I sent a letter to the editor in response to the paper published this month in The American Journal of Forensic Medicine and Pathology, titled: “Self-Chiropractic Cervical Spinal Manipulation Resulting in Fatal Vertebral Artery Dissection: A Case Report and Review of the Literature.” *The editoral staff has decided not to publish it, so I have posted it here for your interest.

For more on this topic, consider taking my online course from the Northeast College of Health Sciences: Preventing Complications of Cervical Spine Manipulation: Applying Chiropractic Adjustments to Difficult Conditions: https://ce.northeastcollege.edu/courses/view/PreventingComplicationsofCervicalSpineManip?fbclid=IwAR0Dqg3OATx_LfCTPqUde8XW3m203xnYHb1pSQJkoss1a2q9PIIGdR2_Xy0

*Fink, Cameron BHS^*; Bryce, Clare H. MD^*; Knight, Laura D. MD^*,†. Self-Chiropractic Cervical Spinal Manipulation Resulting in Fatal Vertebral Artery Dissection: A Case Report and Review of the Literature. The American Journal of Forensic Medicine and Pathology ():10.1097/PAF.0000000000000912, February 1, 2024. | DOI: 10.1097/PAF.0000000000000912

Letter to the Editor: Patient Self-Manipulation Inappropriately Associated with Manipulation Performed By Chiropractors

Acknowledgments: None

Conflicts of Interest and Source of Funding:  The author has no conflicts of interest or funding to declare.

Keywords: chiropractic, spinal manipulation, adverse events, cervical spine, vertebral artery dissection, cervical manipulation, FORENSIC PATHOLOGY, FORENSIC MEDICINE

To The Editor:

With due respect to the authors, there were some glaring oversights in the paper by Fink, et al., Self-Chiropractic Cervical Spinal Manipulation Resulting in Fatal Vertebral Artery Dissection:  A Case Report and Review of the Literature. As someone who has taught cervical spinal manipulation (cSMT) to practicing chiropractors for years, I would point out several of these.

The term “chiropractic manipulation” is a misnomer. The use of the term “Self-Chiropractic cervical manipulation” in the title and throughout the paper is an error. Chiropractors perform cervical spinal manipulation (cSMT), but it is a procedure that is not exclusive to the chiropractic profession. There are various forms of cSMT used by chiropractors, not just the high velocity low amplitude techniques implied in the paper. [i] [ii]

Fink et al. offer the following history, “A 43-year-old woman reportedly laid down with her neck on the top step of a staircase and attempted to perform a self-chiropractic manipulation to “crack her neck.”” This self-performed trauma should not be equated to cSMT performed by a chiropractor. The forces induced by the subject exceeded the limits of tissue integrity. In contrast, cSMT has been well studied and found to be safe and well within the limits of anatomical and physiological integrity. [iii] [iv] [v] [1 ] [vii] [viii] [ix] [x] [xi] [xii] [xiii] [xiv]

The review of the literature focused on the association of cSMT and vertebral artery dissection (VAD). This is not what this case demonstrated. Further, the paper relied solely on case reports on the association of cSMT and vertebral artery dissection (VAD). Case reports are insufficient to establish causation. The authors omitted the more rigorous investigations and higher-level studies (i.e. case-control, case-crossover, systematic reviews, and meta-analysis) that call into question the issue of causality. [xv] [xvi] [xvii] [xviii] [xix] [xx]

To conflate self-induced trauma by an untrained individual to cSMT performed by chiropractors is disingenuous and misleading. This case should instead serve to caution people from attempting to duplicate the intricate nature of any form of professional healthcare intervention on oneself. It can lead to tragic consequences.

Sincerely,

David I Graber, DC

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[i] Wenban AB. Inappropriate use of the title ‘chiropractor’ and term ‘chiropractic manipulation’ in the peer-reviewed biomedical literature. Chiropr Osteopat. 2006 Aug 22;14:16. doi: 10.1186/1746-1340-14-16. PMID: 16925822; PMCID: PMC1570468.

[ii] Wenban A. Misuse of the terms chiropractic and chiropractor. J Neurol Neurosurg Psychiatry. 2004 May;75(5):794; author reply 794. PMID: 15090590; PMCID: PMC1763582.

[iii] Haneline M, Triano J. Cervical artery dissection. A comparison of highly dynamic mechanisms: manipulation versus motor vehicle collision. J Manipulative Physiol Ther. 2005 Jan;28(1):57-63. doi: 10.1016/j.jmpt.2004.12.003. PMID: 15726036.

[iv] Symons BP, Leonard T, Herzog W. Internal forces sustained by the vertebral artery during spinal manipulative therapy. J Manipulative Physiol Ther. 2002 Oct;25(8):504-10. doi: 10.1067/mmt.2002.127076. PMID: 12381972.

[v] Herzog W, Leonard TR, Symons B, Tang C, Wuest S. Vertebral artery strains during high-speed, low amplitude cervical spinal manipulation. J Electromyogr Kinesiol. 2012 Oct;22(5):740-6. doi: 10.1016/j.jelekin.2012.03.005. Epub 2012 Apr 5. PMID: 22483611.

[vi] Gorrell, L. et al (2022) Vertebral arteries do not experience tensile force during manual cervical spine manipulation applied to human cadavers, Journal of Manual & Manipulative Therapy, DOI: 10.1080/10669817.2022.2148048

[vii] Moser N, Mior S, Noseworthy M, et alEffect of cervical manipulation on vertebral artery and cerebral haemodynamics in patients with chronic neck pain: a crossover randomised controlled trialBMJ Open 2019;9:e025219. doi: 10.1136/bmjopen-2018-025219

[viii] Thomas LC, Rivett DA, Bateman G, Stanwell P, Levi CR. Effect of selected manual therapy interventions for mechanical neck pain on vertebral and internal carotid arterial blood flow and cerebral inflow. Phys Ther. 2013 Nov;93(11):1563-74. doi: 10.2522/ptj.20120477. Epub 2013 Jun 27. PMID: 23813088.

[ix] Quesnele JJ, Triano JJ, Noseworthy MD, Wells GD. Changes in vertebral artery blood flow following various head positions and cervical spine manipulation. J Manipulative Physiol Ther. 2014 Jan;37(1):22-31. doi: 10.1016/j.jmpt.2013.07.008. Epub 2013 Nov 15. PMID: 24239451

[x] Kocabey B, Karagözoğlu Coşkunsu D, Güven K, Ağaoğlu MH, Yüce S. Effects of Manual Versus Instrumental Spinal Manipulation on Blood Flow of the Vertebral and Internal Carotid Arteries in Participants With Chronic Nonspecific Neck Pain: A Single-Blind, Randomized Study. J Chiropr Med. 2023 Mar;22(1):1-10. doi: 10.1016/j.jcm.2022.05.006. Epub 2022 Jul 21. PMID: 36844987; PMCID: PMC9947994.

[xi] Yelverton C, Wood JJ, Petersen DL, Peterson C. Changes in Vertebral Artery Blood Flow in Different Head Positions and Post-Cervical Manipulative Therapy. J Manipulative Physiol Ther. 2020 Feb;43(2):144-151. doi: 10.1016/j.jmpt.2019.09.001. Epub 2020 May 30. PMID: 32482436.

[xii] Church EW, Sieg EP, Zalatimo O, Hussain NS, Glantz M, Harbaugh RE. Systematic Review and Meta-analysis of Chiropractic Care and Cervical Artery Dissection: No Evidence for Causation. Cureus. 2016 Feb 16;8(2):e498. doi: 10.7759/cureus.498. PMID: 27014532; PMCID: PMC4794386.

[xiii] Chung CLR, Côté P, Stern P, L’Espérance G. The Association Between Cervical Spine Manipulation and Carotid Artery Dissection: A Systematic Review of the Literature. J Manipulative Physiol Ther. 2015 Nov-Dec;38(9):672-676. doi: 10.1016/j.jmpt.2013.09.005. Epub 2014 Jan 3. PMID: 24387889.

[xiv] Wynd S, Anderson T, Kawchuk G. Effect of cervical spine manipulation on a pre-existing vascular lesion within the canine vertebral artery. Cerebrovasc Dis. 2008;26(3):304-9. doi: 10.1159/000149578. Epub 2008 Jul 31. PMID: 18667811.

[xv] Kosloff, T.M., Elton, D., Tao, J. et al. Chiropractic care and the risk of vertebrobasilar stroke: results of a case–control study in U.S. commercial and Medicare Advantage populations. Chiropr Man Therap 23, 19 (2015). https://doi.org/10.1186/s12998-015-0063-x

[xvi] Whedon JM, et al. Risk of Traumatic Injury Associated With Chiropractic Spinal Manipulation in Medicare Beneficiaries Aged 66 to 99 Years. Spine 2015;40:264–270

[xvii] Church EW, Sieg EP, Zalatimo O, Hussain NS, Glantz M, Harbaugh RE. Systematic Review and Meta-analysis of Chiropractic Care and Cervical Artery Dissection: No Evidence for Causation. Cureus. 2016 Feb 16;8(2):e498. doi: 10.7759/cureus.498. PMID: 27014532; PMCID: PMC4794386.

[xviii] Cassidy JD, Boyle E, Côté P, Hogg-Johnson S, Bondy SJ, Haldeman S. Risk of Carotid Stroke after Chiropractic Care: A Population-Based Case-Crossover Study. J Stroke Cerebrovasc Dis. 2017 Apr;26(4):842-850. doi: 10.1016/j.jstrokecerebrovasdis.2016.10.031. Epub 2016 Nov 21. PMID: 27884458

[xix] Whedon JM, Petersen CL, Li Z, Schoelkopf WJ, Haldeman S, MacKenzie TA, Lurie JD. Association between cervical artery dissection and spinal manipulative therapy -a medicare claims analysis. BMC Geriatr. 2022 Nov 29;22(1):917. doi: 10.1186/s12877-022-03495-5. PMID: 36447166; PMCID: PMC9710172..

[xx] Chu EC, Trager RJ, Lee LY, Niazi IK. A retrospective analysis of the incidence of severe adverse events among recipients of chiropractic spinal manipulative therapy. Sci Rep. 2023 Jan 23;13(1):1254. doi: 10.1038/s41598-023-28520-4. PMID: 36690712; PMCID: PMC9870863.