From the Guidelines
Cervical spine manipulation is generally considered safe when performed by a licensed and experienced healthcare professional, such as a chiropractor or osteopathic physician [ 1 ]. However, as with any medical procedure, there are potential risks and side effects, including neck pain, stiffness, and in rare cases, vertebral artery dissection or stroke.
Important Considerations
To minimize risks, it is essential to consult with a qualified practitioner who will assess your individual condition and medical history before performing the adjustment.
- Patients with certain medical conditions, such as osteoporosis, rheumatoid arthritis, or recent neck trauma, may need to avoid or modify cervical adjustments.
- If you are considering spinal cervical adjustment, inform your practitioner about any medications you are taking, including blood thinners like aspirin or warfarin, and discuss any concerns or questions you may have.
Risk of Vertebral Artery Dissection
The incidence of vertebral artery dissection or occlusion attributable to cervical manipulation in patients <45 years of age was approximately 1.3 per 100,000 within 1 week of manipulative therapy [ 1 ].
Diagnostic Approach
The diagnostic algorithm begins with clinical examination and brain imaging, followed by vascular imaging when an ischemic cause is suspected [ 1 ].
- Carotid duplex ultrasonography may identify a dissection flap and differential flow in the true and false lumens, but CTA or MRA is increasingly used to establish the diagnosis of carotid artery dissection.
From the Research
Safety of Cervical Spine Manipulation
- The safety of cervical spine manipulation is a topic of ongoing debate, with some studies suggesting that the risks outweigh the benefits 2.
- A systematic review and meta-analysis of randomized clinical trials found that high-velocity, low-amplitude (HVLA) cervical manipulation does not impose an increased risk of mild or moderate adverse events compared to control interventions 3.
- However, the same study noted that randomized controlled trials are not appropriate for detecting rare serious adverse events, and therefore the results should be interpreted with caution 3.
- Another systematic review found that cervical arterial dissection was reported in 57% of cases of adverse events after cervical spinal manipulation or mobilization, and that women may be more at risk for this condition 4.
Adverse Events Associated with Cervical Spine Manipulation
- Adverse events associated with cervical spine manipulation can be serious, including cervical arterial dissection and stroke 4.
- A case study found that a patient with postsurgical neck syndrome was successfully treated with chiropractic intervention using instrumental adjustment of the cervical spine, with no adverse events reported 5.
- However, the study noted that further research is needed to determine the safest and most effective approaches to managing postsurgical patients in a chiropractic setting 5.
Precautions and Safety Measures
- Pre-manipulative cervical instability and arterial integrity tests appear to be unreliable in identifying patients at risk for adverse events 4.
- A safe intubation technique for patients with cervical spine injury involves stabilizing the neck with longitudinal traction and avoiding extension at the fracture site 6.
- The use of instrumental adjustment methodology may provide an effective alternative to manual manipulation in cases where the patient's surgical history or presenting symptoms make forceful manipulation of the spine inappropriate 5.