Cervical Arterial Dissections and Association With Cervical Manipulative Therapy

Abstract

3155Purpose-Cervical artery dissections (CDs) are among the most common causes of stroke in young and middle-aged adults.The aim of this scientific statement is to review the current state of evidence on the diagnosis and management of CDs and their statistical association with cervical manipulative therapy (CMT). In some forms of CMT, a high or low amplitude thrust is applied to the cervical spine by a healthcare professional. Methods-Members of the writing group were appointed by the American Heart Association Stroke Council's Scientific Statements Oversight Committee and the American Heart Association's Manuscript Oversight Committee. Members were assigned topics relevant to their areas of expertise and reviewed appropriate literature, references to published clinical and epidemiology studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize existing evidence and to indicate gaps in current knowledge. Results-Patients with CD may present with unilateral headaches, posterior cervical pain, or cerebral or retinal ischemia (transient ischemic or strokes) attributable mainly to artery-artery embolism, CD cranial nerve palsies, oculosympathetic palsy, or pulsatile tinnitus. Diagnosis of CD depends on a thorough history, physical examination, and targeted ancillary investigations. Although the role of trivial trauma is debatable, mechanical forces can lead to intimal injuries of the vertebral arteries and internal carotid arteries and result in CD. Disability levels vary among CD patients with many having good outcomes, but serious neurological sequelae can occur. No evidence-based guidelines are currently available to endorse best management strategies for CDs. Antiplatelet and anticoagulant treatments are both used for prevention of local thrombus and secondary embolism. Case-control and other articles have suggested an epidemiologic association between CD, particularly vertebral artery dissection, and CMT. It is unclear whether this is due to lack of recognition of preexisting CD in these patients or due to trauma caused by CMT. Ultrasonography, computed tomographic angiography, and magnetic resonance imaging with magnetic resonance angiography are useful in the diagnosis of CD. Follow-up neuroimaging is preferentially done with noninvasive modalities, but we suggest that no single test should be seen as the gold standard.

Spinal rehabilitative exercise or manual treatment for the prevention of cervicogenic headache in adults

“…Cervical artery dissection is a rare event and case-control studies have consistently found an association with cervical spine manipulation (Biller 2014; Church 2016). However, the best evidence suggests that the association is not causal.…”

Cervical arterial dissection: An overview and implications for manipulative therapy practice

“…Trauma to the internal carotid artery likely occurs due to cervical extension or sudden neck movement compressing the artery over the bodies or transverse processes of the upper cervical vertebrae or mastoid process . The vertebral artery is most commonly injured at the atlanto-axial segment (C1-2) where most cervical rotation occurs (Biller et al 2014, Bogduk and Mercer, 2000, Haneline and Triano, 2005, Lleva et al 2012. (Figure 3)…”

“…The questions raised are whether the nature of a manipulative technique is responsible for the dissection, or whether the diagnosis of CAD has been missed (Biller et al, 2014).…”

“…Often, symptoms worsen over hours/days. This should prompt the clinician to question about risk factors such as recent exposure to minor trauma or recent infection (Biller et al, 2014). Follow-up questions should seek in some detail, information about any ischaemic features such as visual disturbance, balance or gait disturbance, speech difficulties or limb weakness or paraesthesia.…”

Neuroimaging of Headaches Associated with Vascular Disorders

“…Trauma is a frequent cause of cervical dissection, making a thorough history important in establishing the correct diagnosis. Although an association between cervical dissection and cervical manipulative therapy (chiropractor manipulation) has been established, on the basis of clinical reports and population-control studies, the 2014 American Heart Association/American Stroke Association scientific statement concluded there is insufficient evidence to establish the claim that mechanical forces generated during such manipulative therapy are the cause of the dissection [44].…”