What is the appropriate management for a patient experiencing dizziness with neck pain?

Management of Dizziness with Neck Pain

For patients presenting with dizziness and neck pain, immediately assess for "red flag" symptoms that indicate serious pathology requiring urgent MRI cervical spine without contrast, including constitutional symptoms, neurological deficits, or elevated inflammatory markers; if red flags are absent and the patient has a normal neurological examination, the most likely diagnosis is cervicogenic dizziness, which should be managed with conservative treatment including manual therapy and vestibular rehabilitation. 1

Initial Clinical Triage: Rule Out Life-Threatening Causes

Screen for Neurological Red Flags

• Perform a focused neurological examination to identify signs of posterior circulation stroke, which can present with dizziness and neck pain, particularly in patients with vascular risk factors (older age, hypertension, atrial fibrillation). 1
• If the patient has acute persistent vertigo with abnormal neurological findings (limb weakness, sensory deficits, gait ataxia, dysarthria), obtain MRI head without IV contrast immediately as this suggests central vertigo from posterior circulation infarct. 1
• The HINTS examination (Head Impulse, Nystagmus, Test of Skew) by a trained specialist can differentiate peripheral from central causes—an abnormal HINTS examination warrants immediate neuroimaging. 1

Assess for Cervical Spine Red Flags

• Screen for constitutional symptoms including fever, unexplained weight loss, and night sweats, which suggest infection, malignancy, or inflammatory arthritis. 1, 2
• Check for elevated inflammatory markers (ESR, CRP, WBC count) which indicate vertebral osteomyelitis, discitis, or inflammatory conditions requiring urgent evaluation. 1, 3
• Obtain history of malignancy, immunosuppression, or IV drug use, as these increase risk for metastatic disease or spinal infection. 1, 2
• Assess for myelopathic signs (hyperreflexia, Babinski sign, gait disturbance, bowel/bladder dysfunction) which indicate spinal cord compression requiring urgent surgical evaluation. 1, 2

Imaging Strategy Based on Red Flag Assessment

If Red Flags Present

• Order MRI cervical spine without IV contrast immediately as it is the most sensitive modality for detecting soft tissue abnormalities, disc herniation, nerve root impingement, inflammatory processes, infection, tumor, and vascular pathology. 1, 2, 3
• MRI is superior to CT for identifying degenerative cervical disorders and nerve root compression. 2, 4

If No Red Flags Present

• Defer imaging initially and pursue conservative management, as most acute neck pain resolves spontaneously and imaging has very low diagnostic yield in isolated dizziness (approximately 4% on MRI). 1, 2
• Consider MRI cervical spine without contrast only if symptoms persist beyond 6-8 weeks of conservative therapy, progressive neurological deficits develop, or severe pain is unresponsive to treatment. 1, 2, 4

Diagnosis of Cervicogenic Dizziness

Clinical Characteristics

• Cervicogenic dizziness is a diagnosis of exclusion characterized by dizziness, dysequilibrium, and imbalance associated with neck pain in patients with cervical pathology. 5, 6, 7
• Patients typically report gradual onset of symptoms, light-headedness, visual disturbances, and symptoms triggered by neck movements or positions. 8, 7
• Physical examination reveals restricted cervical range of motion, muscle hypertonicity, decreased neck flexibility, and increased tender points compared to patients with dizziness alone. 9, 8

Differential Diagnosis to Exclude

• Rule out vestibular disorders including benign paroxysmal positional vertigo (BPPV) using Dix-Hallpike testing, vestibular neuritis, and Menière disease through appropriate vestibular function tests. 1, 6
• Exclude vertebrobasilar insufficiency particularly in patients with chronic recurrent vertigo and brainstem neurologic deficits—consider MRA or CTA head and neck if clinically suspected. 1
• Rule out vestibular migraine, labyrinthine concussion, and cervical arterial dysfunction through detailed history and appropriate testing. 6

Treatment Approach for Cervicogenic Dizziness

Conservative Management

• Initiate manual therapy and vestibular rehabilitation as the primary treatment, which has been shown to successfully resolve cervicogenic dizziness when diagnosed correctly. 9, 5, 6
• Treatment should include spinal manipulation (when appropriate), soft tissue release, and rehabilitative exercises targeting cervical musculoskeletal and sensorimotor impairments. 9, 7
• Most cases improve within 4-6 weeks of conservative treatment. 9

Prognosis

• Approximately 50% of patients with neck pain experience recurrent or persistent symptoms at 1-year follow-up, necessitating ongoing management. 1, 4
• When cervicogenic dizziness is correctly diagnosed and treated, patients can achieve complete symptom resolution with full cervical range of motion. 9

Critical Pitfalls to Avoid

• Do not assume benign cervicogenic dizziness in patients with vascular risk factors (older age, hypertension, atrial fibrillation), as posterior circulation stroke can present similarly and requires immediate neuroimaging. 1
• Do not order imaging immediately in the absence of red flags, as this leads to overdiagnosis of incidental degenerative changes that correlate poorly with symptoms—degenerative changes are present in 85% of asymptomatic individuals over 30 years. 2, 3
• Do not rely solely on normal neurological examination to exclude posterior circulation infarct, as a normal exam does not completely rule out stroke; consider MRI in high vascular risk patients even with normal examination. 1
• Do not interpret degenerative changes on imaging as causative without clinical correlation, as cervical spondylosis is extremely common (53.9% prevalence) and often asymptomatic. 4, 3
• Counsel patients against self-manipulation of the cervical spine, as this can precipitate or worsen cervicogenic dizziness and carries risk of vascular injury. 9