Cervicogenic Vertigo Following
Whiplash Injury
George Rappard, MD
Cervicogenic vertigo is a common but under
diagnosed manifestation of a whiplash mechanism of injury to the neck. Understanding the temporal relationship to
the injury, mechanism, differential diagnosis and potential therapies are key
to the effective diagnosis and treatment of this entity. As many cases of whiplash involve automobile
accidents, it's important to document the presence of cervicogenic vertigo as
an objective manifestation of a cervical acceleration-deceleration injury.
Vertigo is defined as a sensation of disequilibrium,
often characterized as dizziness.
Vertigo is different from dizziness in that the hallmark of vertigo is a
sensation of motion where no motion exists, whereas dizziness is a sensation of
unsteadiness. For example, a patient
with true vertigo will experience a sensation that the room is spinning, or
that the floor is tilting. Often,
symptoms can be brought about by rapid head turning.
Cervicogenic vertigo is felt to be brought
on by injury to proprioceptive afferents, or specialized nerve receptors, in the paraspinal musculature or upper
cervical facet joints1. 30% of these receptors lie in the facet
joints2. The job of these receptors is to relay
information to the brain as to the head’s position on the neck. When there is a substantial enough of an
injury discharges from these receptors are disturbed. Spatial disorientation and vertigo results
from this abnormal discharge3. In order to injure these receptors, one can
see that there has to be a substantial enough of an injury to the facet joints
and paraspinal soft tissues that they lie in.
As a result of an injury to these structures, there is an alteration of
normal sensation and relay of positional inputs from these specialized receptors. Therefore, a substantial enough of an injury
mechanism to result in pain from paraspinal soft tissue injury or facet
capsular injury must be present; In other words, there is usually substantial
neck pain. The diagnosis of cervicogenic
vertigo should be suspected when there has been a substantial mechanism, such
as whiplash, and there is neck pain.
Keep in mind, substantial injury mechanism does not mean a high speed
rear end collision. Studies have shown
that even a low speed collision can result in substantial G-forces to the neck. White and Punjabe showed how an 8mph rear end
collision can result in a 5 G force acceleration to a vehicle occupant’s head4.
Perhaps one reason why cervicogenic
vertigo is under appreciated is that it may not manifest itself until the late subacute
or chronic phase following a whiplash mechanism of injury. It is estimated that vertigo with late onset
is seen in up to 58% of patients after closed head injury and whiplash injury5. Appearing later in a patient’s course,
vertigo may be eclipsed by the early and persistent appearance of neck pain
after whiplash. In the presence of a
closed head or concussive injury cervicogenic vertigo may be confused with a
post-concussion syndrome. In this case,
the absence of typical post-concussive findings can exclude vertigo as a
manifestation of a post-concussive injury.
When a closed head injury and neck pain co-exist, the distinction is
difficult but probably more academic than anything else, from a practical
perspective. The key to diagnosis is the
exclusion of other causes and the temporal relationship between vertigonous
symptoms and the injury mechanism.
Exclusion of other causes will be discussed below. When there is a subacute injury mechanism,
such as a motor vehicle accident and neck pain, cervicogenic vertigo should be
high on the differential diagnosis.
There is a broad differential diagnosis
for vertigo. Spontaneous vertigo may
commonly be due to an inner ear problem, such as Menier’s disease,
labrynthitis, (seen after viral infections), or benign paroxysmal positional vertigo
(BPPV). Further evaluation can be
carried out. Menier’s is associated with
hearing loss and audiometry may be helpful. Take note that a similar low tone sensineurial
hearing loss can be seen in a whiplash injury with associated dural sleeve tear
and CSF leak6. To make matters more confusing, cervicogenic
vertigo may be associated with a high pitched tinnitus3. In BPPV,
the Dix-Hallpike maneuver may be positive.
Wrisley et al describe an algorithm for working up suspected cervicogenic
vertigo patients5. First, patients must have neck pain to be
considered for the diagnosis. The
Dix-Hallpike test can then ascertain which patients suffer from BPPV. In patients with a negative Dix-Hallpike, or
a similar tilt table maneuver, (therefore negative for BPPV) vestibular testing
can determine which subset of patients may be suffering from vestibular
disorders. In this algorithm of
exclusion, with negative BPPV and vestibular testing, and the presence of neck
pain, cervicagenic vertigo can be entertained as the diagnosis. As an additional test, the rotating stool
examination may be helpful. A patient
sits on a rotating stool, the head is immobilized in the examiner’s hands and
the neck and trunk is rotated under the head.
In a positive test for cervicogenic vertigo nystagmus is produced. Lastly, the cervicogenic vertigo patient may
be unaware of maintaining their head in a non-neutral position, they may
possess a head tilt3. It’s the author’s opinion that despite a wide
differential the diagnosis can still be made somewhat empirically. In the absence of a viral infection, hearing
loss, a tremendous injury mechanism and associated neurological findings
cervicogenic vertigo remains the most medically reasonable diagnosis based on its
high prevalence relative to the other differential diagnosis, especially with
confirmatory physical examination findings.
In addition to the above differential work
up, I would add that with a history of a significant injury mechanism one must
also evaluate for the presence of a vertebral artery injury. The vertebral artery is relatively fixed as
it travels through the foramen transversarium of the vertebra. As such, it is susceptible to injury from
shear, flexion-extension or rotational forces.
These injuries are usually associated with substantial force. In such cases one can elicit a history of
other vertebrobasilar symptoms, such as dysmetria, diplopia, disequilibrium or
sensory and motor deficits. If the index
of suspicion is high a CT angiogram of the vertebral arteries can be performed
to exclude the diagnosis. MRA can be
performed but may be less sensitive.
Once the diagnosis is established by ruling
out other entities and establishing the temporal relationship between the
injury mechanism and the onset of symptoms one can initiate treatment of the
patient’s cervicogenic vertigo. In most
cases, treatment of cervicogenic vertigo is identical to the treatment of the
patient’s underlying neck pain. Since
the injury to proprioceptive cervical inputs co-exist with cervical paraspinal
soft tissue and joint capsule injury, it makes sense that therapies that might relieve
these structures might also relieve cervicogenic vertigo. Cervical manipulation and mobilization have
been described in the treatment of cervicogenic vertigo2. Physical
therapy7, with and without vestibular
rehabilitative therapy has also been described5. In this case vestibular rehabilitation is
rendered by a qualified therapist. Meclizine,
a now over the counter anti-vertigo medication, may provide symptomatic relief.
Lastly, cervical facet blocks might theoretically improve cervicogenic vertigo,
by anesthetizing the afferent inputs, although this has not been proven.
Vertigo following a cervical
acceleration-deceleration, or whiplash injury, is common. The diagnosis is made based on symptoms,
temporal relationship to the injury mechanism and exclusion. Treatment parallels the treatment of the
patient’s neck pain. In establishing the
presence of a substantial neck injury cervicogenic vertigo is an important
factor. Injury to the neural
proprioceptive inputs is not seen without substantial cervical paraspinal or
facet capsular injury. Cervicogenic
vertigo can thus be both disabling and a testimonial to the substantial nature
of a whiplash injury. Treatment
parallels the treatment of the painful paraspinal and cervical facet joint
injuries that result in cervicogenic vertigo.
Reference List
1. Brown JJ. Cervical contribution to balance: cervical vertigo. In: Berthoz
A, Graf W, and Vidal P. The Head-Neck Sensory Motor System. New York: Oxford University Press; 1992;
2. Cote P, Mior SA, Fitz-Ritson D. Cervicogenic vertigo: a report of 3 cases. The journal of the CCA 1991;35:89-94
3. McKecnie B. Cervicogenic
vertigo. 2013. Online source.
4. White AA, Panjabe NM. Clinical
biomechanics of the spine. New York: JB Lippencott; 1978; 153-158
5. Wrisley DM, Sparto PJ, Whitney SL, et al. Cervicogenic dizziness:
a review of diagnosis and treatment. J Orthop
Sports Phys Ther 2000;30:755-66
6. Schievink WI. Spontaneous spinal cerebrospinal fluid leaks and
intracranial hypotension. JAMA
2006;295:2286-96
7. Fitz-Ritson D.
Phasic exercises for cervical rehabilitation after "whiplash" trauma.
J Manipulative Physiol Ther
1995;18:21-24
