More Complications of Spinal Manipulation
To the Editor:
I read with interest the commentary by Ernst1 regarding life-threatening complications of spinal manipulation. Recently, I reported2,3 3 cases of stroke that occurred after chiropractic manipulation, 2 involving carotid dissection and 1 involving vertebral dissection. Ernst cites 1 literature case of carotid dissection.4 There is a fourth case his research did not uncover.5 I wish to add an unusual case of intracranial hypotension due to presumed dural tear, a heretofore unreported complication of cervical chiropractic manipulation.
A 34-year-old man suffered a whiplash injury in a motor vehicle accident. He consulted a chiropractor for nonradiating neck pain and improved somewhat. Approximately 1 month after the initial injury, the chiropractor performed a rapid rotatory neck manipulation that caused severe, nonradiating neck pain. Approximately 36 hours after the manipulation he noticed severe, throbbing, positional headache; he would suffer bifrontal and cervico-occipital throbbing on assuming the erect position that resolved promptly on his becoming supine. There was mild dizziness, but no diplopia, otorrhea, rhinorrhea, or other complaints. The clinical diagnosis was intracranial hypotension.
The patient’s vital signs were stable. General and neurological examinations were normal as well. Noncontrast head CT was negative. Lumbar puncture demonstrated an opening pressure of 80 mm H2O. Cerebrospinal fluid analysis showed a red blood cell count of 10/mm3, white blood cell count of 2/mm3, protein 96 mg/dL, and glucose 63 mg/dL. Brain MRI with gadolinium failed to show any dural enhancement. Lumbar epidural blood patch was of no benefit. The patient was discharged home after he was able to ambulate without incapacitating headache and was instructed to slowly increase his level of activity as tolerated. When mild positional dizziness developed 5 weeks later, complete myelography was performed. Opening pressure was 210 mm H2O. Small bulges were noted at C6-7 and L4-5. There was no evidence of extravasation of intrathecal contrast.
It is my hypothesis that this patient suffered a dural tear due to cervical manipulation. This has been reported after other forms of neck trauma as well.6 The 36-hour delay from trauma to symptom onset is typical of post–lumbar puncture headache. The initially low opening pressure resolved over several weeks with conservative management, not unlike most cases of dural tears.6 To my knowledge, this is the first reported case of documented intracranial hypotension following chiropractic manipulation.
Ernst E. Life-threatening complications of spinal manipulation. Stroke. 2001; 32: 809–810.
Jeret JS, Bluth MB. Stroke following chiropractic manipulation: report of 3 cases and review of the literature. Presented at the 23rd Annual Meeting of the American Society of Neuroimaging; San Juan, Puerto Rico; January 28, 2000.
Jeret JS, Bluth MB. Stroke following chiropractic manipulation: report of 3 cases and review of the literature. J Neuroimaging. 2000; 10: 52.Abstract
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.
Dr Jeret points out that my search did not uncover all cases of life-threatening complications of spinal manipulation. This is important, because it contributes to underreporting and underrecognition of such adverse events. We have recently published a survey1 conducted on all members of the Association of British Neurologists. The principal questions related to the number of cases seen by these practitioners of neurological complications occurring within 24 hours of cervical spinal manipulation over a 12-month period. Of the 239 respondents, 24 recalled a total of 35 serious neurological complications. Perhaps the most remarkable aspect of these findings was that none of these cases had been published in the peer-reviewed literature. Thus underreporting, in this series, was exactly 100%. Collectively, these data render all estimates of incidence figures more than questionable. The bottom line, it seems, is that chiropractors and other professions should establish the incidence of complications of spinal manipulation as a matter of urgency. In the absence of reliable data, this therapy cannot be regarded as safe.