Abstract
Cervicogenic vertigo is the false sense of motion due to cervical musculoskeletal dysfunction. This chapter details the incidence of this condition, common presenting symptoms, and important exam maneuvers to perform when evaluating a patient with this possible diagnosis. Much of the diagnostic work-up is done to exclude other diagnoses, and a broad differential is outlined in this chapter. Lastly, various treatment strategies supported in the literature are described, including rehabilitation techniques, pharmacologic options, and procedures.
Definition
Cervicogenic vertigo is the false sense of motion that is due to cervical musculoskeletal dysfunction. The symptoms may be secondary to post-traumatic events with resultant whiplash or postconcussive syndrome. Alternatively, cervicogenic vertigo may be part of a more generalized disorder, such as fibromyalgia or underlying cervical osteoarthritis.
Cervicogenic vertigo is thought to result from convergence of the cervical and cranial nerve inputs and their close approximation in the upper cervical spinal segments of the spinal cord. Dizziness and vertigo, common presenting symptoms, are said to affect approximately 20% to 30% of the general population and account for 8 million primary care visits to physicians in the United States each year. In addition, these symptoms represent the most common presenting complaint in patients older than 75 years. Vertigo following neck trauma is extremely common, with estimates as high as 40% to 80%. Particularly, the incidence of symptoms of dizziness and vertigo after whiplash injury has been reported as 20% to 58%.
Symptoms
Patients with cervicogenic vertigo experience a false sense of motion, often whirling or spinning. Some patients experience sensations of floating, bobbing, tilting, or drifting. Others experience nausea, visual motor sensitivity, and ear fullness. Patients with cervicogenic vertigo usually have pain in the lateral and posterior aspect of the neck and occipital region, sometimes accompanied by stiffness of the neck. Neck pain often radiates to the temporal-parietal region in a banana-shaped distribution and may only be present during deep palpation of the neck. Symptoms typically occur in episodic nature, lasting minutes to hours, and they are often provoked or triggered by neck movement or sustained awkward head positioning. At times, patients with coexistent cervical radiculitis may complain of paresthesias in the upper cervical dermatomes, but this is not a symptom specific to cervicogenic vertigo.
Physical Examination
The essential elements of the physical examination are normal neurologic, ear, and eye examination findings for nystagmus. Abnormalities in any of these aspects of the examination indicate a need to exclude other otologic or neurologic conditions, such as Meniere disease, benign paroxysmal positional vertigo (BPPV), and stroke. BPPV is frequently misdiagnosed as cervical vertigo, thus a Dix-Hallpike test is considered a necessary element of the exam. A careful cervical examination should be performed, including range of motion (ROM) testing and palpation of the facet joints to assess mechanical dysfunction. Myofascial trigger points should be sought in the sternocleidomastoid, cervical paraspinal, levator scapulae, upper trapezius, and suboccipital musculature. Patients with cervicogenic headache and disequilibrium have a significantly higher incidence of restricted cervical flexion or extension and painful cervical joint dysfunction and muscle tightness. Palpation in these areas can often reproduce the symptoms experienced as cervicogenic vertigo.
Functional Limitations
Functional limitations may include difficulty with walking, balance, or equilibrium. As a result, patients may not feel confident with activities such as driving because cervical rotation may induce symptoms. Cervical pain or headache may interfere with sleep, leading to fatigue, emotional disturbances, and overall poor quality of life. Occupations that require balance and coordination (such as construction) are often limited. Anxiety about the occurrence of disequilibrium may cause activity avoidance or kinesophobia, compounding the disability.
Diagnostic Studies
Cervicogenic dizziness is a clinical diagnosis; so much of the diagnostic work-up is done to exclude other diagnoses. Testing may include cervical radiographs to rule out cervical osteoarthritis or instability. Cervical magnetic resonance imaging is indicated when cervical spondylosis is suspected, either as a cause of the condition or as an associated diagnosis. To differentiate vertigo from rotational vertebral arterial syndrome, the use of magnetic resonance angiography (MRA) or computed tomography angiography is particularly useful to identify a vertebral arterial compressive pathology. Brain magnetic resonance imaging or MRA may be ordered to exclude vascular lesions or tumor (i.e., acoustic neuroma). A comprehensive neurotologic test battery and consultation are preferred if a primary otologic disorder or post-traumatic vertigo is considered.
Meniere disease
Benign paroxysmal positional vertigo
Labyrinthitis
Vestibular neuronitis
Cardiovascular causes: arrhythmia, carotid stenosis, or postural hypotension
Vestibular migraine
Progressive dysequilibrium of aging
Post-traumatic vertigo
Treatment
Initial
Initial treatment involves reassurance and education of the patient. Nonsteroidal anti-inflammatory drugs are useful to help pain control for those who have underlying cervical osteoarthritis. Muscle relaxants such as cyclobenzaprine, carisoprodol, and low-dose tricyclic antidepressants may be used at bedtime to facilitate sleep and muscle relaxation for myofascial pain. Ondansetron (4 to 8 mg every 8 hours as needed) may be trialed if disequilibrium is accompanied by significant nausea.
Rehabilitation
Rehabilitation is aimed at reducing muscle spasm, increasing cervical ROM, and improving posture to help decrease the intensity of dizziness and ultimately restore function. A physical therapist with training and experience in manual therapy, myofascial and trigger point treatment, and neck and trunk stabilization techniques should evaluate and treat the patient to restore normal cervical function.
Manual therapy, including sustained natural apophyseal glides (SNAGs or Mulligan SNAGs) and passive joint mobilization (PJM or Maitland mobilizations) both have moderate evidence validating their use. A randomized controlled trial (RCT) evaluating these two therapy protocols found no significant difference in the immediate and sustained (12 weeks) reductions in intensity and frequency of chronic cervicogenic dizziness. However, a different RCT compared SNAGs with PJM in the treatment of ROM, head repositioning, and balance in patients with cervicogenic dizziness. This study found that SNAG treatment improved cervical ROM, and the effects were maintained for 12 weeks after treatment, but PJM had very limited impact on cervical ROM. The study did not find any conclusive effect of SNAGs or PJM on joint repositioning accuracy or balance in people with cervicogenic dizziness. Importantly, it has also been reported that both SNAGs and PJM decrease dizziness frequency at 12 months post treatment, suggesting these two forms of manual therapy have long-term beneficial effects in the treatment of chronic cervicogenic dizziness.
Occupational therapy can improve posture, ergonomics, and functional daily activities. Vestibular rehabilitation therapy helps patients to develop compensatory responses and normalizes cervical sensory input. The rationale to combine manual therapy with occupational therapy and vestibular rehabilitation to optimize results is reasonable, but further research to elucidate the potential synergistic effect is needed.
Ergonomic accessories, such as a telephone earset or headset, may help the patient avoid awkward head and neck postures that contribute to symptoms. Psychological or behavioral medicine consultation and treatment can aid the patient in overcoming the fear, avoidance, and anxiety that often develop.
Procedures
Trigger point injections with local anesthetic (1% lidocaine or 0.25% bupivacaine) are often helpful to decrease cervical muscle pain ( Fig. 8.1 ). The clinician should locate those trigger point areas that reproduce the patient’s symptoms. Acupuncture with an emphasis on local treatment of muscle spasm may be an alternative to trigger point injection.
