Risk factors and precipitating neck movements causing vertebrobasilar artery dissection after cervical trauma and spinal manipulation

A narrative review on cervical artery dissection-related cranial nerve palsies

Introduction

This study aimed to emphasize the importance of cranial nerve (CN) palsies in spontaneous cervical artery dissection (sCeAD).

Methods

A search term-based literature review was conducted on "cervical artery dissection" and "cranial nerve palsy." English and German articles published until October 2023 were considered.

Results

Cranial nerve (CN) palsy in sCeAD is evident in approximately 10% of cases. In the literature, isolated palsies of CN II, III, VII, IX, X, and XII have been reported, while CN XI palsy only occurs in combination with other lower cranial nerve palsies. Dissection type and mural hematoma localization are specific to affected CN as CN palsies of II or III are solely evident in those with steno-occlusive vessel pathologies located at more proximal segments of ICA, while those with CN palsies of IX, X, XI, and XII occur in expansive sCeAD at more distal segments. This dichotomization emphasizes the hypothesis of a different pathomechanism in CN palsy associated with sCeAD, one being hypoperfusion or microembolism (CN II, III, and VII) and the other being a local mass effect on surrounding tissue (CN IX, X, XI, and XII). Clinically, the distinction between peripheral palsies and those caused by brainstem infarction is difficult. This differentiation is key, as, according to the reviewed cases, peripheral cranial nerve palsies in sCeAD patients mostly resolve completely over time, while those due to brainstem stroke do not, making cerebrovascular imaging appraisal essential.

Discussion

It is important to consider dissections as a potential cause of peripheral CN palsies and to be aware of the appropriate diagnostic pathways. This awareness can help clinicians make an early diagnosis, offering the opportunity for primary stroke prevention.

Plausible Mechanisms of Causation of Immediate Stroke by Cervical Spine Manipulation: A Narrative Review

It has been proposed that cervical spine manipulation (CSM) can cause dissection in healthy cervical arteries, with resultant immediate stroke. However, research does not support a causal association between CSM and cervical artery dissection (CAD) in healthy cervical arteries. The objective of this study was to review the literature to identify plausible mechanisms of causation of immediate stroke by CSM. Immediate stroke is defined as a stroke occurring within seconds or minutes of CSM. Our review found plausible thromboembolic and thrombotic mechanisms of causation of immediate stroke by CSM in the literature. The common premise of these mechanisms is CAD being present before CSM, not occurring as a result of CSM. These mechanisms of causation have clinical and medicolegal implications for physicians performing CSM.

Identifying Patient Characteristics Associated With the Occurrence of Post Treatment Non-serious Adverse Events After Cervical Spine Manual Therapy Treatment in Patients With Neck Pain

OBJECTIVES

To compare prevalence rates of serious and non-serious adverse events after manipulation and mobilization and to identify risk factors of serious and non-serious adverse events following 4 types of manual therapy treatment in patients with neck pain.

DESIGN

A prospective cohort study in primary care manual therapy practice.

PARTICIPANTS

Patients with neck pain (N=686) provided data on adverse events after 1014 manipulation treatments, 829 mobilization treatments, 437 combined manipulation and mobilization treatments, and 891 treatments consisting of "other treatment modality".

INTERVENTIONS

Usual care manual therapy.

MAIN OUTCOME MEASURES

A chi-square test was performed to explore differences in prevalence rates. Logistic regression analysis was performed within the 4 treatment groups. A priori we defined associations between patient-characteristics and adverse events of odds ratio (OR)>2 or OR<0.5 as clinically relevant.

RESULTS

No serious adverse events, such as cervical artery dissection or stroke, were reported. With regard to non-serious adverse events, we found that these are common after manual therapy treatment: prevalence rates are ranging from 0.3% to 64.7%. We found a statistically significant difference between the 4 types of treatments, detrimental to mobilization treatment. Logistic regression analysis resulted in 3 main predictors related to non-serious adverse events after manual therapy treatment: smoking (OR ranges from 2.10 [95% confidence interval [CI] 1.37-3.11] to 3.33 [95% CI 1.83-5.93]), the presence of comorbidity (OR ranges from 2.32 [95% CI 1.22-4.44] to 3.88 [95% CI 1.62-9.26]), and female sex (OR ranges from 0.22 [95% CI 0.11-0.46] to 0.49 [95% CI 0.28-0.86]).

CONCLUSION

There is a significant difference in the occurrence of non-serious adverse events after mobilization compared with manipulation or a combination of manipulation and mobilization. Non-serious adverse events in manual therapy practice are common and are associated with smoking and the presence of comorbidity. In addition, women are more likely to report non-serious adverse events.

Kinematics of the head and associated vertebral artery length changes during high-velocity, low-amplitude cervical spine manipulation

Background

Cervical spine manipulation (CSM) is a frequently used treatment for neck pain. Despite its demonstrated efficacy, concerns regarding the potential of stretch damage to vertebral arteries (VA) during CSM remain. The purpose of this study was to quantify the angular displacements of the head relative to the sternum and the associated VA length changes during the thrust phase of CSM.

Methods

Rotation and lateral flexion CSM procedures were delivered bilaterally from C1 to C7 to three male cadaveric donors (Jan 2016–Dec 2019). For each CSM the force–time profile was recorded using a thin, flexible pressure pad (100–200 Hz), to determine the timing of the thrust. Three dimensional displacements of the head relative to the sternum were recorded using an eight-camera motion analysis system (120–240 Hz) and angular displacements of the head relative to the sternum were computed in Matlab. Positive kinematic values indicate flexion, left lateral flexion, and left rotation. Ipsilateral refers to the same side as the clinician's contact and contralateral, the opposite. Length changes of the VA were recorded using eight piezoelectric ultrasound crystals (260–557 Hz), inserted along the entire vessel. VA length changes were calculated as D = (L₁− L₀)/L₀, where L₀ = length of the whole VA (sum of segmental lengths) or the V3 segment at CSM thrust onset; L₁ = whole VA or V3 length at peak force during the CSM thrust.

Results

Irrespective of the type of CSM, the side or level of CSM application, angular displacements of the head and associated VA length changes during the thrust phase of CSM were small. VA length changes during the thrust phase were largest with ipsilateral rotation CSM (producing contralateral head rotation): [mean ± SD (range)] whole artery [1.3 ± 1.0 (− 0.4 to 3.3%)]; and V3 segment [2.6 ± 3.6 (− 0.4 to 11.6%)].

Conclusions

Mean head angular displacements and VA length changes were small during CSM thrusts. Of the four different CSM measured, mean VA length changes were largest during rotation procedures. This suggests that if clinicians wish to limit VA length changes during the thrust phase of CSM, consideration should be given to the type of CSM used.

Safety of Five Tuina Manipulations in Rats with Deep Vein Thrombosis

Objective

To study the effects of five tuina manipulations in rats with deep vein thrombosis (DVT) and to explore how to safely perform tuina in the treatment of thrombotic diseases.

Methods

Seventy-two male Sprague-Dawley (SD) rats were randomly divided into the model, pointing manipulation, plucking manipulation, kneading manipulation, pushing manipulation, and pulling manipulation groups (n = 12). DVT model was established by incomplete ligation. The tuina intervention was started on the next day after modeling and applied once a day 10 times by the manipulation simulators. On the 3^rd and 10^th days after intervention, respectively, the effects of tuina on thrombosis were evaluated based on thrombus elasticity, blood coagulation, fibrinolytic function and blood rheology with the ultrasound elastography, four coagulation tests, enzyme linked immunosorbent assay (ELISA), and hemorheology tests.

Results

In the pointing manipulation group, the strain rate ratio, 6-ketoprostaglandin F1α (6-Keto-PGF1α), and high shear rate were decreased, and the thromboxane B₂ (TXB₂) content was increased (P < 0.05). In the plucking manipulation group, the D-dimer and 6-Keto-PGF1α contents were increased, prothrombin time (PT) was shortened, and activated partial thromboplastin time (APTT) was activated, and the high shear rate and plasma viscosity were decreased (P < 0.05). In the kneading manipulation group, APTT was shortened, and 6-Keto-PGF1α, high shear rate, and plasma viscosity were decreased (P < 0.05). In the pushing manipulation group, the strain rate ratio, low shear rate, and high shear rate were all decreased (P < 0.05). In the pulling manipulation group, both the strain rate ratio and the low shear rate were decreased (P < 0.05). The 6-Keto-PGF1α changes on the 3^rd and 10^th days after intervention were opposite in the pushing manipulation group and the pulling manipulation group (P < 0.05).

Conclusion

The pointing, pushing, and pulling manipulations seem to be safe in the early period of thrombosis, but the risk is likely to be elevated as the treatment course of intervention increases. The plucking and kneading manipulations potentially have certain risks in the treatment of DVT in rats.

Traumatic and Spontaneous Vertebral Artery Dissections: An Analysis of Tertiary-Center 310 Patient Cohort

BACKGROUND

Vertebral artery dissections (VADs) are rare yet potentially devastating events. While the etiology of these events is either traumatic or spontaneous, there is a paucity of quantitative literature comparing the two.

OBJECTIVE

To identify differences in predisposing factors, event characteristics, and clinical outcomes between traumatic VADs (tVADs) and spontaneous VADs (sVADs).

METHODS

We retrospectively identified patients with VADs presenting to our institution at VAD onset with at least a 3-mo follow-up. Demographics, event characteristics, treatment details, and neurological outcomes as modified Rankin scale (mRS) scores were collected.

RESULTS

Of the 310 patients sustaining 366 VADs total, 187 (60.3%) patients experienced a total of 221 (60.4%) sVADs and 123 (39.7%) patients experienced a total of 145 (39.6%) tVADs. sVADs were more likely to occur in the intracranial course of the artery (P = .042) and have a lower mRS at discharge, 3-month, and last clinical follow-up (P = 003, .002, and .001, respectively). tVADs were more likely associated with concomitant fractures (P < .001).

CONCLUSION

Despite similar patient populations, tVADs are associated with higher mRS scores at all time points. Although further study is needed, this may suggest other concomitant trauma rather than the VAD itself is contributing to worse neurological status in patients with tVADs.

Can scoliosis lead to spinal cord ischaemia? Early diagnosis and rehabilitation: A paradigmatic case report and literature review

INTRODUCTION

Scoliosis is frequently associated with pain and radiculopathy, but it is not considered a possible cause of acute spinal cord injury (SCI). Here we present a case report in which scoliosis was apparently linked to spinal cord ischaemia.

CASE PRESENTATION

A 20-year-old woman with conservatively treated severe scoliosis presented with acute spinal cord infarction, which occurred during a spinal flexion while she was tidying up the bed. Other causes of SCI were excluded. Early rehabilitation was started and the patient progressively regained motor and sensory functions, with an AIS reduction from A to C. Bowel and bladder disorders persisted and were autonomously managed with a trans-anal irrigation device and intermittent catheterisation after voluntary micturition.

DISCUSSION

Early detection and management of spinal curvature disorders are essential in preventing long-term complications of scoliosis. Although the aetiology of spinal cord ischaemia in severe scoliosis should be better clarified, this rare case report suggests that scoliosis might be involved in its pathogenesis. Thus, we recommend early diagnosis of spinal curvature disorders and adequate rehabilitative treatment in order to prevent potential subsequent neurological complications.

The 100 Most-Cited Papers in Traumatic Injury of the Spine

Background

Traumatic injury to the spine can be a complex diagnostic and therapeutic entity often with devastating consequences. Outside of the isolated vertebral column injury costs; annual costs associated with spinal cord injury (SCI) are estimated to exceed $9.7 billion.

Objective

To identify the 100 most-cited articles on spine trauma.

Methods

The Thomson Reuters Web of Science citation indexing service was queried. The articles were sorted by times cited in descending order. Two independent reviewers reviewed the article titles and abstracts to identify the top 100 most-cited articles.

Results

The top 100 articles were found to be cited between 108 (articles #99-100) and 1595 times (article #1). The most-cited basic science article was cited 340 times (#12 on the top 100 list). The oldest article on the top 100 list was from 1953 and most recent from 2012. The number of patients, when applicable, in a study ranged from 9 (article #34) to 34,069 (article #5). Top 100 articles were published in 41 different journals with a wide range of specialities and fields most commonly multidisciplinary. Basic science research encompassed 34 of the 100 articles on the list.

Conclusions

We present the 100 most-cited articles in spinal trauma with emphases on important contributions from both basic science and clinical research across a wide range of authors, specialties, patient populations, and countries. Recognizing some of the most important contributions in the field of spinal trauma may provide insight and guide future work.

Vertebral Artery Dissection in Sport: A Systematic Review

BACKGROUND

Vertebral artery dissection (VAD) is a potentially catastrophic injury that may occur during sports participation. A comprehensive review is needed to collate documented cases to improve understanding and inform future preventative approaches.

OBJECTIVE

This review aimed to understand the extent of VAD in sport and characterise trends suggestive of mechanisms of injury.

METHODS

Electronic databases were searched using terms related to VAD and sport. Records were included if they described one or more cases of VAD attributed to sport.

RESULTS

A total of 79 records described 128 individual cases of VAD in sport, of which 118 were confirmed by imaging or autopsy and included in analyses. Cases were attributed to 43 contact and non-contact sports. The median age of cases was 33 years (IQR 22-44), and 75% were male. There were 22 cases of fatal injury, of which ten involved an impact to the mastoid region and seven involved an impact to the head or neck. Non-fatal cases of VAD were attributed to impact to the head or neck (not mastoid region), movement or held position without impact, and in some cases no reported incident.

CONCLUSIONS

VAD attributed to sports participation is uncommonly reported and the mechanisms are varied. Impact to the mastoid region is consistently implicated in fatal cases and should be the focus of injury prevention strategies in sport. Efforts may also be directed at improving the prognosis of cases with delayed presentation through clinical recognition and imaging. The review was registered on the international prospective register for systematic reviews ( http://www.crd.york.ac.uk/PROSPERO ) (CRD42018090543).

Effects of Head and Neck Positions on Blood Flow in the Vertebral, Internal Carotid, and Intracranial Arteries: A Systematic Review

BACKGROUND

Manual therapy interventions targeting the neck include various positions and movements of the craniocervical region. The hemodynamic changes in various spinal positions potentially have clinical relevance.

OBJECTIVES

To investigate the effects of craniocervical positions and movements on hemodynamic parameters (blood flow velocity and/or volume) of cervical and craniocervical arteries.

METHODS

A search of 4 databases (PubMed, Embase, CINAHL, and Index to Chiropractic Literature) and, subsequently, a hand search of reference lists were conducted. Full-text experimental and quasi-experimental studies on the influence of cervical positions on blood flow of the vertebral, internal carotid, and basilar arteries were eligible for this review. Two independent reviewers selected and extracted the data using the double-screening method.

RESULTS

Of the 1453 identified studies, 31 were included and comprised 2254 participants. Most studies mentioned no significant hemodynamic changes during maximal rotation (n = 16). A significant decrease in hemodynamics was identified for the vertebral artery, with a hemodynamic decrease in the position of maximum rotation (n = 8) and combined movement of maximum extension and maximum rotation (n = 4). A similar pattern of decreased hemodynamics was also identified for the internal carotid and intracranial arteries. Three studies focused on high-velocity thrust positioning and movement. None of the studies reported hemodynamic changes. The synthesized data suggest that in the majority of people, most positions and movements of the craniocervical region do not affect blood flow.

CONCLUSION

The findings of this systematic review suggest that craniocervical positioning may not alter blood flow as much as previously expected.

LEVEL OF EVIDENCE

Therapy, level 2a. J Orthop Sports Phys Ther 2019;49(10):688-697. Epub 5 Jul 2019. doi:10.2519/jospt.2019.8578.

Effects of Cervical Rotatory Manipulation on Internal Carotid Artery in Hemodynamics Using an Animal Model of Carotid Atherosclerosis: A Safety Study

Background

Spinal manipulation, particularly in cervical rotatory manipulation (CRM), has become increasingly popular in physical therapies, with satisfying effect. However, it is still unclear whether CRM affects internal carotid arteries (ICA) with mild carotid atherosclerosis (CAS), especially in hemodynamics.

Material/Methods

Nine cynomolgus monkeys were randomly divided into 3 groups: the CAS-CRM, the CAS, and the blank control groups. CAS models were developed in the left ICA in the CAS-CRM and the CAS groups. The monkeys in the CAS-CRM group underwent CRM intervention for 3 weeks. Histology and hemodynamics were measured, including peak systolic velocity (PSV), end-diastolic velocity (EDV), time average velocity (TAV), resistance index (RI), and pulsatility index (PI). Measurements were made separately at 3 different rotation angles (0°, 45°, and 90°).

Results

In the 3 groups, with the increase of rotation angle, the decreasing tendency of PSV, EDV, and TAV and the increasing tendency of RI and PI were statistically significant. At each angle, the monkeys in the CAS-CRM and the CAS groups had lower levels of PSV, EDV, and TAV and higher levels of RI and PI compared with the blank control group. No significant difference in hemodynamics was found between the CAS-CRM and the CAS groups.

Conclusions

Both the rotational angle and the atherosclerotic disease can affect the blood flow of the ICA. However, CRM does not cause adverse effects on hemodynamics in cynomolgus monkeys with mild CAS, and appears to be a relatively safe technique.

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.

Blunt vertebral vascular injury in trauma patients: ATLS® recommendations and review of current evidence

Blunt cerebrovascular injury (BCVI) encompasses two distinct clinical entities: traumatic carotid artery injury (TCAI) and traumatic vertebral artery injury (TVAI). The latter is the focus of our review. These are potentially devastating injuries which pose a diagnostic challenge in the acute trauma setting. There is still debate regarding the optimal screening criteria, diagnostic imaging modality and treatment methods. In 2012 the American College of Surgeons proposed criteria for investigating patients with suspected TVAI and subsequent treatment methods, caveated with the statement that evidence is limited and still evolving. Here we review the historical evidence and recent literature relating to these recommendations.

The risk associated with spinal manipulation: an overview of reviews

BACKGROUND

Spinal manipulative therapy (SMT) is a widely used manual treatment, but many reviews exist with conflicting conclusions about the safety of SMT. We performed an overview of reviews to elucidate and quantify the risk of serious adverse events (SAEs) associated with SMT.

METHODS

We searched five electronic databases from inception to December 8, 2015. We included reviews on any type of studies, patients, and SMT technique. Our primary outcome was SAEs. Quality of the included reviews was assessed using a measurement tool to assess systematic reviews (AMSTAR). Since there were insufficient data for calculating incidence rates of SAEs, we used an alternative approach; the conclusions regarding safety of SMT were extracted for each review, and the communicated opinion were judged by two reviewers independently as safe, harmful, or neutral/unclear. Risk ratios (RRs) of a review communicating that SMT is safe and meeting the requirements for each AMSTAR item, were calculated.

RESULTS

We identified 283 eligible reviews, but only 118 provided data for synthesis. The most frequently described adverse events (AEs) were stroke, headache, and vertebral artery dissection. Fifty-four reviews (46%) expressed that SMT is safe, 15 (13%) expressed that SMT is harmful, and 49 reviews (42%) were neutral or unclear. Thirteen reviews reported incidence estimates for SAEs, roughly ranging from 1 in 20,000 to 1 in 250,000,000 manipulations. Low methodological quality was present, with a median of 4 of 11 AMSTAR items met (interquartile range, 3 to 6). Reviews meeting the requirements for each of the AMSTAR items (i.e. good internal validity) had a higher chance of expressing that SMT is safe.

CONCLUSIONS

It is currently not possible to provide an overall conclusion about the safety of SMT; however, the types of SAEs reported can indeed be significant, sustaining that some risk is present. High quality research and consistent reporting of AEs and SAEs are needed.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015030068 .

Spinal Manipulation Vs Sham Manipulation for Nonspecific Low Back Pain: A Systematic Review and Meta-analysis

OBJECTIVE

The purpose of this systematic review was to identify and critically evaluate randomized controlled trials of spinal manipulation (SM) vs sham manipulation in the treatment of nonspecific low back pain.

METHODS

Four electronic databases were searched from their inception to March 2015 to identify all relevant trials. Reference lists of retrieved articles were hand-searched. All data were extracted by 2 independent reviewers, and risk of bias was assessed using the Cochrane Back Review Group Risk of Bias tool.

RESULTS

Nine randomized controlled trials were included in the systematic review, and 4 were found to be eligible for inclusion in a meta-analysis. Participants in the SM group had improved symptoms compared with participants receiving sham treatment (standardized mean difference = - 0.36; 95% confidence interval, - 0.59 to - 0.12). The majority of studies were of low risk of bias; however, several of the studies were small, the practitioner could not be blinded, and some studies did not conduct intention-to-treat analysis and had a high level of dropouts.

CONCLUSION

There is some evidence that SM has specific treatment effects and is more effective at reducing nonspecific low back pain when compared with an effective sham intervention. However, given the small number of studies included in this analysis, we should be cautious of making strong inferences based on these results.

Risk Factors and Clinical Presentation of Cervical Arterial Dissection: Preliminary Results of a Prospective Case-Control Study

STUDY DESIGN

Cross-sectional case-control study.

OBJECTIVES

To identify risk factors and clinical presentation of individuals with cervical arterial dissection.

BACKGROUND

Cervical arterial dissection is a common cause of stroke in young people and has in rare cases been associated with cervical manipulative therapy. The mechanism is considered to involve pre-existing arterial susceptibility and a precipitating event, such as minor trauma. Identification of individuals at risk or early recognition of a dissection in progress could help expedite medical intervention and avoid inappropriate treatment.

METHODS

Participants were individuals 55 years of age or younger from the Hunter region of New South Wales, Australia with radiologically confirmed vertebral or internal carotid artery dissection and an age- and sex-matched comparison group. Participants were interviewed about risk factors, preceding events, and clinical features of their stroke. Physical examination of joint mobility and soft tissue compliance was undertaken.

RESULTS

Twenty-four participants with cervical arterial dissection and 21 matched comparisons with ischemic stroke but not dissection were included in the study. Seventeen (71%) of the 24 participants with dissection reported a recent history of minor mechanical neck trauma or strain, with 4 of these 17 reporting recent neck manipulative therapy treatment. Cardiovascular risk factors were uncommon, with the exception of diagnosed migraine. Among the participants with dissection, 67% reported transient ischemic features in the month prior to their admission for dissection.

CONCLUSION

Recent minor mechanical trauma or strain to the head or neck appears to be associated with cervical arterial dissection. General cardiovascular risk factors, with the exception of migraine, were not important risk factors for dissection in this cohort. Preceding transient neurological symptoms appear to occur commonly and may assist in the identification of this serious pathology.

LEVEL OF EVIDENCE

Prognosis, level 4.

Tissue damage markers after a spinal manipulation in healthy subjects: a preliminary report of a randomized controlled trial

Spinal manipulation (SM) is a manual therapy technique frequently applied to treat musculoskeletal disorders because of its analgesic effects. It is defined by a manual procedure involving a directed impulse to move a joint past its physiologic range of movement (ROM). In this sense, to exceed the physiologic ROM of a joint could trigger tissue damage, which might represent an adverse effect associated with spinal manipulation. The present work tries to explore the presence of tissue damage associated with SM through the damage markers analysis. Thirty healthy subjects recruited at the University of Jaén were submitted to a placebo SM (control group; n = 10), a single lower cervical manipulation (cervical group; n = 10), and a thoracic manipulation (n = 10). Before the intervention, blood samples were extracted and centrifuged to obtain plasma and serum. The procedure was repeated right after the intervention and two hours after the intervention. Tissue damage markers creatine phosphokinase (CPK), lactate dehydrogenase (LDH), C-reactive protein (CRP), troponin-I, myoglobin, neuron-specific enolase (NSE), and aldolase were determined in samples. Statistical analysis was performed through a 3 × 3 mixed-model ANOVA. Neither cervical manipulation nor thoracic manipulation did produce significant changes in the CPK, LDH, CRP, troponin-I, myoglobin, NSE, or aldolase blood levels. Our data suggest that the mechanical strain produced by SM seems to be innocuous to the joints and surrounding tissues in healthy subjects.

The effect of end-range cervical rotation on vertebral and internal carotid arterial blood flow and cerebral inflow: A sub analysis of an MRI study

INTRODUCTION

Cervical spine manual therapy has been associated with a small risk of serious adverse neurovascular events, particularly to the vertebral arteries. Sustained end-range rotation is recommended clinically as a pre-manipulative screening tool; however ultrasound studies have yielded conflicting results about the effect of rotation on blood flow in the vertebral arteries. There has been little research on internal carotid arterial flow or utilising the reference standard of angiography.

OBJECTIVES

To evaluate the mean effect of cervical rotation on blood flow in the craniocervical arteries and blood supply to the brain, as well as individual variation.

DESIGN

This was an observational study.

METHOD

Magnetic resonance angiography was used to measure average blood flow volume in the vertebral arteries, internal carotid arteries, and total cerebral inflow, in three neck positions: neutral, end-range left rotation and end-range right rotation in healthy adults.

RESULTS

Twenty participants were evaluated. There was a decrease in average blood flow volume in the vertebral and internal carotid arteries on contralateral rotation, compared to neutral. This was statistically significant on left rotation only. Ipsilateral rotation had no effect on average blood flow volume in any artery. Total cerebral inflow was not significantly affected by rotation in either direction.

CONCLUSIONS

It appears that in healthy adults the cerebral vasculature can compensate for decreased flow in one or more arteries by increasing flow in other arteries, to maintain cerebral perfusion. Sustained end-range rotation may therefore reflect the compensatory capacity of the system as a whole rather than isolated vertebrobasilar function.

Traumatic vertebral artery injury: proposal for classification of the severity of trauma and likelihood of fatal outcome

Vertebral artery injury (VAI) occurs after (blunt) trauma as well as spontaneously. The risk of incurring VAI from a blunt trauma probably parallels the severity of trauma, often referred to as major- and minor-trauma. However, the literature does not provide concrete definitions of these terms. This study aims to define minor- and major-trauma and to analyze the likelihood of fatal outcome in VAI. For this purpose, classification criteria of major- and minor-trauma were developed and a PubMed database search was performed for articles on VAI published prior to 2013. The definitions of minor- and major-trauma, derived mainly from radiological screening criteria in cervical spine injury and based on the mechanism leading to the injury, were used in the analysis of the literature. The search produced 241 VAI cases with sufficiently detailed data for the comparison of major-trauma (52 cases, 50 lethal), minor-trauma (8 cases, none lethal), and no-trauma (182 cases, 69 lethal). The numbers of lethal cases in the total study population and subgroups differed significantly between the groups (Fisher's exact test) and the likelihood ratios (LRs) of lethal outcome were substantially higher in the major-trauma group compared to the other groups. The highly significant p values show that the proposed criteria differentiate between trauma types with regard to fatal outcome. The presented results can assist in the evaluation of forensic cases of VAI.

WITHDRAWN: Non-invasive physical treatments for chronic/recurrent headache

This review is out of date, but is correct at the date of publication. The review has been withdrawn from The Cochrane Library, but readers can still access previous versions in the 'Other versions' tab. The original author team is preparing three new protocols which will serve to update and replace this review: Manual treatment and spinal rehabilitative exercise for the prevention of migraine attacks in adults, Manual treatment and spinal rehabilitative exercise for the prevention of TTH in adults, and Manual treatment and spinal rehabilitative exercise for the prevention of cervicogenic headaches in adults. For further information, please contact the PaPaS CRG (details here ).

July 2017

At July 2017, the series of three new reviews intended to replace this review were withdrawn as they were not able to be completed within the available editorial resource.

The editorial group responsible for this previously published document have withdrawn it from publication.

Cervical arterial dissections and association with cervical manipulative therapy: a statement for healthcare professionals from the american heart association/american stroke association

PURPOSE

Cervical artery dissections (CDs) are among the most common causes of stroke in young and middle-aged adults. The aim of this scientific statement is to review the current state of evidence on the diagnosis and management of CDs and their statistical association with cervical manipulative therapy (CMT). In some forms of CMT, a high or low amplitude thrust is applied to the cervical spine by a healthcare professional.

METHODS

Members of the writing group were appointed by the American Heart Association Stroke Council's Scientific Statements Oversight Committee and the American Heart Association's Manuscript Oversight Committee. Members were assigned topics relevant to their areas of expertise and reviewed appropriate literature, references to published clinical and epidemiology studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize existing evidence and to indicate gaps in current knowledge.

RESULTS

Patients with CD may present with unilateral headaches, posterior cervical pain, or cerebral or retinal ischemia (transient ischemic or strokes) attributable mainly to artery-artery embolism, CD cranial nerve palsies, oculosympathetic palsy, or pulsatile tinnitus. Diagnosis of CD depends on a thorough history, physical examination, and targeted ancillary investigations. Although the role of trivial trauma is debatable, mechanical forces can lead to intimal injuries of the vertebral arteries and internal carotid arteries and result in CD. Disability levels vary among CD patients with many having good outcomes, but serious neurological sequelae can occur. No evidence-based guidelines are currently available to endorse best management strategies for CDs. Antiplatelet and anticoagulant treatments are both used for prevention of local thrombus and secondary embolism. Case-control and other articles have suggested an epidemiologic association between CD, particularly vertebral artery dissection, and CMT. It is unclear whether this is due to lack of recognition of preexisting CD in these patients or due to trauma caused by CMT. Ultrasonography, computed tomographic angiography, and magnetic resonance imaging with magnetic resonance angiography are useful in the diagnosis of CD. Follow-up neuroimaging is preferentially done with noninvasive modalities, but we suggest that no single test should be seen as the gold standard.

CONCLUSIONS

CD is an important cause of ischemic stroke in young and middle-aged patients. CD is most prevalent in the upper cervical spine and can involve the internal carotid artery or vertebral artery. Although current biomechanical evidence is insufficient to establish the claim that CMT causes CD, clinical reports suggest that mechanical forces play a role in a considerable number of CDs and most population controlled studies have found an association between CMT and VAD stroke in young patients. Although the incidence of CMT-associated CD in patients who have previously received CMT is not well established, and probably low, practitioners should strongly consider the possibility of CD as a presenting symptom, and patients should be informed of the statistical association between CD and CMT prior to undergoing manipulation of the cervical spine.

Clinical effectiveness of manual therapy for the management of musculoskeletal and non-musculoskeletal conditions: systematic review and update of UK evidence report

BACKGROUND

This systematic review updated and extended the "UK evidence report" by Bronfort et al. (Chiropr Osteopath 18:3, 2010) with respect to conditions/interventions that received an 'inconclusive' or 'negative' evidence rating or were not covered in the report.

METHODS

A literature search of more than 10 general medical and specialised databases was conducted in August 2011 and updated in March 2013. Systematic reviews, primary comparative studies and qualitative studies of patients with musculoskeletal or non-musculoskeletal conditions treated with manual therapy and reporting clinical outcomes were included. Study quality was assessed using standardised instruments, studies were summarised, and the results were compared against the evidence ratings of Bronfort. These were either confirmed, updated, or new categories not assessed by Bronfort were added.

RESULTS

25,539 records were found; 178 new and additional studies were identified, of which 72 were systematic reviews, 96 were randomised controlled trials, and 10 were non-randomised primary studies. Most 'inconclusive' or 'moderate' evidence ratings of the UK evidence report were confirmed. Evidence ratings changed in a positive direction from inconclusive to moderate evidence ratings in only three cases (manipulation/mobilisation [with exercise] for rotator cuff disorder; spinal mobilisation for cervicogenic headache; and mobilisation for miscellaneous headache). In addition, evidence was identified on a large number of non-musculoskeletal conditions not previously considered; most of this evidence was rated as inconclusive.

CONCLUSIONS

Overall, there was limited high quality evidence for the effectiveness of manual therapy. Most reviewed evidence was of low to moderate quality and inconsistent due to substantial methodological and clinical diversity. Areas requiring further research are highlighted.

Effect of selected manual therapy interventions for mechanical neck pain on vertebral and internal carotid arterial blood flow and cerebral inflow

BACKGROUND

Manual therapy of the cervical spine has occasionally been associated with serious adverse events involving compromise of the craniocervical arteries. Ultrasound studies have shown certain neck positions can alter craniocervical arterial blood flow velocities; however, findings are conflicting. Knowledge about the effects of neck position on blood flow may assist clinicians in avoiding potentially hazardous practices.

OBJECTIVE

The purpose of this study was to examine the effects of selected manual therapeutic interventions on blood flow in the craniocervical arteries and blood supply to the brain using magnetic resonance angiography (MRA).

DESIGN

This was an experimental, observational magnetic resonance imaging study.

METHOD

Twenty adult participants who were healthy and had a mean age of 33 years were imaged using MRA in the following neck positions: neutral, rotation, rotation/distraction (similar to a Cyriax manipulation), C1-C2 rotation (similar to a Maitland or osteopathic manipulation), and distraction.

RESULTS

The participants were imaged using 3T MRA. All participants had normal vascular anatomy. Average inflow to the brain in neutral was 6.98 mL/s and was not significantly changed by any of the test positions. There was no significant difference in flow in any of the 4 arteries in any position from neutral, despite large individual variations.

LIMITATIONS

Only individuals who were asymptomatic were investigated, and a short section of the arteries only were imaged.

CONCLUSIONS

Blood flow to the brain does not appear to be compromised by positions commonly used in manual therapy. Positions using end-range neck rotation and distraction do not appear to be more hazardous to cerebral circulation than more segmentally localized techniques.

Is manipulative therapy more effective than sham manipulation in adults : a systematic review and meta-analysis

BACKGROUND

Manipulative therapy is widely used in the treatment of spinal disorders. Manipulative techniques are under debate because of the possibility of adverse events. To date, the efficacy of manipulations compared to sham manipulations is unclear. The purpose of the study is: to assess the efficacy of manipulative therapy compared to sham in adults with a variety of complaints.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

Bibliographic databases (PubMed, EMBASE, CINAHL, PEDro, Central) along with a hand search of selected bibliographies were searched from inception up to April 2012.

RESULTS

In total 965 references were screened for eligibility and 19 RCTs (n = 1080) met the selection criteria. Eight studies were considered of low risk of bias. There is moderate level of evidence that manipulative therapy has a significant effect in adults on pain relief immediately after treatment (standardized mean difference [SMD] - 0.68, 95% confidence interval (-1.06 to -0.31). There is low level of evidence that manipulative therapy has a significant effect in adults on pain relief (SMD - 0.37, -0.69 to -0.04) at short- term follow-up. In patients with musculoskeletal disorders, we found moderate level of evidence for pain relief (SMD - 0.73, -1.21 to -0.25) immediate after treatment and low level of evidence for pain relief (SMD - 0.52, -0.87 to -0.17) at short term-follow-up. We found very low level of evidence that manipulative therapy has no statistically significant effect on disability and perceived (asthma) recovery. Sensitivity analyses did not change the main findings. No serious adverse events were reported in the manipulative therapy or sham group.

CONCLUSIONS

Manipulative therapy has a clinical relevant effect on pain, but not on disability or perceived (asthma) recovery. Clinicians can refer patients for manipulative therapy to reduce pain.

Vertebral artery dissection in a patient practicing self-manipulation of the neck

OBJECTIVE

The purpose of this case report is to describe a patient who regularly practiced self-manipulation of her neck who presented with shoulder and neck pain and was undergoing a vertebral artery dissection.

CLINICAL FEATURES

A 42-year-old female patient sought care for left shoulder pain with a secondary complaint of left lower neck pain. Twelve days prior, she had had "the worst headache of her life," which began in her left lower cervical spine and extended to her left temporal region. The pain was sudden and severe, was described as sharp and burning, and lasted 3 hours. She reported nausea, vomiting, and blurred vision.

INTERVENTION AND OUTCOME

Initial history and examination suggested that the patient's head and neck pain was not musculoskeletal in origin, but vascular. She repeatedly requested that an adjustment be performed, but instead was referred to the local emergency department for further evaluation. Magnetic resonance angiogram revealed a dissection of the left vertebral artery from C6 to the C2-C3 interspace and a 3-mm dissecting pseudoaneurysm at the C3 level. She underwent stent-assisted percutaneous transluminal angioplasty combined with antiplatelet therapy (clopidogrel) and experienced a good outcome.

CONCLUSION

This case suggests that careful history taking and awareness of the symptoms of VAD are necessary in cases of sudden head and neck pain. More research is needed on the relationship between vertebral artery dissection and self-manipulation of the neck.

Internal Carotid Artery Strains During High-Speed, Low-Amplitude Spinal Manipulations of the Neck

OBJECTIVE

The primary objective of this study was to quantify the strains applied to the internal carotid artery (ICA) during neck spinal manipulative treatments and range of motion (ROM)/diagnostic testing of the head and neck.

METHODS

Strains of the ICA (n = 12) were measured in 6 fresh, unembalmed cadaveric specimens using sonomicrometry. Peak and average strains of the ICA obtained during cervical spinal manipulations given by experienced doctors of chiropractic were compared with the corresponding strains obtained during ROM and diagnostic testing of the head and neck.

RESULTS

Peak and average strains of the ICA for cervical spinal manipulative treatments were significantly smaller (P < .001) than the corresponding strains obtained for the ROM and diagnostic testing. All strains during ROM and treatment testing were dramatically smaller than the initial failure strains of the ICA.

CONCLUSIONS

This study showed that maximal ICA strains imparted by cervical spinal manipulative treatments were well within the normal ROM. Chiropractic manipulation of the neck did not cause strains to the ICA in excess of those experienced during normal everyday movements. Therefore, cervical spinal manipulative therapy as performed by the trained clinicians in this study, did not appear to place undue strain on the ICA and thus does not seem to be a factor in ICA injuries.

Assessing the risk of stroke from neck manipulation: a systematic review

BACKGROUND

Strokes, typically involving vertebral artery dissection, can follow cervical spinal manipulative therapy, and these types of stroke occur rarely. There is disagreement about whether a strong association between neck manipulation and stroke exists. An earlier systematic review found two relevant studies of association that used controls, which also discussed the limitations of the two papers. Our systematic review updates the earlier review, and aims to determine whether conclusive evidence of a strong association exists.

METHODS

PRISMA guidelines for systematic reviews were followed, and the literature was searched using a strategy that included the terms 'neck manipulation' and 'stroke' from the PubMed, Embase, CINAHL Plus and AMED databases. Citations were included if they met criteria such as being case-control studies, and dealt with neck manipulation and/or neck movement/positioning. Papers were scored for their quality, using similar criteria to the earlier review. For individual criteria, each study was assigned a full positive score if the criterion was satisfied completely.

RESULTS

Four case-control studies and one case-control study, which included a case- crossover design, met the selection criteria, but all of them had at least three items in the quality assessment that failed to be completely positive. Two studies were assessed to be the most robustly designed, one indicating a strong association between stroke and various intensities of neck movement, including manipulation, and the other suggesting a much reduced relative association when using primary care practitioners' visits as controls. However, potential biases and confounders render the results inconclusive.

CONCLUSION

Conclusive evidence is lacking for a strong association between neck manipulation and stroke, but is also absent for no association. Future studies of association will need to minimise potential biases and confounders, and ideally have sufficient numbers of cases to allow subgroup analysis for different types of neck manipulation and neck movement.

Risk factors and clinical presentation of craniocervical arterial dissection: a prospective study

Background

Craniocervical arterial dissection is a major cause of ischaemic stroke in young adults. The pathogenesis is not fully understood but is thought to be related to a combination of an intrinsic weakness in the arterial wall and an external trigger. Intrinsic susceptibility is thought to be a generalised arteriopathy, vascular anomaly or genetic predisposition. Proposed extrinsic factors include recent viral infection and minor mechanical trauma to the neck, including neck manipulation, which has raised concerns amongst manual practitioners in particular as to the appropriate screening of patients and avoidance of more vigorous therapeutic techniques. The presenting features of dissection may mimic a musculoskeletal presentation, creating a diagnostic dilemma for primary care practitioners. Early recognition is critical so that appropriate management can be commenced.

The aims of this study are to prospectively investigate young patients ≤55 years admitted to hospital with radiologically diagnosed craniocervical arterial dissection compared to matched controls with stroke but not dissection, to identify risk factors and early presenting clinical features, so these may be more readily identified by primary care practitioners.

Methods

Patients ≤ 55 years presenting to hospital with craniocervical arterial dissection and controls will have their medical records reviewed and be interviewed and questioned about possible risk factors, preceding events to admission such as recent neck trauma, and presenting clinical features including any preceding transient ischaemic features. Clinical assessment will include a connective tissue screening examination to identify subclinical connective tissue disorders. Radiology and blood screening will be reviewed for typical features and inflammatory markers. Functional outcome will be reviewed to determine the burden of the stroke.

Discussion

This study will provide descriptive and comparative data on intrinsic and extrinsic risk factors for craniocervical arterial dissection and outline the typical clinical presentation, including the nature of early presenting features which might assist practitioners to identify those patients for whom vigorous manual therapy of the neck is inappropriate and alert them to those for whom immediate urgent medical care should be sought.

A structured review of spinal stiffness as a kinesiological outcome of manipulation: its measurement and utility in diagnosis, prognosis and treatment decision-making

PURPOSE

To review and discuss the methods used for measuring spinal stiffness and factors associated with stiffness, how stiffness is used in diagnosis, prognosis, and treatment decision-making and the effects of manipulative techniques on stiffness.

METHODS

A systematic search of MEDLINE, EMBASE, CINAHL, AMED and ICL databases was conducted. Included studies addressed one of four constructs related to stiffness: measurement, diagnosis, prognosis and/or treatment decision-making, and the effects of manipulation on stiffness. Spinal stiffness was defined as the relationship between force and displacement.

RESULTS

One hundred and four studies are discussed in this review, with the majority of studies focused on the measurement of stiffness, most often in asymptomatic persons. Eight studies investigated spinal stiffness in diagnosis, providing limited evidence that practitioner-judged stiffness is associated with radiographic findings of sagittal rotational mobility. Fifteen studies investigated spinal stiffness in prognosis or treatment decision-making, providing limited evidence that spinal stiffness is unlikely to independently predict patient outcomes, though stiffness may influence a practitioner's application of non-thrust manipulative techniques. Nine studies investigating the effects of manipulative techniques on spinal stiffness provide very limited evidence that there is no change in spinal stiffness following thrust or non-thrust manipulation in asymptomatic individuals and non-thrust techniques in symptomatic persons, with only one study supporting an immediate, but not sustained, stiffness decrease following thrust manipulation in symptomatic individuals.

CONCLUSIONS

The existing limited evidence does not support an association between spinal stiffness and manipulative treatment outcomes. There is a need for additional research investigating the effects of manipulation on spinal stiffness in persons with spinal pain.

Vertebral artery strains during high-speed, low amplitude cervical spinal manipulation

Spinal manipulative therapy (SMT) has been recognized as an effective treatment modality for many back, neck and musculoskeletal problems. One of the major issues of the use of SMT is its safety, especially with regards to neck manipulation and the risk of stroke. The vast majority of these accidents involve the vertebro-basilar system, specifically the vertebral artery (VA) between C2/C1. However, the mechanics of this region of the VA during SMT are unexplored. Here, we present first ever data on the mechanics of this region during cervical SMT performed by clinicians. VA strains obtained during SMT are significantly smaller than those obtained during diagnostic and range of motion testing, and are much smaller than failure strains. We conclude from this work that cervical SMT performed by trained clinicians does not appear to place undue strain on VA, and thus does not seem to be a factor in vertebro-basilar injuries.

Pathologic evaluation of the cervical spine following surgical and chiropractic interventions

When patients die after chiropractic or surgical interventions of the cervical spine, pathologists tasked with the autopsy are frequently overwhelmed by the complicated anatomy, laborious dissections, complex operative procedures and surgical hardware, and the necessity to differentiate artifacts from trauma and disease. However, abundant data can be obtained from careful evaluation of the cervical spine in situ; extensive postmortem diagnostic imaging procedures; detailed dissections of the removed, formalin-fixed and decalcified spine; and histology. This study presents a regimented, stepwise approach to the evaluation of the cervical spine in these difficult cases, promotes uniform assessment, facilitates diagnoses, and supports the accumulation of otherwise hard-to-come-by reference material that can be of value in future cases. The resultant detailed autopsy findings may prove useful in the medico-legal death investigation process. Autopsy findings may also be of great value to health care providers involved in quality assurance processes.

Cerebrovascular dissections: a review. Part II: blunt cerebrovascular injury

Traumatic cerebrovascular injury (TCVI) is present in approximately 1% of all blunt force trauma patients and is associated with injuries such as head and cervical spine injuries and thoracic trauma. Increased recognition of patients with TCVI in the past quarter century has been because of aggressive screening protocols and noninvasive imaging with computed tomography angiography. Extracranial carotid and vertebral artery injuries demonstrate a spectrum of severity, from intimal disruption to traumatic aneurysm formation or vessel occlusion. The most common intracranial arterial injuries are carotid-cavernous fistulae and traumatic aneurysms. Data on the long-term natural history of TCVI are limited, and management of patients with TCVI is controversial. Although antithrombotic medical therapy is associated with improved neurological outcomes, the optimal medication regimen is not yet established. Endovascular techniques have become more popular than surgery for the treatment of TCVI; endovascular options include stenting of dissections, intra-arterial thrombolysis for acute ischemic stroke caused by trauma, and embolization of traumatic aneurysms.

The etiology of cervical artery dissection

The etiology of cervical artery dissection (CAD) is unclear, although a number of risk factors have been reported to be associated with the condition. On rare occasions, patients experience CAD after cervical spine manipulation, making knowledge about the cervical arteries, the predisposing factors, and the pathogenesis of the condition of interest to chiropractors. This commentary reports on the relevant anatomy of the cervical arteries, developmental features of CAD, epidemiology of the condition, and mechanisms of dissection. The analysis of CAD risk factors is confusing, however, because many people are exposed to mechanical events and known pathophysiological associations without ever experiencing dissection. No cause-and-effect relationship has been established between cervical spine manipulation and CAD, but it seems that cervical manipulation may be capable of triggering dissection in a susceptible patient or contributing to the evolution of an already existing CAD. Despite the many risk factors that have been proposed as possible causes of CAD, it is still unknown which of them actually predispose patients to CAD after cervical spine manipulation.