Introduction
Benign paroxysmal positional vertigo (BPPV) is one of the most common peripheral vestibular causes of vertigo. It is characterised by bouts of vertigo lasting for less than one minute, and is associated with nystagmus when the patient's head is moved in the plane of the affected semicircular canal.Reference Lea, Kushnir, Shpirer, Zomer and Flecher1 The particle repositioning manoeuvre (or Epley's manoeuvre) has become the ‘gold standard’ for treatment of this disorder.Reference Epley2 Benign paroxysmal positional vertigo can affect any age group but is commoner in older patients.Reference Von-Brevern, Radtke and Lezius3, Reference Froehling, Silverstein and Mohr4 Cervical spine problems (e.g. spondylosis and disc prolapse) are commoner in this age group.Reference Hamilton, Johnston, Madhok and Capell5 Epley's manoeuvre may fail or produce only partial improvement, and is not without complications, including arrhythmias, asystole, nausea and vomiting.Reference Sridhar and Panda6 Epley's manoeuvre necessitates passive movement of the neck. Such movements may not be wise in patients at risk of cervical spine fracture.
A new particle repositioning manoeuvre was designed for these patients, and is described in this report.
Patients and methods
Patients
The study included 40 patients complaining of vertigo and diagnosed as having BPPV.
Diagnosis of BPPV was based on a typical history of transient, positional vertigo when lying on the back or side. The diagnosis was confirmed by observing the typical brief, reproducible, horizontal-rotatory nystagmus when the patient's head was placed in a provocative position.Reference Epley2, Reference Froehling, Silverstein and Mohr4 Dix–Hallpike testing was avoided for fear of inducing cervical spine fracture.
Any features suspicious of cervical spinal problems were noted in the history and confirmed by radiology. All patients were reviewed by the orthopaedic surgeons. Patients' known spinal problems included cervical spondylosis, disc prolapse, previous cervical spine fracture and cervical spine rheumatoid arthritis (Figure 1).
Fig. 1 Lateral cervical spine X-ray of a patient with cervical spondylosis and cervical osteophytes.
Method
The nature of BPPV was explained to every patient, as were the treatment options. All patients supplied either written or verbal consent.
The particle repositioning manoeuvre was performed in an operating theatre with the patient seated upon the operating table. A rigid neck collar was fitted so as to not cause much extension. The mild neck extension maintained by the adjustable rigid neck collar is intended to make the semicircular canal in the proper position in relation to gravity. The following steps were then followed.
(1) The head of the operating table was lowered 30°. The patient sat on the middle of the table, so that their head would be supported by the table when lying down (this was position one; Figure 2).
Fig. 2 Position one. L = lateral semicircular canal
(2) The patient was asked to lie rapidly on the side with vestibular pathology, without being touched (position two; Figure 3). This encouraged movement of particulate debris within the long arm of the posterior semicircular canal, away from the ampulla of the canal.
Fig. 3 Position two.
(3) The patient's body was then rotated onto the other side, without any twisting movement of the neck (position three; Figure 4). This action encouraged passage of the debris into the region of the common crus.
Fig. 4 Position three.
(4) The patient was then asked to lie face-down, maintaining the same head–neck relation (position four; Figure 5). In this position, particulate debris would be expected to pass through the common crus.
Fig. 5 Position four.
(5) The patient was then returned back to the upright position (position five; Figure 6) and the table returned to the horizontal plane. This position encouraged debris to fall into the vestibule.
Fig. 6 Position five.
(6) The rigid neck collar was then removed and the patient was asked to flex their neck in a safe fashion, avoiding any painful movements (position six; Figure 7).
Fig. 7 Position six.
(7) The patient then returned their head to a neutral position, facing forwards (position seven; Figure 8), and the rigid neck collar was replaced.
Fig. 8 Position seven.
Each position was held for either two minutes, or one minute after the subsidence of any nystagmus, whichever was longer.
After the repositioning manoeuvre, patients were given the following instructions: stay still for at least two hours in a neutral position; sleep in a semi-sitting position for two nights; do not sleep on the affected side for one week; and thereafter to go about their normal lives.
Patients were reviewed after two weeks, one month, three months and six months.
Results
This study included 40 patients suffering from BPPV and cervical spine problems. Patients' ages ranged from 45 to 65 years. Nine patients were men and seven women. Table I lists patients' cervical spine problems.
Table I Patients' cervical spine problems
Pts = patients
At one week review, 36 patients (90 per cent) reported complete relief of their vertigo. This was confirmed by complete absence of symptoms and negative nystagmus in the previously positive positional test. Three patients (of the unimproved four) reported a major improvement in their vertigo, while the last patient reported no improvement. All of these patients were negative for positional nystagmus. The last patient was re-evaluated and a diagnosis of cupulo-lithiasis considered; however, no other manoeuvres could be performed on this patient because of his spinal condition. The residual complaint in the previous three patients was relieved by performing the manoeuvre again after two weeks. We followed up the patients at one month, three months, six months and one year. We found that seven patients had suffered minor attacks of typical benign paroxysmal positional vertigo after three months. All the seven patients were relieved of their symptoms after undergoing the new particle repositioning manoeuvre once more.
The repositioning manoeuvre had no specific complications, apart from the mild light-headedness and nausea that commonly occur with Epley's manoeuvre.
Clinical review after one month, three months, six months and one year indicated that seven patients suffered minor attacks of typical BPPV after three months post-treatment. All seven were relieved of their symptoms upon repeated performance of the manoeuvre.
Discussion
Benign paroxysmal positional vertigo is the most common cause of vertigo, including vestibular, central and systemic and results from migration of otoconia into the semicircular canals.Reference Froehling, Silverstein and Mohr4 About 20 per cent of all dizziness is due to BPPV. The older the patient, the more likely their dizziness is to be due to BPPV; about 50 per cent of all dizziness in older people is due to BPPV. In older people, the most common cause of BPPV is degeneration of the vestibular system of the inner ear; BPPV becomes much more common with advancing age.Reference Oghalai7, Reference Scherer8
Cervical spine problems are also commoner in the elderly.Reference Hamilton, Johnston, Madhok and Capell5, Reference Magarey, Rebbeck, Coughlan, Grimmer, Rivett and Refshauge9 Thus, the coincidence of cervical spine problems and vertigo does occur in some patients. Vertigo due to BPPV must be differentiated from cervicogenic vertigo, which can be elicited by hyperactivity of spinovestibular afferents or, much more rarely, by episodic reduction of blood flow in the vertebral artery. Cervicogenic vertigo is usually induced by neck tilt and persists for minutes.Reference Scherer8 Such patients were excluded from the current study.
Lea et al. reported that BPPV characteristics and treatment effectiveness, as measured by a negative Dix–Hallpike manoeuvre, are not age-dependent, and there is no need for any special approach or cautiousness when determining prognosis in older patients.Reference Lea, Kushnir, Shpirer, Zomer and Flecher1
• Benign paroxysmal positional vertigo is commoner in elderly patients
• Cervical spine disease is also more common in the elderly
• This paper describes a new particle repositioning manoeuvre designed to minimise the possibility of damage to the cervical spine
Epley reported that his manoeuvre for treating BPPV was contraindicated in patients with cervical spine problems.Reference Epley2 Other authors have supported this view.Reference Furman and Cass10 This is logical, as this manoeuvre requires manipulation of the neck which may be harmful for patients with spinal conditions, and may even lead to atlantoaxial dislocation. In an attempt to help such patients, the described, new manoeuvre was designed to avoid neck manipulation and the application of pressure to the cervical spine. The manoeuvre depends on gravity to effect movement of endolymphatic particles within the semicircular canal system. The angulations needed to direct these particles along the semicircular canal system were achieved with the help of an adjustable operating table. Clinical follow up showed that this new technique was as effective as the traditional Epley's manoeuvre, with a success rate of 90 per cent after one manoeuvre, which rose to 97.5 per cent after repetition. In comparison, Epley reported an 80 per cent success rate at one week review,Reference Epley2 Parnes and Price-Jones a 79 per cent success rate at 3–4 week review,Reference Parnes and Price-Jones11 and Herdman et al. Reference Herdman, Tusa, Zee, Proctor and Mattox12 a 90 per cent success rate at 2 week review.Reference Herdman, Tusa, Zee, Proctor and Mattox12 However, larger patient numbers are needed to enable better assessment of the current manoeuvre's results.
The effect of postural restrictions after the performance of Epley's manoeuvre is controversial. Most authorsReference Froehling, Silverstein and Mohr4, Reference Marciano and Marcelli13–Reference Fyrmpas, Rachovitsas, Haidich, Constantinidis, Triaridis and Vital16 have indicated that post-manoeuvre restrictions do not improve treatment efficacy. However, Massoud and IrelandReference Massoud and Ireland17 have suggested that such restrictions are beneficial. The current author believes that these restrictions may be of value, especially in the group of patients described.
Conclusion
The described, new particle repositioning manoeuvre is simple, effective and safe for treating patients with BPPV and cervical spine problems.
