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Cervical spinal manipulation and cervical artery dissection


Author: Liesbeth Jans
Supervisor: An-Katrien Broos, MSc. Ost.

Background: Neurologic complications after cervical spinal manipulation are a major concern of osteopaths and other professionals who work with these techniques.  Cervical rotation, extension or a combination of these movements may predispose to vascular injury.  Especially the vertebral artery and less frequent the internal carotid artery are vulnerable for cervical artery dissection.  It has been assumed that cervical arteries endure significant stretch during cervical movements used in cervical manipulative therapy, which may lead to damage to the intima followed by hemodynamic occlusions of blood flow, predisposing the patient to stroke.  Estimates of the risk of stroke vary from 1:5000 to 1:10 million.  Although the proposed risk is extremely small, the consequences of vascular accidents are serious and sometimes irreversible.  This makes it an important issue.

Objective: The major aim of this study was to provide guidance to practitioners, to aid for clinical reasoning and diagnostic decision making concerning the assessment of manipulative treatment to the upper cervical spine.  Recent scientific evidence was combined with international expert opinion in order to be informative.  Second of all, the literature is screened in search of evidence for a possible association of cervical artery dissection and cervical manipulative therapy.  

Methods: Databases as PubMed, Cochrane Library and Pedro were searched for studies between 2000 and 2015 using a defined strategy.  The studies included in this work are selected based on predefined inclusion and exclusion criteria.  

Results: Seven studies were identified fulfilling the inclusion and exclusion criteria.  A higher incidence of cervical manipulative therapy was seen in the days and weeks before the onset of cervical artery dissection but failed to reach statistical significance.  

Conclusion: An association of cervical artery dissection and cervical manipulative therapy cannot be proven.  More research should be done on this item.  In the mean time, it is wise for the practitioner to take a small risk into consideration when choosing for cervical manipulative treatment.  Cervical artery dissections are considered to be very rare, the condition can be serious and should be taken into account in every day practise.  The recognition of a patient at risk or a patient’s presentation of cervical artery dissection is essential for safe cervical manipulative therapy.  An osteopath cannot rely on the results of one test alone to conclude whether there is cervical arterial dysfunction or not.  

Key words: cervical artery dissection – cervical manipulative therapy – stroke – neck pain