MD, PhD, FMedSci, FRSB, FRCP, FRCPEd.

In 2005, I published a systematic review of ophthalmic adverse effects after spinal manipulations. At the time, I found 14 case reports. Clinical symptoms and signs were diverse and included loss of vision, ophthalmoplegia, diplopia and Horner’s syndrome. The underlying mechanism was arterial wall dissection in most cases. The eventual outcome varied and often included permanent deficits. Causality was frequently deemed likely or certain.

I concluded that upper spinal manipulation is associated with ophthalmological adverse effects of unknown frequency. Ophthalmologists should be aware of its risks. Rigorous investigations must be conducted to establish reliable incidence figures.

Now a new article has emerged that throws more light on this issue:

A 46-year-old healthy male with a history of chronic musculoskeletal neck pain presented to the emergency department with left sided weakness after a syncopal episode. The patient had been treated with frequent chiropractic neck manipulations over the past seven years, with his last session one month prior to presentation. One week prior to presentation, the patient developed a new headache, anisocoria, and ptosis of his right upper eyelid. Computed tomography angiography (CTA) of the head and neck showed an internal carotid occlusion with right middle cerebral artery zone of ischemia, and tissue plasminogen activator (tPA) was administered. Subsequently, the patient experienced vision loss in his right eye. MRI and CTA were repeated, revealing a right ICA dissection from below the ophthalmic artery to the posterior communicating artery. On examination, vision in the right eye was no light perception (NLP) and the pupil was amaurotic. Fundus exam showed vascular attenuation, severe pallor of the optic nerve and retina, without a cherry red spot. A diagnosis of ophthalmic artery occlusion was made.

Inpatient workup revealed no stroke risk factors, and he was discharged on aspirin and clopidogrel therapy. Follow up imaging showed re-cannulation of the ICA, although vision remained NLP at outpatient evaluation the following month. Macular spectral domain optical coherence tomography (SDOCT) showed hyperreflectivity of the inner retina diffusely and of the outer retina and retinal pigment epithelium (RPE) centrally. Fluorescein angiography revealed patchy choroidal filling, delayed arterial filling, and macular nonperfusion. Three months after presentation, vision had improved to light perception, and remains stable at one year after the dissection.

Central retinal artery occlusion (CRAO) has been previously described after neck manipulation; however, these cases have been attributed to a dislodged embolic plaque rather than arterial dissection as in this case. Carotid artery dissection after neck manipulation is rare, although the exact incidence is unknown, and may be fatal.

The authors of this case report concluded that internal carotid artery dissection in this case was permanently devastating to the vision of a previously healthy young patient.

What follows is simple:

  1. upper spinal manipulations have no or very little proven benefit;
  2. they are associated with a finite risk;
  3. thus, their risk/benefit balance fails to be positive;
  4. consequently, upper spinal manipulations cannot be recommended as a treatment of any condition.

11 Responses to Ophthalmic Adverse Effects after Chiropractic Neck Manipulation

  • Upper cervical manipulation has been reported to provide benefit in the treatment of Fibromyalgia.
    https://www.ncbi.nlm.nih.gov/pubmed/25782585

    The risk is real but rare according to AHPRA.

    • good try Mr chiro!
      “A total of 120 (52 female) patients with fibromyalgia syndrome (FMS) and definite C1-2 joint dysfunction were randomly assigned to the control or an experimental group. Both groups received a multimodal program; additionally, the experimental group received upper cervical manipulative therapy. Primary outcomes were the Fibromyalgia Impact Questionnaire (FIQ), whereas secondary outcomes included Pain Catastrophizing Scale (PCS), algometric score, Pittsburgh Sleep Quality Index (PSQI), Beck Anxiety Inventory (BAI), Beck Depression Inventory (BDI), and 3D postural measures. Measures were assessed at three time intervals: baseline, 12 weeks, and 1 year after the 12-week follow-up. The general linear model with repeated measures indicated a significant group × time effect in favor of the experimental group on the measures of 3D postural parameters (P < .0005), FIQ (P < .0005), PCS (P < .0005), algometric score (F = P < .0005), PSQI (P < .0005), BAI (P < .0005), and BDI (P < .0005). The addition of the upper cervical manipulative therapy to a multimodal program is beneficial in treating patients with FMS." SMALL SAMPLE SIZE A+B VS B DESIGN NO CONTROL FOR PLACEBO EFFECTS NO INDEPENDENT REPLICATION ------------------------------ GOOD TRY, BUT YOU NEED TO TRY HARDER!

  • @ Edzard

    You could also put that since spinal manipulation is not specific to a particular vertebra when performed, there is no such thing as upper or lower cervical manipulation. There is only cervical spine manipulation which has the same risk/benefit balance.

  • And the very obvious likelihood that hyper-mobile (or normal-motion) vertebral segments are the only ones that can actually cavitate (pop) making the entire premise of “moving displaced or fixated” segments bogus.
    There is ZERO reliability or validity (nor plausibility) to determining which segment needs motion….it’s always arbitrary, capricious and an entrepreneurial theatric masquerading as “health-care”. A quack is as a quack does.

  • The following information about UK chiropractor, Richard Brown, a former President of the British Chiropractic Association and currently Secretary-General of the World Federation of Chiropractic, may be of relevance to this discussion.

    Please note that I do not know anything about Richard Brown’s medical history. However, I do hope that he, and his attending medical doctors, took into account the ophthalmic complications that have been reported following chiropractic neck manipulation when he experienced this unfortunate medical emergency last year:

    QUOTE

    “5. On the morning of 17 January 2017, the Committee was informed that Dr Brown had completed his report and this had been served on the Defence. However, Dr Brown had become unwell and had to attend hospital having lost the sight in one eye. Thereafter he attended the hearing but it was apparent that he was not well enough to continue. He had an appointment to return to the hospital on Thursday 19 January 2017. Mr Milne therefore applied to adjourn the hearing on the basis that it was not known how long Dr Brown would need to recover and even when he did he would need sometime to consider the defence material before being in a position to give his evidence. In all the circumstances, Mr Milne said it was not going to be possible to complete this case within the time available. Mr Goldring did not oppose the application.”

    Ref: Scroll down and click on the Notice of Decision in this link:
    http://www.gcc-uk.org/chiropractor-result/?id=33&postcode=&surname=ambrose&pagenum=1

    Then go to page 6, item (5).

  • Wait…so symptoms occured 3 weeks after his last visit to a chiropractor?

    What else occured during those 3 weeks that may explain the condition?

  • That case report is poor science and you are making assumptions in regards to the chiropractors treatment. Also poor science. A request was sent to the authors through Researchgate and still no reply.

    • I don’t think I made assumptions; I reported what they published.
      do you care to specify what assumptions precisely you refer to?

      • I recall that around 60% of CAD are classified as spontaneous. Simple events like a hard cough have been associated with CAD. There was three weeks between last spinal manipulation and presenting symptoms.

        How the authors determined causation to spinal manipulation wasn’t even outlined in the LTE. In fact, they didnt even specify which area of the cervical spine was manipulated.

        So the use of this LTE as evidence of risk is based upon several questionable assumptions.

      • EE., with your knowledge of anatomy and physiology and all the research you have done on spinal manual therapy, perhaps you should really have a sceptical opinion and review of this research. Three weeks is considered a long time for there to be a cause/relationship between SMT and ophthalmic artery occlusion.
        Through away your known biases and be a bit more sceptical!

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