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.
50 Responses to Acute Subdural Hemorrhage Following Cervical Chiropractic Manipulation
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The more I read about this the more surprised I am that research would even be considered necessary, since these manipulations are so obviously dangerous. They are movements which would virtually never happen in day to day life and if you did happen to have an accident which caused comparable impact on the spine surely you would go to hospital to get checked for damage.
This may seem self-evident, but please explain how “these manipulations are so obviously dangerous.”
Is it the magnitude of the force? If so, has research quantified these forces? How do the forces compare to other common movements, say during sports or a car accident?
Is it the direction and/or degree of movement? If so, what are the usual movements or combination of movements (flexion, rotation, lateral flexion, extension, etc.) used in spinal manipulation and to what degree? How does this compare to common movements throughout the day or during a standard cervical exam?
force does not need to be excessive [less than in many accidents]
extension with simultaneous rotation beyond the physiological range of motion seem to be the greatest risks.
Not excessive is not the same as sufficient to cause harm.
I agree that extension with simultaneous rotation is the direction of movement that appears to increase risk of injury (at least for VAD, I’m not sure about other injuries such as SDH).
Then we must ask, was the SMT performed in this case extension + rotation? Is extension + rotation the way chiropractors perform most SMT?
If chiropractors don’t routinely perform extension + rotation, but instead use strictly rotational maneuvers, rotation + flexion, or lateral flexion only, does that decrease the suspicion that the SMT would be associated with such an injury?
Nathan, You may find this article of interest, as it relates to whiplash:
The average (standard deviation) physiological VA elongation was 5.8 (1.6) mm in left lateral bending and 4.7 (1.8) mm in left axial rotation. Flexion and extension did not result in any appreciable elongation of the VA. The maximum VA elongation during the whiplash trauma significantly correlated with the horizontal acceleration of the sled (R 2 = 0.7,P < 0.05). The VA exceeded its physiological range by 1.0 (2.1), 3.1 (2.6), 8.9 (1.6), and 9.0 (5.9) mm in the 2.5-, 4.5-, 6.5-, and 8.5-g trauma classes respectively. https://www.researchgate.net/publication/13926034_Dynamic_elongation_of_the_vertebral_artery_during_an_in_vitro_whiplash_simulation
Also this one:
It is now thought that vertebral artery dissection is a multifactorial disease process where certain intrinsic factors are present in the setting of an exacerbating extrinsic factor such as a low speed car accident, direct trauma, heavy lifting, or a rotational sports injury. https://www.sciencedirect.com/science/article/abs/pii/S0735675720310378
There are studies that looked at the forces applied during cSMT and others on the VA strain during cSMT.
Nathan, another interesting finding:
In a large, heterogeneous cohort, we found that cervical dissection was associated with an approximately 4-fold increased risk of subsequent aortic dissection. https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.121.055274
Nathan, You may find this article of interest, because it relates to chiropractor neck manipulations:
“Arterial dissection accounts for about 2% of all ischemic strokes, but may be between 8–25% in patients less than 45 years old. VAD can result from trauma of varying severities — from sports, motor vehicle accidents, and chiropractor neck manipulations to violent coughing/sneezing. It is estimated that 1 in 20,000 spinal manipulation results in vertebral artery aneurysm/dissection. In the United States, patients who have multiple chronic conditions are reporting higher use of complementary or alternative medicine, including chiropractic manipulation. Education about the association of VAD and chiropractor maneuvers can be beneficial to the public as these are preventable acute ischemic strokes.” [my emphasis]
https://www.ahajournals.org/doi/abs/10.1161/SVIN.01.suppl_1.000200
Nathan, you may find it of interest to track down the original source of this claim and read what he actually wrote:
“It is estimated that 1 in 20,000 spinal manipulation results in vertebral artery aneurysm/dissection.”
I included that in my quote, but in your usual knee-jerk defence of the indefensible, you didn’t bother to read my comment.
Now tell us, ‘DC’, what actual medical conditions require cervical spine manipulation by a chiropractor?
Pete: I included that in my quote,
What you linked to was an abstract printed in the supplemental section of a journal.
Here, let me help you out…
The earliest reference I have found for the 1 in 20,000 is below (note, Vickers did not provide a reference)
“The most important potential adverse effects of osteopathy and chiropractic are stroke and spinal cord injury after cervical manipulation. Estimates of such severe adverse events vary widely, ranging from 1 in 20 000 patients undergoing cervical manipulation to 1 per million procedures.” Vickers. BMJ. 1999 Oct 30; 319(7218): 1176–1179.
Then, in 2001 Schievink in his paper in the NEJM, referenced Vickers paper stating “as many as 1 in 20,000 spinal manipulations cause a stroke.” Again, no research or data to back this up.
And from that the claim continues to today. Not supported by any evidence that I can locate and it isn’t even close to most estimates. But is fits some folks agenda so it keeps on surfacing.
You’re welcome.
Tell us, ‘DC’, what incidence of vertebral artery aneurysm/dissection would be acceptable to your agenda, thereby invalidating the conclusion:
Education about the association of VAD and chiropractor maneuvers can be beneficial to the public as these are preventable acute ischemic strokes.
Just one event, ever, is horrific, and totally preventable.
Which “problems”[1] require as a solution a cervical spine manipulation by a chiropractor?
1. That is, actual medical conditions, not some chiropractic BS diagnoses.
Pete: Which “problems”[1] require as a solution a cervical spine manipulation by a chiropractor?
Require?
No intervention is “required” for most cases of nonspecific neck pain. Not NSAIDs, not opioids, not muscle relaxers, not physical therapy, not spinal manipulation, etc.
Require: to need something or make something necessary (Cambridge)
And your mention of cSMT being done by chiropractor suggests it is “required” within another profession.
Your question is full of bait. Try again.
You used the word “requiring” here:
https://edzardernst.com/2022/02/vertebral-artery-dissection-in-a-pregnant-woman-after-cervical-spine-manipulation/#comment-137388
How many people have to be maimed or killed by chiropractors in order to finally stop chiropractors playing doctor?
It was the arrogant, ignorant, and incompetent outpourings on this blog, over many years, by your sock puppet of various pseudonyms, that convinced me chiropractic is abject quackery. The lack of concern shown for those injured is disgusting.
Thank you for finally admitting that there are no actual medical conditions that require a cervical spine manipulation by a chiropractor, yet the cervical spine manipulation by a chiropractor can and does cause very serious actual medical conditions, some of which are fatal.
sigh, my use of the word require was pointing out that different problems require different solutions.
You confuse a lack of concern with my critical analysis of what some use as evidence of serious harm.
I have only used one other identifier on this blog. Some objected to my use of the word Dr in that identifier so I changed it to DC as it wasn’t worth my time to argue with them (which of course DC still refers to Doctor but it seemed to appease them).
In healthcare and particularly in manual therapy we look at increasing comfort and function because most come to us because…wait for it…a loss of comfort and function.
Yes, there is the potential to cause harm, I have never said otherwise. Most case reports suggest that serious harm is due to an improper history and exam (although other reasons may exist such as improper technique). Thus, most cases appear to be preventable with a proper history, exam and technique. That, is a different problem that, yes, requires a different solution.
So yes, spinal manipulation isn’t “required” anymore than physical therapy, NSAIDs, etc for most cases. The question is: does the intervention increase comfort and function over doing nothing and is that justified due the potential risk of harm….benefit vs risk.
Now, i shall excuse my self to prepare for a research presentation that deals with a possible new contraindication to cSMT (because I have a lack of concern, right?)
Thanks, Pete. Interesting, perhaps, but unhelpful to answer any of the questions I posed. What does the literature say about the force needed to injure the VA? Are those forces present in SMT? Does the particular direction or technique matter?
As DC mentioned, without a reference for the 1 in 20,000 estimate, that is highly questionable. Back of the envelope calculations would suggest that with ~75,000 practicing chiropractors seeing 20 patients per day, 3 days/week, half of whom get cervical manipulation… we would be seeing ~5600 VADs from cSMT per year in the US?!
The annual incidence of VAD is 4,950 (1.5 per 100,000; 300 million population).
So over 100% of VADs would be caused by chiropractors?
Feel free to correct my math or adjust those assumptions. I’m not saying it’s impossible, but I find it hard to imagine any scenario where 1/20,000 is anywhere near a reasonable estimate.
BTW, I’m not contesting the conclusion that “Education about the association of VAD and chiropractor maneuvers can be beneficial to the public as these are preventable acute ischemic strokes.”
The question is whether that education accurately represents the risks and the lack of evidence for causality.
A better conclusion—which the totality of evidence on the topic point to—is that:
• the association is unclear either way (Haynes, M. J., Vincent, K., Fischhoff, C., Bremner, A. P., Lanlo, O., & Hankey, G. J. (2012). Assessing the risk of stroke from neck manipulation: a systematic review. International Journal of Clinical Practice, 66(10), 940–947. http://doi.org/10.1111/j.1742-1241.2012.03004.x)
• there is no evidence for causality (Church, E. W., Sieg, E. P., Zalatimo, O., Hussain, N. S., Glantz, M., & Harbaugh, R. E. (2016). Systematic Review and Meta-analysis of Chiropractic Care and Cervical Artery Dissection: No Evidence for Causation. Cureus, 1–11. http://doi.org/10.7759/cureus.498)
• clinicians should be highly aware of the risk factors and indications for potential VAD and judicious in their use of manual therapies (Hutting, N., Kerry, R., Coppieters, M. W., & Scholten-Peeters, G. G. M. (2018). Considerations to improve the safety of cervical spine manual therapy. Musculoskeletal Science and Practice, 33, 41–45. http://doi.org/10.1016/j.msksp.2017.11.003; Chaibi, A., & Russell, M. B. (2019). A risk-benefit assessment strategy to exclude cervical artery dissection in spinal manual-therapy: A comprehensive review. Annals of Medicine, 51(2), 1–27. http://doi.org/10.1080/07853890.2019.1590627).
I appreciate the discussion of case studies here. My concern is the implicit or explicit suggestions that the evidence for causality is clear and the lack of further critical inquiry into the possible mechanisms involved.
If you have a health problem, the last person you should consult is a chiropractor
‘DC’ wrote “I have only used one other identifier on this blog. Some objected to my use of the word Dr in that identifier so I changed it to DC as it wasn’t worth my time to argue with them (which of course DC still refers to Doctor but it seemed to appease them).”
You have used at least 6 unique pseudonyms since 2016: “Google it.”
QUOTE by the late Frank Odds on Friday 17 April 2020 at 08:36:
@DC
I think I preferred your comments when you called yourself “DrDale”. At least you were open enough back then (2018) to acknowledge you relished the title Dr and were happy to use it when there was a thrust from chiros to be regarded as primary care physicians (which they’re not and never will be qualified for, however much their “official organizations” kick and squeal their special pleading).
END of QUOTE
https://edzardernst.com/2020/04/if-you-have-a-health-problem-the-last-person-you-should-consult-is-a-chiropractor/#comment-122552
Nathan,
I’ve noticed that too many authors mention just “elongation” of, and/or “strain” on, the arteries — axial extension resulting from axial force — but as you quite rightly asked “Does the particular direction or technique matter?”: yes, both direction and technique matter. A rapid rotation of the neck (high-velocity neck manipulation) will apply a combination of axial force and shear force. If there is an existing clot, or other debris on the artery walls, a high-velocity neck manipulation is far more likely to dislodge the clot/debris than would the axial extension component alone.
You wrote “My concern is the implicit or explicit suggestions that the evidence for causality is clear and the lack of further critical inquiry into the possible mechanisms involved.”
What would be the point of trying to establish exact cause — did the neck manipulation cause the stroke directly (no precondition); or indirectly (triggered a precondition) — when there was no actual medical reason for performing the neck manipulation.
There can never be a reasonable justification for someone who is ‘playing Doctor’ performing a theatrical placebo, which injures some clients and kills others. Arguments about the incident rate show a disgusting disregard for each and every victim, and their families.
Pete: You have used at least 6 unique pseudonyms since 2016: “Google it.”
I recall using two in this blog and when i switched i made it clear to others that I did so. Maybe when I first came here I briefly used another, I don’t recall. I fail to see how it’s relevant to the discussion, it appears more to be an attempt of distraction so whatever.
Pete: A rapid rotation of the neck (high-velocity neck manipulation)
1. If someone is doing a “rapid rotation of the neck” they are doing cSMT wrong, at least on how I was taught.
2. The term used in spinal manipulation is to take the joint to lock out. This is set up by using a slow rotation of the neck until one feels the joint lock out. That is when the thrust is applied. This gaps the joint (millimeters) setting up a reflex to the associated paraspinal muscles. Research has measured this gapping and the typical/average forces needed. Others have measured how much strain this puts on the VA which is less than within normal ROM.
3. Based on the above, IF the overall act of cSMT were to cause a VAD it’s more likely to occur during the process of set up, not during the actually act of manipulation.
3. This is based upon that there is not an intrinsic weakness in the system or anomaly, which appears to be uncommon. The current thought is that within the general public, outside significant trauma, most VAD cases are because there is an intrinsic weakness.
4. We are aware of these known intrinsic factors as they are listed as contraindications to cSMT. There may be others that have yet to be discovered of which one of them is the purpose of my research proposal.
5. If someone does cSMT in the presence of a contraindication, yes it increases the probability of causing a serious AE. It appears this may be the case in many of the published case reports. That is practitioner error. Does that extrapolate to the general population, most likely but that is very difficult to research.
6. If one looks at published case reports and utilization of cSMT amongst the different professions, the indication is that chiropractors are the safest providers of cSMT (yes, one factor may be publication bias). This may be because we have the most (best?) training in that area.
7. I have yet to see any professional organization call for a ban of cSMT by their respective members. Heck, PTs include in their clinical guidelines. I do know there is a movement within the osteopathic profession to ban cSMT, at least in the USA, but nothing official so far and it is being met with resistance.
8. There is a difference between causing a stroke and causing a VAD.
9. I strongly support continued research in this area, even to the point of seriously considering being more active in such projects. Believe it or not, we don’t want to hurt people.
10. Current research indicates there may be some benefit to cSMT for some conditions especially when it is part of a multimodal approach. If research ends up showing a negative serious risk:benefit profile for certain conditions or subgroups or overall, I will be in the front lines calling for chiropractors to stop doing cSMT. As of now the risk of serious AE appears to be so rare (in part because we know when not to do it) it’s hard to even research.
I am sure you (or anyone else) can pick and pull something from the above and try to run down some rabbit hole. If folks stick on topic I’ll expand, if not, you all have a good day.
How many people have to be maimed or killed by chiropractors in order to finally stop chiropractors playing doctor?
The sock puppet ‘DC’ is tediously regurgitating special pleading; Blue Wode demonstrated great patience with it here:
https://edzardernst.com/2021/01/adverse-events-from-manual-therapy-are-few-mild-and-transient-best-not-listen-to-chiropractors-claims-about-the-safety-of-their-manipulationss/#comment-129623
special pleading: argument in which the speaker deliberately ignores aspects that are unfavorable to their point of view. (Oxford)
So what am I ignoring?
So the SMT caused a subdural haematoma that kept ssx free for 2 weeks??? Are you for real???
yes, I am reporting a published case report
“ 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.”
“In addition, although MDRs are a valuable source of information, this passive surveillance system has limitations. The incidence, prevalence, or cause of an event cannot be determined from this reporting system alone due to under-reporting of events, inaccuracies in reports, lack of verification that the device caused the reported event, and lack of information about frequency of device use. Because of these limitations, MDRs comprise only one of the FDA’s several important postmarket surveillance data sources.”
https://www.fda.gov/medical-devices/medical-device-safety/medical-device-reporting-mdr-how-report-medical-device-problems
How about MedWatch?
“Suspect product information, on the other hand, showed high levels of incomplete and inaccurate data. Start and end dates of suspect product use had 37% and 23% completion rates, respectively. Dosage level was completed only 31% of the time, and product lot numbers had only a 9% completion rate. More than 25% of the names of reported suspect products were inaccurate, and 31% of suspect product start dates were inaccurate.”
https://pubmed.ncbi.nlm.nih.gov/23011177/
I support an AE reporting system but at best it would do is give a signal (unless one is a pseudo skeptic then it provides proof).
IMO the best and easiest immediate means…add suspected SMT serious AEs to what is already in place and of course acknowledge its limitations.
that’s why I called it “the most basic tool”
Fair enough.
Of course it is best that the MD and DC work together to see if a case is appropriate to be reported as a suspected AE.
The fact it was published does not make it solid.
Please explain how can cx smt cause interhemispheric rupture and even more so how can it remain sub-clinical for 2 weeks and only than increase ICP and give a clinical presentation and ct findings of an acute subdural bleeding???
I understand this must be nice to have a cause to attach to this case but this goes against all clinical reasoning.
I suggest the editors should give this report another thought.
please do suggest it to them – but don’t forget to mention that you are a chiro
A chiro that apparently understands head trauma and don’t look for political gains… but please don’t let me trouble you with MEDICAL FACTS
a chiro who likes to PLAY doctor – so much so that he uses the title without clarification.
Can you argue the point?
I know it upsets you but try and stay professional…
I did not know you had a point – sorry.
You know exactly what the point is… but as always when you can not argue the point you argue the person…
@Dr. Guy Almog
Are you a medical doctor? I notice that you consistently use the title ‘Dr.’, but apparently, you have no real medical education at all.
Please correct me if I’m wrong. but why do you try to make people believe that you are medically trained when you are not?
In the UK, many entertainers who perform the ‘Punch and Judy’ puppet show are traditionally known as ‘Professor’.
Even children know that’s a gag name for fun.
But use of inaccurate titles in healthcare practice can only be in order to take advantake of the vulnerable and gullible. Why else?
Interesting link.
The presentation of “chiropractic” in there does certainly not convey an impression of medical education, or of any kind?
What worries me is the claim that the chiropractor can treat:
“…headaches and dizziness neck. Symptoms such as numbness, pain or tingling in the developing limbs due to pressure on nerves … Pain or tingling, numbness radiated limbs”
These symptoms are all compatible with developing stroke, severe disc herniation and several other very serious conditions that require urgent medical attention.
“ These symptoms are all compatible with developing stroke, severe disc herniation and several other very serious conditions that require urgent medical attention.”
Yes, and they are also compatible for conditions that don’t require urgent medical attention and may respond to conservative care.
So the question is: are chiropractors, in general, able to know the difference?
I recall there was a study that looked at this question. They found, if I recall, chiropractors are the equivalent to PCP to perform a proper diagnosis, at least for the conditions they presented to both groups.
are you sure that your recall is not a bit selective?
From the paper,
That’s an argument from incredulity. It doesn’t mean much.
M. Almog said: “Please explain…”
Believe it or not, SDH may be asymptomatic, found incidentally on imaging obtained for unrelated symptoms.
Even acute SDH may be intially subclinical. Here’s an arbitrary clinical categorisaton:
●Acute SDH presents 1 to 2 days after onset.
●Subacute SDH presents 3 to 14 days after onset.
●Chronic SDH presents 15 or more days after onset.
A short passage from UpToDate explains how SDH may not become clinically symptomatic until a couple weeks after injury:
It all depends on the amount of bleeding and other factors.
It is easy to see how chiropractic manipulation may cause an SDH. Any sudden forceful accellerrating/decelerating movement of the head may rupture the delicate bridging veins (less often arteries) between the Dura and brain. Especially a rotatory force. Predisoposing factors are mainly low intacranial pressure or atrophy of the brain, which both cause tension on the bridging vessels. Defects in connective/vessel tissue development may also predispose to vascular injury. Also antithrombotic medication. When the bleeding is venous, the amount of blood that collects in the subdural space may be limited as a slight increase in IC pressure may be enough to stop the bleeding. If the bleeding is small, it may be practically asymptomatic or subclinical until the blood has broken down and started to cause delayed symptoms by expansion and hygroma formation, that are more likely to be nonfocal.
FWIW he does a fairly decent manipulation here, the second one he does is better. Ideally the head shouldn’t move at all…no head rotation during manipulation.
https://youtu.be/1q70NMsXw2o
the manipulation is done on the rotated neck
Yes. And the VA will slide during the manipulation.
The point is that the manipulation is done with very little/no additional rotation.
We have evidence that VAD occurs with rotation and without manipulation.
Example:
For example, as noted previously by Choi et al,57 golfers tend to have CAD in the posterior rather than in the anterior circulation and predominantly on the right side. The authors suggest that rotational forces on the vertebral arteries that occur during the swing may be responsible for this observation.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6453193/#!po=30.5970
Since manipulation is done when there is lesser strain on the VA compared to normal ROM how likely is it that the act of cSMT will cause a VAD compared to when there is the most strain on the VA?
I recall this case when it first came out. I don’t have access to the full paper but the abstract states that a MRI revealed “neck trauma”. It makes me wonder how much force was applied to the neck for trauma to show up on the MRI. This sounds like someone didn’t know what they were doing.
“Cranial and cervical magnetic resonance imaging revealed findings supportive of intracranial hypotension and neck trauma, respectively.”
SMT=trauma
To show up on a MRI? Now that is a study I would like to see.
EE: SMT=trauma
please point out the evidence of trauma. Thanks.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3756802/figure/F7/?report=objectonly
The authors already did.
Fair enough. It’s behind a paywall. So they must have dated the trauma to the time the SMT was performed.
So what went on here is that this woman’s CSF slowly leaked out, causing a decrease in volume of the CSF – scary thought! – which lowered the pressure of her CSF – which caused blood vessels at the surface of her brain to hemorrhage?