Cases · BPPV (trap) · foundation

Brief spinning when lying down

A 58-year-old truck driver with brief positional spinning — but is it the neck or the inner ear?

Vignette

A 58-year-old long-haul truck driver presents with three weeks of intense spinning vertigo lasting 10–15 seconds, triggered when he lies down to sleep, when he rolls over in bed, and when he tilts his head back to look at high shelves. He has chronic mechanical neck pain from years of driving. He has been told by a colleague that this is "his neck" and to see someone about it.

Examination and workup

Cervical examination shows reduced rotation bilaterally (a long-standing finding the patient confirms) and tenderness over C5/6. Active cervical rotation in the seated position does not reproduce his vertigo. Dix-Hallpike with the right ear down: after a 5-second latency, sustained 25-second upbeating-and-right-torsional nystagmus accompanied by his characteristic vertigo, which fatigues with repeat manoeuvre. Cervical torsion test (with head held still on the trunk and body rotated): negative. vHIT and audiometry normal.

Question

What is the correct management?

ACervical mobilisation and proprioceptive retraining for cervicogenic dizziness
BEpley canalith repositioning manoeuvre, then reassess after 1–2 weeks
CMRI brain to exclude central pathology
DVestibular suppressant therapy with prochlorperazine for 6 weeks
EAudiometry and MRI with IAC protocol to exclude vestibular schwannoma

Select an option to reveal the answer.

Teaching point

**Always perform Dix-Hallpike and supine roll before any cervical provocation**. BPPV is the commonest cause of position-triggered dizziness and the most commonly mis-attributed to the neck — particularly in patients with co-existing chronic mechanical neck findings. The discriminator is the Cervical Torsion Test: if symptoms are reproduced only with head-on-body position change but not with body-on-head rotation while head stays still, the inner ear is implicated, not the cervical proprioceptors.

References

⁴¹ von Brevern M, Bertholon P, Brandt T, Fife T, Imai T, Nuti D, Newman-Toker D (2015). Benign paroxysmal positional vertigo: Diagnostic criteria. Journal of Vestibular Research, 25(3–4):105–117. link
¹⁸ Treleaven J, Jull G, Sterling M (2003). Dizziness and unsteadiness following whiplash injury: characteristic features and relationship with cervical joint position error. Journal of Rehabilitation Medicine, 35(1):36–43. link