What is the appropriate management for a 30-year-old patient presenting with dizziness and back pain after a fall, where they hit their head, left shoulder, and back?

Management of Post-Traumatic Dizziness and Back Pain

This 30-year-old patient requires immediate head CT imaging and spinal precautions due to multiple red flags: head trauma with subsequent dizziness, back pain, and age within the high-risk demographic for spinal injury. 1, 2, 3

Immediate Assessment Priorities

Neurological Evaluation

• Obtain Glasgow Coma Scale score immediately - any score <15 mandates head CT imaging 3
• Assess for focal neurological deficits including cranial nerve abnormalities, motor weakness, sensory changes, or coordination problems 3
• Document presence of vomiting - this is a critical red flag requiring neuroimaging 3
• Clarify if loss of consciousness occurred at time of fall - even brief LOC necessitates CT imaging 3

Spinal Injury Risk Assessment

This patient meets multiple high-risk criteria for cervical spine injury that warrant spinal motion restriction: 1

• Age 10-30 years (patient is 30)
• Fall mechanism with head impact
• Back and neck pain present
• Dizziness (potential neurological symptom)

Manually stabilize the head and neck to minimize motion of the head, neck, and spine - do not use immobilization devices unless specifically trained, as they may cause harm 1

Mandatory Imaging Decision

Obtain non-contrast head CT immediately if ANY of the following are present: 3

• GCS <15
• Any focal neurological deficit
• Vomiting
• Loss of consciousness at time of injury
• Post-traumatic amnesia
• Dangerous mechanism (fall with head impact qualifies)

The American College of Emergency Physicians guidelines indicate head CT has 94-96% sensitivity for neurosurgical lesions and is essential because delayed intracranial hemorrhage can present hours to days after seemingly minor trauma. 3

Dizziness-Specific Evaluation

Distinguish Between Causes

• Assess for positional vertigo characteristics - brief episodes triggered by head movements without hearing loss, tinnitus, or ear fullness suggest BPPV 2
• Perform Dix-Hallpike maneuver only after cervical spine injury is ruled out - positive test shows characteristic nystagmus with brief latency that is fatigable 1, 2
• Check orthostatic vital signs - measure blood pressure and heart rate supine and after 3 minutes standing; drops of ≥20 mmHg systolic or ≥10 mmHg diastolic indicate orthostatic hypotension 3

Post-Traumatic BPPV Considerations

If BPPV is diagnosed, recognize that post-traumatic BPPV has a significantly higher recurrence rate (up to 67%) compared to spontaneous BPPV 1, 2

Back Pain Evaluation

Red Flag Assessment

Examine for emergent spinal pathology indicators: 4

• Saddle anesthesia
• Bowel or bladder dysfunction
• Progressive motor weakness
• Fever (suggesting infection)
• Severe pain at rest or night pain

Imaging for Spine

• Cervical spine imaging is indicated given the mechanism (fall with head/back impact), age demographic (males 10-30 years at highest risk), and presence of back pain 1
• Obtain flexion-extension views if atlantoaxial instability is suspected based on mechanism and symptom pattern 5

Treatment Algorithm Based on Findings

If Intracranial Injury Identified

• Immediate neurosurgical consultation and admission 3

If Post-Traumatic BPPV Confirmed

• Perform Epley maneuver - 80-90% success rate for symptom resolution 2
• Implement fall precautions immediately - BPPV significantly increases fall risk, especially critical given recent trauma 1, 2, 3
• Schedule follow-up within 1 week to assess treatment response and repeat Epley if necessary 2
• Consider vestibular rehabilitation if symptoms persist after canalith repositioning 1, 2

If Orthostatic Hypotension Present

• Initiate volume repletion 3
• Review all medications for contributors (antihypertensives, diuretics) 3

If Musculoskeletal Neck/Back Pain Without Red Flags

• Apply ice for first 24 hours, then transition to heat 6
• Prescribe NSAIDs and consider muscle relaxants for acute phase 6
• Avoid prolonged cervical collar use - limit to 2-3 weeks maximum as it may delay recovery 6
• Initiate early passive mobilization and range of motion exercises to accelerate recovery 6

Critical Safety Counseling

Educate the patient on fall risk - this is particularly important as BPPV dramatically increases fall risk and the patient has already experienced one traumatic fall 1, 3

Provide explicit return precautions: 3

• Worsening or persistent dizziness
• New neurological symptoms (weakness, numbness, vision changes)
• Persistent nausea/vomiting
• Gait disturbance
• New or worsening headache
• Subjective hearing loss

Counsel on BPPV recurrence - post-traumatic BPPV recurs in up to 67% of cases, so the patient should recognize symptoms and return promptly for repeat treatment 1, 2

Common Pitfalls to Avoid

• Do not dismiss dizziness as benign without ruling out intracranial injury - concussion can cause a neuro-metabolic cascade leading to dizziness even without loss of consciousness 3
• Do not perform Dix-Hallpike maneuver before clearing cervical spine - this could worsen occult spinal injury 1
• Do not assume normal initial presentation excludes serious pathology - delayed intracranial hemorrhage can present days after trauma 3
• Do not use rigid cervical collars without proper training - immobilization devices may be harmful when improperly applied 1