Cervical Degeneration and Cervical Vertigo

Cervical Degeneration and Cervical Vertigo

Cervical vertigo is a controversial entity in the world of balance and vestibular disorders. It has generally been a diagnosis of exclusion when a patient is feeling dizzy but has no diagnosable pathology in the inner ear or brain.

The reality is that problems in the cervical spine are commonly linked to feelings of imbalance and disequilibrium. Cervical spine problems are rarely tied to the spinning rotational vertigo of someone having inner ear pathology. Most people with cervical “vertigo” really have which can include feelings of being really off balance, shaky, or a tilt like feeling of motion.

A 2018 study looked at how a degenerative problem in the neck can be associated with a diagnosis of cervical vertigo:

Mechanoreceptors in Diseased Cervical Intervertebral Disc and Vertigo

The study looked at patients with neck and arm pain related to cervical disc problems presenting for surgery. The patients were divided into patients with and without a complaint of vertigo. The patients with vertigo were examined to rule out other causes of vertigo like vestibular neuritis, benign positional vertigo, or stroke.

The research team examined the discs from patients with vertigo, without vertigo, and a control group of cadavers with no disc degeneration. The findings were really interesting.

In patients with vertigo, there are large increases in mechanical receptors in the degenerated discs compared to the patients without vertigo, and to the control group. These Ruffini Corpuscles help detect movement and position from your joints and muscles to help tell your brain what your joint is doing in space. Free nerve fibers are responsible for transmission of stimuli usually associated with pain. You can see the distribution below:

Patients with vertigo had significantly more Ruffini Corpuscles in their degenerated discs than the non-vertigo and control group. What does this mean for dizzy patients?

 

The data from the above chart in bar graph form showing increased receptors in the vertigo patients.

As expected, the patients with neck pain only, and neck pain with vertigo have a similar increases of free nerve fibers compared to controls. That’s probably why their neck is hurting.

However, a big reason why this study is interesting is because many people in the world of rehab and manual medicine would usually associate dizziness with a decrease in mechanical receptors in their spine, not an increase.

So what gives?

We don’t know exactly what this means, but it’s possible that increased density of these receptors may be transmitting excessive or erroneous information to the brain about the joint position.

The same group did a follow up study after they had performed disc surgeries on these patients. You can see the link to the study below:

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

During the study, they performed surgery on 50+ patients and 25 patients refused the surgery and received basic physical therapy and cervical collar recommendations. You can see the results below:

 

Comparison of patients with cervical dizziness and neck pain getting surgery vs routine physical therapy and neck bracing.

So Is Surgery the Right Answer for Cervical Dizziness?

Maybe for some cases. If you have radiating arm pain with weakness tied to a badly herniated disc, then surgery might be able to help resolve both complaints, but there’s still a lot of research that needs to be done. Surgery is a BIG deal, and generally reserve that for really bad herniation cases with clear signs of neurological deficit like weakness, loss of reflexes, and atrophy of muscle.

The good news is there are a lot of ways to address cervical dizziness beyond routine physical therapy, and they have really great outcomes. One method is by improving the curve in the neck. A randomized trial of curve based rehab compared to routine physical therapy showed significant improvements in neck pain and dizziness at 1 year.

You can read some more about cervical curves and dizziness at this link:

Working on your curves: Long term outcomes from fixing military necks

A randomized clinical trial of cervical curve rehab on cervical dizziness

There’s also numerous cases of cervical dizziness that have no signs of degeneration in their spine. This is especially prevalent in patients with dizziness after whiplash and head injury in young athletes. These patients seem to do well when we focus on the upper neck where the injury is likely to affect the ligaments of the craniocervical junction.

Comparison of mulligan sustained natural apophyseal glides and maitland mobilizations for treatment of cervicogenic dizziness: a randomized controlled trial.

Long story short, degeneration of the cervical spine doesn’t have to be a sentencing for dizziness. It’s a risk factor, but it can be modified with the application of effective conservative interventions for the neck.

How to Tell if a Migraine is Coming from Your Neck

A recent systematic review in the prominent journal Headache showed that spinal manipulation could have an effect on headache days and pain intensity in patients with migraine headaches. While this is old news to many practicing chiropractors, this is one of the first instances that a major headache journal has acknowledged that manipulation could have a legitimate positive effect in patients suffering with migraines.

When it comes to migraine headaches and chiropractic, there’s a big gap in knowledge between what clinicians see in the field everyday and what the published literature says about our effectiveness. The published literature has generally shown that chiropractic might be good for tension headaches, but clinical trials on migraines have suggested that it’s not significantly better than placebo.

On the other side, patients with migraine headaches are often our most successful cases in upper cervical chiropractic. It’s not even that we tend to be just a little bit successful with chronic migraines patients, many of us expect these 85-90% of these patients to get a lot better in a matter of weeks. It’s usually not the easy migraine patient that comes into our offices either. Typically people don’t find an upper cervical chiropractor until they’ve tried a wide variety of treatments and medications.

So what gives? Why is there such a gap between private practice and published research?

I believe there’s 2 main reasons:

  1. Most spinal manipulations done in research have used non-specific contact, general manipulation of the neck, where as upper cervical techniques use a very precise and targeted force to one part of the neck. To date, there are no clinical trials investigating migraine headache and upper cervical work. (But this is a soap box for another day)
  2. Previous clinical trials haven’t done a great job in identifying patients that have the signs of a cervical spine dysfunction.

Identifying Cervical Spine Dysfunction in Migraine Patients

While getting your spine corrected is healthy in of itself and anyone could benefit from it, I only take on cases that I believe can significantly improve your quality of life. In order to do that, I always screen patients to make sure that I am going to have a high likelihood of success in helping you reach your goal.

In the case of a migraine patient, we are looking for clues that tell us that your migraine symptoms are primarily being generated by the neck. Migraines can have different causes:

  • Some have a biochemical issue in the brain and may benefit from something like a ketogenic diet.
  • Some have a higher hormone component and need to be addressed by modifying the endocrine system
  • And many have a major cervical spine component

How can you tell if it’s coming from the neck? Beyond just looking for neck pain, here are some major clues that have been identified in migraine research:

  1. Worse ability to turn their upper neck side to side – A test of upper neck rotation called the flexion rotation test has been shown to be more asymetrical in some migraine patients compared to normal controls [Source]
  2. Decreased sensitivity to 2 point discrimination in the upper neck – A study showed that migraine patients have decreased ability to differentiate between 2 points when applied to their neck. [Source]
  3. Increased pain and tenderness in the upper neck – patients with cervical spine issues show increased tenderness to touch in their upper neck. It becomes even more significant if pressing on a sensitive area recreates the pattern of head pain [Source]

Can The Neck Be Fixed?

A 2015 study looked at the effects of an atlas realignment in patients with chronic migraine headaches. The study showed that a gentle correction to the upper neck showed significant improvements in headache days and quality of life in migraine patients over the course of 8 weeks.

We rely on 3 big factors for improving the neck.

  1. We need to see a structural change in the biomechanical alignment of the neck after an atlas correction.
  2. We want to see a global change in posture in response to correcting the alignment of the neck
  3. We want to see a change in the tenderness of the muscles and nerves stemming from the upper neck. Just as we saw that those tender spots predicted migraine, when we feel those tender points subside right after a correction, it’s a strong marker that we are on the right track.

While we can’t fix everyone, there’s a large segment of the migraine population that would do well with this form of care, but we have to make sure we identify the right candidates.

Long Term Outcomes from Treating Cervical Hypolordosis

I’ll admit that I’ve gone back and forth on the importance of cervical curves in my career. When I was in chiropractic school I was adamant about the importance of cervical curves and how the loss of a curve could affect the progression of spinal arthritis.

Then once I was in practice for a few years, I saw that most neck curves wouldn’t really change very much. Despite the fact that it didn’t change, I’d see really great changes and improvements of many of my patients, so I assumed that it is a nice feature, but probably not necessary to resolving a complaint. You can read some of my previous thoughts on cervical curves here:

I Have Military Neck: Now What?

So What Has Changed my Mind?

I still stand by my previous writings and say that having a proper neck curvature is a really good and positive thing, but you can still get really great results with most secondary conditions even if the neck curve doesn’t come back.

However, I have started to come around on the importance of having a proper neck curvature for the health of the human brain and nervous system. So what changed my mind?

Here are three pretty recent studies looking at the impact that cervical curve changes have on dizziness and cerebral blood flow.

Increase in cerebral blood flow indicated by increased cerebral arterial area and pixel intensity on brain magnetic resonance angiogram following correction of cervical lordosis

The first paper is a study that looked at consecutive patients getting imaging of the arteries going into the brain. Magnetic resonance angiography (MRA) measured the intensity of blood flow with the neck in patients with a straight or military neck pattern. The patients were then placed on a foam orthotic to produce a curve in the neck and a new MRA was taken with the neck in a curved position.

Before and after changes in blood flow to the brain using a device to improve cervical curve.

The patients’ MRA scans showed significant improvements in blood flow in the brain when they were lying on the orthotic with an improved cervical curve! The interesting thing is that it’s been known for years that a loss of cervical curve was associated with decreased blood flow in the brain, but there was no evidence showing that improving the curve would change blood flow. Now there is.

The effect of normalizing the sagittal cervical configuration on dizziness, neck pain, and cervicocephalic kinesthetic sensibility: a 1-year randomized controlled study.

While the previous paper is interesting, it’s limited by the small sample size and lack of controls. It was also a proof of concept study, and not one where an intervention was performed and tested to see if it made a difference long term. However, it may help explain why patients can get significant improvement in pain and dizziness.

This next paper features a randomized clinical trial of cervical curve correction along with cervical manual therapies compared to manual therapy alone for cervical dizziness.

The study looked at the results for patients with neck pain and dizziness for short term improvement at 10 weeks, and to see if they sustained improvement at a 1 year follow-up. The results are below.

 

Differences in patients with cervical dizziness at 10 weeks and 1 year. Changes after 10 weeks were similar to regular physical therapy, but the changes were hugely different at 1 year when there was an improved curve in the neck

The chart shows that the patients who were in the cervical curve correction group had significant improvements in head posture and curvature at 10 weeks, but the scores in pain and dizziness were pretty similar for both groups. Both groups got better, but they had similar improvements.

However, the changes at 1 year were impressive, and highlighted in red. While the control group had some regression into neck pain and dizziness, the cervical curve group maintained their symptomatic improvement much better. The mean improvements for both groups all crushed statistical significance, and the mean difference of the Dizziness Handicap Inventory (DHI) was by almost a whopping 30 points. That’s massive!

Does improvement towards a normal cervical sagittal configuration aid in the management of cervical myofascial pain syndrome: a 1- year randomized controlled trial.

A similar study was published on patients with persistent neck pain where physical manual therapy was compared to manual therapy and curve correction.

Just like the study involving dizziness, this paper on neck pain showed that both groups had similar improvements in scores on the Neck Pain Disability Index (NDI).

Changes in neck pain with manual thearpy and exercise alone vs manual therapy, exercise, and cervical curve restoration. Cervical curve patients were a little btter at 10 weeks, but were much better at 1 year follow up!

Again, like in the previous study, the 1-year follow-up is where things got interesting. The group that had treatment to improve their cervical curve had a much stronger ability to maintain their improvements in neck pain, while the control group started to return to their original pain scores. This was also largely statistically significant.

Long-Term Improvements Matter

So the big thing that changed my mind is that there is a growing body of work that supports the idea that creating structural changes in your cervical curve seem to help improve long term outcomes.

So while I still believe you can get significant improvement with or without a curve in your neck, your chances of maintaining your results over time seem to increase a LOT when you rehabilitate that curve.

Then you have the possible added benefit of improved blood flow to your brain, and that provides a potential bonus of better brain health.

Hidden Injury Series: Cerebellar Tonsilar Ectopia after Whiplash

The Hidden Injury Series: In this series of articles, we review potential causes of chronic symptoms after a whiplash type injury. These injuries are not commonly diagnosed by traditional physicians, and many cases are inappropriately attributed to mental health problems. The correct exam and a knowledgeable doctor may be able to help. Today we cover cerebellar tonsilar ecptopia. Cerebellar tonsilar herniation or cerebellar tonsilar ectopia (CTE) is a condition in which the base of the brain begins to descend down through the skull and into the spinal canal. You may know these findings as a condition called Arnold Chiari malformations. The severity of this displacement of brain tissue can vary, and is usually classified into 4 types:
  • Chiari I – Small protrusion of the cerebellum into the foraman magnum
  • Chiari II – Larger protrusion involving the cerebellum and brainstem into the foramen magnum. Considered to t be the classic form of Chiari and is associated with the development of a spinal cord syrinx.
  • Chiari III – a rare and sever form of Chiari which prounounced herniation. Associated with tethered cord and pronoucned neurologic deficits
  • Chiari IV – rare form of chiari where the cerebellum is significantly underdeveloped.
Chiari II is the most common clinically relevant form of Chiari. It can be asymptomatic which makes its true prevalence unknown, but it can be tied to symptoms such as:
  • Neck pain
  • Hearing/balance problems
  • Difficulty swallowing
  • Weakness
  • Dizziness
  • Tinnitus
  • Ataxia
  • Drop attacks
Most chiari malformations are thought to be congenital and exist from childhood. However, Chiari I malformations can be secondary and induced by things like spinal taps, infection, and even…..traumatic injury.

Whiplash and Cerebellar Tonsilar Herniation

A 2010 study published in the journal Brain Injury found that a significantly higher proportion of patients involved in motor vehicle accidents met the MRI criteria for a chiari malformation. The study recruited 1200 patients with 600 involved in an accident and 600 controls. They also wanted to observe if there were any differences in findings when an upright MRI was used compared to a recumbant MRI. The results were pretty astounding. In the non-trauma control group, both the upright and recumbent MRI showed 5.3% and 5.7% of the subjects met the criteria for chiari malformation. However, in the trauma group, the numbers increased significantly. In the recumbent MRI, 9.8% of the scans showed cerebellar tonsilar ectopia (CTE) which is a pretty large increase from the non-trauma population. However, subjects that received an MRI in a seated position showed that 23.3% of the scans showed CTE! That is a massive difference! Considering that the vast majority of MRI scans are performed lying down, there could be a large number of people who have received an MRI but have no idea that they have a chiari malformation.

So what? They might be asymptomatic

We know that many of these ectopias can be asymptomatic so, when it comes to identifying these types of injuries, it’s important to correlate them with clinical findings. What’s unique about whiplash injuries is that many patients will go to their doctor with complaints of headache, dizziness, and other new and unusual symptoms. When these patients are sent for diagnostic imaging and other tests, they often come back empty handed. Many of these patients then get diagnosed with a non-specific pain disorder, or are told that their symptoms are likely psychogenic. There’s no doubt that mental health can play a role in many accident cases. However, a thorough neurological exam can reveal subtle signs cranial nerve and brain related dysfunction. This can include:
  • Eye movement abnormalities and nystagmus
  • Asymmetric uvula/tongue deviations
  • Subtle signs of ataxia and dysmetria
  • Persistent deficiencies in balance exams
While these tests aren’t necessarily diagnostic of a chiari malformation, they can help paint a more complete clinical picture for why a patient may not be responding well to treatment.

The Downside of Listening to Your Body Too Much

Historically I’ve been a big advocate of being “in-tune” with your body. For the most part, I do think that a generally healthy person can benefit from developing a better awareness of what their body is experiencing. It’s a good guide for adapting your training and developing a meditative practice like breath awareness. In recent years, I’ve come to the conclusion that there are situations where a patient can be TOO in-tune with what their body feels, and this perception of what their body feels can actually create fear, apprehension, and further harm to their mental state and quality of life. Today we’ll discuss some of these types of situations and what a patient can do to help themselves break a negative connection with their own self-awareness.

When Listening to Your Body Goes Wrong

There’s a lot of research that shows that paying attention to inner body activities can be extremely beneficial for you. Things like being aware of your breath, meditation, counting your heart beat are all tools used in yoga and mindfulness practices that really help people a lot! The concept of listening to your body has been popularized in the circles of fitness. It’s a phrase used to guide people in sport or exercise to recognize when their body may not be in the best state to complete a task. It involves feeling out different aches or pains, observing where the body seems to be putting a restriction on movement, or just an inner awareness of fatigue. It’s supposed to be a guide against overtraining and possibly develop an awareness of impending injury. In cases where this is an otherwise healthy person with no history of chronic pain problems, it serves a good purpose. However, in my experience seeing patients with chronic pain daily, a heightened attention and awareness of their own pain can be very counterproductive to a patient’s recovery and progression. Let’s talk about why.

Being In-Tune With Body Pain

It’s natural for your brain to pay attention to areas of your body that are in pain. It’s one of the ways your body protects itself whenever it has suffered an injury like a sprained ankle or a large cut on your hand. By avoiding contact of the injured body part, you are allowing your body to temporarily immobilize an area so that the natural healing responses can have time to fix the damaged tissue. This is a necessary and completely normal response to physical injury. While this is a big generalization, the healing time for various tissues is shown in the graphic below. You can see that most minor muscle and ligament injuries can take a few days to heal while moderate to severe injuries can take several months.

Image Credit http://drcalebburgess.com/ and Instagram @drcalebburgess

So even in a worst-case scenario where you have an unstable injury that needs surgery, it takes about 2 years for a tissue to heal completely. If we know that these are the general healing times for people, then what explains the pain patients can feel for several years? However, for some people there can be problems that develop in neurological pathways that perceive pain. What seemed like a simple, straight forward injury leads to chronic or persistent pain that lasts long beyond the normally allotted time for tissues to heal. The problem in these cases is that many of these patients will avoid movements or activities to protect an area of injury that may not need protection and avoidance. So there ends up being a cycle of injury, stopping exercise, followed by deconditioning from lack of exercise leading to more risk of injury and pain.

The brain can learn to fear movement to avoid pain creating a vicious cycle often seen in persistent pain patients.

This is the result of treating the pain issue as a muscle or joint problem, when it’s really a brain and neurologically rooted problem. The kicker is that while avoiding movement is necessary for true joint injuries, avoidance may actually make a persistent pain problem in the brain even worse. Many times when someone suffers with persistent pain issues that have no diagnosable injury, being too aware of your body’s painful triggers can be detrimental to healing and recovery.

Pain Science

One of the more popular concepts in pain science is the idea that chronic pain can develop from factors known as hypervigilance, catastrophizing, and fear-avoidance.
  • Pain Hypervigelance – “when there is an excessive tendency to focus on pain or somatic sensation, or an excessive readiness to select pain-related information over other information from the environment.” [1]
  • Catastrophizing – “an concept where people show exaggerated thoughts and descriptions of the negative consequences of pain featuring magnification, rumination, and helplessness” [2]
  • Fear-Avoidance – a model of chronic pain that describes how people develop and maintain chronic pain as a result of attention processes and avoidant behavior based on pain-related fear. [3]
Those are nice academic definitions, but what do they mean for us? A lot of it comes down to being really fixated on how bad the pain is and avoiding anything that might be associated with the pain. And we now know that the fixation and avoidance behavior can reinforce maladaptive patterns in the way the brain is working. So it is to say that being too focused on your pain when you are trying to heal can reinforce the cycle of staying in chronic pain.

Fostering an Anti-Fragile Mindset

One of the big things that drew me to chiropractic was a philosophical idea that the body is strong and has a remarkable ability to heal itself. It’s a mindset that I’ve had growing up while playing sports where my coaches would see someone get injured and they’d always say to just walk it off. Obviously it’s not something you want to do with an unstable or serious injury like major sprains or a concussion. However, for things like scraping our shins, getting hit by a pitch in the back, pulling a muscle, or having a mild ankle sprain this approach trained our young minds to:
  • Understand that the pain will go away on it’s own in time
  • That our body and mind is strong enough to will away pain
  • That we aren’t fragile
Ultimately, we came away with the mental state that we will feel better and pain goes away with time. This also meant that we were pushed towards our normal activities as quickly as possible. As a chiropractor, a big part of my job is to foster a sense of strength and resiliency in my patients. It means that I want my patients to foster a sense of independence from their pain. That means I don’t want my patients to fear doing activities or to be dependent on any intervention whether that’s a drug, massage, or even chiropractic adjustment. I want my patients to never need me, but they can certainly count on me to be there when they want to be better.

Nuance

So before anyone takes my points to the extremes, let me just say this.
  • Mental state won’t cure every pain
  • Don’t avoid doctors, especially with serious injury/illness
  • Many people will still have chronic pain even without a sense of fear avoidance and catastrophizing.
So with that out of the way. Mental state can be a powerful influence on the development and resolution of pain, but it can be really, really difficult. When we know there no longer a risk of worsening an injury, in order for patients to make the next step in their recovery, we have to engage them in doing the normal activities that they have avoided. That might mean lifting some moderately heavy objects, bending their back forward, turning their heads, or getting back into exercise. Yes, sometimes that means we have to make patients revisit their pain and forcing their brain and nervous system to adapt and stop fearing it. It means they have to stop listening to their body for a bit, and actually push through the false alarm signal so they can adapt. It’s not easy, and it doesn’t happen quickly. But when patients are able to get their, the whole world opens up again, and we can start to pop the bubble that they’ve lived in because their brain is free again.