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\begin{document}

\title{The Status of Cervical Vestibular Evoked Myogenic Potentials in Patients
with Cervical Discopathy and Different Types of Vertigo}



\author[1]{Alper Yazıcı}%
\author[2]{Güzeldir O.T.}%
\author[1]{Kadriye Ugur}%
\author[1]{Koç C}%
\affil[1]{TOBB Ekonomi ve Teknoloji Universitesi Tip Fakultesi}%
\affil[2]{Istanbul Saglik ve Teknoloji Universitesi}%


\vspace{-1em}



  
  \date{June 08, 2024}


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\selectlanguage{english}
\begin{abstract}
Objective: This research study aims to assess the status of cervical
vestibular evoked myogenic potentials (cVEMP) in patients diagnosed with
cervical discopathy and experiencing different types of vertigo.
Cervical discopathy is a common condition characterized by disc
degeneration and herniation in the cervical spine. Vertigo, a symptom of
vestibular dysfunction, can be caused by various factors including
cervical discopathy. However, the relationship between cervical
discopathy and different types of vertigo remains unclear. Design: The
study will recruit a sample of patients diagnosed with cervical
discopathy, and presenting with different types of vertigo. The cVEMP
test will be conducted to evaluate the vestibular function specifically
related to the cervical disc status. The cVEMP test involves measuring
the muscular responses of the sternocleidomastoid muscle in response to
auditory stimuli. Result: The primary outcomes of this study include the
assessment of cVEMP parameters such as peak-to-peak amplitudes and
latencies in patients with cervical discopathy and various types of
vertigo. These parameters will be compared with a control group of
individuals without cervical discopathy or vertigo. Additionally, the
study will explore potential correlations between cVEMP findings and
clinical symptoms and characteristics related to cervical discopathy.
Conclusion: The results of this research will provide valuable insights
into the vestibular function associated with cervical discopathy and
different types of vertigo. The findings may contribute to the
understanding of the pathophysiology of vertigo in patients with
cervical discopathy and help develop targeted management strategies.
Ultimately, this study aims to improve the diagnosis and treatment of
patients experiencing vertigo associated with cervical spine disorders.%
\end{abstract}%



\sloppy


The Status of Cervical Vestibular Evoked Myogenic Potentials in Patients
with Cervical Discopathy and Different Types of Vertigo

Objective: This research study aims to assess the status of cervical
vestibular evoked myogenic potentials (cVEMP) in patients diagnosed with
cervical discopathy and experiencing different types of vertigo.
Cervical discopathy is a common condition characterized by disc
degeneration and herniation in the cervical spine. Vertigo, a symptom of
vestibular dysfunction, can be caused by various factors including
cervical discopathy. However, the relationship between cervical
discopathy and different types of vertigo remains unclear.

Design:

The study will recruit a sample of patients diagnosed with cervical
discopathy, and presenting with different types of vertigo. The cVEMP
test will be conducted to evaluate the vestibular function specifically
related to the cervical disc status. The cVEMP test involves measuring
the muscular responses of the sternocleidomastoid muscle in response to
auditory stimuli.

Result: The primary outcomes of this study include the assessment of
cVEMP parameters such as peak-to-peak amplitudes and latencies in
patients with cervical discopathy and various types of vertigo. These
parameters will be compared with a control group of individuals without
cervical discopathy or vertigo. Additionally, the study will explore
potential correlations between cVEMP findings and clinical symptoms and
characteristics related to cervical discopathy.

Conclusion: The results of this research will provide valuable insights
into the vestibular function associated with cervical discopathy and
different types of vertigo. The findings may contribute to the
understanding of the pathophysiology of vertigo in patients with
cervical discopathy and help develop targeted management strategies.
Ultimately, this study aims to improve the diagnosis and treatment of
patients experiencing vertigo associated with cervical spine disorders.

Keywords: cervical vestibular evoked myogenic potentials, cVEMP,
cervical discopathy, vertigo, vestibular dysfunction

Key points

\begin{itemize}
\tightlist
\item
  Cervical discopathy refers to the degenerative changes that occur in
  the cervical spine and are associated with symptoms such as neck
  stiffness, radiculopathy, and vertigo.
\item
  cVEMP is the extraction of the information from the inner ear
  vestibular portion by the recording of induced sternocleidomastoid
  muscle mechanoreceptors potentials.
\item
  Among patients with cervical discopathy, benign peripheral vertigo is
  more frequently observed compared to cervical vertigo, making it the
  most common type of vertigo in this population
\item
  The study findings indicated that the presence or absence of cervical
  disc pathology did not show any statistically significant difference
  in cVEMP results.
\item
  The use of cVEMP for assessing peripheral vertigo seems to be
  applicable regardless of the presence or absence of cervical disc
  pathology.
\end{itemize}

Introduction

Cervical spondylosis and cervical disc herniation are highly prevalent
degenerative diseases affecting the cervical spine. In certain
instances, they can lead to myelopathy, thereby elevating the potential
for significant disability. Key manifestations of these conditions
encompass neck pain, stiffness, radiculopathy, and symptoms specific to
the affected segment of the spinal cord. \textsuperscript{1}

Cervical vestibular evoked myogenic potentials (cVEMP) provide an
objective approach to extracting information about the vestibular
portion of the inner ear through the stimulation of the
sternocleidomastoid muscle. cVEMPis elicited by delivering alternating
500 Hz tone bursts via air conduction and is directly recorded from the
sternocleidomastoid muscle mechanoreceptors.\textsuperscript{2} This
response originates from a reflex circuit that begins in the saccule and
proceeds to the ipsilateral vestibular nuclei, ultimately reaching the
ipsilateral spinal accessory nerve nuclei.\textsuperscript{3}Abundant
manuscripts could be found about cervical vertigo and cervical disc
pathologies.\textsuperscript{4},\textsuperscript{5} On the other hand
the effect of cervical disc pathologies on cVEMP in patients that have
noncervical vertigo remains scarce.

The aim of this present study is to investigate the prevalence and the
types of peripheral vertigo in patients with cervical hernia and to
consider the difference in the cVEMP results of the vertigo patients
according to cervical disc status

Material and Methods

Subjects

Between January 2021 and July 2022 thirty-three patients with different
diagnoses of peripheral vertigo enrolled in this study. Written informed
consent was obtained from the patients. The study design and reporting
followed the guidelines set forth by the EQUATOR network for prospective
studies.

After taking medical records, all patients with vertiginous symptoms
underwent detailed ear nose and throat physical examination. The most
common peripheral vertigo diagnosis were; benign paroxysmal positional
vertigo (BPPV), vestibular migraine, semicircular canal dehishence
syndrome . Benign paroxysmal positional vertigo diagnosed with head
thrust, rotating chair and dix-hallpike tests. Vestibular migraine
diagnosis was by the criteria of at least five episodes with vestibular
symptoms of moderate or severe intensity, lasting five minutes to
seventy-five hours, current or previous history of migraine, and one or
more migraine features with at least 50\% of the vestibular
episodes.\textsuperscript{6} Semicircular canal dehiscence syndrome was
diagnosed with thin slice petrous temporal tomography in the patients
with complaints of hearing loss, vertigo and/ or pulsatile tinnitus.

All the patients were checked for the pain that radiates through the
ear, neck, arm and shoulder with a gait and imbalance and the numbness
of the shoulder and arm. Any of the mentioned complaints were recorded
when the patient underwent a cervical MRI.

The cervical VEMP (cVEMP) procedure was started with skin preparation by
using an alcohol swap. Three electrodes (active, reference and ground)
were placed. The active surface electrode was placed at the skin,
approximately to the sternocleidomastoid muscle middle part. The upper
sternum was the reference electrode location. The forehead was the
ground electrode location.

The unilateral air conducted alternating 500 Hz tone bursts was applied
by using ER3A-insert earphones. (Etymotic Research, Elk Grove Village,
IL, USA.) The initial stimulus intensity was 85 dBnHL and increased
incrementally to 95 dBnHL and 105 dBnHL. Electromyography signals were
identified, amplified (5000X), filtered (Blackman gating function
bandpass 10-1500 Hz) and recorded. The calculation of the interaural
difference (IAD) ratio was made by dividing the inter-ear difference of
p1-n1 interamplitude by the sum of the p1-n1 interamplitude of both
ears. (\textsuperscript{7},\textsuperscript{8})

Statistical Analysis

Statistical analysis made by STATA SE 17 software (Copyright 1985-2021
StataCorp LLC StataCorp 4905 Lakeway Drive College Station, Texas 77845
USA). Mean\selectlanguage{ngerman}±standard deviation is the expression of continuous data.
Non-normal data were converted into logarithmic form and compared with
the Mann-Whitney U test. The comparison of variables was performed by
the independent student T-Test, p values under \textless{}0,05
considered statistically significant. This study has been approved by
Local Committee of Ethics at the University XXX.

Conflict of Interest : None

Results

33 patients 20 female, 13 male. Age 51.51 ±15.67 (min 21- max 85) Most
common peripheric vertigo etiology left benign paroxysmal positional
vertigo (bppv), right bbpv and migratuar vertigo. (Table 1)

Table 1: The distribution of different types of peripheral vertigo among
the study population\selectlanguage{english}
\begin{longtable}[]{@{}lll@{}}
\toprule
Diagnosis & Frequency & Percentage (\%)\tabularnewline
\midrule
\endhead
Left BPPV & 19 & 57,5\tabularnewline
Right BPPV & 3 & 9\tabularnewline
Migretuary vertigo & 3 & 9\tabularnewline
Left semicircular canal dehiscence & 3 & 9\tabularnewline
Left Horizontal BPPV & 2 & 6,5\tabularnewline
Vestibular neuritis & 1 & 3\tabularnewline
Anterior BPPV & 1 & 3\tabularnewline
Right semicircular canal dehiscence & 1 & 3\tabularnewline
\bottomrule
\end{longtable}

Cervical hernia was found 21 of 33 patients. All of the patients with
cervical hernia had multiple level of cervical discopathies. Most common
locations of cervical hernia were c5-c6 (22 of 33 patients ( c4-c5 21 of
33 patients) ), c6-c7 (21 of 33 patients) and Table 2 shows the cervical
hernia status of vertigo patients with different diagnoses.

Table2 : Cervical Hernia Status Among Different Types of Vertigo\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
& Cervical Hernia Status & Cervical Hernia Status & Cervical Hernia
Status\tabularnewline
\midrule
\endhead
Diagnosis & Positive & Negative & Total\tabularnewline
Left BPPV & 13 & 6 & 19\tabularnewline
Right BPPV & 2 & 1 & 3\tabularnewline
Migretuary vertigo & 2 & 1 & 3\tabularnewline
Left semicircular canal dehiscence & 2 & 1 & 3\tabularnewline
Left Horizontal BPPV & 1 & 1 & 2\tabularnewline
Vestibular neuritis & 1 & 0 & 1\tabularnewline
Anterior BPPV & 0 & 1 & 1\tabularnewline
\bottomrule
\end{longtable}

The interaural difference ratio among different decibels is displayed at
Table 3. The comparison of the IRA VEMP results did not show any
statistical significance according to the presence of the cervical
hernia on both patients.

Table 3 : The interaural difference ratio among cervical hernia status.\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
& Cervical Hernia & Cervical Hernia &\tabularnewline
\midrule
\endhead
Decibel value of IAD(DB) & Positive & Negative & P value\tabularnewline
85 & 37.29\selectlanguage{ngerman}±25.45 & 31,42\selectlanguage{ngerman}±21.68 & 0.48\tabularnewline
95 & 35.95\selectlanguage{ngerman}±23.84 & 32.31\selectlanguage{ngerman}±21.26 & 0.65\tabularnewline
105 & 27.79\selectlanguage{ngerman}±15.67 & 35.31\selectlanguage{ngerman}±29.36 & 0.41\tabularnewline
\bottomrule
\end{longtable}

DISCUSSION

The function of the otolithic and inferior vestibular nerves can be
tested through the use of cervical vestibular evoked myogenic potentials
(cVEMP). The accessory nerve, which innervates the sternocleidomastoid
(SCM) muscle, is responsible for transmitting the signals from these
nerve, leading to the production of cVEMP waves. While these waves are
typically observed in healthy individuals, some elderly subjects may not
produce an observable response.\textsuperscript{9}

Many clinician tend to attribute vertiginous symptoms in patients with a
cervical hernia to cervical vertigo, but a recent study suggests
otherwise.\textsuperscript{10} Consistent with our own findings, this
study has also identified benign paroxysmal positional vertigo (BPPV) as
the most prevalent type of peripheral vertigo among patients with
cervical degenerative myelopathies. Benign paroxysmal positional vertigo
(BPPV) has also been declared as the predominant peripheral vertigo
subtype among patients diagnosed with cervical
spondylosis.\textsuperscript{11} \textsuperscript{,12}

The findings of the study indicate that the majority of patients with
cervical hernias who experience vertiginous symptoms are actually
suffering from benign paroxysmal positional vertigo (BPPV). This is a
noteworthy observation, as it implies that the root cause of vertigo in
these patients may not be directly linked to the hernia itself, but
instead attributed to an underlying disturbance within the inner
ear.\textsuperscript{12} It has been hypothesized that abnormal movement
of the cervical vertebrae resulting from the hernia may affect the inner
ear.\textsuperscript{13} This underscores the criticality of accurate
diagnosis and appropriate treatment of cervical hernias to mitigate the
occurrence of BPPV-related symptoms.

Based on our findings, there was no observable statistical difference in
cVEMP results with respect to the presence or absence of cervical
hernia. Cervical myopathies also thought to be a factor that changes the
myogenic potentials of the muscles of the
neck.\textsuperscript{14},\textsuperscript{13}, From this perspective,
we anticipated observing modifications in cervical vestibular-evoked
myogenic potential (cVEMP) results among patients with cervical hernia.
This contradiction could be attributed to the possibility that cervical
hernias may exclusively impact the cervical rootlets.. Affection of
cVEMP may rather be attributed to pathologies that result in compression
of the vestibular nucleus or the pathway through the spinal accessory
nerve nuclei.\textsuperscript{15} In addition to our results, a previous
report has been observed that when addressing disc pathologies that
occur at multiple levels, surgical interventions lead to varying degrees
of improvement in vertigo symptoms..\textsuperscript{16} This research
involved assessing patients with vertigo caused by multiple degenerated
cervical discs, both before and after surgical treatment, using
subjective tests like the Visual Analog Score (VAS) and the Cervical
Vertigo Evaluation Score (CVES)

A similar metholody with our study had similar results with our
findings.\textsuperscript{17} The study was limited in its scope as it
solely enrolled patients diagnosed with cervical disc herniation and
excluded those with peripheral vertigo symptoms. Our study, in contrast,
investigated vertigo patients with reference to their specific cervical
pathology status.

Limitations were the population is relatively small for the different
diagnosis of the peripherical vertigo. Only air-conductive type of tone
burts was utilized. Therefore, conductive type of hearing loss was an
exclusion criteria. Given these limitations, further research with a
larger sample size is necessary to confirm and validate our findings.

The present study's findings indicate that the occurrence of cervical
disc herniation does not strongly relate to the different types of
peripheral vertigo that patients experience. Moreover, cWEMP results may
not be notably influenced by cervical herniation in patients with
peripheral vertigo.

REFERENCES

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2. Yang L, Yang C, Pang X, et al. Mechanoreceptors in Diseased Cervical
Intervertebral Disc and Vertigo. \emph{Spine (Phila Pa 1976)} .
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3. Dlugaiczyk J. Evidence-based diagnostic use of VEMPs : From
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4. Peng B. Cervical Vertigo: Historical Reviews and Advances.\emph{World
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5. Devaraja K. Approach to cervicogenic dizziness: a comprehensive
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criteria (Update): Literature update 2021 * Consensus document of the
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Res} . 2022;32(1):1. doi:10.3233/VES-201644

7. Rosengren SM, Colebatch JG, Young AS, Govender S, Welgampola MS.
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8. Ochi K, Ohashi T, Nishino H. Variance of vestibular-evoked myogenic
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doi:10.3390/JCM10112496/S1

11. Kadanka Z, Kadanka Z, Jura R, Bednarik J. Vertigo in patients with
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12. Yang TH, Xirasagar S, Cheng YF, Kuo NW, Lin HC. Association of
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13. Vasaghi-Gharamaleki B, Naser Z. Predicting the risk of hearing
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14. Khan A, Khan Z, Bhati P, Hussain ME. Influence of Forward Head
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15. Prabhu P, Anish A, Vijayan D, Shiju A, S P S, Sreenivas R.
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17. Kastanioudakis I, Saravakos P, Zigouris A, Ragos V, Reichel O.
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