VERTIGO AND DIZZINESS IN WHIPLASH INJURIES

Royal Belgian E.N.T. SocietyNovembre 2007

Professeur Raymond BONIVER

O.R.L.

Professeur invitéà l’Université de LIEGE

Grade Presumed pathology Clinical presentation

I Microscopic or multimicroscopic lesion

Usually presents to a doctor more than 24 h after trauma

Lesion is not serious enough to cause muscle spasm

II Neck sprain and bleeding around soft tissue (articular capsules, ligaments, tendons, and muscles)

Muscle spasm secondary to soft issue injury

Usually presents to a doctor in the first 24 h after trauma

Nonspecific radiation to the head, face, occipital region, shoulder, and arm from soft tissues injuries

Neck pain with limited range of motion due to muscle spasm

III Injuries to neurologic system by mechanical injury or by irritation secondary to bleeding or inflammation

Presents to a doctor usually within hours after the trauma

Limited range of motion combined with neurologic symtoms and signs

Clinical spectrum of whiplash-associated disorders as proposed by the Quebec Task Force (1995)

Grade Clinical presentationa

0 No complaints about the neck

No physical sign(s)

I Neck complaint of pain, stiffness, or tenderness

No physical sign(s)

II Neck complaint and

Musculoskeletal sign(s): decreased range of motion and point tenderness

III Neck complaint and

Neurological sign(s): decreased or absent deep tendon reflexes, weakness, and sensory deficits

IV Neck complaint and

Fracture or dislocationa Symptoms and disorders that can be manifest in all grades include deafness, dizziness, tinnitus, headache, memory loss, dysphagia, and temporomandibular joint pain. Grades I-II are the limits of terms of reference of the Quebec Task Force on Whiplash-Associated Disorders

Clinical classification on whiplash-associated disorders proposed by the Quebec Task Force (1995)

Aetiology

Lesions of Soft Tissues of the Neck

Lesions of peripheral nerves

Dizziness

AetiologyVestibular lesions

– Benign Positional Vertigo

– Otolithic vertigo without cupulolithiasis

– Labyrinthin Concussion

– Perilymphatic fistula

– Hydrops endolymphatic delayed

Vertigo

AetiologyCentral Nervous System Lesions

– Vascular problems± Wallenberg syndrom– Dissection of vertebral arteries

– Trauma– Chiropracty

– Contusion of vestibular nuclei or vestibular central pathways

– Phobic secondary postural syndrom

Vertigo

Phobic vertigoThe syndrome of phobic postural vertigo, described by Brandt in 1991, is characterised by combination of situationally triggered panick attacks including vertigo and subjective postural and gait instability and the fear of imminent death. Patients complain of vertigo rather than anxiety and feel physically ill. This syndrome should be explained by the hypohesis that an impairment of the space constancy mechanism leads to partial uncoupling of the efferent copy for active head movements. This triggers phobic attacks. Allowing to Brandt it represents the third cause of vertigo in a specialised consultation. Clinical experience does point the existence of persons with positional vertigo who are conditioned to be dizzy, with or without objective signs of vertigo. At present, this syndrom is of uncertain validity or significance as it lacks a specific test for diagnosis.

- benign paroxysmal positioning vertigo

- immediate

- late onset : days to several weeks

- slow degeneration of the otolith organ after labyrinth concussion

- settling of dislodged otoconia in the utricular cavity before entering the semicircular canal

- time needed for several pieces of otoconia to form a cloth (canalolith) to become causative.

Gacek Hypothesis

The pathophysiological mechanism responsible for a position-induced vestibulo-ocular response in this disorder is neural, rather than mechanical stimulation of the sense organ. Loss of the inhibitory action of otolith organs on canal activation caused by degeneration of otolith neurons (saccular, utricular) is a possible explanation of the brief canal response induced by the positional stimulus.

TREATMENT1. Dizziness from soft tissues lesions or peripheral nerves:

We refer to the chapter

« Whiplash Inury : Orthopaedic and Rehabilitative Approach to Neck Pathology »

P. Sibilla, S. Negrini, S. Atanas

In Whiplash Injury. Diagnosis and Treatment. Springer Verlag.

Degree Lesion Treatment

1st Simple strain Soft collar, 20 days

2nd Strain Soft collar with a good containment, 20 days

3rd Serious strain Hard collar, 25/30 days

4th Compromising of mechanical stability

Minerva in Articast, 30/40 days

5th Articular dislocation and or bony fractures

Surgery

Summary of Sibilla and al. classification

REHABILITATIVE TOOLS

Physical Exercises

- Pain Relief - Proprioception

- Decontraction - Posture

- Streng thening - Activity of Daily Life

- Mobilisation -Thoracic and Lumbar Spine

- Normalisation - Active participation of the Patient

Physical Therapy

- Magnetotherapy 20 x 20 min à 60 Gauss 5x/week

- Laser therapy on trigger points

- Heat : never if there is vertigo or dizziness, never ultrasound

- Electrotherapy : no

- Cold : no

Mechanical Therapy

!!! Excessive mobilisation

- Manipulation : no

- Massage : to reduce muscular contraction

- Traction : danger to damage soft tissues

- Acupuncture : on some cases.

TREATMENT

2. VERTIGO

Benign paroxysmal vertigo

- Posterior (Hallpike manoeuver)

-Semont

- V.H.T.

- Horizontal

- Lempert

- Vanucchi

- V.H.T.

Lempert’s Manœuvers

MANOEUVERS OF THE VHT-TESTBATTERY

SEQUENCE DIRECTION DESCRIPTION OF MANOEUVER change of position from to M1 middle sitting supine M2 left supine left side M3 right left side right side M4 middle supine sitting standing M5 * turning to the right M6 * turning to the left sitting, change of position from to M7 right nose closed to Le knee Ri ear closed to Ri shoulder M8 left nose closed to Ri knee Le ear closed to Le shoulder sitting, movements M9 * turning head CCW ** M10 * turning head CW *** M11 * bending forward M12 * from sitting to erect standing position M13 * moving head forwards/backwards change of position from to M14 left sitting to head hanging and turned to the left M15 left return to sitting position M16 right sitting to head hanging and turned to the right M17 right return to sitting position M18 middle sitting to head hanging in midline M19 middle return to sitting position ________________________________________________________________________________ * Manoeuvers where nystagmus never occurred. ** Counter-clockwise *** Clock

Otolithic Posttraumatic Vertigo

V.H.T.

Labyrinthin Concussion

V.H.T.

Perilymphatic fistula

- Rest

- In case of failure : surgery

Hydrops

- Medical treatment

Central Vertigo

- Drugs : - Vincamine

- Piracetam

- Ginkgo biloba

- Rehabilitation by exercises

Phobic postural syndrome

- Psychological approach

- Posture exercises

- Physiotherapy

OUR EXPERIENCE

150 cases of whiplash with cervical syndrome and dizziness

- 16 cases with central vestibular dysfunction

-100 cases with postural abnormalities (15 with TM problems)

- 30 cases with B.P.P.V.

- 4 cases of labyrinthine concussion