Stroke from Chiropractic Neck Manipulation
On Sunday, Jon made a forum post about Sandra Nette, an Edmonton woman who is suing her chiropractor because she suffered a disabling stroke after receiving a neck adjustment. The correlation between stroke and chiropractic neck manipulation has been studied for years, even back to the 1940s. The incidence is rare but not insignificant. By the 1990s, the medical community had made the case for causation.
Unfortunately, the treatment risk is not widely known. Even Dr. Harriet Hall, the SkepDoc, admits that:
“I had never heard about this phenomenon myself until a few years ago, when I heard it mentioned on an episode of Alan Alda’s Scientific American Frontiers. I questioned his accuracy, but I quickly found confirmation in the medical literature.”
Below the fold is a list of website links and recent medical journal article citations on the the risks and criticisms of chiropractic spinal manipulation therapy.
Skeptical Inquirer magazine. Jan/Feb 08.
“Chiropractic: A Profession Seeking Identity.” S. Homola.
“A Skeptical Consumer’s Look at Chiropractic Claims: Flimflam in Florida?“ B. Thyer, G. Whittenberger.
“Chiropractic’s Dirty Secret: Neck Manipulation and Strokes.” S. Barrett. 2 Jul 06.
“Don’t Let Chiropractors Fool You.” S. Barrett. 31 Jul 98.
“Chiropractic: Does the Bad Outweigh the Good?“ S. Homola. 23 Mar 01.
“Chiropractic’s Elusive Subluxation.” S. Barrett. 21 May 06.
Chirobase website – Your skeptical guide to chiropractic history, theories, and practices
Includes many applicable sections and articles.
Recent Medical Journal Articles – Complications Linked to Spinal Manipulation (citations with available abstracts)
Clinical Neurology and Neurosurgery. “Chiropractic manipulation: reasons for concern?” 2007 Dec;109(10):922-5.
Chiropractic’s popularity is rising among the general population. Moreover, few studies have been conducted to properly evaluate its safety. We report three cases of serious neurological adverse events in patients treated with chiropractic manipulation. The first case is a 41 years old woman who developed a vertebro-basilar stroke 48 h after cervical manipulation. The second case represents a 68 years old woman who presented a neuropraxic injury of both radial nerves after three sessions of spinal manipulation. The last case is a 34 years old man who developed a cervical epidural haematoma after a chiropractic treatment for neck pain. In all three cases there were criteria to consider a causality relation between the neurological adverse events and the chiropractic manipulation. The described serious adverse events promptly recommend the implementation of a risk alert system.
Neurosurgery. “Lumbar epidural hematoma after chiropractic manipulation for lower-back pain: case report.” 2007 Jul;61(1):E170-1.
Mt. Sinai Journal of Medicine. “Chiropractic sympathectomy: carotid artery dissection with oculosympathetic palsy after chiropractic manipulation of the neck.” 2005 May;72(3):207-10.
Journal of Neurology. “Cervical artery dissection–clinical features, risk factors, therapy and outcome in 126 patients.” 2003 Oct;250(10):1179-84.
The highly variable clinical course of cervical artery dissections still poses a major challenge to the treating physician. This study was conducted (1) to describe the differences in clinical and angiographic presentation of patients with carotid and vertebral artery dissections (CAD, VAD), (2) to define the circumstances that are related to bilateral arterial dissections, and (3) to determine factors that predict a poor outcome. Retrospectively and by standardised interview, we studied 126 patients with cervical artery dissections. Preceding traumata, vascular risk factors, presenting local and ischemic symptoms, and patient-outcome were evaluated. Patients with CAD presented more often with a partial Horner’s syndrome and had a higher prevalence of fibromuscular dysplasia than patients with VAD. Patients with VAD complained more often of neck pain, more frequently reported a preceding chiropractic manipulation and had a higher incidence of bilateral dissections than patients with CAD. Bilateral VAD was significantly related to a preceding chiropractic manipulation. Multivariate analysis showed that the variables stroke and arterial occlusion were the only independent factors associated with a poor outcome. This study emphasises the potential dangers of chiropractic manipulation of the cervical spine. Probably owing to the systematic use of forceful neck-rotation to both sides, this treatment was significantly associated with bilateral VAD. Patients with dissection-related cervical artery occlusion had a significantly increased risk of suffering a disabling stroke.
Neurology. “Spinal manipulative therapy is an independent risk factor for vertebral artery dissection.” 2003 May 13;60(9):1424-8.
OBJECTIVE: To determine whether spinal manipulative therapy (SMT) is an independent risk factor for cervical artery dissection.
METHODS: Using a nested case-control design, the authors reviewed all patients under age 60 with cervical arterial dissection (n = 151) and ischemic stroke or TIA from between 1995 and 2000 at two academic stroke centers. Controls (n = 306) were selected to match cases by sex and within age strata. Cases and controls were solicited by mail, and respondents were interviewed using a structured questionnaire. The medical records of interviewed patients were reviewed by two blinded neurologists to confirm that the patient had stroke or TIA and to determine whether there was evidence of arterial dissection.
RESULTS: After interview and blinded chart review, 51 patients with dissection (mean age 41 +/- 10 years; 59% female) and 100 control patients (44 +/- 9 years; 58% female) were studied. In univariate analysis, patients with dissection were more likely to have had SMT within 30 days (14% vs 3%, p = 0.032), to have had neck or head pain preceding stroke or TIA (76% vs 40%, p < 0.001), and to be current consumers of alcohol (76% vs 57%, p = 0.021). In multivariate analysis, vertebral artery dissections were independently associated with SMT within 30 days (OR 6.62, 95% CI 1.4 to 30) and pain before stroke/TIA (OR 3.76, 95% CI 1.3 to 11).
CONCLUSIONS: This case-controlled study of the influence of SMT and cervical arterial dissection shows that SMT is independently associated with vertebral arterial dissection, even after controlling for neck pain. Patients undergoing SMT should be consented for risk of stroke or vascular injury from the procedure. A significant increase in neck pain following spinal manipulative therapy warrants immediate medical evaluation.
Neuroradiology. “Simultaneous bilateral internal carotid and vertebral artery dissection following chiropractic manipulation: case report and review of the literature.” 2003 May;45(5):311-4.
Revista de Neurologia. “Wallenberg’s syndrome secondary to dissection of the vertebral artery caused by chiropractic manipulation” 2003 Nov 1-15;37(9):837-9.
INTRODUCTION: Chiropractic manipulations of the cervical region are techniques that are used more and more frequently to treat a number of osteomuscular pathologies, but can give rise to important complications, such as the dissection of the cervical arteries. Dissection of the vertebral artery generally presents as alternating syndromes, of which Wallenberg s syndrome, either complete or incomplete, is the most frequent. In this paper we review the literature published to date on the pathogenesis, risk factors, clinical features, chronopathology, diagnosis, treatment and prognosis of this complication.
CASE REPORT: We describe the case of a young patient who suffered from incomplete Wallenberg s syndrome a few hours after a single session of cervical chiropractic manipulation, and we also show the resonance images that were used to support the diagnosis.
CONCLUSIONS: The appearance of a pain in the neck and neurological symptoms in a patient who has undergone chiropractic manipulation in the last few hours or days must lead us to consider a possible dissection of the cervical arteries. Dissection of the vertebral artery usually gives rise to alternating syndromes, the most frequent of which is lateral bulbomedullary infarction or Wallenberg s syndrome due to proximal occlusion of the posteroinferior cerebellar artery. Magnetic resonance angiography of the supra aortic trunks and cranial magnetic resonance scanning are valid techniques for demonstrating the dissection of the artery and the associated ischemic lesion.
Stroke. “Chiropractic Manipulation and Stroke: A Population-Based Case-Control Study.” 2001;32(10):1054-60.
BACKGROUND AND PURPOSE: Several reports have linked chiropractic manipulation of the neck to dissection or occlusion of the vertebral artery. However, previous studies linking such strokes to neck manipulation consist primarily of uncontrolled case series. We designed a population-based nested case-control study to test the association. METHODS: Hospitalization records were used to identify vertebrobasilar accidents (VBAs) in Ontario, Canada, during 1993-1998. Each of 582 cases was age and sex matched to 4 controls from the Ontario population with no history of stroke at the event date. Public health insurance billing records were used to document use of chiropractic services before the event date.
RESULTS: Results for those aged <45 years showed VBA cases to be 5 times more likely than controls to have visited a chiropractor within 1 week of the VBA (95% CI from bootstrapping, 1.32 to 43.87). Additionally, in the younger age group, cases were 5 times as likely to have had >/=3 visits with a cervical diagnosis in the month before the case’s VBA date (95% CI from bootstrapping, 1.34 to 18.57). No significant associations were found for those aged >/=45 years.
CONCLUSIONS:While our analysis is consistent with a positive association in young adults, potential sources of bias are also discussed. The rarity of VBAs makes this association difficult to study despite high volumes of chiropractic treatment. Because of the popularity of spinal manipulation, high-quality research on both its risks and benefits is recommended.
American Journal of Opthamology. “Horner’s syndrome and dissection of the internal carotid artery after chiropractic manipulation of the neck.” 2001 Apr;131(4):523-4.
PURPOSE: To report a case of Horner’s syndrome and dissection of the internal carotid artery after chiropractic manipulation of the neck.
METHODS: Case report. A 44-year-old woman with no prior ocular or vascular history presented with severe right-sided head and neck pain, ptosis, and miosis following chiropractic treatment for a strained right shoulder muscle.
RESULTS: Magnetic resonance angiography of the neck and brain revealed a dissection of the right internal carotid artery as well as a suggestion of subtle dissection in the right vertebral artery. No significant brain abnormalities were noted on magnetic resonance imaging. Pharmacological testing was consistent with preganglionic oculosympathetic damage.
CONCLUSION: Acute, painful Horner’s syndrome as a manifestation of vascular dissection may be associated with chiropractic manipulation of the neck.
Neurosurgical Review. “Vertebral and carotid artery dissection following chiropractic cervical manipulation.” 1999 Oct;22(2-3):127-9.
A 50-year-old woman presented a sudden left occipital headache and a posterior circulation stroke after cervical manipulation for neck pain. Magnetic resonance imaging documented a left intracranial vertebral artery occlusive dissection associated with an ipsilateral internal carotid artery dissection with vessel stenosis in its prepetrous tract. This is the first reported case showing an associate vertebral and carotid artery dissection following cervical manipulation. Carotid dissection was asymptomatic and, therefore, its incidence may be underestimated. We emphasize that cervical manipulation should be performed only in patients without predisposing factors for artery dissection and after an appropriate diagnosis of neck pain.
Recent Medical Journal Articles – Chiropractic in General (citations with available abstracts)
Journal of Pain Symptom Management. “Chiropractic: a critical evaluation.” 2008 May;35(5):544-62.
Chiropractic was defined by D.D. Palmer as “a science of healing without drugs.” About 60,000 chiropractors currently practice in North America, and, worldwide, billions are spent each year for their services. This article attempts to critically evaluate chiropractic. The specific topics include the history of chiropractic; the internal conflicts within the profession; the concepts of chiropractic, particularly those of subluxation and spinal manipulation; chiropractic practice and research; and the efficacy, safety, and cost of chiropractic. A narrative review of selected articles from the published chiropractic literature was performed. For the assessment of efficacy, safety, and cost, the evaluation relied on previously published systematic reviews. Chiropractic is rooted in mystical concepts. This led to an internal conflict within the chiropractic profession, which continues today. Currently, there are two types of chiropractors: those religiously adhering to the gospel of its founding fathers and those open to change. The core concepts of chiropractic, subluxation and spinal manipulation, are not based on sound science. Back and neck pain are the domains of chiropractic but many chiropractors treat conditions other than musculoskeletal problems. With the possible exception of back pain, chiropractic spinal manipulation has not been shown to be effective for any medical condition. Manipulation is associated with frequent mild adverse effects and with serious complications of unknown incidence. Its cost-effectiveness has not been demonstrated beyond reasonable doubt. The concepts of chiropractic are not based on solid science and its therapeutic value has not been demonstrated beyond reasonable doubt.
Clinical Orthopaedics and Related Research. “Chiropractic: history and overview of theories and methods.” 2006 Mar;444:236-42.
Chiropractic is one of the most controversial and poorly defined healthcare professions with recognition and licensure in the United States. Chiropractic was started by D. D. Palmer, a magnetic healer who formulated the vertebral subluxation theory. The profession was developed by his son, B. J. Palmer. Although the definition of chiropractic as a method of correcting vertebral subluxations to restore and maintain health is questionable, spinal manipulation is of value in the treatment of some types of back pain. The chiropractic profession is still based on the vertebral subluxation theory, and has the confusing image of a back specialty capable of treating a broad scope of health problems. Despite opposition to use of spinal manipulation as a method of treating a broad scope of health problems (as opposed to the generally accepted use of manipulation in the treatment of back pain), chiropractors seek support as primary care providers in alternative medicine. It is essential to understand the theories, philosophies, and methods of chiropractic for an objective evaluation.
Journal of General Internal Medicine. “Patient expectations as predictors of outcome in patients with acute low back pain.” 2008 Feb;23(2):148-53.
BACKGROUND: Few studies have evaluated the association between patient expectations for recovery and clinical outcomes, and no study has evaluated whether asking patients to choose their therapy modifies such an association.
OBJECTIVE: To evaluate the association between patients’ expectations and functional recovery in patients with acute low back pain (LBP), and to determine whether that association is affected by giving patients choice of therapy.
DESIGN AND PARTICIPANTS: A secondary analysis of a randomized controlled trial comparing usual care alone to usual care plus choice of chiropractic, acupuncture, or massage in 444 adults with acute LBP, lasting less than 21 days.
MEASUREMENTS AND MAIN RESULTS: Primary outcome was functional disability (Roland score) at 5 and 12 weeks. Patients’ general expectations for improvement were associated with improvement in functional status (beta = 0.96, 95% CI = 0.56, 1.36). A 1-point increase in general expectations was associated with a 0.96-point improvement in Roland score. The association of expectation with outcome was 2-3 times greater in the usual care group than the choice group. However, these differences did not reach statistical significance.
CONCLUSIONS: In patients with acute LBP, higher expectations for recovery are associated with greater functional improvement. Eliciting patient expectations for improvement may be a simple way to identify patients with the highest (or lowest) likelihood of experiencing functional improvement. Incorporating questions about patient expectations in future trials may clarify the role of this important correlate of clinical outcomes.