What is the relationship between Vertebral Artery Dissection (VAD) and chiropractic care?

From the Guidelines

Chiropractic neck manipulations may rarely cause vertebral artery dissection, a serious condition where the inner lining of the vertebral artery tears, potentially leading to stroke, with an estimated risk of 1 in 20,000 to 1 in 250,000 manipulations. The relationship between vertebral artery dissection (VAD) and chiropractic care is a significant concern, as VAD can lead to severe morbidity and mortality. According to the guidelines from the American Heart Association/American Stroke Association 1, carotid or vertebral artery dissection is an uncommon but sometimes dramatic cause of acute or progressive neurological ischemic symptoms. The guidelines also mention that minor trauma, such as hyperflexion or hyperextension of the neck, chiropractic manipulation, coughing, and nose blowing, have been associated with carotid dissection.

Key Points to Consider

• The incidence of vertebral artery dissection has not been well defined, but a structured review found that 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.
• Warning signs of vertebral artery dissection include sudden severe neck or head pain, dizziness, visual disturbances, slurred speech, or weakness on one side of the body, which require immediate emergency medical attention.
• Alternative treatments for neck pain with potentially lower risk profiles include physical therapy, gentle mobilization techniques, massage therapy, acupuncture, and appropriate medication.
• Patients should discuss their complete medical history with healthcare providers before undergoing any neck manipulation procedures.

Recommendations

• Patients with risk factors such as connective tissue disorders, hypertension, smoking history, or recent neck trauma should be particularly cautious when considering chiropractic neck manipulations.
• Healthcare providers should inform patients about the potential risks and benefits of chiropractic neck manipulations and discuss alternative treatment options.
• Further research is needed to fully understand the relationship between VAD and chiropractic care, but current evidence suggests that the risk of VAD associated with chiropractic neck manipulations is low, but not negligible 1.

From the Research

Relationship Between Vertebral Artery Dissection (VAD) and Chiropractic Care

• Vertebral artery dissection (VAD) is a cause of ischemic stroke in young adults, and patients may present with neck pain, headache, visual disturbance, or focal extremity weakness 2.
• Risk factors for the development of VAD include neck manipulations, trauma, or abnormal posturing 2.
• Chiropractic manipulation of the cervical spine has been associated with an increased risk of VAD, particularly bilateral VAD 3.
• A study of 126 patients with cervical artery dissections found that patients with VAD complained more often of neck pain and had a higher incidence of bilateral dissections than patients with carotid artery dissections, with preceding chiropractic manipulation being a significant factor in bilateral VAD 3.
• Another study highlighted the potential dangers of neck manipulation and the risk for dissection and devastating stroke, with a case report of a 32-year-old woman who underwent chiropractic manipulation and had vertebral artery dissection with subsequent brainstem infarct 4.
• A survey of neurological departments in Germany over a three-year period found 36 patients with VAD after chiropractic neck manipulation, with clinical symptoms consistent with VAD starting in 55% of patients within 12 hours after neck manipulation 5.
• While the exact mechanisms are not clear, there appears to be an important relationship between arterial dissection and neck movements or minor trauma, including indirect neck trauma such as dancing or trivial falls 6.

Clinical Presentation and Diagnosis

• The clinical presentation of VAD is highly variable, but dissection should be considered in a young patient with craniocervical pain, even in the absence of neurological symptoms 2.
• Digital subtraction angiography (DSA) remains the gold standard imaging exam for diagnosis of VAD, but recognition of VAD on more common non-invasive modalities, such as computed tomography angiogram or magnetic resonance angiogram (MRA), is critical for establishing the correct diagnosis 2, 5.
• Early diagnosis and treatment of VAD can lower the risk of long-term neurologic sequelae 2.

Risk Factors and Outcomes

• Risk factors associated with artery dissections, such as fibromuscular dysplasia, were present in only 25% of subjects with VAD after chiropractic neck manipulation 5.
• Multivariate analysis showed that the variables stroke and arterial occlusion were the only independent factors associated with a poor outcome in patients with cervical artery dissections 3.
• Patients with dissection-related cervical artery occlusion had a significantly increased risk of suffering a disabling stroke 3.