Timothy C. Hain, MD • Page last modified: August 2, 2020
see also: Main cervical vertigo page.
|MRI of person with cervical vertigo associated with cervical stenosis. Arrow points to region of narrowing.||MRI of person with cervical vertigo associated with cervical stenosis, after a cervical fusion done years ago. The green line corresponds to the level of the axial image on the right. This gentleman complained of dizziness after rolling his head to the side.|
The MRI scan above shows cervical cord compression, which can sometimes cause vertigo (Benito-Leon, Diaz-Guzman et al. 1996; Brandt 1996). In this case, ascending or descending tracts in the spinal cord that interact with the cerebellum, vestibular nucleus or vestibulospinal projections are the culprit. This may be painless. In our opinion, based on clinical observations during videonystagmography, this is a common mechanism of cervical vertigo. Management is not very successful as surgery is generally not felt to be appropriate, and mobilization of the neck is rarely useful as well as being irrational.
There should be little or no hearing symptoms or findings, other than an occasional low-tone sensorineural hearing reduction (an audiogram and OAE is recommended). There may be ear pain (otalgia), as part of the ear is supplied by sensory afferents from the high cervical nerve roots.
On physical examination, there should be no spontaneous nystagmus, but there may be positional nystagmus. Many patients who have vertigo in the context of neck disease have a BPPV type nystagmus on positional testing. This suggests that the neck afferents may interact strongly with vestibular inputs derived from the posterior canal.
Use of VNG to diagnose cervical vertigo: Although the idea is logical, the author has not generally found it helpful clinically to compare positional results with the head kept constant on body to positional tests where there is head on trunk movement. Often it is helpful to compare nystagmus elicited with the head prone to with the head supine, as if the nystagmus does not reverse, cervical vertigo seems fairly certain.
Head-turning upright test. Another useful maneuver is to turn the head to one side to the limit of range, while the examinee is upright and simply wait for 30 seconds. The figure below shows a weak positive and the movie below in the case section shows a strong positive. Clinically, nystagmus that changes direction according to the direction of the head on neck, rather than with gravity, makes cervical vertigo likely. It is the author's personal observations that persons who are positive on this test nearly always have a disk abutting their cervical cord, generally at C5-6.
|Cervical nystagmus recorded with head turned to left.|
More detail about this test can be found here.
Laboratory studies: If cervical vertigo still seems likely after excluding reasonable alternatives, one next needs to look for positive confirmation. Routine studies in working up cervical vertigo
If one accepts that this entity really exists, then it would follow that the only logical treatment is to decompress the cervical spinal cord. There is no physical therapy procedure that can make herniated disks move back into place, and therefore no physical therapy that is likely to alleviate this type of cervical vertigo.
Most neurosurgeons are somewhat dubious about this premise, perhaps because the method that they use for spinal cord decompression, anterior cervical fusion, is associated with significant morbidity. Most patients are required to wear a Philadelphia collar or similar device for about 6 weeks to ensure that the fusion knits together. After the surgery, there is permanent restriction of neck motion (perhaps this is why the surgery works), as well as commonly residual pain and stiffness. Fusions often fail above and below the level of the fusion due to increased motion that occurs at these levels. After cervical fusions, balance problems and dizziness are frequent 10 years later (Hermansen et al, 2019). All this being said, it is our experience that patients who cannot drive prior to surgery, usually can drive again after surgery. This is often important to maintenance of livelihood.
|MRI of person with cervical fusion.|
Case: Herniated disk. Another otherwise healthy man was involved in an auto accident. He was wearing a seat belt, and while his head rotated forward and backward, there was no substantial trauma to the head. A disabling vertigo ensued, characterized by nausea and motion intolerance. Physical examination revealed a weak horizontal nystagmus that could be elicited by turning the head to one side (positive "vertebral artery test"). MRI of the neck revealed a C5-C6 disk herniation, abutting the thecal sac. Comment: Nystagmus in this case does not begin immediately but starts after about 10 seconds of head turning. This is the most common association between neck injury and dizziness.
Movie of cervical vertigo (30 meg download)