REVIEW

URRENT
C
OPINION

Cervicogenic causes of vertigo

Timothy C. Hain

Purpose of review
Herein we discuss the recent literature concerning cervicogenic vertigo including vertigo associated with
rotational vertebral artery syndrome, as well as whiplash and degenerative disturbances of the cervical
spine. We conclude with a summary of progress regarding diagnostic methods for cervicogenic vertigo.
Recent findings
Several additional single case studies of the exceedingly rare rotational vertebral artery syndrome have
been added to the literature over the last year. Concerning whiplash and degenerative disturbances of the
cervical spine, four reviews were published concerning using physical therapy as treatment, and two
reviews reported successful surgical management. Publications regarding diagnostic methodology remain
few and unconvincing, but the cervical torsion test appears the most promising.
Summary
Little progress has been made over the last year concerning cervicogenic vertigo. As neck disturbances
combined with dizziness are commonly encountered in the clinic, the lack of a diagnostic test that
establishes that a neck disturbance causes vertigo remains the critical problem that must be solved.
Keywords
cervical, dizziness, proprioception, vascular, vertigo, vestibular function

INTRODUCTION
Cervicogenic vertigo is illusory motion deriving from
a disturbance of the neck. Although dizziness contains vertigo and imbalance within its definition, in
this review we consider the terms cervical vertigo,
cervicogenic vertigo, and cervicogenic dizziness as
the same entity. Cervicogenic vertigo is currently out
of fashion. This is largely because of several influential reviews over the last 20 years. Brandt and Bronstein [1] concluded that the debate on the relevance
and mechanism of cervicogenic vertigo is more of
theoretical interest than of practical relevance.
Nevertheless, there is clear experimental and clinical
evidence that the neck perturbations can induce
vertigo and imbalance [2 ,3,4]. We will first discuss
recent studies concerning the three main categories
of cervicogenic vertigo: vascular, whiplash, and vertigo associated with cervical injuries other than whiplash. We conclude with a review of the current state of
the art of diagnosis of cervicogenic vertigo.
&

VERTIGO ASSOCIATED WITH

IMPINGEMENT OF THE VERTEBRAL
ARTERIES IN THE NECK
Patients who develop symptomatic occlusion of
the vertebral artery on sustained head rotation on

the trunk have cervicogenic vertigo. This most commonly occurs at the atlantoaxial level as the
majority of head rotation occurs between C1 and
C2. This syndrome was first described in 1978 by
Sorensen [5] who reported a patient who became
symptomatic when practicing archery. Accordingly,
this condition is sometimes called Bow-Hunter syndrome but the descriptive term rotational vertebral
artery syndrome (RVAS) is more useful. Only about
40 proven cases of RVAS were reported in the entire
literature as of 2012 [6]. In the largest series, Lu et al.
[7] presented nine patients who suffered from RVAS
and concluded that the most common cause of
arterial compression was an osteophyte (56%),
and the most frequent location was at the level of
C1 (44%).
As RVAS patients are exceedingly rare, the literature consists largely of single case studies. These
have continued in the recent literature. Sarkar et al.
[8] reported a case of bow-hunters syndrome in a

Northwestern University and University of Chicago, Chicago, USA

Correspondence to Timothy C. Hain, MD, Emeritus Professor, Northwestern University, Chicago Dizziness and Hearing, 645 N Michigan,
Suite 410, Chicago, IL 60611, USA. E-mail: t-hain@northwestern.edu
Curr Opin Neurol 2015, 28:6973
DOI:10.1097/WCO.0000000000000161

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Neuro-ophthalmology and neuro-otology

KEY POINTS
 Cervicogenic vertigo/dizziness is probably common,
but it lacks a validated clinical test.
 The rotational vertebral artery syndrome is
extremely rare.
 Physical therapy is the preferred treatment for most
kinds of cervicogenic vertigo.
 The cervical torsion test is the most promising
diagnostic procedure at present.

young man, attributed to muscular hypertrophy.

Pinol et al. [9] reported another young man with
an anomalous course of the vertebral artery at the
level of C6. Ogawa et al. [10] reported a case of downbeat nystagmus induced by neck rotation, anteflexion, and lateral flexion, attributed to reversible
vertebral artery occlusion.
Although physical therapy is the recommended
treatment for most other kinds of cervicogenic vertigo,
physical therapy is not effective, and even potentially
dangerous for patients with RVAS, as the cause is
related to blood flow rather than a process that can
be affected with neck manipulation or exercise. Treatment must address the vascular problem [6,7].

WHIPLASH ASSOCIATED DISORDER AND

VERTIGO
Whiplash associated disorder (WAD) is defined as
symptoms that follow a neck injury, generally
associated with a rear end collision. In patients
who experience whiplash, although vertigo is
uncommon, about half of them report dizziness
and imbalance [11,12]. As these individuals have
all experienced perturbations of their neck, and
inner ear disorders are rare after neck trauma [13],
these are patients with presumed cervicogenic vertigo. Concerning the mechanism, the most prevalent hypothesis is that in WAD, trauma modifies
cervical proprioception and produces dizziness
through a mismatch between vestibular, visual,
and proprioceptive inputs to the vestibular nucleus.
Also highly prevalent is the opinion that psychosocial factors including the chance of secondary gain
after whiplash plays the predominant role in persistence of subjective symptoms such as pain and
dizziness [14]. Modification of cervical proprioception is just one of many other plausible hypotheses
for cervical vertigo [1].
There have been no recent studies published
concerning the relationship between WAD and dizziness or vertigo. Regarding treatment, Humphreys
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et al. [15] and associates reported that 7880% of

patients were improved after 6 months of chiropractic treatment. This result must be considered in the
context of the older literature that notes that prognosis for chronic disability after acute whiplash is
extremely variable.
Humphreys et al. [15] also noted that neck pain
patients with dizziness reported significantly higher
pain and disability scores at baseline than patients
without dizziness. This observation is consistent
with the older literature. Recent studies concerning
the diagnosis of dizziness accompanying whiplash
are discussed in the final section of this review.

DEGENERATIVE CERVICAL DISORDERS

AND VERTIGO
There are far more patients with cervical arthritis or
disk disease in the general population than there are
patients with WAD or vertebral artery compromise,
and given the assumption that they disturb cervical
proprioception and knowing that proprioceptive
disturbances of the neck cause imbalance and/or
nystagmus in animals [3], it is reasonable to hypothesize that this group is the largest with cervicogenic
vertigo. Unfortunately (see following section on
testing), lacking a specific test for cervicogenic vertigo, clinicians have no method of separating out
patients with dizziness caused by neck disorders,
from persons who have both a neck disorder and
dizziness. There have been no recent studies on the
epidemiology or clinical characteristics of this subgroup of cervicogenic vertigo.
Regarding treatment, Reid et al. [16,17] reported
good results for Mulligan sustained natural apophyseal glides and Maitland mobilizations compared
with placebo treatment but no effect on joint repositioning accuracy [16]. There are other recent studies of improvement with physical therapy [18]. On
the contrary, Hansson et al. [19] reported that vestibular rehabilitation had no effect on either neck
pain or cervical range of motion in patients with
whiplash and dizziness. The implication of this
result is that vestibular physical therapy is not a
substitute for physical therapy for the neck. In our
opinion, physical therapy focusing on relieving
neck pain and spasm and improving mobility is
reasonable treatment for patients thought to have
cervicogenic vertigo associated with either whiplash
or degenerative disorders of the neck.
Regarding surgical treatment, recent studies
include that of Ren et al. [20] who reported an
excellent outcome in 18 out of 35 patients who
underwent percutaneous laser disk decompression.
Li et al. [21] also reported good results following
more extensive cervical surgery. Freppel et al. [4]
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Cervicogenic causes of vertigo Hain

reported that surgery for cervical radiculopathy

reduced the contribution of visual input to postural
control. This would be generally thought to be a
positive outcome. Although these reports are
encouraging, and support the conjecture that the
neck disorders cause cervicogenic vertigo, we think
that it remains unreasonable to perform cervical
surgery for patients thought to have cervicogenic
vertigo, but lacking other indications for surgery
than dizziness or imbalance.

approach has been explored on numerous occasions

[2628]. The cervical torsion test is performed with
the same methodology as the vertebral artery test
[27]. It is a simple procedure wherein nystagmus is
monitored with the patient sitting upright in total
darkness. The head turned approximately 90 degrees
on the trunk for 15 s, keeping their eyes centered in
the orbit, first to one side and then to the other.
Nystagmus with the head in the center is compared
with nystagmus with the head turned. LHeureuxLebeau et al. [29 ] recently reported that more than
2 degrees per second nystagmus during the cervical
torsion test was more common in patients with
cervicogenic vertigo than patients with benign paroxysmal positional vertigo. The cervical torsion test
is not affected by cognitive variables. Furthermore,
it has recently become much easier to perform
because of the recent wide availability of videoFrenzel goggles that can detect small amounts of
nystagmus at the bedside [30]. The cervical torsion
test, with technological improvements, appears to
be the best diagnostic possibility on the horizon for
cervicogenic vertigo and needs more study.
Also using eye movements, the manual therapy
community has reported procedures such as the
smooth pursuit neck torsion test: to be useful for
diagnosis of cervicogenic vertigo [31,32]. Smooth
pursuit, is a complex multiple input system that is
vulnerable to cognitive variables, age, and sedation.
For this reason, it is unlikely that any smooth pursuit test could ever be of general utility for diagnosis
of cervicogenic vertigo. Fischer et al. [28] reviewed
many reports of abnormal oculomotor function in
whiplash, and found no consistency or underlying
pattern. This direction of inquiry appears to be a
dead end.
The third category of diagnostic tests involves
measuring the effect of head on neck movement on
balance. Several studies including the very recent
literature have reported that postural stability is
reduced in patients with cervical injuries such as
due to whiplash [3335]. This is logical as injuries
to the neck might disturb the difficult adjustment
between the two coordinate systems of the head and
body [36]. Bianco et al. [33] recently reported that
imbalance can be documented using posturography
in patients with whiplash injury compared with controls. Freppel et al. [4] reported that the contribution
of visual input to postural control was reduced in
patients operated on for degenerative cervical spine
disorders. Yu et al. [35] reported that body sway is
increased to a greater extent by neck torsion than
head forward, comparing whiplash patients to normal controls. On the contrary, LHeureux-Lebeau
et al. [29 ] found no difference in a timed 10-m walk
test with head turns between patients with presumed
&&

Diagnostic tests for cervicogenic vertigo

As of this writing, a specific clinical test is not
available for cervicogenic vertigo [2 ,22]. Diagnostic
tests can be divided into ones that use blood flow,
eye movements, postural sway, and subjective joint
position as outcome variables.
This diagnosis of vascular cervicogenic vertigo is
attained through vascular imaging studies, comparing blood flow with the head in provoking position
to neutral positions. As the prevalence of vascular
rotational vertigo is exceedingly low, the diagnostic
yield is also exceedingly low and the risk of a false
positive is exceedingly high. False positives may
arise not only from testing error, but also from
variability in the population as vertebral artery
blood flow is compromised with full contralateral
rotation in healthy individuals [23]. Chang et al. [24]
reported a variety of changes on MRI blood flow in
cervicogenic vertigo. Overall, given the extreme
infrequency of RVAS and the changes in blood flow
found in normal individuals, the value of these
procedures in vertigo provoked by sustained head
rotation is small.
Although extremely rare, fear of provoking
vertebral territory ischemia has caused some groups
within the medical community to advocate use of
screening tests such as the vertebral artery test or
VAT as a routine procedure prior to administering
therapy to patients involving neck rotation. This
test consists of determining whether the combination of head extension and rotation provokes
dizziness. Cote et al. [25] found that the VAT test
has little or no predictive value for vertebral artery
blood flow. It also seems unlikely that a sustained
head rotation test would predict risk from a high
acceleration head thrust as is commonly used for
treatment of neck facet disorders. Nevertheless, the
VAT may have value as a defense against litigation
wherein neurological symptoms are attributed to
head rotation.
A second category of diagnostic testing concerns
attempts to document cervical nystagmus eye
movement associated with sustained neck rotation
or body rotation under the neck. This logical
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Neuro-ophthalmology and neuro-otology

cervicogenic vertigo and benign paroxysmal positional vertigo patients. Thus, a test of gait speed
failed to detect cervicogenic vertigo but tests of sway
appear to be often positive.
These studies of postural stability add to a substantial previous literature suggesting that patients
with cervicogenic vertigo sway more than normal
controls. Impairment of postural stability occurs in
many other disorders than cervicogenic vertigo and
postural instability can be simulated. Whereas postural stability testing is not diagnostic of cervicogenic vertigo due to its lack of specificity and
vulnerability to cognitive factors, a normal posturography sway test might be helpful in reducing the
likelihood of cervicogenic vertigo.
Finally, it has also been proposed that reduced
cervical proprioception or joint position error might
be a diagnostic sign of cervicogenic vertigo [37].
LHeureux-Lebeau et al. [29 ] reported that there
was elevated joint position error in 25 patients with
cervicogenic vertigo. Unfortunately, as this procedure requires cooperation from the individual,
it is vulnerable to cognitive variables. More data
are needed to decide if this methodology is helpful
in clinical diagnosis.
To summarize, other than in the extremely rare
RVAS cases, we do not have a clinical test that can
prove that a neck disturbance causes vertigo. Vestibular laboratory tests serve to exclude inner ear
disorders as an alternative cause of vertigo. Imaging
studies are useful to detect structural injury to the
neck, which increases the probability of cervicogenic vertigo, but they do not establish cause. This
leaves the clinician with a group of patients who
might have cervicogenic vertigo, but without a way
to prove or disprove the diagnosis. Thus, the diagnostic situation for cervicogenic vertigo resembles
that of other common clinical diagnoses in the dizzy
population such as vestibular migraine [38], or
chronic subjective dizziness [39], that also lack
objective tests to rule them in or out.
&&

CONCLUSION
Although experimental and clinical epidemiologic
data suggest that cervicogenic vertigo is a significant
source of dizziness, in 2014 it remains out of
fashion. The key problem remains a lack of a sensitive and specific test that differentiates between the
chance coincidence of a neck injury and dizziness,
and the situation where the neck injury actually
causes dizziness.
Acknowledgements
None.
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Financial support and sponsorship

None.
Conflicts of interest
There are no conflicts of interest.

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