Visuo-proprioceptive interactions in degenerative cervical spine diseases requiring surgery

Romberg's test revisited: Changes in classical and advanced sway metrics in patients with pure sensory neuropathy

OBJECTIVES

The Romberg test, undoubtedly a classical and well-established method in physical neurological assessment of patients with sensory ataxia, has long been suspected to be prone to several limitations. Here, we quantified upright stance before and after visual deprivation in a selected cohort of patients with pure sensory neuropathy.

METHODS

Static balance was assessed in sensory neuropathy patients during quiet stance on a force platform under different visual and proprioceptive feedback conditions. Sural nerve neurography was employed to evaluate the severity of peripheral neuropathy. Conventional and advanced postural sway metrics were investigated to draw a quantitative analogy to the clinical Romberg test.

RESULTS

Posturographic analyses showed that patients displayed Romberg and vestibular Romberg quotient values around 2, indicating an approximately twofold increase in body sway in the absence of vision. However, the diagnostic discrimination ability between patients and controls was only modest. Even less impactful were the diagnostic contributions of frequency domain and non-linear sway analyses. This was primarily attributed to the heightened body sway exhibited by patients with sensory neuropathy under 'eyes open' conditions, diminishing the contrast with the 'eyes closed' condition as assessed in the classical Romberg test.

CONCLUSION

We conclude that the Romberg test, even in its quantitative form with the aid of an apparatus, had an unsatisfactory classification value in terms of distinguishing patients from healthy controls. Instead, it should be interpreted within the comprehensive context of the broader neurological examination and the electrodiagnosis of peripheral nerve function.

Risk of Cervical Dizziness in Patients With Cervical Spondylosis

Importance

The dizziness associated with cervical spondylosis is a controversial topic given that many experts believe that cervical spondylosis is a common cause of dizziness, whereas others do not believe it exists.

Objective

To compare the risk of dizziness between patients with cervical spondylosis and matched controls (ie, patients with lumbar spondylosis after propensity score matching [PSM]).

Design, Setting, and Participants

This cohort study used medical claims data from the National Health Insurance Research Database of Taiwan for patients 60 years or older with cervical or lumbar spondylosis newly diagnosed in any outpatient department between January 1, 2010, and December 31, 2015. Patients diagnosed with cervical spondylosis were included as the study cohort, and those diagnosed with lumbar spondylosis who were matched to the study cohort via PSM were selected as the control cohort. Both cohorts were followed up for 1 year unless they were diagnosed with dizziness, censored by death, or withdrew from the health insurance program. Data analysis was performed from August 9 to September 20, 2022.

Main Outcomes and Measures

The main outcome was the date of outpatient diagnosis of dizziness. The risks of dizziness were compared between groups. The relative risk and incidence rate difference were calculated.

Results

A total of 3638 patients with cervical spondylosis (mean [SD] age, 67.9 [7.1] years; 2024 [55.6%] male) and 3638 patients with lumbar spondylosis (mean [SD] age, 68.0 [7.1] years; 2024 [55.6%] male) after PSM were selected as the study and control cohorts, respectively. The patients with cervical spondylosis had higher risk of dizziness than matched controls, with a 1-year relative risk of 1.20 (95% CI, 1.03-1.39). The 1-year incidence of dizziness was 10.2% (95% CI, 9.2%-11.2%) in patients with cervical spondylosis and 8.6% (95% CI, 7.7%-9.5%) in the matched group of lumbar spondylosis. The incidence rate difference between the groups was 1.6% (95% CI, 0.3%-3.0%).

Conclusions and Relevance

These data support the association between dizziness and cervical spondylosis, but the small difference between groups reveals that dizziness associated with cervical spondylosis is uncommon. Clinicians should be wary of diagnosing a cervical cause for dizziness based on an actual history of cervical spondylosis.

The association between contact sport exposure and cervical sensorimotor dysfunction: a scoping review of implications for future musculoskeletal injury risk

BACKGROUND

While morphological changes to the cervical spine have been observed for over 40 years in response to contact sport participation, little is known about the secondary effects of the cervical impairment on future musculoskeletal injury and disability.

OBJECTIVES AND DESIGN

A scoping review was performed to discuss the relationship between contact sport participation and morphological changes to the cervical spine. Moreover, the correlation between morphological changes in the musculoskeletal structures of the cervical spine and resultant deficits in cervical sensorimotor and neuromotor function are discussed. Lastly, how alterations in cervical sensorimotor function may affect overall risk of musculoskeletal injury is discussed.

METHODS

The scientific literature was searched in PubMed, Sport Discus, and Web of Science pertaining to contact-sport athletes and/or cervical pathology and the cervicocephalic network. The Asksey and O'Malley's framework and PRISMA for Scoping Reviews were used to conduct and report the following review. Included articles were grouped into three categories: (1) Morphological changes to the cervical spine in contact sport athletes. (2) The role of the neuromotor pathways of the cervical spine in maintenance of postural tone and coordination of the extremities. (3) The correlation between altered cervical sensorimotor function and a resultant increase in musculoskeletal injury risk.

RESULTS

Our search identified 566 documents, of which 405 underwent full-text screening, resulting in 54 eligible studies for the review. Widespread cervical sensorimotor dysfunction was observed in contact sport athletes. Independently, cervical sensorimotor function was demonstrated to play a critical role in postural control and limb coordination. However, limited research exists exploring the interaction between contact sport participation and altered cervical sensorimotor function, as well as an associated increase in musculoskeletal injury risk.

CONCLUSIONS

Limited evidence exists linking cervical injury and/or observed deficits in cervical sensorimotor and neuromotor function to musculoskeletal injury risk. Longitudinal studies combining imaging measures (e.g., MRI, DEXA), cervical functional test, and prospective injury risk are needed to further explore the correlation between resultant cervical sensorimotor deficits following contact sport impacts and future musculoskeletal injury risk.

The Bárány Society position on 'Cervical Dizziness'

This paper describes the Bárány Society Classification OverSight Committee (COSC) position on Cervical Dizziness, sometimes referred to as Cervical Vertigo. This involved an initial review by a group of experts across a broad range of fields, and then subsequent review by the Bárány Society COSC. Based upon the so far published literature, the Bárány Society COSC takes the view that the evidence supporting a mechanistic link between an illusory sensation of self-motion (i.e. vertigo - spinning or otherwise) and neck pathology and/or symptoms of neck pain - either by affecting the cervical vertebrae, soft tissue structures or cervical nerve roots - is lacking. When a combined head and neck movement triggers an illusory sensation of spinning, there is either an underlying common vestibular condition such as migraine or BPPV or less commonly a central vestibular condition including, when acute in onset, dangerous conditions (e.g. a dissection of the vertebral artery with posterior circulation stroke and, exceedingly rarely, a vertebral artery compression syndrome). The Committee notes, that migraine, including vestibular migraine, is by far, the commonest cause for the combination of neck pain and vestibular symptoms. The committee also notes that since head movement aggravates symptoms in almost any vestibular condition, the common finding of increased neck muscle tension in vestibular patients, may be linked as both cause and effect, to reduced head movements. Additionally, there are theoretical mechanisms, which have not been explored, whereby cervical pain may promote vaso-vagal, cardio-inhibitory reflexes and hence by presyncopal mechanisms, elicit   transient   disorientation and/or imbalance. The committee accepts that further research is required to answer the question as to whether those rare cases in which neck muscle spasm is associated with a vague sense of spatial disorientation and/or imbalance, is indeed linked to impaired neck proprioception. Future studies should ideally be placebo controlled and double-blinded where possible, with strict inclusion and exclusion criteria that aim for high specificity at the cost of sensitivity. To facilitate further studies in "cervical dizziness/vertigo", we provide a narrative view of the important confounds investigators should consider when designing controlled mechanistic and therapeutic studies. Hence, currently, the Bárány COSC refrains from proposing any preliminary diagnostic criteria for clinical use outside a research study. This position may change as new research evidence is provided.

The Enduring Controversy of Cervicogenic Vertigo, and Its Place among Positional Vertigo Syndromes

The idea of cervicogenic vertigo (CV) was proposed nearly a century ago, yet despite considerable scrutiny and research, little progress has been made in clarifying the underlying mechanism of the disease, developing a confirmatory diagnostic test, or devising an appropriately targeted treatment. Given the history of this idea, we offer a review geared towards understanding why so many attempts at clarifying it have failed, with specific comments regarding how CV fits into the broader landscape of positional vertigo syndromes, what a successful diagnostic test might require, and some practical advice on how to approach this in the absence of a diagnostic test.

Short-term effects of an upper cervical spine traction-manipulation program in patients with cervicogenic dizziness: A case series study

BACKGROUND

Damage on the somatosensory system could cause sensation of dizziness, a condition known as cervicogenic dizziness (CD). Manual physical therapy has shown beneficial effects, relieving the symptoms of cervicogenic dizziness. However, the effect of upper cervical spine manipulation is unknown, as this is a technique that respects the International Federation of Orthopedic Manipulative Physical Therapists (IFOMPT) safety criteria.

OBJECTIVE

To assess the effects of upper cervical spine traction-manipulation in subjects with cervicogenic dizziness.

METHODS

This was a descriptive case series study. Treatment focused on the upper cervical spine manipulation procedure. Evaluation was performed before and after the treatment. Variables recorded include upper and lower cervical range of motion, Cervical Flexion-Rotation Test (CFRT), dizziness intensity and cervical pain (VAS), self-perceived dizziness measured with Dizziness Handicap Inventory (DHI) and subjective perception of outcome (GROC-scale).

RESULTS

Ten subjects were recruited. After the treatment protocol, there was an increased range of movement towards the most restricted side, as measured by the CFRT (p< 0.001), decreased intensity of dizziness (p< 0.001) and intensity of pain (p< 0.001). Functional capacity also improved after the intervention (p< 0.011).

CONCLUSION

Upper cervical spine manipulation may decrease dizziness intensity and cervical pain and improve functional ability and upper cervical spine mobility in patients with cervicogenic dizziness.

Osteopathic manipulative treatment in individuals with vertigo and somatic dysfunction: a randomized, controlled, comparative feasibility study

Context

There is a paucity of research assessing the efficacy of osteopathic manipulative treatment (OMT) in patients with vertigo.

Objective

To assess the feasibility of conducting a randomized, controlled trial comparing OMT and vestibular rehabilitation therapy (VRT), alone or in combination, in patients with vertigo and somatic dysfunction.

Methods

Volunteers with vertigo who were also diagnosed with somatic dysfunction (SD) were prospectively enrolled in a blinded, randomized, controlled cohort comparative effectiveness study and assigned to 1 of 4 groups: OMT alone, VRT alone, a combination of OMT and VRT (OMT/VRT), or a nonintervention control group. Participants between 18 and 79 years of age were included if they had experienced symptoms of vertigo for at least 3 months' duration, demonstrated somatic dysfunction, and could participate in computerized dynamic posturography (CDP) testing, tolerate manual therapy and exercises, and communicate effectively in English or Spanish. A total of 3 treatments lasting 45 minutes each were administered 1 week apart to each participant. OMT in this study consisted of counterstrain, myofascial release, balanced ligamentous tension, soft tissue, HVLA, and articulatory techniques. Comparisons were made between composite scores (CS) assessed with computerized dynamic posturography (CDP), dizziness handicap inventory (DHI), optometric evaluation, and osteopathic structural examinations collected before the first treatment, after the third/final treatment, and 3 months after the final treatment. (ClinicalTrials.gov number NCT01529151).

Results

A total of 23 patients were included in the study: 7 in the OMT group, 5 in the VRT group, 6 in the OMT/VRT group, and 5 in the control group. The OMT/VRT group demonstrated significant improvement in DHI score (P=0.0284) and CS (P=0.0475) between pre- and 3-month posttreatment measures. For total severity, improvements were significant in the OMT group both from pretreatment to immediate posttreatment measures (P=0.0114) and from pretreatment to 3-month posttreatment measures (P=0.0233). There was a statistical difference between the OMT and control groups from pretreatment to 3-month posttreatment DHI scores (P=0.0332). Also, there was a statistical difference in DHI score between VRT and control from pre- to 3-month posttreatment scores (P=0.0338). OMT/VRT statistically and clinically improved visual acuity in patients' right eyes from pre- to posttreatment (P=0.0325). In all participants, vergence dysfunction was prevalent (5; 21.7%) in addition to vertical heterophoria (15; 65.2%).

Conclusion

A combination of OMT and VRT significantly reduced vertigo and improved balance 3 months after treatment (P<0.05). There was a high prevalence in vergence and vertical heterophoria, which are not typical screening measurements used by physical therapists and physicians to assess vertigo patients. With a small sample size, this study demonstrated the feasibility of an interdisciplinary team evaluating and treating patients with vertigo in a community setting. A larger study is needed to assess the efficacy of OMT/VRT in vertigo patients.

Postural Control in Lyric Singers

BACKGROUND

Singers are unique musicians because they use their whole body as a musical instrument. Posture and proprioception are key components for a robust and healthy voice.

OBJECTIVE

This study aimed to analyze the postural control of lyric singers in different sensorimotor conditions.

METHODS

Seventeen lyric singers were compared to a control group of 12 participants in static postural control test in eyes open (C1) and eyes closed (C2) conditions. Postural control of singers was also assessed in four specific singing conditions: singing posture eyes open (C3) and eyes closed (C4), vocalization (C5) and free aria (C6), low values being representative of good postural control. Singers also completed the Singing Voice Handicap Index (SVHI) French version, low scores reflecting a good SVHI result.

RESULTS

No significant difference was observed between the two groups in C1 and C2. Postural control of singers was more accurate in C3 than in C1. Increased values in all postural parameters were seen in the singing conditions. Scores obtained at the SVHI were correlated to the area covered by the center of foot pressure in C5, low scores at the SVHI being correlated with low area values in this postural condition.

CONCLUSIONS

Singing is a multitask situation which involves several movements including breathing, and management of factors such as stress. This can affect balance and so rigorous work on posture and proprioception is required as soon as a singer begins to perform in order to take care of the voice.

Balance problems and dizziness after neck surgery - associations with pain and health-related quality of life

Introduction: Symptoms of dizziness or imbalance are often present in individuals with a variety of neck-disorders. The aims of this study were to determine the prevalence of patient-reported balance problems and dizziness 10-13 years after surgery for cervical degenerative disc disease; evaluate associations with neck pain and health-related quality of life; and investigate how these individuals described dizziness. Material and methods: Sixty-eight individuals, 10 years or more after anterior cervical decompression and fusion surgery, who previously participated in a randomized controlled trial were included. Participants completed questionnaires including ratings of dizziness and balance problems, the Dizziness Handicap Inventory, and an open-ended question regarding their experience of dizziness. Secondary outcomes were neck pain and quality of life. Results: Seventy-two percent experienced occasional or daily symptoms of unsteadiness and/or dizziness. Intensity ratings for dizziness during movement and for balance problems were similar and rather low, but had an impact on quality of life. Ratings of dizziness at rest were even lower. Dizziness ratings were associated with neck pain. Strenuous activities were related to dizziness and dizziness was primarily described as intermittent and non-rotatory. Conclusions: Dizziness or balance problems in the long-term after surgery for cervical degenerative disc disease are common and have an impact on daily life. Ratings of problem frequency and intensity were usually low. Dizziness and balance problems may affect quality of life. Patients' descriptions of these problems are in line with common symptoms of cervicogenic dizziness.

Cervical Intervertebral Disc Degeneration Contributes to Dizziness: A Clinical and Immunohistochemical Study

OBJECTIVES

Dizziness often happens in patients with chronic neck pain with only cervical disc degeneration but without cervical radiculopathy or myelopathy. We prospectively selected a series of patients who showed cervical disc degeneration with concomitant chronic neck pain and intractable dizziness who did not respond to conservative treatment to test a new diagnostic method for this dizziness, to analyze the results of anterior cervical discectomy and fusion (ACDF) surgery based on the test, and to explore its pathogenesis.

METHODS

Seventy-seven patients who had a transient neck pain and dizziness relief after injection of bupivacaine into a suspected disc were included in the study. In total, 52 underwent ACDF as surgery group, and 25 refused surgery and accepted conservative treatments as conservative group from June, 2015 to October, 2016 with subsequent follow-up to 1 year. The outcomes were visual analogue scale for neck pain, Neck Disability Index, and intensity and frequency of dizziness. During ACDF, the 72 specimens of degenerative cervical discs were collected to determine the innervation in degenerative cervical discs immunohistochemically.

RESULTS

After surgery, the patients experienced a significant reduction in neck pain and dizziness. Symptomatic relief in surgery group was obviously better than conservative group at each time point of follow-up (P = 0.001). Ruffini corpuscles and substance P-positive free nerve fibers were obviously increased in the number and deeply ingrown into the inner degenerative cervical discs.

CONCLUSIONS

Current clinical and immunohistochemical studies strongly suggest that chronic neck pain and intractable dizziness in this series of patients stem from the degenerative cervical discs.

Cervical Vertigo: Historical Reviews and Advances

Vertigo is one of the most common presentations in adult patients. Among the various causes of vertigo, so-called cervical vertigo is still a controversial entity. Cervical vertigo was first thought to be due to abnormal input from cervical sympathetic nerves based on the work of Barré and Liéou in 1928. Later studies found that cerebral blood flow is not influenced by sympathetic stimulation. Ryan and Cope in 1955 proposed that abnormal sensory information from the damaged joint receptors of upper cervical regions may be related to pathologies of vertigo of cervical origin. Further studies found that cervical vertigo seems to originate from diseased cervical intervertebral discs. Recent research found that the ingrowth of a large number of Ruffini corpuscles into diseased cervical discs may be related to vertigo of cervical origin. Abnormal neck proprioceptive input integrated from the signals of Ruffini corpuscles in diseased cervical discs and muscle spindles in tense neck muscles secondary to neck pain is transmitted to the central nervous system and leads to a sensory mismatch with vestibular and other sensory information, resulting in a subjective feeling of vertigo and unsteadiness. Further studies are needed to illustrate the complex pathophysiologic mechanisms of cervical vertigo and to better understand and manage this perplexing entity.

Mechanoreceptors in Diseased Cervical Intervertebral Disc and Vertigo

STUDY DESIGN

We collected the samples of cervical intervertebral discs from patients with vertigo to examine the distribution and types of mechanoreceptors in diseased cervical disc.

OBJECTIVE

The aim of this study was to determine whether mechanoreceptors are distributed more abundantly in cervical discs from patients with cervical spondylosis, and whether they are related to vertigo.

SUMMARY OF BACKGROUND DATA

Previous limited studies have found that normal cervical intervertebral discs are supplied with mechanoreceptors that have been considered responsible for proprioceptive functions. Several clinical studies have indicated that the patients with cervical spondylosis manifested significantly impaired postural control and subjective balance disturbance.

METHODS

We collected 77 samples of cervical discs from 62 cervical spondylosis patients without vertigo, 61 samples from 54 patients with vertigo, and 40 control samples from 8 cadaveric donors to investigate distribution of mechanoreceptors containing neurofilament (NF200) and S-100 protein immunoreactive nerve endings.

RESULTS

The immunohistochemical investigation revealed that the most frequently encountered mechanoreceptors were the Ruffini corpuscles in all groups of cervical disc samples. They were obviously increased in the number and deeply ingrown into inner annulus fibrosus and even into nucleus pulposus in the diseased cervical discs from patients with vertigo in comparison with the discs from patients without vertigo and control discs. Only three Golgi endings were seen in the three samples from patients with vertigo. No Pacinian corpuscles were found in any samples of cervical discs.

CONCLUSION

The diseased cervical discs from patients with vertigo had more abundant distribution of Ruffini corpuscles than other discs. A positive association between the increased number and ingrowth of Ruffini corpuscles in the diseased cervical disc and the incidence of vertigo in the patients with cervical spondylosis was found, which may indicate a key role of Ruffini corpuscles in the pathogenesis of vertigo of cervical origin.

LEVEL OF EVIDENCE

1.

Cervicocephalic relocation test to evaluate cervical proprioception in adolescent idiopathic scoliosis

PURPOSE

Adolescent idiopathic scoliosis (AIS) is a three-dimensional deformity of the spine associated with disturbed postural control. Cervical proprioception participates in controlling orthostatic posture via its influence on head stabilization. We hypothesized that patients with AIS exhibit altered cervical proprioception.

METHODS

We conducted a case-control study to evaluate cervical proprioception using the cervicocephalic relocation test (CRT) in 30 adolescents with AIS (15.5 ± 1.5 years; Cobb 24.8° ± 9.5°) versus 14 non-scoliotic controls (14.6 ± 2.0 years). CRT evaluates cervical proprioception by measuring the capacity to relocate the head on the trunk after active rotation of the head in the transversal plane without visual control. Each subject performed ten right and then ten left head rotations.

RESULTS

The CRT results were pathological in 12 AIS patients (40 %). The CRT mean was significantly different between AIS patients with a pathological CRT (5° ± 1.4° for right rotation; 4.2° ± 0.9° for left rotation) compared with AIS patients with a normal CRT (2.7° ± 0.6° for right rotation; 2.9° ± 0.8° for left rotation) or with the control group (3.5° ± 2.1° for right rotation; 3.1° ± 1.2° for left rotation).

CONCLUSION

Cervical proprioception is impaired in certain AIS patients. This anomaly may worsen the prognosis of AIS (headache; balance disorders; worsened spinal deformity; complication after spinal fusion). We recommend systematic screening for altered cervical proprioception in AIS patients.

Greater Cervical Muscle Fat Infiltration Evaluated by Magnetic Resonance Imaging is Associated With Poor Postural Stability in Patients With Cervical Spondylotic Radiculopathy

STUDY DESIGN

A population-based, cross-sectional study.

OBJECTIVE

The aim of this study was to quantitatively evaluate the relationship between static postural stability and fat infiltration within cervical multifidus muscle in patients with cervical spondylotic radiculopathy (CSR).

SUMMARY OF BACKGROUND DATA

CSR causes denervation by compression of nerve roots. This denervation is detected by fatty infiltration or results in fatty infiltration within muscles. Proprioceptive information in cervical multifidus muscle plays an important role in coordinated movement of postural stability; however, there have been few studies evaluating the relationship between postural stability and fat infiltration within cervical multifidus muscle among CSR patients.

METHODS

Sixteen CSR patients with C6 injuries and 25 age-matched healthy controls underwent magnetic resonance images to examine bilateral cervical multifidus muscle. For evaluation of fat within muscle, a muscle fat index (MFI) was calculated by using both measurement of cervical multifidus muscle and intermuscular fat. Participants' postural stability at upright position with eyes-opened and eyes-closed for 60 seconds was examined by a platform. Two parameters, the total length and the area of the center of pressure (COP), were used for evaluation.

RESULTS

The CSR group showed significantly poorer postural stability than the control group (eyes-opened the total length; P < 0.05, eyes-closed the total length; P < 0.05, eyes-closed the area; P < 0.05). There were significant group differences at C4, C5, and C6 MFI (P < 0.05). In the CSR group, a correlation analysis demonstrated that the age, C4, C5, and C6 MFI values were significantly associated with the eyes-closed the total length of the COP (P < 0.05).

CONCLUSIONS

Fat infiltration within muscle could lead to inhibition of normal activity of musculature. The present study suggests that fat within cervical multifidus muscle could directly cause postural instability in static standing, even though the proprioceptive information has normal lower limbs.

Cervicogenic causes of vertigo

PURPOSE OF REVIEW

Herein we discuss the recent literature concerning cervicogenic vertigo including vertigo associated with rotational vertebral artery syndrome, as well as whiplash and degenerative disturbances of the cervical spine. We conclude with a summary of progress regarding diagnostic methods for cervicogenic vertigo.

RECENT FINDINGS

Several additional single case studies of the exceedingly rare rotational vertebral artery syndrome have been added to the literature over the last year. Concerning whiplash and degenerative disturbances of the cervical spine, four reviews were published concerning using physical therapy as treatment, and two reviews reported successful surgical management. Publications regarding diagnostic methodology remain few and unconvincing, but the cervical torsion test appears the most promising.

SUMMARY

Little progress has been made over the last year concerning cervicogenic vertigo. As neck disturbances combined with dizziness are commonly encountered in the clinic, the lack of a diagnostic test that establishes that a neck disturbance causes vertigo remains the critical problem that must be solved.