Cases of immediate stroke following cervical spine manipulation (CSM) are documented in the medical literature, as far back as the first case report in 1947.1–8 Research suggests if CSM is performed in the presence of an existing cervical artery dissection (CAD), immediate thromboembolic or thrombotic stroke can occur.1,9-18
Two of these research studies were led by Scott Haldeman, a doctor of chiropractic.10,12 In 1999, Haldeman proposed thromboembolic and thrombotic mechanisms of stroke from CSM: “It has been suggested the cervical manipulation in many cases may have been administered to patients who already had spontaneous dissection in progress. This suggestion arises from the observation that many patients with spontaneous dissection have initial symptoms of acute neck pain and headaches that progress to infarction with passing time. Because most cervical manipulations are administered to treat neck pain and headaches, these patients with a dissection in progress on seeing a practitioner are likely to be manipulated, and in turn could precipitate a vascular occlusion or dislodge an embolus.”10
In 2002, Haldeman again proposed thrombotic and thromboembolic mechanisms of stroke from CSM:
- “The sudden onset of acute and unusual neck and/or head pain may represent a dissection in progress and be the reason a patient seeks manipulative therapy that then serves as the final insult to the vessel leading to ischemia.”
- “Our data raise the possibility that in certain cases manipulation may not be the primary insult causing the dissection but rather an aggravating factor or coincidental event precipitating ischemia.”
- “It does, however, suggest many of these dissections may be spontaneous or due to trivial trauma and manipulation may be simply the final insult that precipitated the vascular occlusion or release of a thrombotic embolism.”12
Cassidy, a doctor of chiropractic, was the lead researcher for the oft-cited 2008 study, which states:
- “We have not ruled out neck manipulation as a potential cause of some VBA strokes.”
- Cassidy proposed a plausible thromboembolic mechanism of causation: “It might also be possible chiropractic manipulation, or even simple range-of-motion examination by any practitioner, could result in a thromboembolic event [stroke] in a patient with a pre-existing vertebral artery dissection.”
- Cassidy designed their 2008 and 2017 studies taking into account CSM might cause immediate stroke: “For the chiropractic analysis, the index date was included in the hazard period, since chiropractic treatment might cause immediate stroke and patients would not normally consult a DC after having a stroke.”13,19
Cassidy concluded, “We found no evidence of excess risk of VBA stroke associated with chiropractic care compared to primary care.” However, Cassidy’s conclusion is irrelevant to cases of immediate post-manipulative stroke, occurring within seconds or minutes of CSM. Cassidy did not analyze an immediate cohort for either DC visits or PCP visits. The shortest cohort was 0-1 day. The 0- to 1-day PCP visit cohort was excluded and therefore could not be compared and contrasted to the 0- to 1-day DC visit cohort.13 This was a landmark study in the history of chiropractic research in this area; however, it is not relevant to immediate post-manipulative stroke.
It is often reported that no causal association between CSM and stroke can be established in the absence of randomized controlled trials (RCTs). However, RCTs are infeasible in these clinical settings due to the rarity and life-threatening nature of CAD and stroke. As RCTs are infeasible, physicians must use the next best external evidence to establish causation.20 Causation can be established as more likely than not using an analysis of plausibility, temporality and lack of a more probable explanation.21 In a malpractice case, the standard for causation is more likely than not.
As a profession, chiropractic needs to acknowledge the numerous studies presenting plausible mechanisms by which CSM can cause immediate stroke. Until these mechanisms are acknowledged, clinical efforts to avoid triggering these mechanisms cannot be effectively implemented. Efforts should also be made to protect the DC from professional liability if immediate post-manipulative stroke occurs. Here are 10 recommendations for DCs to survive a stroke malpractice claim.
- Legible documentation. If you do not have an EHR/EMR system, get one. Illegible documentation does not impress a judge or jury.
- Obtain verbal and written informed consent to the risk of thromboembolic or thrombotic stroke from CSM. The risk of causation of stroke by CSM is low; however, as it carries serious consequences including paralysis and death, it should be regarded as a material risk requiring disclosure. This is the standard of care (SOC) per research and the Association of Chiropractic Colleges.22,23
- Obtain verbal and written informed consent to the risk of CAD from CSM. CAD and stroke are separate medical conditions. CAD is a tear in the inner lining of a cervical artery; stroke is a decrease in blood supply to the brain. CAD can lead to a stroke; however, generally CAD will heal spontaneously when left alone and has a good clinical prognosis when treated in routine clinical fashion.11,24,25 Church found no convincing evidence to support a causal link between CSM and CAD in a healthy cervical artery.26Numerous other studies support Church’s conclusions.27-32 However, if the patient enters the office with an unhealthy cervical artery which is prone to dissection, CSM could cause CAD. Therefore, informed consent to the risk of CAD from CSM is the SOC.
- Perform a thorough history-taking and examination. History-taking, especially regarding the time of symptom onset, is the single most important factor for detecting CAD.33 There is no single screening test for CAD. The chiropractic physician must know the clinical symptoms of CAD to make the diagnosis.34 Confirming the diagnosis requires a high index of suspicion and good vascular imaging.13
- Record vital signs as recommended by practice guidelines.35 High blood pressure and a high BMI are risk factors for stroke. A low BMI is a risk factor for CAD. The physician needs this information for correct medical decision-making and to demonstrate clinical competence in the event of a malpractice claim.
- Perform a differential diagnosis to rule out CAD before performing CSM.33 Research supports the SOC is to include CAD in a differential diagnosis whenever neck pain, headache or dizziness are present, even if they are the only presenting symptoms.34,36,37
- If the patient presents with neck pain and headaches suspicious for CAD, the SOC is an immediate referral to the medical emergency department.33 Do not adjust the patient. If the patient refuses a referral to medical emergency, the liability shifts to the patient, and away from you. Keep in mind, some ER physicians will not order cervical artery imaging if ischemic symptoms are not present. If so, order the imaging yourself. Time is of the essence if a CAD is present. If you do not know the imaging to order, educate yourself. There are at least 29 postgraduate courses on manipulation and stroke for DCs.
- If the patient presents with neck pain and headache suspicious for CAD and ischemic symptoms, the SOC is an immediate referral to the medical emergency department.33 Do not adjust the patient. Do not attempt to order the cervical artery imaging yourself. If the patient is having ischemic symptoms, it is not just a CAD, it is a stroke.
- If the patient develops symptoms of immediate post-manipulative ischemic stroke, most commonly dizziness and vomiting, the SOC is an immediate referral to the medical emergency department. Call 911. Do not “re-adjust” the patient. Do not assume the patient has low blood sugar or the flu. Do not assume the patient is having a “reaction to the adjustment.” Do not attempt to drive the patient to the emergency department. If you call EMS and the patient refuses an ambulance, the liability shifts to the patient, and away from you. Report the incident to your chiropractic malpractice insurance carrier immediately.
- Complete chart notes promptly with an electronic date and time signature stamp. In a malpractice case, you must show you did not alter your documentation after the fact in an effort to decrease your liability. Do not change your chart notes, ever. If a stroke occurs after CSM in your office, you should document the incident in an electronically signed and dated addendum to your chart note. When in doubt, document. However, never alter an existing chart note. An audit report from your EHR/EMR software will show every change made to a chart note, sometimes down to the exact keystroke and the exact second.
STEVEN BROWN, DC, DIPL MED AC, is a chiropractic expert witness for the plaintiff or defense emphasizing cases of manipulation, dissection, stroke, pneumothorax and spinal cord injury. He lectures nationally on manipulation and stroke and can be reached at drbrown@brownchiro.com.
References
- Smith WS, et al. Spinal manipulative therapy is an independent risk factor for vertebral artery dissection. Neurology. 2003;60(9):1424–1428. PubMed. https://pubmed.ncbi.nlm.nih.gov/12743225/. Accessed Jan. 9, 2024.
- Pratt-Thomas HR, Berger KE. Cerebellar and spinal injuries after chiropractic manipulation. J Am Med Assoc. 1947;133(9):600–603. JAMA. https://jamanetwork.com/journals/jama/article-abstract/291970. Accessed Jan. 9, 2024.
- Kennell KA, et al. Cervical artery dissection related to chiropractic manipulation: One institution’s experience. J Fam Pract. 2017;66(9):556–562. PubMed. https://pubmed.ncbi.nlm.nih.gov/28863201/. Accessed Jan. 9, 2024.
- Turner RC, et al. The potential dangers of neck manipulation and risk for dissection and devastating stroke: An illustrative case and review of the literature. Biomed Res Rev. 2018;2(1):10. PubMed. https://pubmed.ncbi.nlm.nih.gov/29951644/. Accessed Jan. 9, 2024.
- Terrett AGJ. Current concepts in vertebrobasilar complications following spinal manipulation. 2nd ed. West Des Moines, Iowa: NCMIC; 2001.
- Haldeman S, et al. Arterial dissections following cervical manipulation: the chiropractic experience. CMAJ. 2001;165(7):905–906. PubMed. https://pubmed.ncbi.nlm.nih.gov/11599329/. Accessed Jan. 9, 2024.
- Haldeman S, et al. Unpredictability of cerebrovascular ischemia associated with cervical spine manipulation therapy: a review of sixty-four cases after cervical spine manipulation. Spine. 2002;27(1):49–55. PubMed. https://pubmed.ncbi.nlm.nih.gov/11805635/. Accessed Jan. 9, 2024.
- Hufnagel A, et al. Stroke following chiropractic manipulation of the cervical spine. J Neurol. 1999;246(8):683–688. PubMed. https://pubmed.ncbi.nlm.nih.gov/10460445/. Accessed Jan. 9, 2024.
- Mas JL, et al. Dissecting aneurysm of the vertebral artery and cervical manipulation: a case report with autopsy. Neurology. 1989;39(4):512–515. PubMed. https://pubmed.ncbi.nlm.nih.gov/2927675/. Accessed Jan. 9, 2024.
- Haldeman S, et al. Risk factors and precipitating neck movements causing vertebrobasilar artery dissection after cervical trauma and spinal manipulation. Spine. 1999;24(8):785–794. PubMed. https://pubmed.ncbi.nlm.nih.gov/10222530/. Accessed Jan. 9, 2024.
- Norris JW, et al. Sudden neck movement and cervical artery dissection. The Canadian Stroke Consortium. CMAJ. 2000;163(1):38–40. PubMed. https://pubmed.ncbi.nlm.nih.gov/10920729/. Accessed Jan. 9, 2024.
- Haldeman S, et al. Stroke, cerebral artery dissection, and cervical spine manipulation therapy. J Neurol. 2002;249(8):1098–1104. PubMed. https://pubmed.ncbi.nlm.nih.gov/12195461/. Accessed Jan. 9, 2024.
- Cassidy JD, et al. Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study. Spine. 2008;33(4):176-183. PubMed. https://pubmed.ncbi.nlm.nih.gov/18204390/. Accessed Jan. 9, 2024.
- Schwartz NE, et al. Clinical and radiographic natural history of cervical artery dissections. J Stroke Cerebrovasc Dis. 2009;18(6):416–423. PubMed. https://pubmed.ncbi.nlm.nih.gov/19900642/. Accessed Jan. 9, 2024.
- Albuquerque FC, et al. Craniocervical arterial dissections as sequelae of chiropractic manipulation: patterns of injury and management. J Neurosurg. 2011;115(6):1197–1205. https://thejns.org/view/journals/j-neurosurg/115/6/article-p1197.xml. Accessed Jan. 9, 2024.
- Tuchin P. Chiropractic and stroke: association or causation? Int J Clin Pract. 2013;67(9):825–833. PubMed. https://pubmed.ncbi.nlm.nih.gov/23952462/. Accessed Jan. 9, 2024.
- Whedon JM, et al. Risk of traumatic injury associated with chiropractic spinal manipulation in Medicare Part B beneficiaries aged 66 to 99 years. Spine. 2015;40(4):264–270. PubMed. https://pubmed.ncbi.nlm.nih.gov/25494315/. Accessed Jan. 9, 2024.
- Thomas LC. Cervical arterial dissection: An overview and implications for manipulative therapy practice. Man Ther. 2016;21:2–9. PubMed. https://pubmed.ncbi.nlm.nih.gov/26250600/. Accessed Jan. 9, 2024. Cassidy JD, et al. Risk of carotid stroke after chiropractic care: a population-based case-crossover study. J Stroke Cerebrovasc Dis. 2017;26(4):842–850. PubMed. https://pubmed.ncbi.nlm.nih.gov/27884458/. Accessed Jan. 9, 2024.
- Ahuja AS. Should RCT’s be used as the gold standard for evidence based medicine? Integr Med Res. 2019;8(1):31–32. PubMed. https://pubmed.ncbi.nlm.nih.gov/30805294/. Accessed Jan. 9, 2024.
- Freeman MD. A practicable and systematic approach to medicolegal causation. Orthopedics. 2018;41(2):70–72. PubMed. https://pubmed.ncbi.nlm.nih.gov/29566252/. Accessed Jan. 9, 2024.
- Lehman JJ, et al. Should the chiropractic profession embrace the doctrine of informed consent? J Chiropr Med. 2008;7(3):107–114. PubMed. https://pubmed.ncbi.nlm.nih.gov/19646372/. Accessed Jan. 9, 2024.
- Association of Chiropractic Colleges. Association of Chiropractic Colleges Informed Consent Guideline [Internet]. https://acc.memberclicks.net/informed-consent-guideline. Accessed Jan. 9, 2024.
- Park KW, et al. Vertebral artery dissection: natural history, clinical features and therapeutic considerations. J Korean Neurosurg Soc. 2008;44(3):109–115. PubMed. https://pubmed.ncbi.nlm.nih.gov/19096659/. Accessed Jan. 10, 2024.
- Morris NA, et al. Timing of incident stroke risk after cervical artery dissection presenting without ischemia. Stroke. 2017;48(3):551–555. PubMed. https://pubmed.ncbi.nlm.nih.gov/28232592/. Accessed Jan. 10, 2024.
- Church EW, et al. Systematic review and meta-analysis of chiropractic care and cervical artery dissection: no evidence for causation. Cureus. 2016;8(2):e498. PubMed. https://pubmed.ncbi.nlm.nih.gov/27014532/. Accessed Jan. 10, 2024.
- Achalandabaso A, et al. Tissue damage markers after a spinal manipulation in healthy subjects: a preliminary report of a randomized controlled trial. Dis Markers. 2014;2014:815379. PubMed. https://pubmed.ncbi.nlm.nih.gov/25609853/. Accessed Jan. 10, 2024.
- Symons B, Herzog W. Cervical artery dissection: a biomechanical perspective. J Can Chiropr Assoc. 2013;57(4):276–8. PubMed. https://pubmed.ncbi.nlm.nih.gov/24302772/. Accessed Jan. 10, 2024.
- Gorrell LM, et al. Vertebral arteries do not experience tensile force during manual cervical spine manipulation applied to human cadavers. J Man Manip Ther. 2023;31(4):261–269. PubMed. https://pubmed.ncbi.nlm.nih.gov/36382347/. Accessed Jan. 10, 2024.
- Chung CLR, et al. The association between cervical spine manipulation and carotid artery dissection: a systematic review of the literature. J Manipulative Physiol Ther. 2015;38(9):672–676. PubMed. https://pubmed.ncbi.nlm.nih.gov/24387889/. Accessed Jan. 10, 2024.
- Whedon JM, et al. Association between cervical artery dissection and spinal manipulative therapy – a medicare claims analysis. BMC Geriatr. 2022;22(1):917. PubMed. https://pubmed.ncbi.nlm.nih.gov/36447166/. Accessed Jan. 10, 2024.
- Whedon JM, et al. The association between cervical artery dissection and spinal manipulation among US adults. Eur Spine J. 2023;32(10):3497-3504. PubMed. https://pubmed.ncbi.nlm.nih.gov/37422607/. Accessed Jan. 10, 2024.
- Chaibi A, Russell MB. A risk-benefit assessment strategy to exclude cervical artery dissection in spinal manual-therapy: a comprehensive review. Ann Med. 2019;51(2):118–127. PubMed. https://pubmed.ncbi.nlm.nih.gov/30889367/. Accessed Jan. 10, 2024.
- Gottesman RF, et al. Clinical characteristics of symptomatic vertebral artery dissection: a systematic review. Neurologist. 2012;18(5):245–254. PubMed. https://pubmed.ncbi.nlm.nih.gov/22931728/. Accessed Jan. 10, 2024.
- Whalen W, et al. Best-practice recommendations for chiropractic management of patients with neck pain. J Manipulative Physiol Ther. 2019;42(9):635–650. PubMed. https://pubmed.ncbi.nlm.nih.gov/31870638/. Accessed Jan. 10, 2024.
- Futch D, et al. Vertebral artery dissection in evolution found during chiropractic examination. BMJ Case Rep. 2015;2015:bcr2015212568. PubMed. https://pubmed.ncbi.nlm.nih.gov/26564115/. Accessed Jan. 10, 2024.
- Arnold M, et al. Pain as the only symptom of cervical artery dissection. J Neurol Neurosurg Psychiatry. 2006;77(9):1021–1024. PubMed. https://pubmed.ncbi.nlm.nih.gov/16820416/. Accessed Jan. 10, 2024.