A new patient presented to our clinic after a motor-vehicle accident. She stated that her regular chiropractor was on an extended vacation and she needed pain relief. She said her regular chiropractor treated her for neck pain and headaches, but that those symptoms had become severe following the accident. Over the past year, she had visited her regular chiropractor about once a month for cervical and thoracic manipulation.
Presenting Symptoms / Evaluation
The patient had no vertigo, diplopia, dysarthria, dysphagia, nausea, nystagmus, or face numbness, and she reported no loss of consciousness after the accident. The patient was a normally developed, normally nourished 67-year-old female, 64 inches tall, weighing 147 pounds, and with a temperature of 98.2 degrees, pulse rate of 78, and blood pressure of 145/86.
We performed neurological and orthopedic tests with the following findings: All neurological tests were normal. Foraminal compression and shoulder depressor were positive bilaterally. There was restriction to cervical range of motion – flexion, extension and right lateral flexion were restricted 20% with pain. There was muscle spasm with pain: suboccipitals and splenius capitis (7/10), sternocleidomastoid (8/10), levator scapulae (7/10), and upper trapezius (6/10).
The patient told us she was a smoker with a severe case of atherosclerosis and was taking several medications: a statin (to lower cholesterol levels), an antiplatelet and an anticoagulant (to prevent blood clotting), a beta blocker (to reduce blood pressure), and a diabetes medication (to control blood sugar levels). She said her regular chiropractor had never communicated with her GP, or discussed her medications or atherosclerosis. We requested a medical record release from her GP.
A Dangerous Potential Complication
Factors such as atherosclerosis, high cholesterol, hypertension, smoking, diabetes, and older age increase the risk of a vertebral artery dissection.1 Cervical manipulation might contribute to a vertebral artery dissection in very-high-risk patients.2
Vertebral artery injury can have devastating complications. Sanelli, et al., reported a stroke rate of 24% and a death rate of 8%.6 We refrained from performing cervical manipulation on this patient until we had discussed it with her GP.
We provided the patient with cold packs, electrical muscle stimulation, cervical soft-tissue therapy, and thoracic manipulation, and she responded well. Following this first visit, we reviewed and signed a report that was faxed to her MD.
The next day her GP called and stated that cervical manipulation is contraindicated. He explained that a CT angiography (taken three years ago) had revealed serious vertebral artery abnormalities.
After a couple of weeks of passive care, the patient had made good progress and demonstrated only mild pain and dysfunction. After completing a physical performance test, the patient commenced spinal rehab. After one month of spinal rehab, the patient had no pain or dysfunction and had good to excellent results on the follow-up physical performance test. We discharged her to home-based rehab and recommended a Mediterranean diet, a no-smoking program, and 30 minutes of walking five days a week – with a follow-up appointment for one month later.
The general practitioner received our discharge report and then had a face-to-face meeting with us. Over the next year, that GP has referred over 20 patients to our clinic.
Key Learning Points
Gathering medical records is a priority. Request not only a patient’s GP records, but also any records from a pertinent medical specialty. The CT angiography, the patient’s medications, and their relevance should have altered her regular chiropractor’s care. In this case, the regular chiropractor should have avoided cervical manipulation.
It’s important to note that in two landmark studies, Cassidy and Kosloff concluded there is no excess risk of cerebrovascular artery (CVA) stroke associated with chiropractic care compared to primary medical care.2,4 CVA strokes occurring in chiropractic clinics are more likely a reflection of the background risk related to the natural history of the condition, with an estimated frequency of approximately one in 100,000.5 Causality has not been established.
A critical analysis using Hill’s nine criteria for causality found a lack of evidence that chiropractic spinal manipulation is causally associated with stroke.8 However, these studies do not rule out cervical manipulation as a possible contributory factor in some high-risk instances4 – which is why this case highlights a crucial truth: Communication with medical doctors is not just a professional courtesy; it is a patient safety necessity.
Good evidence supports the benefits of a thoracic thrust protocol (cervical soft-tissue therapy and thoracic manipulation) for patients with cervical symptoms.9
Spinal rehab not only improves a patient’s spinal pain and function, but also acts as a strong preventive for a new episode.3,7 Lifestyle advice might be even more important than our monthly chiropractic manipulation visits. Of course, you can always do both at the same visit.
Medical doctors can be our treatment partners. By embracing the responsibility to communicate with them, we not only protect our patients; we also elevate our profession. As this case illustrates, when we demonstrate sound clinical judgment, physicians take notice. What starts as a single conversation can build a bridge between chiropractors and medical providers that benefits countless patients.
References
- Burle VS, Panjwani A, Mandalaneni K, et al. Vertebral artery stenosis: a narrative review. Cureus, 2022 Aug 16;14:e28068.
- Cassidy JD, Boyle E, Côté P, et al. Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study. Spine, 2008 Feb 15;33(4 Suppl):S176-83.
- de Campos TF, Steffens D, Fuller JT, Hancock MJ. Exercise programs may be effective in preventing a new episode of neck pain: a systematic review and meta-analysis. J Physiother, 2018;64:159-165.
- Kosloff TM, Elton D, Tao J, Bannister WM. Chiropractic care and the risk of vertebrobasilar stroke: results of a case-control study in U.S. commercial and Medicare Advantage populations. Chiropr Man Therap, 2015 Jun 16;23:19.
- Micheli S, Paciaroni M, Corea F, et al. Cervical artery dissection: emerging risk factors. Open Neurol J, 2010 Jun 15;4:50-5.
- Sanelli PC, Sykes JB, Ford AL, et al. Imaging and treatment of patients with acute stroke: an evidence-based review. AJNR Am J Neuroradiol, 2014;35:1045-51.
- Shiri R, Coggon D, Falah-Hassani K. Exercise for the prevention of low back pain: systematic review and meta-analysis of controlled trials. Am J Epidemiol, 2018 May 1;187(5):1093-1101.
- Tuchin P. Chiropractic and stroke: association or causation? Int J Clin Pract, 2013;67:825-33.
- Yang J, Zhao S, Zhang R, et al. Effectiveness and safety of thoracic manipulation in the treatment of neck pain: an updated systematic review and meta-analysis. Technol Health Care, 2024;32(S1):385-402.
