Vertebral artery dissections (VAD) pose a significant risk for strokes, particularly in young adults. This case report details the presentation and management of a 48-year-old patient who was diagnosed with an extracranial VAD following cervical spine manipulation (CSM).
The patient’s symptoms included:
- acute right-sided ataxia,
- giddiness,
- vertigo,
- nausea,
- vomiting,
- persistent pain behind the right ear.
They prompted immediate evaluation. After ruling out acute intracerebral hemorrhages, a computed tomography angiogram (CTA) of the head and neck identified a severe narrowing of the right distal vertebral artery with a string sign at the level of the right C1 loop (V3 segment), indicating an extracranial VAD. This finding was further supported when ultrasound (US) imaging revealed a high resistance flow pattern in the right distal vertebral artery. Furthermore, T2 and diffusion-weighted magnetic resonance imaging (MRI) confirmed a 1.8 cm VAD/hematoma and a 1.4 cm acute/subacute infarct in the right posterior inferior cerebellar artery (PICA) territory.
The authors concluded by stressing the importance of recognizing and addressing that neck pain can be a symptom of musculoskeletal dysfunction or could have neurovascular origins. In this case, the patient’s neck pain may have been musculoskeletal or could have been due to a previous dissection. Thus, differentiation should be considered before cervical spine manipulation.
The link between CSM and arterial dissection is hard to deny. On this blog, we have discussed these issues with depressing regularity, e.g.:
- Cervical Arterial Dissections and Association With Cervical Manipulative Therapy
- Double-sided vertebral artery dissection in a 33-year-old man. The chiropractor is not guilty?
- A ‘Self-Chiropractic Spinal Manipulation’ that resulted in death
- Chiropractic spinal manipulations are safe!!! … Or aren’t they?
- Another case of stroke due to chiropractic
- The death of Mr Lawler highlights the scandals of chiropractic
- Another serious complication after chiropractic manipulation; best to avoid neck manipulations altogether, I think
- Ophthalmic Adverse Effects after Chiropractic Neck Manipulation
- New review confirms: neck manipulations are dangerous
- Upper neck manipulations (by chiropractors) regularly cause serious harm. Why are they still used?
- Evidence for a causal link between chiropractic treatment and adverse effects
- More on the risks of spinal manipulation
- Another serious complication after neck manipulation + a reminder of the importance of informed consent
Whether the CSM was the cause of the dissection of a previously intakt artery, or whether the CSM made a pre-existing problem worse, might often be difficult to decide in retrospect. What is crucial in both scenarios, is that CSM carries serious risks. This insight is all the more important, if we consider that the benefits of CSM are minimal or unproven. The inescapable conclusion, therefore, is that the risk/benefit balance of CSM is not positive. In other words, the only sensible advice here is this:
don’t allow chiropractors (who use CSM more often that any other profession), osteopaths, physiotherapists, etc. perform CSMs on your neck.
37 Responses to Yet another case of vertebral artery dissection following cervical spine manipulation
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Unfortunately, once again, a paper that doesn’t provide a detailed and complete history of the patient. Regardless, based upon what little information the authors provided, this would be considered a contraindication to initial cSMT in my clinic.
“the reason they sought CSM was that they had been experiencing right-sided neck pain for two weeks, which was a 9/10 in pain and radiated from the right shoulder up.”
Physically you cannot dissect a healthy artety with manual manipulation, you can dislodge a thrombus… Like happens in many cases where people look up or twist their neck without any treatment involved.
I don’think this is true – please post some evidence to support your claim
symons et al 2002 show increase in carotid arteries tension of 1.7-7.5% during cervical manipulation (depend on location) while the level of tension required for intima tears were 139-162% (in healthy arteries depend on location). Hertzog et al 2015 reported similar findings and there are more.
since physically its impossible to dissect a healthy young artery by cx smt it is the current understandng that the patients presenting with neck, face and headache are actually presenting with an ongoing aneurysm that the smt may aggrivate the tear or more likely according to the findings dislodge the thrombus leading to a acute ischemic CVA.
in either case the chiropractor is responsible.
to be fair, do you know of a good reliable technique to identify arterial aneurysms in the carotid arteries? yet alone the vertebral arteries?
how many pending aneurysms like these in the pre-cva stage are picket up when presenting to their GP or ER ?
I have been studying the issue for a while now with the help of several vascular surgeons and neurologists, this issue is more complex than throwing the blame on chiropractors (please remember this is the most common cause of cva in young people most of which never saw a chiropractor in their lifetime)
“… more complex than throwing the blame on chiropractors”
The blame to be thrown is performing an intervention with risk > zero and no objective benefit. As Edzard has explained, unscrupulous chiros want it both ways. CSM is safe for those with healthy arteries, and then when something bad happens, well, arteries must not have been healthy. How can they justify the risk of CSM without thorough knowledge of someone’s condition, especially if presenting with potential contraindications? And even then…
Do you support claims made for subluxation, or are you one of the “good” chiros?
“…no objective benefit.”
Which objective benefits are considered valid outcome measures?
Sorry, I can’t prove a negative, I can only say that I am not aware of any objective evidence to support claims of benefit from CSM.
I didn’t ask for evidence of no evidence.
My question was on objective outcome measures. Which ones are considered acceptable for nonspecific neck pain?
Arterial dissection is one objective benefit that is a valid outcome measure, albeit a strongly negative objective benefit; damage.
Are words difficult for you?
Benefit: a helpful or good effect, or something intended to help: Cambridge
In the case that is the subject of the article on which you are commenting, the objective benefit — measurable benefit — was catastrophically NEGATIVE.
“Benefit: a helpful or good effect, or something intended to help: Cambridge”
The treatment provide by the chiropractor was, perhaps, “intended to help”, but the valid outcome [your term] was negative objective benefit [your term]: disaster; damage.
Edzard wrote, with which I fully agree:
An objective, measurable benefit, not something along the lines of “I feel better.” This is beyond my expertise, all I can say is that I have never seen any evidence presented in support of CSM other than something along the lines of “I feel better.” That along with the absence of a plausible mechanism, and you have at least a 95 on the 100-point bullshit scale (100 = pure bullshit).
The more common outcome measure in clinics and research is the Neck Disability Index.
It can also be used as a prediction rule
Neck Disability Index (NDI)
• Tseng et al. identified six predictors of success for cervical manipulation, one being “initial score on NDI < 11.50
https://medicine.osu.edu/-/media/files/wexnermedical/patient-care/healthcare-services/sports-medicine/education/medical-professionals/other/cervical-manipulation-cpg-final.pdf?la=en&hash=92333A2728C39932CC0B58CEE0A0133705757235
The more common outcome measure in clinics and research is the Neck Disability Index.
It can also be used as a prediction rule
Neck Disability Index (NDI)
• Tseng et al. identified six predictors of success for cervical manipulation, one being “initial score on NDI < 11.50”
https://medicine.osu.edu/-/media/files/wexnermedical/patient-care/healthcare-services/sports-medicine/education/medical-professionals/other/cervical-manipulation-cpg-final.pdf?la=en&hash=92333A2728C39932CC0B58CEE0A0133705757235
As far as plausible mechanisms, look in muscle spindles response to stretching and the PAG with SMT.
I see that Wexner swallows chiropractic whole:
“Chiropractic care focuses on the relationship between the body’s structure—mainly spine—and how it functions, according to the National Institutes of Health’s National Center for Complementary and Alternative Medicine. Chiropractors make adjustments (manipulations) to the spine or other parts of the body to correct alignment problems, relieve pain, improve function and support the body’s natural ability to heal.”
Thanks for the NDI reference. Do you have another one that describes how those measurements are actually made in a clinical setting?
After reading the Tseng abstract, I am having trouble understanding how subjective, self-reported information can be interpreted as objective.
Also from Tseng: “The successful response was determined by improvements seen in one of the three outcome variables that included reduction of pain intensity, significant perceived improvement, and high satisfaction level.” The “six predictors of success” are mostly subjective pre-treatment criteria used to predict success, and NDI is completely subjective.
There are certainly some objective observations done in the course of an examination like measuring blood pressure but I have yet to see any criteria that are not subjective used to measure outcomes.
What am I missing? What is the best example of a trial in this area that used objective criteria to show efficacy?
I am unaware of any purely objective clinical tool that significantly correlates with those measurements that have a subjective component.
There has been some research on inflammatory markers but do we really need to monitor these in a clinical setting for a non-pathological condition?
Example
https://pubmed.ncbi.nlm.nih.gov/32621397/
There are several studies that have examined imaging differences in neck pain (see Table 1) but very little has been done to see if therapeutic approaches improve these area and the clinical significance.
https://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/s12891-017-1694-y/tables/1
So we are left with what is practical and feasible in a clinical setting and currently that is using outcome measurement tools like the NDI.
We’re not doing surgery or treating cancer….it’s nonspecific neck pain and function.
So if your point is…there are no practical and purely objective clinical measurements for treating neck pain, OK, also tell that to the MDs that are dolling out NSAIDs and PTs who are prescribing exercises…should they all stop until they have a purely objective measurement?
Or do you have a different point you wish to make?
“Or do you have a different point you wish to make?”
The only point that needs to be made is the one made by Edzard: “don’t allow chiropractors (who use CSM more often that any other profession), osteopaths, physiotherapists, etc. perform CSMs on your neck.”
Unlike your examples of NSAIDs and exercise, there is insufficient evidence and no plausible mechanism described that justifies the risk.
Right
“This means there was a small difference between the two treatments, but it was not clinically relevant. People receiving NSAIDs also scored 2.0 points better on a 24‐point disability scale than those receiving placebo. This is unlikely to be of real‐world benefit.”
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7161726/
“The database study revealed that people who took NSAIDs had a 1.76-fold higher risk of chronic pain than those taking acetaminophen and other drugs that relieve pain but don’t suppress inflammation.”
https://www.aaas.org/news/anti-inflammatory-medications-raise-risk-chronic-back-pain-patients#:~:text=The%20database%20study%20revealed%20that,but%20don't%20suppress%20inflammation.
“Each year, 1 to 4 percent of NSAID users have serious gastrointestinal tract complications such as hemorrhage, with an estimated cost of $15,000 to $20,000 per hospitalization. An estimated 16,500 NSAID-related deaths occur annually among patients with osteoarthritis or rheumatoid arthritis.”
https://www.aafp.org/pubs/afp/issues/2001/0215/p637.html
This site lists a few possible mechanisms.
Neurophysiological Effects spinal manipulation.
https://www.physio-pedia.com/Spinal_Manipulation
Only if you define “cx smt” to be precisely that which does not, ever, result in the arterial dissection of “a healthy young artery”.
That, is a circular argument and it exemplifies the difference between the scientific method and the pseudoscientific method.
please argue the point. I have shown you empirical evidence suggesting you can not cause dissection of a healthy cx artery using manual smt. do you have some evidence to suggest otherwise?
Please stick to science and spare us the arrogant arguments.
it very much depends on what you define as a healthy artery.
there is evidence, I think, that all arteries show signs of ageing after an age of ~30.
so you can easily declare most arteries dissected by SMT as being not healthy.
the more logical way of approaching this might be to speak of a healthy paerson, one with no symptoms.
and there is clearly no question that SMT can damage the arteries of such an individuaal.
the evidence for this is the collection of cases where exactly that has happened.
“a healthy paerson, one with no symptoms”
there are diseases/conditions that can be asymptomatic in the early stages, are you claiming they are still healthy?
yes, there are also rivers without water – but I am trying to speak the language of a lay person who reads this blog.
“there are also rivers without water”
Actually, no, not by definition. One may call that a wadis.
Regardless, it is currently thought for a VAD to occur there are intrinsic and extrinsic factors present (outside of major trauma…MVA, fall from height, etc.)
So if there are no intrinsic factors present (i.e. a “healthy” cervical spine) could enough force be applied to the cervical spine via a properly applied HVLA to cause a VAD? Or, one could ask, how much force would need to be applied to cause a VAD in said persons?
There are around 40 million visits to a chiropractor per year in the USA for neck issues but around only 10,000 VADs diagnosed a year in the USA. Thus, intrinsic factors, missed contraindications, poor technique. An education issue it seems to me.
gosh golly gee, YOU ARE CLEVER!!!
tell me one more thing, please: if VADs are not a thing after SMT, why do you know so much about it?
[it almost feels as though you are reading a lot on the issue with the aim of white-washing your useless profession]
Whitewashing? My first comment stated that based on the limited information provided I wouldn’t have performed cSMT.
G. Almog, DC, is conveniently ignoring the fact that chiropractic cx smt [sic] is not an adequately documented, auditable, procedure[𝟭]. Therefore his claim “…since physically its [sic] impossible to dissect a healthy young artery by cx smt” is untestable; unverifiable; poppycock; abject BS.
𝟭. as discussed here:
https://edzardernst.com/2023/08/the-effectiveness-of-neck-manipulation-for-neck-pain-is-highly-uncertain-the-risks-are-known-therefore-dont-do-it/#comment-147293
and here:
https://edzardernst.com/2023/02/a-young-womans-visit-to-a-chiropractor-left-her-unable-to-walk/#comment-144686
This abstract does not identify the professional status of the manipulator (as far as I could see).
I was working at a tertiary centre which successfully dealt with complications caused by CSM by an orthopaedic surgeon, who only did an XR afterwards, and identified a tumour in C2!
This blog thread is rightly critical of CSM, not chiropractic as such.
Ethical chiropractors will agree with the Prof’s conclusions.
It just mentions: “A 48-year-old patient presented to the emergency department immediately after chiropractic manipulation of the cervical spine.”
Ah!
Well spotted.
So a chiropractor was involved.
Hmmm…
But of course this paper is about cervical spine manipulation.
How is that different from “chiropractic manipulation of the cervical spine”?
The scandal in the Lawler case was that the coroner accepted a chiropractor as an ‘expert witness’, and did not have evidence from a medically qualified expert or a spinal surgeon – and the chiropractor ‘expert’ stated that using the ‘drop technique’ in an elderly man with ankylosing spondylitis was acceptable!
Assuming there wasn’t misattribution which has been known to occur in these published cases.
In the grand scheme it really doesn’t matter if:
1 a proper history and exam was taken
2. the procedure was done properly
Of course this is yet another paper which severely lacks such pertinent information.
Richard,
Here’s the full text of the case report on PubMed Central®:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11088753/
Toluie A, Joseph AT, Hrehorovich PA.
Vertebral Artery Dissection in a Young Adult: A Case Report.
Cureus. 2024 Apr 12;16(4):e58100.
doi:10.7759/cureus.58100.
PMID: 38738014;
PMCID: PMC11088753.
Many thanks.
Must put my reading glasses on!