Another common cause of vertigo we see in the office is called Cervicogenic Vertigo.
What is it?
Dizziness and vertigo may arise from one or multiple anatomical structures. The central origins include the brain stem, cerebellum, or other supratentorial structures. The peripheral origin includes vestibular, visual, and spinal proprioceptive systems.
The cervical spine plays a critical role in the maintenance of balance. Cervicogenic vertigo is defined by dizziness or disequilibrium originating from abnormal proprioceptive activity in the cervical spine. The mechanism of cervicogenic vertigo is widespread, however most researchers ascribe to an altered mechanoreceptive (a sensory stimuli response) theory. The sensory mismatch between visual, vestibular, and cervical mechanoreceptive input “confuses” the brain into a temporary state of dizziness.
Other mechanisms believed to contribute to cervicogenic vertigo are vascular compression, vasomotor changes (how blood travels through the blood vessels) affecting the cervical sympathetic chain (nerves coming from the cervical spine, down the neck into the shoulder), or stimulation of the nerves in the cervical sympathetic chain.
Patients with cervicogenic vertigo frequently present with muscle hypertonicity (overactivity), limited upper cervical range of motion, and joint position errors.
There is generally a temporal relationship between the cervical spine injury and the onset of vertigo, although symptoms can be delayed for days to months. Stress and anxiety are thought to be compounding factors for dizziness, as these conditions may increase muscle tone and sympathetic (nerve) firing rates.
Cervicogenic vertigo is usually present when there is a history of dizziness associated with cervical movement and concurrent neck pain. Patients complain of light-headedness, floating sensation, unsteadiness, or general imbalance. Symptoms are generally episodic, provoked by movement and eased by maintaining a stable position.
Occipital based headaches may accompany cervicogenic vertigo. However, some symptoms that suggest that it is not cervicogenic vertigo are trauma, frequent unexplained falls, hearing loss, and a few more. A clinician will be able to recognize the symptoms of cervicogenic vertigo.
The assessment of vertigo includes the performance of various provocative rotary maneuvers, intended to reproduce complaints. A neck torsion test is performed with the patient rotating their body on an exam stool while the clinician stabilizes their head, minimizing vestibular input. Reproduction of dizziness or nystagmus when the head is stabilized suggests a cervical component.
While assessing, clinicians will be looking for the presence of nystagmus. There are two motions of nystagmus that determine the origin. Vertical nystagmus suggests a central origin and horizontal nystagmus suggests a peripheral origin. Nystagmus usually presents as a late onset and progressively intensifies.
Patients with cervicogenic vertigo may demonstrate slower eye tracking movements when their head is turned. Findings will also show a loss of cervical range of motion, upper cervical tenderness, and upper cervical joint restriction. Deep palpation of the suboccipital (where the skull and neck meet on the back side of the body) region may reproduce vertigo symptoms in some patients. Some spinal manipulations may serve as the best diagnostic test for cervicogenic vertigo.
A CT or MRI with contrast can be helpful to rule out suspicions of CNS pathology. Otoscopic evaluation may identify middle ear problems.
Clinicians may perform a thorough neurological exam, including assessment of cranial nerve function and observing signs of upper motor neuron lesion.
Cervicogenic vertigo and benign paroxysmal positional vertigo are the two most common types of vertigo seen by clinicians in a chiropractic office. However, they do have differences that will help determine which type the patient has. Patients with cervicogenic vertigo will have a sense of floating whereas BPPV patients will experience a sensation of spinning.
Level rotation of the neck should exacerbate cervicogenic vertigo symptoms, while those with BPPV will not report these same types of symptoms.
Another way of determining the different types of vertigo include the maneuver performed with the clinician. A neck torsion maneuver is performed if cervicogenic vertigo symptoms are more present and if BPPV is suspected then the epley’s maneuver is performed by the clinician.
The most common cause of vertigo is BPPV, which is responsible for about 42% of all cases.
Cervicogenic vertigo is managed through conservative treatment, including manual therapy. There is a 90% success rate when utilizing manipulation for the treatment of cervicogenic vertigo.
The clinician will assess and treat for lower cervical and thoracic regions. Several studies have shown improvements with traditional manual therapy.
Therapy must address associated soft tissue components. Myofascial release and/or stretching may be needed in the cervical muscles such as suboccipital, upper trapezius, levator and pectoral muscles. Postural corrections may be necessary as well.
Rehabilitation exercises that assess and correct weakness in the deep neck flexor muscles are necessary for recovery. Breathing exercises are appropriate as well.
Acupuncture accompanied by manual therapy may help with symptoms. Physical therapy modalities such as ice, heat, and more may be appropriate.
Patients not responding to a brief trail of conservative therapy will require additional diagnostic workup and/or medical referral to a neurologist or ENT specialist.