What Is Cervicogenic Vertigo?

Introduction

Cervicogenic vertigo is a feeling of light-headedness, imbalance, and disorientation in space, as a result of cervical dysfunction.¹ According to the classification of vestibular disorders, cervicogenic vertigo is not regarded as true vertigo, but complaints of light-headedness, and loss of equilibrium should be classified as dizziness.

Thus, it can be referred to more appropriately as cervicogenic dizziness.² It has also been called cervical vertigo or proprioceptive vertigo in the research literature. Some medical experts regard it as a tenacious entity with other possible explanations, which should only be confirmed after excluding other vestibular disorders.³

Commonly affected structures resulting in cervicogenic vertigo are the neck afferents, carotid bodies, arteries, and cervical joints.¹ There are some postulations on the mechanism of how cervicogenic vertigo arises. Most of these hypotheses have revolved around vascular and nerve-related issues in the cervical region affecting normal proprioceptive signals and communication leading to this feeling of vertigo.

However, there remains no clear mechanism as to its cause. Cervicogenic vertigo is a diagnosis of exclusion. It is called a diagnosis of exclusion because there is no single special test that is used to confirm the diagnosis. It has no specific signs and symptoms that can be confirmed through imaging or laboratory tests that do not overlap with other conditions. Therefore, it requires a skilled and experienced clinician who can identify and rule out other alternative diagnoses before arriving at a definite conclusion of cervicogenic vertigo.

Importance of understanding cervicogenic vertigo

Cervicogenic vertigo is reported as the main complaint by individuals over the age of 65and an increase of over 35% of patients reported to emergency departments presented with complaints of vertigo.⁵ Furthermore, it has been linked to whiplash injuries from car accidents. Whiplash injuries occur as a result of the rapid acceleration-deceleration movements in road traffic accidents, causing injuries to the neck. It has been commonly associated with cervicogenic vertigo. Whiplash can be chronic and patients are often scrutinised about their symptoms, as such, a better understanding of cervicogenic vertigo will also help manage associated litigation costs.¹

Causes of cervicogenic vertigo

The causes can be traumatic causing an acute onset of symptoms, or insidious, in progressive neck pain conditions.

They include:

• Degenerative conditions of the cervical spine. Cervical disc degenerative disease (discogenic) is a frequent cause of cervicogenic (cervical + discogenic) vertigo, and presents commonly among the elderly.⁶ This is a result of the inflammatory process that accompanies degeneration leading to the damage of joint receptors in the upper areas of the cervical spine. Abnormal cervical inputs from these receptors cause an inconsistency between the vestibular and visual systems, resulting in cervicogenic vertigo.

• Whiplash injuries from road traffic accidents can cause strain to the joint capsules and surrounding neck muscles, and affect proprioception. 25-50% of patients with whiplash-associated injuries have been reported to present with vertigo. In these post-traumatic incidents, if one suddenly presents with vertigo, it is necessary to see a clinician to rule out any other red flags.

• Bow hunter syndrome: This arises due to an obstruction of the vertebral artery when the neck is rotated to its sides. It can be identified through clinical imaging, but it's thought to be quite rare. This is also called rotational vertebral artery occlusion syndrome.⁷

• Migraine: cervicogenic vertigo has been linked to migraine. Usually, before vertigo symptoms, these patients already present with neck pain and stiffness.

• Myofascial pain syndrome: Patients can also present with vertigo due to tender trigger points in the muscles of the head, neck, and shoulders. 

• Beauty parlour stroke syndrome: aptly named as it is a consequence of neck compression when the neck is extended, with the head hanging during hair washing or dressing in a beauty parlour or salon.⁸

Symptoms

The most common symptoms of cervicogenic vertigo are neck and shoulder pain. Other symptoms include a reduced range of movement, dizziness, imbalance, and motion sickness.⁹ Vertigo symptoms are usually aggravated with head movements, lasting momentarily, for some seconds or minutes, while severe cases can last for hours.¹ Therefore, it is necessary to rule out other types or causes of vertigo

Other types of vertigo that are not of cervicogenic origin include:

1. Benign Paroxysmal Positional Vertigo (BPPV): This is a disorder with the inner ear, causing a spinning sensation with head or eye movements. It is usually treated with specific exercises and manoeuvres
2. Meniere's disease: This causes vertigo that can last for hours, and it is caused by the build-up of fluid in the ear. Other symptoms are hearing difficulties and/or loss and tinnitus
3. Vestibular neuritis: This occurs as a result of the vestibular nerve inflammation after a viral illness such as the flu, shingles, or umps. Nausea and poor concentration are also reported as symptoms

Vertigo may also be as a result of postural hypotension (drop in blood pressure when standing from sitting or lying), anxiety, side effects of drugs, low blood sugar, and dehydration.⁹

Diagnosing cervicogenic vertigo

Medical history and physical examination

The history and onset of symptoms are very important in identifying cervicogenic vertigo. If one is having vertigo or dizziness without neck pain, it is easy to immediately rule out cervicogenic vertigo.⁴ If the symptoms are provoked when the head is stabilised but the body is rotated on the side, then cervicogenic vertigo is suspected. Symptoms such as hearing difficulties or tinnitus are usually not associated with cervicogenic vertigo.

Some of the questions you will be asked when seeing a doctor include: 

Did symptoms occur following an accident? 

One might report an acute onset of neck pain, for example, following whiplash from a road traffic accident. The clinician will triage and request for a scan if needed.

What are the factors that produce your symptoms? 

vertigo or dizziness of cervicogenic origin could be related to neck positions, moving from sitting to standing, and sharp head turns.

Has this caused you to pass out? 

In most cases, cervicogenic vertigo will cause a feeling of unsteadiness and you can prevent yourself from falling without any loss of consciousness. If you are frequently falling or losing consciousness with vertigo, other causes will have to be investigated.

A physiotherapist can also assess the range of movement in your neck, your posture, muscle strength, balance, and coordination.

Imaging

Diagnostic imaging is usually requested if there is trauma or suspicion of a red flag condition. Any associated difficulties with vision, speech, swallowing, or nausea, are red flags.

For chronic cases, a doctor can request for an MRI or CT scan to visualize any changes, or lesions in the cervical spine. If a vascular cause is suspected, an angiography can be used to rule out any pathology of arterial origin. 

Treatment Options

Conservative treatments

A. Physical therapy

A physiotherapist will educate you further about the condition and your particular presentation. They will treat the neck pain, prescribe neck range of movement exercises, and strengthen weak muscles for better neck control. The treatment sessions will be evaluated to see if your vertigo symptoms improve. You can also see a vestibular physiotherapist who will in addition to the assessment of the musculoskeletal physiotherapist, assess your vestibular system and recommend exercises depending on the findings made.¹¹

B. Medications

These can be prescribed if cervicogenic vertigo is associated with migraines. In persons with muscle spasms and stiffness in their neck and shoulders, muscle relaxants can also help ease symptoms, and improve the vertigo symptoms.¹¹

Invasive treatments

A. Nerve blocks 

Cervical medial branch blocks for patients with chronic neck pain can be used as a diagnostic and treatment tool. It blocks the afferent signals from the spinal nerve, and if it is indicated as the cause, a procedure called radiofrequency neurotomy is a further treatment option.¹²

B. Surgery

Surgery is rare for only cervicogenic vertigo. However, disc replacements, decompression, and fusions may be indicated for patients with severe structural abnormalities in the cervical spine. 

Prevention strategies

Posture and ergonomics 

The correct posture will prevent muscle imbalances in your neck and maintain normal cervical joint function. People who sit for long hours or use computers or phones a lot must make workplace adjustments, so they do not develop a forward head posture and rounded upper back. Working with an ergonomic consultant will reduce the risk of these cervicogenic-related injuries.¹³

Exercise 

A proper stretching and strengthening routine for the neck and upper back will maintain joint mobility, even as you age.¹⁰

Summary

Cervicogenic vertigo is a condition that causes a feeling of unsteadiness or dizziness, associated with neck pain and reduced movement. It is a diagnosis that is reached when all other alternative explanations for the vertigo have been excluded.

Common causes include disc degenerative disease, migraine, and whiplash. In addition to the feeling of imbalance and unsteadiness with cervicogenic vertigo, neck and shoulder pain are the most common symptoms.

• It is important to see a doctor and rule out other types of vertigo such as BPPV, Meniere's disease; or causes such as low blood pressure or medication side-effects
• Depending on your presentation, a doctor might request for further imaging or refer you to a physiotherapist for the assessment of your neck
• Treatment is mostly conservative with physical therapy and medications. While injections and surgeries are only considered for severe cases
• Proper posture, ergonomic assessment, and exercises are good lifestyle modifications to prevent carcinogenic-related symptoms like vertigo