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

Vertebral artery dissection is an uncommon, but potentially fatal, vascular event. This case aimed to describe the pathogenesis and clinical presentation of vertebral artery dissection in a term pregnant patient. Moreover, the authors focused on the differential diagnosis, reviewing the available evidence.

A 39-year-old Caucasian woman presented at 38 + 4 weeks of gestation with a short-term history of vertigo, nausea, and vomiting. Symptoms appeared a few days after cervical spine manipulation by an osteopathic specialist. Urgent magnetic resonance imaging of the head was obtained and revealed an ischemic lesion of the right posterolateral portion of the brain bulb. A subsequent computed tomography angiographic scan of the head and neck showed a right vertebral artery dissection. Based on the correlation of the neurological manifestations and imaging findings, a diagnosis of vertebral artery dissection was established. The patient started low-dose acetylsalicylic acid and prophylactic enoxaparin following an urgent cesarean section.

Fig. 1

Right vertebral artery dissection with ischemia in the posterolateral medulla oblongata. In DWI (a) and ADC map (b) the arrow shows a punctate, shiny ischemic lesion, with typical reduction of ADC in the right posterolateral medulla oblongata. c and d CT angiography (axial and 3D reformat, c and d, respectively) showing a focal dissection of the V2 distal segment of the right vertebral artery, with the arrow in figure c pointing to the dissection. e MRI angiography (time of flight, TOF) showing the absence of visualization of right PICA.

The authors concluded that vertebral artery dissection is a rare but potential cause of neurologic impairments in pregnancy and during the postpartum period. It should be considered in the differential diagnosis for women who present with headache and/or vertigo. Women with a history of migraines, hypertension, or autoimmune disorders in pregnancy are at higher risk, as well as following cervical spine manipulations. Prompt diagnosis and management of vertebral artery dissection are essential to ensure favorable outcomes.

In the discussion section, the authors point out that the incidence of VAD in pregnancy is twice as common as in the rest of the female population. They also mention that a review of the literature regarding adverse effects of spinal manipulation in the pregnant and postpartum periods identified adverse events in five pregnant women and two postpartum women. The authors also include a table that summarizes all cases of VAD reported both prior and after delivery, with 24 cases distributed with a prevalence during the postpartum period (19 of the 24 cases). The clinical presentation of these cases is varied, with a higher frequency of headaches, vertigo, and diplopia, and the risk factors most represented are hypertension and migraines.

The authors finish with this advice: practitioners who do spinal manipulations should be aware of the possible complications of neck manipulation in pregnancy and the postpartum period, particularly in mothers with underlying medical disorders that may predispose to vessel fragility and VAD.

I would add advice of a different nature: consumers should always question whether the risks of any intervention outweigh its benefit. In the case of neck manipulations, the answer is not positive.

44 Responses to Vertebral artery dissection in a pregnant woman after cervical spine manipulation

  • “Another possible condition that can lead to VAD is cervical spine manipulation [4].”

    Not according to that case study. She presented with an “an unusual acute occipital headache” and neck pain. History of migraines and a smoker. Most likely the VAD was in progress.

    The pregnancy case didn’t even give the history of why she presented to the osteopath. Another poorly written case study to use if one is suggesting causation.

    • serious question:
      do you know of a case report of VAD after SMT that is in your estimation sound?
      if so, please provide a link.

      • Most case reports fail on one of two criteria, sometimes both.

        1. No clear record of why the patient sought chiropractic care (symptoms that may indicate a VAD in progress or not)

        2. Eliminating any other possible causes of the VAD especially in the week prior to SMT.

        I would have to search but I recall a case report of a woman presenting for maintenance care (no head or neck symptoms at the time) and after cSMT was dx with a VAD. Asymptomatic VADs are very rare thus there is a high probability that cSMT induced the VAD in that case, IMO.

        Although not published I had a dialogue with a MD where a patient underwent a MRI, had cSMT the next day and developed new symptoms thus another MRI was shortly done and was dx with a VAD. I encouraged her to publish the case but apparently she did not.

        There was a paper published that looked at the quality of these case reports, most are poor.

        • you are not saying that ALL case reports are flimsy, are you?
          this would look as though you have a slight bias against case reports not supporting your stance.

          • My stance?

            “This study has demonstrated that the literature infrequently reports useful data toward understanding the association between cSMT, CADs and stroke.”

            https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3604043/

          • and you have demonstrated again and again that you are in denial about the risks of SMT.

          • Denial? You seem confused between denial and the criteria required to claim causation.

            It’s broken down as such by the WHO based upon criteria:

            Certain
            Probable
            Possible
            Unlikely
            Unclassified
            Unclassifiable

            It’s not my fault case report authors (usually MDs) struggle to produce a high quality case report.

            Oh, and can you produce even once that I am in “denial about the risks of SMT.”?

            Denial: a statement that something is not true or does not exist: (Cambridge)

            Heck, I just stated “…thus there is a high probability that cSMT induced the VAD in that case…”

          • “It’s not my fault case report authors (usually MDs) struggle to produce a high quality case report.”
            show me one that you think is of high quality

          • Best one? IDK, I haven’t organized them from best to worst and I don’t have the time to do so.

            Regardless, I did find this latest one of interest due to its uniqueness.

            https://link.springer.com/article/10.1007/s00415-022-10964-9

          • “best one”
            your invention?

    • If you’re seriously suggesting that the dissection was the reason the poor woman sought chiropractic help, that really doesn’t absolve anyone of responsibility for trying to breaths life-.threatening vascular disorder with an inappropriate & dangerous manipulation.

      • Different problem requiring a different solution.

        • ‘DC’ wrote “Different problem requiring a different solution.”

          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.

          • Different discussion. Try to stay on topic.

          • Just name the actual medical conditions that require as a solution a cervical spine manipulation by a chiropractor. I’m sure it would be a difficult question to answer for those who promote quackery; for those who pretend to know things they don’t know; for those who aren’t even qualified to lance a boil. It really isn’t a difficult question to answer by those who really do know what they are talking about.

            I’d be more than happy to ask you each time you mention cervical spine manipulation or cSMT.

          • And I am happy to ignore you when you drift off of topic.

          • ‘DC’ wrote “And I am happy to ignore you when you drift off of topic.”

            You have thus far written 15 of the 30 comments. You seem unable to ignore anyone. Your predictable knee-jerk responses bring to mind respondent conditioning 🛎

    • So if it was a VAD in progress that sent the patient to the chiropractor……why in the world would the chiro make the condition worse by performing a cervical manipulation? Is it just possible that chiropractors have no scientific method to determine if it is a VAD in progress that sends the patient to the chiropractor?

      • Who says chiropractors don’t have the means?

        • They do not have the means….chiropractic offices are not equipped with the diagnostic equipment found in hospitals that enable medical doctors, neurologists and radiologists to diagnosis an arterial dissection.

          • chiropractic offices are not equipped with the diagnostic equipment found in hospitals that enable medical doctors, neurologists and radiologists to diagnosis an arterial dissection.

            Would an osteopath outside a hospital be able to diagnose a VAD? Or better able than a chiropractor?

          • in the US, osteopaths are fully trained doctors; everywhere else not.

          • Means: a method or way of doing something (Cambridge).

            If your point is that chiropractors can’t do a MRA on site, well, neither can my local medical clinics.

            Your point is silly.

      • One would think that chiropractors wouldn’t do neck manipulation if someone’s symptoms even vaguely suggested VAD, because of the suggested risk of causing VAD with neck manipulation. In that case, VAD after seeing a chiropractor would be *less* likely than chance – not more likely, if neck manipulation doesn’t increase the risk of VAD.

  • It seems like the risk of causing VAD by neck manipulation, or making an already existing VAD more dangerous could be quantified by using Bayes theorem – i.e. how many cases of VAD that were preceded by neck manipulation would be expected if neck manipulation doesn’t cause it, vs. how many such cases are actually seen.

    • Cassidy attempted to look at this with a different approach. Granted some issues with the study.

      https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2271108/

        • As I stated, the Cassidy project had issues. But it did attempt to look at this at a different angle which is what I think Laura was alluding to.

          • not that you like research ‘with issues’ as long as it fits your biases!

          • Sigh. This is the only mention of cSMT in the case:

            “After a detailed medical history, the patient stated for the first time that she had undergone cervical spine manipulations by an osteopathic specialist in the days preceding the beginning of the symptoms.”

            No mention of why she sought care from the osteopath and what, if any events, prior to or after the manipulation that may have caused the VAD. Did she do yoga, paint a ceiling, cough, vomit, sneeze, see a dentist, have her hair done, etc.?

            Or do you just assume that because cSMT was mentioned that IT caused the VAD because it fits YOUR bias?

            “To establish causality you must have the following three things.

            Temporal sequencing — X must come before Y

            Non-spurious relationship — The relationship between X and Y cannot occur by chance alone

            Eliminate alternate causes — There are no other intervening or unaccounted for variable that is responsible for the relationship between X and Y.”

            https://info.umkc.edu/drbanderson/establishing-causality/

            A poorly written case study if one wishes to use it as evidence of causality.

          • ‘DC’ had a lame attempt at defining “cause”.

            QUOTE from Wikipedia Causality [my formatting]
            J. L. Mackie argues that usual talk of “cause” in fact refers to INUS conditions (insufficient but non-redundant parts of a condition which is itself unnecessary but sufficient for the occurrence of the effect).[21]

            An example is a short circuit as a cause for a house burning down. Consider the collection of events: the short circuit, the proximity of flammable material, and the absence of firefighters. Together these are unnecessary but sufficient to the house’s burning down (since many other collections of events certainly could have led to the house burning down, for example shooting the house with a flamethrower in the presence of oxygen and so forth). Within this collection, the short circuit is an insufficient (since the short circuit by itself would not have caused the fire) but non-redundant (because the fire would not have happened without it, everything else being equal) part of a condition which is itself unnecessary but sufficient for the occurrence of the effect.

            So, the short circuit is an INUS condition for the occurrence of the house burning down.
            END of QUOTE

  • Also, one could look at areas of the world where cervical spine manipulation is more or less frequently done, and look at the incidence of VAD. From this, one could estimate the risk that CSM will cause a VAD.
    Has something like this been done?

  • DC you made my point very well. It is difficult and requires specific expertise and very expensive diagnostic tools not found in a doctors office to diagnosis an arterial dissection in progress. That is why, when a patient presents with head and neck pain, it is too dangerous to perform a cervical manipulation. The risk of making the dissection worse or causing a dissection far outweighs any benefits. Thank you.

    • You do know that the greatest strain on the VA occurs within normal range of motion? Should MDs put everyone with neck pain in a cervical collar until they can do a MRA?

      You do know the incidence of VAD?

      “ The annual incidence of spontaneous carotid artery dissection is 2.5 to 3 per 100,000, while the annual incidence of spontaneous vertebral artery dissection is 1 to 1.5 per 100,000. Traumatic dissection occurs in approximately 1% of all patients with blunt injury mechanisms, and is frequently initially unrecognized.”

      https://pubmed.ncbi.nlm.nih.gov/18574926/

      “ Population-based studies have reported the incidence of dissection as ranging from 2.6 to 2.9 cases per 100,000 per year.23 The true incidence of cervicocerebral arterial dissection is likely higher than these estimates, however, because asymptomatic patients and patients with pain but no neurologic symptoms are underdiagnosed.”

      https://www.sciencedirect.com/book/9780443066009/stroke

      Now consider that around 10% of those case might see a chiropractor. Do the math. Rare to see a rare.

      A proper history and exam could suggest many/most of them. Example:

      https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4654207/

      Note in that case the ER dismissed her even though they had the means to dx it.

      “ We found that ≈1 in 30 dissection patients was probably misdiagnosed in the 2 weeks before their diagnosis.”

      https://www.ahajournals.org/doi/full/10.1161/STROKEAHA.120.029390

  • Yikes! From the 2003 study Sudden neck movement and cervical artery dissection

    Stroke resulting from neck manipulation occurred in 28% (21/74) of our cases [of cervical artery dissection]. Neck manipulation as a therapeutic strategy for head and neck pain is common and may be effective. In a recent literature review a chiropractic group in the United States estimated that 6% of patients with headache consulted alternative health care providers (mostly chiropractors) following the failure of conventional medical treatment. However, neck manipulation should probably be avoided in patients with recent acute neck pain, especially if it follows closely upon an accidental injury, because a fragile clot formed over an otherwise asymptomatic arterial tear is easily dislodged by abrupt head movement, especially rotation. Most patients undergoing therapeutic neck manipulation will have no ill effects, but there is no doubt that chiropractic neck manipulation can result in dissection of the carotid or vertebral arteries leading to stroke. Until a high-risk group can be identified, chiropractors should inform all patients of possible serious complications before neck manipulation.

    Maybe chiropractors have cleaned up their act since then, maybe not.

  • There should be mandatory reporting of VADs serious enough to land the person in the hospital, along with a history of what might have caused it, similarly to the mandatory reporting of some infectious diseases, and child abuse.
    It’s unacceptable to have chiros and osteopaths highly suspected of killing people occasionally, and not to have accurate statistics on how often that happens, because the people suspected often don’t monitor for adverse events after their treatments.

    • It’s being worked on. The main issue seems to be to getting the MDs on board as they are part of the process.

      FYI. Mandatory reporting is not within the dental, physical therapy or optometry professions either, at least in the USA. It was an act of Congress in the USA that forced the required adverse reporting system in the medical profession. Even that system has issues.

      • I will bet money that “being worked on” equates to them trying to come up with a reporting system that won’t show them to be deadly quacks.

        In the mean time there should be an absolute moratorium on the practice, because (a) there is no credible independent evidence of benefit, (b) there is non-trivial evidence of serious harm, and (c) there is no evidence that chiropractors accept either of the above, sufficiently to obtain proper informed consent.

        Which is kind of ironic, when you think there are chiropractors demanding “informed consent” for vaccines that incorporates long refuted anti-vaccination propaganda.

        • Guy: In the mean time there should be an absolute moratorium on the practice

          Is this even feasible? Who would enact and enforce it since it covers 4 professions?

  • A treatment that has no robustly established benefit (and frankly no benefit at all argued by anyone other than those selling it), which can cause stroke and potentially death, would, in any reality-based branch of practice, be stopped immediately.

    The problem for all forms of SCAM is that they studiously avoid any research that raises the possibility of refutation, because it’s a quasi-religious practice, not a scientific one. If you tell a patient that X will make them feel better, and they spend money on X, then of course they are going to tell you that X made them feel better – and that is the *best* chiropractors can do here.

    • Guy: A treatment that has no robustly established benefit (and frankly no benefit at all argued by anyone other than those selling it), which can cause stroke and potentially death, would, in any reality-based branch of practice, be stopped immediately.

      Robust established benefit, that is interesting considering:

      “In a primary care-oriented medical reference, 18% of recommendations were based on consistent, high-quality patient-oriented evidence (Strength of Recommendations Taxonomy (SORT) A), while approximately half were based on expert opinion, usual care or disease-oriented evidence (SORT C).” BMJ Evidence-Based Medicine 2017;22:88-92.

      “In this systematic review of 51 current guideline documents that included 6329 recommendations, 8.5% of recommendations in ACC/AHA guidelines and 14.3% of recommendations in ESC guidelines were classified as level of evidence A (supported by evidence from multiple RCTs), compared with 11.5% of recommendations in a systematic review of ACC/AHA guidelines conducted in 2009.” JAMA. 2019;321(11):1069–1080. doi:10.1001/jama.2019.1122

Leave a Reply

Your email address will not be published.

This site uses Akismet to reduce spam. Learn how your comment data is processed.

Subscribe to new posts

Enter your email address to subscribe to this blog and receive notifications of new posts by email.

Recent Comments

Note that comments can be edited for up to five minutes after they are first submitted but you must tick the box: “Save my name, email, and website in this browser for the next time I comment.”

The most recent comments from all posts can be seen here.

Archives
Categories