Association Between Cervical Artery Dissection & Spinal Manipulation in Older Patients

Association Between Cervical Artery Dissection & Spinal Manipulation in Older Patients

Patients with cervical artery dissection (CeAD) involving the carotid or vertebral arteries may be asymptomatic, although they frequently experience neck pain and/or headache (therefore they may seek chiropractic care!). A recent case-control study involving 165 patients < 50 years-of-age with ischemic strokes found that headache and neck pain were positively correlated with CeAD (references listed in Review). CeAD may lead to a stroke if the blood filled and weakened arterial wall obstructs blood flow to the brain or if a thrombus becomes dislodged.

CeAD is the most serious safety concern associated with cervical manipulation, but it is considered a rare condition, accounting for approximately 2% of ischemic strokes overall (that 2% includes both carotid and vertebral artery dissections). The reported annual incidence is approximately 3 per 100,000 persons for carotid artery dissection (CAD) and 1 per 100,000 for vertebral artery dissection (VAD). Nevertheless, VADs have been reported to occur following cervical spinal manipulation (CSM) 3 times more often than CADs.

CSM has been shown to be effective in the treatment of chronic nonspecific neck pain and several medical associations recommend its use for managing neck pain in older adults. However, a systematic review that evaluated 31 case control studies reported a strong association between CSM and CeAD-associated stroke, with an adjusted odds ratio of 3.8. It has been suggested that much larger sample sizes would be required to fully assess the safety of CSM. The American Heart Association (AHA) and the American Stroke Association (ASA) recommend that patients should be informed of the association between CSM and CeAD and this is something chiropractors discuss with patients during a typical informed consent process prior to providing neck manipulation.

CeAD is typically considered to be a condition that mainly affects younger, middle-aged people, although recent studies have suggested that it may have been underdiagnosed in older patients. In fact, based on data from the National Inpatient Sample, the prevalence of CeAD related stroke hospitalizations increases with age. Accordingly, this study evaluated the relationship between CSM and CeAD among Medicare beneficiaries using claims data from Medicare enrollees aged 65–99. Several different control groups were included, and advanced statistical methods were used to control for possible confounding.

RESEARCH REVIEW: “Association Between Cervical Artery Dissection & Spinal Manipulation”

This paper was published in BMC Geriatrics (2022) and this Review is posted in Spinal Manipulation – Adverse Events & Safety, Geriatrics and the 2023 Archive.