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Which structures are the densest source of cervical proprioceptive information for the central nervous system?

1. AThe intervertebral discs
2. BThe deep suboccipital muscles (rectus capitis posterior major and minor, obliquus capitis superior and inferior)
3. CThe cervical zygapophyseal joints
4. DThe trapezius and sternocleidomastoid

The cervico-ocular reflex (COR) and the vestibulo-ocular reflex (VOR) interact to:

1. AGenerate the optokinetic response to large moving visual fields
2. BProduce smooth-pursuit eye movements when tracking a moving target
3. CStabilise gaze during head and trunk movement by combining vestibular and neck signals
4. DConvert sensed head position into postural muscle output

Which afferent pathway transmits cervical proprioceptive information to the vestibular nuclei?

1. ADirect projection from cervical roots to the inferior cerebellar peduncle, bypassing the brainstem nuclei
2. BVia the central cervical nucleus and the vestibular nuclei in the lateral medulla
3. CThrough the spinothalamic tract directly to the thalamic VPL nucleus
4. DVia the trigeminal sensory nucleus and the reticular formation
5. EThrough the dorsal column-medial lemniscal pathway to S1 only

Why is the C1–C2 segment particularly important in the genesis of cervicogenic dizziness?

1. AIt carries the highest mechanical load of the cervical spine
2. BIt is the most common site of cervical disc prolapse
3. CIts vertebral artery is the most likely to develop atherosclerotic stenosis
4. DIt contributes the dominant share of cervical-rotation range of motion and carries the densest proprioceptive afference
5. EIt uniquely projects to the cortical vestibular network via the thalamus

Which of the four mechanism routes from Module 3 typically dominates the chronic post-whiplash patient who has been off-balance for over a year?

1. AProprioceptive mismatch
2. BVestibulo-sympathetic loop dominant
3. CRotational vertebral artery syndrome (RVAS)
4. DCentral reweighting (chronic)

The vestibulo-sympathetic loop is the mechanism that explains:

1. AWhy some patients with vestibular neuritis develop persistent hearing loss
2. BWhy some cervicogenic patients present with autonomic features (nausea, pallor, palpitations) more prominent than the spinning itself
3. CWhy BPPV produces brief positional vertigo
4. DWhy neck manipulation can occasionally cause vertebral artery dissection

What is the proposed mechanism by which sustained head rotation can produce rotational vertebral artery syndrome (RVAS, Bow Hunter)?

1. AEmbolic shower from an atherosclerotic plaque dislodged by rotation
2. BSympathetic-mediated vasospasm of the contralateral posterior cerebral artery
3. CDynamic mechanical compression of the dominant vertebral artery (usually the V3 segment) when the head is held in rotation, with insufficient collateral flow from the contralateral vertebral artery
4. DCervical proprioceptive overactivation producing reflex bradycardia

A patient with chronic cervicogenic dizziness has an abnormal Sensory Organisation Test (SOT) pattern showing impaired performance in conditions 3 and 6 but preserved performance in conditions 5 and 2. This pattern is most consistent with:

1. ABilateral vestibular hypofunction
2. BVisual preference / visual dependence — consistent with central reweighting toward vision
3. CPure proprioceptive deficit
4. DAcoustic neuroma / vestibular schwannoma
5. EMigraine-related dizziness

The Cervical Torsion Test distinguishes cervicogenic dizziness from peripheral vestibular disorders because:

1. AThe patient closes their eyes during the test, isolating proprioception
2. BThe test specifically provokes BPPV when the head is taken into the affected position
3. CThe head is held still while the trunk rotates underneath it — provoking the cervical receptors without moving the vestibular system
4. DThe test measures the latency of the vestibulo-ocular reflex

Joint Position Error (JPE) testing in cervicogenic dizziness usually shows:

1. AAn increase in repositioning error of 1–2°, mostly on extension
2. BAn increase in repositioning error of >4.5° on cervical rotation, more pronounced on the painful or restricted side
3. CNormal repositioning unless symptoms are present at the moment of testing
4. DImprovement compared with healthy controls due to compensatory hypervigilance

The Smooth Pursuit Neck Torsion (SPNT) test is positive when:

1. ASmooth pursuit gain falls below 0.8 in any head position
2. BSaccadic intrusion is present at all pursuit speeds
3. CSmooth pursuit gain is substantially worse with the trunk rotated relative to the head than with both aligned (difference > 0.10)
4. DThere is direction-changing nystagmus with head rotation

A patient referred with 'cervicogenic dizziness' has neck pain, a positive Cervical Torsion Test, and abnormal JPE — but ALSO has direction-changing horizontal nystagmus on supine roll testing. What is the most appropriate next step?

1. ABegin manual therapy and cervical proprioceptive retraining as the diagnosis is established
2. BRefer urgently to neurology for suspected central vertigo
3. CPerform a Lempert manoeuvre to treat the lateral canal BPPV, then re-evaluate the cervical findings 1–2 weeks later
4. DOrder an MRI brain to exclude central pathology
5. ETrial cinnarizine for 6 weeks for symptomatic vestibular suppression

Which test is the most appropriate first investigation for a patient with chronic dizziness and neck pain, BEFORE concluding the cause is cervicogenic?

1. AA clinical bedside examination including Dix-Hallpike, supine roll, vHIT, and audiometry — a peripheral vestibular workup
2. BCervical spine MRI
3. CTilt-table testing
4. DCervicogenic-dizziness questionnaire scoring

A patient has chronic neck-related dizziness. Their video Head Impulse Test (vHIT) shows reduced gain on the right (0.62, with corrective saccades) and normal gain on the left (0.94). The audiogram shows symmetric high-frequency loss. What does this imply?

1. AThe findings support a cervicogenic diagnosis — vHIT abnormalities are common in cervicogenic dizziness
2. BThe findings are due to neck-related VOR cross-talk and can be ignored
3. CThe patient has bilateral vestibulopathy
4. DThe patient has a right peripheral vestibular hypofunction and a cervicogenic diagnosis alone cannot account for the picture
5. EThe audiogram is the more informative finding and confirms Meniere's disease

A 56-year-old with chronic neck pain, dizziness, and a high DHI score has normal Dix-Hallpike, normal vHIT, and normal calorics. Their cVEMP shows reduced amplitude on the left with normal latencies; the contralateral side is normal. What is the most appropriate interpretation?

1. AThis confirms cervicogenic dizziness — VEMP is the diagnostic test for the condition
2. BAn asymmetric cVEMP suggests inferior vestibular nerve or saccular dysfunction on the affected side — investigate further; cervicogenic dizziness cannot be diagnosed in isolation when a peripheral abnormality is present
3. CThe result is incidental and unrelated to symptoms
4. DOrder an immediate cervical MRI to look for an upper cervical lesion
5. EBegin betahistine as the picture suggests early Meniere's

Posturography in cervicogenic dizziness most commonly shows:

1. AA pattern of severe sway only in condition 5 (sway-referenced platform with eyes closed)
2. BA pattern of normal scores across all six conditions
3. CA visual-preference pattern (abnormal in conditions 3 and 6, with relatively preserved 5)
4. DA pattern indistinguishable from BPPV

What does the evidence say about cervical-spine MRI in the routine workup of cervicogenic dizziness?

1. AMRI should be obtained in every patient before a cervicogenic diagnosis is established
2. BCervical-spine imaging does not aid the diagnosis of cervicogenic dizziness and is reserved for red flags
3. CMRI is necessary to confirm the diagnosis but CT is not
4. DPlain X-rays of the cervical spine are sufficient for diagnosis

A patient is suspected to have rotational vertebral artery syndrome (RVAS). What is the most appropriate first imaging investigation?

1. ADynamic transcranial or cervical duplex Doppler in neutral position and in the provocative rotation
2. BStatic MRA of the cervical vessels in neutral position
3. CCT angiogram of the neck with contrast
4. DCatheter angiography

Which combination of findings on dynamic vascular imaging is most consistent with RVAS?

1. ABilateral 50% reduction in vertebral artery diameter at rotation, with prompt return to baseline
2. BA normal study in neutral position with no abnormality on rotation
3. CA static internal carotid artery stenosis >70%
4. DSignificant flow reduction in the dominant vertebral artery on sustained rotation, with insufficient contralateral compensation, and reversibility on returning the head to neutral

What is the single most-commonly missed diagnosis in patients labelled 'cervicogenic dizziness'?

1. AMénière's disease
2. BPosterior circulation TIA
3. CVestibular migraine
4. DGeneralised anxiety disorder

Which feature most strongly distinguishes vestibular migraine from cervicogenic dizziness?

1. AThe presence of neck pain
2. BDiscrete attacks of moderate-to-severe vestibular symptoms lasting 5 minutes to 72 hours, with well intervals between attacks, often with migrainous accompaniments (photophobia, phonophobia)
3. CThe duration of cervical pain symptoms
4. DAn abnormal vHIT

Which clinical scenario best distinguishes RVAS from cervicogenic dizziness?

1. ANeck pain that worsens on rotation
2. BSymptoms triggered by busy visual environments
3. CFoggy unsteadiness rather than spinning
4. DBrief, stereotyped symptoms reproducibly triggered by sustained head rotation into a specific position, with brainstem features (diplopia, presyncope, dysarthria, drop attacks) that resolve immediately on returning to neutral

A patient meets both the Bárány Society criteria for cervicogenic dizziness AND the Lempert criteria for vestibular migraine. What is the recommended diagnostic strategy?

1. ADiagnose with the condition that fits the most features
2. BOrder vestibular testing to determine which is the 'true' diagnosis
3. CTreat the migraine first — prophylaxis, trigger control, attack treatment — and reassess the cervical features after 8–12 weeks
4. DRefer to vestibular physiotherapy for combined manual therapy and migraine education

Persistent postural-perceptual dizziness (PPPD) differs from chronic cervicogenic dizziness primarily in:

1. AThe presence of neck pain
2. BThe trigger pattern — PPPD is triggered by upright posture, motion, and busy visual environments rather than by specific cervical positions
3. CThe age of the patient population
4. DThe response to manual therapy

The first-line treatment for proprioceptive-mismatch cervicogenic dizziness is:

1. AManual therapy combined with cervical proprioceptive retraining and deep cervical flexor strengthening
2. BLong-term vestibular suppressant medication
3. CCervical surgery to decompress the affected segment
4. DPure vestibular habituation drills

Which treatment is contraindicated in suspected rotational vertebral artery syndrome (RVAS)?

1. AHigh-velocity cervical manipulation
2. BCardiovascular risk factor management
3. CPatient education to avoid provocative positions
4. DVascular imaging to characterise the structural cause

Following Epley repositioning for posterior canal BPPV, the AAO-HNS 2017 clinical practice guideline recommends:

1. AStrict postural restrictions for 48 hours (sleeping upright, no head-down positions)
2. BNo specific postural restrictions; the patient may resume normal activities immediately
3. CTwo weeks of vestibular suppressant therapy
4. DBrandt-Daroff exercises three times daily for 4 weeks

A chronic cervicogenic patient has been on 6 months of structured manual therapy and cervical proprioceptive retraining without progress. Their cervical examination has normalised, but they report worsening dizziness in busy environments and avoidance of supermarkets. What is the appropriate next step?

1. AIntensify the manual therapy programme
2. BOrder cervical MRI to rule out an occult structural cause
3. CShift to vestibular rehabilitation focused on sensory reweighting plus visual desensitisation, with CBT for the avoidance behaviour — Route 4 management
4. DAdd a long-term vestibular suppressant

Which pharmacological agent has the best evidence base for first-line treatment of PPPD?

1. ABetahistine 16 mg three times daily
2. BAn SSRI or SNRI
3. CA long-term benzodiazepine
4. DA first-generation antihistamine such as cinnarizine
5. EA topiramate trial

A patient with confirmed RVAS on dynamic Doppler and CTA has identified C1–C2 atlantoaxial instability with osteophytic compression. Conservative management with positional avoidance and antiplatelet therapy has been trialled for 3 months without symptom control. What is the most appropriate next step?

1. AContinue conservative management indefinitely
2. BAdd a second antiplatelet agent
3. CRefer to neurosurgery / vascular neurology for consideration of surgical decompression, often with posterior C1–C2 arthrodesis
4. DOrder long-term anticoagulation