8: Cervicogenic Vertigo

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Last modified 22/05/2015

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CHAPTER 8

Cervicogenic Vertigo

Joanne Borg-Stein, MD

Melissa Colbert, MD

Synonyms

Cervicogenic dizziness

Neck pain associated with dizziness

ICD-9 Codes

723.1  Neck pain

780.4  Vertigo

780.4  Dizziness

ICD-10 Codes

M54.2  Neck pain

R42 Vertigo

R42 Dizziness

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 [1,2]. Dizziness and vertigo, common presenting symptoms, account for 8 million primary care visits to physicians in the United States each year and represent the most common presenting complaint in patients older than 75 years [3]. In fact, 40% to 80% of patients with neck trauma experience vertigo, particularly after whiplash injury. The incidence of symptoms of dizziness and vertigo in whiplash patients has been reported as 20% to 58% [4,5].

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 [6]. The symptoms are often provoked or triggered by neck movement or sustained awkward head positioning [79]. Cervical pain or headache may interfere with sleep and functional activities. At times, patients with coexistent cervical radiculitis may complain of paresthesias in the upper cervical dermatomes.

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, and stroke [5,10]. A careful cervical examination should be performed, including range of motion 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 [11,12]. Palpation in these areas can often reproduce the symptoms experienced as cervicogenic vertigo [13].

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. Occupations that require balance and coordination (such as construction) are often limited. Anxiety about the occurrence of disequilibrium may contribute to secondary disability.

Diagnostic Studies

Cervicogenic dizziness is a clinical diagnosis. 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. Brain magnetic resonance imaging or magnetic resonance angiography 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 [14

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