89 % of general dizziness is cervicogenic!

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Importance of cervicogenic general dizziness
Sho Takahashi 1

1Department of Neurosurgery, Takahashi Neurosurgery and Dermatology Clinic, Japan
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1Department of Neurosurgery, Takahashi Neurosurgery and Dermatology Clinic, Japan
Correspondence: Sho Takahashi, M.D., Ph.D., Department of Neurosurgery, Takahashi Neurosurgery and Dermatology Clinic, 2-3-17 Sumiyoshi-cho, Shibata, Niigata 957-0061, Japan. E-mail: pj.en.nco.aococ@ohs
Received 2018 Jan 2; Accepted 2018 Jan 22.


Abstract
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.


Introduction
General dizziness is a symptom frequently encountered in everyday clinical practice. However, the causes of this symptom are highly varied and can often be difficult to treat. In addition, reaching a definitive diagnosis in patients with general dizziness can prove difficult. At our hospital, patients who complain of general dizziness despite having no intracranial disease presentation and no clear signs of inner ear dysfunction or systemic conditions, patients complaining of severe dizziness for which treatments attempted by multiple medical facilities have failed to achieve adequate results, and patients with refractory dizziness and those with dizziness of an unknown cause are frequently treated.
This study was a retrospective analysis of the patients who visited our hospital with a chief complaint of general dizziness. Herein, I primarily consider cervicogenic general dizziness, which was the most common cause of our patients’ symptoms.

 

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Symptoms

Of the patients diagnosed with cervicogenic general dizziness,
744 (83%) presented with lightheadedness,
and 155 patients (17%) exhibited rotatory vertigo.

Seven-hundred and six patients (79%) presented with stiff shoulders,
416 (46%) had a sensation of a heavy head or headache (tension-type headache),
198 (22%) had numbness of the hands/upper extremities,
104 (12%) had scapular pain, and 46 (5%) had tinnitus.

It was believed that the tinnitus was the result of tension applied to the neck and scapular muscle group, which also affected the ossicular muscles. Therefore, tinnitus in the patients in this study was determined not to be a cochlear symptom (these symptoms disappeared in all cases following treatment with a muscle relaxant).

It is not unusual for nystagmus to occur in patients with cervicogenic general dizziness as a result of lightheadedness, rotatory vertigo, or anterior or posterior flexion of the neck.

However, no distinct characteristics were observed during the diagnosis. This symptom was thus deemed to have little value in diagnostic confirmation.

Eighty-four of the 193 patients who did not experience stiff shoulders complained of a headache or a heavy head sensation believed to be indicative of a tension-type headache.

Based on these observations, 790 patients (88%) diagnosed with cervicogenic general dizziness were determined to have hyperflexion of the neck, scapular muscles, or temporalis muscle.
...
Drug therapy for cervicogenic general dizziness


Correction is most important when symptoms are accompanied by excessive tension of the neck and scapular muscles or a tension-type headache. Muscle relaxants and opioid drugs were used in all 790 cases determined to be caused by tension-type headaches or excessive tension of the neck, scapular muscles, or temporalis muscle.

Muscle relaxants with stronger effects were selected in the majority of the cases.

Doses of 1–6 mg per day of tizanidine were generally administered to non-elderly patients, and milder drug regimens, such as 40–60 mg per day of afloqualone, were prescribed for elderly patients.

Another commonly prescribed drug was eperisone, which was prescribed at doses of 100–150 mg per day. Dantrolene may also be effective in intractable cases.

The above findings indicate that the selection of muscle relaxant drug type and dose were made on a patient-by-patient basis to ensure that the underlying causes of the symptoms were addressed appropriately and effectively.

When the effects of typical muscle relaxants were inadequate, a dibenzodiazepine-class or benzodiazepine-class anxiolytic drug with muscle relaxant effects was used in combination with Chinese herbal medicines, such as peony and licorice decoctions (Shakuyakukanzoto), which is a neurotropin used as a therapeutic agent.

This medicine is used to suppress pain affecting the lower body and to improve blood circulation in the upper body.

Non-steroidal anti-inflammatory drugs were also used, as appropriate, to address upper body pain symptoms, including headache, as such symptoms can create a vicious circle that exacerbates tension on the neck and scapular muscles.

Tocopherol nicotinate and opioid drugs were used in combination in patients without stress on the neck and scapular muscles. These patients were also provided with comprehensive lifestyle guidance to help them avoid excessive stress on the neck.

Cervicogenic general dizziness prognosis

General dizziness improved in all cases within a short period, provided that a suitable drug therapy was selected, and patients were able to adjust their trigger behaviors.

General dizziness symptoms disappeared or exhibited clear evidence of improvement within 1 week in 806 patients (90%) and within 2 weeks in another 33 patients (4%).

Improvement first appeared after 1 month in 18 patients (2%) and after 2 months in 3 patients (0.3%).

No improvement was observed in 39 patients (4%).

The subsequent clinical course for these patients is unknown.

In cases wherein general dizziness improved, understanding the causal condition and reducing the amount of stress placed on the neck resulted in no recurrences during the shortest observation period of 3 months.

General dizziness symptoms only recurred repeatedly when patients resumed placing excessive stress on the neck.