A Case Report: Severe Vertigo Precipitated by Misapplication of Spinal Manipulation
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1
Innova Brain Rehabilitation, United States
Objective: Elucidate the hazards and benefits of cervical spinal manipulation related to influence on central processing of the vestibular system.
Clinical Features: A fifty-nine year old male was seen with a complaint of severe vertigo of 2 days duration. He reported that when he arose the morning after having his neck manipulated by his health care provider, he had to close his eyes to walk due to dizziness, nausea and headache. The subject reported mild improvement on the day of his initial visit, but “wasn’t right” with discomfort of his neck since the manipulation. Examination revealed very poor pursuit activity to the right, but all directions contained catch-up saccades. Saccades had protracted latencies and were hypometric omnidirectionally, but most severe horizontally. Convergence was impaired in the right eye and precipitated a left convergence spasm with hyperphoria. Upper extremity alternating movements were slow bilaterally, with a break down of smooth movement on the left with flexed and extended elbow. Active cervical spine range of motion was globally limited with joint fixations of C1-C0, C4-C5, and the left 1st chondrosternal articulation. Occluded videonystagmography demonstrated persistent 2-3 Hz nystagmus that varied in directionality and type (jerk and pendular) depending upon head position related to gravity and relative head-body positioning (Dix-Hallpike included). There was a shortened, wide based gait.
Intervention: Spinal manipulation of C1 on C0, reducing extension joint fixation on the right, C4 on C5, reducing a left rotation fixation, and left first chondrosternal joint fixation was performed initially. There was a favorable outcome of reduced rate and amplitude of the persistent nystagmus. Additionally, there were improved pursuits, saccades, convergence, and increased rate of finger-thumb tapping on the right. Gait was narrowed and lengthened. The patient reported “feeling better and more connected”. A second visit, 24 hours later, revealed no nystagmus in upright head-body positions of neutral, right rotation, and extended. Right beating nystagmus was seen in head left, and flexed positions without visual fixation. Instrument assisted right temperomandibular manipulation was performed to reduce joint dysfunction of the right temperomandibular joint. Seventy two hours following the initial visit, the patient reported occasional, mild vertigo and demonstrated marked improvement in all eye movements that showed aberrancies. Occluded videonystagmography demonstrated no nystagmus for any head position, except following the initial 11 seconds of left head rotation, there were a few, very low amplitude,and less than 1Hz beats of right nystagmus. On the patient’s fourth visit, dynamic computerized posturography on a perturbed surface demonstrated a lowest stability score of 54.0% with head extended. Following a single cervical manipulation, a repeated dynamic computerized posturography on a perturbed surface demonstrated a markedly improved stability score with head extended of 78.5%. The patient reported feeling “way more stable” during the repeat posturography.
Discussion: This case suggests that spinal manipulation may induce or ameliorate cervicogenic vertigo due to possibly creating or reducing a joint fixation in the cervical spine. More investigation is warranted to better understand the interplay of the proprioceptive afferents of the cervical spine on vestibular integration.
References
Aleksander Chaibi and Peter J. Tuchin, Chiropractic spinal manipulative treatment of cervicogenic dizziness using Gonstead method: a case study; J Chiropr Med. 2011 Sep; 10(3): 194–198. doi: 10.1016/j.jcm.2011.06.001
PMCID: PMC3259942
Jongkees, L.B.W., Cervical vertigo, The Laryngoscope, August 1969 Full publication history
DOI: 10.1288/00005537-196908000-00011
Keywords:
cervicogenic vertigo,
spinal manipulation,
Nystagmus,
posturography,
Videonystagmography
Conference:
International Symposium on Clinical Neuroscience: Clinical Neuroscience for Optimization of Human Function, Orlando, United States, 7 Oct - 9 Oct, 2016.
Presentation Type:
Poster Presentation
Topic:
Abstracts ISCN 2016
Citation:
Duffy
JL and
Patterson
FE
(2016). A Case Report: Severe Vertigo Precipitated by Misapplication of Spinal Manipulation.
Front. Neurol.
Conference Abstract:
International Symposium on Clinical Neuroscience: Clinical Neuroscience for Optimization of Human Function.
doi: 10.3389/conf.fneur.2016.59.00096
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Received:
02 Sep 2016;
Published Online:
07 Sep 2016.
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Correspondence:
Dr. James L Duffy, Innova Brain Rehabilitation, Marietta, Georgia, 30062, United States, jduffy@innovabrain.com