Cervicocephalic syndrome

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Definition / Description

Cervicocephalic syndrome is a cervical syndrome associated with deep or superficial pain in the head, dizziness and often visual (nystagmus for example) or auditory disturbances such as tinnitus or dysphagia. The cervico-cephalic syndrome (CCS) plays an important part in various diseases of the upper cervical spine. The syndrome results in pain and restriction of motion of the upper cervical spine which destinguishes from cervicogenic headache[1]. For a better understanding of the symptoms, the specific anatomical structures and the relationship with the possible manifestations will be discussed. [9].

When spondylotic spurs cause serious compression of the vertebral artery the condition of vertebrobasilar insufficiency, of greater or lesser severity may develop. Typically, the symptoms caused by interference with the blood flow appear when the neck is inclined to one side, rotated or extended. Angiography is required to prove that serious mechanical compression of the arthery is occuring. (10) (L.O.E.5)

www.physio-pedia.com/Cervicogenic_Headache

Clinically Relevant Anatomy

The upper cervical complex consists of the occipito-atlantal (C0-C1), the atlanto-axial (C1-C2) and the superior aspect of C2.Those are the atypical segments of the cervical spine. Biomechanically there is a lot of research and study of this region. Although the upper cervical complex works as an integrated region, each level has to be regarded individually to see its contribution to the overall function.
The vertebral arteries begin in the root of the neck, usually the left artery is larger than the right. The cervical parts of the vertebral arteries ascend through the transverse foramina of the first six cervical vertebrae. The dura and arachnoid is perforated by the atlantic parts of the vertebral arteries that pass through the foramen magnum. At the caudal border of the pons the basilar artery is formed out of the intracranial parts of the vertebral arteries. 

www.physio-pedia.com/Cervical_Vertebrae

Epidemiology /Etiology

The so-called cervicocephalic syndrome is often a mixed syndrome caused by spondylogenic irritation and actual compression. (10) (L.O.E.5)
The essential factors are:
1. irritation of sensory nerve fibers, rarely of motor and autonomic fibers
2. irritation or compression of the vertebral artery
3. irritation of greater and lesser occipital nerves (10) (L.O.E.5)

Impingement on the vertebral artery and the sympathetic nerve near the cervical spine can be related to induces cervicocephalic syndrome. By stimulation of nociceptors in zygapophyseal joints, (also known as) approximate muscles and tendons the symptoms can be stimulated. The irritations can possibly be caused by malpositioned joints at the head/neck junction, deviations of the cervical spine from the body axis, displacement of vertebrae and constriction of the vertebral artery.

Characteristics/Clinical Presentation

Cervical headaches affect approximately 2,5% of the adult population and comprise roughly 15 to 20% of all chronic and recurrent headaches (Cervicogenic) headache en neck pain are the two most common complaints reported by patients with cervicocephalic syndrome. Other symptoms associated with the syndrome are dizziness, auditory – and visual disturbance. ‘Cervicocephalic kinesthetic sensibility’ is a common complaint related to chronical neck disorders, mostly accompanied with a decreased postural balance. The ability to recognize movements in the neck is reduced due to a disturbed proprioception.

Differential Diagnosis

Many diseases cause headache, differential diagnosis is therefore important. General causes of headache ( metabolic disease, hypertension nd visual disturbance) can be ruled out quite easily: metabolic disease, hypertension and visual disturbances. CCS is sometimes incorrectly diagnosed as migraine, but differs in many ways from CCS. Common migraine differs from cervicocephalic migraine in duration of each attack as well as the corresponding symptoms such as vomiting and nausea. Other symptoms (dizziness and vestibular disturbances) related to cervicocephalic syndrome can be provoked or worsened by movements of the head and cervical spine, unlike symptoms associated with ordinary dizziness and vestibular disturbances.

Listing some pathologies who are often exchanged with cervicocephalic syndrome
• Disc herniation
• Spondylotic bony compression
• Spinal cord syndrome
• Tumor metastase
(10) LOE: 5

Diagnostic Procedures

The Cervicogenic Headache Study Group established the following criteria for the diagnosis of CH (Hesselbarth 2005): Provocation by head movements, maintenance of antalgic head posture and (partial) relief of pain by diagnostic blockade. As CCS comprises of cervicogenic headache, the preconceived criteria are therefore of use in the diagnostic procedure of CCS. Complaints such as dizziness and vestibular disturbances arouse with certain head movement as said in previous subtitles. (Kraemer et al.)

Outcome Measures

Patients who followed a proprioceptive rehabilitation programme improved a significant in controlling head repositioning accuracy compared with a controle group who didn’t follow this programme But It isn’t clear if the difference in reposition angle also has clinical relevance (2 degrees). Clinical parameters like pain, analgesica intake, ROM and daily functioning are also improved significant in the intervention group. 

Examination

The sensibility of head orientation can be evaluated by relocating the head after an active movement. When performing his test the patient is asked to relocate his/her head after an active rotation to the left and right.  When healthy persons and patients are compared, the patient group indicates significantly worse scores on the test. The validity and test-retest reliability demonstrate an excellent result for measuring the cervical proprioception.

Cervicocephalic kinesthesia tests was also used to measure cervical ROM, since moderate- substantia test retest reliability has been reported (ICC: 0,61 – 0,97) for measurements of cervical mobility. (13) (L.O.E.5)t

There are five tests to determine the cervicocephalic kinaesthesia. It is clear that patients with cervicocephalic syndrome have more difficulties to relocate the head to a neutral head posture and to repeat head movements (figure eight movement)

1.Tests of cervicocephalic kinaesthesia
The movement of axial rotation was chosen as the predominant test movement as humans use rotation most commonly in exploring the external environment (14;15).(L.O.E.5)

Test 1: Relocation to the NHP (natural head posture) (16) (L.O.E.5) The starting position was sitting with the head in NHP. Subjects were asked to perform full active cervical rotation to the left and right in turn and then to return and indicate when they considered they had relocated the starting position as accurately as possible.This point was recorded by activation of the electronic marker switch. Between each test movement, the subject’s head was manually adjusted back to the original starting position by the principal researcher who was guided by the real-time computer display. The examiner’s accuracy in relocating subjects’ heads was within ±0.2˚, as indicated by the marker,which changed colour from red to green when the accuracy was within the set limits.
When healthy persons and patients are compared, the patient group indicates significantly worse scores on the test[2]. The validity and test-retest reliability demonstrate an excellent result for measuringthe cervical proprioception[4].

Test 2: Relocation to the 30˚ rotation position and to NHP (17) (L.O.E.5) In this test, the examiner pre-positioned the subject’s head in 30˚ left rotation and subsequently in right rotation. The computer visual display unit (VDU) guided the researcher. A marker was placed to indicate the 30˚ position. Subjects were permitted to concentrate on this position of reference for a few seconds. They then turned their head to NHP and then returned to the 30˚ rotation position. Recordings were taken on each occasion subjects returned to the NHP and to the 30˚ position.

Test 3: Preset trunk rotation Subjects sat on a chair positioned on a specially constructed platform. A familiarization session was conducted before the formal test. Subjects first concentrated on their NHP.Whilst the researcher held the subject’s head steady, the platform (and therefore the subject’s trunk) was rotated to a pre-marked 30˚position of left rotation. Subjects were required to relocate their NHP with respect to the body and then return to the starting position (30˚ relative neck rotation). Following three trials in left trunk rotation, the test was repeated with the trunk rotated to the right.

Test 4: Figure-of-eight relocation test Subjects were taught to perform a discreet figure-of-eight movement by moving the head. As a guide, a 10-cm diameter diagram of a figure-of-eight lying on its side was placed on a stand one metre in front of the subject. Subjects were instructed to trace the figure-of-eight with their nose toconfine movement predominantly to the upper cervical spine. Each subject was permitted three practice trials of the movement with their eyes open. The examiner corrected the performance if the movement was too little or too large, that is, involving the lower cervical spine. In the formal test,subjects performed the movement three times and, after each trial, were required to relocate to the start position as accurately as possible.

Test 5: Figure-of-eight movement test. In this test, subjects repeated the figure-of-eight movement three times, without stopping, as consistently as possible. Each time a crossover was made in the figure-of-eight movement, subjects were asked to pass through their NHP as accurately as possible. They therefore crossed the starting position five times in the test sequence.There was no practice in advance of this test.
The test may be divided into two categories: 1) NHP and 2)uncommon postures and movements
These tests are reliable and have a good IC.(18) L.O.E.5)

Medical Management

Medication

As the problem is situated on a biomechanical level. The roll of mediation in purely symptomatic. No evidence is found for influence of the drugs on the volume or consistency of the cervical discs. Despite this fact medication has been proven to be effective because it relieves the patient of his deep and severe pain. Also Sedatives and tranquillizers can be used. Those can lessen the central sensitization of the biomechanical stress. They can also help relieving the night pain which prevents the patient from having not only physical but also emotional stress. The therapy benefits from these results. Important is that medication is only used as an asset to the physical therapy.

They can also help relieving the night pain which prevents the patient from having not only physical but also emotional stress. Night pain and emotional stress are in relation to each other because the patient might feel stressed before going to sleep that he/she will have night pain and have a restless and painful night again. Night pain means also that the patient doesn’t sleep enough during night which is another reason to sense emotionally stressed. the therapy benefits from these results.

It’s important that the patient is well informed and has a say in the therapy as misuse of these drugs is very dangerous.
Local injections

The use of local anesthetics or steroids can be indicated when the earlier mentioned medication and heat do not relieve pain and or muscle spasm.

1. Local Muscle infiltration
2. Cervical epidural injection
3. Cervical sympathetic and radicular blockade

Surgery

In exceptional cases when conservative therapy does not work, surgery can be applied to help patients with chronic and recurrent cervicocephalic syndrome and unbearable pain

Percutaneous drill resection (PDR) is an effective technique with a reported 85–95% success rate. Through radiofrequency (FR) generator, an alternative heats the tissue and detroys it. The target temperature is between 60-100 degrées..
Conclusions. CT-guided radiofrequency thermocoagulation is an effective, precise and secure, minimally invasive treatment for non radicular cervical pain that is caused by zygapophysial joint arthropathy, when CT-guided, lateral drug instillation does not cause a lasting improvement.(12)(L.O.E.2C)
Our to use radiofrequency to limit recurrences and complications that we had observed with PDR, such as skin necrosis.

Physical Therapy Management

• Manipulation: There is moderate evidence for manipulation when this technique is combined with mobilisation of the cervical spine. When manipulation is done, there is just low evidence for pain relief and improvement in function. Thoracic manipulation could be an additional therapy to realise pain reduction.
• Mobilisation: There is low evidence for improvement when only mobilisations are performed during the therapy. There is no difference compared with acupuncture for acute pain reduction^.
• Exercise: Stretching and strengthening of the cervical region and the areas around it shows a moderate quality of evidence in pain reduction and improvement in function on short term to intermediate follow-up.
• Electrotherapy: Very low to low evidence is available that TENS, EMS, pulsed electromagnetic field therapy and repetitive magnetic stimulation show a greater therapy effect compared with a placebo treatment.
• Patient education: When doing physical exercises with patients, the therapist has to convince the patient about its positive effects to avoid patient’s satisfaction.
• Traction: A review based on 7 RCT’s shows no significant difference in pain reducation and daily functioning when a traction therapy is compared with a placebo traction.
  

Recent Related Research (from Pubmed)

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