Spinal Manipulation and Stroke, A Response
March 18, 2005
Recent media coverage has raised questions about the safety and efficacy of spinal manipulation, particularly as it relates to the neck. Dissection of the vertebral artery is generally recognized as the source of most vascular complications associated with manipulation of the cervical spine, so the question becomes – What causes the artery to tear? The simplest answer is – we don't know.
Just as a certain percentage of otherwise healthy individuals suddenly die from a brain aneurysm, it appears a certain percentage of patients have a weakening of the vascular structures in the neck. These vessels are subjected to mechanical strain when the neck is tipped backward, and twisted to the side. In theory, a patient at risk for vascular injury should avoid positions of extension and rotation of the neck. This would include backing up your car, having your hair washed, painting a ceiling, playing tennis or bird watching. So, would avoiding neck adjustments reduce your risk of vascular injury? Maybe. But, you should be aware that it is the position of the head and neck, not the adjustment itself, which places you at risk. Both Dr. Stone and I adjust the neck with the patient lying on the back, with the head piece elevated. This avoids the extension element of strain, resulting in a safer adjustment.
How do we identify patients at risk? Just like most testing, there is no definitive test which tells us with certainty there is no risk. Patients presenting with neurologic symptoms such as vertigo, vomiting, blurred vision, altered states of consciousness and atypical headaches need to be examined for possible vascular compromise in the neck. Some of these tests can be performed in the office, and involve placing the head and neck in certain positions to see if your symptoms worsen. We can also listen to the large vessels in the front of the neck, checking for signs of obstruction or narrowing. If any of these tests are positive, you should not have your neck manipulated, and we would refer you to your medical doctor for further evaluation and treatment.
Current literature investigating the risk of stroke or vascular injury arising from manipulation of the cervical spine suggests complication occur at a rate of 1 in 1,000,000 adjustments. On analysis, spinal manipulation of the most conservative, least invasive and safest procedures available in the treatment of head and neck pain. This is especially true when compared to the rate of complication associated with other treatment options- such as epidural injections, prescription medications and surgery.
While it is very difficult to lessen a risk that is so remote to begin with, our doctors understand the warning signs, and perform the appropriate testing to screen for potential problems. If you have concerns or questions, please feel free to discuss them with us. We are here to help.
Sincerely,
Dr. Jeff Robichaud
