Cervical spondylosis: a cause of dizziness?

GM, 08, 2013.

Dr Imran Malik, Dr Raja Biswas
Cervical spondylosis is a common condition, briefly described as osteroarthritis of the cervical
spine. It arises as a result of age-related dryness of nucleus pulposus and its collapse, causing
bulging of the annulus fibrosus. This causes increased mechanical stress at the cartilaginous end
plates of the vertebral body lip, leading to osteophytic spurs, which helps to stabilise the
hypermobile vertebrae as a result of loss of disc space.5,6
These osteophytes cause cord space narrowing. Age-related hypertrophy of the ligamentum
flavum and thickening of bone may result in further narrowing of the cord space.5
Clinical presentation
Cervical spondylosis affects around 10% in the fourth decade of life and is radiologically present
in more than 95% of people over the age of 70 years, hence a common finding in apparently
healthy individuals above 50 years. It is slightly more prevalent in males.7 It can be
asymptomatic but once symptomatic it produces pressure symptoms mainly on surrounding
structures, especially spinal cord and originating nerves causing cervical myelopathy or
radiculopathy respectively.
It usually presents as intermittent neck and shoulder pain with or without neurological
deficit,5 although one-third of the patients present with headache, often in sub-occipital area
radiating to vertex of the skull.8 Presentation with neurological deficit is usually divided into
three clinical categories:
1. Primarily radiculopathy: Root dysfunction reflected by radicular pain and focal neurological
deficit
2.

Primarily myelopathy: Cord involvement with pyramidal tract signs involving lower limbs

3. Mixed: Root and cord involvement, eg. neck pain with root deficit and clumsy hand along
with spastic paraparesis and gait disturbances.
Some of these symptoms are exacerbated by movements and hence can lead to cervical dystonia
in severe disease.
Mechanism of cervical vertigo and supporting evidence
Vertigo resulting from cervical spondylosis is not a widely accepted phenomenon. It was first
described by Claude Bernard in 1858, followed by Barr in 1926. In cervical spondylosis,
vertigo is normally provoked by head movements, hence the term cervical vertigo. In fact the
vertigo can be relieved by eliminating neck torsion against the head.9

The pathogenesis of cervical spondylosis leading to vertigo presented in the literature is quite
complex and contentious. There are numerous studies in the literature discussing the underlying
aetiology and based on the information from these studies, the pathogenesis is broadly divided
into two major categories.

Neurogenic
Afferent impulses from the neck travel via posterior cervical roots to the vestibular nuclei, which
when intersected in experimental rabbits causes positional vertigo when the head is moved on the
trunk.10 Also the transverse section of suboccipital muscles, surgical deafferentation of C1-C3, or
suboccipital anaesthesia results in locomotor ataxia.
Local anaesthesia of deep posterolateral neck tissue in humans usually elicits a transiently
increased ipsilateral and decreased contralateral extensor muscle tone with a tendency to fall, gait
deviation, and pastpointing towards the injected side.11
In cervical spondylosis, alteration in the cervical afferent flow may be due to the pressure on the
cervical nerve roots by disc protrusions.12
In 1976, Mangat and McDowall investigating the incidence of vertigo in 55 patients with
cervical spondylosis, illustrated the resolution of vertigo and nystagmus with anterior cervical
decompression, and suggested that abnormal afferent flow in the posterior cervical nerves in
patients with cervical spondylosis lead to unstable vestibular tone, which is further upset by neck
torsion.13
Barre et al14 proposed that the irritation of sympathetic nerves around vertebral arteries could
play a part in production of vertigo and nystagmus as a result of cervical osteophytes, since
vertigo in Meniere's disease can successfully be treated with cervical sympathectomy.
Vasogenic
The vertebrobasilar circulation supplies the vestibular labyrinth, VIII nerve, brain stem,
cerebellum and occipital lobes.1 Cervical osteophytes can press on the vertebral artery causing its
occlusion during head turning to the same or opposite side.15, 16, 17
The most common complaint in patients with vertebrobasilar insufficiency is vertigo.18,19 As the
blood supply to vestibulocochlear organ, is an end artery, it is totally reliant on vertebrobasilar
circulation and hence more susceptible to vertebrobasilar insufficiency20 leading to vestibular
vertigo.
Olszewski et al.16 examined 80 patients with radiological evidence of cervical spondylosis but
with normal CT or MRI brain examination and no neurological symptoms (except cervical
radicular symptoms) with 40 patients complaining of positional vertigo of at least six months
durations. These patients had neuro-otological examinations and cochlear function tests to

exclude other causes of vertigo and extracranial vertebral artery and carotid artery stenosis were
also ruled out. All patients had transcranial doppler ultrasound with head rotations and it
confirmed significant association between flow velocity in basilar artery after neck rotation and
age, prevalence of vertigo and grade of radiological changes. It was also shown that vertebral
artery flow velocity in neutral position was not affected by degenerative changes in cervical
spine.
Bayrak et al21 also found no considerable changes in vertebral artery flow in neutral position on
Doppler measurements of 91 patients with radiologically confirmed cervical degenerative
changes.
Sheehan et al22 demonstrated vertebrobasilar insufficiency from vertebral artery compression due
to cervical spondylosis on vertebral arteriography, during head turning. It is critical in those who
have vascular risk factors that may compromise the integrity of the circle of Willis, particularly
the elderly20,23,24 when there is 25% reduction in basilar flow between 20 and 70 years of age.16, 21
Moubayed and Saliba in Montreal University performed a double blinded retrospective cohort
study in 258 patients. They reviewed their MRA reports describing vertebral arteries and
compared 72 patients with normal vertebral arteries with 61 patients with stenotic vertebral
arteries. It found 85.7% of patients with stenosed vertebral arteries complained of isolated
positional vertigo on the questionnaire.25
Another factor thought to have contributed to positional vertebrobasilar insufficiency is that in
cervical spondylosis there is diminution in the size of the disc spaces causing a reduction in the
length of cervical spine with a concomitant decrease in length of the vertebral arteries. As this
causes increased tortuosity of both vertebral arteries, any neck rotation causes further
compromise in vertebral artery blood flow. Surgical fusion and neck traction post-operatively
restore the length and hence the flow of vertebral artery, which result in resolution of
symptoms.13
Several case reports have been published that showed significant relief from vertigo in patient
with significant vertebral artery compression from cervical osteophytes.26-30
Mazloumi and Samini17 compared 16 patients with cervical spondylosis, suffering from vertigo,
who had dynamic angiography and/or Doppler sonography with head rotations to show vertebral
artery compression. They showed better symptomatic relief in surgically treated patients (75%)
than conservatively managed, and recommended that vertebral artery should be released if there
is significant compression confirmed radiologically and symptoms are poorly controlled with
conservative management.
Investigations
The widely used initial investigation is the plain C-spine radiographs to demonstrate the discspace narrowing, osteophytosis, loss of cervical lordosis and vertebral canal diameter.15

As these degenerative changes are commonly seen in asymptomatic subjects, the use of plain xrays can be misleading and inconclusive.29 Adams et al reported no significant difference in the
severity of the radiological changes between C-spine radiographs of 32 elderly patients clinically
diagnosed as having symptomatic cervical spondylosis causing pressure effect with those of 32
age- and sex-matched controls.31
MRI is a non-invasive imaging that provides excellent imaging of the spinal cord and of the
neural elements and thus it has become the standard diagnostic study for spondylotic disease
with pressure effect, to rule out soft tissues compression and when contemplating surgery.32
CT scanning is another important imaging modality, superior to MRI in its definition of bony
anatomy including neural foramina and canal diameter.32
Myelography is useful for demonstrating nerve root lesions to localise the exact nerve
encroachment but is an invasive imaging and hence particularly useful in patients needing
surgical intervention.
Transcranial doppler ultrasound,16,33 magnetic resonance imaging/angiography34 and selective
arteriography35 can be used to assess vascular compression from cervical osteophytes.
Neurological, vestibular, and psychosomatic disorders must first be excluded before the dizziness
and unsteadiness in cervical pain syndromes can be attributed to a cervical origin.3
Treatment
Treatment of cervical spondylosis is dependant on symptoms severity and response to
conservative management, which is the mainstay of treatment.
Conservative options including neck immobilisation, pharmacological treatments including
analgesia and muscle relaxants, lifestyle modifications, and physical modalities ie. spinal
manipulation, and an exercise programme in minor non-progressive disease.5
Patients with progressive neurological dysfunction or fixed deficit of short duration should be
considered for surgery5 after careful assessment and in full discussion with the patients. Surgical
options include decompression via posterolateral or anterolateral approach, laminectomy,
foraminotomy and neurolysis, which may be combined with osteophyte excision.
The treatment of cervical vertigo is less well defined but should be multidisciplinary. It should
involve the otorhinolaryngologist, orthopaedic surgeon, physiotherapist, physician, psychiatrist
and neurosurgeons to prevent the chronicity of symptoms.15, 31
For non-significant cervical vertigo, the usual treatment for cervical spondylosis should be
offered, as the relevance and mechanism of cervical vertigo is more of theoretical interest.4
Patients with severe cervical spondylosis, complaining of significant disabling positional vertigo,
unresponsive to conservative management should be examined by transcranial doppler

ultrasound with head rotations. If vertebrobasilar insufficiency is seen, it should be confirmed

with further angiographic examination so as to plan suitable treatment13-17,26,30 involving the
multidisciplinary team.

Conflict of interest: none declared

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