Cochleovestibular disorders in neck injuries: causes, symptoms, diagnosis, treatment

In the pathogenesis of a number of labyrinthopathies, along with osteochondrosis, cervical spondylosis, pathological tortuosity and other anomalies of the vertebral artery, a certain role is played by acute and chronic neck injuries, causing damage to the vessels and nerves that play an important role in the functions of the inner ear (vertebral artery, cervical sympathetic plexus, etc.). This position was formulated and developed by A. de Klein (1927), who described the phenomenon of cervical dizziness, and W. Bertschy-Roshen (1949), who described some manifestations of vestibular dysfunction in neck injuries.

Pathogenesis and clinical picture of cochleovestibular disorders in neck injuries. Neck injuries are divided into chronic and acute.

Chronic trauma occurs with frequent mechanical impacts on the anatomical structures of the neck, which do not cause obvious damage to the ligamentous, cartilaginous and bone apparatus of the cervical spine. These impacts are caused either by forced production positions of the body and head, or by practicing the corresponding sports (assembly work in narrow and low spaces, boxing, wrestling, etc.). The symptom complex that develops in this case, in addition to chronic radiculoalgia, is manifested by signs of Martland syndrome - post-traumatic encephalopathy that occurs in professional boxers as a result of head and neck injuries inflicted on them, manifested by memory loss, slowness of thinking and multiple sclerosis of the brain, leading to parkinsonism or even to symptoms similar to those of Alzheimer's disease) in combination with signs of vertebrobasilar vascular insufficiency. Signs of vertebrogenic labyrinthine dysfunctions and Martland syndrome are observed with chronic exposure of the spine to general vibration in severe degrees of vibration disease.

Such patients complain of headaches, insomnia, irritability, frequent attacks of dizziness. They show signs of vegetative-vascular dystonia, increased sensitivity to accelerations with simultaneous hyporeactivity to provocative tests, and hearing loss of varying degrees.

Acute neck trauma occurs with sudden violent flexion, extension and twisting of the neck, with sharp lateral displacements of the head caused by a blow, when falling from a height onto the feet or onto the head. Whiplash neck trauma occurs with sudden violent flexion or extension of the head, which damages the muscles and ligaments of the neck, stretches the upper parts of the spinal cord, sometimes bruising the latter on the tooth of the second cervical vertebra. The typical localization of cervical spine trauma is the V-VIII vertebrae. In this area, vertebral dislocations most often occur. Most often, cervical spine trauma occurs with a stretched neck, for example, during hanging during an execution or suicide.

In neck injuries, the spinal cord is damaged as a result of direct impact of vertebral bodies or bone fragments. This disrupts blood circulation and lymph flow, causing intracerebral and meningeal hemorrhages, edema, and swelling of the brain tissue. Large hematomas at the base of the skull in the area of the foramen magnum may manifest themselves with elements of Laruelle syndrome - increased intracranial pressure, paroxysmal pain in the back of the head, vomiting of central origin, spasm of the cervical muscles, torticollis, tachypnea, convulsive swallowing, mask-like face, congestion of the optic nerve, a negative Quekenstedt test (symptom) (the test reveals a sign of impaired circulation of cerebrospinal fluid - in healthy people, compression of the jugular vein increases intracranial pressure, which is evident from the increased frequency of dripping during lumbar puncture; when the central canal in the area of the foramen magnum is compressed by a tumor or hematoma, there is no increase in the frequency of dripping of cerebrospinal fluid) - or foramen magnum syndrome. Neck trauma can cause repercussion damage to various parts of the brainstem (degeneration of neurons in the lateral vestibular nucleus, reticular formation, and even the red nucleus).

Trauma to the vertebral artery leads to the development of small aneurysms in them or to the formation of post-traumatic atherosclerotic plaques, causing arterial stenosis.

Symptoms of whiplash neck injury consist of three periods: acute, subacute and residual.

The acute period is characterized by a number of symptoms that immediately appear after the injury, such as Charcot's triad (intense tremors, scanned speech, nystagmus - the main symptoms of multiple sclerosis), as well as headache, pain in the neck during palpation and movement, dizziness, spontaneous nystagmus, hyperacusis, tinnitus, and various autonomic disorders.

Diagnosis of labyrinthine disorders in this period is limited to examination of hearing with live speech, tuning fork tests, if possible - tone threshold audiometry and the statement of the presence of spontaneous pathological vestibular reactions. All studies are carried out under strict bed rest.

The subacute period is characterized by delayed symptoms that appear 2-3 weeks after the injury. Attacks of sharp pain in the neck appear, both spontaneous and arising from movements in it, protective (not meningeal) rigidity of the occipital muscles, caused by a pronounced radicular syndrome. Against the background of non-systemic dizziness with passive turns of the head (they should be done very slowly, with great caution, at a limited angle, since they cause sharp radicular pain), systemic dizziness and spontaneous horizontal-rotatory nystagmus of position occur. These signs are a harbinger of serious pathological changes in the neurovascular apparatus of the neck, causing the development of the so-called ataxic syndrome. The latter is characterized by disturbances in fine coordination of the upper limbs (their ataxia), static and dynamic balance (staggering and falling in the Romberg position, gait disturbances), cervical positional nystagmus and dizziness, severe constant radicular pain in the neck, radiating to the shoulder-scapular regions and upper limbs.

Pathological changes in the cervical sympathetic plexus caused by primary trauma and secondary phenomena (hemorrhage, edema, compression) are the cause of pronounced vascular dysfunctions both in the ear labyrinth and in the meninges and distant areas of the brain, migraine attacks and often "flickering" focal symptoms. The most characteristic signs of vasomotor disorders in the inner ear are constant tinnitus, dizziness, cervical positional nystagmus. In general, clinical manifestations in this period are characterized by signs close to Barre-Lieou and Bertschy-Roshen syndromes. The subacute period can last from several weeks to 3 months. By the end of the period, the condition of the victim gradually normalizes, but his ability to work, depending on the severity of the injury, is either absent or limited for a long time.

During the period of residual effects, the victim continues to be bothered by tinnitus, in some cases progressive hearing loss of the sound perception type, dizziness attacks accompanied by nausea and weakness, constant, paroxysmal neck pain, especially at night and with sharp turns of the head. The tonal audiogram reveals a descending type of bone and air conduction curves of a symmetrical or asymmetrical nature, with provocative tests (with bithermal and threshold rotational tests) revealing a mixed type of interlabyrinthine asymmetry. The third period can last from several months to several years, and in some cases residual effects in the form of cervical radicoalgia, migraine, stiffness in the cervical spine, hearing loss, etc. can persist throughout life.

Treatment of cochleovestibular disorders in neck injuries. Neck injuries associated with damage to the spinal cord, nerve trunks and plexuses, blood vessels, ligament-articular and bone apparatuses, require the participation of many specialists in the treatment of such patients (neurosurgeon, neurologist, traumatologist, orthopedist, ENT specialist, otolaryngologist, audiologist, etc.). In case of hearing and vestibular disorders, antineuritic and sedative treatment methods are used.

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