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

Guest post by Catherine de Jong

 

On the 22nd of February 2022, a criminal court in the Netherlands ruled in a case brought by a 33-year-old man who suffered a double-sided vascular dissection of his vertebral arteries during a chiropractic neck manipulation.

What happened?

On the 26th of January 2016, the man visited a chiropractor because he wanted treatment for his headache. The chiropractor treated him with manipulations of his neck. The first treatment was uneventful but apparently not effective. The man went back for a second time. Immediately after the second treatment, the patient felt a tingling sensation that started in his toes and spread all over his body. Then he lost consciousness. He was resuscitated by the chiropractor and transported to a hospital.  Several days later he woke up in the ICU of the university hospital (Free University, now Amsterdam UMC). He was paralyzed and unable to speak. He stayed in the ICU for 5 weeks. After a long stay in a rehabilitation center, he is now at home. He is disabled and incapacitated for life.

Court battles

The professional liability insurance of the chiropractor recognized that the treatment of the chiropractor had caused the disability and paid for damages. The patient was thus able to buy a new wheelchair-adapted house.

Health Inspection investigated the case. They noticed that the chiropractor could not show that there was informed consent for the neck manipulation treatment, but otherwise saw no need for action.

Six days after the accident the man applied to the criminal court. The case was dropped because, according to the judge, proof of guilt beyond reasonable doubt was impossible.

In rare occasions, vertebral artery dissection (VAD) does occur spontaneously in people without trauma or a chiropractor manipulating their neck. The list of causes for VAD show, besides severe trauma to the head and neck (traffic accidents) also chiropractic treatment, and rare connective tissue diseases like Marfan syndrome. A spontaneous dissection is very rare.

It took several attempts to persuade the criminal court to start the case and the investigation into what had happened in the chiropractor’s office. Now the verdict has been given, and it was a disappointing one.

The chiropractor was acquitted. The defense of the chiropractor argued, as expected, that two pre-existent spontaneous dissections might have caused the headache and that, therefore, the manipulation of the neck would have played at most a secondary role.

It is this defense strategy, which is invariably followed in the numerous court cases in the US. Chiropractors in particular give credence to this argumentation.

The defense of the patient was a professor of neurology. He considered a causal link between manipulation to the neck and the double-sided VAD to be proven.

In the judgment, the judge refers 14 times to the ‘professional standard’ of the Dutch Chiropractors Association, apparently without realizing that this professional standard was devised by the chiropractors themselves and that it differs considerably from the guidelines of neurologists or orthopedics. In 2016, the Dutch Health Inspection disallowed neck manipulation, but chiropractors do not care.

The verdict of the judge can be found here: ECLI:EN:RBNHO:2022:1401

Chiropractic is a profession that is not recognized in the Netherlands. Enough has been written (also on this website) about the strange belief of chiropractors that a wrong position of the vertebrae (“subluxations”) is responsible for 95% of all health problems and that detecting and correcting them can relieve symptoms and improve overall health. There is no scientific evidence that chiropractic subluxations exist or that their alleged “detection” or “correction” provides any health benefit. In the Netherlands, there are about 300 practicing chiropractors. Most are educated in the UK or the USA. The training that those chiropractors receive is not recognized in the Netherlands.

Most chiropractic treatments do little harm, but that does not apply to neck manipulation. When manipulating the neck, the outstretched head is subjected to powerful stretches and rotations. This treatment can in rare cases cause damage to the arteries, which carry blood to the brain. In this case, a double-sided cervical arterial dissection can lead to strokes and cerebral infarctions. How often this occurs (where is the central complication registration of chiropractors?) is unknown, but given that the effectiveness of this treatment has never been demonstrated and that therefore its risk/benefit ratio is negative, any complication is unacceptable.

How big is the chance that a 33-year-old man walks into a chiropractor’s office with a headache and comes out with a SPONTANEOUS double-sided vertebral artery dissection that leaves him wheelchair-bound and invalid for the rest of his life? I hope some clever statisticians will tell me.

PS

Most newspaper reports of this case are in Dutch, but here is one in English

42 Responses to Double-sided vertebral artery dissection in a 33-year-old man. The chiropractor is not guilty?

  • Back to my old question:

    If they wanted to care for patients with headaches or pains in the neck/neurology, why did these folks become chiropractors and not doctors?

    Any informed consent form must state clearly that chiropractic is founded on an unevidenced belief and that orthodox medical and scientific opinion has not identified any benefit from ‘adjustment’, nor any structure that needs ‘adjustment.’

    Patients are being taken advantage of otherwise.

    • “ orthodox medical and scientific opinion ”

      Opinion?

      “ SMT alone or in combination with other modalities was effective for patients with acute neck pain. ” J Clin Med. 2021 Oct 28;10(21):5011.
      doi: 10.3390/jcm10215011.

      “ The combination of SMT and exercise may provide one of the best approaches for the management of NP.” Front. Pain Res., 25 October 2021 | https://doi.org/10.3389/fpain.2021.765921

      “ Studies published since January 2000 provide low-moderate quality evidence that various types of manipulation and/or mobilization will reduce pain and improve function for chronic nonspecific neck pain compared to other interventions.” Pain Physician 2019; 22:E55-E70 • ISSN 2150-1149

      “ There was moderate level evidence to support the immediate effectiveness of cervical spine manipulation in treating people with cervical radiculopathy.” Clin Rehabil. 2016 Feb.

      • A heavy deployment of fishing and quote mining.

        Following the above quote from Ref 1 is:
        “However, due to the large heterogeneity of the included RCTs, small sample sizes, lack of blinding, and unanswered placebo effects, future more robust RCTs are required for firm conclusions.”

        Ref 2 [https://doi.org/10.3389/fpain.2021.765921] also states:
        “Due to the low quality of evidence, the efficacy of SMT compared with a placebo or no treatment remains uncertain.”
        “Overall, the current body of literature provides stronger support for thoracic rather than cervical SMT for the treatment of NP”

        Ref 4:
        Does cervical spine manipulation reduce pain in people with degenerative cervical radiculopathy? A systematic review of the evidence, and a meta‑analysis

        Liguo Zhu ¹, Xu Wei  ², Shangquan Wang ³
        Affiliations
        1. Department of Spine, Wangjing Hospital, Beijing, People’s Republic of China.
        2. Department of Scientific Research, Wangjing Hospital, Beijing, People’s Republic of China.
        3. Department of General Orthopedics, Wangjing Hospital, Beijing, People’s Republic of China.

        Data sources:
        PubMed, the Cochrane Central Registry of Controlled Trials (CENTRAL) in the Cochrane Library, EMBASE, Chinese Biomedical Literature Database (CBM), Chinese National Knowledge Infrastructure (CNKI), Chinese Scientific Journal Database (VIP), Wanfang data, the website of Chinese clinical trial registry and international clinical trial registry by US National Institutes of Health.

        DOI: 10.1177/0269215515570382

    • Admission to Medical School is highly competitive and not everyone who wants to help patients can attend. I doubt that all such candidates understand the vast difference between alternatives such as dentists, podiatrists and opticians versus Chiropractors and naturopaths.

      • “Highly competitive…” for a good reason.

        It’s called “setting standards”.

        But why do folks who cannot (for whatever reason) train to be doctors, not take up nursing or physiotherapy?
        Surely ‘Chiropractic’ does not advertise its colleges as “For those who are not up to doing medicine”?
        On the contrary, they claim to be offering training in a field that is more beneficial to patients than ‘orthodox medicine’.
        But where does that idea come from, and, in the 21st centuary, remain?
        Has their disclipine not moved on from Palmer’s concepts -based on A.T. Still’s, and Paul Caster’s bone setting before then?
        ‘Medicine’ is constantly ‘moving on’.
        Are chiropractors reverting to faith healing?
        Sigh.

        But we should not make ‘chiropractic’ illegal any more than any other faith.
        We should identify it for what it is.
        Thank you Professr Ernst for helping here.

        • To be honest chiropractic has just basically admitted that its colleges are for those who can’t get into med school.

        • But why do folks who cannot (for whatever reason) train to be doctors, not take up nursing or physiotherapy?
          Surely ‘Chiropractic’ does not advertise its colleges as “For those who are not up to doing medicine”?

          To find out about their motivations, you can look to people who once were alt practitioners, like Britt Hermes. The book The Adventures of Holistic Harry is a novelized version of the experiences of an MD, formerly of an alternative flavor. He describes well the disillusion from being a true believer, and the temptations of continuing as a conscious quack bc it’s easier to make money that way. Also, it’s a good description of other alt-med practitioners: a spectrum of believers and conscious quacks.

  • What a terrible thing to happen.
    The only way to stop this happening is to make chiropractic illegal.

  • “ He considered a causal link between manipulation to the neck and the double-sided VAD to be proven.”

    Apparently he was wrong.

  • Is the defence regarding the “dissection already taking place” non justifiable? Was it likely not the cause of the persisting head/neck pain?

    • The temporal association is hard to ignore but is not enough to infer causality.
      The author seems to dismiss it as merely an argument of the chiropractor’s defense. Apparently, she isn’t aware of numerous papers by medical neurologists who agree with you.
      “There is an association between manual adjustment and VAD but no causative relationship has been established. It is more likely that pain from VAD leads to neck manipulation than that neck manipulation leads to VAD.” Harold, P., & Robert, H. (2020). Commentary on: A risk–benefit assessment strategy to exclude cervical artery dissection in spinal manual therapy: a comprehensive review. Annals of Medicine, 0(0), 1–2. http://doi.org/10.1080/07853890.2019.1639807

      • case reports are never enough!
        the best approach is to consider the totality of the available evidence. By doing this, one cannot exclude the possibility that spinal manipulations cause serious adverse effects. If that is so, we must abide by the precautionary principle which tells us to use other treatments that seem safer and at least as effective.

        • Hmmm, let’s change that a bit…

          The best approach is to consider the totality of the available evidence. By doing this, one cannot exclude the possibility that NSAIDs and opioids cause serious adverse effects. If that is so, we must abide by the precautionary principle which tells us to use other treatments that seem safer and at least as effective.

          So based upon the totality of the available evidence, which is safer and at least as effective: cervical spinal manipulation vs NSAIDs/opioids?

          • almost correct!
            but very daft because there are less risky treatments than either opioids or SMT (and the addition of NSAIDs here is based on very poor data: https://edzardernst.com/2019/01/are-cervical-manipulations-for-neck-pain-truly-much-safer-than-the-use-of-nsaids/)
            so for people a bit slow on the uptake, let me put it this way:
            the best approach is to consider the totality of the available evidence. By doing this, one cannot exclude the possibility that spinal manipulations cause serious adverse effects. If that is so, we must abide by the precautionary principle which tells us to use other treatments that seem safer and at least as effective such as physiotherapeutic exercise therapy.

          • “the best approach is to consider the totality of the available evidence.”

            so when choosing between NSAIDs and spinal manipulation, which is safer based upon the totality of the available evidence?

            “The risk of heart attack or stroke can occur as early as the first weeks of using an NSAID.

            NSAIDs can increase the risk of heart attack or stroke in patients with or without heart disease or risk factors for heart disease.

            There is an increased risk of heart failure with NSAID use.”

            https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-fda-strengthens-warning-non-aspirin-nonsteroidal-anti-inflammatory

          • I am not discussing here the choice between NSAIDs and spinal manipulation
            you are just distracting from:
            the best approach is to consider the totality of the available evidence. By doing this, one cannot exclude the possibility that spinal manipulations cause serious adverse effects. If that is so, we must abide by the precautionary principle which tells us to use other treatments that seem safer and at least as effective such as physiotherapeutic exercise therapy.

          • I am thinking like a someone who cares for patients. But I can understand why you don’t want to answer the question.

          • you can’t understand a lot, it seems to me.

          • True. I don’t understand

            How MDs can claim cSMT causes a VAD when they don’t know if the VAD was pre-existing or not.

            Why MDs claim this happens a lot and they “see it all the time” but prospective studies can’t even find enough cases to run a proper analysis.

            Why, when MDs claim we are harming so many people, that when we attempt to do research on it, many MDs won’t even agree to participate.

            Why, if we are ruining so many lives, that my malpractice premiums are less than my utility bill.

          • How MDs can claim cSMT causes a VAD when they don’t know if the VAD was pre-existing or not.

            Why MDs claim this happens a lot and they “see it all the time” but prospective studies can’t even find enough cases to run a proper analysis.
            NOT TRUE

            Why, when MDs claim we are harming so many people, that when we attempt to do research on it, many MDs won’t even agree to participate.
            UNWARRANTED GENERALISATION

            Why, if we are ruining so many lives, that my malpractice premiums are less than my utility bill.
            NOT TRUE

          • How MDs can claim cSMT causes a VAD when they don’t know if the VAD was pre-existing or not.

            No response

            Why MDs claim this happens a lot and they “see it all the time” but prospective studies can’t even find enough cases to run a proper analysis.
            NOT TRUE

            “Recruitment took 3 years, due to the relative low occurrence of CAD cases, at which point the study was halted….the desired sample size was not met.”

            JOSPT 2015 45:7 503

            Why, when MDs claim we are harming so many people, that when we attempt to do research on it, many MDs won’t even agree to participate.
            UNWARRANTED GENERALISATION

            I hope so but not according to the researchers I have talked to.

            Why, if we are ruining so many lives, that my malpractice premiums are less than my utility bill.
            NOT TRUE

            Oh, you know my premiums and utility bill?

          • It’s your choice, ‘DC’, to be anonymous on this website and to use various pseudonyms, but doing so renders unverifiable all unevidenced statements that you make. Your personal statements have the same level of authority and credibility as a that of a nymshifting Internet troll: none; zero: nada.

            With everything that you have written, it is prudent for the readers to apply Hitchens’s epistemological razor:

            That which can be asserted without evidence can also be dismissed without evidence.”
            — Christopher Hitchens.

          • DC you comment that MDs will not participate into research into spinal manipulation.
            Usually when people will not participate in research it is because the research or the thing being researched is so dangerous that it shouldn’t be researched at all

          • John. It depends on the design of the study. Looking at cases that come thru a trauma center is a worthy and an acceptable study.

            Why wouldn’t a MD want to participate in such a study if the general thought is that cSMT is causing many of these VADs?

            Perhaps a ER doctor or two who follow this blog and can give some insight?

        • “case reports are never enough!”
          I’m not sure who brought up case reports, but since I agree, should we dismiss the one presented in this post?

          “the best approach is to consider the totality of the available evidence.”
          Agreed. Although, from what I can tell, the totality of available evidence on VAD risk that you present here consists almost exclusively of case reports. Have you discussed the research looking at biomechanical plausibility? Have you commented on the systematic reviews beyond than dismissing them out of hand? Do you acknowledge the neurosurgeons whose conclusion from the evidence differ from yours?

          “By doing this, one cannot exclude the possibility that spinal manipulations cause serious adverse effects.”
          Agreed. There is a possibility.

          “If that is so, we must abide by the precautionary principle which tells us to use other treatments that seem safer and at least as effective.”
          Ddisagree. This statement strikes me as an opinion based on absolutism rather than a rational conclusion. Where else in medicine does the mere presence of a possible serious adverse effect immediately lead to avoiding a treatment? Are there no safer alternatives to NSAIDs? (http://doi.org/10.1016/j.amjmed.2017.06.028) Are there no safer alternatives to spinal cord stimulators? (http://doi.org/10.1097/PTS.0000000000000971) How about the common orthopedic procedures with little evidence of effectiveness but a non-zero risk of serious harm? (http://doi.org/10.1136/bmj.n1511) I applaud the intent behind the precautionary principle and think it is an ideal to aspire to. While it “does play a role in health care, […] it should never rule medical decision making as an absolute principle.” (http://doi.org/10.1016/j.taap.2004.11.032)

  • Intriguing and unnerving how many cases I have seen and examined that describe the symptoms appearing immediately after or shortly following a repeat cervical manipulation. The obvious inference from this would be that intimal injury takes place and coagulation happens, which is then dislodged on the second manipulation to cause stroke.
    The fact that the symptoms of a preexisting cervical artery lesion are quite unspecific and they cannot be ruled out, should lead to the conclusion that cervical manipulation is contraindicated in the presence of symptoms from the head and neck areas.

    Also. How many cases are never discovered because the delayed stroke event happened while driving home after manipulation?

    If cervical manipulation was a drug, would it not be under serious surveillance or even already taken off the market because of an alarming accumulation of extremely serious albeit rare adverse events discovered by ongoing post-marketing surveillance?

  • Bjorn
    “Also. How many cases are never discovered because the delayed stroke event happened while driving home after manipulation? If cervical manipulation was a drug, would it not be under serious surveillance or even already taken off the market because of an alarming accumulation of extremely serious albeit rare adverse events discovered by ongoing post-marketing surveillance?”

    ERr… ummm
    Would this example be similar to the phenomenon that patients experience after taking a vaccine jab, but later are told that the reaction is not due to the jab because correlation is not causation ?

    I think so
    Nothin to see here, move along.

    NO WAIT ! IT’S a DOUBLE STANDARD !

    • Would this example be similar to the phenomenon that patients experience after taking a vaccine jab, but later are told that the reaction is not due to the jab because correlation is not causation ?

      First, the assumption that what they experience is due to the vaccine is an example of the post hoc ergo propter hoc fallacy, not because “correlation is not causation”.
      But also, more work has to be done in order to establish causation than simply noticing that there have been many people who’ve had a stroke shortly after a chiropractor manipulates their neck.
      This does give rise to a *suspicion* of causation, which has to be investigated.
      In the case of vaccines, many suspicions of causation have been intensively investigated and found to be false – i.e. the vaccine wasn’t causing the harm.
      The Johnson & Johnson Covid vaccine *was* temporarily halted because there was a suspicion, but no proof, that it might, very rarely, cause blood clots.
      So no, it doesn’t look like a double standard. Regulators are very cautious about the safety of vaccines that are given to billions of people.

      • @Laura

        lol….
        You folks remind me too much of the hypocrisy of the political tyrants… “rules for thee, but not for me”

        • That has no logical content, just an insult. I explained to you the problems with your reasoning.

          • And why post comments like this? There are a lot of such comments on this site, from the skeptics as well as the true believers in something or other. They detract from the discussion, and don’t add anything useful.

    • @ concerned patient

      Would this example be similar to the phenomenon that patients experience after taking a vaccine jab, but later are told that the reaction is not due to the jab because correlation is not causation ?

      After taking the jab and walking out of the doctor’s office, I hit my head on the door and that caused bad bruising. At first, I thought the vaccine caused me to bump my head on the door with one potential explanation being that I was being briefly controlled by someone via the 5G chip in the vaccine jab I just took, I did some brief internet searches and confirmed that to be the case. I immediately talked to the doctor and was told that “correlation is not causation” and that there are no 5G chips in the vaccine and that I was just a clumsy idiot. I was told to go home and ice my head and forget about it. I did ice my head but did not forget about it. I did more research on the topic and found several people online that had similar experiences where they got clumsy and fell or hit something after taking the jab. We shared our experience via a FB group, and we all decided that the jab is to be blamed for our troubles. Now that I have the 5G chip in my body I had no way of removing it. I designed a special tinfoil hat that blocks the 5G signal and started wearing it. As soon as I put my tinfoil hat on, I started feeling better and regained complete control of myself. My story is proof that vaccines contain 5G chips and that we are being controlled remotely like cattle under the guise of pandemic. Why am I telling you this? Because I want you to know what is happening to people after getting the jab and that you should be concerned about the shenanigans of big pharma. We need more people like you questioning the motivations behind vaccines and other life saving drugs that big pharma produces. Finally, if you think hard enough and do your “research”, most often than not “correlation leads to causation”.

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