Neurosurgeons from the Philippines recently presented the case of a 36-year-old woman who presented with severe bifrontal and postural headache associated with dizziness, vomiting, and double vision. A cranial computed tomography scan showed an acute subdural hematoma (SDH) at the interhemispheric area. Pain medications were given which afforded minimal relief.
The headaches occurred 2 weeks after the patient had received a cervical chiropractic manipulation (CM). Cranial and cervical magnetic resonance imaging revealed findings supportive of intracranial hypotension and neck trauma. The patient improved with conservative management.
The authors found 12 articles of SIH and CM after a systematic review of the literature. Eleven patients (90.9%) initially presented with orthostatic headaches. Eight patients (66.7%) were initially treated conservatively but only 5 (62.5%) had a complete recovery. Recovery was achieved within 14 days from the start of supportive therapy. Among the 3 patients who failed conservative treatment, 2 underwent non-directed epidural blood patch, and one required neurosurgical intervention.
The authors concluded that this report highlights that a thorough history is warranted in patients with new-onset headaches. A history of CM must be actively sought. The limited evidence from the case reports showed that patients with SIH and SDH but with normal neurologic examination and minor spinal pathology can be managed conservatively for less than 2 weeks. This review showed that conservative treatment in a closely monitored environment may be an appropriate first-line treatment.
As the authors rightly state, their case report does not stand alone. There are many more. In 2014, an Australian chiropractor published this review:
Background: Intracranial hypotension (IH) is caused by a leakage of cerebrospinal fluid (often from a tear in the dura) which commonly produces an orthostatic headache. It has been reported to occur after trivial cervical spine trauma including spinal manipulation. Some authors have recommended specifically questioning patients regarding any chiropractic spinal manipulation therapy (CSMT). Therefore, it is important to review the literature regarding chiropractic and IH.
Objective: To identify key factors that may increase the possibility of IH after CSMT.
Method: A systematic search of the Medline, Embase, Mantis and PubMed databases (from 1991 to 2011) was conducted for studies using the keywords chiropractic and IH. Each paper was reviewed to examine any description of the key factors for IH, the relationship or characteristics of treatment, and the significance of CSMT to IH. In addition, other items that were assessed included the presence of any risk factors, neck pain and headache.
Results: The search of the databases identified 39 papers that fulfilled initial search criteria, from which only eight case reports were relevant for review (after removal of duplicate papers or papers excluded after the abstract was reviewed). The key factors for IH (identified from the existing literature) were recent trauma, connective tissue disorders, or otherwise cases were reported as spontaneous. A detailed critique of these cases demonstrated that five of eight cases (63%) had non-chiropractic SMT (i.e. SMT technique typically used by medical practitioners). In addition, most cases (88%) had minimal or no discussion of the onset of the presenting symptoms prior to SMT and whether the onset may have indicated any contraindications to SMT. No case reports included information on recent trauma, changes in headache patterns or connective tissue disorders.
Discussion: Even though type of SMT often indicates that a chiropractor was not the practitioner that delivered the treatment, chiropractic is specifically cited as either the cause of IH or an important factor. There are so much missing data in the case reports that one cannot determine whether the practitioner was negligent (in clinical history taking) or whether the SMT procedure itself was poorly administered.
The new case report can, of course, be criticized for being not conclusive and for not allowing to firmly establish the cause of the adverse event. This is to a large extent due to the nature of case reports. Essentially, they provide a ‘signal’, and once the signal is loud enough, we need to act. In this case, action would mean to prohibit the intervention that is under suspicion and initiate conclusive research to prove or disprove a causal relationship.
This is how it’s done in most areas of healthcare … except, of course in so-called alternative medicine(SCAM). Here we do not even have the most basic tool to get to the bottom of the problem, namely a transparent post-marketing surveillance system that monitors the frequency of adverse events.
And whose responsibility is it to put such a system in place?
I let you guess.