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Cervical Vertigo or Disequilibrium

Cervical vertigo or disequilibrium may have been described first by a Chicago neurosurgeon, Walter Sugar. The limited literature on it makes this at best a diagnosis which is controversial.[1] The online search engine for medical literature sponsored by the National Library of Medicine, PubMed,does not abstract a great deal of trustworthy information on it but enough literature exists to believe that some cervical spine issues in some patients can cause either imbalance or vertigo. This disorder seems to arise most commonly in patients who have cervical spine problems from trauma or from degernative processes. However, persisting symptoms of vertigo are not common after neck injuries.[2] The characteristic patient has vertigo or imbalance (disequilibrium) associated with neck strain and/or neck pain. During spells of vertigo or of worsened balance, these patients do NOT experience associated changes in hearing or ear ringing but they may have a pressure sensation in the ear, behind the ear, or on the side of the head as well as the adjacent neck. They may have visible eye movements called nystagmus but many have not been observed carefully enough to see such. When vertigo is the dominant symptom, pain commonly accompanies the balance complaint and affects the side of the head, the neck and may extend from the neck towards the shoulder. Spells may last minutes to hours, sometimes with nausea, vomiting, and heavy sweating. These patients usually have head-neck-shoulder positions which are variable symptom triggers and they commonly happen while sleeping or while maintaining a head-turned position for a period of time. Differentiating this from migraine related vertigo is that major neck pain is not typically a part of migrainous vertigo. Differentiating from benign paroxysmal positioning vertigo is that event-related symptoms last much longer in cervical vertigo. Ménière's disease patients do have ear specific symptoms which are or have a history of being heightened in association with vertigo events.

When imbalance is the dominant symptom, chronic neck soreness and stiffness is common, typically from a whiplash or other neck injury history. Published research shows this pattern may occur in whiplash patients. With the imbalance patients, like in the vertigo patients, no change in ear specific symptoms occurs other than perhaps a sense of ear fullness on one or both sides. Differentiating this from imbalance of aging, and other vestibular symptom disorders can be hard, but neck stiffness, pain with neck rotation, and chronic tenderness between the base of the skull down the sides of the neck seem to be common.

Since this diagnosis is controversial, other potential causes need to be considered before assuming this might be the answer. The medical literature describes "vestibulocollic reflexes" in which trunk rotation while keeping the head still causes eye movement, nystagmus.[3], [4] That the neck contributes to vestibular function is well established and reasonable evidence exists that nystagmus can be elicited by rotating the trunk while keeping the head still.[5] Evidence also suggests that injury of the cervical spine leads to alteration of the normal reflex eye movement to spine rotation but no test is widely accepted for this entity to localize pathology.[6] Fortunately, most cervical vertigo/disequilibrium patients spontaneously improve and/or adapt but some do not.[7] In the literature, some physical therapy seems vaguely proposed and treating what can be found in terms of cervical spine dysfunction may be helpful.

Many whiplash patients who have vague disequilibrium have no objective findings to explain their imbalance and/or vertigo. Some head-injured patients have a contused labyrinth and other post-concussive dizziness which cannot be objectified satisfactorily.


References

  1. Cervical vertigo--reality or fiction?, Brandt, T , Audiol Neurootol, 1996 Jul-Aug, Volume 1, Issue 4, p.187-96, (1996)
  2. Otological and vestibular symptoms in patients with low grade (Quebec grades one and two) whiplash injury., Rowlands, R G., Campbell I K., and Kenyon G S. , J Laryngol Otol, 2009 Feb, Volume 123, Issue 2, p.182-5, (2009)
  3. Head movements produced during whole body rotations and their sensitivity to changes in head inertia in squirrel monkeys., Reynolds, J S., and Gdowski G T. , J Neurophysiol, 2008 May, Volume 99, Issue 5, p.2369-82, (2008)
  4. [Cervicoproprioceptive provocation of horizontal and vertical nystagmus in test subjects]., Hölzl, M, Weikert S, Gabel P, Topp N, Orawa H, and Scherer H , HNO, 2008 Oct, Volume 56, Issue 10, p.1013-9, (2008)
  5. Cervicocollic reflex: its dynamic properties and interaction with vestibular reflexes., Peterson, B W., Goldberg J, Bilotto G, and Fuller J H. , J Neurophysiol, 1985 Jul, Volume 54, Issue 1, p.90-109, (1985)
  6. Adaptation of the cervico- and vestibulo-ocular reflex in whiplash injury patients., Montfoort, Inger, Van Der Geest Joseph N., Slijper Harm P., De Zeeuw Chris I., and Frens Maarten A. , J Neurotrauma, 2008 Jun, Volume 25, Issue 6, p.687-93, (2008)
  7. Long-term outcome after whiplash injury. A 2-year follow-up considering features of injury mechanism and somatic, radiologic, and psychosocial findings., Radanov, B P., Sturzenegger M, and Di Stefano G , Medicine (Baltimore), 1995 Sep, Volume 74, Issue 5, p.281-97, (1995)