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CMAJ • March 20, 2001; 164 (6)
© 2001 Canadian Medical Association or its licensors

Letters
Correspondance

Cervical manipulation: How risky is it?

Brian Lecker and Tim Pethrick

Chiropractor Winnipeg, Man.; Chiropractor Gimli, Man.

The article by John Norris and colleagues on sudden neck movement and cervical artery dissection does not mention risk factors for stroke such as migraine, diabetes, smoking and the use of oral contraceptives.1 There is 1 occurrence of stroke after every 1–3 million cervical manipulations.2 Although it has been suggested that neck positioning during anesthesia may in fact pose a higher risk of dissection than manipulation,3,4 this was not mentioned as a possible risk factor by Norris and colleagues. The type and area of manipulation were also not identified. Haldeman and colleagues concluded that the literature does not assist in the identification of the mechanical trauma, neck movement or type of manipulation that precipitates vertebrobasilar artery dissection.5

We both have had a patient in the past year presenting with stroke-like symptoms. In neither case was the patient's cervical spine manipulated, and each patient was immediately referred for medical assessment; quite likely these cases are now (inappropriately) 2 of the consortium's statistics.

The authors state that "neck pain is a reliable symptom of the onset of dissection."1 Considering that neck pain is often the presenting symptom when one visits a chiropractor, how did the consortium distinguish pre- from post-manipulation pain?

The principles of science are fundamental to good case management. In the absence of a control group and statistical analysis, Norris and colleagues have presented what can only be described as junk science masquerading as research. Although medicine and chiropractic should be working together to find better detection and prevention methods, Norris and colleagues seem to be more interested in scaring the public and fanning the flames between our professions.

References

  1. Norris JW, Beletsky V, Nadareishvili ZG, on behalf of the Canadian Stroke Consortium. Sudden neck movement and cervical artery dissection [commentary]. CMAJ 2000;163(1):38-40. [Free Full Text]
  2. Shekelle PG, Coulter I. Cervical spine manipulation: summary report of a systematic review of the literature and a multidisciplinary expert panel. J Spinal Disord 1997;10(3):223-8. [Medline]
  3. Tettenborn B, Caplan LR, Sloan MA, Estol CJ, Pessin MS, DeWitt LD, et al. Postoperative brainstem and cerebellar infarcts. Neurology 1993; 43(3 Pt 1):471-7. [Abstract/Free Full Text]
  4. Fisher CM. Basilar artery embolism after surgery under general anesthesia: a case report. Neurology 1993;43(9):1856-7. [Free Full Text]
  5. Haldeman S, Kohlbeck FJ, McGregor M. Risk factors and precipitating neck movements causing vertebrobasilar artery dissection after cervical trauma and spinal manipulation. Spine 1999; 24(8):785-94. [Medline]




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