What are the management and treatment options for a patient with cervical spondylosis experiencing disorientation and vision changes when looking over their shoulder?

Management of Cervical Spondylosis with Disorientation and Vision Changes

Patients experiencing disorientation and vision changes when looking over their shoulder due to cervical spondylosis should be urgently referred to a neuro-ophthalmologist or neurologist for evaluation, as these symptoms suggest possible vertebrobasilar insufficiency or brainstem compression requiring specialized assessment.

Diagnostic Considerations

When evaluating patients with these symptoms, it's important to consider several potential neurological mechanisms:

1. Vertebrobasilar Insufficiency (VBI):

   • Compression of vertebral arteries by osteophytes during head rotation 1
   • Can cause transient ischemia to the brainstem and cerebellum
   • Symptoms include dizziness, disorientation, and visual disturbances

2. Skew Deviation:

   • Vertical strabismus associated with disorders of vestibular pathways or brainstem 2
   • May present with:
     • Vertical diplopia
     • Torticollis (abnormal head position)
     • Subjective tilting of the visual field
     • Ocular torsion

3. Cranial Nerve Involvement:

   • Compression of cranial nerves by degenerative changes
   • May affect oculomotor function

Diagnostic Approach

A thorough neurological and ophthalmological evaluation should include:

• Complete sensorimotor evaluation with emphasis on:

  • Measuring torsion
  • Determining positions of gaze with greatest deviation 2
  • Parks-Bielschowsky three-step test if vertical misalignment is present

• Neurological examination looking for:

  • Horner's syndrome
  • Cranial nerve palsies
  • Internuclear ophthalmoplegia (INO)
  • Nystagmus
  • Other brainstem signs 2

• Imaging studies:

  • MRI of the brain and cervical spine with contrast is the preferred initial study 3
  • CT myelography if MRI is contraindicated
  • Consider cerebral angiography if VBI is suspected 1

Management Algorithm

1. Initial Management:

• Urgent referral to neuro-ophthalmologist and/or neurologist
• Neck immobilization with a soft collar to prevent positions triggering symptoms
• Medication for pain and inflammation:
  • NSAIDs for pain control
  • Muscle relaxants for associated muscle spasm

2. Non-surgical Management (for mild cases):

• Activity modification to avoid provocative head positions
• Isometric neck exercises to strengthen supporting musculature 4
• Physical therapy focusing on:
  • Posture correction
  • Range of motion exercises
  • Strengthening exercises

3. Ophthalmological Management (if visual symptoms persist):

• Prism glasses for small vertical deviations 2
• Botulinum toxin injections for persistent diplopia while awaiting definitive treatment 2

4. Surgical Management (indicated for):

• Progressive neurological deficits
• Severe or persistent symptoms despite conservative management
• Evidence of significant cord or vascular compression 5, 3

Surgical options include:

• Anterior approach (preferred for most cases) 5:

  • Discectomy and/or osteophytectomy
  • Fusion with bone autograft or cages
  • With or without plate fixation

• Posterior approach:

  • Decompressive laminectomy for multilevel compression 5
  • Indicated in specific cases with primarily posterior compression

Important Considerations and Pitfalls

1. Don't delay referral: Any patient with suspected vertebrobasilar symptoms or neurological signs should be promptly referred to a specialist 3

2. Don't miss red flags:

   • Progressive neurological deficits
   • Gait disturbances
   • Hand dexterity issues
   • These may indicate cervical spondylotic myelopathy requiring urgent intervention 3

3. Beware of misdiagnosis: Symptoms may be incorrectly attributed to:

   • Peripheral vertigo
   • Primary eye disorders
   • Migraine

4. Recognize that imaging findings don't always correlate with symptoms:

   • Asymptomatic cord compression is common
   • Clinical correlation is essential 4

5. Consider vascular assessment: In patients with positional symptoms, vascular studies may be necessary to evaluate for vertebrobasilar insufficiency 1

The long-term prognosis is generally favorable with appropriate management, with 70-80% of patients showing improvement after surgical intervention when indicated 4.