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

I have repeatedly discussed the risks of chiropractic manipulation. Sadly, when doing so, we have to rely mostly on case reports (there is no monitoring system that would record such events, reliable incidence figures are therefore not available). This means every new case report is of considerable importance.

Korean neurosurgeons recently reported the case of a patient who had an infarction of the posterior inferior cerebellar artery (PICA) after a chiropractic cervical manipulation. A 39-year-old man visited the emergency room with signs of cerebellar dysfunction, presenting with a 6-hour history of vertigo and imbalance. Two weeks before, he had been treated by a chiropractor for intermittent neck pain. At the time of admission, brain computed tomography, magnetic resonance imaging, and angiography revealed an acute infarction in the left PICA territory and occlusion of the extracranial vertebral artery (VA; V1/2 junction) as a result of a dissection of the VA. Angiography revealed complete occlusion of the left PICA and arterial dissection was shown in the extracranial portion of the VA. The patient was treated with antiplatelet therapy. Three weeks later, he was discharged without any sequelae.

The authors concluded that the possibility of VA dissection should be considered at least once in patients presenting with cerebellar dysfunctions with a recent history of chiropractic cervical manipulation.

In the discussion section, the authors leave little doubt about the question of causality: damage to the V3 portion is the most common injury that may occur after chiropractic manipulation related to anatomical structures. The VA is located horizontally in a groove in the upper side of the atlas’ posterior arch. During abruptly forced neck rotation and stretching, the gap between the atlas and the atlanto-occipital membrane, which the VA penetrates, can be stretched, resulting in dissection. In our case, it appeared that the V1/2 junction had been dissected due to excessive lateral bending of the neck, thought to be caused by an impact to the left transverse foramen of the sixth cervical spine, through which the left VA passes. It is presumed that there was a mechanical injury to the vessel wall at the time of the procedure, which caused dissection and then the thrombus generated, and two weeks after small emboli caused the occlusion of PICA. Low-speed, high-amplitude manipulations that consist of a series of smooth, repetitive movements are configured in certain areas of the neck, and this does not often cause damage. However, a sudden thrust or high-speed, low-amplitude manipulation is often considered the cause of VA dissection. In particular, this type of manipulation can be theorized to result in a sudden, symmetrical rotation of the extended cervical vertebrae, leading to damage to the high cervical and proximal parts of the carotid artery and VA.

It is high time, I think, that chiropractors take such events seriously. At the very minimum, we need a system of monitoring such cases, so that – eventually – we will be able to define their frequency. In this context, it is obviously important to remember that there is precious little evidence to suggest that neck manipulations are effective for any condition. What inescapably follows is clear: until we have reliable incidence data, it is wise to avoid chiropractic neck manipulations altogether.

44 Responses to Another serious complication after chiropractic manipulation; best to avoid neck manipulations altogether, I think

  • IMHO it is wise to avoid neck manipulations altogether.
    The only time I have done them is when reducing injury/trauma induced dislocations.
    And then, 50% of reductions were not achievable without open reduction.

    I can also report a case of which I have knowledge where an orthopaedic surgeon manipulated a neck under anaesthesia, only to find he had caused damage by not having identified a tumour. Hadn’t even taken a radiograph!
    No system of audit back then, and not much better now, but I support the call for all iatrogenic complications to be mandatorily reported.
    (Using ‘iatrogenic’, my largesse includes chiropractors as ‘physicians’ for this purpose – even though they are not!).

    As Professor Riccardo, Consultant charlatan and Specialist in the Care of the Gullible, I demonstrate how to crack a neck. It’s a trick, but makes folks feel better. Even though they know I am a magician, they still say they feel better!
    Must be my charisma.

  • Thanks for the update but since the legal status of chiropractic in Korea is unclear and the risk of prosecution exists, this low-level strength of evidence publication(case report) does not warrant the need for mandated international reporting of serious events because we do not know if the “chiropractor” is really an internationally recognised trained chiropractor or just a local Korean, traditional bonesetter.
    Nevertheless, chiropractic practices and procedures are proving that spinal realignment of the cervical spine provides superior results in the management of cervical myofascial pain compared to standard physiotherapy treatment. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6233550/

  • how do you know that the spinal manipulation two weeks prior caused this event?

    • I don’t
      I just report what the experts who actually saw the patient and did all the tests reported

      • well, fortunately some of us can critically evaluate such papers to determine if it supports a position or not.

        • @DC
          Why do you not share your critical evaluation? We would love to see it.
          Of course no one can verify that the manipulation caused the dissection but it is both plausible and probable. The mechanism of injury is clear and the time perspective as well. A clot can very well dislodge days and weeks after an intimal tear and/or dissection. If the dissection in this case happened before the manipulation then it certainly was not improved by it. If the dissection became manifest in the interval after manipulation, it may still have been initiated by an intimal tear caused by the manipulation. Most importantly, the manipulation of this young person’s neck was not indicated. Research has not corroborated the efficacy of chiropractic ( or other) neck manipulation for any reason.
          Also I do not see why a neck manipulation by a chiropractor is any different risk-wise, than one performed by some other faction of neck wringers. There are many well known cases of young persons succumbing to arterial injury in a chiropractic parlour or directly afterwards. Even Mr. Casidy, famous for being a science minded chiropractor, had a patient with near immediate stroke after wringing his neck, if I recal right.

          • for starters….

            why did he seek care from a “chiropractor”? Did he have any symptoms of a VAD in progress?

            was the severe pain prior, during or after the spinal manipulation? the wording makes it unclear.

            was it a chiropractor who did the manipulation? (we know cases where its called chiropractic manipulation even when the person was not a chiropractor)

            what, if anything, may have occurred between the time of spinal manipulation and the two weeks later that he presented to the ER that may account for this?

            was there any other symptoms during those two weeks?

            what, if anything, occurred around 6 hours prior to ER when the dizziness started?

            why not mention the possibility of a spontaneous VAD?

            You know, the questions that one should ask.

            But whatever, you all are on a witch hunt…I am sure you find what you want to see.

  • Why not to monitor hair stylist when washing someone’s hair in extension and rotation or other activities as painting that involve similar
    head position?

    • they don’t move spinal joints out of their physiological range of motion

      • EE: they don’t move spinal joints out of their physiological range of motion

        That may not be a major factor

        INTERPRETATION:
        The results of this study suggest that vertebral artery strains during head movements including spinal manipulation, do not exceed published failure strains. This study provides new evidence that peak strain in the vertebral artery may not occur at the end range of motion, but rather at some intermediate point during the head and neck motion.

        https://www.clinbiomech.com/article/S0268-0033(14)00249-6/fulltext

    • Heck, what a football game, boxing or wrestling tournament, look at the findings from car accidents, tell me, how fragile is the vertebral artery?

  • The problem with some of these manipulations is the head is extended in addition to the rotational and side bending components. Removing the extension component takes the stretch off of the deep visceral vessels. I am of the osteopathic community, not chiropractic, in case anyone was wondering.

  • dear mister E or Dr E, I am assuming you’re not an idiot what is your motivation for this odd article? If you are truly concerned about iatrogenic injuries why are you not beating the drum about all the medical injuries according to John Hopkins University they’re over 250,000 patients a year killed by the right drug given for the right diagnosis there are over 750000 patients killed each year by medical mistakes in the United States alone this is all confirmed and documented by the United States own medical schools. 65% of all patients over 60 that are brought to emergency rooms are there for symptoms side effects related to the medications drugs they’re taking that’s out of USA Today. So to find some obscure injury in Korea or a patient may have been treated by a chiropractor on orthopedist or a bonesetter two weeks previous and to start making assumptions is at the very least bizarre

  • I find it interesting that you spend so much time working to prove the risks of chiropractic adjustments. The adjustment was performed 2 weeks prior to symptom presentation. That is an incredibly poor correlation. If you want something to to be concerned over read the report by the Journal of the American Medical Association in 1998 that projected 106,000 deaths deaths annually due to normal and proper prescription medication use. Current estimates are as many as 122,000 annual deaths. That is over one million people in the last decade that have been killed due to normal and proper prescription medication use. How many individuals have been harmed let alone killed by chiropractic adjustments in the last decade? Zero!

    • John MDC wrote: “…according to John Hopkins University they’re over 250,000 patients a year killed by the right drug given for the right diagnosis there are over 750000 patients killed each year by medical mistakes in the United States alone this is all confirmed and documented by the United States own medical schools”

      and Veloy Cook wrote: “…read the report by the Journal of the American Medical Association in 1998 that projected 106,000 deaths annually due to normal and proper prescription medication use. Current estimates are as many as 122,000 annual deaths. That is over one million people in the last decade that have been killed due to normal and proper prescription medication use.”

      @ John MDC and Veloy Cook

      Those are quite comprehensive stats. Do chiropractors and other alternative medicine providers supply similar? Here’s a snippet from Death by Medicine, FYI:

      QUOTE
      “Doctor-bashers use their numbers to argue that alternative medicine is safer. Maybe it is. I suppose not treating at all would be safer still. It depends on how you define ‘safe’. To my mind, a treatment is not very ‘safe’ if it causes no side effects but lets you die. Most of us don’t just want ‘safe’: we want ‘effective’. What we really want to know is the risk/benefit ratio of any treatment. The ironic thing is that all the statistics these doctor-bashers have accumulated come from the medical literature that those bashed doctors have written themselves. Scientific medicine constantly criticizes itself and publishes the critiques for all to see. There is NOTHING comparable in the world of alternative medicine.”

      Link http://www.sciencebasedmedicine.org/death-by-medicine/

      The above highlights some very pertinent points. For example, U.S. chiropractors have no patient adverse event reporting systems due to a loophole:
      http://www.ebm-first.com/chiropractic/risks/1842-letter-from-britt-harwe-president-chiropractic-stroke-awareness-group-csag.html

      and the chiropractic adverse event monitoring systems that are currently in place are essentially useless:
      http://tinyurl.com/6dhcxdc

      Meanwhile, reports of deaths after chiropractic treatment are “about three times the number of deaths from trovafloxacin, an excellent antibiotic abandoned in the U.S. as too dangerous”:
      https://www.sciencebasedmedicine.org/compare-and-contrast/

      Ergo…

      “If spinal manipulation were a drug with such serious adverse effects and so little demonstrable benefit, then it would almost certainly have been taken off the market.”

      Ref: https://www.secularism.org.uk/beware-the-spinal-trap-original.html (Dr Simon Singh)

      However, despite the above appalling warnings, I doubt that we’ll see chiropractors taking action to prevent harms any time soon as it would almost certainly impact their livelihoods – e.g. a chiropractor confesses here: if [I] were to tell patients that “I can kill you”, then “half of them would walk out”:
      http://www.ebm-first.com/chiropractic/risks/464-amani-oakleys-closing-in-the-lana-dale-lewis-inquest.html

      In a nutshell, this is the stark reality for any responsible chiropractor:

      QUOTE
      “If a chiropractor limited his practice to muscular conditions such as simple backaches, if he saw patients only on referral from medical doctors after medical diagnosis has been made, if he were not overly vigorous in his manipulations, if he consulted and referred to medical doctors when he couldn’t handle a problem, and if he avoided the use of x-rays, his patients might be relatively safe. But he might not be able to earn a living.”

      The problem has previously been pointed out in para 193 of the Statement of Claim of tetraplegic chiropractic victim, Sandra Nette:

      QUOTE
      “The bad faith, abuse of power and abuse of public trust of the College in promoting Inappropriate and Non-beneficial Adjustment constituted a marked, persistent and conscious departure from the standards of conduct required of it. It disregarded measures it knew were necessary to protect the plaintiffs and other Class Members from economic predation that threatened their bodily integrity and to protect them from injury in contumelious disregard of their personal safety and rights. The College’s indifference to the consequences warrant the condemnation of this Court through the imposition of punitive damages.”

      Ref: http://www.casewatch.org/mal/nette/claim.pdf

      You can read about Sandra Nette’s case, and the outcome, here:
      http://www.ebm-first.com/chiropractic/sandra-nette-v-stiles-et-al.html

      • ^^^ Jebus! Not one of those references are from a credible peer reviewed publication. You might as well be referencing The Mirror or National Enquirer.

        What a bunch of bunk! Even ER doc’s have difficulty dx’ing a VAD and this page is expecting chiros to be held to a higher standard that that?!?! https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5361750/

        There is no convincing evidence to support a causal link between chiropractic manipulation and CAD. Belief in a causal link may have significant negative consequences such as numerous episodes of litigation. https://www.cureus.com/articles/4155-systematic-review-and-meta-analysis-of-chiropractic-care-and-cervical-artery-dissection-no-evidence-for-causation

        The only manner in which the real incidence of dissection following cervical manipulation can be established and the feasibility of screening patients determined is to carry out research in which both chiropractors and neurologists participate. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC81498/

        Patents seek chiros for neck pain as it may be effective as any other treatment.

        The initial effects of a cervical spine manipulative physiotherapy treatment on the pain and dysfunction of lateral epicondylalgia. https://www.ncbi.nlm.nih.gov/pubmed/9252000?dopt=Abstract

        Subacute/chronic patients treated with SMT were significantly more likely to report relevant “improvement” compared with CNRI patients. There was no difference in outcomes when comparing acute patients only. https://www.ncbi.nlm.nih.gov/m/pubmed/27040033/?i=3&from=lumbar%20radiculopathy%20spinal%20manipulation

        The combination of all findings would support the proposal that SMT may, at least initially, exert part of its influence via activation of the PAG. https://www.mskscienceandpractice.com/article/S1356-689X(00)90378-3/pdf

        So, unfortunately someone experiencing a VAD is going o present to chiros, er’s, even PT’s, and statistically there will be misdiagnoses across the board. ALL professions recognize that, but Mr Ernst continues to single out ONE profession. The bias here is overwhelming!

        Andrew Still- I agree that proper technique is most importation. Chiros are DRILLED in proper technique and to remove extension. I do not know the instruction of other healthcare providers that may incorporate manipulation, but as somebody mentioned here, many of these double blind studies are not using chiros to perform the manipulation, or even the ‘sham’ manipulation, It is doubtful that it was a trained chiro in good standing that this OP refers to in Korea. But, as usual, Ernst cherry picks his info and promotes it as gospel.

        • ” Ernst cherry picks his info and promotes it as gospel.”
          there is nothing cherry-picking when reporting about adverse effects of Chiropractic.
          AS THE CHIRO PROFESSION HAS SO FAR FAILED TO ESTABLISH A PROPER SURVEILLANCE SYSTEM, IT IS MY DUTY TO DO THIS

          • What “Surveillance” system do you envision? Because now you DO open the discussion to the effectiveness of other “surveillance” systems in other professions. And thus bringing in the comparisons of medical failures and their systems. I’m not sure you want to do that when 3,405 Medicare patients died during a hospital stays for ELECTIVE surgery between 2009 and 2013. https://www.propublica.org/article/were-still-not-tracking-patient-harm

          • you seem to be talking utter tosh

          • @Edzard Ernst
            We tried to set up an adverse event reporting system in hospital ER’s, where all AE’s are ACCURATELY reported and referred to the appropriate board for investigation, here in Australia years ago for ALL professions including GP’s, ALL specialists in private practice (outside the hospitals with their own AE reporting systems), Physio’s, Chiro’s, Osteo’s etc. It failed due to “sniveling from the doctors” to quote a medical specialist that was involved.
            You would think it was their DUTY to administer such an important surveillance system for ALL health care professions lacking a surveillance system not just chiropractic.
            The chiropractic profession supported the establishment of this reporting system which was BLOCKED BY DOCTORS.

          • do we have more than your word for this?

          • Ahh…I see how this is: https://tinyurl.com/y8ujqmoq

  • In Switzerland to apply chiropractic is allowed only for physicians. In Germany chiropractic is allowed to apply only by physicians and legally licensed naturopaths (Heilpraktikers). The whole neck region is extremly vulnerable therefore it’s a point for killing in martial arts and in unarmed combat.
    Strokes dissections phrenic nerve injuries etc. are reported. It needs a worldwide national reporting strategy. The legal problem is that such cases are not considered like in adverse drug reactions but as malpractices or medical error for such cases a compulsatory reporting system doesn’t exist
    If manual manipulations problems to the spinal area would be considered as adverse manipulative reactions there would be a must of recording them to such a national system compulsatory like in adverse drug reactions. That’s my idea so far. It’s a problem of legislation! Any other ideas to gather and collect reliable data??

    • another very expensive option would be to advertise in newspapers broadcast and tv regularly asking people to report such cases to a national institution (Ärztekammern in Germany) but who would pay the millions of Dollars or Euros for it???

    • @Osteopathie Praxis im Klinikum Karlsruhe
      We tried to set up a standardized AE reporting system here years ago in hospital ER’s for all professions where accurate data (free of bias) was collected and sent to the appropriate registration board for investigation.
      It was killed off by the doctors while the chiropractic associations supported it.
      Edzard and Co on this site want readers to believe that this lack of an AE reporting system purely is a failure of the chiropractic profession. We tried.

      • “Edzard and Co on this site want readers to believe that this lack of an AE reporting system purely is a failure of the chiropractic profession.”
        rubbish; I never even tried to explain the reasons.
        and we do not need any little local initiative, we require national and international systems.

  • @Veloy Cook

    You are wrong, it is fully possible that the vascular injury occurred two weeks before presenting with stroke. You are obviously not medically educated and qualified to understand this.
    This is perhaps the most ominous fact regarding chiropractic neck injury, the consequences can be delayed significantly and therefore the incidence is grossly underestimated. Some have postulated that vascular injury is much more common. Most vascular injury goes unnoticed. Perhaps other factors paly a role such as thrombophilia i.e. an abnormality of blood coagulation that increases the risk of thrombosis.
    Even if a clot forms, it does not always dislodge and even then it does not always hit a critical branch of the cerebrovascular tree.
    Serious consequences may be few and far between but the terrible consequences of such events cannot be discarded.
    Chiropractic or other ) neck manipulations are unnecessary and hazardous and should therefore be banned.
    Ignoring this risk or trying to divert attention from them by referring to erroneous interpretations of the risk panorama in medicine only serves to reveal your ignorance.
    The old trope about medicine/doctors/Big Bad Pharma etc. killing patients is repeatedly being brought up by newcomers to this blog. It is erroneous, ignorant and irrelevant in this context and has been thoroughly dealt with and debunked here and elsewhere.

    • I whole heartily agree that is serves us chiros no good to point out how other professions fail. I can appreciate that chiropractic, like any profession, undergoes continued scrutiny. However, it should be noted that the overall danger a bad chiropractor poses to society PALES in comparison to the overall danger a bad surgeon poses. This is currently one of the most popular podcasts in the world right now: https://wondery.com/shows/dr-death/

  • Medical errors are the 3rd leading cause of death in America. Should we stop seeing medical docs?

    On average 275 people die from FDA approved medications. Should we stop medications completely?

    What’s the cost of malpractice for a chiropractor vs a surgeon?

  • I find it very interesting that there is no mention of the fact that the profession of Chiropractic is not yet legally recognized by the Korean government as an independent health profession as to date. That so called these “chiropractic” manipulations are being conducted by MDs Pts and Oriental practitioners as well as the neighborhood bonesetters who has had a weekend training seminar from a visiting chiropractor from abroad.
    As an American liscensed Korean Chiropractor, I would be put in jail should I choose to open up my own clinic in Korea, for there is no Liscensure for Chiropractic that exist in current Korea. Of 50 or so brave pioneering Chiropractors who chose to move back to Korea (my last count) after being formally educated in Chiropractic are forced to practice incognito.
    That is the current state or Chiropractic in Korea.
    If any discussioon is to be had, it should be about gross manipulation being conducted by unlicensed individuals being labeled as “chiropractic”. This is what can happens when chiropractic as profession is locked out of a country.

    • I know, all the negatives are caused by rogue chiropractors of some type or another; and all the positives are due to the good guys.
      Simple!
      Perhaps too simple?

  • This is absolutely ridiculous! The amount of training a DC has is comparable to a medical doctor. Medical doctors often have cases of VAD occur in their offices far more frequently than chiropractors yet there’s no witch hunt to shut down MDs. VADs don’t occur from adjustments of the cervical spine unless an aneurysm is already present during the adjustment. In that case you can blame the chiropractor for not doing enough to check on the state of the vertebral arteries but that negligence falls on to a single doctor not the profession as they are taught the same as MDs to use imaging and testing. Get off your high horse Dr. E. MDs are more prone to creating life or death moments in a patients life than a chiropractor. Also chiropractic has evolved over the years. Unless you’re a very poorly trained chiropractor they will not combine extension and rotation into a cervical adjustment. Malpractice premiums also show the safety of the profession as they are based on the risk involved and chiropractic has the lowest premiums.

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