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.

     

Is cervical spinal manipulation dangerous?

OBJECTIVE: Concern about cerebrovascular accidents after cervical manipulation is common. We report a case of cerebrovascular infarction without sequelae. CLINICAL FEATURES: A 39-year-old man with nonspecific neck pain was treated by his general practitioner with cervical manipulation. INTERVENTION AND OUTCOME: This immediately elicited severe headache and neurologic symptoms that disappeared completely within 3 months despite permanent signs of a complete left-sided cerebellar infarction on computed tomography and magnetic resonance imaging. At 7-year follow-up the patient was fully employed, and repeated magnetic resonance imaging still showed infarction of the left cerebellar hemisphere. However, the patient remained completely free of neurologic symptoms, and color duplex ultrasonography showed normal cervical vessels, including patent vertebral arteries. CONCLUSION: It appears that the risk of cerebrovascular accidents after cervical manipulation is low, considering the enormous number of treatments given each year, and very much lower than the risk of serious complications associated with generally accepted surgery. Provided there is a solid indication for cervical manipulation, we believe that the risk involved is acceptably low and that the fear of serious complications is greatly exaggerated.     

Vertebral artery dissection and cerebellar infarction following chiropractic manipulation

Vertebral artery dissection (VAD) associated with chiropractic cervical manipulation is a rare but potentially disabling condition. In this report, we present a young patient manifesting with repeated vertigo. Owing to the initial misdiagnosis, the patient later developed cerebellar stroke with inability to stand or walk. Vertigo and disequilibrium are the usual presenting symptoms of this condition, which can result from inner ear or vestibular nerve dysfunction, vertebrobasilar insufficiency, and even lethal cerebellar infarction or haemorrhage; these last two, although rarely seen in young adults, can be caused by traumatic or spontaneous arterial injury, including injury secondary to chiropractic cervical manipulation. A number of cases of VAD associated with chiropractic cervical manipulation have been reported, but rarely in the emergency medicine literature. We present a case of this rare occurrence, and discuss the diagnostic pitfalls.     

Uneventful upper cervical manipulation in the presence of a damaged vertebral artery

OBJECTIVE: To discuss a case in which a patient with a previously injured vertebral artery underwent manipulation in the upper cervical spine without alteration of her symptom pattern. The literature concerning the relative safety of specific upper cervical manipulative techniques is reviewed. CLINICAL FEATURES: A 42-year-old woman had a 3-week history of unilateral suboccipital pain that she related to a sudden twisting of her head and neck that occurred while she was putting sheets of drywall on top of her car. Subsequent examination by a neurologist 2 weeks later was unremarkable, and a tension-type headache was diagnosed. Approximately 10 days later (3 weeks after injury), a single high-velocity upper-cervical manipulation (incorporating slight rotation and full lateral flexion) was performed with no change in her symptom pattern. Two weeks after that, the patient had development of a lateral medullary syndrome (also known as Wallenberg syndrome) after she briefly extended and rotated her upper cervical spine while painting a ceiling. INTERVENTION AND OUTCOME: The patient was treated with anticoagulant therapy, and the lateral medullary infarct healed without incident. The spinocerebellar and subtle motor symptoms also resolved, but the ipsilateral suboccipital headache and the loss of temperature sensation associated with the spinothalamic tract lesion were still present 9 months later. CONCLUSION: This case report demonstrates that vigorous manipulation of the upper cervical spine is possible without injuring an already damaged vertebral artery. It is suggested that the line of drive used during the single manipulation, almost pure lateral flexion with slight rotation, was responsible for the apparent innocuous response. Guidelines for the evaluation and management of vertebral artery dissection are reviewed. Because it is currently impossible to identify patients at risk of having a dissected vertebral artery with standard in-office examination procedures, rotational manipulation of the upper cervical spine should be abandoned by all practitioners, and schools should remove such techniques from their curriculums.     

Headache as the initial manifestation of acute aortic dissection type A

The most common initial symptom of aortic dissection is chest pain. Other initial symptoms include pain in the neck, throat, abdomen and lower back, syncope, paresis, and dyspnoea. Headache as the initial symptom of aortic dissection has not been described previously. A 61-year-old woman with a history of migraine and arterial hypertension developed continuous bifrontal headache. Two hours later, right-sided thoracic pain and a diastolic murmur were suggestive of aortic dissection that was confirmed by echocardiography and subsequent surgery. The dissection commenced in the ascending aorta and involved all cervical arteries until the base of the skull. Headache as the initial manifestation of aortic dissection was assumed due to either vessel distension or pericarotid plexus ischemia. Aortic dissection has to he considered as a rare differential diagnosis of frontal headache, especially in patients who develop aortic regurgitation or chest pain for the first time.     

Postpartum headache due to spontaneous cervical artery dissection

Postpartum headache is quite common and often related to potentially ominous cerebrovascular accidents. As illustrated in previously published reports, spontaneous cervical artery dissection is a rare but possible cause of headache in the postpartum. We provide 2 additional cases to the 19 described so far, including the first ever report of migraine with aura-like symptoms. Additionally, we summarize the literature and we speculate about the possible etiopathological mechanism underlying this condition.     

Headache as a manifestation of a life-threatening vascular disorder

Headache is a common complaint among patients seeking medical assistance. The differentiation between a primary headache disorder versus headache as a symptom of a serious underlying disease is of crucial importance. Dissections of the carotid or vertebral arteries frequently present with headache and can result in ischemic stroke. Rarely, headache or neck pain is a presenting symptom in patients with spontaneous proximal aortic dissection. We report on a 53-year-old man with a history of migraine with aura, who was admitted to the hospital because of severe frontal headache and neck pain. An anterior chest pain lasting for 10 minutes the day before and a diastolic heart murmur suggested a proximal aortic dissection, which was confirmed by transesophageal echocardiography. Patients with proximal aortic dissection rarely have headache or neck pain, reflecting the low incidence of carotid artery involvement in this disease. However, differentiation between an isolated cervical artery dissection and a proximal aortic dissection extending to the carotid arteries is pivotal, since treatment options are vastly different.     

Vertebral artery dissection onset mimics migraine with aura in a graphic designer

Headache is the most common symptom in patients with cervical artery dissection. This symptom, however, rarely occurs in isolation, and more commonly is associated with other neurological symptoms and signs. Visual symptoms associated with vertebral artery dissection (VD) have also been observed, but do not typically mimic the migraine aura. Here, we report a young patient who presented VD, embolic ischemic lesions, and visual symptoms with the features of aura, followed by migraine headache. The suggestion of VD dissection should be kept in mind in those cases complaining of the first attack of headache that mimics migraine with aura. In these cases, an extensive neuroimaging study is advisable.     

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.     

Spontaneous bilateral vertebral artery dissections: case report and literature review.

Vertebral artery dissection (VAD) has been increasingly identified as a cause of ischemic stroke in young adults. We report the clinical and radiographic findings in a case of spontaneous bilateral VADs and review the literature on the causes, pathophysiology, diagnostic considerations, and treatment options for VAD. A 29-year-old man was admitted to our hospital after sudden onset of headache and nuchal rigidity that progressed to a posterior lateral medullary syndrome in a 2-week period. The diagnosis of bilateral VADs was based on findings on cranial magnetic resonance imaging and conventional angiography. The patient was given anticoagulant therapy and had no further neurologic deterioration. The differential diagnosis of craniocervical pain in young patients should include arterial dissection of the neck because early diagnosis and treatment may reduce the chances of long-term neurologic sequelae.     

Vertebrobasilar ischemia after cervical spine manipulation: A case report

INTRODUCTION: The most serious accidents after cervical spine manipulation are vertebrobasilar ischemia. Their incidence is underestimated. Their risk of apparition is lower if the contraindications are respected and if they are realised according to suitable practice. CASE REPORT: Mrs B, 39 years old, was an active smoker and had migraine for 10 years ago. One day, she presented an unusual headache associated with neck pain that was treated by a cervical spine manipulation. Seven hours after, she developed an alternate syndrome with a right sensory motor defect, a cerebellar syndrome, a pyramidal syndrome and a left defect of cranial nerves. The arteriography showed a thrombosis of the basilar trunk and a dissection of the left vertebral artery. A thrombolysis "in situ" was realized six hours and a half after the onset of the neurological defects. After eight months of rehabilitation, there were still a paralysis of the right upper limb, of the cranial nerves and a cerebellar syndrome but the patient was able to walk with two crutches and can eat by herself. DISCUSSION: Several risk factors were present in this case and there was also a major contraindication to manipulations: unusual acute occipital headache. Given the long period between the onset of neurological symptoms and the confirmation of the diagnosis, intravenous thrombolysis could not be done. Unfortunately, after eight months, important neurological sequels persisted. In order to avoid this type of accident after cervical manipulations, it is necessary to realize a strict medical examination and to implement the recommendations from the French society of manual and orthopaedic osteopathic medicine (Société fran?aise de médecine manuelle orthopédique et ostéopathique [SOFMMOO]).     

Is it time to stop functional pre-manipulation testing of the cervical spine?

The combined extended and rotated cervical spine position has been postulated to affect vertebral artery blood flow by primarily causing a narrowing of the vessel lumen, usually within the artery contralateral to the side of head rotation. The production of brainstem symptoms during the manoeuvre has generally been considered to be a positive test result. As a consequence, functional pre-manipulation testing of the cervical spine has been part of clinical screening undertaken by chiropractors and other manual practitioners to rule out the risk of possible injury to the vertebral artery. To date, these testing procedures are taught to students and carried out in daily clinical practice, despite the considerable controversy that exists about their validity. This paper considers and discusses the usefulness of functional pre-manipulation testing for clinical scenarios, involving dissection, spasm or stenosis of the vertebral artery, and makes the following recommendations: (1) Practitioners must assess the patient thoroughly, through careful history taking and physical examination, for the possibility of vertebral artery dissection. It is important to note that vertebral artery dissection (VAD) may present as pain only, and may not be associated with symptoms and signs of brainstem ischaemia. (2) If there is a strong likelihood of VAD, provocative pre-manipulation tests should not be performed, and the patient must be referred appropriately. (3) In the patient presenting with symptoms of brainstem ischaemia due to non-dissection stenotic vertebral artery pathologies, provocative testing is very unlikely to provide any useful additional diagnostic information. (4) In the patient with unapparent vertebral artery pathology, where spinal manipulative therapy (SMT) is considered as the treatment of choice, provocative testing is very unlikely to provide any useful information in assessing the probability of manipulation induced vertebral artery injury.     

Neck pain and minor trauma: normal radiographs do not always exclude serious pathology

A 37-year-old woman presented following a trampolining accident with neck pain and paraesthesia of the left arm. Cervical spine radiographs were normal and a provisional diagnosis of whiplash was made. Three hours later she developed rotational vertigo and then cerebellar signs. Magnetic resonance angiography and magnetic resonance imaging of the brain confirmed the diagnosis of vertebral artery dissection (VAD) with cerebellar embolic infarcts. She was anticoagulated and symptoms resolved over one week. VAD is a relatively common cause of posterior circulation stroke in young people. It usually presents following (often minor) trauma, with headache, neck pain, cerebellar, sensory and cranial nerve signs. However, it remains a diagnosis that is frequently missed or misdiagnosed.     

Waking cervical pain and stiffness, headache, scapular or arm pain: gender and age effects

A random population-based study using a structured telephone questionnaire was undertaken to determine the frequency, duration and prevalence of waking cervical spine pain and stiffness, headache, and aching between the scapulae or in the arm and their relationship to age and gender. Seventy-six per cent of households contacted completed the questionnaire, yielding a total of 812 questionnaires. Subjects most commonly reported waking with scapular or arm pain (27%) followed by headache (19%), cervical pain (18%) and cervical stiffness (17%). The majority of subjects reported that symptoms lasted for more than an hour on one or two occasions during the week. Subjects who reported the presence of one type of waking symptom were significantly more likely to report other waking symptoms. Females were significantly more likely to wake with a headache than males (OR 2.5, 95% CI 1.6 to 4.0), while all subjects aged over 60 years were significantly less likely to wake with a headache than subjects in other age groups (OR 0.6, 95% CI 0.4 to 1.0). Females exhibited a decline in waking cervical pain, stiffness and headache with increasing age. In contrast, males exhibited a peak prevalence of waking cervical pain, stiffness and headache in the 40 to 59 year age group. The prevalence of waking with aching between the scapulae or in the arm behaved differently from the other symptom groups in both genders.     

Cervical manipulation to a patient with a history of traumatically induced dissection of the internal carotid artery: a case report and review of the literature on recurrent dissections.

OBJECTIVE: To describe the use of rotational cervical manipulation in treating a patient who had undergone a traumatically induced dissection of the internal carotid artery and to review the literature on recurrent cervical artery dissections. CLINICAL FEATURES: A 21-year-old woman with hemiparesis from an internal carotid artery dissection that occurred as the result of a motor vehicle accident had neck pain and headaches. Moderate range of motion restrictions in the neck were present along with articular restrictions to movement palpation. INTERVENTION AND OUTCOME: After a year of soft-tissue treatment, we obtained detailed, informed consent from the patient to attempt diversified manipulation to the neck. The patient described greater and more immediate relief and longer pain-free periods than could be achieved by soft-tissue treatment alone. CONCLUSION: Patients with previous cervical artery dissections may present with unrelated neck pain and headaches and request treatment. In selected cases, with complete informed consent, manipulation of the neck may relieve these symptoms. A review of published case reports on recurrent dissections suggests that trauma is not a significant factor in the second dissection. Care must be taken in extrapolating the results from this case to any other patient with a history of cervical artery dissection.     

Headache: an unusual presentation of aortic dissection.

The most common presenting symptom of aortic dissection is chest pain - headache as the initial manifestation is rare. We report a patient with a history of hypertension who presented with severe bifrontal headache, and was found to have an acute aortic dissection in the absence of carotid artery dissection. A discussion of the atypical presentation and possible pathophysiology follows.     

How common are side effects of spinal manipulation and can these side effects be predicted?

Little scientific support is available concerning usual and unusual reactions after spinal manipulation although such reactions are very common in clinical practice. Fifty-nine manipulative therapists were requested to enroll 15 consecutive patients attending for their first visit to receive spinal manipulation. These patients were asked to complete a questionnaire after this first visit that asked for possible risk factors for spinal manipulation and asked about any side effects after the manipulation. The participating practitioners were asked to note medical diagnosis, manipulated spinal region, number of treated areas and type of additional treatment. Four hundred and sixty five valuable responses were analysed. Two hundred and eighty three patients (60.9%) reported at least one post-manipulative reaction. The most common were headache (19.8%), stiffness (19.5%), local discomfort (15.2%), radiating discomfort (12.1%) and fatigue (12.1%). Most of these reactions began within 4 h and generally disappeared within the next 24 h. Women were more likely to report adverse effects than men (P < 0.001). Multivariate analysis showed that upper cervical manipulation (OR: 3.20; 95%CI: 1.89-7.77), use of medication (OR: 2.20; 95%CI: 1.31-3.69), gender (OR: 1.66; 95%CI: 1.01-2.75) and age (OR: 1.02; 95%CI: 1.00-1.05) were independent predictors of headache after spinal manipulation. The results of this study indicate that reactions to spinal manipulation may be relatively common but are benign in nature and of short duration. Although it is difficult to label side effects as a risk, it is important to differentiate those patients who are susceptible to side effects in order to inform them correctly.     

Risk factors and clinical features of craniocervical arterial dissection

Craniocervical arterial dissection is one of the most common causes of ischaemic stroke in young people and is occasionally associated with neck manipulation. Identification of individuals at risk will guide risk management. Early recognition of dissection in progress will expedite medical intervention. Study aims were to identify risk factors and presenting features of craniocervical arterial dissection. Medical records of patients from the Hunter region of New South Wales, Australia aged ≤ 55 years with radiographically confirmed or suspected vertebral or internal carotid artery dissection, were retrospectively compared with matched controls with stroke from some other cause. Records were inspected for details of clinical features, presenting signs and symptoms and preceding events. Records of 47 dissection patients (27 males, mean age 37.6 years) and 43 controls (22 males, mean age 42.6 years) were inspected. Thirty (64%) dissection patients but only three (7%) controls reported an episode of mild mechanical trauma, including manual therapy, to the cervical spine within the preceding three weeks. Mild mechanical trauma to the head and neck was significantly associated with craniocervical arterial dissection (OR 23.53). Cardiovascular risk factors for stroke were less evident in the dissection group (<1 factor per case) compared to the controls (>3).     

Musculoskeletal head and neck pain

Musculoskeletal head and neck pain is an extremely common clinical syndrome in outpatient pain practice. Cervical structures are a frequent cause of headache and must be differentiated from primary headache disorders. Convergence of cervical and trigeminal nociceptive pathways in the upper part of the cervical spinal cord is the neurophysiologic basis of this connection. An interdisciplinary pain management approach that addresses psychosocial factors, pharmacologic and interventional pain management and incorporates progressive exercise training is most likely to be effective. This review discusses the comprehensive evaluation and management of musculoskeletal head and neck pain with a focus on cervicogenic headache, cervical myofascial pain, and temperomandibular dysfunction.     

Does cervical kyphosis relate to symptoms following whiplash injury?

The mechanisms for developing long-lasting neck pain after whiplash injuries are still largely unrevealed. In the present study it was investigated whether a kyphotic deformity of the cervical spine, as opposed to a straight or a lordotic spine, was associated with the symptoms at baseline, and with the prognosis one year following a whiplash injury. MRI was performed in 171 subjects about 10 d after the accident, and 104 participated in the pain recording at 1-year follow-up. It was demonstrated that postures as seen on MRI can be reliably categorized and that a straight spine is the most frequent appearance of the cervical spine in supine MRI. In relation to symptoms it was seen that a kyphotic deformity was associated with reporting the highest intensities of headache at baseline, but not with an increased risk of long-lasting neck pain or headache. In conclusion, a kyphotic deformity is not significantly associated with chronic whiplash associated pain. Moreover, it is a clear clinical implication that pain should not be ascribed to a straight spine on MRI. We suggest that future trials on cervical posture focus upon the presence of kyphotic deformity rather than just on the absence of lordosis.