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Peak Systolic Flow Velocity as a Measure of Internal Carotid Stenosis. The relationship between peak systolic flow velocity in the internal carotid artery and the severity of stenosis as measured by contrast angiography is illustrated. Note the considerable overlap between adjacent categories of stenosis. Error bars indicate 61 standard deviation about the mean values. Reprinted with permission from Grant et al. 113
Source publication
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...
Context in source publication
Context 1
... ultrasound does not directly measure the diameter of the stenotic lesion; instead, blood flow velocity is an indicator of severity (Figure 2). The peak systolic velocity in the internal carotid artery and the ratio of the peak systolic velocity in the internal carotid artery to that in the ipsilateral common carotid artery correlate with angiographically determined stenosis. ...
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Objective:
The aim of this study was to study mechanism, risk factors, and prognosis of patients with vertebral artery dissection (VAD) from acute cervical spine trauma (CST).
Methods:
A total of 149 consecutive patients were chosen from 2014 to 2019 from our institute data base, and their records were retrospectively studied. Morphology of frac...
Background:
Failing to recognise the signs and symptoms of subarachnoid haemorrhage (SAH) causes diagnostic delay and may result in poorer outcomes. We report a rare case of SAH secondary to a vertebral artery dissection (VAD) that initially presented with cauda equina-like features, followed by symptoms more typical of SAH.
Case presentation:
A...
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 Dece...
Objective: Basilar artery occlusion (BAO) is an infrequent form of acute life-threatening stroke and may occur secondary to vertebral artery dissection (VAD). VAD, which occurs spontaneously and sometimes results from mechanical stress or blunt force trauma to the neck, sometimes occurs in the V1−V2 junction, but there are not many reported cases o...
Citations
... CSM causes little or no strain on the cervical arteries [2,3]. In a statement from the American Heart Association and American Stroke Association, Biller et al. [4] found that biomechanical evidence is insufficient to establish the claim that CSM causes CAD and recommended that practitioners should strongly consider CAD as a presenting symptom prior to CSM. Church et al. [5], a group of neurosurgeons from Penn State Hershey Medical Center, found no convincing evidence that CSM can cause CAD in an otherwise healthy artery. ...
... However, research shows that in cases of stroke immediately following CSM, the patient likely had an existing CAD before the CSM [9,10]. Biller et al. [4] recommended that practitioners should strongly consider CAD as a presenting symptom prior to CSM. ...
Recent media coverage of high-profile cases of cervical artery dissection (CAD) has ignited the discussion about the role of cervical spine manipulation (CSM) in causing cervical artery dissection.
However, research does not support a causal association between cervical spine manipulation and cervical artery dissection in a healthy cervical spine. The objective of this study was to review the 10 most recent case reports of cervical spine manipulation and cervical artery dissection for convincing evidence of the causation of cervical artery dissection by cervical spine manipulation.
Nine of 10 case reports showed no convincing evidence of a causal relationship between cervical spine manipulation and cervical artery dissection. The 10th case report was exceptional as the CSM was contraindicated by pre-existing cervical spine pathology.
We conclude that these 10 case reports provide no convincing evidence of the causation of cervical artery dissection by cervical spine manipulation in a healthy cervical spine. One case report demonstrated that cervical spine manipulation can cause cervical artery dissection when performed in the presence of pre-existing cervical spine pathology. Therefore, we conclude that practitioners should exclude cervical spine pathology before performing cervical spine manipulation.
... CICAD is often caused by strong external forces such as automobile collisions and is rarely related to low-impact sports such as tennis [1]. Compared with spontaneous ICA dissection, the susceptible age for traumatic CICAD is younger (approximately 40 years) and the location is more distal (usually around the first to third cervical vertebrae) [12]. The typical symptoms of CICAD include unilateral neck, facial, and head pain, sometimes accompanied by Horner's syndrome, cerebral infarction, or retinal ischemia [12]. ...
... Compared with spontaneous ICA dissection, the susceptible age for traumatic CICAD is younger (approximately 40 years) and the location is more distal (usually around the first to third cervical vertebrae) [12]. The typical symptoms of CICAD include unilateral neck, facial, and head pain, sometimes accompanied by Horner's syndrome, cerebral infarction, or retinal ischemia [12]. In this case, the fundus examination was normal, and there was no evidence of cerebral infarction. ...
Traumatic cervical internal carotid artery dissection (CICAD) is a rare condition caused by blunt trauma to the neck, often through automobile- or sports-related collisions, assaults, or falls. Herein, we report an unusual case in which engaging in a low-impact sport (tennis) caused CICAD, without a direct injury. A 56-year-old man with hypertension suddenly experienced a visual field loss in his right eye while playing tennis. Carotid echocardiography revealed severe stenosis of the right internal carotid artery (ICA). Angiography revealed severe and irregular stenosis of the right ICA from the bifurcation to the petrous portion, suggesting CICAD. Upon admission, the patient had left upper visual field defects in his right eye and neck pain. Antiplatelet therapy was initiated with prasugrel (3.75 mg/day), with the intent to treat surgically if the stenosis or symptoms progressed. Follow-up angiography and magnetic resonance imaging showed gradual resolution of the stenosis, and the patient was discharged on day 28 with a modified Rankin Scale score of 1. The CICAD should be considered as a diagnosis for neurological symptoms, even in the context of low-impact sports such as tennis. Antithrombotic therapy is a reasonable first-line treatment for stable CICAD.
... Our findings are in agreement with a previous systematic review that reported that MT appears to have a relatively lower risk for adverse events compared to medications [47]. Previous evidence deriving from small observational studies and expert opinions has suggested a potential association between MT and craniocervical arterial dissections [48,49]. Our analysis, however, does not confirm these findings. ...
Background
This systematic review and meta-analysis seeks to investigate the effectiveness and safety of manual therapy (MT) interventions compared to oral pain medication in the management of neck pain.
Methods
We searched from inception to March 2023, in Cochrane Central Register of Controller Trials (CENTRAL), MEDLINE, EMBASE, Allied and Complementary Medicine (AMED) and Cumulative Index to Nursing and Allied Health Literature (CINAHL; EBSCO) for randomized controlled trials that examined the effect of manual therapy interventions for neck pain when compared to medication in adults with self-reported neck pain, irrespective of radicular findings, specific cause, and associated cervicogenic headaches. We used the Cochrane Risk of Bias 2 tool to assess the potential risk of bias in the included studies, and the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach to grade the quality of the evidence.
Results
Nine trials (779 participants) were included in the meta-analysis. We found low certainty of evidence that MT interventions may be more effective than oral pain medication in pain reduction in the short-term (Standardized Mean Difference: -0.39; 95% CI -0.66 to -0.11; 8 trials, 676 participants), and moderate certainty of evidence that MT interventions may be more effective than oral pain medication in pain reduction in the long-term (Standardized Mean Difference: − 0.36; 95% CI − 0.55 to − 0.17; 6 trials, 567 participants). We found low certainty evidence that the risk of adverse events may be lower for patients that received MT compared to the ones that received oral pain medication (Risk Ratio: 0.59; 95% CI 0.43 to 0.79; 5 trials, 426 participants).
Conclusions
MT may be more effective for people with neck pain in both short and long-term with a better safety profile regarding adverse events when compared to patients receiving oral pain medications. However, we advise caution when interpreting our safety results due to the different level of reporting strategies in place for MT and medication-induced adverse events. Future MT trials should create and adhere to strict reporting strategies with regards to adverse events to help gain a better understanding on the nature of potential MT-induced adverse events and to ensure patient safety.
Trial registration
PROSPERO registration number: CRD42023421147.
... Cervical spine manipulation (CSM) is a manual therapy in which a controlled, high-velocity, low-amplitude thrust is applied to the cervical spine and induces a therapeutic stretch on the cervical spine joints. The majority of CSM performed in North America is done by chiropractic physicians; however, CSM is also performed by osteopathic physicians, naturopathic physicians, medical physicians, and doctors of physical therapy [1]. ...
... In 2013, Symons and Herzog summarized the results of four biomechanical cadaver studies demonstrating that strains to the cervical arteries during CSM are typically less than 50% of strains obtained during normal range of motion (ROM) testing, and far less than failure strains [5]. In 2014, Biller et al. performed a literature review and concluded that biomechanical evidence was insufficient to establish the claim that CSM causes CAD [1]. Church et al. (2016) performed a systematic review and meta-analysis of published data on CSM and CAD. ...
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.
... For the prevention of early and late stroke recurrences, anticoagulants and antiplatelet agents are generally used. When applicable, secondary stroke prevention 1 1 1 2 1 recommendations should be followed with regard to other causes of IS [4,7]. ...
... We consider that his carotid dissection was likely related to that session. Despite the lack of direct evidence to support chiropractic manipulation's association with CAD, clinical reports have suggested that mechanical forces could play a role in cervical and vertebral artery dissection in young stroke patients [7]. ...
... Patients with acute IS related to CAD without contraindications should be treated with thrombolysis without delay within 4.5 hours. The use of tissue-type plasminogen activator (TPA) is safe for patients with acute IS due to CAD, as it does not increase the risk of intracranial hemorrhage [7,10]. TPA was not used in our case due to the patient's late arrival at the hospital (72 hours after the onset of symptoms). ...
Guidelines for the treatment and management of ischemic strokes triggered by stenosis versus dissection are well established. However, the presence of both entities in the same patient, although rare, poses challenges for short- and long-term treatment. Here, we describe the case of a 55-year-old man who presented to the emergency department with a 72-hour history of headache, dizziness, unbalanced gait, nausea, and two episodes of vomiting. Stroke was initially suspected, but the computerized tomography (CT) scan showed no hemorrhage. His magnetic resonance imaging (MRI) showed right inferior cerebellar acute ischemia in the territory of the right posterior inferior cerebellar artery (PICA), with smaller foci of early acute infarcts in the bilateral inferior cerebellum. Furthermore, magnetic resonance angiography (MRA) and CT angiography revealed right vertebral artery stenosis and left cervical internal carotid artery dissection (ICAD). This clinical report describes a rare case of stroke secondary to vertebral artery stenosis with concomitant carotid artery dissection. The treatment course and evolution are presented.
... 11 Models were weighted for prespecified variables that have been shown or are thought to potentially alter the stroke risk and possibly affect treatment choice, 8,[12][13][14][15] or increase major bleeding risk. [16][17][18][19] Variables used for weighting and adjustment are shown in Table S1. ...
Background: Small, randomized trials of cervical artery dissection (CAD) patients showed conflicting results regarding optimal stroke prevention strategies. We aimed to compare outcomes in patients with CAD treated with antiplatelets versus anticoagulation. Methods: This is a multi-center observational retrospective international study (16 countries, 63 sites) that included CAD patients without major trauma. The exposure was antithrombotic treatment type (anticoagulation vs. antiplatelets) and outcomes were subsequent ischemic stroke and major hemorrhage (intracranial or extracranial hemorrhage). We used adjusted Cox regression with Inverse Probability of Treatment Weighting (IPTW) to determine associations between anticoagulation and study outcomes within 30 and 180 days. The main analysis used an "as treated" cross-over approach and only included outcomes occurring on the above treatments. Results: The study included 3,636 patients [402 (11.1%) received exclusively anticoagulation and 2,453 (67.5%) received exclusively antiplatelets]. By day 180, there were 162 new ischemic strokes (4.4%) and 28 major hemorrhages (0.8%); 87.0% of ischemic strokes occurred by day 30. In adjusted Cox regression with IPTW, compared to antiplatelet therapy, anticoagulation was associated with a non-significantly lower risk of subsequent ischemic stroke by day 30 (adjusted HR 0.71 95% CI 0.45-1.12, p=0.145) and by day 180 (adjusted HR 0.80 95% CI 0.28-2.24, p=0.670). Anticoagulation therapy was not associated with a higher risk of major hemorrhage by day 30 (adjusted HR 1.39 95% CI 0.35-5.45, p=0.637) but was by day 180 (adjusted HR 5.56 95% CI 1.53-20.13, p=0.009). In interaction analyses, patients with occlusive dissection had significantly lower ischemic stroke risk with anticoagulation (adjusted HR 0.40 95% CI 0.18-0.88) (Pinteraction=0.009). Conclusions: Our study does not rule out a benefit of anticoagulation in reducing ischemic stroke risk, particularly in patients with occlusive dissection. If anticoagulation is chosen, it seems reasonable to switch to antiplatelet therapy before 180 days to lower the risk of major bleeding. Large prospective studies are needed to validate our findings.
... Apart from neck pain and headache being two of the most common reasons for seeking chiropractic care [7], chiropractors routinely encounter those at risk for VAD, such as pregnant women and patients with hypertension [7,49]. Patients with hypermobility syndromes (i.e., connective tissue disorders) frequently have musculoskeletal pain and may seek chiropractic care, yet are at an increased risk of spontaneous VAD [2,50]. Patients with other forms of vasculopathy due to infectious, inflammatory, autoimmune, and genetic diseases can be at a higher risk for spontaneous VAD as well [50]. ...
... Patients with hypermobility syndromes (i.e., connective tissue disorders) frequently have musculoskeletal pain and may seek chiropractic care, yet are at an increased risk of spontaneous VAD [2,50]. Patients with other forms of vasculopathy due to infectious, inflammatory, autoimmune, and genetic diseases can be at a higher risk for spontaneous VAD as well [50]. ...
Early symptoms of vertebral artery dissection (VAD) may be nonspecific, including neck pain and headache. Neck pain and headache are also common reasons for patients to seek chiropractic care. We hypothesized that neck pain and/or headache would be the most prevalent symptoms among patients with undiagnosed VAD presenting to chiropractors compared to dizziness or other symptoms. We searched PubMed, Ovid, the Index to Chiropractic Literature, Google Scholar, and gray literature through September 2023 for observational studies describing patients aged ≥10 with previously undiagnosed VAD presenting to a chiropractor. Article selection, data extraction, and quality assessment were performed in duplicate. We synthesized the point prevalence of symptoms and other clinical features. We included 10 case reports describing 10 patients (mean age = 37, SD = 7, 60% female). All patients had either neck pain or headache (100%; 95% confidence interval (CI) = 100%-100%). The most prevalent individual symptoms were neck pain (90%; 95% CI = 71%-100%), headache (80%; 95% CI = 55%-100%), visual disturbance (50%; 95% CI = 19%-81%), and dizziness (40%; 95% CI = 10%-70%). The certainty of results was very low due to publication bias. While our findings suggest that neck pain and/or headache are the most prevalent symptoms among patients with undiagnosed VAD visiting a chiropractor, the small sample size and reliance on case reports preclude any definitive conclusions. Further research with larger sample sizes, control groups, and better control of confounders is required to corroborate these results. Chiropractors should be aware of VAD features and refer suspected patients for emergency care.
... The more serious risk-associated chiropractic practices (although rare and used by only 4% of respondents) are also noteworthy. Chiropractic is a well-established and widely used form of AH in Canada; however, there remains considerable controversy over risks associated with some of the interventions marketed by this profession, such as cervical spinal manipulation [2,16,[76][77][78][79]. It appears those undertaking these therapies are either unaware of the potentially serious side effects (including arterial dissection and stroke) or are more risk tolerant. ...
This paper builds on prior work exploring the use of risk-associated alternative healthcare (RAAH) in Canada. RAAH uptake was surveyed to explore the characteristics of adult RAAH users and the value of established psychometric instruments previously used in alternative healthcare studies in predicting RAAH behaviours: the Control Beliefs Inventory (CBI), the Reward Responsiveness Behavioural Activation System (RBAS) scale, the Positive Attitudes to Science (PAS) scale, the Satisfaction with Orthodox Medicine (SOM) scale, and the brief version of the Susceptibility to Persuasion-II (StP-II-B) scale. Findings suggest RAAH is influenced by gender, age, income, education, employment, chronic illness status, and ethnicity. Engagement in some form of RAAH was common (around 40%) and the most common types of RAAH use reported were physical manipulation and herbal/nutritional supplement use. Other higher-risk AH activities (such as use of toxins and physically invasive procedures) were also reported by about 5% of respondents. The StP-II-B and PAS instruments were predictive of the likelihood of engagement in RAAH behaviours, as illustrated by higher risk tolerance, desire for novelty, positive attitude to advertising and social influence, and positive beliefs about science. The CBI, RBAS, and SOM instruments were not predictive overall. However, the CBI and SOM instruments were predictive of engagement with physical manipulative RAAH activities, while the RBAS was predictive of herbal/nutritional RAAH engagement. These findings can help inform health professionals’ understanding of public health-seeking behaviours with respect to risk.
... 1,2 However, a cervical arterial dissection is the most frequent reason for stroke in young and middle-aged adults. 3 Patients with cervical arterial dissection can present with musculoskeletal neck pain and/or headache as one of the first symptoms and sometimes the only symptom. 4,5 For these complaints, patients often first visit primary care clinicians such as general practitioners and physiotherapists. ...
... 13 Serious adverse events (eg, dissection of the vertebral or carotid artery) have been reported in the literature, 14,15 but the reported incidence of vascular pathology following spinal manipulation is low (ranging from 0.4 to 5.0 per 100,000 patients). 13,16 These serious adverse events may be the result of misdiagnosed or missed vascular pathologies, 15,3 or the direct consequence of the intervention without pre-existing vascular pathology. The causality still remains debatable. ...
Question:
What is the diagnostic accuracy of the International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) framework to assess the risk of vascular complications in patients seeking physiotherapy care for neck pain and/or headache?
Design:
Cross-sectional diagnostic accuracy study.
Participants:
One hundred and fifty patients seeking physiotherapy for neck pain and/or headache in primary care.
Methods:
Nineteen physiotherapists performed the index test according to the IFOMPT framework. Patients were classified as having a high, intermediate or low risk of vascular complications, following manual therapy and/or exercise, derived from the estimated risk of the presence of vascular pathology. The reference test was a consensus medical decision reached by a vascular neurologist and an interventional neurologist, with input from a neuroradiologist. The neurologists had access to clinical data and magnetic resonance imaging of the cervical spine, including an angiogram of the cervical arteries.
Outcome measures:
Diagnostic accuracy measures were calculated for 'no contraindication' (ie, the low-risk category) and 'contraindication' (ie, the high-risk and intermediate-risk categories) for manual therapy and/or exercise. Sensitivity, specificity, predictive values, likelihood ratios and the area under the curve were calculated.
Results:
Manual therapy and/or exercise were contraindicated in 54.7% of the patients. The sensitivity of the IFOMPT framework was low (0.50, 95% CI 0.39 to 0.61) and its specificity was moderate (0.63, 95% CI 0.51 to 0.75). The positive and negative likelihood ratios were weak at 1.36 (95% CI 0.93 to 1.99) and 0.79 (95% CI 0.60 to 1.05), respectively. The area under the curve was poor (0.57, 95% CI 0.49 to 0.65).
Conclusion:
The IFOMPT framework has poor diagnostic accuracy when compared with a reference standard consisting of a consensus medical decision.
... Other clinical practice guidelines recommend SMT for management of neck pain [15], neck pain-associated disorders [16], and headache associated with neck pain [17]. However, the American Heart Association (AHA) and the American Stroke Association (ASA) have issued recommendations that patients should be informed of the association between CSM and CeAD [18]. The true risk of CeAD related to CSM remains unclear and a rigorous examination of the potential relationship between CSM and CeAD is warranted. ...
... However, for purposes of informed clinical decision-making, clinicians and patients should interpret estimates of comparative risk in the context of incidence. Among previous studies, only four [21,[24][25][26] were large enough to inform the AHA/ASA position paper on the association between CSM and CeAD [18]. These studies have been criticized for controls which, although age-and sexmatched, were much healthier than the cases [27]. ...
Purpose
Cervical artery dissection (CeAD), which includes both vertebral artery dissection (VAD) and carotid artery dissection (CAD), is the most serious safety concern associated with cervical spinal manipulation (CSM). We evaluated the association between CSM and CeAD among US adults.
Methods
Through analysis of health claims data, we employed a case–control study with matched controls, a case–control design in which controls were diagnosed with ischemic stroke, and a case-crossover design in which recent exposures were compared to exposures in the same case that occurred 6–7 months earlier. We evaluated the association between CeAD and the 3-level exposure, CSM versus office visit for medical evaluation and management (E&M) versus neither, with E&M set as the referent group.
Results
We identified 2337 VAD cases and 2916 CAD cases. Compared to population controls, VAD cases were 0.17 (95% CI 0.09 to 0.32) times as likely to have received CSM in the previous week as compared to E&M. In other words, E&M was about 5 times more likely than CSM in the previous week in cases, relative to controls. CSM was 2.53 (95% CI 1.71 to 3.68) times as likely as E&M in the previous week among individuals with VAD than among individuals experiencing a stroke without CeAD. In the case-crossover study, CSM was 0.38 (95% CI 0.15 to 0.91) times as likely as E&M in the week before a VAD, relative to 6 months earlier. In other words, E&M was approximately 3 times more likely than CSM in the previous week in cases, relative to controls. Results for the 14-day and 30-day timeframes were similar to those at one week.
Conclusion
Among privately insured US adults, the overall risk of CeAD is very low. Prior receipt of CSM was more likely than E&M among VAD patients as compared to stroke patients. However, for CAD patients as compared to stroke patients, as well as for both VAD and CAD patients in comparison with population controls and in case-crossover analysis, prior receipt of E&M was more likely than CSM.
