The vestibular system governs perceptual, oculomotor, and postural functions. Among its clinical assessments, evaluation of vestibulo-spinal pathways—particularly gait and truncal stability—offers crucial diagnostic value in acute vestibular syndromes (AVS). Grade 3 truncal ataxia, marked by an inability to sit unsupported, reliably suggests a central etiology. Recent studies underscore that vestibulo-spinal signs, even in the absence of nystagmus or oculomotor abnormalities, can aid in distinguishing central from peripheral causes of vertigo. This is particularly relevant in emergency settings where oculomotor expertise may be lacking. Notably, central lesions can present with dissociation between vestibulo-spinal and oculomotor findings, highlighting the importance of incorporating postural assessment into bedside evaluations. Further exploration of the pathophysiology behind these discrepancies may refine vestibular topodiagnosis and improve clinical algorithms for AVS.