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Nasretdinova Mahsun Tahirovna, Samarkand Medical Institute, Department of Otorhinolaryngology, the city of Samarkand Uzbekistan Karabaev To Hurr Asankulovich, Tashkent Pediatric Medical Institute Department of children's Otorhinolaryngology, dentistry course Tashkent Uzbekistan E-mail: [email protected]
VESTIBULAR VERTIGO IN EMERGENCY NEUROLOGY AND CERVICAL OSTEOCHONDROSIS
Abstract. The paper deals with the study of reasons for urgent neurological hospitalization for vestibular vertigo and a role of cervical osteochondrosis in the development of vestibular disorders. A subgroup of 109 patients (84 women and 25 men) who had isolated vestibular vertigo (without other symptoms of nervous system lesion) was identified among 230 patients with acute systemic dizziness, nausea, vomiting with the referral diagnosis of "cervical osteochondrosis, vertebral artery syndrome", or "acute vertebrobasilar circulatory attack". The patients underwent a standard neurological examination, brain magnetic resonance imaging, an otorhinolaryngologist's advice with otoscopy, cervical spine X-ray in two interperpendicular (frontal and lateral) projections, and functional spondylography (flexion, extension). The "cerebral" level ofvestibular disorders could be excluded in most (82.3%) patients. The latter had acute peripheral vestibular pathology that required cerebral stroke or hemorrhage to be ruled out according to clinical data in most cases.
Keywords: vestibular vertigo, cervical osteochondrosis, acute peripheral vestibulopathy, vertebral artery syndrome.
Dizziness often occurs at different ages, depriving a person of the ability to maintain balance. Dizziness is the cause of falls and injuries, it reduces the adaptive capacity of a person, limits the ability to receive education in the whole number of professions, has a psychotraumatic effect, worsens the quality of life, and with the recurrent nature of acute rotational dizziness leads to disability [2; 3]. The multiplicity of causes causing dizziness makes it difficult to find a clear nosological form in this pathology. Thus, at the outpatient stage, the final diagnosis of the disease manifested by dizziness is established only in 20% of cases [4]. Mnogobrojne - headed nature of the possible lesions of the vestibular Ana - lysator creates difficulties in the differential diagnosis of this disease in terms of neurological Stazione - RA, where in our country are traditionally sent the pain - and with the attack of acute vestibular (rotational) vertigo.
In our opinion, in recent years there has been a tendency to increase the number of patients hospitalized in neurological hospitals with acute "vestigial" crisis, the only manifestation ofwhich is rotational dizziness. Many patients - tov surveyed in neurological hospitals, erroneously diagnosed "acute violation of brain, the blood circulation in vertebrobasilar system" [3]. One of the most common causes of dizziness is still con-
sidered cervical osteochondrosis, which leads to a negative impact on the vertebral arteries and blood supply in the vertebrobasilar system. The present study was conducted to determine the causes of emergency hospitalization of patients in a neurological hospital in connection with vestibular headache and the role of cervical osteochondrosis in the development of acute vestibular disorders.
Material and methods of research All patients were selected in the clinic № 1 of Samarkand medical Institute at the Department of neurology for the period from 2012 to 2018 "cervical degenerative disc disease, vertebral artery syndrome", acute circulatory disorders in the vertebrobasilar basin", which accounted for 13% in the structure of emergency hospitalization.
Out of 230 patients, 18(7.7%) were clinically diagnosed with heart attacks in the dorsolateral medulla oblongata (Wal-lenberg-Zakharchenko syndrome), infarcts in the anterior and inferior posterior arteries of the cerebellum.
In the remaining 212(82.3%) patients, no data were found for acute cerebrovascular accident, while in all elderly patients with stroke risk factors, the diagnosis of stroke was excluded both from clinical data and from the results of magnetic resonance imaging (MRI).
From this group 109 patients (84 women and 25 men) who had isolated vestibular vertigo (without other symptoms of damage to the nervous system) were isolated from this group. Of these, 67 patients experienced dizziness for the first time in life, the remaining 42 patients it was repeated.
Patients underwent standard neurological examination, brain MRI, consultation of consultation with otoscopy, radiography of the cervical section of the spine in two perpendicular projections (frontal and lateral), as well as functional spondylography (flexion, extension). For verification of reflex-muscular and myofascial pain syndromes as a cause of spinal artery irrigation in exacerbation of cervical osteochondrosis, a thorough manual examination was carried out. The search for hypertensive peninsular muscles of the head, tonic asymmetry, other myofascial pain syndromes, well-known to date [1; 2].
Taking into account the fact that a significant part of patients were long-term observed with the diagnosis of cervical osteochondrosis, 35 patients (18 women and 17 men) underwent x-ray examination; thus, to clarify the development of posterior and posterolateral osteophytes of vertebral bodies, deformation of hook-like processes, spondylograms were performed in oblique projections. In the complex assessment of the state of the cervical spine, the criteria for movement disorders in the vertebral - motor segments, impairment of disc depreciation function and fixation function of the vertebrae were used [3]. The degree of compression of intradural space was also evaluated. To determine the severity and prevalence of osteochondrosis, the classification proposed by Saker (1952) and modified by I. S. Abel'skaya in 2003 was used [4; 5].
Research result
The duration of pronounced vestibular dysfunction up to 1 day was observed in 74(68%) patients, in other cases vestibular disorders were stopped within 48-72 hours, followed by "fading" light dizziness induced by vestibular loads (rapid head tilt, extension. In 42(39%) patients dizzy spells wore stereotypical recurrent in nature. Characteristics of vestibular syndrome (in less the sensation of dizziness during the fixation of the gaze, increased dizziness when changing the position of the head and shaking the head, rapid vegetative reaction, relative short duration of vestibular attacks), as well as the absence of symptoms of brain stem and cerebellum lesion allowed all 109 patients to diagnose peripheral dizziness. All 109 patients was counseled ENT, OTO-examination with no pathology found. In manual examination of patients there were no muscle contractures, pain on the interosseous ligament, bending of the arch of the posterior articular surface. The majority of patients had moderate pain during palpation of standard biological active points of the neck and posterior surface of the occipital region, including the projection of the exit point of the vertebral artery, which is normal.
Palpation of the posterior Lateral muscle masses, the upper head of the trapezius muscle, the angular muscle of the spades did not reveal muscle bundles, trigger zones of the posterior straight and lower oblique muscles of the head, capable of responding to finger pressing with distant pains. In 15 women, there was pain characteristic of fibromyalgia syndrome (bilateral, unstable topography of deep muscle pain of variable intensity). There was no correlation between the severity of dizziness and changes found in the manual examination of patients.In MRI of the head, none of the patients showed signs of cerebral infarction or hemorrhage. Signs of leukoaraiosis, single lacunar infarctions were observed in 5(4.5%) patients, Chiari malformation - 2(1.8%), retrocer-ebellar arachnoid cyst - in 1 (0,9%). The results of the x-ray examination of 55 patients in whom according to the anamnesis and clinical picture it was possible to assume the role of cervical osteochondrosis in the development of the disease are presented in the table. In patients up to 29 years of age have not been established lay - Kie changes of the cervical spine (0-degree I - d), characterized by the straightening of the physiological lordosis, "the unstable bias" several callcov with no signs of decrease in height of intervertebral discs. In the groups of patients from 30 to 49 years and 50 years and older, the changes corresponding to the II stage of osteochondrosis (54 and 68% of cases, respectively) prevailed, more often there was a combination of functional and structural changes in the spine (decrease in the height of intervertebral dis - cov I degree, signs of instability). The diagnosis of osteochondrosis III and IV degree was made only 8 students (2 people aged 45 to 49 years, 6 people 50 years and older). Determined structural changes: subhand - General sclerosis, marginal bone growth, spondylo - arthritis, decrease of height of intervertebral disks II and III, deforming encountres.
To clarify the degree of narrowing of the intervertebral holes and the spinal canal were produced spon - demografia in the oblique projections. Only 5 patients had moderate narrowing of intervertebral openings, more often unilateral, mainly at the level of CV - CVI, CVI - CVII, and 2 patients had moderate narrowing of the spinal canal by osteophytes (tea - kovsky index 0.7 and less).
Of the total number of patients examined, 2 (one from the first and second groups) were diagnosed with anomalies the Atlanto-occipital region (partial fusion of the Atlan-TA with the occipital bone, signs of basilar IMPRESSIA), 2 people from the second group were determined by partial concres-sence of a pair of upper cervical vertebrae.
In no case was lateroflexia detected on radiographs in combination with rotation, which is opposite to physiological and leads to spinous processes of III - CIV, experiencing lateralized traction of the reduced postural muscles. X-ray
follow-up and functional spondylography did not reveal isolated axial rotation, cervical flexure, which was often found in other patients treated in the national neurological hospital for reflex - muscle syndromes associated with exacerbation of cervical osteochondrosis.
Traumatic history only in 1 woman allowed to assume the possibility of a history of whiplash herbs - we cervical spine. However, she also had no asymmetry in the stretching of the
occipital muscles and ligaments of the posterior surface of the neck, and the data of functional spon-dilography did not differ from the group of patients with III degree of cervical osteochondrosis.
Patients had no correlation between the degree of degenerative changes in the cervical spine and the frequency and severity of recurrent vestibular collapses. The intensity of degenerative changes in the cervical spine was associated with an increase in the growth of patients.
OBS uz-message
Examination of patients hospitalized in connection with vestibular dizziness allowed to exclude "cerebral" level of vestibular disorders in the majority (82.3%) of patients. These patients had acute peripheral vestibular pathologies, which in most cases required clinical data to exclude cerebral infarction or hemorrhage, which was done according to the results of MRI.
Most doctors blame vestibular attacks on cervical osteo-chondrosis. This traditional point of view is widespread in the medical environment. "The cervical OS - teachedrs, vertebral artery syndrome" - a standard diagnosis of the neurologist in cases of acute vestibular occasionally - Yes. Indeed, the role of the cervical spine in the regulation of postural equilibrium is known. There are both the proprioceptive nature of nystagmus and the proprioceptive imbalance disorder [7]. Occipital tonic reflexes involved in the control of balance arise already in the first weeks of life, allowing the child to turn and hold the head, fix the gaze [14]. But the main role that allows you to rotate the head in all positions, tying in the space labyrinth and behold - tional coordinate system, belongs to the pre-emptive, but the first two vertebrae. It is they, having the maximum- rotation is controlled by a powerful apparatus of muscles and tendons, equipped with "proprioceptive" sensors providing postural stability [8]. Meanwhile, the nature of degenerative changes in the spine in cervical osteochondrosis
excludes the defeat of the vertebrae of this localization simply because of the physiological absence of intervertebral discs at this level. In addition, in the process of ontogenesis, tonic occipital activity, which performs the function of "control" of postural equality, gives way to the main labyrinth reflexes [15]. Consequently, clinical patterns of vertigo in cervical osteochondrosis are characterized by mild or moderate postural instability (proprio - ceptive dizziness) in contrast to the dramatic "vestibular attack" in acute rotational vertigo observed in patients included in our study. The results of the manual and x-ray examination did not show any connection between the severity of dizziness and manifestations of pathology of the cervical spine.
We consider the diagnosis of "posterior cervical sympathetic syndrome", "cervical osteochondrosis, vertebral artery syndrome" in the case of isolated rotational dizziness to be incompetent. In the structure of ICD-10 rassmatrivaet - may, the pathology is classified as "peripheral th - lavorazione" (H 81.3). In most neuro - logical needed: children's hospitals, the equipment (for videonystagmography, elektronis - termo-grafii, audiometry, cochleogram, etc.), traditionally within the sphere of interest of otolaryngology [16], trudnye for neurologists to establish the specific diagnostic for peripheral vestibular disorders: Meniere's disease, benign paroxysmal positioning - ing dizziness, vestibular neurons, etc. In connection with this, we consider it possible in patients hospitalized in neurological hospitals with isolated acute rotational dizziness to formulate di-agnosis as "acute peripheral vestibulopathy" and to recommend to these patients the consultation of an otoneurologist.
Thus, the majority of patients who are urgently referred to the neurological Department with a diagnosis of "acute
violation of cerebral circulation in the vertebral - basilar system" or "cervical degenerative disc disease, vertebral artery syndrome" in connection with sharp rotational Guo - love-christian showed no structural changes of svi - delictuosa on a cerebral level vestibular disorders. Intermittent, recurrent, transient vestibular attack in a patient population, neither the timing nor the clinically - mi data is not associated with aggravation of cervical osteochon - rose. There is no correlation between the degree of degenerative processes and wild weakne - tion changes in the cervical spine and the frequency and severity of recurrent vestibular attacks.
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