Cervical and otolith vertigo

Anterior cervical discectomy and fusion to treat cervical instability with vertigo and dizziness: A single center, retrospective, observational study

Purpose

The current study attempts to investigate the role of anterior cervical discectomy and fusion (ACDF) in alleviating symptoms in patients with cervical vertigo associated with cervical instability.

Methods

The patients of cervical instability with vertigo and dizziness who underwent ACDF between January 2011 and December 2019 were followed-up for more than two years. Demographic data (age, sex, follow up period and levels of instable cervical segments) were assessed; Symptoms of vertigo and dizziness before and after surgery were assessed by the 15-item version of the Vertigo Symptom Scale (VSS) and the 25-item Dizziness Handicap Inventory (DHI). The severity and frequency of other symptoms like neck and occipital pain, gastrointestinal discomfort, nausea, vomiting, tinnitus, palpitations, headache, diplopia and blurring of vision before and after surgery were also assessed.

Results

A total of 92 patients underwent ACDF for cervical instability with vertigo and dizziness between January 2011 and December 2019, of which 79 patients were included in the final analysis. The number of instable levels had no correlation with VSS and DHI scores before surgery (p > 0.05), while patients with C3/4 instability suffering a severer vertigo than other levels. Both DHI and VSS scores were significantly reduced after ACDF and this was sustained within two years after surgery (p < 0.001). Although there was no statistical difference in the ratio of patients with vertigo relief, patients with one-level cervical instability demonstrated a more rapid recovery than patients with multi-level cervical instability (p = 0.048). Also, there was improvement in other symptoms such as neck and occipital pain, gastrointestinal discomfort, nausea, vomiting, tinnitus, palpitations, headache and blurring of vision after surgery.

Conclusions

Vertigo caused by C3/4 instability was severer than other levels such as C4/5 and C5/6. During 2 years' follow-up the significant relief of vertigo and dizziness was observed after anterior cervical surgery. Other accompanying symptoms except hypomnesia were also extenuated in follow-up period.

Importance of cervicogenic general dizziness

A 15-month retrospective study of 1,000 outpatients was conducted to determine the exact cause of general dizziness. The most common diagnosis in all analyzed cases was cervicogenic general dizziness (89%). The majority of the patients who underwent magnetic resonance imaging of the cervical spine had narrow spinal canals. Measuring the anteroposterior diameter of the spinal canal in each case was critical to obtain an accurate diagnosis in line with the diagnostic criteria used. General dizziness may develop because of inappropriate neck posture over long periods of time in individuals with some form of underlying cervical disease. The causes of general dizziness were different between male and female patients and between patients of different age groups. Triggers leading to general dizziness included engaging in farming, gardening, or weeding activities for long periods of time, particularly in elderly women. Selection of the appropriate muscle relaxant type and dosage is important in the treatment of patients with cervicogenic general dizziness who also experience a stiff neck and shoulders. Following treatment, 90% of patients no longer experienced general dizziness or exhibited clear improvements in their symptoms within 1 week. The results of this study emphasize the importance of cervicogenic general dizziness, which is due to cervical vertebral lesions and is exacerbated by excessive stress on the cervical spine.

Abnormal postural reflexes in a patient with pontine ischaemia

The control of body posture is a complex activity that needs a very close relationship between different structures, such as the vestibular system, and the muscle and joint receptors of the neck. Damage of even one of these structures can lead to abnormal postural reflexes. We describe a case of a woman with a left pontine ischaemia who developed a 'dystonic' extensor posture of the left limbs while turned on the right side. This clinical picture differs from previous reports on the subject, and may relate to ischaemic damage of a pontine structure involved in posture control, or of adjacent neural connections to be yet identified. To the best of our knowledge, this is the first case reported in the literature. Clinical examples of an altered interplay between vestibular and neck receptors are rare.

Benign paroxysmal positional vertigo after dental surgery

We investigated the relationship between dental and maxillofacial surgery and benign paroxysmal positional vertigo (BPPV). BPPV represents the most frequent cause of vertigo of labyrinthine origin. BPPV has been reported following surgical trauma from various surgical interventions, regarding anatomical site and technical execution. A surgical origin is, in many cases, supported by the temporal relation to the surgical intervention as well as by the clinical picture. We considered eight BPPV cases of suspected iatrogenic origin focusing our attention on dental surgery with particular reference to surgical extraction of included teeth through rotating tools. The cases taken into account had no other inner ear disease and BPPV risk indicator. We conclude that dental surgery is a risk factor for BPPV.

Temporomandibular disorders, head and orofacial pain: cervical spine considerations

Head and orofacial pain originates from dental, neurologic, musculoskeletal, otolaryngologic, vascular, metaplastic, or infectious disease. It is treated by many health care practitioners, such as dentists, oral surgeons, and physicians. The article focuses on the nonpathologic involvement of the musculoskeletal system as a source of head and orofacial pain. The areas of the musculoskeletal system that are reviewed include the temporomandibular joint and muscles of mastication--collectively referred to as temporomandibular disorders (TMDs) and cervical spine disorders. The first part of the article highlights the role of physical therapy in the treatment of TMDs. The second part discusses cervical spine considerations in the management of TMDs and head and orofacial symptoms. It concludes with and overview of the evaluation and treatment of the cervical spine.

Neck afferent involvement in cardiovascular control during movement

It is well established that labyrinth and neck afferent information contributes to the regulation of somatomotor function during movement and changes in posture. There is also convincing evidence that the vestibular system participates in the modulation of sympathetic outflow and cardiovascular function during changes in posture, presumably to prevent orthostatic hypotension. However, the labyrinth organs do not provide any signals concerning body movements with respect to the head. In contrast, the neck receptors, particularly muscle spindles, are well located and suited to provide information about changes in body position with respect to the head and vestibular signals. Studies in the cat suggest that neck afferent information may modulate the vestibulosympathetic reflex responses to head-neck movements. There is some evidence in the cat to suggest involvement of low threshold mechanoreceptors. However, human studies do not indicate that low threshold mechanoreceptors in the neck modulate cardiovascular responses. The human studies are consistent with the studies in the cat in that they demonstrate the importance of otolith activation in mediating cardiovascular and sympathetic responses to changes in posture. This paper briefly reviews the current experimental evidence concerning the involvement of neck afferent information in the modulation of cardiovascular control during movement and changes in posture.

Oculomotor dysfunction in rheumatoid patients with upper cervical dislocation

Several studies of patients with chronic cervical pain and chronic whiplash syndrome report a high frequency of oculomotor function derangements pointing towards brainstem involvement and/or default sensory input from neck afferents. In light of these reports, it seems important to investigate other patient groups with similar upper cervical spine disorders. In this study, voluntary eye motor performance was evaluated in 11 rheumatoid patients (RA) with upper cervical dislocation and a clearly noticed joint affection of the cervical spine. The results were compared with 6 RA patients without cervical engagement and normal individuals. Nine of the 11 patients with atlanto-axial dislocation showed pronounced oculomotor disturbances of smooth pursuits compared with only minor changes in the control group. The pattern of oculomotor dysfunction in patients with rheumatoid cervical dislocation indicates brainstem involvement, which may be an early sign of brainstem affection/myelopathy.

Benign paroxysmal positional vertigo

Benign paroxysmal positional vertigo (BPPV) has received renewed clinical interest. At the Johns Hopkins Otological Vestibular Laboratory, 781 patients were tested on more than one occasion between September 1976 and November 1992. Of these patients, 187 (24%) were found to have positional nystagmus consistent with a diagnosis of BPPV. A retrospective analysis of these patients' records, including vestibular test and eye movement reports, audiograms, questionnaires, and hospital charts was performed. After this review, the nystagmus, initially diagnosed as due to BPPV, was believed to be a manifestation of another disease process in 36 cases. Of the remaining 151 cases, 52 (34%) presented with no significant preceding disorder and have been termed primary BPPV. In the remaining 99 patients we found coexisting or associated disorders which included Meniere's disease, head trauma, prior ear surgery, vestibular neuronitis, migraine, and others. Forty-five of these 151 patients (31%) had an associated diagnosis of Meniere's disease. To our knowledge a significant association between Meniere's disease and BPPV has not been reported. A review of the literature with discussion of BPPV and the associated disorders is offered.

Head extension effect in static posturography

The effect of head extension on the standing position has been studied by analysis of recordings made by static posturography type III (SPGIII), a set of six test of posturography for sensory interaction. The head extension effect in posturography was evaluated by comparing the results of testing with head extension on a stable platform and on foam rubber to testing with a normal head position. In normal subjects head extension increased the postural sway, but there was no more effect on foam rubber than on the stable platform. For patients with peripheral vestibular disorders the head extension effect on the measured postural sway was evaluated by the difference from the normal condition. This difference could be positive, zero, or negative on the stable platform as well as on foam rubber. In both patients and normal subjects, foam rubber had no more effect than the stable platform. The several types of results could be seen in each category of peripheral vestibular disorders. Only minor nuances could be observed: positive differences were more pronounced in benign paroxysmal positional vertigo, whereas negative ones were more obvious in unilateral vestibular deficits. These findings, moreover, deny that head extension in SPGIII should be considered a condition revealing vestibular dysfunction, as has been supposed. As head extension has an influence on the neck proprioceptor as well as on the position of the otoliths, its effect is ambiguous, which makes the interpretation rather difficult. A neck proprioceptive as well as an otolithic explanation appears to have some clinical support.

Particle repositioning maneuver for benign paroxysmal positional vertigo

Benign paroxysmal positional vertigo is a common, most often self-limited, vestibular end organ disorder that in some cases may be quite disabling. Recent evidence suggests that some, if not most, cases result from free-floating posterior semicircular canal endolymph particles. We postulate that the particle repositioning maneuver displaces these particles from the posterior canal through the common crus into the utricle, where they no longer induce pathologic responses. Our report focuses on 38 consecutive patients treated with this simple bedside technique during a 10-month period. On follow-up, 26 patients (68.4%) were free of disease, 4 (10.5%) were significantly improved, 4(10.5%) remained unchanged, and 4(10.5%) were lost to follow-up. Of the 4 patients who remained unchanged, 2 underwent successful posterior semicircular canal occlusions. The direction of the nystagmus during the second stage of the maneuver appears important in predicting the efficacy, with reversal of nystagmus denoting a poor response. These findings provide additional insight into the pathophysiology of this disorder.

Influences of neck receptors on soleus motoneuron excitability in man

We studied the influence of the asymmetric tonic neck reflexes on the excitability of the human soleus motoneuronal pool by mapping the H amplitude as a function of rotation of the body relative to the fixed head. Eight normal adult volunteers were tested. On each subject 15 consecutive H reflexes were recorded from the right soleus muscle, for each of the following test position, 4 degrees, 8 degrees, 12 degrees, 16 degrees, as well as at the control position (0 degrees), both before and after each change in body position. Our results showed that the H reflex amplitude was progressively facilitated for contralateral rotation in respect to the recording side and conversely inhibited for ipsilateral rotation. The results indicate that neck receptors of one side enhance the excitability of the contralateral soleus motoneurons and depress the ipsilateral ones.

Intravenous digital subtraction angiography for patients with positional nystagmus

Thirty cases of intractable positional vertigo were studied by means of digital subtraction angiography (DSA). Benign paroxysmal positional vertigo was not included. DSA allows real time digital subtraction of X-ray transmission data using an image intensifier and television system. Intravenous DSA (IV DSA) was used to compare blood vessel flow in the right and left vertebral arteries. Abnormal findings were noted in 27 patients, with 10 being affected on the left side, 7 on the right, and 10 bilaterally. Twenty-three patients had slight stenosis, and bending and kinking were observed in 17. DSA results were related to the 6 established types of positional nystagmus. DSA is, therefore, considered to be an important tool in the diagnosis and treatment of positional vertigo.

Patterns of primary afferent termination in the external cuneate nucleus from cervical axial muscles in the cat

Using the method of transganglionic transport of horseradish peroxidase (HRP), the distribution of primary afferent projections was examined in the external cuneate nucleus (ECN) from different muscle groups in the forequarter of the cat. The terminal zones of afferent fibers from three shoulder muscles--clavotrapezius, acromiotrapezius, and spinotrapezius--were compared to projections from suboccipital muscles, dorsal neck extensors, and muscles of the proximal forelimb. Each muscle group had a labelled terminal zone that occupied a different subvolume of the ECN. The zone labelled from trapezius muscles formed a continuous column in the ECN running from the caudal pole of the nucleus to a level 3.0 mm rostral to the obex. Terminal zones of suboccipital muscles and dorsal neck extensors formed longer columns that extended into the most rostral tip of the ECN, while those of proximal forelimb muscles formed shorter columns confined to the caudal two-thirds of the ECN. At comparable cross-sectional levels in the caudal and middle portions of the ECN, terminal zones from proximal limb muscles were located most dorsomedially, while those from shoulder muscles, dorsal neck muscles, and suboccipital muscles were located in progressively more ventral and lateral regions. The subvolume of the ECN occupied by projections from cervical axial muscles was estimated to be more than 40% of the volume of the nucleus, suggesting that the ECN has a major role in the transmission of sensory information from axial musculature to the cerebellum. Following exposure of all muscle nerves to tracer, a second labelled zone was also identified close to the ECN in the descending vestibular nucleus at transverse levels 2.0-3.0 mm rostral to the obex. Here, reaction product was concentrated around a circumscribed collection of medium-sized, multipolar cells.

The splenius capitis muscle of the rat, architecture and histochemistry, afferent and efferent innervation as compared with that of the quadriceps muscle

The splenius muscle of the rat was investigated with regard to its structure and innervation. The latter was compared with that of the quadriceps muscle. The results can be summarized as follows: The splenius muscles of both sides form a bipennate muscle plate connecting the occipital bone with the spinous process of the second thoracic vertebra. The lateral parts of both muscles are attached directly to this prominent bony process, whereas the medial parts end in a median raphe which forms a tendinous cranial extension of the second thoracic vertebra. This tendinous extension, showing no connection to the cervical vertebrae, serves also for the attachment of acromio-trapezius muscle fibers. The lateral part of the splenius muscle is divided into two parts by a tendinous intersection. The splenius muscle consists mainly of fast twitch fibers: 55% were characterized as IIB and 40% as IIA fibers by histochemical demonstration of myosin ATPase-activity. A high content of muscle spindles--57 spindles per gram of muscle tissue--was found. Comparing several aspects of the innervation of the splenius to that of the quadriceps muscle, the following results could be obtained: The ratio of motor end plate size to muscle fiber volume is significantly higher in the splenius than in the quadriceps muscle. As demonstrated by transganglionary HRP-transport, the main part of labeled splenius afferents to the spinal cord terminates in the central cervical nucleus. Quadriceps afferents, entering the lower thoracic and upper lumbar segments, mainly end in the area of Clarke's column. Several labeled fibers descend to the sixth lumbar and first sacral segments, where they terminate in the area of Stilling's nucleus. A group of primary afferents from both muscles--most probably III- and IV-afferents--projects to the dorsal laminae of the dorsal horn; terminals from the splenius are accumulated in the lateral parts of these laminae, whereas those of the quadriceps are more concentrated in the medial areas. Within the brain stem, most afferents from the splenius terminate in the external cuneate nucleus. Most of the quadriceps afferents course to the gracile nucleus. Terminals from both muscle nerves were found in the area of the spinal vestibular nucleus. In conclusion, the most conspicuous results were: 1) Besides the segmental projection to the dorsal horn there is an almost exclusive projection of splenius primary afferents to relay nuclei to the cerebellum. 2) The relatively high ratio: end plate size/muscle fiber volume, which is characteristic of finely adjusting muscles.(ABSTRACT TRUNCATED AT 400 WORDS)

A reexamination of "neck reflex" eye movements in the rabbit

Horizontal eye movements of rabbits were recorded during sinusoidal oscillation (15-40 degrees, pk-pk; 0.1-8 Hz) and step displacement of the body in yaw about a fixed head. Modulated, slow-phase eye movements followed all frequencies of stimulus with relatively invariant amplitudes (2-4 degrees). Saccadic movements, up to 17 degrees, accompanied all frequencies of oscillation and particularly step displacements. Saccadic amplitude was unrelated to measurable characteristics of the stimuli but was a function of arousal. The latency of any eye movement was a minimum of 80 msec. It is concluded that none of the observed eye movements provide stabilization during head movements but are evidence of the contribution of neck information to general mechanisms of whole body orientation.

Hind leg ataxia of cervical origin and cervico-lumbar spinal interactions with a supratentorial pathway

1. Unilateral section of the nerves to an extensor muscle of the head, biventer cervicis, leads to an ataxia of the hind legs in cats.2. In chloralose anaesthetized cats, shocks to the central end of the cut biventer cervicis muscle nerves leads to direct discharges over lumbosacral ventral roots, to a facilitation of monosynaptic reflexes in flexor and extensor muscles and to a prolonged inhibition of spino-bulbo-spinal reflexes. Such effects are not unique, but follow stimulation of skin and muscle nerves of the forepaw.3. Supratentorial pathways are involved in descending spinal interactions in the chloralose anaesthetized cat, but are more critical for interactions taking origin in biventer cervicis nerve than in forepaw nerves.4. In non-anaesthetized spinal cats showing interactions from forepaw nerves, no interactions could be found taking origin in biventer cervicis nerves. Descending interactions from forepaw nerves could be reduced or abolished by anaesthetic doses of chloralose.5. The rich pathway from biventer cervicis nerve to the superior colliculus does not appear to be involved in the descending interactions reported here as neither stimulation nor ablation of the superior colliculi has any effect on descending interactions.

Involvement of neck proprioceptive system in visual after-effect from prolonged head tilt

Judgements of object orientation after prolonged head tilt differ relative to those made before tilt. This visual spatial after-effect was investigated with lateral head tilt relative to the upright and supine body. The data from two experiments indicate that the magnitude and direction of the visual after-effect does not differ under the two body postures. It is concluded that the proprioceptive system of the neck, as opposed to the otolith system of the utricle, is involved in the after-effect.