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Dizziness

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Introduction

Cervical vertigo (CV) is a vertigo or dizziness that is provoked by a particular neck posture no matter what the orientation of the head is to gravity. For example, dizziness provoked by turning the head about the vertical axis, while sitting upright.

Signs & Symptoms

When cervical vertigo is diagnosed, the usual symptoms are dizziness associated with neck movement. There should be no hearing symptoms (other than tinnitus) or hearing loss but the patient may present with ear pain (often a muscular referral). Brandt (1996) reviewed this topic from a diagnostic perspective, and the Physiotherapy approach has been reviewed by Wrisely et al (2000).

Causes

The precise incidence of cervical vertigo is controversial, but it is estimated that 20-58% of patients who sustain closed-head injuries or whiplash experience late onset symptoms of dizziness, vertigo and disequilibrium.

 

Physiologically, there are many potential causes of CV. Damage to the vertebral artery (shown left), vestibular receptors (inner ear), or a mild head injury are all possible causes of dizziness following head injury. Dizziness is most commonly attributed to disturbed sensory properties of cervical (neck) joints and muscle receptors resulting from the trauma or subsequent functional impairment.  These conditions are generally very rare.

 

There are two distinct mechanisms; compression and dissection.

 

Compression – the vertebral arteries in the neck (see above) can become compressed by the vertebrae (spinal bones) which they traverse, or other structures (Kamouchi, Kishikawa et al. 2003; Sakaguchi, Kitagawa et al. 2003). Arthritis, neck surgery, and chiropractic manipulation are all potential precipitants of neurological symptoms including stroke.

 

Dissection – it is thought that vertebral arteries can be damaged at the points that they are anchored in the upper cervical spine, through a stretching mechanism. In this regard, there is a substantial database of neurological literature showing that chiropractic manipulation of the neck is associated with a increased risk of vertebral artery territory stroke (Rothwell et al, 2001; Smith et al, 2003; Vibert et al, 1993). However, a recent large Canadian study reported that the risk of vertebral artery territory stroke was greater for both chiropractic and primary care visits (Cassidy et al, 2008). They concluded that the same risk of stroke was seen in patients no manipulation of the neck was performed.

 

Whiplash injury have also been reported to be associated with asymmetrical vertebral artery flow (Kendo et al, 2006). The significance of this observation is presently unclear, but again the suggested mechanism is stretching of the upper portions of the vertebral arteries. Neck injuries have increased in the UK in recent years with auto accidents, presumably due to interaction between use of seat-belts and chest restraints. While chest restraints reduce the risk of death, mechanically by restraining the trunk, they can be associated with greater relative movement of the unrestrained head on neck due to simple biomechanics involving momentum transfer.

 

Sensorimotor Control

Abnormal sensory input from neck proprioceptors – sensors in our body which give information on body position and movement, such as Golgi- tendon organs, may be damaged following a Whiplash injury. Sensory information from the neck may be unreliable or absent. Sensory information from the neck is combined with vestibular and visual information to determine the position of the head on the neck, and space (Brandt 1996).

This mechanism was investigated by DeJong and DeJong (1977) who injected local anesthetics into their own necks. Such injections caused unsteadiness and minor amounts of dizziness. It is possible that some individuals are more sensitive than others, and also that neck inputs interact with other causes of vertigo (see below). Cervical proprioception can be assessed in clinic.

 

Spinal Cord Compression

In this case, ascending or descending pathways in the spinal cord that interact with various parts of the brain are the culprit.  Management is not very successful as surgery is generally not felt to be appropriate. (Benito-Leon, Diaz-Guzman et al. 1996; Brandt 1996).

 

Cerebrospinal Fluid Leak

There is potential for trauma to cause a tear of cervical root sleeve leading to dizziness and headache (Vishteh, Schievink et al. 1998). For example, a whiplash injury may tear a cervical root causing reduced cerebrospinal fluid (CSF) pressure and hearing symptoms. CSF leaks can cause low-tone hearing loss, resembling bilateral Meniere’s disease.

 

Irritation of Cervical Sympathetic Nerves

Damage to the superior cervical ganglion (bundle of nerves), located at the C2-C3 level (upper neck), may cause reduced posterior blood circulation.

 

Relationships with Other Types of Vertigo

The neck also interacts with other types of vertigo. Neck input may be used as sensory input to assist in stabilizing vision. Injuries to the neck may also damage structures related to the ears. Although blunt neck trauma has been reported to affect hearing, it is likely an additional injury to the inner ear may occur at the time of the trauma.

 

Sternocleidomastoid (SCM)

Sternal Division (left): Head pain, “sinus” pain, visual disturbances, “sore throat,” difficulty swallowing, dry cough.   Clavicular Division (right): Autonomic and proprioceptive disturbances; frontal “sinus” headache, ear pain, nausea, dizziness and car-sickness; reversible tinnitus/deafness. 

 

Sternocleidomastoid is the big ropey muscle that runs from the mastoid process (jaw) to the sterno-clavicular joint (shoulder). This paired muscle pulls the head forward and down, and acts as a check rein to prevent the head from falling backward. Both of these actions are involved in rolling where you must tuck the head for safety.

 

When the SCM is strained or shortened the muscle itself rarely hurts, no matter how stiff or tight it may be. Problems are referred elsewhere, to head and neck, ears, eyes, nose and throat. There is a long list of pain and dysfunction including severe dizziness and other neurological symptoms. These may be mistakenly diagnosed as migraine, sinus headache, atypical facial neuralgia, trigeminal neuralgia and arthritis of the sternoclavicular joint. Always, these possibilities should be eliminated through differential diagnosis by well trained Physiotherapists at Pure. However, because of its intimate relationship with the brain and several nerves including the vagus nerve, the SCM can produce many neurological disturbances on its own producing cervical vertigo symptoms.

Assessment & Diagnosis

Physiotherapists at Pure manage a wide variety of different types of problems, as well as privately we have various referrers requesting Physiotherapy input from us; this includes medico-legal and those that have been in road traffic accidents. Therefore we are exposed to some of the associated symptoms with trauma and well versed at being vigilant and knowing when to refer to other services i.e. medical. Cervical vertigo is matter of considerable concern because of the high litigation related costs of whiplash injuries. CV from other causes is much less common.

 

The first thing that must be done is to rule out other causes of vertigo such as vestibular issue (the control centre of orientation and the relationship between the brain, ears and eyes). This can be done with positional testing and whilst getting a history of your problem in the first part of your Physiotherapy assessment.

 

There should be little or no hearing symptoms or findings however there may be ear pain (otalgia), as part of the ear is supplied by nerves roots high in the neck.

 

On physical examination, we look for something called nystagmus which involves flickering on the eyes. It is not typical for this to happen spontaneously but it may come on with certain positions. Often it is helpful to compare nystagmus and if it is present with you laying on your back and front – but of course this should only be tested by a professional.

 

It is possible to do something called a Vertebral doppler. This test the efficiency of the flow of blood in the vertebral arteries – similar to when looking for a deep vein thrombosis in the calf. Procedures are rarely abnormal however and it is common to find non-harmful changes in the most people. CT angiography procedures are useful.

 

With a thorough history of your injury and a comprehensive physical examination, your Physio will provide you with a fast and accurate diagnosis so that the most appropriate treatment can begin straight away, helping to facilitate optimal outcomes for your recovery. We will work with you to develop a set of personal goals that will help direct your treatment.

Self-Management

Your Physio will educate you on the condition so that you are able to help support your recovery. Initial treatment should focus on reducing pain and inflammation. Your clinician will also recommend that you limit or avoid activities that make your symptoms worse and can also suggest methods of completing tasks in a different way so as to avoid reproducing your symptoms. Regular re-assessment will check your progress and will allow adaptations to be made to your treatment plan.

Physiotherapy

Physiotherapy treatment may include gentle mobilisation of the neck (cervical) joints, exercises to strengthen deep neck flexors and regain normal movement patterns, posture re-education, trigger point therapy and vestibular exercises – combined balance, eye and neck movements to help restore equilibrium.

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