Vertebrobasilar Arterial Insufficiency

Vertebrobasilar arterial insufficiency is a rare clinical occurrence in chiropractic practice. In order to better understand the clinical presentation of vertebrobasilar arterial insufficiency, 52 cases from the literature were reviewed with respect to the presenting symptoms so as to identify the relative frequency of their occurrence.^1-33

Chiropractic cervical manipulation was identified as the etiology for 21 reported cases of the 52 cases cited. There were 9 cases in which cervical manipulation was administered but the type of practitioner treating the patient was not identified. Osteopathic manipulation was implicated in three cases and spinal manipulations performed by medical doctors were identified as the etiology in two cases. One reported case involving a medical doctor was caused by a stroke during usual and customary cervical range of motion testing following a skiing accident. One reported case involved a physical therapist administering a cervical manipulation. Two reported cases were due to yoga exercises and another was related to self-administered cervical adjustments. Two cases clearly indicated head rotation while "looking over the shoulder" as the causative etiology for the vertebrobasilar arterial attack. The remainder of the cited cases occurred without manipulative intervention.

It must also be noted that in every case in which a loss of consciousness accompanied vertebrobasilar arterial insufficiency, dire consequences ranging from persistent neurological deficits to coma and death were the result. Therefore, one must consider loss or alteration in the level of consciousness following manipulation as an emergency situation requiring immediate medical attention. Terrett and Kleynhans examined 126 vascular accidents cited in the literature which occurred over a 55 year period.34 Their review revealed that only 29 cases of death following manipulation were identified world-wide in this 55 year period. When one considers the number of spinal manipulations administered each year, the risk for complications from this procedure is astronomically low.

References

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2. Hanus SH, Homer TD, and Harter DH, Vertebral artery occlusion complicating yoga exercise. Arch Neurol, 34:574-575, 1977.

    

3. Miller RG and Burton R, Stroke following chiropractic manipulation of the spine. JAMA, 229:189-190, 1974.

    

4. Schellhas KP, et al. Vertebrobasilar injuries following cervical manipulation. JAMA, 244:1450-1453, 1980.

    

5. Smith RA and Estridge MN. Neurologic complications of head and neck manipulations. JAMA, 182:528-531, 1962.

    

6. Daneschmend TK, et al. Acute brain stem stroke during neck manipulation. BMJ, 288:189, 1984.

    

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8. Zimmerman AW et al. Traumatic vertebrobasilar occlusive disease in childhood. Neurology, 28:185-188, 1978.

    

9. Davidson KC, Weiford EC, and Dixon GD. Traumatic vertebral artery pseudoaneurysm following chiropractic manipulation. Radiology, 115:651-652, 1975.

    

10. Terrett AGJ. Vascular accidents from cervical spine manipulation: Report on 107 cases. J. Australian Chiropractic Assoc. 17:15-24, 1987.

     

11. Pratt-Thomas HR and Berger KE. Cerebellar and spinal injuries after chiropractic manipulation. JAMA, 133:600-603, 1947.

     

12. York vs. Daniels. Medicolegal abstracts. Chiropractors: injury to spinal meninges during adjustments. JAMA, 159:809, 1955.

     

13. Bladin PF and Merory J. Mechanisms in cerebral lesions in trauma to high cervical portion of the vertebral artery -- rotation injury. Proc Aust Assoc Neurol, 12:35-41, 1975.

     

14. Kreuger BR and Okazaki H. Vertebral-basilar distribution infraction following chiropractic cervical manipulation. Mayo Clin Proc, 55:322-332, 1980.

     

15. Braun IF, et al. Brain stem infraction due to chiropractic manipulation of the cervical spine. Souther Med J., 76:1199-1201, 1983.

     

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17. Horn SW. The Locked-In Syndrome following chiropractic manipulation of the cervical spine. Ann Emerg Med, 12:648-650, 1983.

     

18. Bolton SP. Vascular accidents. J. Aust Chiro Assoc, 17:75, 1987.

     

19. Dhamoon SK, et al. Ipsilateral hemiplegia and the Wallenberg Syndrome. Arch Neurol, 41:179-180, 1984.

     

20. Bakewell vs. Kahle. Medicolegal abstract. Chiropractors: rupture of brain tumor following adjustment. JAMA, 148:699, 1952.

     

21. Kanshepolsky J., et al. Vertebral artery insufficiency and cerebellar infract due to manipulation of the neck. Bull LA Neurol Soc, 37:62-66, 1972.

     

22. Kommerall G and Hoyt WF. Lateropulsion of saccadic eye movements. Arch Neurol, 28:313-318, 1973.

     

23. De Vivo DC and Farrell FW. Arch Neurol, 26:278-281, 1972.

     

24. Brain L. Some unsolved problems of cervical spondylosis. BMJ, March 23, 1963, 771-777.

     

25. Hardin CA, Williamson WP, and Steegmann AT. Vertebral artery insufficiency produced by cervical osteoarthritic spurs. Neurology.

     

26. Bauer R, Sheehan S, and Meyer JS. Arteriographic study of cerebrovascular disease. Arch Neurol, 4:119-131, 1961.

     

27. Marks RL and Freed MM. Nonpenetrating injuries of the neck and cerebrovascular accident. Arch Neurol, 28:412-414, 1973.

     

28. Brust JCM, et al. The pathology of drop attack: A case report. Neurology, 29:786-790, 1979.

     

29. Grayson MF. Horner's syndrome after manipulation of the neck. BMJ, 295:1381-1382, 1987.

     

30. Roche L, et al. Lesions traumatiques de la colonne cervicale et attientes de l'artere vertebrale. Ann Med Leg, 43:232-235, 1963.

     

31. Easton JD and Sherman DG. Cervical manipulations and stroke. Stroke, 8:594-597, 1977.

     

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34. Terret AGJ, and Kleynhans AM. Cerebrovascular complications of manipulation. In: Haldeman S. Principles and Practice of Chiropractic, second edition, Appleton and Lange, Norwalk, Connecticut, 1992.