Why Cervical Spondylosis Alone Cannot Explain This Clinical Picture
The combination of neck pain, vertigo, and intermittent headache in an older adult requires exclusion of more serious pathology because these symptoms—particularly vertigo—suggest either vertebrobasilar insufficiency from vascular compression, cervical myelopathy, or radiculopathy, none of which are "simple" cervical spondylosis. 1, 2
The Core Problem: Degenerative Changes Don't Correlate with Symptoms
Spondylotic changes on imaging are common in patients over 30 years of age and correlate poorly with the presence of neck pain. 3, 1 This is the fundamental issue: finding degenerative changes on imaging does not establish causation for symptoms. In fact, imaging findings in cervical spondylosis correlate poorly with symptoms, as degenerative changes are commonly found in asymptomatic individuals. 1
A 10-year longitudinal MRI study demonstrated that cervical disc degeneration progressed in 85% of patients, yet symptoms developed in only 34%. 3 This means the majority of people with progressive degenerative changes remain asymptomatic, making it inappropriate to attribute symptoms to "simple" spondylosis without excluding more serious pathology.
Red Flags That Demand Investigation
Vertigo Is Not a Typical Spondylosis Symptom
Vertigo represents a critical red flag that suggests:
Vertebrobasilar insufficiency from mechanical compression: Osteophytes from cervical spondylosis can compress the vertebral artery during head rotation, causing vertebrobasilar insufficiency symptoms including vertigo. 4 This is an uncommon but serious complication requiring vascular imaging.
Cervical myelopathy: Vertigo combined with neck pain can indicate spinal cord compression, which requires urgent evaluation. 2
Atypical symptoms from dural/cord stimulation: Vertigo, along with headache, palpitation, nausea, tinnitus, and blurred vision can result from stimulation of the dura mater and spinal cord in cervical spondylosis. 5 These are not "simple" presentations and require advanced imaging.
Intermittent Headache Patterns Matter
Headaches in cervical pathology can indicate:
Cervical radiculopathy: Severe occipital headache radiating down the neck suggests radiculopathy, not simple mechanical pain. 2
Referred pain from nerve root compression: This requires MRI evaluation to exclude structural compression. 2
What Must Be Ruled Out Before Accepting "Simple" Spondylosis
Critical Exclusions Required
You cannot diagnose "simple" cervical spondylosis until you exclude:
- Progressive motor weakness 2
- Bilateral symptoms affecting upper AND lower extremities 2
- New bladder or bowel dysfunction 2
- Loss of perineal sensation 2
- Gait disturbance or difficulty with fine motor tasks 2
- Vertebrobasilar insufficiency symptoms during head rotation 4
The Imaging Imperative
MRI of the cervical spine is the preferred initial diagnostic study when neurologic symptoms are present, as it is more sensitive than CT in identifying degenerative cervical disorders and correctly predicts 88% of cervical radiculopathy lesions. 3, 2 The presence of vertigo and headache with neck pain represents potential neurologic involvement, making imaging mandatory rather than optional.
The Clinical Pitfall: Assuming Correlation Equals Causation
The most common error is seeing degenerative changes on imaging and assuming they explain the symptoms. 3, 1 This is particularly dangerous because:
- Asymptomatic degenerative changes are the norm in older adults 3, 1
- True pathology (myelopathy, radiculopathy, vascular compression) can coexist with degenerative changes 4, 5
- Attributing symptoms to "simple" spondylosis delays diagnosis of treatable serious conditions 2, 4
The Appropriate Diagnostic Algorithm
Perform detailed neurologic examination looking specifically for motor weakness, sensory deficits, gait abnormalities, and upper motor neuron signs. 2
Assess for vertebrobasilar insufficiency by evaluating whether vertigo occurs with specific head positions or movements. 4
Order MRI cervical spine without contrast as the first-line imaging study when neurologic symptoms (vertigo, headache with neck pain) are present. 2
Consider vascular imaging (CTA or MRA) if vertigo is positional and suggests vertebrobasilar insufficiency. 4
Only after excluding myelopathy, radiculopathy, and vascular compression can you consider this "simple" spondylosis requiring conservative management. 1, 2
When Conservative Management Is Appropriate
Conservative management with activity modification, NSAIDs, physical therapy, and neck immobilization is appropriate only after serious pathology is excluded. 6, 7 Even then, 30-50% may have residual or recurrent symptoms up to 1 year, requiring ongoing monitoring. 2
The presence of vertigo and intermittent headache with neck pain in an older adult represents a complex presentation that cannot be dismissed as "simple" cervical spondylosis without thorough evaluation to exclude myelopathy, radiculopathy, or vertebrobasilar insufficiency. 2, 4, 5