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

Abstract

BackgroundStrokes, 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.MethodsPRISMA 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.ResultsFour 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.ConclusionConclusive 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.

Vertebral artery dissection in evolution found during chiropractic examination

“…While the optimal imaging evaluation of VAD remains controversial, MRA or CTA are the diagnostic studies of choice given their excellent anatomic delineation and ability to evaluate for complications (including infarction and changes in brain perfusion) 14. Some advocate the use of Doppler ultrasound;15 however, it has limited utility given the course of the vertebral artery in the neck and limited evaluation of the vertebral arteries cephalad to the origin. Additionally, ultrasound imaging is unlikely to allow visualisation of the dissection itself and thus can be negative in the absence of significant arterial occlusion 16 17…”

Compensation claims for chiropractic in Denmark and Norway 2004¿2012

“…For this reason chiropractors need to devote time to explain this to patients and emphasize that these are not AE but normal benign reactions to the manual treatment. While the causality between MT and CAD remains uncertain [20,21,[48][49][50], these events will continue to occur in association with cervical spine manipulation. Evidence-based frameworks for early identification of CAD have recently been published [51] and we encourage clinicians to stay up-todate on the evolving evidence surrounding CAD.…”

Surgical positicion, cause of extracranial internal carotid artery disection, presenting as pourfour du petit sundrome. case report and literature review

“…The literature describes cases of dissection due to forced positions of the neck, especially in patients with risk factors (9,(11)(12)(13)21), but there are no case reports for a common surgical position.…”