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A Risk-benefit Assessment Strategy to Exclude Cervical Artery Dissection in Spinal Manual-therapy: A Comprehensive Review

The Chiro.Org Blog

SOURCE:   Annals of Medicine 2019 (Mar 19): 1–10 [Epub]

Aleksander Chaibi & Michael Bjørn Russell

Head and Neck Research Group,
Research Centre, Akershus University Hospital,
Oslo, Norway.

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.

• 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.

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Vertebral Artery Dissection as a Cause of Cervical Radiculopathy

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SOURCE:   Asian Spine J. 2013 (Dec); 7 (4): 335–338

Benjamin Isaac Silbert, Mark Khangure, and
Peter Linton Silbert

Department of Neurology,
Royal Perth Hospital,
Perth, Australia.

The acute onset of neck pain and arm weakness is most commonly due to cervical radiculopathy or inflammatory brachial plexopathy. Rarely, extracranial vertebral artery dissection may cause radiculopathy in the absence of brainstem ischemia. We describe a case of vertebral artery dissection presenting as cervical radiculopathy in a previously healthy 43-year-old woman who presented with proximal left arm weakness and neck pain aggravated by movement. Cervical magnetic resonance imaging (MRI) and angiography revealed dissection of the left vertebral artery with an intramural hematoma compressing the left C5 and C6 nerve roots. Antiplatelet treatment was commenced, and full power returned after 2 months. Recognition of vertebral artery dissection on cervical MRI as a possible cause of cervical radiculopathy is important to avoid interventions within the intervertebral foramen such as surgery or nerve root sleeve injection. Treatment with antithrombotic agents is important to prevent secondary ischemic events.

KEYWORDS:   Cervical spine; Neck pain; Radiculopathy; Vertebral artery dissection

From the FULL TEXT Article:

Introduction

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Chiropractic Response to a Spontaneous Vertebral Artery Dissection

The Chiro.Org Blog

SOURCE:   J Chiro Med 2015 (Sep); 14 (3): 183–190 ~ FULL TEXT

Gary Tarola, DC, and Reed B. Phillips, DC

Private Practice,
Lehigh Valley Medical Network,
Allentown, PA.

OBJECTIVE:   The purpose of this case report is to describe a case in which early detection and proper follow-up of spontaneous vertebral artery dissection led to satisfactory outcomes.

CLINICAL FEATURES:   A 34-year old white woman reported to a chiropractic clinic with a constant burning pain at the right side of her neck and shoulder with a limited ability to turn her head from side to side, periods of blurred vision, and muffled hearing. Dizziness, visual and auditory disturbances, and balance difficulty abated within 1 hour of onset and were not present at the time of evaluation. A pain drawing indicated burning pain in the suboccipital area, neck, and upper shoulder on the right and a pins and needles sensation on the dorsal surface of both forearms. Turning her head from side-to-side aggravated the pain, and the application of heat brought temporary relief. The Neck Disability Index score of 44 placed the patient’s pain in the most severe category.

INTERVENTION AND OUTCOME:   The patient was not treated on the initial visit but was advised of the possibility of a vertebral artery or carotid artery dissection and was recommended to the emergency department for immediate evaluation. The patient declined but later was convinced by her chiropractor to present to the emergency department. A magnetic resonance angiogram of the neck and carotid arteries was performed showing that the left vertebral artery was hypoplastic and appeared to terminate at the left posterior inferior cerebellar artery. There was an abrupt moderately long segment of narrowing involving the right vertebral artery beginning near the junction of the V1 and V2 segments. The radiologist noted a concern regarding right vertebral artery dissection. Symptoms resolved and the patient was cleared of any medications but advised that if symptoms reoccurred she was to go for emergency care immediately.

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Systematic Review and Meta-analysis of Chiropractic Care and Cervical Artery Dissection:
No Evidence for Causation

The Chiro.Org Blog

SOURCE:   Cureus 2016 (Feb 16);   8 (2):   e498

Ephraim W. Church, MD,   Emily P. Sieg, MD,
Omar Zalatimo, MD,   Namath S. Hussain, MD,
Michael Glantz, MD,   Robert E. Harbaugh, MD

Department of Neurosurgery,
Penn State Hershey Medical Center

BACKGROUND:   Case reports and case control studies have suggested an association between chiropractic neck manipulation and cervical artery dissection (CAD), but a causal relationship has not been established. We evaluated the evidence related to this topic by performing a systematic review and meta-analysis of published data on chiropractic manipulation and CAD.

METHODS:   Search terms were entered into standard search engines in a systematic fashion. The articles were reviewed by study authors, graded independently for class of evidence, and combined in a meta-analysis. The total body of evidence was evaluated according to GRADE criteria.

RESULTS:   Our search yielded 253 articles. We identified two class II and four class III studies. There were no discrepancies among article ratings (i.e., kappa=1). The meta-analysis revealed a small association between chiropractic care and dissection (OR 1.74, 95% CI 1.26-2.41). The quality of the body of evidence according to GRADE criteria was “very low.”

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