Can cervical spine encroachment at C2-7 without soft tissue changes on MRI cause dizziness in patients with Ehlers-Danlos syndrome?

Cervical Spine Encroachment and Dizziness in Ehlers-Danlos Syndrome

Cervical spine encroachment at C2-7 without soft tissue changes on MRI can cause dizziness in patients with Ehlers-Danlos syndrome due to the connective tissue laxity that characterizes this condition, leading to potential cervical instability and neurovascular compromise.

Pathophysiological Mechanism

Patients with Ehlers-Danlos syndrome (EDS) have inherent connective tissue abnormalities that can lead to several spine-related complications:

• Ligamentous Laxity: The primary issue in EDS is connective tissue laxity, which can affect the ligaments supporting the cervical spine, particularly at the craniovertebral junction and throughout the cervical spine 1
• Cervical Instability: This ligamentous laxity can result in cervical instability or hypermobility, which may not be fully apparent on static MRI imaging 1
• Neurovascular Effects: Cervical spine encroachment can affect:
  • Vertebral arteries and their branches
  • Cervical nerve roots
  • Proprioceptive pathways important for balance

Diagnostic Considerations

When evaluating dizziness in EDS patients with cervical spine encroachment:

1. Standard MRI Limitations:

   • Static, recumbent MRI may not reveal the full extent of cervical instability 2
   • Soft tissue changes are not always necessary for symptoms to occur in EDS patients

2. Positional Testing:

   • Consider that symptoms may be positional or movement-dependent
   • The American College of Radiology notes that chronic vestibular syndrome (presenting as dizziness lasting weeks to months) can be associated with cervical spine abnormalities 3

3. Differential Diagnosis:

   • Rule out other common causes of dizziness such as BPPV, vestibular neuritis, or Ménière's disease 4
   • Consider vascular causes, as EDS patients are also prone to arterial dissections 5

Clinical Correlation

The relationship between cervical spine findings and dizziness in EDS is supported by:

• Cervical instability in EDS can lead to specific symptoms including vertigo, headaches, tinnitus, vision changes, and syncope 1
• Neurosurgical literature documents that EDS patients are prone to instability, especially in the occipital-cervical region 6
• Chronic microvascular angiopathy can cause dizziness through disruption of white matter tracts involved in balance and spatial orientation 4

Management Considerations

For EDS patients with dizziness and cervical spine encroachment:

1. Advanced Imaging:

   • Consider positional MRI (pMRI) to evaluate for dynamic changes not visible on standard MRI 2
   • Evaluate for craniovertebral junction abnormalities which are common in EDS 6

2. Specialist Consultation:

   • Neurosurgical evaluation may be warranted for patients with significant symptoms 6
   • Vestibular testing to rule out peripheral causes of dizziness 4

3. Conservative Management:

   • Cervical stabilization exercises
   • Proper neck support
   • Avoidance of activities that exacerbate symptoms

Pitfalls to Avoid

• Missing Dynamic Instability: Static MRI may not capture positional changes that occur during movement 2
• Attributing Symptoms Solely to Degenerative Changes: The pathophysiology in EDS is different from typical degenerative spine disease
• Overlooking Vascular Complications: EDS patients, particularly those with type IV, are at risk for arterial dissections that can also cause dizziness 5

In conclusion, cervical spine encroachment at C2-7 in EDS patients represents a plausible mechanism for dizziness even without soft tissue changes on MRI, due to the unique connective tissue abnormalities that characterize this condition.