Is Vertebral artery compression a cause of cervicogenic vertigo in cervical spondylosis patients? A color doppler ultrasound correlation study

Kranti Bhavana; Subhash Kumar; Sudeep Kumar; Pragya Kumar; Anup Kumar; Prem Kumar

doi:10.4103/JODP.JODP_21_19

ORIGINAL ARTICLE

Year : 2020 | Volume : 3 | Issue : 1 | Page : 3-7

Is Vertebral artery compression a cause of cervicogenic vertigo in cervical spondylosis patients? A color doppler ultrasound correlation study

Kranti Bhavana¹, Subhash Kumar², Sudeep Kumar³, Pragya Kumar⁴, Anup Kumar³, Prem Kumar²
¹ Department of Otorhinolaryngology, Ear, Nose, Throat, All India Institute of Medical Sciences, Patna, Bihar, India
² Department of Radiology, All India Institute of Medical Sciences, Patna, Bihar, India
³ Department of Orthopaedics, All India Institute of Medical Sciences, Patna, Bihar, India
⁴ Department of Community and Family Medicine, All India Institute of Medical Sciences, Patna, Bihar, India

Date of Submission	26-Dec-2019
Date of Decision	13-Feb-2020
Date of Acceptance	24-Jan-2020
Date of Web Publication	30-Apr-2020

Correspondence Address:
Kranti Bhavana
Department of Otorhinolaryngology, All India Institute of Medical Sciences, Phulwarisharif, Patna - 801 507, Bihar
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JODP.JODP_21_19

Abstract

Introduction: Pathophysiology of vertigo in patients having neck pain is not well understood, and many theories have been postulated. Cervical spondylitis is one of the most common causes of neck pain, and these are the group of patients who often complain of vertigo. The role of vascular flow alteration in these patients in causing vertigo is under investigation. We intended to study the vascular flow pattern in the vertebral circulation using color Doppler ultrasound in these patients and compare it with controls. Material and Methods: Fifteen cases and 11 controls were evaluated using color Doppler ultrasound. All these patients were evaluated in detail by the Ear, Nose, Throat and the orthopedics department. The statistical analysis was done by IBP SPSS version 22 software. Independent t-test was performed to compare the case and control groups. Results: The mean intimal thickness of common carotid artery of cases was significantly less than the controls (0.35 mm vs. 0.51 mm for the right common carotid artery and 0.38 mm vs. 0.54 mm for the left common carotid artery, P < 0.05). The diameter of the right vertebral artery (VA) in neutral and left rotation positions was less in cases than in controls, but the difference was not significant, whereas the diameter in the right rotation position was the same both in cases and controls. The blood flow velocity in the right VA was less in the cases than controls, but this difference was not statistically significant. The diameter of the left VA in all the three positions (neutral, right rotation, and left rotation) was less in cases than in controls, and this was statistically significant (P < 0.05) for neutral and left rotation positions. The blood flow velocity in the left VA was less in the cases than controls for all the three positions, but this difference was not statistically significant. Conclusion: 1. Our study demonstrates the role of vascular compromise in the VA circulation in patients suffering from cervical spondylosis and vertigo. Narrowing of VA was present in cases and that too on the left side. The cause behind left-sided predilection could not be ascertained with certainty. Since the difference in blood flow was not significant in cases and controls, a definitive correlation is possible only if the sample size is more and results are replicated 2. Mild relief in symptoms after physiotherapy in the form of transcutaneous nerve stimulation and interferential therapy also points toward a possible role of nerve irritation in causing vertigo in patients of cervical spondylosis. The causation seems to be multifactorial in nature.

Keywords: Cervical spondylosis, color Doppler ultrasonography, vertebral artery, vertigo

How to cite this article:
Bhavana K, Kumar S, Kumar S, Kumar P, Kumar A, Kumar P. Is Vertebral artery compression a cause of cervicogenic vertigo in cervical spondylosis patients? A color doppler ultrasound correlation study. J Orthop Dis Traumatol 2020;3:3-7

How to cite this URL:
Bhavana K, Kumar S, Kumar S, Kumar P, Kumar A, Kumar P. Is Vertebral artery compression a cause of cervicogenic vertigo in cervical spondylosis patients? A color doppler ultrasound correlation study. J Orthop Dis Traumatol [serial online] 2020 [cited 2023 Jun 4];3:3-7. Available from: https://jodt.org/text.asp?2020/3/1/3/283678

Introduction

Vertigo in patients of neck pain is a common presentation. It is a very disabling feature in patients of neck pain. Patients having pain in the neck already have difficulty in carrying out their day-to-day activity and accompanying vertigo can further worsen their quality of life. Pathophysiology of vertigo in patients having neck pain is not well understood, and many theories have been postulated. Cervical spondylitis is one of the most common causes of neck pain, and these are the group of patients who often complain of vertigo. The role of vascular flow alteration in these patients in causing vertigo is under investigation.

In the past, the phenomenon of cervical vertigo was considered a myth by some due to the commonness of both vertigo and cervical spondyloses, particularly in the elderly. Recent studies using neurovascular imaging techniques have established the association between vertigo and cervical spondyloses expressing as rotational vertebral artery occlusion (RVAO) (Citow and Macdonald, 1999; Ogino et al., 2001; Brandt and Baloh, 2005; Cagnie et al., 2005; Choi et al., 2005; Majak et al., 2005; Netuka et al., 2005; Olszewski et al., 2005 and 2006). RVAO is important in those who have vascular risk factors that may compromise the integrity of the circle of Willis, particularly in the elderly (Kuether et al., 1997; Ogino et al., 2001; Brandt and Baloh, 2005).

This study aims to evaluate vascular flow alteration, especially in the vertebral artery (VA) in patients of cervical spondylitis using color Doppler ultrasound of the neck vessels. Reduce blood flow in VA and the posterior brain circulation may be a cause of dizziness in these patients.

Materials and Methods

Place of study

This study was conducted in the Department of Otorhinolaryngology, All India Institute of Medical Sciences (AIIMS), Patna, along with the collaboration of the Department of Radiology and Department of Orthopaedics, AIIMS, Patna.

Aim of the study

To establish whether VA compression during neck rotation in cervical spondylosis patients is a cause of vertigo in these patients.

Case definition

Patients of neck pain having vertigo.

Control definition

Patients having no neck pain or vertigo.

Inclusion criteria

Patients with neck pain having vertigo symptoms.

Exclusion criteria

Patients of neck pain having vertigo due to any other cause
Patients having any ear pathology which may contribute in vertigo symptoms
Any infection, abscess, trauma, or tumors of the spine and neck regions
Any pathology of the spine wherein movement of the spine would be very limited and dangerous. This would preclude a detailed evaluation of the neck during ultrasound. It may further add to the morbidity of the patient.

Total number of study population

Cases: 15 patients
Controls: 11 patients.

Duration of study

One year (2017–2018).

Plan

Patients presenting primarily to the orthopedics department with pain in the back of the neck and having vertigo were evaluated initially, and a detailed orthopedic evaluation was undertaken.

Orthopedic evaluation

All the patients were evaluated primarily by the orthopedic team, and a diagnosis of cervical spondylosis was established. Clinical and radiological evaluation was done to establish the diagnosis. Patients who were established as cases of cervical spondylosis were only selected for the cases.

ENT evaluation of cases

All the patients who fulfilled the criteria of a case underwent a detailed ENT evaluation where any other cause of vertigo such as benign paroxysmal positional vertigo, vestibular neuronitis, labyrinthitis, and suppurative otitis media were excluded. Patients who had no other comorbid conditions other than cervical spondylosis were then referred to the radiology department for color Doppler study of the neck vessels [Table 1].

Table 1: Gender-wise distribution of study participants

Click here to view

USG and Doppler protocol for the study

Step 1: A patient lies supine with a pillow/rolled towel put underneath the upper back between the shoulder blades so as to hyperextend the neck
Step 2: Scanning in the neutral position – With the patient looking straight, both the vertebral arteries are evaluated one by one and the various parameters were obtained
Step 3: Scanning with rotation of the neck – The patient is asked to rotate the neck as far as possible on the right, usually between 60° and 80°, and the vertebral arteries are evaluated on both sides. Next, the patient is asked to rotate the neck as far as possible on the left, usually between 60° and 80°, and the vertebral arteries are evaluated on both sides [Figure 1] and [Figure 2].

Figure 1: Flow in the right vertebral artery USG color Doppler image

Click here to view

Figure 2: Flow in the left vertebral artery USG color Doppler image

Click here to view

The vertebral arteries are evaluated on two places:

In V1 segment
At V2 segment usually at the C5–6 intervertebral level.

Method of quality control

In order to assure that this study would be free of any biases and end up as a powerful study following steps were taken:

Our case definition was fixed and no alteration was accepted
We avoided taking any control which may become a case on longer run
The radiologist was unaware whether he was performing USG in the case limb or the control limb
The calibration of ultrasound machine was checked and ensured at the start of the study and in between the study.

Ethical consideration

The study was approved by the Institutional Ethical Committee of AIIMS, Patna. Informed written consent was obtained from each participant.

Statistical analysis

The statistical analysis was done by IBP SPSS version 22 (IBM, New York, USA) software. Independent t-test was performed to compare the case and control group.

Results

The mean intimal thickness of the common carotid artery of cases was significantly less than the control (0.35 mm vs. 0.51 mm for the right common carotid artery and 0.38 mm vs. 0.54 mm for the left common carotid artery, P < 0.05). The diameter of right VA in neutral and left rotation positions was less in cases than in controls, but the difference was not significant, whereas the diameter in right rotation position was the same both in cases and controls. The blood flow velocity in right VA was less in the cases than controls, but this difference was not statistically significant. The diameter of left VA in all the three positions (neutral, right rotation, and left rotation) was less in cases than in controls, and this was statistically significant (P < 0.05) for neutral and left rotation positions. The blood flow velocity in left VA was less in the cases than controls for all the three positions, but this difference was not statistically significant [Table 2].

Table 2: Comparison between cases and controls on the basis of ultrasound color Doppler finding

Click here to view

Interpretation

After statistical analysis, few significant facts could be deciphered.

There was a statistically significant difference in the mean intimal thickness of common carotid artery of cases and controls. Cases had less intimomedial thickness of the common carotid artery. This obviously does not explain vertigo in cases as no significant radiological narrowing of common carotid vessels was observed in either cases or controls
The diameter of left VA in all the three positions (neutral, right rotation, and left rotation) was less in cases than controls, and this was statistically significant. This could explain some kind of vascular compromise to the posterior cerebral circulation in cervical spondylosis patients, especially on changing posture of the neck. This could be one of the reasons for dizziness in these patients. The blood flow velocity was also found to be less in cases in comparison to controls, but it was not statistically significant. These findings give us an idea that there is some vascular cause to the dizziness in patients of cervical spondylosis. Reduced circulation in the VA system can lead to reduction in the posterior circulation of the brain which may, in turn, result in dizziness.

Discussion

The most accepted hypothesis regarding the cause of vertigo in cervical spondylosis patients is that of a vascular one. In patients of cervical spondylitis, there is expected to be some osteophytes, and these osteophytes would also be present in the vertebral canal of the vertebra. Since VA passes through this canal, it is expected that there would be some compression on this vessel which would eventually lead to reduction in blood supply to the brain, and this, in turn, would lead to vertigo/dizziness in these sets of patients. Once this correlation has been established, it is thought that the removal of such compression by surgical means would alleviate the symptoms of vertigo. A definitive correlation has not been fully established and many studies refute this claim.

Vertigo resulting from cervical pathologies was first described in 1858 by Claude Bernard. It has been attributed to many causes and several mechanisms.^[1] The pathogenesis of cervical spondylosis leading to vertigo presented in the literature is quite complex and contentious. Our study was to establish whether the pathogenesis of cervicogenic vertigo was of the vascular origin or had some other factors contributing to its generation.

Many theories have been postulated in relation to the cause behind cervicogenic vertigo. The most common ones are neurogenic and vascular.

The vertebrobasilar circulation supplies the vestibular labyrinth, VIII nerve, brain stem, cerebellum, and occipital lobes.^[2] Cervical osteophytes can press on the VA causing its occlusion during head turning to the same or opposite side.^[3],[4],[5]

The most common complaint in patients with vertebrobasilar insufficiency is vertigo.^[6],[7] As the blood supply to vestibulocochlear organ is an end artery, it is totally reliant on vertebrobasilar circulation and hence more susceptible to vertebrobasilar insufficiency ^[1] leading to vestibular vertigo. RVAO due to cervical osteophytes which, in turn, causes ischemia of the posterior cerebral circulation and of the vestibulocochlear artery has been postulated as one of the causes of vertigo of cervical origin. Cervical osteophytes pressing upon the VA causing its occlusion on neck rotation have been given by multiple authors (Fujita et al., 1995; Kuether et al., 1997; Ogino et al., 2001; Nwaorgu et al., 2003; Cagnie et al., 2005; Bulsara et al., 2006). Recent studies using neurovascular imaging techniques have established the association between vertigo and cervical spondyloses expressing as RVAO (Citow and Macdonald, 1999; Ogino et al., 2001; Brandt and Baloh, 2005; Cagnie et al., 2005; Choi et al., 2005; Majak et al., 2005; Netuka et al., 2005; Olszewski et al., 2005 and 2006). Our study demonstrated a reduction in the diameter of VA on the left side both in neutral and neck rotation in cases in comparison to controls, and it was statistically significant. This finding correlates with the work of many authors before. This difference in diameter could be due to compression by cervical osteophytes, but then, there was no significant difference in blood flow velocity in the vertebral arteries between cases and controls. The vascular cause appears to be important in causing dizziness and vertigo in the patients suffering from cervical spondylosis. Using color Doppler ultrasound for the assessment of neck vessels is an easy and cost-effective modality. It is a useful adjunct to assess any alteration in blood flow in vertebral arteries in patients of cervical spondylitis having vertigo. All these patients were advised Transcutaneous Electrical Nerve Stimulation (TENS) and interferential therapy (IFT). Patients receiving this form of treatment had some improvement in their symptoms. Pain was relieved, and there was a generalized sense of well-being. Dizziness too had some improvement. These treatments have no effect on the vascular supply but have muscle-relaxing properties.

Bayrak et al.^[8] also found no considerable changes in VA flow in neutral position on Doppler measurements of 91 patients with radiologically confirmed cervical degenerative changes.

Cervical radiculopathy is a disease process marked by nerve compression from herniated disk material or arthritic bone spurs. This impingement typically produces neck and radiating arm pain or numbness, sensory deficits, or motor dysfunction in the neck and upper extremities.^[9]

In 1973, 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 leads to unstable vestibular tone, which is further upset by neck torsion.^[10]

Barre ^[11] 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. All these patients were advised TENS and IFT. Patients receiving this form of treatment had some improvement in their symptoms. Pain was relieved, and there was generalized sense of well-being. Dizziness too had some improvement. These treatments have no effect on the vascular supply but have muscle-relaxing properties. This, in turn, proves that cervicogenic vertigo is not completely a vascular entity but also has some neurogenic component. It essentially is multifactorial.

Conclusion

Our study demonstrates the role of vascular compromise in the VA circulation in patients suffering from cervical spondylosis and vertigo. Narrowing of VA was present in cases and that too on the left side. The cause behind left-sided predilection could not be ascertained with certainty. Since the difference in blood flow was not significant in cases and controls, a definitive correlation is possible only if the sample size is more and results are replicated
Mild relief in symptoms after physiotherapy in the form of TENS and IFT points toward a possible role of nerve irritation in causing vertigo in patients of cervical spondylosis. The causation seems to be multifactorial in nature.

Compliance with ethical standards

Ethical approval: All procedures performed in this study were in accordance with the ethical standards of our institute's Ethical Committee. Ethical clearance from the Ethical Committee of AIIMS, Patna, was taken before starting this project. Informed written consent was obtained from each participant.

Financial support and sponsorship

The investigation modality for this research was color Doppler ultrasonography which was done free of cost at our institute.

Conflicts of interest

There are no conflicts of interest.

References

1.	Brandt T, Baloh RW. Rotational vertebral artery occlusion: A clinical entity or various syndromes? Neurology 2005;65:1156-7.
2.	Mahoney CF. Causes of balance disorders. Scotts Brown's Otolaryngology. 6^th ed. Vol. 2. USA: CRC Press Taylor and Franci; 1997.
3.	Nwaorgu OG, Onakaoya PS, Usman MA. Cervical Vertigo and cervical spondylosis- A need for adequate evaluation. Nigerian J Med 2003;12:140-4.
4.	Olszewski J, Majak J, Pietkiewicz P, Luszcz C, Repetowski M. The association between positional vertebral and basilar artery flow lesion and prevalence of vertigo in patients with cervical spondylosis. Otolaryngol Head Neck Surg 2006;134:680-4.
5.	Mazloumi M, Samini S. Evaluation of the results of surgical and medical treatment in 16 patients with vertigo secondary to cervical spondylosis. Med J Islamic Rep Iran 2006;20:2.
6.	Yamasoba T, Kikuchi S, Higo R. Deafness associated with vertebrobasilar insufficiency. J Neurol Sci 2001;187:69-75.
7.	Paksoy Y, Vatansev H, Seker M, Ustün ME, Büyükmumcu M, Akpinar Z. Congenital morphological abnormalities of the distal vertebral arteries (CMADVA) and their relationship with vertigo and dizziness. Med Sci Monit 2004;10:CR316-23.
8.	Bayrak IK, Durmus D, Bayrak AO, Diren B, Canturk F. Effect of cervical spondylosis on vertebral arterial flow and its association with vertigo. Clin Rheumatol 2009;28:59-64.
9.	Eubanks JD. Cervical Radiculopathy: Nonoperative Management of Neck Pain and Radicular Symptoms. Am Fam Physician 2010;81:33-40.
10.	Mangat KS, McDowall GD. Vertigo and nystagmus in cervical spondylosis and the role of 'anterior cervical decompression'. J Laryngol Otol 1973;87:555-63.
11.	Barre J. Rev Neurologuique 1926;1:1246.