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In its 110-year history, chiropractic doctors have administered millions of
cervical spinal manipulations or adjustments. Today there are over 50,000 chiropractors
in the United States and many thousands more in other countries. The incidents
of serious complications, such as Vertebral Artery Dissection (VAD) leading to stroke that have occurred after
a patient has received a chiropractic manipulation are rare. Using the data
that appears in scientific literature, estimates range from one incident for
every 500,000 cervical spinal manipulations to one incident for every 5 million
treatments.
A Canadian study in 2001 reviewed malpractice data of all claims of stroke
following chiropractic care in a ten-year period from 1988-1997 processed by
the leading malpractice insurance carrier. Using extrapolated figures, it was
estimated that during this period chiropractors insured by the malpractice carrier
performed 135.5 million cervical spinal manipulations. There were 43 cases of
neurological symptoms following cervical manipulation during this ten-year period.
Of these, 20 were minor and another 23 cases were vertebral artery dissection
that followed cervical manipulation.
Studies that have attempted to measure the effectiveness of chiropractic cervical
spinal manipulation for neck conditions and headache, of which there have been
approximately 20 randomized clinical trials (which are not retrospective, but
"prospective" studies of current patients) have not reported any serious complications
from cervical spinal manipulation.
VAD: Trauma-Induced or Spontaneous?
VAD can be initiated by a significant traumatic incident, such as an auto accident,
a fall, or penetrating injury. In the absence of trauma, VAD is considered "spontaneous"
with no known cause. However, a number of activities may precede the development
of VAD. These include medical procedures such as neck extension during anesthesia
or surgery and other medical risk factors. Non-medical activities that may precede
the development of VAD include overhead work such as ceiling painting, nose
blowing, judo, dancing, yoga, and turning the head while driving, and other
daily activities. Spinal manipulation to the neck is considered one of these
activities that are associated with an incident of VAD in an apparently vulnerable
individual.
Patients who use oral contraceptives, have hypertension (high blood pressure)
and pathologies affecting the cervical vessels appear to be associated with
higher risks to VAD. An error in metabolism of a body chemical called homocysteine
may weaken the structure of the cervical arteries and predispose them to damage.
Chiropractic Studies and VAD
The chiropractic profession has been very involved in studying and evaluating
the risk of cervical spinal manipulation as it has been documented in the medical
literature. There is some controversy as to how many incidents of VAD are associated
with spinal manipulation performed by chiropractors. The problems of retrospective
studies have been mentioned. Incidents in the literature regarding the connection
between VAD and spinal manipulation have sometimes failed to note the small
number of incidents in proportion to the number of treatments administered.
Some medical commentators appear to have little understanding of what occurs
in a chiropractic cervical spinal manipulation and wrongly associate the treatment
with an aggressive, indiscriminate wrenching of the neck. On the contrary, chiropractors
are taught precise, gentle spinal manipulation techniques in 6-8 year programs
of study. Chiropractic has an extremely low rate of malpractice incidents and
low malpractice rates.
VAD Screening: Need Identified
There is a small risk in vulnerable individuals when cervical spinal manipulation
is performed. There are risks in all medical procedures, prescription drug use,
and almost all daily activities. Further, the chiropractic profession is energetically
engaged in minimizing this risk by studying ways to screen/evaluate/identify
which patients are at risk for VAD in an office setting.
Bottom Line: Risks are Small
The risk of spinal manipulation to the neck is small in relation to the number
of patients receiving manipulative therapy and the benefits of that therapy.
It appears to primarily involve a small number of patients who are vulnerable
to vertebral artery dissection. Neck manipulation most likely represents a final
insult, which initiates injury to already susceptible arteries.
It is doubtful whether a neck manipulation, as it is practiced by chiropractors,
would have the force to damage healthy arteries. This seems to be supported
by the significant number of patients who are treated without incident. Unbiased,
prospective studies with controls will yield further useful information on all
aspects of cervical spinal manipulation, including the benefits and risks.
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