Letter to the Editor

Abstract

In reviewing Melikyan et al., we discuss what we think are weaknesses in the case report. The authors did not report on known risk factors for cerebrovascular accident and vertebral artery dissection. Known symptoms that appear early in vertebral artery dissection were not reported or denied, specifically related to changes in the patient's pattern of neck pain. Causality was assumed when only a weak temporal relation was involved. Finally, the case report makes it appear that the manipulation was performed by someone other than a chiropractor but therefore erroneously uses chiropractic in the title.

We recently read the Melikyan et al.,¹ article “Cortex-sparing infarction in triple cervical artery dissection following chiropractic neck manipulation”, in Qatar Medical Journal. The authors are to be commended on writing an article to improve practitioners’ knowledge on the important issue of stroke. However, there are many weaknesses in this case report, and these issues significantly alter their conclusion.

There are many potential causes for stroke and many associated risk factors which the authors either did not mention or just gave scant details in the case report.^2–5 As stated in the article, “A 55-year-old man, smoker, with history of diabetes mellitus, hypertension and dyslipidemia, presented to the emergency department”. These details are completely inadequate to determine the significance of these well-established risk factors in comparison to spinal manipulative therapy (SMT). All of these risk factors are more likely the cause of his stroke than SMT.^6–9

The authors did not mention in the case report many risk factors. For example, the weight of the person, any history of homocysteinaemia, migraine, recent infection/fever, NSAID use, cardiac abnormalities (such as patent foramen ovale), excessive alcohol consumption, and recent physical or potential traumatic activities.^10–13 These are all important, well-established risk factors in increasing the risk of stroke.

Cerebrovascular accident (CVA) due to vertebral artery dissection (VAD), is a serious disorder which can occur spontaneously and have been reported immediately following SMT. Whilst CVA after SMT are very rarely reported, it is important to document the clinical situations in which these events may occur, to improve clinicians’ knowledge about these cases. Any case report regarding stroke temporally associated with VAD and SMT needs to include all of the previously mentioned risk factors.¹⁴

Given the patient in this case report suffered from chronic neck pain (and the fact that VAD often causes neck pain and headache), very important questions needed to be asked regarding changes in the pain pattern prior to SMT. Thus, the course of the patient's neck pain prior to the VAD should have been presented. This would have revealed if the patient had a significant exacerbation of their symptoms, which has been commonly reported.

While temporal relation is one important criteria (but not determinative by itself) in establishing causality as the time between the two events (i.e., SMT and VAD) increases, plausibility of causality diminishes. The one-week interval between SMT and presentation to hospital is therefore very important. Furthermore, given the number of artery dissections (i.e., three) and the well documented finding that there is no association between SMT and internal carotid artery dissection, it seems likely this person has vascular/connective tissue disease.

Last, but most importantly, the paper seems to suggest that the SMT was performed by an un-qualified person (e.g., masseuse or barber) that performed the SMT, and not a trained chiropractor. As it does not appear that the manipulation was performed by a chiropractor the case report should not have been titled “chiropractic neck manipulation”. Manipulation is only chiropractic when it is performed by a credentialed chiropractor. This is similar to saying that a barber performed “surgery” because he used a scalpel, and therefore all surgery is dangerous and should not be performed.

The article concluded “Chiropractic cervical manipulation can result in catastrophic vascular lesions preventable if these practices are limited to highly specialized personnel under very specific situations.” This is an inappropriate conclusion to the case report as it suggests causality when there is no evidence of causality in this case.

Author Response to Letter to the Editor

Whether the patient has multiple vascular risk factors, stroke in our case occurred as a result of triple-vessel dissection (confirmed radiologically) and not atherosclerotic occlusion due to risk factors. We agree that dissection could have occurred due to multiple etiological factors, but we ruled out all possible causes which were included in the article (connective tissue disorder, infections, trauma etc.) We are unaware of the relation between dissection and migraine but would have mentioned it if it were present. We ruled out absolutely all causative factors for stroke including PFO, drug use, alcohol abuse. We were discussing here not only a simple stroke case but dissection of bilateral carotid and vertebral arteries with developing of bilateral massive stroke and spared cortex after the neck manipulation. Not having any intention to offend professional chiropractors, we concluded that in some conditions manipulation can be dangerous and should be avoided.