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Chiropractic Manipulation of the Neck and Cervical Artery Dissection

Raymond E. Bertino, MD; Arun V. Talkad, MD; Jeffrey R. DeSanto, MD; Jane H. Maksimovic, DO; and Shyam G. Patel, MD
[+] Article and Author Information

From University of Illinois College of Medicine at Peoria, Peoria, IL 61637.

Potential Conflicts of Interest: None disclosed.


Ann Intern Med. 2012;157(2):150-152. doi:10.7326/0003-4819-157-2-201207170-00023
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Grahic Jump Location
Figure.

Computed tomographic angiography at the level of articulation of the cranium and C-1 vertebra (top), and magnetic resonance diffusion weighted imaging of the posterior fossa (bottom).

Top. Craniocervical articulation is indicated by “Sp”. Small veins course just lateral to the vertebral arteries bilaterally (arrowheads). The right V3 segment (large arrow) is filled with contrast; the left (large arrow) has a lumen nearly obliterated by dissection. The left V4 segment (small arrow) has been diminished in size and has a round filling defect medially consistent with clot or obstructing intima from dissection. Bottom. Bright areas of high-signal intensity in the left cerebellar hemisphere are areas of infarction. There were also areas of infarction in the vermis and a single area in the pons.

Grahic Jump Location

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TO THE EDITOR
Posted on September 3, 2012
Peter Tuchin, Christopher Lewis, Peter Wise
Macquarie University
Conflict of Interest: None Declared

TO THE EDITOR. Whether cervical artery dissection occurs due to chiropractic manipulation or merely coinciding with it, is complex and difficult to establish (1-3). The case presented by Bertino et al, gives a limited number of details regarding what is a rare and complex event. Spontaneous vertebral artery dissection (VAD) account for 10-25% of ischaemic strokes in young and middle aged patients while VAD in any age group occurs in around 1 per 100,000 making this a very rare event (4-6). The Bertino article implies chiropractic manipulation as the sole causative factor for the stroke in this 37 year old nurse. However, readers of Annals should be aware of well known risk factors for dissection such as recent respiratory infection, hyperhomocysteinemia, migraine, hypertension, hyperlipidemia, the oral contraceptive pill, smoking, extension and rotational movements of the neck, genetic factors and connective tissue abnormalities which have all been well documented (7-10). It is significant to report that some vascular events coincide with activities involving neck movements such as various sporting activities, practicing yoga, whiplash injury, sudden neck movement and severe coughing (11)

Unfortunately, the Bertino paper did not mention any risk factors for VAD in the limited case history provided. Further to the lack of detail regarding risk factors, a “new episode or an exacerbation of neck pain and associated disorders” should undergo a thorough diagnostic triage to rule out serious pathology (12,13). Again, details about this new onset were overlooked, which may have been very significant in this case. There is the possibility that the practitioner misdiagnosed a VAD, which is a contra-indication for SMT, and therefore this is a case of negligence rather than a fault with manipulation (14). Given that this patient had a decade-long history of chiropractic neck manipulation without incident, it is apparent that a significant event has been omitted from the case report. Any exacerbation of any aforementioned risk factors could have resulted in the “new neck pain”. This person may have suffered a stroke due to some type of trauma (possibly mild), which caused the symptoms (ie new neck pain) that encouraged them to consult the chiropractor. Indeed Cassidy et al concluded there is “no excess risk of VBA stroke associated with chiropractic care compared to primary care physicians” and further mentioned that patients with headache and neck pain from VBA dissection seeking care prior to their stroke results in an increase visits to chiropractors and primary care physicians (3). In addition, one must carefully examine the mechanisms of the “manipulation”, when only given the description “the patient’s head was turned suddenly and she heard a loud pop”. This “loud pop” is most likely a cavitation which occurs when a sudden decrease in joint intracapsular pressure causes dissolved gasses in synovial fluid to be released into the joint cavity and is a benign and common event (15). The implication drawn is that during manipulation the forces exerted by the chiropractor were sufficient to cause a dissection of the distal V2, entire V3 and proximal (intracranial) portion of the V4 segments of the left vertebral artery. Studies into the stresses placed on vertebral arteries by SMT demonstrate that significantly more tensile load is placed on the vertebral arteries in range of motion testing than is placed during chiropractic manipulation (16,17). Further to this, the strain placed on the vertebral artery during manipulation or range of motion is well below the strain tissue tolerance of a healthy vertebral artery. While this study was only performed on cadaveric spines, a further study noted that manipulative forces used in cadaveric spines were greater than those used in live patients (18).

Another interesting note is the “intraluminal filling defect” believed to represent thrombus or dissecting intimal flap. Indeed the literature suggests a physiological implausibility of thrombus formation accounting for the immediate signs and symptoms of stroke given the time required for clot formation is depicted at around 4.7 minutes (19). Immediate neurological signs and symptoms of stroke from a thrombus would require previous atherosclerosis or thrombus formation to have been dislodged from the vertebral arteries. While the possibility of a dissecting piece of intimal flap still remains, surely this foreign body would have required surgical removal. However, if this is the case, further relevant information was overlooked in the initial publication. As the patient was discharged on anti-platelet therapy, this is suggestive of a thrombus formation rather than a physical body causing embolism. The papers cited by Bertino and colleagues as references for chiropractic as a cause of CAD also have many limitations. For example, Smith’s retrospective analysis was based on 7 patients having stroke or transient ischaemic attack (TIA) after chiropractic compared to 3 patients in the matched control group (a very small number for analysis)(15). Firstly, it must be noted that TIA and stroke are clinically very different entities and a TIA is a far more common occurrence (83/100,000)(16). As such, measuring TIA and stroke simultaneously will result in a greater incidence than measuring stroke alone. Secondly, the small sample size must be highlighted, as a control-matched group of 3 does not carry a great deal of statistical power. Furthermore, this 2003 article has since been outdated by the of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and it’s Associated Disorders which reviewed and case matched over 800 cases over a 9-year period (3). The link made between chiropractic manipulation and VAD made in the Bertino case- report is not supported by the data presented, as there are many other plausible explanations. Certainly a very thorough history should be completed prior to any new neck pain in a patient in order to determine potential causes of stroke. In the Bertino case report, the onset of new neck pain (due to a factor most likely neglected in the report) probably indicated compromise of the vertebral artery (in this patient), which began the dissection process.

Peter Tuchin- BSc GradDipChiro DipOHS PhD FACC

Christopher Lewis- BChiroSc MChirSc

*Peter Wise- BHSc MChirSc**candidate

References1. Tuchin PJ. A replication of the study 'Adverse effects of spinal manipulation: a systematic review'. Chiropractic & Manual Therapies. 2012 (in press) MS ID: 1453247924740230.

2. Haldeman S, Kohlbeck FJ & McGregor M. Unpredictability of cerebrovascular ischaemia associated with cervical spine manipulation therapy. Spine. 2002; 27: 49-55.

3. Cassidy JD, Boyle E, Cote P, He Y, Hogg-Johnson S, Silver F. Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study. Spine. 2008;33:S176 - S83.

4. Schievink WI. Sopntaneous Dissection of the Carotid and Vertebral Arteries. New England Journal of Medicine. 2001;344(12):898.

5. Rothwell PM, Coull AJ, Giles MF, Howard SC, Silver LE, Bull LM, et al. Change in stroke incidence, mortality, case-fatality, severity, and risk factors in Oxfordshire, UK from 1981 to 2004 (Oxford Vascular Study). The Lancet. 2004;363(9425):1925-33.

6. Putaala J, Metso AJ, Metso TM, et al. Analysis of 1008 consecutive patients aged 15 to 49 with first-ever ischemic stroke: the Helsinki Young Stroke Registry. Stroke. 2009; 40:1195–1203.

7. Brandt T, Orberk E, Weber R, Werner I, Busse O, Muller BT, et al. Pathogenesis of cervical artery dissections: association with connective tissue abnormalities. Neurology. 2001 Jul 10;57(1):24-30.

8. Chandra A, Suliman A, Angle N. Spontaneous dissection of the carotid and vertebral arteries: the 10-year UCSD experience. Ann Vasc Surg. 2007 Mar;21(2):178-85.

9. Debette S LD. Cervical-artery dissections: predisposing factors, diagnosis, and outcome Lancet Neurology. 2009;8:668-78.

10. Grau AJ, Brandt T, Buggle F, Orberk E, Mytilineos J, Werle E, et al. Association of cervical artery dissection with recent infection. Arch Neurol. 1999 Jul;56(7):851-6.

11. McCrory. VAD causing stroke in sport. Journal of Clinical Neuroscience. 2000;7(4):289-300.

12. Guzman J, Haldeman S, Carroll LJ, Carragee EJ, Hurwitz EL, Peloso P, et al. Clinical Practice Implications of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders: From Concepts and Findings to Recommendations. J Manip Physiol Ther. 2009;32(2, Supplement):S227-S43.

13. Haldeman S, Carey P, Townsend M, Papadopoulos C. Arterial dissections following cervical manipulation: the chiropractic experience. CMAJ 2001; 165: 905–6.

14. Rubinstein SM, et al. The benefits outweigh the risks for patients undergoing chiropractic care for neck pain: a prospective, multicenter, cohort study. J ManipPhysTher. Aug 2007; 30(6): 408-418

15. Brodeur R. The audible release associated with joint manipulation. J Manip Physiol Ther. 1995;18(3):155-64.

16. Herzog W, Leonard TR, Symons B, Tang C, Wuest S. Vertebral artery strains during high-speed, low amplitude cervical spinal manipulation. Journal of Electromyography and Kinesiology. 2012(0).

17. Symons BP, Leonard T, Herzog W. Internal forces sustained by the vertebral artery during spinal manipulative therapy. J Manip Physiol Ther. 2002;25(8):504-10.

18. Symons B, Wuest S, Leonard T, Herzog W. Biomechanical characterization of cervical spinal manipulation in living subjects and cadavers. Journal of Electromyography and Kinesiology. 2012;ePub Ahead of Print(0).

19. Mann KG, Brummel K, Butenas S. What is all that thrombin for? Journal of Thrombosis and Haemostasis. 2003;1(7):1504-14.

20. Smith WS JS, Sklabrin EJ, Weaver M, Azari P, Albers GW, et al. Spinal manipulative therapy is an independant risk factor for vertebral artery dissection. Neurology. 2003;60:1424-8.

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