MD, PhD, FMedSci, FRSB, FRCP, FRCPEd

The authors of a recent paper stated that cerebellar and spinal cord injuries related to cervical chiropractic manipulation were first reported in 1947. By 1974, there were 12 reported cases. Non-invasive imaging has since greatly improved the diagnosis of cervical artery dissection and of stroke, and cervical artery dissection is now recognized as pathogenic of strokes occurring in association with chiropractic manipulation. 

The purpose of their study was to determine the frequency of patients seen at a single institution who were diagnosed with a cervical vessel dissection related to chiropractic neck manipulation.

The authors identified cases through a retrospective chart review of patients seen between April 2008 and March 2012 who had a diagnosis of cervical artery dissection following a recent chiropractic manipulation. Relevant imaging studies were reviewed by a board-certified neuro-radiologist to confirm the findings of a cervical artery dissection and stroke. The authors also conducted telephone interviews with each patient to ascertain the presence of residual symptoms in the affected patients.

Of the 141 patients with cervical artery dissection, 12 had documented chiropractic neck manipulation prior to the onset of the symptoms that led to medical presentation. The 12 patients had a total of 16 cervical artery dissections. All 12 patients developed symptoms of acute stroke. All strokes were confirmed with magnetic resonance imaging or computerized tomography. Follow-up information could be obtained from 9 patients, 8 of whom had residual symptoms and one of whom died as a result of their injury. The tables below give the full details. [Click to enlarge.]

The authors concluded that in this case series, 12 patients with newly diagnosed cervical artery dissection(s) had recent chiropractic neck manipulation. Patients who are considering chiropractic cervical manipulation should be informed of the potential risk and be advised to seek immediate medical attention should they develop symptoms.

How many times have we on this blog issued similar warnings?

And how many times have chiropractors countered with denial?

This time will be no different, I am sure.

They will cite the Cassidy study and assure us that neck manipulations are entirely safe.

But sadly, repeating a lie many times does not turn it in to a truth.

15 Responses to Cervical artery dissection and stroke related to chiropractic manipulation

  • Excellent information!
    A few concepts directly related to the manipulation-stroke issue that strike me:
    1. There is enough evidence to at least be circumspect regarding letting your neck get cranked side-to-side.
    2. Getting your neck cranked side-to-side should appear to any rational person to be like putting mustard on spaghetti i.e. why would you even bother? WHAT is the purpose?
    3. I suspect the vertebra that “crack” are only and always vertebra that are in effect ‘hyper-mobile’…already mobile.
    4. ANY ‘movement therapy’ involving the spinal vertebrae done lying down MUST be based on the scam-of-subluxation….a false, spurious concept based in pre-scientific nonsense and trickery.
    5. Since there are no reliable or valid tests to “diagnosis” any subluxation or subluxation-like entity ANY cranking is always and only an arbitrary, theatrical action with only spurious underpinnings. What else? “Since you neck hurts I’m going to lay you down, pick a vertebra based on caprice then whack at it in the hope I’ll make it “move” better or more than it is…..even though I have no god damned idea how it actually moved before I whacked on it….OR if it’s supposed “motion” has any bearing on anything but my bank account……however IF you think you feel better afterwards (which will be a surprise to both of us….) don’t expect the ‘relief’ to last more than 18minutes.
    Professor Bogduk said it succinctly: “Manipulation for neck pain does not work”. NO Chiropractor is in a position to countermand his statement…..though in their arrogant style and customary aplomb undoubtedly will.

  • “Perhaps the one-month observation period of Cassidy et al was excessive. Many post-manipulation events occur within hours or at most a few days, as would be expected given the hypothesized pathogenic mechanism. Perhaps if they had shortened their interval of study to the preceding 3 days, their findings may have been different.”
    Cassidy 2008 paper stated:
    “We tested different hazard periods, including 1 day, 3 days, 1 week, 2 weeks, and 1 month before the index date. Exposure occurred if any chiropractic or PCP visits were recorded during the designated hazard periods.”
    Also of interest is the 2016 paper by Cassidy, Cote and Haldeman was not included that specifically looked at chiro’s and PCP doctors and they observed the chiro’s group immediately after treatment. Yet they included the 2016 paper by the neurosurgeons in Cureus.
    The authors also stated:
    “Our case series has several limitations. The study was retrospective. Existing documentation of associated chiropractic care was often sparse, necessitating phone calls to supplement the information. We believe it is possible that cases may have been missed because of inaccurate medical record documentation, deficits in the interview process concerning chiropractic care at the time of hospitalization, or because information concerning chiropractic care was not recorded in the chart.
    A significant portion of our information came through phone contact with several of the patients. In some cases, we relied heavily on their recollection of events that had occurred anytime from a few days to a few years earlier. The accuracy and completeness of the information supplied by patients was not verified, allowing for potential recall bias.”
    Documentation was sparse and had inaccurate medical record documentation. What procedures did the chiropractors use?
    How did this paper make it though peer review?

    What is needed is accurate recording of any adverse events presenting to hospital emergency departments which is then referred to the relevant board (chiro, osteo, physio, GP etc) for investigation. We went through this in Australia several years ago with the support of the chiropractic profession. The whole thing fell through due to “snivelling” (a pain medicine doctors word not mine) from the hospitals over who would pay for it. From what I hear the development of an adverse event reporting form is being developed in one of the Australian Universities at the moment by a PhD candidate.

    • “What is needed is accurate recording of any adverse events”
      I agree – and until we have that, the precautionary principle obliges us to assume that neck manipulations are not safe.

      • @EE
        There is so much fact and fiction on this issue.
        Do retrospective studies like those by Cassidy, Cote and Haldeman answer the question?
        If we need a prospective study how would you design it and ensure that it would not be prohibitively expensive? It is rare so data sets in the multiple of millions would be needed.

        • it needs to be handled like all safety issues in therapeutics are handled – no need to re-invent the wheel; no need for double standards.
          BUT UNTIL WE HAVE SOUND EVIDENCE, WE MUST APPLY THE PRECAUTIONARY PRINCIPLE!!!

      • All neck manipulations are risky.
        Some have been performed by orthopaedic surgeons (in the private sector).
        If anything goes wrong – stumn.
        I have personal knowledge of an orthopod manipulating a neck, partially paralysing a patient, referring her to the centre where I worked, where we did discovered a cervical vertebral tumour (very rare) and had to stabilise the spine.
        Patient was grateful we had discovered her tumour. With no manadatory reporting, I bet no one outside a small circle knew of this adventure.

        Only answer is for all C manipulations, for whatever reason, by whomsoever, be recorded – and for an audit of outcomes.
        A very difficult task – but don’t pick on chiropractors exclusively. That’s ad hominem.

        This paper should not have included ‘chiropractic’ in its title.
        It was the manipulation wot done it – not (specifically) the practitioner.
        This paper should not have included the word ‘chiropractic’ in its title.
        It was the manipulation wot done it!

        • Richard Rawlins wrote: “don’t pick on chiropractors exclusively. That’s ad hominem”

          It’s true that’s it’s not an exclusively chiropractic problem, but chiropractors do seem to be the worst offenders. See Fig.2 here: https://tinyurl.com/yafwnb6e

          It’s also worth remembering that the reasons for use of manipulation/mobilisation by an evidence-based manual therapist are not the same as the reason for use of adjustment/manipulation by most chiropractors:
          http://jmmtonline.com/documents/HomolaV14N2E.pdf

          • it is not ad hominem at all, in my view

          • @Richard Rawlins
            “Only answer is for all C manipulations, for whatever reason, by whomsoever, be recorded – and for an audit of outcomes.”
            Several years ago this was proposed here in Australia. Accurate collection of adverse event data in the hospital emergency departments for all professions that then gets referred to the relevant board for investigation. Unfortunately it fizzled at the hospital level. The chiropractic associations were in full support of the initiative. Very frustrating.
            I hear that a current chiropractic PhD candidate is well advanced in producing an adverse event reporting form for hospitals.

            @Michael Kennny
            Years ago I visited Nicolai Bogduk’s lab in Newcastle after he published his book “Biomechanics of Back Pain”. He is very even handed in his skepticism when it comes to ALL approaches for back and neck pain. We discussed the mechanisms and neurology underlying SMT and his response was invariably “sounds reasonable, prove it”. He had a sign up on the wall “In god I trust. Everyone else must bring data”. A surgeon who is a good friend studied medicine at Newcastle said that Nicolai’s prickly nature and skepticism for everything medical was legendary. I have also listened to him at several multidisciplinary conferences over the years and agree with much of what he says.

            @Blue Wode
            Evidence based manual therapists includes the majority of the chiropractic profession Blue. If you follow the evidence all of us should be heading down the same path.

  • Critical_Chiro wrote: “I hear that a current chiropractic PhD candidate is well advanced in producing an adverse event reporting form for hospitals.”

    Let’s hope that it will be used in hospitals on a global basis. Meanwhile, the only adverse event reporting system that chiropractors have is worse than useless:
    http://www.ebm-first.com/chiropractic/uk-chiropractic-issues/1888-british-chiropractic-association-members-attitudes-towards-the-chiropractic-reporting-and-learning-system-a-qualitative-study.html

  • @CC: I will respectfully suggest Bogduk didn’t say: “manipulation’s neurology and mechanisms sound reasonable…prove it”. “Prove it” yes “sounds reasonable” I doubt…excepting for a pinched miniscoid perhaps, to which he points out clears in a few days anyway. Dr. Ernst wrote the review prompting the Bogduk reply and irrespective of whether you visited him it would appear aligning yourself with a profession of ‘bone-crackers’ who have no idea what they are doing (yet have ample access to Ernst, Bogduk and science in general to strongly suggest they QUIT what they’re doing…) and who continue to side-step all of it in the name of specious mechanical and ‘neurological’ outcomes….boggles my imagination.
    Professor Menke used the expression “resentful demoralization” indicating doing SOMETHING may be better than nothing….however that shouldn’t include deluded fake-doctors with NO hospital internship training opening practices selling theatrics to the under-educated. That should remain the job of the Catholic church.

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