition and can generally be caused by various factors such as proprioception, vertebral artery and sympathetic nerve.
I. Cervical vertigo ：
Cervical vertigo is caused by abnormal impulses from the proprioceptors of the upper cervical spine to the vestibular nucleus. Cervical vertigo is caused by organic or functional changes in the cervical spine and related soft tissues (joint capsule, ligaments, nerves, blood vessels, muscles, etc.) and is also called Barre-Lieon syndrome. The traditional concept of “cervical vertigo” is that vertigo occurs when the soft tissues of the cervical segment, especially the upper cervical segment, are chronically damaged and the internal pressure is high, which reflexively stimulates the nerve branches in them, and because the nerves in the brain communicate with the nerves in the soft tissues of the cervical segment, they also stimulate the vestibular nucleus and red nucleus of the brain and other vertigo centers.
(1) Lesions causing cervical vertigo.
1.Cervical spine bone damage: such as cervical degenerative changes, osteophytes, inflammation, trauma, etc.
2, cervical soft tissue lesions : such as cervical muscle damage, cervical cervical spondylosis, rheumatic cervical myelitis, swelling of cervical joint capsule, trauma, disc herniation, ligament damage, neuronitis, nerve root damage, etc.
3, cervical coagulation : for cervical spine segment dysfunction. The symptoms caused by the injury sensory reflex after the restriction of movement there are caused by overload or improper loading of the cervical spine.
(2) Clinical manifestations of cervical vertigo.
1.Vertigo : It can be motion illusion vertigo, which mostly occurs when the neck is moving; sometimes it presents varicose vertigo when sitting up or lying down, and a few of them can have cochlear symptoms. The clinical symptoms of “cervical vertigo” usually include dizziness, nausea, vomiting, tinnitus, blurred vision, etc. The most prominent feature is “postural vertigo”, which means that vertigo is aggravated when changing position, especially when twisting the head, and sudden collapse may occur in serious cases, but it is usually not accompanied by impaired consciousness.
Patients with cervical vertigo may have balance disorders. The symptoms include difficulty in standing, twisting and walking on a narrow basal plane, difficulty in reaching objects, unevenness of the ground when walking or standing, and dimness of the surrounding environment. Insufficient blood supply to the vertebrobasilar artery is not necessarily the causative factor of cervical vertigo.
2. Neck and/or occipital pain: It occurs mostly in the morning. The absence of cervical pain can almost exclude the possibility of cervical vertigo.
3. Cervical nerve root compression symptoms: abnormal arm sensation, weakness, and involuntary falling of held objects.
4. There may be foreign body sensation in the throat and blurred visual symptoms.
(3) Diagnostic tests of cervical vertigo
1. During examination, pressure, tension, firmness or hardness can be found in the spinous process, interspinous process, transverse process, paraspinous cervical muscles, below the outer occipital ridge, and suprascapular area. Even overnight patients may have vertigo and nystagmus when pressing a certain area or vertigo may be significantly reduced when looking at the suboccipital muscle group in the cervical spine, and head and neck movement may be limited.
2. Neck distortion test and cervical nystagmus test may be positive.
3.Other excitation nystagmography may not be abnormal, or there may be cephalad nystagmus and enhanced cold and heat test in juveniles.
4.X-ray/C-T examination/Magnetic resonance imaging (MRI) examination/Pulse Doppler ultrasonography, etc. can be helpful.
II. “Vertebral artery type cervical spondylosis” and “sympathetic nerve type cervical spondylosis”.
The main symptoms of “vertebral artery type cervical spondylosis” are traditionally thought to be: headache, vertigo and visual disturbance caused by ischemia of the posterior cerebral artery, which manifests as episodes of diminished vision, flashing lights in front of the eyes, dark spots, visual field defects, as well as diplopia and hallucinations, etc. Headache is caused by insufficient blood supply to the basal vertebral artery as well as many cranio-cerebral signs, etc. Vertigo is the most common symptom of the disease, which can be rotational in nature, i.e., hallucinations of rotation of oneself or the surrounding scenery in a certain direction, or general vertigo, manifesting as body swaying and unstable standing and walking or ground movement, tilting, sinking, etc., often triggering symptoms when changing positions.
Anatomically, the vertebral artery and sympathetic nerve are in parallel. Therefore, vertebral artery type cervical spondylosis is often accompanied by some sympathetic symptoms: such as pseudo-angina, myocardial ischemia, impaired secretion of sweat glands, excessive or little sweating of local limbs or half of the body, and digestive dysfunction.
There are two cases of cervical vertigo, one is the mechanical compression of vertebral artery by bone spur and narrowing or occlusion, and this compression is easier to happen when the pushing vein itself is diseased; the second is the stimulation of cervical sympathetic nerve, which causes spasm of the pushing vein. In both cases, there is a prerequisite that the head and neck must be turned to a certain position to allow the pushing vein to be compressed or the sympathetic nerve to be stimulated. In short, the vertigo attack is clearly related to the position of the head and is called “positional vertigo”.
Some patients may have a history of sudden collapse, mostly when they hear shouting behind them while walking, and when they look back, they suddenly fall to the ground with weakness in their lower limbs, and after they fall to the ground, their head position returns and the symptoms disappear, and they can get up immediately. Vertebral artery vertigo is characterized by positional vertigo of the head and neck, which occurs when the head and neck are turned or bent sideways to a specific position, and the symptoms disappear after the position is restored.
After 2-3 episodes, the patient is conscious of this and is very alert to avoid this specific position. However, when vertebral artery type cervical spondylosis has the role of sympathetic plexus of vertebral artery involved in it, or when it occurs mixed with sympathetic type cervical spondylosis, the vertigo symptoms can become atypical, unusually complicated and difficult to distinguish.
Third, cervicogenic vertigo is mostly the result of the joint action of many factors.
”The main factor of cervicogenic vertigo, on the other hand, is the soft tissue damage in the cervical-occipital area. It can produce vertigo symptoms through indirect stimulation of vestibular vertigo center by several links. It can also lead to ischemic damage to the brain due to insufficient blood supply to the vertebrobasilar artery. In summary, cervicogenic vertigo is “postural vertigo” (cervical vertigo), “positional vertigo” (vertebral artery vertigo), and “diffuse” vertigo (sympathetic vertigo). ). They may each lead the way, or they may be interspersed with each other.
Therefore, the key to non-surgical treatment lies in two points: to enhance and actively exercise the function of soft tissues (joint capsule, ligaments, nerves, blood vessels, muscles, etc.) in the neck; and to use other means to increase the blood supply to the brain to relieve ischemic injury.
1, soft tissue injury in the neck including traumatic injury, degenerative changes in old age, soft tissue inflammatory spastic lesions, etc., but regardless of the cause of the lesion, it is necessary to actively exercise and enhance the function of the soft tissues of the neck to reduce the stimulation of soft tissue changes such as hyperplasia, spasm and swelling on the central vestibular nerve.
2. In patients with insufficient blood supply from vertebral artery disease, early stage of the disease is due to loosening and dislocation of the hook vertebral joint after vertebral segment instability, which stimulates or compresses the vertebral artery causing changes such as vascular spasm, narrowing, twisting or curvature; middle and late stage of the disease is due to direct compression of the vertebral artery by hook vertebral osteophytes and nucleus pulposus prolapse, which affects the vestibular center of the brain and produces vertigo symptoms.
IV. Treatment of cervicogenic vertigo.
1. Regular rest/moderate activity: Long-term ambulatory workers and manual operators who keep their heads down for a long time will damage the physiological curvature of the cervical vertebrae and lead to cervical physiological curvature inversion (reverse bending), so it is advisable to take regular rest and carry out moderate head raising training at work. People engaged in computer operation, the neck is fixed in a posture for a long time, also easy to lead to strain injury of the neck muscles and ligaments, work should also be regular rest and appropriate activities to enhance the blood supply of the neck muscles and ligaments, enhance flexibility, to avoid cumulative strain injury.
2, strengthen the neck muscles and ligaments: active exercise of the neck muscles can effectively enhance the stability of the biomechanical structure of the cervical spine, strengthen the normal physiological curvature of the cervical spine, promote blood and lymph circulation, can effectively prevent and reduce cervical spondylosis. According to the survey: the chances of cervical spondylosis attacks decreased by 80% in people with developed neck muscles. However, not all exercise is beneficial, and blind, wrong exercise may even bring irreversible and fatal consequences, especially for patients who have already developed cervical spine biomechanical structural instability, and should not perform intense exercises such as head shaking, neck forward extension, left and right swaying, head lowering, etc.
The correct exercise method is (illustrated): sitting or prone position, both upper limbs straight and placed behind the body, hands crossed (or not crossed if crossed with difficulty), both arms try to extend backward, while lifting the head as hard as possible (preferably slowly), the muscles of the back of the neck and the muscles between the shoulder blades are tensed as much as possible for 10 seconds, then stop and return to normal position, try to relax the tensed muscles;
After resting for 10 seconds, perform the above exercise again, repeat the exercise until you feel fatigue or slight sweating, it is not advisable to exercise excessively at one time, 3-5 times a day, this exercise should not be performed in the standing position, so as not to fall in case of dizziness, this exercise will effectively promote the recovery of the physiological curvature of the cervical spine and strengthen the relevant muscle strength and enhance the stability of the cervical spine. People with special diseases such as cervical spine bone tuberculosis, bone tumor, and fracture patients are prohibited from performing neck exercises.
In addition, the head-up position must be maintained during breaststroke, which is also conducive to maintaining the physiological curvature of the cervical spine, so it is often recommended by clinicians. However, cervical spine patients should also pay attention to avoid getting cold, so they should do sufficient preparation exercises before entering the pool, and immediately after entering the pool, breaststroke. After stopping breaststroke should immediately go ashore and put on clothes to avoid being cold in the pool for a long time.
3, cervical spine short-term traction effective: for the cervical spine, the most important thing is to maintain a normal, stable biomechanical structure, and the basis of the normal biomechanical structure of the cervical spine is the physiological curvature (also known as physiological forward flexion, convexity), and traction will lead to cervical spine physiological curvature straightening rather than recovery, so cervical spine traction should be careful, should not often traction. Short-term traction requires 15°-20° of forward flexion of the cervical spine (shown in the figure), and traction weight of 2.0-2.5kg.
4, sympathetic ganglion or vertebral artery closure effective: the cause is unclear, the site is uncertain, stellate ganglion closure can be immediate; such as the cause is clear, the site is clear, the stimulated vertebral artery and accompanying sympathetic nerve local closure effective. To assist in the diagnosis of the method optional X-ray / C-T examination / magnetic resonance imaging (MRI) examination / pulse Doppler ultrasonography, etc.
5.Tui-na massage: For acute vertigo, tui-na and massage are not helpful. After the acute period, it can be applied appropriately.
6.Physiotherapy: It is effective for improving local blood flow, relieving muscle spasm and improving clinical symptoms.
7.Improve the microcirculation in the inner ear by targeting the obstruction of blood supply to the inner ear: commonly used drugs include dibazol, niacin, pethidine, flunarizine, compound Chuanxiongzin, compound Danshin tablets, Ducoxib, etc. To reduce blood viscosity, dipyridamole, aspirin, etc. are available.
8, vestibular sedatives: commonly used diazepam, promethazine, diphenhydramine, etc.
9.Cervical coagulation: physiotherapy, procaine paravertebral injection, non-steroidal antipyretic analgesics are available, and the first treatment should be cautious.
10, change the bad lying position: the pillow can not be too high or too low, when sleeping, in addition to the head pillow, should make the upper shoulder also pillow, the neck often exercise.
11, to prevent trauma and pillow: trauma (such as car accidents caused by the “whip injury”) may damage the neck muscles and ligaments, and further damage the stability of the cervical spine, and thus induce or aggravate cervical spondylosis. Pillow is also an injury, caused by improper use of pillows, so always after sleep onset.
12, avoid cold: cold will lead to increased muscle pressure, loss of elasticity, which is easy to damage, increased tension will also increase intervertebral disc pressure, compression gap and worsen the symptoms of nerve root compression, cold may also lead to increased inflammation around the nerve root.
13. Cervical brace fixed day and night for 3 months.
Cervicogenic vertigo has a common point that vertigo is induced when the head moves faster especially when it is rotated. If the head movement can be restricted, vertigo can be reduced or avoided, so cranial braking is effective. Patients with vertigo should be immobilized day and night for 3 months (both for diagnosis/and treatment/and forgetting). In terms of (100%) restriction of normal cervical motion: (100%) plaster neck brace > (70%) brace neck brace > (30%) brace collar. But the cervical brace is more suitable for sitting and lying, and the effect is good.
14.Cervical spine surgery is the main treatment: conventional anterior and posterior cervical spine surgery, atlantoaxial gougectomy, posterior atlantoaxial fusion, occipitocervical fusion and posterior atlantoaxial arch resection, hook spondylolisthesis and transverse foraminotomy, etc.