Vertebrobasilar Insufficiency: What Do You Do?

With the physical therapist's increased emphasis on incorporation of manual therapy when treating the cervical spine, the concern of vertebrobasilar insufficiency is frequently discussed. Even though fewer people have adverse effects from cervical manipulations compared to NSAID's, there is still a stigma revolving around the disease, and rightfully so. Part of the reason the incidence of adverse effects following cervical treatment is due to appropriate screening methods. We all know that the Vertebral Artery test has insufficient psychometric properties for diagnosis. If a test is negative, it doesn't change anything. If it is positive, the patient might have VBI. The sensitivity and specificity of the test is so low that some clinicians actually prefer not using the test. Personally, I still use it, due to the public perception that it is required for "screening"; however, I consider the diagnostic accuracy in my clinical reasoning. What is more beneficial in the screening process is a thorough subjective history. There are signs and symptoms that increase the likelihood of the patient having the disease. We should be asking about nausea and vomiting, the 5 d's (dizziness, drop attacks, diploplia, dysphagia, dysarthria), and look for nystagmus. Also, consider other past medical history like cardiovascular disease. Most programs and manual therapy classes spend time going through how to properly take the subjective and what to look for when determining the likelihood of VBI. So what do you do when both the subjective and objective are ruling in VBI?

I recently had a patient with "neck pain" come to my clinic for an evaluation. I noticed immediately that the patient had a sense of caution when turning her neck. She described her neck pain extremely vaguely on both sides of her cervical spine and upper trap. As part of my screening process for upper quarter patients, I ask about dizziness, N&V, and a few other questions that are linked to various pathologies. The patient reported she did have some dizziness when turning her head and changing positions. Initially I suspected BPPV, but also wanted to continue exploring other possible symptoms. The patient reported dizziness, fainting, blurred vision when turning her head, and difficulty forming words occasionally. That is 4/5 D's and she ended up having positive nystagmus with full cervical rotation after about 10 seconds which also recreated her dizziness. The patient apparently never told the doctor about her dizziness, fainting, or trouble speaking because she thought they were unrelated. Additionally, the patient reported a history of HTN and was in her upper 50's.

Having never actually encountered someone with a collection of these S&S that may be associated with VBI, I knew I would not perform treatment without further work-up by the physician. I called her doctor and they wanted her to come in that day. I was unsure; however, if, had I not been able to get a hold of the doctor, should I have sent her to the ER. She had been walking around with these symptoms for 6 months, but with the risk for stroke, should we be referring these patients to the ER? It is a tough decision that may be based on each patient's individual presentation. We don't want to send any patient with neck pain and dizziness to the hospital. A single "red flag" does not have much clinical value, but a collection of them does and we need to act appropriately. What do you think is the next correct step?



-Chris

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