Cervical Arterial Dissections and Association With Cervical Manipulative Therapy
"Data on the effectiveness of CMT for neck pain are sparse and questionable.73,80C85 The most recent Cochrane review consisting of some low-quality trials found that the effect of cervical manipulation was comparable to that of mobilization, which does not include a thrust.80C82 Two studies, published
since this systematic review, investigated the effects of cervical manipulation on neck pain. Bronfort et al83a found that cervical manipulation, together with other physical interventions, was as effective as a home exercise program and that each was more
effective than treatment with ≥1 of the following: nonsteroidal anti-inflammatory drugs, acetaminophen, muscle relaxants, and narcotics. Dunning et al73 compared cervical and thoracic
thrust manipulation with cervical and thoracic nonthrust mobilization for patients with neck pain and found an improvement in the manipulation (versus mobilization) group at 48 hours.
Association of cervical artery dissection (rupturing an artery to the brain, CD) and cervical manipulative therapy (CMT)
There has been considerable discussion and debate about the association between CMT and CD.68,83C85 The majority of the literature associating CMT with VAD/vertebrobasilar artery territory stroke is from case reports/case series,66,83,83a,86C105
surveys,106,107 or expert opinions.108C113 Given the very low incidence of CD,8,104,114,115 the best study design that has been used to date to determine whether CMT may cause CD is the case-con-
trol study.116 There have been 6 reported case-control studies of CD that have evaluated an association with CMT.15,67,84,85,117,118
Two of these case-control studies were very small and of lower quality.15,85 In a small retrospective study from Germany, 47 consecutive patients <60 years of age with CD were compared with 47 consecutive age-matched patients with stroke
of another cause.15 Although cervical manipulations within 30 days of stroke were twice as frequent in CD patients (21.3%, 10 of 47) compared with non-CD stroke controls (10.6%, 5 of 47), there was no significant difference in this small study. In a small retrospective study, Thomas and colleagues85 reviewed records of 47 dissection patients and 43 controls <55 years of age with stroke from another cause. Mild mechanical trauma to the head and neck was significantly associated with craniocervical arterial dissection (OR, 23.53; 95% confidence interval [CI], 6.31C87.70). "Neck manual therapy" was reported in 23% of CD cases (8 vertebrobasilar artery, 3 ICA) and only 2% of the non-CD stroke cases (OR, 12.67; 95% CI, 1.58C104.28). As a result of their preliminary observations, the authors proposed
a prospective study.119
Four larger case-control studies found an association between CMT and VAD/vertebrobasilar artery territory stroke in young patients (<45 years of age) with reported ORs of 3 to 12,67 5.5,84
6.6,117 and 3.6 to 11.9,118 respectively (Table 2). Two of the 4 studies specifically evaluated chiropractic visits.67,84 Rothwell and colleagues84 reviewed the Ontario administrative database
from 1993 to 1998 to identify patients with vertebrobasilar artery territory stroke. Of the 582 cases identified, which were age and sex matched to 4 controls from the Ontario general population, they determined that young patients (age <45 years)
with vertebrobasilar territory stroke were 5 times more likely than controls to have visited a chiropractor within 1 week of the event (OR, 5.02; 95% CI, 1.32C43.87). Among the 112 stroke cases <45 years of age, 4.5% visited a chiropractor within 1
week of the stroke compared with 0.9% of the controls."
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