Cervicocephalic Syndrome (CCS)

Cervicocephalic syndrome (CCS) involves pain and stiffness in the upper cervical spine with associated headache. The syndrome often presents with dizziness and visual (e.g., nystagmus) or auditory disturbances (e.g., tinnitus) [1].

This term is outdated and is not commonly used in modern clinical practice, but it may still be encountered in some parts of the world. Symptoms may relate to vertebrobasilar insufficiency, where reduced blood flow in the vertebral artery occurs during lateral flexion, rotation or extension of the neck.

Clinically Relevant Anatomy

The upper cervical complex comprises the atlanto-occipital joint (C0–C1), the atlanto-axial joint (C1–C2) and the upper part of C2.The vertebral artery originates in the root of the neck, and the left artery is usually larger than the right. The arteries pass through the transverse foramina from C6 to C1, pierce the dura and arachnoid, and enter through the foramen magnum. On the underside of the pons they form the basilar artery [1][2].

Epidemiology / Aetiology

Cervicocephalic syndrome is often a mixed condition caused by spondylogenic irritation and compression [3].

Key factors:

• Irritation of sensory nerve fibres (motor/autonomic fibres more rarely)

• Irritation or compression of the vertebral artery

• Irritation of the greater and lesser occipital nerves [3]

Compression of the vertebral artery and the sympathetic nervous system may be related to CCS. Malalignment in the cranio-cervical junction, deviations in the cervical spine, vertebral displacement and narrowing of the vertebral artery may produce such symptoms [2].

Clinical Presentation

Cervicogenic headaches affect approximately 2.5% of the adult population and account for about 15–20% of all chronic and recurrent headaches. Headache and neck pain are the most common symptoms. Other symptoms include dizziness, auditory and visual disturbances.CCS is often associated with reduced proprioception and impaired postural balance [2][4].

Differential Diagnosis

Many conditions can cause headache, so thorough differential diagnosis is essential. CCS may be misdiagnosed as migraine; however, CCS differs in that symptoms can be provoked by neck movements.

Other conditions resembling CCS include:

• Disc prolapse

• Spondylotic compression

• Myelopathy

• Tumour metastases [3]

Diagnostic Procedures

The Cervicogenic Headache Study Group has defined criteria: pain provoked by neck movement, antalgic head posture and pain relief after diagnostic blockade. CCS partially overlaps with cervicogenic headache and may be diagnosed similarly. Symptoms such as dizziness are often exacerbated by neck movements [1].

Outcome Measures

Proprioceptive rehabilitation has shown improvement in head-repositioning accuracy compared with controls. Clinical parameters such as pain, medication use, mobility and daily function also improve significantly.

Examination

• Exclude vertebral artery dissection

• Test head orientation sense via repositioning after active movement; CCS patients perform worse than healthy controls; test–retest reliability is high [4]

• Use cervicocephalic kinaesthesia tests to measure cervical ROM; these show moderate to high test–retest reliability [4]

• Five tests are used for cervicocephalic kinaesthesia; CCS patients have difficulty finding neutral and repeating movements

Tests for Cervicocephalic Kinaesthesia

Rotation was selected as the principal movement because humans most often use rotation to explore the environment [6][7].

Test 1: Return to neutral head position (NHP)

Starting position: sitting with the head in NHP. Participants perform full active cervical rotation left and right, then return to the perceived starting position. This point is recorded by triggering an electronic marker. Between trials, the examiner manually returns the head to start using a real-time display. Examiner accuracy was within ±0.2°. Patients perform significantly worse than healthy individuals [2]. Validity and test–retest reliability are excellent for measuring cervical proprioception [4].

Test 2: Return to 30° rotation and to NHP

The examiner places the patient’s head in 30° rotation left, then right. The patient studies this position visually before returning to NHP and then to the 30° position again. Measurements are taken for both the return to NHP and the return to 30°.

Test 3: Pre-set trunk rotation

The patient sits on a chair mounted on a platform. After instruction, the platform (and trunk) is rotated to 30°. The patient then attempts to reposition the head relative to the body and then return to the 30° rotation. Three repetitions per side.

Test 4: Figure-of-eight test

The patient learns to draw a horizontal figure-of-eight with the nose, primarily using upper cervical motion. The diagram (10 cm diameter) is placed 1 metre ahead. Three practice rounds with eyes open; the examiner corrects errors. In testing, the patient performs the movement three times, then returns the head to the start position as accurately as possible.

Test 5: Figure-of-eight movement test

The patient performs the figure-of-eight movement three times without pause, crossing NHP five times. No prior instruction is given.

Medical Management

As the condition is biomechanical, medications provide symptomatic relief only. No studies show that drugs change the volume or consistency of cervical discs. They may reduce deep pain, and sedative medications can help reduce central sensitisation and nocturnal pain, which often lead to emotional stress. Medications should be used only as an adjunct to physiotherapy.

Night pain leads to poor sleep and emotional stress; patients may become anxious about recurrent nightly pain. Clear information and collaboration are essential. Misuse can be harmful. Local anaesthetic or steroids may be considered if other measures fail.

Local procedures:

• Local infiltration

• Cervical epidural injection

• Cervical sympathetic and radicular blockade

Surgery

For chronic, disabling CCS unresponsive to conservative care, surgery may be considered.

Percutaneous burring resectionAn effective method with 85–95% success. Radiofrequency (RF) uses heat (60–100 °C) to ablate target tissue.

CT-guided radiofrequency thermocoagulationEffective, precise, safe and minimally invasive for zygapophysial joint pain without radicular involvement, especially after failed conservative care. This technique also reduces complications such as skin necrosis seen with percutaneous burring.

Physiotherapy Management

Manipulation:Moderate evidence supports manipulation when combined with cervical mobilisation. Versus an active control group, manipulation alone shows low evidence for pain and functional improvement. Thoracic manipulation may be used as an adjunct for pain relief [11].

Mobilisation:

Limited evidence for improvement with mobilisation as a stand-alone treatment [11][12]. No difference compared with acupuncture for acute pain relief [11].

Exercise:

• Stretching and strengthening of the cervical region and adjacent areas show moderate evidence for pain reduction and functional improvement short- to mid-term [12]

• Low evidence (one study; two publications; n=24) that general conditioning is no better than a control group (health advice only) for (sub)acute/chronic neck pain immediately post-treatment [13]

Electrotherapy:

Very low to low evidence that TENS, EMS, pulsed electromagnetic field therapy and repetitive magnetic stimulation outperform placebo [14].

Patient education:

Education on the benefits of physical activity is important to improve adherence and satisfaction [12].

Traction:

A review of seven RCTs showed no significant difference in pain reduction or daily function when mechanical traction was compared with sham traction [14].

Endurance training:

Moderate evidence (one study; n=198) for moderate pain reduction immediately post-treatment with scapulothoracic/upper-limb endurance training in (sub)acute/chronic mechanical neck disorders [15]. Number needed to treat = 4.

Stretching:

Low evidence (one study; n=16) that stretching before or after manipulation does not alter pain or function compared with manipulation alone for chronic neck pain immediately post-treatment [16].

Neuromuscular exercises:

Uncertain benefit for eye–neck coordination exercises. Very low evidence (one study; n=60) of moderate pain relief and functional improvement short-term in chronic neck pain [17]. NNT pain = 4; NNT function = 3.

Examples of exercises:

• Reposition the head with eyes closed

• Reposition the head while the physiotherapist provides light resistance

• Reposition the shoulders while keeping the head in neutral

• Reposition the shoulders with eyes closed

Clinical Conclusion

Cervicocephalic syndrome is associated with deep or superficial head pain, dizziness and often hearing or visual disturbances (e.g., nystagmus, tinnitus). The condition is commonly due to spondylogenic irritation and compression causing pain and reduced mobility in the upper cervical region. The Head Relocation Test is among the best tests to assess for cervicocephalic syndrome. Within physiotherapy, there is low evidence for pain relief with manipulation, mobilisation, exercise (stretching, strengthening, general conditioning), electrotherapy, patient education and neuromuscular exercises. More research is required on CCS and on which treatments offer the best outcomes.

References

1. DeStefano LA. Greenman’s Principles of manual medicine – 4th ed. Baltimore, MD : Lippincott Williams & Wilkins/Wollters Kluwer. 2011.

2. Gevargez A, Braun M, Schirp S, Weinsheimer PA, Groenemeyer DH.[Chronic non radicular cervicocephalic syndrome: CT-guided percutaneous RF-thermocoagulation of the zygapophysial joints].Schmerz. 2001 Jun;15(3):186-91.

3. Rickenbacher J, Landolt AM, Theiler K. Applied anatomy of the back., by Springer-Verlang Berlin Heidelberg 1985

4. Shrout PE. Measurement reliability and agreement in psychiatry. Stat Methods Med Res 1998;7:301-17.

5. Kristjansson E, Dall'Alba P, Jull G. Cervicocephalic kinaesthesia: reliability of a new test approach. Physiother Res Int. 2001;6(4):224-35.

6. Taylor JL, McCloskey DI. Proprioceptive sensation in rotation of the trunk. Experimental Brain Research 1990; 81: 413–416.

7. Rubin AM, Wolley, SM, Dailey VM, Goebel JA.Postural stability following mild head or whiplash injuries. American Journal of Otology 1995; 16:216–221.

8. Revel M, Andre-Deshays C, Minguet M. Cervico-cephalic kinesthetic sensibility in patients with cervical pain. Archives of Physical Medicine and Rehabilitation 1991; 72: 288–291.

9. Loudon JK, Ruhl M, Field E. Ability to reproduce head position after whiplash injury. Spine 1997;22: 865–868.

10. Gross A, Kay TM, Paquin JP, Blanchette S, Lalonde P, Christie T, Dupont G, Graham N, Burnie SJ, Gelley G, Goldsmith CH, Forget M, Hoving JL, Brønfort G, Santaguida PL; Cervical Overview Group. Exercises for mechanical neck disorders. Cochrane Database Syst Rev. 2015 Jan 28;1:CD004250.

11. Gross A. Miller J, D’Sylva J, Burnie S.J, Goldsmith C.H, Graham N, Haines T, Bronfort G, Hoving J.L. Manipulation or mobilisation for neck pain. The Cochrane Library, 12/05/2010.

12. Kay T.M, Gross A, Goldsmith C.H, Rutherford S, Voth S, Hovingg J.L, Bronfort G, Santaguida P.L. Exercises for mechanical neck disorders. The Cochrane Library, 15/08/2010. Evidence level: 1A (review)

13. Andersen LL, Kjaer M, Søgaard K, Hansen L, Kryger AI, Sjøgaard G. Effect of two contrasting types of physical exercise on chronic neck muscle pain. Arthritis Rheum. 2008 Jan 15;59(1):84-91.

14. Graham N, Gross A, Goldsmith C.H, Moffett J.K, Haines T, Burnie S.J, Peloso P.M.J. Mechanical traction for neck pain with or without radiculopathy. The Cochrane Library, 17/02/2010.

15. Andersen LL, Saervoll CA, Mortensen OS, Poulsen OM, Hannerz H, Zebis MK. Effectiveness of small daily amounts of progressive resistance training for frequent neck/shoulder pain: randomised controlled trial. Pain. 2011 Feb;152(2):440-6.

16. Allan M, Brantingham JW, Menezes A. Stretching as an adjunct to chiropractic manipulation of chronic neck pain- before, after or not at all? A prospective randomized controlled clinical trial. European Journal of Chiropractic 2003;50:41–52

17. Revel M, Minguet M, Gergoy P, Vaillant J, Manuel JL.Changes in cervicocephalic kinesthesia after a proprioceptive rehabilitation program in patients with neck pain: a randomized controlled study. Archives of Physical Medicine Rehabilitation 1994;75:895–9.