Dizziness and Neck Pain in a Middle-Aged Adult
A 52-year-old woman presents with 2 months of intermittent dizziness, described as "lightheaded and off-balance," worse with quick head turns and when looking up. She also has neck stiffness and occipital headaches. She has no true vertigo, no hearing loss, no tinnitus, and no syncope. She has hypertension and hyperlipidemia. On exam: cervical rotation is limited bilaterally with reproduction of dizziness at end-range right rotation; Dix-Hallpike is negative; no nystagmus on primary gaze; cranial nerves II-XII intact; no carotid bruit; blood pressure 138/84. She asks whether "neck manipulation will fix the dizziness."
1. What is your differential for her dizziness, and how does the exam help you prioritize it?
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Differential:
- Cervicogenic dizziness - dizziness provoked by neck movement/position, with limited cervical motion and reproduction at end-range rotation; no auditory symptoms. Fits well.
- BPPV (posterior canal) - would show a positive Dix-Hallpike with latency and fatigability; hers is negative.
- Vertebrobasilar insufficiency (VBI) - consider in a patient with vascular risk factors (HTN, hyperlipidemia); symptoms would include diplopia, dysarthria, dysphagia, drop attacks, or bilateral paresthesias. She has none of these.
- Central causes - no focal neurologic findings, no nystagmus on primary gaze.
- Orthostatic hypotension - no positional drop reported; BP is stable.
Prioritization:
- The provocation by neck rotation and the absence of auditory or central features favor cervicogenic dizziness.
- VBI must be screened for given her vascular risk factors, even though she lacks classic symptoms.
Teaching point: Cervicogenic dizziness is a diagnosis of exclusion; screen for BPPV, VBI, and central causes before treating.
2. What screening do you perform before cervical manipulation, and what is your treatment approach?
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Pre-manipulation screening:
- Vertebrobasilar screening: Ask about diplopia, dysarthria, dysphagia, drop attacks, and bilateral symptoms. Perform a vertebral artery test (cervical extension with rotation, held ~30 seconds) and monitor for reproduction of symptoms. Note: the test has limited sensitivity/specificity, so it is adjunctive, not definitive.
- Carotid screening: auscultate for bruits; ask about amaurosis fugax.
- Neurologic exam: cranial nerves, gait, and coordination.
- Vascular risk factor review: HTN and hyperlipidemia raise concern; consider further workup if symptoms are atypical.
Treatment approach:
- Avoid high-velocity cervical thrust if the vertebral artery test reproduces symptoms or if there is any doubt about vascular safety.
- Use non-thrust OMT: muscle energy, myo-fascial release, and gentle cervical traction.
- Vestibular rehabilitation referral if BPPV or vestibular dysfunction is suspected.
- Reassess after 2-4 weeks; if symptoms persist or worsen, refer to neurology or ENT.
Teaching point: Cervical manipulation for dizziness is only appropriate after vascular and vestibular screening; non-thrust techniques are a safer first-line option.