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Orthopaedic Division

Cervical artery dissection and manipulation:

a review of relevant research with implications
for diagnosis and management
Peter A. Huijbregts, PT, MSc, MHSc, DPT, OCS, FAAOMPT, FCAMT
Rob A. B. Oostendorp, PT, MT, PhD

Peter A. Huijbregts, Assistant Professor, University of St. Augustine for Health Sciences, St. Augustine, FL
Consultant, Shelbourne Physiotherapy & Massage Clinic, Victoria, BC, Advisory Faculty, North American
Institute of Orthopaedic Manual Therapy, Eugene, OR
Rob A. B. Oostendorp. Emeritus Professor of Allied Health Sciences, Scientific Institute for Quality of
Healthcare, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands, Emeritus Professor
of Manual Therapy, Faculty of Medicine and Pharmacology, Free University of Brussels, Brussels, Belgium
Corresponding author: Peter A. Huijbregts, Shelbourne Physiotherapy & Massage Clinic
100B-3200 Shelbourne Street, Victoria V8P 5G8,

Introduction ease who attend a spinal manipulative therapy practi-

When considering the issue of safety in the context of tioner and then suffer these rare strokes is so well docu-
orthopaedic physiotherapy we cannot ignore the associ- mented as to be beyond reasonable doubt indicating a
ation that has been proposed between cervical manipu- possible causal relationship...”
lation and stroke due to vertebral and/or internal carotid Even without consensus on a cause-and-effect rela-
artery dissection (together called cervical artery dissec- tionship between cervical manipulation and CAD, the
tion or CAD). CAD occurs in about 1-2% of patients, who neck pain, headache, and vertiginous dizziness with
have sustained blunt trauma including severe facial frac- which patients with CAD often present (Graziano et al
tures, skull base fractures, and traumatic brain injury. 2007) make the physiotherapist (even one, who does
Patients with major thoracic injuries have an increased not use thrust manipulation as a clinical intervention)
incidence of carotid artery dissection, whereas cervical a professional, who at some point may be confronted
spine fractures and spinal cord injury increase the risk with this pathology. The goal of this article, therefore,
of vertebral artery dissection. However, as physiothera- is to provide current best evidence on the association
pists we are less concerned with CAD associated with between manipulation and CAD but also to inform the
such severe trauma. Most relevant to us is spontaneous physiotherapist with regard to clinical diagnosis for this
CAD defined as dissection associated with minor trauma, pathology.
including but not limited to sporting activities, whip-
lash injury, stretches, sudden neck movements, severe Research on the association between
coughing, and -of interest to this paper- cervical manipu- manipulation and CAD
lation (Debette and Leys 2009). Evidence linking cervical manipulation to stroke has
Epidemiological data indicates that CAD is rare. In a included multiple narrative reviews of case reports
North-American population-based study, Lee et al (2006) found in the literature (DiFabio 1999, Ernst 2001, Terrett
estimated incidence at 2.6 (95% CI: 1.86-3.33) per 100,000 2000, Triano and Kawchuk 2006). Hurwitz et al (1996)
per year. Debette and Leys (2009) reported a 1-year in- acknowledged the likely high under-reporting bias and
cidence for carotid artery dissections of 2.9 per 100,000 noted an estimated risk-adjusted for an only 10% re-
in Dijon, France. Lee et al (2009) noted that vertebral porting rate in the literature of 5-10 per 10 million for all
artery dissection at 0.97 (95% CI: 0.52-1.4) was almost complications, 6 in 10 million for serious complications,
half as common as carotid artery dissection at 1.72 (95% and 3 in 10 million for the risk of death. Haneline et al
CI: 1.13-2.32) per 100,000 per year. With only up to 20% (2003) found 13 cases of internal carotid artery dissec-
of CAD progressing to a stroke, this condition is even tion temporally associated with cervical manipulation in
less common (Blunt and Galton, 1997). So Terrett (2000) a 1966-2000 Medline review and estimated the chance of
made an observation certainly in need of further inquiry developing CAD in this artery post-manipulation at 1 in
when he noted, “... The temporal relationship between 601,145,000.
young healthy patients without osseous or vascular dis- Research into risk of harm is wrought with method- January/February 2010 - Interdivisional Review 23

ological shortcomings and not only because of the ob- Clinical diagnosis
vious ethical concerns with studies that would pro- With the scope of physiotherapy often limited with
spectively expose patients to a suspected risk factor regard to ordering and interpreting relevant medical di-
(Rubinstein et al 2005). In the context of risk of harm agnostic tests, clinical diagnosis based on history taking
it would seem prudent to consider the epidemiological including an inventory of risk factors and physical exam-
Bradford-Hill criteria that state that a cause-and-effect ination are the most important tools for the therapists
relationship becomes likely when the following criteria when confronted with a patient with neck pain, head-
are all met (Triano and Kawchuk 2006): ache, and dizziness or vertigo.
1. The proposed relationship is biologically plausible Risk factors
2. The proposed cause is temporally related to the oc- Even without answering the question on causation it
currence is plausible that in the case of a pathologically weakened
3. The relationship is consistent across different sam- artery mechanical forces such as those induced during
ples and groups thrust and non-thrust manipulation of the cervical spine
4. There exists a positive correlation between expo- may cause mechanical or traumatic damage to the vessel
sure and occurrence wall of the cervical arteries, in particular the vertebral
5. There exists no other plausible explanation artery. This means that the therapist needs to be able to
identify possible risk factors predisposing the artery to
Although opinions certainly and justifiably differ, case CAD whether iatrogenic, i.e. due to manipulation, or due
reports and narrative reviews of such case reports pro- to mechanical events other than manipulation. Table 1
vided by authors in diverse geographical locations tem- provides the rather large list of risk factors identified
porally linking possible mechanical trauma of the cer- but not necessarily validated in the literature.
vical arteries due to manipulation to CAD would seem to Trauma
qualify as supporting the first three criteria. With regard to the role of trauma of head and neck,
Exploring the criterion of a correlation between expo- Beaudry and Spence (2003) attributed 70 of 80 traumat-
sure to manipulation and occurrence of CAD, Rothwell ically- induced cases of vertebrobasilar ischaemia to
et al (2001) compared 582 patients with vertebrobas- motor vehicle accidents. Cogbill et al (1994) reported
ilar accidents over the period 1993-1998 with age- and that 72% of trauma-induced internal CAD in their study
sex-matched controls from the provincial insurance da- was the result of a motor vehicle accident. However,
tabase in Ontario, Canada. They also determined expo- note that many patients after whiplash trauma note diz-
sure to chiropractic using this same database. These au- ziness and meet criteria for inner ear pathology (Grimm
thors found that subjects younger than 45 years were 2002, Oostendorp et al 1999, Wrisley et al 2000).
five times more likely (95% CI: 1.31-43.87) to have visited
a chiropractor in the month preceding the stroke. This
Age and gender
same age group was also five times (95% CI: 1.34-18.57)
Although age of 30-45 years and female gender have
more likely to have had three or more visits with cer-
been proposed as risk factors for manipulation-associ-
vical or thoracic spine-related complaints or headache
ated CAD, Terrett (2000) indicated that the overall dis-
in the month prior to the stroke. No significant associa-
tribution of patients with regard to gender and age at-
tion was noted for subjects older than 45 years.
tending for chiropractic care closely matches the gender
Cassidy et al (2008) used a very similar study design
and age distribution of those with serious adverse
comparing 818 patients with vertebrobasilar accidents
events thereby discounting these proposed risk factors.
to age- and sex-matched controls from a provincial in-
Kawchuk et al (2008) also found no association for age
surance database and also found an odds ratio (OR) of
and gender and the incidence of CAD post-manipulation.
3.13 (95% CI: 0.52-1.32) for having visited a chiropractor
Relevant to the clinical diagnosis of spontaneous if not
in the month before the stroke in those younger than 45
manipulation-induced CAD is that Lee et al (2006) re-
years, whereas the OR was 0.83 (95% CI: 0.52-1.32) for
ported a mean age of 45.8 years for North American pa-
those older than 45 years. However, these researchers
tients. In Europe, Touzé et al (2003) reported a mean age
also looked at visits to general medical practitioners
of 44.0 and Arnold et al (2006) noted a mean age of 45.3
preceding the stroke and found an OR of 3.57 (95% CI:
years. In three large studies (Beletsky et al 2003, Lee et
2.17-5.86) for those under 45 years and 2.67 (95% CI: 2.25-
al 2006, Schievink et al 1994) 50-52% of patients with CAD
3.17) for patients having visited their medical doctor
were women, whereas in two European studies (Arnold
in the month preceding the vertebrobasilar accident.
et al 2006, Touzé et al 2003) 53-57% were men. Carotid
These authors suggested that the similar association
artery dissection seems to be more common in men and
between chiropractic and medical visits might indicate
at an older age (47.0 versus 43.4 years) than is vertebral
that patients with an undiagnosed vertebral artery dis-
artery dissection (Dziewas et al 2003, Lee et al 2006).
section seek clinical care for headache and neck pain
before having a stroke rather than lending credence to Arteriopathy
an exposure-and-occurrence relationship between ma- Arteriopathies predisposing the artery to dissection
nipulation and CAD. as a result of pathological weakening of the vessel wall

24 January/February 2010 - Interdivisional Review

Table 1. Proposed risk factors cervical artery dysfunction

include Ehlers-Danlos syndrome, fibromuscular dys- for CAD include hyper tens ion, tobacco us e, hyper cho-
plasia, cystic medial necrosis, and autosomal dominant les ter olaemia, hyper lipidaemia, diabetes , and at her o-
polycystic kidney disease. Alpha-1-antitrypsin deficiency s cler os is . Mos t r es ear ch into this ar ea has compar ed
initially showed highly elevated ORs but this association pat ient s wit h CAD t o pat ient s wit h is chaemic s t r okes .
currently finds little support in the literature (Triano Per haps as a r es ult of this under lying differ ence in
and Kawchuk 2006). Although associated with collagen pathophys iology mos t car diovas cular r is k factor s
tissue abnormalities and arteriopathy, evidence for actually s how ORs below 1 indicating a “pr ot ective”
Marfan syndrome and osteogenesis imperfecta as a risk function. Of cour s e, this is likely due to the method-
factor for CAD is absent (Debette and Leys 2009). In all, ology of the r es ear ch compar ing “apples to or anges ”.
these risk factors can, at best, be suspected based on In thes e s tudies , hyper tens ion was the only s ignifi-
physical examination but would seem relevant if noted cant r is k factor with an OR of 1.94 (95% CI: 1.01-3.70).
in the medical history. Research evidence for these arte- Although a s eemingly plaus ible r is k factor with a s tiffer
riopathies in the etiology of CAD, however, is limited. ar ter y mor e s us ceptible to mechanical damage, t he
Cardiovascular risk factors evidence for ather os cler os is as a r is k factor is bas ed
Car diovas cular r is k factor s pr opos ed as r is k factor s s olely on cadaver s tudies and the finding that blood January/February 2010 - Interdivisional Review 25

Table 2. Classic cardinal signs of vertebrobasilar compro- subsequently had a manipulation-associated stroke:
mise: Five D's And three N's
* 47.4% noted neck pain and stiffness
* 19.7% noted neck pain, stiffness, and headache
* 16.8% had torticollis
Of course, these predominant symptoms help little in
the way of distinguishing those patients with mechanical
neck problems that might benefit from physiotherapy
management perhaps including manipulation and those
that are in the process of having a CAD.
Non-ischaemic and ischaemic symptoms
Although diagnostic utility of these symptoms has
yet to be established, therapists are all familiar with the
ischaemia-related cardinal signs and symptoms indica-
tive of vertebrobasilar circulatory compromise (Table
2). However, it is important to realize that with CAD isch-
aemic symptoms are not the only symptoms that occur.
Non-ischaemic symptoms usually develop first and are
likely the result of stimulation of free nerve endings and
subsequent substance P-mediated neurogenic inflam-
mation of the tunica adventitia of the affected artery
and direct compression on local somatic structures in-
cluding cervical nerve roots, cranial nerve nuclei, and
the cervical sympathetic chain (Kerry and Taylor 2006).
flow is pr opor tional to the four th power of vessel diam- In fact, these non-ischaemic symptoms occur hours to
eter (Mitchell 2002). days and even a few weeks prior, although usually less
than a month prior to the ischaemic findings (Blunt and
Galton 1997, Debette and Leys 2009). Ischaemic findings
There is a noted seasonal variation in the incidence
develop in 30-80% of all dissections and as noted above
of CAD with significantly more cases occurring in winter
up to 20% progress to a full cerebrovascular accident
as compared to other seasons (Paciaroni et al 2006).
(Blunt and Galton, 1997).
Perhaps explaining this seasonal variation, a prospec-
Additional symptoms other than those in Table 2
tive study showed an adjusted OR of 3.1 (95% CI: 1.1-9.2)
have been described for CAD. Table 3 provides a list of
for an acute infection in the four weeks preceding a cer-
ischaemic and non-ischaemic signs and symptoms asso-
vical artery incident (Guillon et al 2003).
ciated with CAD (Blunt and Galton 1997, Haneline and
Other risk factors Lewkovich 2004, Kerry and Taylor 2006, Kerry et al 2008).
In a systematic review Rubinstein et al (2005) noted Although in a large hospital-based series described in
as clinically relevant risk factors migraine (OR 3.6; 95% only 7% of patients with CAD (Debette and Leys 2009),
CI: 1.5-8.6), recent infection (OR 1.6; 95% CI: 0.67-3.80), when present cranial nerve palsies are relevant to the di-
and trivial trauma including cervical manipulation (OR agnosis of CAD. Due to their close anatomical association
3.8; 95% CI: 1.3-11). Triano & Kawchuk (2006) reported with the internal carotid artery, dissection of this artery
an OR of 1.6 (95% CI: 0.67-3.80) for coughing, sneezing, and the associated increase in its girth mainly causes
or vomiting; vascular risk factors and a current smoking dysfunction of the cranial nerves IX-XII with the hypo-
habit had ORs of 0.14 (95% CI: 0.34-0.65) and 0.49 (95% glossal nerve (XII) initially affected and then the other
CI: 0.18-1.05), respectively. Although earlier research im- three nerves; eventually all cranial nerves except the ol-
plicated oral contraceptive use as a risk factor, Haneline factory (I) can be affected. Whereas cranial nerve dys-
and Lewkovich (2006) indicated that currently no con- function has a non-ischaemic etiology in internal carotid
sensus exists on relevance of this proposed risk factor. artery dissection, it is part of the ischaemic presentation
In all, this inventory of risk factors would seem to indi- of a vertebral artery dissection. Nerve root impairment
cate no shortage of possible alternative explanations for at the C5-C6 level can result from compression by an
CAD. enlarged vertebral artery (Debette and Leys 2009). The
pathognomonic “thunderclap headache” with CAD is a
History referred pain due to stimulation of vascular nociceptive
The most common complaints with which patients nerve endings as a result of the ongoing dissection and
with CAD in progress might present for therapy in- inflammation of the artery (Triano and Kawchuk 2006).
clude neck pain, headache, and vertiginous dizziness With our physiotherapy training inducing a healthy
(Graziano et al 2007). Terrett (2000) provided data on the dose of vigilance with regard to CAD, physiotherapists
presenting complaints of 137 chiropractic patients, who often are unaware that not all CAD will lead to a worst-

26 January/February 2010 - Interdivisional Review

Table 3. Non-ischaemic and ischaemic signs and symptoms of cervical artery dysfunction

case scenario. In their population-based study, Lee et al here that presentation of a stroke in the internal carotid
(2006) found that 33% of patients with CAD have only distribution is more common knowledge among physio-
local signs and symptoms with no retinal or cerebral therapists.
ischaemia and that 6% of patients are asymptomatic.
Symptoms are often limited and benign and include tran- Vertebral artery-related strokes
sient headache, neck pain, Horner syndrome, and cranial In Wallenberg syndrome or dorsolateral medullary
nerve palsies that may vary based on the artery involved syndrome of Wallenberg occlusion of the posterior infe-
and the extent of the causative pathology. Although rior cerebellar artery, frequently due to distal extension
Debette and Leys (2009) noted that in such statistics of a vertebral artery dissection, leads to destruction of
socio-professional effects are insufficiently captured, in the nuclei and pathways in the dorsolateral medulla
the Lee et al (2006) study, for example, 92% of patients oblongata. Another cause may be the occlusion of the
had a good outcome. Still, in the context of diagnosis parent vertebral artery, in which case the syndrome is
therapists need to be familiar with the two types of ver- called syndrome of Babinski-Nageotte. Ischaemia of the
tebral artery-related strokes (Terrett 2000). We assume inferior cerebellar peduncle leads to ipsilateral ataxia January/February 2010 - Interdivisional Review 27

and hypotonia. Destruction of the descending spinal tract Extension-rotation as a clinical test has been exten-
and the trigeminal nucleus (located from the midbrain to sively studied with equivocal results. Some authors have
the medulla) causes a loss of pain and temperature sen- reported significant decreases in blood flow (Rivett et
sation on the ipsilateral face in addition to loss of the al 1999, Yi-Kai et al 1999), whereas other studies have
ipsilateral corneal reflex. Destruction of the ascending found no changes (Arnold et al 2004, Licht et al 2000).
lateral spinothalamic tract causes loss of pain and tem- Case reports have noted false negative results (Rivett et
perature sensation in the contralateral trunk, which to- al 1998, Westaway et al 2003), and case series have re-
gether with the sensory loss in the ipsilateral face results ported 75-100% false positive results (Arnold et al 2004,
in a pathognomonic presentation of alternating anal- Haynes 2002). Research findings for the sustained cer-
gesia. Ischaemia of the descending sympathetic tract as vical rotation test are equally equivocal with significant
it courses downward in the medulla oblongata and cer- decreases (Arnold et al 2004, Mitchell 2003, Nakamura
vical spinal cord causes Horner syndrome, damage to et al 1998, Rivett et al 1999, Yi-Kai et al 1999) or no effect
the vestibular nuclei causes nystagmus, vertigo, nausea, noted on vertebral artery blood flow or volume (Haynes
and vomiting, and ischaemia in the nucleus ambiguous et al 2002, Licht et al 1999). A recent meta-analysis of
of the glossopharyngeal nerve can cause hoarseness, Doppler studies of vertebral artery blood flow velocities
dysphagia, or intractable hiccups (Terrett, 2000). during cervical rotation found that blood flow was com-
Locked-in syndrome or cerebromedullospinal discon- promised more in patients than in asymptomatic sub-
nection syndrome occurs due to occlusion of the mid- jects, on contralateral rotation, in sitting more than lying,
basilar artery. This effectively transects the brain stem and intracranial more than cervical (Mitchell 2009).
at the mid-pons level. Because the reticular formation More recently studies have also looked at the effects
and the ventral pons are unaffected the patient retains of these tests on perfusion in the internal carotid artery
consciousness but decerebrate rigidity develops due (ICA). Refshauge (1994) noted an increase in right ICA
to the cerebrospinal tracts having been destroyed. The blood flow velocity with sustained contralateral rotation
nuclei for the cranial nerves V-XII are destroyed but cra- in healthy volunteers. In contrast, Licht et al (2002) found
nial nerve IV is spared leaving only eye convergence and no change in peak flow or time-averaged mean flow ve-
upward gaze for the patient to communicate with his locity during sustained extension-rotation test. Clinically
environment. Skin sensation remains grossly intact be- relevant is that the patients in that study nonetheless ex-
cause the lateral spinothalamic tract is usually spared perienced symptoms (including vertigo, visual blurring,
and the patient can still hear because the auditory nausea, hemicranial paraesthesiae) classically consid-
nerves ascend in the brainstem lateral to the infarction ered a positive response on this test. Rivett et al (1999)
area (Terrett 2000). reported an increase in ICA blood flow velocity with cer-
vical extension and attributed this to narrowing in the
Physical examination ICA. In contrast to the other two studies, they noted a
decrease in peak systolic and end-diastolic blood flow
Cranial nerve examination, observation, and auscultation velocity in both ICA during sustained rotation. Again rel-
If the history reveals symptoms that would suggest evant with regard to the clinical interpretation is the fact
CAD (Tables 2 and 3), targeted neurological and other that these authors found no between-group differences
tests are carried out that do not put the patient at undue for subjects that were positive or negative on this test.
risk. In this context we should think of cranial nerve ex- Richter and Reinking (2005) calculated diagnostic ac-
amination and observation of the miosis (inability to curacy statistics for the De Kleyn-Nieuwenhuyse test
dilate a pupil), ptosis (droopy upper eye lid), enoph- based on studies by Côté et al (1996) and Sakaguchi et
thalmus (deeper seated eye), and anhydrosis (decreased al (2003) by comparing ultrasound flow study findings to
sweating ipsilateral head and shoulders) consistent with clinical symptoms thought indicative of vertebral artery
Horner syndrome. Auscultation for a carotid bruit may compression. Sensitivity for the both vertebral arteries
be indicated. Magyar et al (2002) noted 56% sensitivity in the Côté et al (1996) study was 0% and specificity for
and 91% specificity for detection of a 70-99% carotid ste- the right vertebral artery was 86%, whereas the left ver-
nosis when compared to Doppler duplex ultrasound. tebral artery scored 67%. Note that a positive test was
defined as the occurrence on a 30-second hold of ver-
Sustained extension-rotation and rotation tests tigo, nausea, tinnitus, lightheadedness, visual problems,
In 1927, De Kleyn and Nieuwenhuyse reported de- and numbness of the face or on one side of the body,
creased and absent vertebral artery blood flow based on nystagmus, vomiting, or loss of consciousness.
cadaver perfusion studies in various head and neck po- Diagnostic accuracy data calculated from the Sakaguchi
sitions. Based on these early perfusion studies, the sus- et al (2003) study included sensitivity of 9.3% (95% CI: 4-
tained extension-rotation and sustained rotation tests 19.9%), specificity of 97.8% (95% CI: 96.7-98.5%), a posi-
have been proposed and widely instructed and clini-
tive likelihood ratio (LR) of 4.243 (95% CI: 1.678-10.729),
cally used as tests to determine the presence of verte-
brobasilar artery circulatory compromise. In fact, 17 of and a negative LR of 0.928 (95% CI: 0.851-1.011). In light
20 member organizations of IFOMT still teach these tests of the very low incidence of CAD discussed in the intro-
(Rivett and Carlesso 2008). duction, the effect of a positive test finding on post-test

28 January/February 2010 - Interdivisional Review

probability despite a moderately high positive LR is very Beaudry M and Spence JD (2003): Motor vehicle accidents: The most
common cause of traumatic vertebrobasilar ischaemia. Can J Neurol Sci
limited. Most relevant, however, is that the very low sen- 30:320-325.
sitivity and negative LR indicate that this test is useless
Beletsky V, Nadareishvili Z, Lynch J, Shuaib A, Woolfenden A and Norris
for its intended purpose of screening for cervical artery JW (2003): Cervical arterial dissection: Time for a therapeutic trial?
circulatory compromise. Stroke 34:2856-2860.
In addition, Thiel and Rix (2005) rightfully question Blunt SB and Galton C (1997): Cervical carotid or vertebral artery dissec-
the ability of positional testing in a still patent vessel tion. BMJ 314:243.
to produce clinically useful information with regard to Cassidy JD, et al. (2008): Risk of vertebrobasilar stroke and chiropractic
the risk of adverse effects with manipulative interven- care. Spine 33:S176-S183.
tion. They also noted that the test itself might put the pa- Cogbill TH, Moore EE, Meissner M, et al (1994): The spectrum of blunt
tient at risk in case of a pathologically weakened vessel, injury to the carotid artery: A multi-center perspective. J Trauma 37:473-
especially since cadaver studies have shown greater 479.
strain values with the test as compared to manipulation. Côté P, et al (1996): The validity of the extension-rotation test as a clin-
Haldeman et al (2002) also questioned the predictive va- ical screening procedure before neck manipulation: A secondary anal-
ysis. J Manipulative Physiol Ther 19:159-164.
lidity of the test: In their retrospective review of 64 med-
icolegal cases where manipulation was associated with Debette S and Leys D (2009): Cervical artery dissections: Predisposing
factors, diagnosis, and outcome. Lancet Neurol 8:668-678.
stroke, in 27 patients the test was documented with neg-
ative results in all cases. In summary, the test lacks di- De Kleyn A and Nieuwenhuyse AC (1927): Schwindelanfälle bei einer
bestimmten Stellung des Kopfes. Acta Otolaryngologica 11:155-157.
agnostic and prognostic validity and may put patients
at risk for cervical artery circulatory compromise, espe- DiFabio RP (1999): Manipulation of the cervical spine: Risks and ben-
efits. Phys Ther 79:50-65.
cially if the history indicates the possibility of such dys-
function leading us to recommend discarding this test Dziewas R, Konrad C, Drager B, et al (2003): Cervical artery dissection:
Clinical features, risk factors, therapy and outcome in 126 patients. J
and its variants altogether. Neurol 250:1179-1184.
Conclusion Ernst E (2002): Manipulation of the cervical spine: A systematic review of
There is little doubt that there is a biologically plau- case reports of serious adverse events, 1995-2001. Med J Aust 176:376-
sible mechanism for the observed temporal association
of CAD and manipulation that appears consistent across Graziano DL, Nitsch W andHuijbregts PA (2007): Positive cervical artery
testing in a patient with chronic whiplash syndrome: Clinical decision
diverse geographical areas. However, evidence on the making in the presence of diagnostic uncertainty. J Manual Manipulative
relation between exposure to manipulation and the oc- Ther 15:E45-E63.
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have been identified that offer alternative explanations 1:65-75.
for the occurrence of CAD. It would seem that manipula- Guillon B, et al (2003): Infection and the risk of spontaneous cervical
tion is one possible factor in the multi-factorial etiology artery dissection. Stroke 34:e79-e81.
of CAD. Haldeman S, et al (2002): Unpredictability of cerebrovascular ischaemia
Although various risk factors have been identified in with cervical spine manipulation therapy: A review of sixty-four cases
the etiology of CAD, with research evidence for these after cervical spine manipulation. Spine 27:49-55.
risk factors absent or at best limited, accurate identifi- Haneline MT, Croft AC and Frishberg BM (2003): Association of internal
carotid artery dissection and chiropractic manipulation. The Neurologist
cation of a patient population at risk for CAD with ma- 9:35-44.
nipulation is not a viable option as of yet. Current best
Haneline MT and Lewkovich (2004): Identification of internal carotid
evidence would indicate refraining from manipulation if artery dissection in chiropractic practice. J Can Chiropr Assoc 48:206-
risk factors are identified. 210.
Considering the current level of evidence perhaps Haneline M and Triano J (2005): Cervical artery dissection: A compar-
more important is that the therapist is able to recog- ison of highly dynamic mechanisms: Manipulation versus motor vehicle
nize the signs and symptoms of CAD that may have been collision. J Manipulative Physiol Ther 28:57-63.
the patient or perhaps even a referring physician as an Haynes MJ (2002): Vertebral arteries and cervical movement: Doppler
indication for physiotherapy management. In this con- ultrasound velocimetry for screening before manipulation. J Manipulative
Physiol Ther 25:556-567.
text information from the history seems more relevant
than physical examination findings. In fact we suggest Haynes MJ, Cala LA, Melsom A, Mastaglia FL, Milne N and McGeachie
JK (2002): Vertebral arteries and cervical rotation: Modeling and mag-
discarding the sustained (extension) rotation tests alto- netic resonance angiography studies. J Manipulative Physiol Ther
gether due to their lack of diagnostic and prognostic ac- 25:370-383.
curacy and the potential for harm to the patient. Kawchuk GN, et al (2008): The relationship between the spatial distribu-
tion of vertebral artery compromise and exposure to cervical manipula-
tion. J Neurol 255:371-377.
Arnold C, Bourassa R, Langer T and Stoneham G (2004): Doppler Kerry R and Taylor AJ (2006): Cervical arterial dysfunction assessment
studies evaluating the effect of a physical therapy screening protocol on and manual therapy. Man Ther 11:243-253.
vertebral artery blood flow. Man Ther 9:13-21. Kerry R, Taylor AJ, Mitchell J, McCarthy C and Brew J (2008): Manual
Arnold M, Kappeler L, Georgiadis D, et al (2006): Gender differences in therapy and cervical arterial dysfunction, directions for the future: A clin-
spontaneous cervical artery dissection. Neurol 67:1050-1052. ical perspective. J Manual Manipulative Ther 16:39-48. January/February 2010 - Interdivisional Review 29

Lee VH, Brown RD, Mandrekar JN and Mokri B (2006): Incidence and out- Rivett DA, Milburn PD and Chapple C (1998): Negative premanipulative
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Licht PB, Christensen HW and Høilund-Carlsen PF (1999): Vertebral Rivett DA, Sharpless KJ and Milburn PD (1999): Effect of premanipula-
artery volume flow in human beings. J Manipulative Physiol Ther 22:363- tive tests on vertebral artery and internal carotid artery blood flow: A pilot
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Licht PB, Christensen HW, and Høilund-Carlsen PF (2000): Is there a role Rothwell DM, Bondy SJ and Williams JI (2001): Chiropractic manipula-
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30 January/February 2010 - Interdivisional Review