Dr David McGrath

Spine Physician

MB BS (Hons) FAFOM, RACP, FAFMM
Master of Pain Medicine

Is Spinal Manipulation Dangerous

Not according to practitioners of this technique. The science is much less supportive.
Neck manipulation in particular, has been implicated, as the cause of stroke and death, throughout the world.
The actual incidence of these adverse events,however is unknown. The often quoted 1/5,000,000 estimate, is likely to be due to a gross under reporting. In my own town of Canberra Australia (population 300,000), I had direct experience of one case of stroke,and knew of two other cases. None of these cases, were reported in the either the local news media or scientific literature. This was the result of out of court settlement agreements. A closer estimate, is more likely to be around 1/400,000 manipulations.

Anatomically, the danger lies in the close proximity of brain arteries and spinal cord to the joints. A forceful movement across the joints, with no opportunity to monitor sensation, can endanger both of these structures.

The ateries include

1. The intervertebral arteries

2. The internal and external carotid arteries

These arteries can dissect, leading to occlusive thrombosis, and brain infarction (stroke or death )

The spinal cord can

1. Bruise

2. The Cord Membranes can be torn (dura,arachnoid,pia matter)

This can lead to traumatic syringomyelia,arachnoiditis,spinal cord haemorrhage, and spinal cord infarction.

It should be realised that there are no means of knowing, prior to a manipulation, who is at risk. There are no reliable clinical methods to identify, at risk people. Youth, is also not protective. The personal case I knew of, was only a young lady.

In addition, to these catastrophic events, simple joint trauma can lead to capsular damage, osteochondral fractures and joint instability. (pain,noises,irritability)

Physical stress across the region is not the only cause of these events. Infection in particular,has also been implicated. (colds,flu,gastro-intestinal,kidneys, etc)

Given these facts, it seems sensible to adopt a conservative approach.
1. Can the problem be solved without manipulation ?
2. If you are suffering from a recent or current infection, delay or seek another treatment

REFERENCES:

Ref. 1: Is it time to stop functional pre-manipulation testing of the cervical spine? by Thiel H, Rix G, Man Ther. 2005 May

Ref. 2: Carotid artery blood flow during pre-manipulative testing by Licht PB et al, J Manipulative Physiol Ther. 2002 Nov-Dec

Ref. 3: Spinal manipulative therapy is an independent risk factor for vertebral artery dissection by Smith WS et al, Neurology. 2003 May 13

Ref. 4: Environmental factors and cervical artery dissection by Caso V et al. Front Neurol Neurosci. 2005

Ref. 5: Hyperhomocysteinemia: a potential risk factor for cervical artery dissection following chiropractic maniputation of the cervical spine by Pezzini A et al, J Neurol. 2002 Oct

Ref. 6: Cervical artery dissection- clinical features, risk factors, therapy and outcome in 126 patients by Dziewas R et al, J Neurol. 2003 Oct

Ref. 7: Vertebral artery dissections after chiropractic neck manipulation in Germany over three years by Reuter U et al, J Neurol. 2006 Jun

Ref. 8: Adverse Effects of Spinal Manipulation: a Systematic Review by E Ernst in Journal of the Royal Society of Medicine Vol. 100, July 2007 pp 330-338.

Ref. 9: Infection and the Risk of Spontaneous Cervical Artery Dissection: A Case-Control Study by Beniot Guillon et al, Stoke 2003, Journal of the American Heart Association

Ref. 10:Mild mechanical traumas are possible risk factors for cervical artery dissection by Dittrich R et al, Cerebrovasc Dis. 2007

Ref 11: Seasonal variability in spontaneous cervical artery dissection by Paciaroni M et al, J Neurol Neurosurg Psychiatry. 2006 May