Is a Definitive Diagnosis of Cervical Vertigo Possible in 2020? a Narrative Review and a Proposed Diagnostic Algorithm
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Is a Definitive Diagnosis of Cervical Vertigo Possible in 2020? A Narrative Review and a Proposed Diagnostic Algorithm Jianli Jan Wu. SAERA. School of Advanced Education Research and Accreditation INTRODUCTION Basic science, animal and human clinical research worldwide incidence rate in adults of 15–20% has demonstrated evidence for the labyrinth and (Neuhauser, 2016) and prevalence rate of 17-30% cervical afferent influence over somatic motor (Murdin & Schilder, 2015). Common attributed control in human movement. The multi modal causes were cardiovascular and sensory integration required in this system is otological/peripheral with up to 80% of cases complex. Multiple afference inputs allow for classified as “no specific diagnosis possible” redundancy and adaptation. However, failure to (Bösner et al., 2018). Vestibular related vertigo compensate can result in clinically relevant and accounts for 1⁄4 of dizziness complaints, this functional disabilities that have social and increases with age and with a 3:1 female gender economic impact. Dizziness and vertigo are some prevalence (Neuhauser, 2016). of the most common complaints among patients Vestibular related reductions in quality of life presenting to primary care physicians, outcomes are common in addition to substantial neurologists, and otolaryngologists. These economic burdens (Agrawal et al., 2018; Bronstein symptoms are nonspecific vestibular symptoms et al., 2010; Ferrer-Peña et al., 2019; Murdin & (Bisdorff et al., 2009) and include a wide range of Schilder, 2015). Direct (healthcare related) and differential diagnosis. The following paper serves indirect (sick leave and disability) costs have to capture the current state of the literature with recently been estimated at 64,929 USD per patient regard to diagnostic considerations and presents lifetime or a lifetime societal burden of 227 billion an evidence informed clinical algorithm of what USD for the US population over 60 years of age has been historically and clinically known as (Kovacs et al., 2019). This represents a significant cervical vertigo or cervicogenic dizziness. functional and economic burden on the affected Epidemiology patient, their families and on society as a whole. The incidence of dizziness with or without neck In a study of 288 chiropractic practices in Australia, pain has been well documented in the scientific and dizziness was present in 28% of all neck pain medical literature (Ferrer-Peña et al., 2019), with a patients with 24.1% being diagnosed with SAERA – School of Advanced Education, Research and Accreditation cervicogenic vertigo (Vindigni et al., 2019). reproduction and nystagmus were also observed However, there exists a paucity of quality with neck bending. epidemiological studies on specific vestibular From the outset, there existed multiple competing disorders (Murdin & Schilder, 2015). Dizziness can aetiologies of cervical vertigo: Ryan and Cope as be general manifestations of neurologic, described above with their 3 distinct mechanisms; cardiovascular, psychiatric, or vestibular Maran (1963) discussed aetiologies of arthritis, disorders. However, dizziness and neck pain can vertebral artery occlusion, stenosis of the basilar also be symptoms of other more life-threatening artery and proprioceptive connections, and; Weeks diseases. It can be part of the prodrome of arterial and Travell (1955) and Gray (1956), who reported dissections (Ohshima et al., 2019), tumours or on myofascial pain syndrome and extra- masses (Darouassi et al., 2017), or rotational labyrinthine causes of vertigo and its symptomatic vertebral artery occlusion (Bow Hunters relief with intramuscular injections of anaesthetic. Syndrome) (Zaidi et al., 2014). Nomenclature These global statistics highlight the need and Currently naming conventions of cervical vertigo benefits of prompt diagnosis of vestibular have been debated; proposed clinical aetiologies symptoms. Grill et al. (2018) commented on have expanded beyond spondylosis, and; a paucity inappropriate and insufficient diagnostic accuracy of high-powered diagnostic tests have hampered and treatment timeliness in Europe. He attributes the acceptance of this clinical entity. Cervical this to a lack of interdisciplinary collaboration, vertigo is considered a diagnosis of exclusion due insufficient knowledge of standards in diagnosis to a lack of reliable and valid diagnostic tests and and therapy and a lack of prospective multicentric its incidence in a tertiary audiology clinic was studies. reported at 17% (Somefun et al., 2010). For the Early cases and a historical view of Cervical Vertigo purpose of this essay, cervicogenic; cervical; and Cervical Vertigo as a clinical entity was first neck are all deemed to be equivalent in the described in a series of four cases by Ryan and symptomatic description of vestibular symptoms Cope (1955). In their seminal case study, they had attributed to the cervical region. There exists a isolated instances of Cervical Vertigo from patients paucity of: direct causal evidence for, and; that had 1) cervical spondylosis 2) patients treated diagnostic specificity for this diagnosis. Until such with neck traction and 3) patients that had certain time that one is formalized, the next appropriate types of neck injury. Their clinical characteristics naming convention should rely on specific observed included posterior neck pain or stiffness, symptomatic descriptors. Previously used suboccipital pain and postural vertigo. Symptom definitions of dizziness included: vertigo, disequilibrium, presyncope, or light-headedness. SAERA – School of Advanced Education, Research and Accreditation This nomenclature is an often semantically driven of distorted self-motion during an otherwise source of much divisiveness in the medical normal head movement; (non-vertiginous) community (Stanton et al., 2007; Lystad et al., dizziness is defined as the sensation of disturbed or 2011). impaired spatial orientation without a false or Cervicogenic Vertigo, in its evolution of distorted sense of motion, and; postural symptoms nomenclature from cervical vertigo or cervical are balance symptoms related to maintenance of proprioceptive vertigo has slowly given way to postural stability, occurring only while upright cervical/cervicogenic dizziness. Recently a new (seated, standing, or walking) contrary to non-hierarchical consensus classification has been symptoms linked to changing body posture with presented by the Bárány Society towards an respect to gravity (e.g., standing up). These latter international classification of vestibular disorders symptoms are referred to as “orthostatic”. (ICVD). This classification includes: symptom On the necessity of the monumental undertaking of definitions that are purely phenomenological an ICVD, the authors note: Having structured without reference to a theory on pathophysiology criteria for diagnosis is obviously mandatory for for a particular disease; definitions that are non- disciplines which rely heavily on symptom-driven overlapping and non-hierarchical but allow one or syndromic diagnosis, such as psychiatry and more symptoms to coexist in a particular patient; headache, where often there is no histopathologic, and consideration was given in the choice of radiographic, physiologic, or other independent terminology to ease of translation to languages diagnostic standard available. However, diagnostic beyond English, given current word usage patterns standards and classification are also crucial in (Bisdorff et al., 2009). This new classification areas of medicine such as epilepsy and prioritizes the future evidence informed clinical rheumatology, where, although confirmatory tests and research usage of symptom timing, duration, do exist, there is substantial overlap in clinical triggers vs inconsistent subjective descriptors features or biomarkers across syndromes (Bisdorff (Stanton et al., 2007; Caplan, 2007). Accordingly, et al., 2009, p1). vertigo and dizziness, indeed all vestibular This classification scheme is still in its infancy and symptoms, are non-hierarchical and can both be with a diagnostic conundrum that exists in used individually or concurrently as valid vestibular symptoms (vertigo or dizziness) vestibular symptom descriptors (Bisdorff et al., attributed to the cervical region, these steps cannot 2009). come fast enough. A valid and reliable operational Bisdorff et al. (2009) defined the following: definition is vital to further research, clinical (internal) vertigo is the sensation of self-motion knowledge synthesis and knowledge translation. when no self-motion is occurring or the sensation The term Cervicogenic Vestibular Symptoms is SAERA – School of Advanced Education, Research and Accreditation utilised here as an evidenced informed general combine input from: cortical; cerebellar; categorisation. oculomotor and; spinal sources, including cervical Neuroanatomical and physiological basis of proprioception. (Figure 1) The central lateral, cervicogenic vestibular symptoms medial and descending (spinal) vestibular nuclei “The brain integrates information from multiple play a prominent roll integrating cervical spine sensory modalities to generate appropriate motor afferents and coordinating efferents between output and create perceptual experiences of the various ipsi and contralateral vestibular, environment.” (Yakusheva, 2019, p21). oculomotor, cerebellar and cervical spine nuclei Spatial orientation to self and the environment is implicated in control of posture via vestibulospinal