Introduction
Vertigo is defined as “a condition in which somebody feels a sensation of whirling or tilting that causes a loss of balance.” To describe the sensation of vertigo, patients often use words such as dizziness, giddiness, unsteadiness, or lightheadedness. The neurological vertigo center is called the vestibular nucleus. The vestibular nucleus is located in the brainstem. It extends from the caudal portion of the pons through the caudal portion of the medulla.
The afferent information that enters the vestibular nucleus to initiate the sensation of vertigo arises primarily from four sources:
1) Labyrinthine Inner Ear (1)
2) Cerebellum (2)
3) Temporomandibular Joint (TMJ) (3, 4, 5)
4) Cervical spine afferents, especially from C1 – C3 (6)
All health care providers should also be aware that vertigo could result as a consequence of vascular compromise of the posterior circulation of the brainstem (the vertebral and basilar arteries, and their branches) (7).
Pathology
The first study to link problems in the cervical spine to vertigo was published in the journal Lancet in 1955 (8). Today (October 12, 2015), a search of the National Library of Medicine with PubMed, using the words “cervical vertigo” locates 2,211 citations.
It was established in 1977 that the injection of saline irritants into the deep tissues of the upper cervical spine would create the sensation of vertigo in normal human volunteers (6).
Clinicians have documented a relationship between cervical spine trauma and the symptoms of vertigo (9). In her chapter titled “Posttraumatic Vertigo”, Dr. Linda Luxon (10) notes that this vertigo can be explained by “disruption of cervical proprioceptive input.” She notes that the major cervical spine afferent input to the vestibular nuclei “arises from the paravertebral joints and capsules, with relatively minor input from paravertebral muscles.” Dysfunctional upper cervical spinal joints and their capsules can alter the proprioceptive afferent input to the vestibular nucleus resulting in the symptoms of vertigo. Treatment would be to improve the mechanical function of these joints.
In 2001, an article appeared in the Journal of Neurology, Neurosurgery, and Psychology titled (11):
Cervical Vertigo
This article reviews the theoretical basis for cervical vertigo. These authors note:
“Proprioceptive input from the neck participates in the coordination of eye, head, and body posture as well as spatial orientation,” and this is the basis of the of cervical vertigo syndrome. Cervical vertigo is when the suspected mechanism is proprioceptive.
“Degenerative or traumatic changes of the cervical spine can induce altered sensory input causing vertigo.
“Dizziness and unsteadiness suspected to be of cervical origin could be due either to loss or inadequate stimulation of neck receptors in cervical pain syndromes.”
“Section or anesthesia of cervical roots or muscles causes an asymmetry in somatosensory input, unilateral irritation or deficit of neck afferents could create a cervical tone imbalance, thus disturbing integration of vestibular and neck inputs.”
“As somatosensory cervical input converges with vestibular input to mediate multisensory control of orientation, gaze in space, and posture, the clinical syndrome of cervical vertigo could theoretically include perceptual symptoms of disorientation, postural imbalance, and ocular motor signs.”
“A convincing mechanism of cervical vertigo would have to be based on altered upper cervical somatosensory input associated with neck tenderness and limitation of movement.”
“In summary, vertigo can be accompanied by cervical pain, associated with head injury, whiplash injury, or cervical spine disease.”
“If cervical vertigo exists, appropriate management is the same as that for the cervical pain syndrome.”
In 2002, an article appeared in the Journal of Whiplash & Related Disorders, titled (12):
A Cross-Sectional Study of the Association Between Pain and Disability in Neck Pain Patients with Dizziness of Suspected Cervical Origin
In this article, these authors state:
“The term ‘cervical vertigo’ was introduced to describe dizziness and unsteadiness associated with cervical spine pain syndromes.”
“Increasing evidence suggests that dizziness and vertigo may arise from dysfunctional cervical spine structures.”
“Whiplash patients are likely to suffer from dizziness, vertigo and associated neck pain and disability resulting from traumatized cervical spine structures.”
“Cervicogenic dizziness, especially in whiplash patients, may result from disturbed sensory information due to dysfunctional joint and neck mechanoreceptors.”
“Dizziness and vertigo are common complaints of neck pain patients with 80 to 90% of whiplash sufferers reporting these symptoms.”
“Dysfunction or trauma to connective tissues such as cervical muscles and ligaments rich in proprioceptive receptors (mechanoreceptors) may lead to sensory impairment.”
“Emerging evidence suggests that dizziness and vertigo may commonly arise from dysfunctional cervical spine structures such as joint and neck mechanoreceptors, particularly from trauma.”
In this study, the authors evaluated 180 consecutive neck pain patients over the age of 18 who were recruited from an outpatient clinic. Of these, 71 patients (40.57%) reported neck pain resulting from trauma and 60 patients (33.5%) were suffering from dizziness. Pain intensity was measured using the Numerical Rating Scale while disability was measured with the Neck Disability Index (NDI).
The authors note that dizzy patients also describe their symptoms with “lightheadedness, seasickness, instability, rotatory vertigo, etc.” Regarding dizziness, females were significantly more likely to report dizziness compared to males while no significant difference was found for dizziness versus age. Patients experiencing dizziness also reported greater intensity of neck pain compared to those without dizziness. Increasing duration of neck pain was significantly associated with increasing reports of dizziness. Subjects who reported dizziness were significantly more likely to have been involved in an injury. Neck pain patients with dizziness reported significantly more disability (total NDI score) compared to neck pain patients without dizziness.
The authors concluded that neck pain patients with dizziness were significantly more likely to have suffered a traumatic injury, experienced greater pain intensity and disability levels, and experienced for a longer period of time, compared to neck pain patients without dizziness.
This “study results reinforce the concept of neck pain and disability leading to cervicogenic dizziness/vertigo due to dysfunction of the somatosensory system of the neck.” The basic model presented in this article is that trauma causes “dysfunctional cervical spine structures” resulting in altered “joint and neck mechanoreceptor” function, causing both pain and dizziness.
In 2003, a group from the University of Queensland, Brisbane, Australia, published a study in the Journal of Rehabilitative Medicine titled (13):
Dizziness and Unsteadiness Following Whiplash Injury: Characteristic Features and Relationship with Cervical Joint position Error
These authors note that dizziness and/or unsteadiness are common symptoms of chronic whiplash-associated disorders, and that if the cervical spine injury is the suspected origin of these complaints that it can be assessed with “joint position error.” Joint position error is the accuracy to return to the natural head posture following extension and rotation. Consequently, these authors measured joint position error in 102 subjects with persistent whiplash-associated disorder and 44 control subjects. These authors found:
“The results indicated that subjects with whiplash-associated disorders had significantly greater joint position errors than control subjects.”
“Within the whiplash group, those with dizziness had greater joint position errors than those without dizziness following rotation.”
“Cervical mechanoreceptor dysfunction is a likely cause of dizziness in whiplash-associated disorder.”
“When there is no traumatic brain injury, abnormal cervical afferent input from damaged or functionally impaired neck joint and muscle receptors is considered the likely cause.”
Dizziness of cervical origin “originates from abnormal afferent activity from the extensive neck muscle and joint proprioceptors, which converges in the central nervous system with vestibular and visual signals, confusing the postural control system.”
These authors “contend that our results support a likely cervical cause of dizziness and or unsteadiness rather than other causes of dizziness in these subjects with persistent whiplash associated disorders and the joint position error findings highlight the role of cervical mechanoreceptor dysfunction.”
“The study highlights the role of cervical mechanoreceptor dysfunction and the importance of assessment and management of this impairment in persistent whiplash associated disorders, particularly in those complaining of dizziness and unsteadiness.”
These authors also noted that the most common words used were “lightheaded”, “unsteady” and “off-balance”. Other descriptions were clumsy, giddy, imbalance, motion sickness, falling/veering to one side, imbalance in the dark, vision jiggle (disturbance), faint feeling, might fall. Unsteadiness was the most common description, being stated by 90% of the subjects.
In 2012, neurological investigators from Buenos Aires, Argentina, and from the Chicago Dizziness and Hearing Center confirmed the existence and pathophysiology of post-traumatic cervical vertigo, and cervicogenic proprioceptive vertigo. Their article appeared in the journal Neurologia, and is titled (14):
Cervical Vertigo:
Myths, Facts, and Scientific Evidence
These authors note that aspects of “cervical vertigo” have “survived the test of time and may be found in the literature today.” They recommend that the provider rule out “rotational vertebral artery syndrome,” and state:
“Once potentially severe causes of the symptoms have been ruled out, the most appropriate strategy seems to be use of manipulative and vestibular physical therapy.”
In 2014, researchers from the University of Montreal assessed 25 subjects with cervicogenic dizziness and 25 subjects with labyrinthine dizziness to determine which clinical tests were best able to distinguish between the two groups. Their study was published in the journal Otology & Neurotology, and titled (15):
Evaluation of Para-clinical Tests in the Diagnosis of Cervicogenic Dizziness
These authors concluded subjects with cervicogenic dizziness were more likely to:
Treatment
There is strong evidence spanning decades, arising from multiple countries, and published in a variety of well-respected peer reviewed medical journals indicating that the reason for cervical vertigo is a mechanical lesion/dysfunction of the cervical spine. This lesion may be articular, capsular, ligamentous, muscular, or a combination there of. The strongest evidence is that the lesion/dysfunction is in the upper cervical spine, from C1-C3. Consequently, a variety of mechanical approaches to treatment of cervical vertigo have been assessed and the results are usually quite favorable.
These mechanical therapies include physiotherapy, varieties of passive joint mobilizations, manipulation, and muscle work. This same type of mechanical therapeutic approach is also effective in treating spinal pain conditions. The explanation for this is that the improvement in mechanical function creates a neurological sequence of events that closes the “Pain Gate.” (16)
The studies below review some of these mechanical approaches and their effectiveness is duly noted: