From the Guidelines
Cervical spine X-rays are not recommended for evaluating dizziness with neck extension due to their limited ability to detect vascular compression or other underlying causes of this symptom. A more appropriate initial approach would be a thorough clinical evaluation focusing on vestibular assessment, including the Dix-Hallpike maneuver and other positional tests 1. If vertebrobasilar insufficiency is suspected (dizziness triggered by neck extension), magnetic resonance angiography (MRA) or computed tomography angiography (CTA) would be more appropriate imaging studies as they can visualize blood vessels and potential compression.
Key Points to Consider
- Plain X-rays have limited value in this context as they only show bony structures and cannot detect vascular compression, which is often the underlying cause of extension-related dizziness 1.
- Cervical X-rays expose patients to radiation without providing sufficient diagnostic information for this specific complaint.
- The American College of Radiology suggests that CT is the gold standard for identifying cervical spine fractures, but it is inferior to MRI in identifying soft-tissue injuries 1.
- A referral to neurology or otolaryngology may be warranted for specialized vestibular testing if symptoms persist.
- The condition may be related to cervical spondylosis causing compression of vertebral arteries during neck extension, but this would not be adequately visualized on plain radiographs.
Alternative Imaging Options
- CT with IV contrast does not aid in detection of cervical spine injury 1.
- MRI may be warranted in some patients to identify cervical spine instability that was not appreciable on CT 1.
From the Research
Cervical Spine X-ray for Dizziness with Extension
- The use of cervical spine x-rays, including flexion and extension views, has been studied in the context of evaluating cervical spine trauma and instability 2, 3.
- A study from 1999 found that flexion and extension radiographs may suggest signs of ligamentous and soft tissue injuries, but patients with acute injuries and severe pain may not be able to move their necks effectively, compromising the diagnostic yield of the radiographs 2.
- Another study from 2011 investigated the usefulness of flexion and extension radiographs in ruling out acute instability in patients with negative computed tomography scans, and found that these radiographs do not appear to be clinically useful in assessing acute instability 3.
- The role of imaging in cervical spine trauma has evolved, with computed tomography (CT) and magnetic resonance imaging (MRI) being commonly used for evaluation 4, 5, 6.
- MRI has been shown to be superior in demonstrating spinal cord pathology and intervertebral disc herniation, while CT is superior in demonstrating osseous injury 6.
- The use of MRI in acute cervical spine fractures has been found to be useful in identifying additional clinically relevant findings that can affect management, particularly in older patients, those with neurologic deficits, and those with polytrauma 5.