Vertebral and carotid artery dissection following chiropractic cervical manipulation

A risk-benefit assessment strategy to exclude cervical artery dissection in spinal manual-therapy: a comprehensive review

Cervical artery dissection refers to a tear in the internal carotid or the vertebral artery that results in an intramural haematoma and/or an aneurysmal dilatation. Although cervical artery dissection is thought to occur spontaneously, physical trauma to the neck, especially hyperextension and rotation, has been reported as a trigger. Headache and/or neck pain is the most common initial symptom of cervical artery dissection. Other symptoms include Horner's syndrome and lower cranial nerve palsy. Both headache and/or neck pain are common symptoms and leading causes of disability, while cervical artery dissection is rare. Patients often consult their general practitioner for headache and/or neck pain, and because manual-therapy interventions can alleviate headache and/or neck pain, many patients seek manual therapists, such as chiropractors and physiotherapists. Cervical mobilization and manipulation are two interventions that manual therapists use. Both interventions have been suspected of being able to trigger cervical artery dissection as an adverse event. The aim of this review is to provide an updated step-by-step risk-benefit assessment strategy regarding manual therapy and to provide tools for clinicians to exclude cervical artery dissection. Key messages Cervical mobilization and/or manipulation have been suspected to be able to trigger cervical artery dissection (CAD). However, these assumptions are based on case studies which are unable to established direct causality. The concern relates to the chicken and the egg discussion, i.e. whether the CAD symptoms lead the patient to seek cervical manual-therapy or whether the cervical manual-therapy provoked CAD along with the non-CAD presenting complaint. Thus, instead of proving a nearly impossible causality hypothesis, this study provide clinicians with an updated step-by-step risk-benefit assessment strategy tool to (a) facilitate clinicians understanding of CAD, (b) appraise the risk and applicability of cervical manual-therapy, and (c) provide clinicians with adequate tools to better detect and exclude CAD in clinical settings.

What are the risks of manual treatment of the spine? A scoping review for clinicians

Background

Communicating to patients the risks of manual treatment to the spine is an important, but challenging element of informed consent. This scoping review aimed to characterise and summarise the available literature on risks and to describe implications for clinical practice and research.

Method

A methodological framework for scoping reviews was followed. Systematic searches were conducted during June 2017. The quantity, nature and sources of literature were described. Findings of included studies were narratively summarised, highlighting key clinical points.

Results

Two hundred and fifty articles were included. Cases of serious adverse events were reported. Observational studies, randomised studies and systematic reviews were also identified, reporting both benign and serious adverse events.Benign adverse events were reported to occur commonly in adults and children. Predictive factors for risk are unclear, but for neck pain patients might include higher levels of neck disability or cervical manipulation. In neck pain patients benign adverse events may result in poorer short term, but not long term outcomes.Serious adverse event incidence estimates ranged from 1 per 2 million manipulations to 13 per 10,000 patients. Cases are reported in adults and children, including spinal or neurological problems as well as cervical arterial strokes. Case-control studies indicate some association, in the under 45 years age group, between manual interventions and cervical arterial stroke, however it is unclear whether this is causal. Elderly patients have no greater risk of traumatic injury compared with visiting a medical practitioner for neuro-musculoskeletal problems, however some underlying conditions may increase risk.

Conclusion

Existing literature indicates that benign adverse events following manual treatments to the spine are common, while serious adverse events are rare. The incidence and causal relationships with serious adverse events are challenging to establish, with gaps in the literature and inherent methodological limitations of studies. Clinicians should ensure that patients are informed of risks during the consent process. Since serious adverse events could result from pre-existing pathologies, assessment for signs or symptoms of these is important. Clinicians may also contribute to furthering understanding by utilising patient safety incident reporting and learning systems where adverse events have occurred.

Safety of cervical spine manipulation: are adverse events preventable and are manipulations being performed appropriately? A review of 134 case reports

BACKGROUND

Cervical spine manipulation (CSM) is a commonly utilized intervention, but its use remains controversial.

PURPOSE

To retrospectively analyze all available documented case reports in the literature describing patients who had experienced severe adverse events (AEs) after receiving CSM to determine if the CSM was used appropriately, and if these types of AEs could have been prevented using sound clinical reasoning on the part of the clinician.

DATA SOURCES

PubMed and the Cumulative Index to Nursing and Allied Health were systematically searched for case reports between 1950 and 2010 of AEs following CSM.

STUDY SELECTION

Case reports were included if they were peer-reviewed; published between 1950 and 2010; case reports or case series; and had CSM as an intervention. Articles were excluded if the AE occurred without CSM (e.g. spontaneous); they were systematic or literature reviews. Data extracted from each case report included: gender; age; who performed the CSM and why; presence of contraindications; the number of manipulation interventions performed; initial symptoms experienced after the CSM; and type of resultant AE.

DATA SYNTHESIS

Based on the information gathered, CSMs were categorized as appropriate or inappropriate, and AEs were categorized as preventable, unpreventable, or unknown. Chi-square analysis with an alpha level of 0.05 was used to determine if there was a difference in proportion between six categories: appropriate/preventable, appropriate/unpreventable, appropriate/unknown, inappropriate/preventable, inappropriate/unpreventable, and inappropriate/unknown.

RESULTS

One hundred thirty four cases, reported in 93 case reports, were reviewed. There was no significant difference in proportions between appropriateness and preventability, P = .46. Of the 134 cases, 60 (44.8%) were categorized as preventable, 14 (10.4%) were unpreventable and 60 (44.8%) were categorized as 'unknown'. CSM was performed appropriately in 80.6% of cases. Death resulted in 5.2% (n = 7) of the cases, mostly caused by arterial dissection.

LIMITATIONS

There may have been discrepancies between what was reported in the cases and what actually occurred, since physicians dealing with the effects of the AE, rather than the clinician performing the CSM, published many of the cases.

CONCLUSIONS

This review showed that, if all contraindications and red flags were ruled out, there was potential for a clinician to prevent 44.8% of AEs associated with CSM. Additionally, 10.4% of the events were unpreventable, suggesting some inherent risk associated with CSM even after a thorough exam and proper clinical reasoning.

Risk of stroke due to spontaneous cervical artery dissection

Although spontaneous cervical artery dissection (SCAD) is generally a rare contributor to a stroke, this condition triggers a considerable percentage of the strokes that are observed in young to middle-aged patients. We herein report the findings of a patient who presented with a stroke and a severe headache. A diagnosis of SCAD was made following a series of examinations. The patient had high-grade stenosis in the cervical artery and received carotid angioplasty along with stenting. A diagnosis of SCAD should be suspected if a patient who is less than 50 years of age presents with a stroke and a severe headache, and CT or an MRI scan rules out hemorrhage.

Cerebral embolus following chiropractic manipulation in a patient with a calcified carotid artery

BACKGROUND AND PURPOSE

Dissection of the cervicocranial vessels is the principal cause of ischemic brain injury following cervical spinal manipulation. Cervical spinal manipulation leading to cerebral embolus in the absence of dissection is not described in the literature. Current case documents cerebral embolism originating from extensively calcified internal carotid artery immediately following cervical spinal manipulation in the absence of dissection.

METHODS

We describe a case and imaging findings of a 63-year-old male who underwent cervical spinal manipulation and developed sudden onset of left-arm numbness and weakness.

RESULTS

Computed tomography angiography demonstrated extensively calcified right internal carotid artery at the site of redone carotid endarterectomy as well as calcified embolus in the right inferior middle cerebral artery.

CONCLUSIONS

Calcified carotid artery may be at risk for embolization following cervical spinal manipulation. Our recommendation is that, patients with extensively calcified carotid arteries should refrain from aggressive neck maneuvers and cervical spine manipulation therapy to avoid liberation of cerebral embolus.

Craniocervical arterial dissections as sequelae of chiropractic manipulation: patterns of injury and management

OBJECT

Chiropractic manipulation of the cervical spine is a known cause of craniocervical arterial dissections. In this paper, the authors describe the patterns of arterial injury after chiropractic manipulation and their management in the modern endovascular era.

METHODS

A prospectively maintained endovascular database was reviewed to identify patients presenting with craniocervical arterial dissections after chiropractic manipulation. Factors assessed included time to symptomatic presentation, location of the injured arterial segment, neurological symptoms, endovascular treatment, surgical treatment, clinical outcome, and radiographic follow-up.

RESULTS

Thirteen patients (8 women and 5 men, mean age 44 years, range 30-73 years) presented with neurological deficits, head and neck pain, or both, typically within hours or days of chiropractic manipulation. Arterial dissections were identified along the entire course of the vertebral artery, including the origin through the V(4) segment. Three patients had vertebral artery dissections that continued rostrally to involve the basilar artery. Two patients had dissections of the internal carotid artery (ICA): 1 involved the cervical ICA and 1 involved the petrocavernous ICA. Stenting was performed in 5 cases, and thrombolysis of the basilar artery was performed in 1 case. Three patients underwent emergency cerebellar decompression because of impending herniation. Six patients were treated with medication alone, including either anticoagulation or antiplatelet therapy. Clinical follow-up was obtained in all patients (mean 19 months). Three patients had permanent neurological deficits, and 1 died of a massive cerebellar stroke. The remaining 9 patients recovered completely. Of the 12 patients who survived, radiographic follow-up was obtained in all but 1 of the most recently treated patients (mean 12 months). All stents were widely patent at follow-up.

CONCLUSIONS

Chiropractic manipulation of the cervical spine can produce dissections involving the cervical and cranial segments of the vertebral and carotid arteries. These injuries can be severe, requiring endovascular stenting and cranial surgery. In this patient series, a significant percentage (31%, 4/13) of patients were left permanently disabled or died as a result of their arterial injuries.

Vertebral artery dissections after chiropractic neck manipulation in Germany over three years

Vertebral artery dissection (VAD) has been observed in association with chirotherapy of the neck. However, most publications describe only single case reports or a small number of cases. We analyzed data from neurological departments at university hospitals in Germany over a three year period of time of subjects with vertebral artery dissections associated with chiropractic neck manipulation. We conducted a country-wide survey at neurological departments of all medical schools to identify patients with VAD after chirotherapy followed by a standardized questionnaire for each patient. 36 patients (mean age 40 + 11 years) with VAD were identified in 13 neurological departments. Clinical symptoms consistent with VAD started in 55% of patients within 12 hours after neck manipulation. Diagnosis of VAD was established in most cases using digital subtraction angiography (DSA), magnetic resonance angiography (MRA) or duplex sonography. 90% of patients admitted to hospital showed focal neurological deficits and among these 11 % had a reduced level of consciousness. 50% of subjects were discharged after 20 +/- 14 hospital days with focal neurological deficits, 1 patient died and 1 was in a persistent vegetative state. Risk factors associated with artery dissections (e. g. fibromuscular dysplasia) were present in only 25% of subjects. In summary, we describe the clinical pattern of 36 patients with vertebral artery dissections and prior chiropractic neck manipulation.

Iatrogenic carotid artery injury in neurosurgery

Iatrogenic carotid artery injury (CAI) results from various neurosurgical procedures. A review of the literature was conducted to provide an update on the management of this potentially devastating complication. Iatrogenic CAIs are categorized according to each diagnostic or therapeutic procedure responsible for the injury, i.e., anterior cervical spine surgery, central venous catheterization, chemical substances, chiropractic manipulation, diagnostic cerebral angiography, middle-ear surgery, percutaneous procedures for trigeminal neuralgia, radiation therapy, skull-base surgery, tracheostomy, and transsphenoidal surgery. The incidence, mechanisms of injury, diagnostic imaging modalities, and reparative procedures are discussed for each procedure. Iatrogenic CAI may be more prevalent than had previously been thought, mostly because of a heightened awareness on the part of physicians and the earlier detection of asymptomatic patients owing to sophisticated and less-invasive imaging modalities. Prevention is the best treatment for every iatrogenic injury, and it is expected that further accumulation of experience with and knowledge of iatrogenic CAI will result in further reduction of this complication. Although some CAIs, such as radiation-induced carotid artery stenosis, may not be preventable, earlier intervention before the patient becomes symptomatic may favorably alter the prognosis. Following the rapid development of endovascular techniques in recent years, surgically inaccessible lesions can be treated in a more reliable and safe manner than before.

Acute vertigo following cervical manipulation

OBJECTIVE/HYPOTHESIS

Either licensed American chiropractors or traditional Chinese herbalists may produce vertiginous attack in a patient after cervical manipulation. The purpose of the study was to present our experience in treating these patients to determine the risk of this procedure.

STUDY DESIGN

A retrospective study from May 1999 to April 2002.

METHODS

Nine patients (one man and eight women) with acute vertigo after cervical manipulation were admitted and underwent a battery of audiometric and vestibular tests, accompanied by magnetic resonance imaging and magnetic resonance angiography examination.

RESULTS

The mean interval for the onset of acute vertigo after cervical manipulation was within 1 day (17 h). Electronystagmography revealed multiple central signs. Magnetic resonance angiography scan also disclosed abnormality in the vertebral artery such as occlusion, stenosis, or slow blood flow in three patients. After treatment with dextran, relief of vertigo without neurological deficits was experienced in all nine patients.

CONCLUSIONS

When there are multiple central signs in electronystagmography results or slow blood flow of the vertebral artery is displayed in neck on Doppler sonography or magnetic resonance angiography scan, the therapeutic benefits of cervical manipulation cannot be expected to outweigh its potential risk for the morbidity of cervical vessels.

Association of internal carotid artery dissection and chiropractic manipulation

BACKGROUND

To determine the relationship between chiropractic manipulative therapy and internal carotid artery dissection, a MEDLINE literature search was performed for the years 1966 through 2000 using the terms internal carotid dissection. Literature that included information concerning causation of ICAD, as well as all case studies and series, was selected for review.

REVIEW SUMMARY

In reviewing the cases of internal carotid dissection potentially related to CMT, there were many confounding factors, such as connective tissue aberrations, underlying arteriopathy, or coexistent infection, that obscured any obvious cause-and-effect relationship. To date there are only 13 reported cases of ICAD temporally related to CMT. Most ICADs seem to occur spontaneously and progress from local symptoms of headache and neck pain to cortical ischemic signs. Approximately one third of the reported cases were manipulated by practitioners other than chiropractic physicians, and because of the differential risk related to major differences in training and practice between practitioners who manipulate the spine, it would be inappropriate to compare adverse outcomes between practitioner groups.

CONCLUSIONS

The medical literature does not support a clear causal relationship between CMT and ICAD. Reported cases are exceedingly scarce, and none support clear cause and effect.

Stroke after chiropractic manipulation as a result of extracranial postero-inferior cerebellar artery dissection

OBJECTIVE

To describe a case of dissection of the postero-inferior cerebellar artery (PICA) after cervical manipulation.

CLINICAL FEATURES

After cervical manipulation, a 42-year-old woman had a cerebellar syndrome related to an infarct in the area supplied by the PICA, confirmed by computed tomography of the brain. Cerebral angiography showed a normal appearance of the vertebral artery, a cervical extradural origin of PICA, and a dissection of the latter at the C1-C2 level.

INTERVENTION AND OUTCOME

Anticoagulant treatment with heparin was implemented. A positive outcome was achieved after 3 weeks.

CONCLUSION

Anatomical variations of the vertebral arteries and their branches are not infrequent and may constitute a predisposing factor to complications after neck manipulation.

Pain, dizziness, and central nervous system blood flow in cervical extension: vascular correlations to beauty parlor stroke syndrome and salon sink radiculopathy

OBJECTIVE

Professional shampoos have previously been implicated in beauty parlor stroke syndrome and salon sink radiculopathy. The purpose of this study was to record pain, dizziness, and cervical blood flow while subjects were specifically placed into the salon sink position and to determine whether an additional cervical support would alter these symptoms and measurements.

DESIGN

In 25 volunteers who reported previous dizziness from salon shampoos, we recorded subjective levels of pain and dizziness and objective measurements of blood flow within the vertebral and carotid arteries at baseline and then during cervical extension into a salon sink, with and without additional cervical support.

RESULTS

When the additional cervical support was not used, there was significantly greater dizziness, neck pain, and carotid blood flow. No statistically significant differences were seen in the vertebral artery blood flow when comparing the three positions.

CONCLUSIONS

Pain and dizziness were commonly reproduced in this previously symptomatic population but significantly less frequently when a supplemental cervical support was used. Individuals with a history of such symptoms should probably exercise caution when deciding whether to receive a salon sink shampoo.

Risks associated with spinal manipulation

The aim of this systematic review was to summarize the evidence about the risks of spinal manipulation. Articles were located through searching three electronic databases (MEDLINE, EMBASE, Cochrane Library), contacting experts (n =9), scanning reference lists of relevant articles, and searching departmental files. Reports in any language containing data relating to risks associated with spinal manipulation were included, irrespective of the profession of the therapist. Where available, systematic reviews were used as the basis of this article. All papers were evaluated independently by the authors. Data from prospective studies suggest that minor, transient adverse events occur in approximately half of all patients receiving spinal manipulation. The most common serious adverse events are vertebrobasilar accidents, disk herniation, and cauda equina syndrome. Estimates of the incidence of serious complications range from 1 per 2 million manipulations to 1 per 400,000. Given the popularity of spinal manipulation, its safety requires rigorous investigation.

Manipulation of the cervical spine: a systematic review of case reports of serious adverse events, 1995-2001

OBJECTIVE

To summarise recent evidence from case reports (published January 1995-September 2001) of adverse events after cervical spine manipulation.

DATA SOURCES

Five computerised literature searches (MEDLINE-Pubmed; EMBASE, the Cochrane Library, AMED [Allied and Complementary Medicine Database], and CISCOM [Centralised Information Service for Complementary Medicine] were performed. No language restrictions were applied.

STUDY SELECTION

All case reports containing original data of adverse events after cervical spine manipulation were included.

DATA EXTRACTION

All articles were evaluated and key data extracted according to pre-defined criteria: patient's age, sex and diagnosis; type of therapist; type of treatment; nature of adverse event; method of diagnosis; and clinical outcome.

DATA SYNTHESIS

Thirty-one case reports (42 individual cases) were found. The patients were equally distributed between the sexes (21 male, 20 female, one unknown) and mostly middle-aged (range, 3 months to 87 years). Most were treated by chiropractors. Arterial dissection causing stroke was reported in at least 18 cases.

CONCLUSIONS

Serious adverse events after cervical spine manipulation continue to be reported. As the incidence of these events is unknown, large and rigorous prospective studies of cervical spine manipulation are needed to accurately define the risks.

Vertebral artery injuries

Vertebral artery injuries are identified more frequently now than in the past for both penetrating and blunt trauma. This is as a result of increased suspicion and awareness, liberal use of color flow Doppler, CT angiography, and traditional four-vessel angiography. The vast majority of patients who are not exsanguinating at the time of presentation can be managed nonoperatively or by angiographic embolization. Operative management should be reserved only for patients with severe active bleeding or when interventional radiology fails. The surgical exposure is complex and demands excellent knowledge of the local anatomy.

Carotid artery dissection

Carotid artery dissection (CAD) is one of the more common causes of stroke in persons younger than 50 years. In this age group and in older persons, CAD is most often associated with trauma. Significant morbidity can be a consequence of CAD, particularly a stroke or other permanent neurologic deficit. Because stroke is the third leading cause of death in the United States, attention has focused in the past decade on understanding the phenomenon of dissection of the carotid artery. This article presents a review of the risk factors associated with CAD, the role of the nurse as a provider of care for these persons, and the approaches to prevent or limit disability related to CAD, the ultimate goal of patient care. Nurses play a crucial role in the detection of CAD and in the prevention of strokes or other neurologic disabilities through recognition of persons at risk, assessment for early signs and symptoms, and implementation of prophylactic measures. Because more than half of persons with CAD have cerebral ischemia, thrombolytic, anticoagulant, and antiplatelet regimens have evolved to limit the development of a thromboembolic event associated with dissection. The administration of these agents, the monitoring for their effectiveness, and the education of patients receiving them are fundamental aspects of care.