Manipulation Does Not Cause Dissection

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• Early case reports suggested that cervical manipulation (CM) was the cause of cervical artery dissection (CAD) in patients and their resultant cerebrovascular accidents.
• Cassidy published a 2008 report in Spine calling this assertion into question and found that the association of dissection following chiropractic physician exposure was similar to exposure to primary care physicians. Since that time, multiple papers have continued call into question whether CM was causative of CAD.
• Based on the current research, it appears that CM does not place the cervical arteries in a strained position.
• The current understanding of the literature is that patients with neck and headache pain from dissection seek chiropractic and medical care and eventually are found to have dissection, either by subsequent investigation of from the development of stroke.
• This new paper concludes that no causal link has been established between CM and CAD and further suggests that this misunderstanding may be the genesis of inappropriate litigation against chiropractic physicians.   

Abstract

Background

Case reports and case control studies have suggested an association between chiropractic neck manipulation and cervical artery dissection (CAD), but a causal relationship has not been established. We evaluated the evidence related to this topic by performing a systematic review and meta-analysis of published data on chiropractic manipulation and CAD

Methods

Search terms were entered into standard search engines in a systematic fashion. The articles were reviewed by study authors, graded independently for class of evidence, and combined in a meta-analysis. The total body of evidence was evaluated according to GRADE criteria.

Results

Our search yielded 253 articles. We identified two class II and four class III studies. There were no discrepancies among article ratings (i.e., kappa=1). The meta-analysis revealed a small association between chiropractic care and dissection (OR 1.74, 95% CI 1.26-2.41). The quality of the body of evidence according to GRADE criteria was “very low.”

Conclusions

The quality of the published literature on the relationship between chiropractic manipulation and CAD is very low. Our analysis shows a small association between chiropractic neck manipulation and cervical artery dissection. This relationship may be explained by the high risk of bias and confounding in the available studies, and in particular by the known association of neck pain with CAD and with chiropractic manipulation. There is no convincing evidence to support a causal link between chiropractic manipulation and CAD. Belief in a causal link may have significant negative consequences such as numerous episodes of litigation.

Abstract

Ephraim W. Church1 , Emily P. Sieg1, Omar Zalatimo1, Namath S. Hussain1, Michael Glantz1, Robert E. Harbaugh1. Systematic Review and Meta-analysis of Chiropractic Care and Cervical Artery Dissection: No Evidence for Causation. Cureus 8(2): e498. doi:10.7759/cureus.498