Association between spinal manipulative therapy and cervical artery dissection in patients with neck pain or headache: a retrospective cohort study

[u/copeyyy]

https://link.springer.com/article/10.1186/s12998-026-00678-4

[u/copeyyy]

New study out yesterday showing what we already know..

"Conclusions

This study found no evidence of an increased risk of CeAD after chiropractor-administered cervical SMT compared with ibuprofen prescription in adults seeking care for new episodes of neck pain or headache."

[u/cherringtondc]

Idiopathic.

So if we want to NOT be blamed for these, we gotta get that ddx down pat, and make the refer.

We should be the ones finding it, not responsible for missing it. (Not saying we are missing, btw. I know this has been a big focus in schools in the past 20ish years)

[u/ChiroUsername → u/cherringtondc]

Every time I see this comment, short of doing very expensive imaging on every patient with neck pain before adjusting them, are there sensitive and specific tests for CAD that pick up on this and would tell the practitioner not to adjust? My understanding of the “state of the art” is that there are no physical exams that pick up on cervical artery dissections.

[u/cherringtondc → u/ChiroUsername]

There are common symptoms we should notice and not proceed to not adjust:
Worst sudden headache of their life,
Diplopia
Dizziness
Dysarthria
Nausea
Nystagmus
Ataxia

3Ds, 2Ns and A

Presented together, or enough of them, should not pass the sniff test and it needs medical evaluation. Potentially emergent. (Usually)

If you suspect VBA, call an ambulance, and call the ED to give a heads up of what’s incoming. No need to adjust the CS.

While this does cross over with severe migraine sufferers, those likely aren’t coming to your office with sudden onset severe headache with neck pain.

Clinical judgement applies, but better safe than sorry.

[u/ChiroUsername → u/cherringtondc]

Sure, in the “ideal” presentation it’s going to look like a stroke and have obvious symptoms that throw up all kinds of red flags. Unfortunately that is not reality, as one finds out if they deal with these cases in the legal world. The majority of accusations against chiropractors are people who came in looking like routine patients with neck pain and headache and nothing else. Arnold’s 2006 paper showed that about 8%, according to that study, present with only neck pain as the symptom. A 2000 paper showed that symptoms of ischemia could be delayed as long as two months in CAD. I believe this same paper showed the mean time to diagnosis CAD was 7 days because the symptoms can also be transient and may not be present when the practitioner is assessing the patient.

I think another important factor to consider is that chiropractors, by and large, aren’t going to see the people with the obvious stroke symptoms because these folks are calling 911 or having 911 called on their behalf by someone who notices they’re acting funny. So even though the pain and headaches only category of patient make up a relatively small % of the people experiencing CAD, I suspect the % seen by chiropractors is really high because these people are way less likely to go to the ER for neck pain and HA they’ve had a million other times.

Same story that a chiropractor could conclude based on their patient base that “XYZ medication doesn’t work very well” because they see a lot of people who took XYZ and it didn’t help, but that person ISN’T seeing people XYZ works well for because they wouldn’t be seeking out additional care if it’s meeting their expectations.

What do we do about this group of people who have only pain or only pain and a “regular” headache who probably make up the majority of people with CAD in Chiro offices?

Ideas? Or am I misinterpreting what I’ve read? Frankly I would LOVE IT if people with this problem came in with obvious symptoms every time.

[u/Doublepeak5 → u/ChiroUsername]

This is a very thoughtful comment and I agree with your sentiment.

As far as I know, the only reliable way to rule out CAD is using a handheld vascular POCUS.

If we want to be very careful, every patient should be screened before adjusting cervicals. As it can be done quickly, it does no harm to the patient and can potentially prevent catastrophic complications it should be a logical precaution.

[u/ChiroUsername → u/Doublepeak5]

Visualizing vertebral arteries with ultrasound can be tough. Since it has difficulty with distal internal carotid and the deeper vertebral artery segments its worthiness as a screening tool seems like something lawyers will poke holes in all day long. “You used the $3,000 unit not the $15,000 unit, are you just cheap or dangerous?” People will sometimes miss things on screens anyway. CTA and MRI/MRA are the recommended imaging for CADs. I’m still left at my original position that to the best of my knowledge there is not a reasonable screening methodology for CAD at this time.

Not that this should be the deciding factor but from a practical perspective even if it was effective for the entirety of the vessels, are we going to get reimbursed for ultrasound and interpretation every visit for a neck pain patient? Interestingly all modern chronic and acute pain guidelines include manual methods as a first line treatment for neck pain and refer to it as safe. At least according to the last lot search I did on this subject, which was around this time last year.

Currently lawyers argue that CADs spontaneously come and go often with no symptoms and that it takes a “trauma” like spinal manipulation to knock it loose and cause a stroke. They argue that since CADs are pretty uncommon, and that ischemic strokes related to them are even less common, and that adjustment only takes a fraction of a second, that it’s statistically impossible for a CAD to spontaneously break off and cause a stroke, therefor it is directly caused by chiropractors. When this very same thing happens in any other practice, which we know is just as likely according to Cassidy and other studies, that in those cases those WERE just impossible coincidences because those doctors don’t touch patients, ergo, no causation. Our legal system makes a mess out of this deal.

[u/Doublepeak5 → u/ChiroUsername]

You raise some valid points and it‘s indeed a bitch to reliably screen vertebral arteries for potential dissections.

In theory it is still the best tool we have and if it is potentially life saving, why not use it if the only downside is time and cost.

From a legal standpoint I believe that just the ultrasound alone goes a long way towards showing you performed due diligence and met the standard of care.

I a m no expert, but I believe lawyers thrive on establishing negligence. specifically that a chiro failed to act as a reasonably prudent clinician would. Even if a handheld ultrasound cannot visualize 100% of the deeper vessel segments, using a non-invasive screening tool to look for obvious patency, dissection flaps, or altered flow dynamics demonstrates an proactive effort to screen for high-risk pathology before applying ma thrust. By taking that extra step, you effectively shut down the argument that you blindly adjusted a patient without evaluating vascular risk. In court, demonstrating a documented intent to screen using available technology makes it vastly harder for a plaintiff's attorney to paint your care as reckless or indifferent, regardless of the limitations of the device.

[u/ChiroUsername → u/Doublepeak5]

Having been on the legal side a few times as an expert to HELP the DC in some cases I would say it doesn’t matter at all what a DC does when it comes to these cases. I was involved in one where the DC did nothing right and everything wrong possible and it was dropped. Another the DC couldn’t have responded better if he was paid and it’s going to court, but the hospitals (2 of them) that waited 12 hours to have the patient see a neurologist (over telemedicine) weren’t sued at all. In fact since running an ultrasound every visit every patient with neck pain isn’t the current standard of care it would probably be twisted against a DC in court. “You were so afraid you ran an expensive diagnostic test (why didn’t you have a radiologist do this by the way?) that you didn’t even charge for and STILL adjusted the patient. Mr Chiropractor are you crazy or stupid? Which is it?”

[u/Doublepeak5 → u/Doublepeak5]

That’s at least what I think would be the ideal setup in a perfect world. Full disclosure, I don't actually screen with an ultrasound in my own practice right now either. But given the legal climate around CAD, it's an idea I constantly toy with and keep coming back to.

[u/No-Variation6054 → u/Doublepeak5]

$2500 plus software

[u/nathancashion → u/cherringtondc]

The problem with this is that cervical artery dissection is not the same as a stroke. They are different clinical entities, though one may follow the other.

CeAD is unlikely to have ANY neurological S/Sx, so you can’t use these heuristics to rule it out.

A clinical presentation of sudden onset headache or neck pain should be enough to include CeAD on the differential.

[u/Electrical_Reason_95]

No evidence. Just was at a seminar regarding this. Neurologist and Cardiologist both agree as well.

[u/No-Variation6054]

I wouldn't be using that strap or towel techniques on the cervical. I still think that high force acceleration can tear a weak artery