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

Reports of serious complications of chiropractic manipulation keep on coming. Take this one, for instance:

My daughter went for a routine chiropractor appointment. Now she’s paralysed – 1:20 000 chiropractic neck manipulations result in stroke from vertebral artery dissection.

Or take a recent article by US neurosurgeons:

Cranio-cervical artery dissection (CeAD) is a common cause of cerebrovascular events in young subjects with no clear treatment strategy established. This study evaluated the incidence of major adverse cardiovascular events (MACE) in CeAD patients treated with and without stent placement. COMParative effectiveness of treatment options in cervical Artery diSSection (COMPASS) is a single high-volume center observational, retrospective longitudinal registry that enrolled consecutive CeAD patients over a 2-year period. Patients were ≥ 18 years of age with confirmed extra- or intracranial CeAD on imaging. Enrolled participants were followed for 1 year evaluating MACE as the primary endpoint.

One-hundred ten patients were enrolled (age 53 ± 15.9, 56% Caucasian, and 50% male, BMI 28.9 ± 9.2). Grade I, II, III, and IV blunt vascular injury was noted in 16%, 33%, 19%, and 32%, respectively. Predisposing factors were noted in the majority (78%), including

  • sneezing,
  • carrying a heavy load,
  • chiropractic manipulation.

Stent was placed in 10 (10%) subjects (extracranial carotid n = 9; intracranial carotid n = 1; extracranial vertebral n = 1) at the physician’s discretion along with medical management. Reasons for stent placement were early development of high-grade stenosis or expanding pseudoaneurysm. Stented patients experienced no procedural or in-hospital complications and no MACE between discharge and 1 year follow up. CeAD patients treated with medical management only had 14% MACE at 1 year.

The authors concluded that in this single high-volume center cohort of CeAD patients, stenting was found to be beneficial, particularly with development of high-grade stenosis or expanding pseudoaneurysm. These results warrant confirmation by a randomized clinical trial.

Yes, I know: this study was not meant to investigate the link between chiropractic manipulations and CeAD. The finding that chiropractic manipulation is a predisposing factor for CeAD is entirely incidental. But it is an important finding nevertheless.

Chiropractors will laugh about the notion that manipulation is a risk factor akin to sneezing and thus try to trivialize the danger of their treatments. I would then point out that sneezing is unavoidable and fulfills a purpose. Chiropractic manipulations do neither.

13 Responses to Chiropractic spinal manipulation is a risk factor for cranio-cervical artery dissection

  • But chiropractic manipulations do ‘adjust’ vertebrae which are subluxed (in the imagination of the chiropractor) and do release ‘innate’ (whatever that is) – so that’s something.

    A risk/benefit analysis must be carried out and understood by all intending patients and fully informed consent obtained by all attending chiropractors.

    Good luck.

  • 1. One can’t comment much on the case of the unfortunate incident with this young gal until more details come forth. However I do question how a properly performed traditional cSMT can cause a quadruple dissection in a healthy individual. I suspect an underlying genetic condition and nonspecific manipulation.

    2 The use of 1/20,000 causing strokes is misleading and wrong . The author who first used that ratio, Vickers in 1999, actually wrote that serious AE due to cSMT could be 1/20,000 up to 1/1 million. It was Schievink in the NEJM who referenced Vickers and stated the 1/20,000 caused strokes. Neither author provided any specific references to studies to support their statements making it merely opinions.

    3. Regarding the paper in Catheter Cardiovasc chiropractic manipulation was only mentioned twice. Once in the abstract and once in the introduction. Strange spinal manipulation wasn’t mentioned in the results section of the paper, as well as other possible predisposed factors, yet they were listed in the abstract with a percentage.

    4. Your claim that cSMT doesn’t fulfill a purpose. Well, that’s been discussed and referenced in the past. One simply has to read the several MA and SR on the topic.

    • “The use of 1/20,000 causing strokes is misleading and wrong”
      True! As there is no surveillance system, nobody knows – in fact, it could be worse that that.

      • Worse than 1/20,000? That would mean that SMT is associated with around 50 strokes a week in the USA. If most/all of those are due to VAD that would mean cSMT is associated with around 40% of all VADs.

        Yet it appears to be so rare that it is difficult to research and the research that has been done does not support those numbers. One paper concluded that a chiropractor would have to be in practice for an average of 1430 years before even being aware of a VAD event.

        “The likelihood that a chiropractor will be made aware of an arterial dissection following cervical manipulation is approximately 1:8.06 million office visits, 1:5.85 million cervical manipulations, 1:1430 chiropractic practice years and 1:48 chiropractic practice careers.”

        https://www.ncbi.nlm.nih.gov/pmc/articles/PMC81498/#:~:text=The%20likelihood%20that%20a%20chiropractor,1%3A48%20chiropractic%20practice%20careers.

        The current evidence doesn’t support 1/20,000 or more. Most authors put it around 1/1 million.

        • “Worse than 1/20,000? That would mean that SMT is associated with around 50 strokes a week in the USA. If most/all of those are due to VAD that would mean cSMT is associated with around 40% of all VADs.”
          In the absence of reliable evidence, that is as good a hypothesis as any.

    • Thank you for keeping EE honest and being the voice of reason.

  • I’ve just heard Thérèse Coffey on the Today programme claim that the majority of health care is delivered through doctors, dentists and ……. chiropractors.

    I do hope this was just a slip of the tongue, but I’m not confident.

    • Just listened (at 3h 23m 00s). Coffey said:

      The majority of healthcare is actually delivered through Primary Care, through our doctors, through our dentists, through chiropractors… all those other supports that is there not just hospitals

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