Evaluation and Management of Vestibular Vertigo in Spondyloarthropathy
In patients with spondyloarthropathy presenting with vertigo, the primary focus should be on identifying and treating common peripheral vestibular disorders—particularly benign paroxysmal positional vertigo (BPPV)—rather than attributing symptoms to cervical spine disease, as cervical vertigo remains a controversial and likely over-diagnosed entity.
Initial Diagnostic Approach
Bedside Positional Testing (First-Line)
Perform the Dix-Hallpike maneuver bilaterally to diagnose posterior canal BPPV, which accounts for 85-95% of BPPV cases and presents with torsional upbeating nystagmus with 5-20 second latency 1.
If the Dix-Hallpike is negative but history suggests positional vertigo, perform the supine roll test to assess for lateral semicircular canal BPPV, which represents 10-15% of cases 1.
Do not order imaging or vestibular testing unless there are neurological signs inconsistent with BPPV, such as severe postural instability, cranial nerve deficits, or downward-beating nystagmus 2, 1.
Assessment of Modifying Factors
Before initiating treatment, evaluate for impaired mobility or balance, CNS disorders, lack of home support, and increased fall risk—factors particularly relevant in spondyloarthropathy patients who may have limited cervical range of motion 2, 1.
Identify physical limitations that may contraindicate standard repositioning maneuvers, including severe cervical stenosis, severe rheumatoid arthritis, cervical radiculopathies, ankylosing spondylitis, or spinal cord injuries 2, 1.
Treatment Algorithm
For Posterior Canal BPPV (Most Common)
Perform the Epley maneuver (canalith repositioning procedure) immediately upon diagnosis, which achieves 80% success rates with 1-3 treatments and 90-98% with repeat attempts 1.
For patients with contraindications to the Epley maneuver (such as severe cervical stenosis or ankylosing spondylitis), consider Brandt-Daroff exercises performed three times daily for two weeks, though these are significantly less effective (24% vs 71-74% success rate at 1 week) 1.
Allow patients to resume normal activities immediately after repositioning—postprocedural restrictions provide no benefit and may cause unnecessary complications 1.
For Lateral Canal BPPV
For geotropic variant, perform the Gufoni maneuver (93% success rate) or Barbecue Roll maneuver (50-100% effectiveness) 1.
For apogeotropic variant, use the modified Gufoni maneuver with the patient lying on the affected side 1.
Medication Management
Do not prescribe vestibular suppressant medications (meclizine, antihistamines, benzodiazepines) as primary treatment for BPPV, as there is no evidence of effectiveness and these agents cause drowsiness, cognitive deficits, increased fall risk, and interference with central compensation mechanisms 1, 3.
- Vestibular suppressants may be considered only for short-term management of severe nausea/vomiting in severely symptomatic patients 1.
The Cervical Vertigo Controversy
Evidence Against Cervical Spine as Primary Cause
In a prospective study of 38 patients with degenerative cervical myelopathy (the most severe form of cervical spondylosis), 47% reported vertigo, but in every case the etiology was attributed to causes outside the cervical spine—including orthostatic dizziness (22%), hypertension (14%), BPPV (11%), and psychogenic dizziness (3%) 4.
No patient in this cohort responded positively to cervical torsion testing or showed significant vertebral artery stenosis, confirming that cervical vertigo is likely over-diagnosed 4.
When Cervical Factors May Contribute
While cervical spine disease is not a primary cause of vertigo, some studies suggest that advanced degenerative changes (cervical degenerative index ≥25) may be associated with decreased vertebral artery blood flow during head rotation, potentially contributing to symptoms in select cases 5, 6.
- However, this association does not establish causation, and other vestibular pathology should be thoroughly excluded first 4.
Follow-Up and Treatment Failures
Reassess all patients within 1 month to confirm symptom resolution or identify persistent BPPV 2, 1.
If symptoms persist after initial treatment, repeat the diagnostic test (Dix-Hallpike or supine roll) to confirm persistent BPPV, which responds to repeat repositioning in 90-98% of cases 1, 7.
Evaluate for canal conversion (occurs in 6-7% of cases), multiple canal involvement, or coexisting vestibular dysfunction 1, 7.
Red Flags Requiring Urgent Imaging
Order urgent MRI brain with diffusion-weighted imaging if any of the following are present 8, 7:
- Nystagmus that changes direction without head position change
- Downward-beating nystagmus during Dix-Hallpike
- Spontaneous nystagmus without provocation
- Severe postural instability with falling
- Cranial nerve deficits, severe headache, or visual disturbances
- Lack of response after 2-3 properly performed repositioning maneuvers
Special Considerations in Spondyloarthropathy
The case report of bilateral vestibulopathy with spondyloarthropathy 9 demonstrates that vertigo symptoms may have complex etiologies, including psychological factors (chronic subjective dizziness, agoraphobia) that require a biopsychosocial approach.
Physical limitations from spondyloarthropathy may necessitate modified examination tables or alternative treatment approaches, such as self-administered repositioning procedures or vestibular rehabilitation therapy 1.
Vestibular rehabilitation therapy may be offered as adjunctive therapy (not as substitute for repositioning) for patients with residual dizziness, postural instability, or heightened fall risk after successful treatment 1.
Common Pitfalls to Avoid
Attributing vertigo to cervical spine disease without excluding common peripheral vestibular disorders first—BPPV is far more common and highly treatable 4.
Prescribing vestibular suppressants as primary therapy—these medications are ineffective for BPPV and carry significant adverse effects 1, 3.
Failing to perform the supine roll test when Dix-Hallpike is negative—lateral canal BPPV accounts for 10-15% of cases and is frequently missed 1, 8.
Ordering imaging or vestibular testing in patients with typical BPPV—diagnosis is clinical and imaging has <1% yield for isolated dizziness 8.