The potential dangers of neck manipulation & risk for dissection and devastating stroke: An illustrative case & review of the literature

Abstract

Chiropractic cervical manipulation is a common practice utilized around the world. Most patients are never cleared medically for manipulation, which can be devastating for those few who are at increased risk for dissections. The high velocity thrust used in cervical manipulation can produce significant strain on carotid and vertebral vessels. Once a dissection has occurred, the risk of thrombus formation, ischemic stroke, paralysis, and even death is drastically increased. In this case report, we highlight a case of a 32-year-old woman who underwent chiropractic manipulation and had vertebral artery dissection with subsequent brainstem infarct. She quickly deteriorated and passed away shortly after arrival to the hospital. Although rare, one in 48 chiropractors have experienced such an event. We utilize this case to highlight the risk associated with cervical manipulation and urge open dialogue between chiropractors and physicians. Receiving medical clearance prior to cervical manipulation in potential at risk patients would drastically reduce morbidity and mortality.

Keywords: Brainstem infarct; Chiropractic manipulation; Medical clearance; Open communication; Vertebral artery dissection.

Figure 1

CT Stroke Protocol at time of presentation. A.) 4D CTA demonstrating top of the basilar occusion and poor flow in the right vertebral artery; B.) coronal CA demonstrating dissection of verterbral arteries at the C1–C2 level, particularly prominent on the right; C.) relative blood volume; and D.) corrected relative blood volume.

Figure 2

CT Stroke Protocol with perfusion imaging demonstrating primary involvement of occipital lobe, cerebellum, and brainstem. Perfusion imaging reflecting rCBV, TTP, rCBF, MTT, and delay (from top-left to bottom-right).

Figure 3

Digital subtraction angiography at time of presentation demonstrating A.) anterior-posterior view showing basilar and PICA occlusion, B.) lateral view showing basilar and PICA occlusion, C.) left vertebral artery dissection, and D.) right vertebral artery dissection.

Figure 4

Immediate post-procedure magnetic resonance imaging demonstrating ischemic stroke within the cerebellum, brainstem, and left occipital cortex. A.) attenuated diffusion coefficient (ADC) sequence capturing left occipital stroke and B.) diffusion-weighted imaging capturing cerebellar, brainstem, and left occipital cortex stroke.