Commentary on: A risk–benefit assessment strategy to exclude cervical artery dissection in spinal manual therapy: a comprehensive review

Chaibi and Russell present their perspective on the relationship between chiropractic/manual adjustment and cervical artery dissection (CAD) [1]. A number of studies suggest that although a causal relationship has not been established an association exists when considering vertebral artery dissection (VAD), but not internal carotid artery dissection [2,3].

We have several concerns with this publication. The assertion a physical examination can discriminate between neck pain due to CAD and neck pain due to other causes is unsupported. The signs and symptoms of spontaneous CAD do not include cervical radiculopathy, neck swelling, or midline tenderness. Series of CAD patients do not report these presenting symptoms [4–6]. Despite this, the authors suggest that these factors warrant referral to an emergency room.

Tenderness of the midline spinous processes of the cervical spine is viewed by the authors as a sign of fracture and a possible mechanism for traumatic CAD. However, numerous non-fracture etiologies that are far more common, including ligamentous injury or strain, muscular injury, facet, and disc problems can lead to tenderness of the spinous processes of the cervical spine. A history of trauma is far more helpful in developing a differential diagnosis than is midline tenderness.

Hypertension is so prevalent in the general population that its inclusion in a decision tree is of no practical value. In some series, the prevalence of hypertension is similar in CAD and control populations [4]. There is no office examination to rule out CAD. Church et al. [3] and Biller et al (on behalf of the American Heart Association Stroke Council and the American Stroke Association) [2] provide important analyses of the current state of our understanding of the association between manual adjustment of the neck and CAD. There is an association between manual adjustment and VAD but no causative relationship has been established. It is more likely that pain from VAD leads to neck manipulation than that neck manipulation leads to VAD.

The force and strain data available currently suggest that manual adjustment is roughly equivalent to range of motion testing, vertebrobasilar insufficiency testing, and by extension, many of the activities we perform daily [7]. It should also be noted that the initial symptom of CAD is almost always pain, not stroke. The median time to stroke from an untreated VAD is 2 weeks [2].

The authors provide an incomplete description of the symptoms associated with carotid artery dissection. While many of the symptoms they describe are associated, carotid dissection does not cause generalized neck pain. It causes pain associated with the anterior and lateral portions of the neck, frequently extending up to the angle of the jaw. This delineation may be helpful in the office when considering the diagnosis of carotid dissection.

Both authors have served as expert witnesses in litigation related to CAD. Dr Harbaugh receives no personal remuneration for these services, with all proceed going to the Penn State Department of Neurosurgery.

Disclosure statement

No potential conflict of interest was reported by the authors.