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(Stroke. 2001;32:2440-a.)
© 2001 American Heart Association, Inc.

Letters to the Editor

Life-Threatening Complications From Spinal Manipulation Are Rare

Joseph O. Di Duro, DC, DACNE

Private Practice, Vicenza, Italy

To the Editor:

The letter by Dr Ernst¹ is misleading from the title. Are long thoracic nerve palsy and "local discomfort" life-threatening? The estimated annual incidence of spontaneous vertebral artery dissection (VAD) is 1 to 1.5 cases per 1000.²

Estimates of cerebrovascular events associated with cervical manipulation range from 0.1 to 5.0 per 100 000.³ These are estimates of events and do not extrapolate to deaths or permanent impairment, which is an even smaller percentage that would be considered "life-threatening."

In contrast, the risk of stroke from pregnancy is between 26 and 69 per 100 000.⁴ "Iatrogenic" arterial dissection as a complication of cerebral angiography has an "underreported" incidence rate of 400 per 100 000.⁵

"Spontaneous" VAD can be caused by innocuous movements,^2,6–10 and one would wonder whether the reports of manipulation being involved in VAD are just reports of the same entity. The concept of "spontaneous" lends to an idea of "instantaneous," further confusing to etiology of this disease entity when manipulation is involved.

While some stress the temporal coincidence of trivial movements/chiropractic care with the onset of cervical artery dissection, easily concluding cause, suspicion should be raised with the discrepancy between relatively minor forces resulting in such severe vascular lesions.⁶

An underlying arteriopathy leading to weakness of vessel walls and predisposing patients to "spontaneous" and/or chiropractic dissections has been proposed.^8–10 In a rare autopsy examination after manipulation, the histopathological study by Peters et al¹¹ of cervical arteries revealed widespread underlying disease of the arteries, with focal and segmental degeneration of smooth muscle tunica media and cystic transformation of the vessel walls.⁵ Additional predisposing factors were also described.

It would appear to be of more benefit to the public if articles identified the genetic, environmental, and maladaptive factors, rather than hyping the rare life-threatening complications of chiropractic care.

References

1. Ernst E. Life-threatening complications of spinal manipulation. Stroke. 2001; 32: 809–810.[Free Full Text]
2. Schievink WI. Spontaneous dissection of the carotid and vertebral arteries. N Engl J Med. 2001; 344: 898–906.[Free Full Text]
3. Assendelft WJ, Bouter LM, Knipschild PG. Complications of spinal manipulation: a comprehensive review of the literature. J Fam Pract. 1996; 42: 475–480.[Medline] [Order article via Infotrieve]
4. Jaigobin C, Silver FL. Stroke and pregnancy. Stroke. 2000; 31: 2948–2951.[Abstract/Free Full Text]
5. Cloft HJ, Jensen ME, Kallmes DF, Dion JE. Arterial dissections complicating cerebral angiography and cerebrovascular interventions. AJNR Am J Neuroradiol. 2000; 21: 541–545.[Abstract/Free Full Text]
6. Hinse P, Thie A, Lachenmayer L. Dissection of the extracranial vertebral artery: report of four cases and review of the literature. J Neurol Neurosurg Psychiatry. 1991; 54: 863–869.[Abstract/Free Full Text]
7. Mascalchi M, Bianchi MC, Mangiafico S, Ferrito G, Puglioli M, Marin E, Mugnai S, Canapicchi R, Quilici N, Inzitari D. MRI and MR angiography of vertebral artery dissection. Neuroradiology. 1997; 39: 329–340.[Medline] [Order article via Infotrieve]
8. McCormick GF, Halbach VV. Recurrent ischemic events in two patients with painless vertebral artery dissection. Stroke. 1993; 24: 598–602.[Abstract/Free Full Text]
9. Touze E, Randoux B, Meary E, Arquizan C, Meder JF, Mas JL. Aneurysmal forms of cervical artery dissection: associated factors and outcome. Stroke. 2001; 32: 418–423.[Abstract/Free Full Text]
10. Brandt T, Hausser I, Orberk E, Grau A, Hartschuh W, Anton-Lamprecht I, Hacke W. Ultrastructural connective tissue abnormalities in patients with spontaneous cervicocerebral artery dissections. Ann Neurol. 1998; 44: 281–285.[Medline] [Order article via Infotrieve]
11. Peters M, Bohl J, Thomke F, Kallen KJ, Mahlzahn K, Wandel E, Meyer zum Buschenfelde KH. Dissection of the internal carotid artery after chiropractic manipulation of the neck. Neurology. 1995; 45: 2284–2286.[Abstract/Free Full Text]

E. Ernst, MD, PhD, FRCP(Edin)

Department of Complementary Medicine, University of Exeter, Exeter, England

Response

Dr Di Duro’s interest is much appreciated. In my view, however, his arguments are of debatable validity. Firstly, my editorial¹ did discuss many life-threatening complications and also included, for the sake of completeness, some minor adverse events. Thus, I do not feel that the title was misleading. Second, estimates of cerebrovascular accidents (CVAs) after spinal manipulation may well be invalid. They are built on certain assumptions regarding the level of underreporting. We have recently shown that, in the United Kingdom setting, underreporting seems to be 100%.² This renders estimates hardly worth the paper they are printed on. Third, a recent, large case-control study has demonstrated that spontaneous and chiropractic-induced CVAs are, in fact, not the same.³ At least some populations seem to be at risk of suffering a CVA from chiropractic spinal manipulation which is significantly above that of spontaneous CVAs.

In essence, this leaves us with the following situation. There is preciously little hard evidence that upper spinal manipulation produces significant health benefits for any type of patient. There is mounting evidence that these procedures are associated with relevant risks. Thus, there is considerable uncertainty regarding the risk benefit profile of upper spinal manipulation. It is now up to the chiropractic profession to convincingly demonstrate that the benefits outweigh the risks. Until such data are available, it is legitimate, I would even say prudent, to be cautious and critical—primum non nocere!

References

1. Ernst E. Life-threatening complications of spinal manipulation. Stroke. 2001; 32: 809–810.
2. Stevinson C, Honan W, Cooke B, Ernst E. Neurological complications of cervical spine manipulation. J R Soc Med. 2001; 94: 107–110.[Abstract/Free Full Text]
3. Rothwell DM, Bondy SJ, Williams SJ. Chiropractic manipulation and stroke: a population-based case-control study. Stroke. 2001; 32: 1054–1060.[Abstract/Free Full Text]

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