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頚性めまいについて 臨床推論カンファ 2016年9月16日

f:id:jyoutoubyouinsougounaika:20160916201604p:plain

中年女性

3か月前から頸椎ヘルニアで左手の痺れ、脱力

同時期より間欠的な頭痛と浮動感

頭痛は拍動性ではないが、2-6時間ほど継続し、音過敏・光過敏も伴い、悪心もある。

⇒偏頭痛?? ただしそれまでは頭痛もちではなかった

来院当日の緩徐発症の、回転性めまい、耳鳴り、頭痛

頭痛は後頸部に放散

神経学的な巣症状は乏しく来院時眼振もなし。

椎骨脳底動脈解離疑いでMRI取るも特に異常なし。

診断は?

 

〇頸性めまい症

・首の回転・伸展により誘発されるめまい症。

・椎骨脳底動脈不全との関連性や、頸反射、頸部周囲の交感神経の亢進などが機序として考えられる。

 

ロッキーノートにとてもまとまった記事があります。

http://rockymuku.sakura.ne.jp/seikeigeka/keiseimemai.pdf

 

 

頸性めまいのレビューもあります。

http://www.painphysicianjournal.com/current/pdf?article=MjM3NQ%3D%3D&journal=89

 

It has been found that the afferent cervical activity is more likely
controlled by neck mechanoreceptors in the upper
cervical spine. These mechanoreceptors’ function can
be altered by direct trauma, muscular fatigue, degenerative
changes, or direct effect of pain (28). Therefore,
these anatomical bases may explain why upper cervical
dysfunction can cause cervical vertigo.

頸の機械受容器の活動の亢進がメインの病態

 

Whiplash injuries are experienced by 0.1% of the population (29)
and the incidence of symptoms of vertigo in whiplash
sufferers has been variously reported as 20 – 58% (1),
25 – 50% (30), and as high as 80 – 90% (31).

ムチうちに高頻度に合併する。

 

In a study by Treleaven
et al (34) in 2003, people with whiplash-associated dizziness
and/or unsteadiness (n = 102) were shown to have
significantly greater joint position errors and a higher
neck pain index than control subjects (n = 44), consistent
with cervical mechanoreceptor dysfunction being
a likely cause of the symptoms.

ムチうちに伴う頸性めまいは、頸椎の位置異常や痛みと関連

 

Colledge et al (6) studied the causes of vertigo in
the elderly, and found that 65% were caused by cervical
spondylosis.

高齢者では、頸椎症に伴う頸性めまいが多い。

 

Later, Wapner et al (12) found
that the electrical stimulation to the cervical muscle
could cause equilibrium disturbance

筋肉のスパズムも関連

 

〇分類

 

f:id:jyoutoubyouinsougounaika:20160916203803p:plain

 

〇Barré - Liéou Syndrome

・1926年に最初に報告

・症状: vertigo, 耳鳴り,頭痛、眼のかすみ, 散瞳、悪心

椎骨脳底動脈の血流不全が関与?

They speculated that it may
be the compression or stimulation of the sympathetic
nervous system other than the vertebral artery which
induces symptoms such as vertigo, dizziness, headache,
tinnitus, nausea and vomiting, heart throb, hypomnesia,
and gastroenterologic discomfort.

むしろ頚部交感神経の関与も大きいかもしれない。

 

〇(Bow-Hunter Syndrome)

・頸部回旋にともなう椎骨脳底動脈不全

・C1-C2レベルの狭窄が多い

・椎骨脳底動脈領域のMRAやCTangioが有効

 

〇偏頭痛に伴う眩暈

・偏頭痛に伴う眩暈は一般的な概念

・一方で頸部の痛みは、偏頭痛とも関連

Blaschek et al (76) found that neck and shoulder pain was closely
associated with migraine in adolescents and 63%
of the group of migraine patients reported cervical
and shoulder pain.

 

〇診断

頸部痛がなければ、頸性めまいは否定的

If a patient has a chief complaint of vertigo,
but it is not accompanied by neck pain, a diagnosis of
cervical vertigo may first be excluded (13,15).

 

通常、後頸部、後頭部の痛みを伴う

Patients with cervical vertigo usually have pain in
the back of the neck and occipital region, sometimes
accompanied by stiffness of the neck.

 

首の動きや頸部痛で悪化し、頸部痛が改善すれば症状も改善

Symptoms resulting from cervical vertigo are often increased with
neck movements or neck pain and decreased with interventions
that relieve neck pain (1).

 

頸椎、頸部の筋肉 の触診や圧痛で眩暈を誘発

Examination findings in cervical vertigo include reproducible vertigo
with manipulation of the neck, pain with palpation of
the suboccipital region, cervical transverse processes of
C1 and C2, cervical spinous processes of C2 and C3, levator
scapulae, upper trapezius muscle, splenius, rectus,
and semi-spinalis muscles.

 

BPPVと誤診されることが多い

Benign paroxysmal positional vertigo (BPPV) is often misdiagnosed
as cervical vertigo.

 

MRAとCTangioは特に椎骨脳底動脈の評価に有用

 

頚部回旋および伸展状態のDSAが有用

The most reliable and essential

test to identify the exact area of mechanical vertebral
arterial compression and to make a surgical decision
is digital subtraction angiography (DSA), especially on
position with head rotation (rotation and extension).

 

頚部回旋で眼振を誘発するのも有用だが、特異度は低い

The neck torsion nystagmus test is considered by
some researchers to identify cervical vertigo.

 

頸部痛と眩暈に強い関連がある場合に考えるべき

the following relevant factors should be
considered: a close temporal relationship between neck
pain and symptoms of vertigo, previous neck injury or
pathology, and elimination of other causes of vertigo

 

*レビューには書いていないが、頸部回旋で椎骨脳底動脈領域のエコーの血流の低下を

認めれば診断的だと思う。

ただ、頚部交感神経刺激に伴う機序の診断しようがないのでは・・ レビューにも書いているように診断は極めて難しい印象。

 

〇治療

・ぱっとしたものはないが、ひとまず頸部痛に対する治療が優先。

・Sustained Natural Apophyseal Glides(SNAGs)治療はよいかもしれない

⇒要は徒手的理学療法の一種。ちなみに徒手的理学療法ガイドラインにも記載

http://www.japanpt.or.jp/upload/jspt/obj/files/guideline/22_manual_physical_therapy.pdf

 

・al (93) reported 35 patients with cervical vertigo
underwent percutaneous laser disc decompression
(PLDD). After follow-up of 24 – 66 months, vertigo
was improved; good to excellent clinical results were
attained in 71.4% of these patients.

椎間板の減圧も有効⇒要は頸椎症の治療が優先か。

 

 

As to RVAO, treatment options, introduced by
acase report, range from lifestyle modification (avoidance
of head turning), anticoagulation, endovascular,
and stenting to surgical treatments (95).

頚部回旋に伴う椎骨脳底動脈不全では、頸部回旋の禁止、抗凝固、ステント、手術などが考慮

f:id:jyoutoubyouinsougounaika:20160916212717p:plain

 

・本症例はBarré - Liéou Syndrome+偏頭痛?? ただ証明のしようはないのだが・・