Cervical Spine X-Ray - Lateral View Analysis

1. Alignment and Curvature

• Loss of cervical lordosis - The normal forward (lordotic) curve is straightened. This is a significant finding commonly seen with:
  • Muscle spasm (cervical strain/whiplash)
  • Pain-related guarding
  • Ligamentous injury in acute trauma
• No obvious anterolisthesis or retrolisthesis (vertebral slippage) is seen. The anterior vertebral line, posterior vertebral line, and spinolaminar line appear intact.

2. Vertebral Bodies

• Vertebral body heights from C2-C7 appear well preserved.
• No obvious compression fractures, wedging, or destructive lesions visible.
• Bone density appears normal for a young adult male.

3. Disc Spaces

• Intervertebral disc spaces appear relatively well maintained with no severe narrowing suggestive of advanced degenerative disc disease.

4. Prevertebral Soft Tissue

• The prevertebral soft tissue space appears within normal limits - no widening to suggest hematoma, abscess, or significant soft tissue injury.

5. Airways

• Pharyngeal and laryngeal air columns appear patent.

6. Incidental Finding

• A radiopaque artifact (T-shaped/button-like) is visible anterior to the upper cervical/mandible region - likely an external object (clothing fastener, jewellery, or neck collar component), not an internal anatomical finding.

Summary of Findings

Clinical Significance

• Cervical strain/sprain
• Acute trauma (whiplash)
• Early spondylosis

• Soft tissue structures (disc herniation, ligaments, spinal cord, nerve roots) are not visible on plain radiograph.
• If the patient has symptoms like arm numbness, tingling, weakness, or persistent severe neck pain, an MRI of the cervical spine is the next appropriate investigation.

Note: This analysis is for educational reference only. Formal reporting must be performed by a qualified radiologist with full clinical correlation.

Differentiating PPPD from Cervicogenic Dizziness

Quick Concept Summary

1. Clinical History - The Most Important Starting Point

PPPD - What to Look For

• Chronic non-spinning dizziness present on most days for ≥ 3 months
• Typically preceded by a triggering event: BPPV, vestibular neuritis, Meniere's, panic attack, head injury, or whiplash (notably, whiplash can trigger BOTH)
• Symptoms worsen with upright posture, active or passive movement, and complex visual environments (busy shopping malls, scrolling screens, crowds)
• Visual hypersensitivity is often the most disabling feature
• Symptoms improve with lying or sitting down
• Strong association with anxiety, depression, obsessive-compulsive traits
• Social avoidance and phobic behaviour around triggers

Cervicogenic Dizziness - What to Look For

• Dizziness is directly linked to neck pain or cervical dysfunction - the two symptoms move together
• Onset typically follows cervical trauma (whiplash, MVA), surgery, or degenerative cervical disease
• Dizziness is often described as vague disorientation or imbalance, not spinning
• Neck movement provokes dizziness - especially sustained rotation or extension
• Associated with neck pain, restricted cervical ROM, and cervicogenic headache
• No significant visual hypersensitivity as a dominant complaint
• No prominent anxiety-driven avoidance behaviour

Critical differentiator: In PPPD, any motion (not just neck movement) triggers symptoms, and visual stimuli are particularly provocative. In CGD, the trigger is predominantly cervical - neck position or neck pain drives the dizziness. Ask: "Does your dizziness come on when your neck hurts more, or when you see busy visual environments?"

2. Bárány Society Diagnostic Criteria

PPPD - All 5 criteria must be met (Bárány Society / ICVD)

Cervicogenic Dizziness - No Official Criteria

• Dizziness temporally associated with neck pain/dysfunction
• Positive cervical torsion test (body rotated while head fixed)
• Reduced cervical ROM
• All vestibular and vascular causes excluded

3. Physical Examination - Key Differentiating Tests

Tests Suggestive of CGD

Tests Important for PPPD

4. Overlapping Features That Cause Diagnostic Confusion

1. Whiplash is a precipitant of BOTH - cervical trauma can cause cervical proprioceptive disruption AND trigger the maladaptive fear-avoidance cycle of PPPD. Both can coexist.
2. Movement sensitivity is shared - both worsen with head/neck movement.
3. Both have normal standard vestibular testing in established cases.
4. Both can follow the same inciting event (e.g. car accident, head injury).
5. The Bárány Society notes that neck muscle tension is common in any vestibular disorder as a secondary finding, because patients guard their head movement - so neck pain in a dizzy patient does not automatically mean CGD.

The 2022 Bárány position (PMID 36404562) specifically warns: vestibular migraine is the most common cause of combined neck pain + vestibular symptoms and must always be excluded before diagnosing CGD.

5. Red Flags to Rule Out First (Before Either Diagnosis)

• Vertebral artery dissection (acute-onset dizziness + neck pain + Horner's = emergency)
• Posterior fossa/brainstem lesion (abnormal neurological exam, gaze-evoked nystagmus)
• Vestibular migraine (neck pain + dizziness + migrainous features)
• BPPV (positive Dix-Hallpike)
• Vertebrobasilar insufficiency

6. Practical Diagnostic Algorithm

Chronic dizziness + neck pain
        |
        ├─ Exclude: BPPV, vestibular neuritis, vestibular migraine, vertebrobasilar
        |           insufficiency, vertebral artery dissection, central lesions
        |
        ├─ Is dizziness present ≥3 months, most days?
        |   AND worsened by visual stimuli and upright posture?
        |   AND preceded by a vestibular/medical/anxiety trigger?
        |   AND significant anxiety/avoidance behaviour?
        |   → PPPD (if all Bárány criteria met)
        |
        ├─ Is dizziness tightly coupled with neck pain fluctuations?
        |   AND reproduced by cervical torsion test / suboccipital palpation?
        |   AND restricted cervical ROM with positive joint position error?
        |   AND all vestibular causes excluded?
        |   → Cervicogenic Dizziness (diagnosis of exclusion)
        |
        └─ Features of BOTH? → Consider dual diagnosis; treat cervical
           dysfunction first, reassess residual dizziness for PPPD

7. Response to Treatment as a Diagnostic Tool

Therapeutic response is itself diagnostic - if cervical manual therapy substantially resolves both neck pain and dizziness simultaneously, CGD is strongly supported. If residual dizziness persists despite cervical improvement with anxiety-driven avoidance, PPPD is likely.

Summary Table

• Cummings Otolaryngology Head and Neck Surgery, pp. 3232-3234
• Seemungal et al., Bárány Society position on Cervical Dizziness, J Vestib Res 2022 - PMID 36404562
• Li et al., Proprioceptive Cervicogenic Dizziness: Pathogenesis, Diagnosis & Treatment, J Clin Med 2022 - PMID 36362521
• De Hertogh et al., Dizziness and neck pain perspective, Front Neurol 2025 - PMID 40166638

Can Cervicogenic Dizziness (CGD) Be Cured?

1. Prognosis by Underlying Cause

2. What the Evidence Shows About Treatment

Manual Therapy

• Mulligan mobilisation showed significantly better improvement in cervical range of motion (CROM) compared to placebo in short-term studies, though effects on balance were similar - per the 2026 systematic review by Canlı et al. - PMID 41796312.
• However, that same review (13 studies, n=785) found that 10 of 13 studies had high risk of bias, meaning the evidence base is promising but not yet definitive.
• Manual therapy reduces cervical pain and stiffness, which directly addresses the proprioceptive disruption causing dizziness.

Exercise + Sensorimotor Rehabilitation

• All treatment groups (manual therapy ± sensorimotor training) showed medium to large effect size improvements in dizziness, pain, and balance
• Best outcomes were in patients who received manual therapy PLUS joint position sense/oculomotor exercises PLUS balance training
• Improvements were maintained at 6 and 12 months - suggesting durable, not just temporary, benefit
• This supports a genuine "cure" potential in appropriately treated patients

Vestibular Rehabilitation

3. Why Some Patients Don't Fully Resolve

• Central sensitisation - in chronic CGD, the CNS becomes sensitised to cervical input and dizziness persists even after the cervical source is reduced. This overlaps with PPPD.
• Untreated degenerative changes - osteophytes, disc disease, and foraminal narrowing may continue to disrupt proprioceptive input despite conservative treatment.
• Missed co-diagnosis - if PPPD, vestibular migraine, or anxiety have developed on top of CGD, treating only the neck will leave residual symptoms.
• Inadequate treatment programme - manual therapy alone without proprioceptive retraining gives inferior long-term outcomes.

4. Treatment Protocol for Best Outcomes

Step 1: Address acute cervical pain and stiffness
        → Manual therapy (mobilisation/manipulation)
        → Mulligan SNAG techniques
        → Soft tissue therapy

Step 2: Restore cervical proprioception
        → Joint position error training (laser pointer exercises)
        → Oculomotor / gaze stability exercises
        → Smooth pursuit neck torsion training

Step 3: Sensorimotor integration and balance
        → Balance exercises in cervical neutral vs. torsion
        → Gait training with head movement challenges

Step 4: Functional and occupational rehabilitation
        → Ergonomic correction (especially occupational subgroup)
        → Graded return to provocative activities

Step 5: Address central/psychological overlay if present
        → Vestibular rehabilitation for habituation
        → CBT / pain neuroscience education if sensitisation present

5. Honest Summary