Cervicogenic dizziness, headaches and visual disturbance are relatively frequent observations in the physiotherapy clinic. The spectrum of pathological possibilities is broad and we have discussed these previously in our whiplash discussions.
I recently had a longstanding patient of mine re-present with a two week history of blurred vision following a heavy fall during a martial arts training. He was wearing protective headgear but landed on the right shoulder with subsequent impact on the head. He did not loose consciousness (due to the chosen nature of his sport was very familiar with that). Without labouring his history he has recurrent episodes of cervicogenic headache, scapular and myofascial symptoms. He also has sacroiliac symptoms all of which are transient in nature. He has the usual cluster of physical signs that one would expect.
He did have an unusual postural alignment of a “laterally displaced” cervical spine. I distinguish this from a “laterally flexed” cervical spine as would be seen in a torticollis or acute radiculopathy. While some of these features were driven from altered pelvic alignment they still persisted in seating when spinal alignment was re-established. He had no structural kyphotic or scoliotic features.
What concerned me more about this more recent episode was he reported a loud clunking sensation in the upper cervical spine. Again I distinguish this from crepitus, which he frequently reported and of course is a feature we all observe clinically frequently. Having seen him through several previous episodes of upper cervical dysfunction (but without dizziness and trauma), I have seen anterior throat symptoms, difficulty in swallowing and hoarseness all of which have been thoroughly investigated without findings. I have been suspicious of some form of subtle instability in this area although I could not diagnose it with any of the currently described upper cervical stability tests – at least not in my hands.
I treated him with a combination of localised upper cervical joint mobilisations, intermittent manual traction and some soft tissue work all in neutral positions, largely as a trial intervention while awaiting the results of a brain scan. I would be strongly suspicious that any of the routine radiological investigations of the cervical spine would not elicit overt instability particularly in the light of this man’s level of athletic function.
Having the advantage of familiarity with a long history over years does allow the clinician the luxury of trial interventions provided they comply with reasonable judgement and are respectful of potential pathology. Of course this is a clinical judgement and unlikely to comply with guidelines!
You maybe interested to know that there is an increasing trend in the U.S. amongst our chiropractic colleagues to use video fluoroscopy for imagining spinal motion and essentially providing a digital motion X-ray of intersegmental motion. The American Medical Association (AMA) produce a series of encyclopaedic guides known as the AMA Guides which categorise pathology and functional impairment. Subtle spinal instability is now recognised and diagnosable using this technology. I am still reaching out to my radiological colleagues to see if there is potential to utilise this within routine clinical practice but it certainly appears to provide an exciting opportunity.
I will keep you posted on the outcome of this case.
It does raise some interesting questions in relation to interpretation of symptoms and matching the physical signs, symptoms and historical accounts.
Do you think I was taking a risk treating this patient without a full diagnostic work up?
Do you think there is a risk of patient familiarity leading us to overlooking serious pathology?
Or conversely, does familiarity give us confidence to progress with treatment of cervicogenic dizziness knowing the patient’s normal response characteristics?
Let us know your thoughts.
Enjoy the clinical challenge.
David.GHTime Code(s): nc