BPPV and the unstable cervical spine

It is good and standard practice to always check with your patients before performing the Dix-Hallpike and ask them if they have any neck or back issues. I usually phrase it “Do you have any issue with your neck or back that would make laying you down and moving your neck around a problem?”  Most just say “NO,” but some will start telling you a long story about their chronic lower back pain. I will usually interrupt that story with the statement/question, “I am talking about an unstable disc. Have you ever had back/neck surgery or had it recommended?” If they say “No” to that, we are good to proceed.

When the patient’s answer is “Yes,” you need to stop and change your plan. I would be hesitant to perform a typical head hanging Dix-Hallpike on a patient with a history of cervical spine disease. We use a JedMed S Chair, which works great for these types of patients. The head is fully supported throughout the maneuver. In patients with kyphosis, we may put a small pillow or rolled up towel behind their neck for additional support. This is safe and comfortable for the patient, and will frequently allow us to confirm the diagnosis of BPPV.

What do you do now? In order to perform CRP effectively, you must have the patient’s head hanging. The JedMed S chair has a removable head rest, which we remove to perform CRP on most patients. Should you do this on the patient with the unstable cervical spine?

I would say “No.” You have to weigh the potential benefit against the potential harm. BPPV is a benign condition with a typical duration of about a month before spontaneous resolution. An injury to the spine can be lasting and devastating.

Why even bother performing the Dix-Hallpike if you have no intention of performing CRP? It allows you to confirm the diagnosis so the patient can avoid a lot of other tests and treatments that won’t help them. You can also explain the physiology in a way to make it less frightening and more manageable for the patient while they wait for it to resolve on its own. If they understand it and know that it will probably get better over a few weeks, it becomes a less scary experience.