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Client Testimonial

I am writing to thank you for your thoughtful work in evaluating the records of many of my clients over the past several years. As you are well aware, my clients are young people who have suffered brain injury (and/or death) from cerebrovascular accidents that followed shortly after chiropractic cervical manipulations. I know that you have an active practice and that you evaluate and treat many patients in your Atlanta office on a daily basis. So I appreciate the time that you have taken to carefully evaluate the records that I have sent to you. You have advised me where the chiropractor has deviated from the standard of care, as well as those instances where you have found no negligence on the part of the chiropractor. In each and every instance you have pointed out that a chiropractor has a duty to evaluate each patient before commencing treatment to determine whether the patient has a condition that is treatable by the practice of chiropractic. I very much appreciate the guidance that you have provided to me, and the services that you have provided to my clients and to their families.

Michael A. Abelson Esq.
Washington D.C.

5500 Errol Place • Atlanta, Georgia 30327 • 678.777.1161

Stroke Due to Cervical Manipulation

Written by Alan H. Bragman D.C.

As an expert witness in the field of chiropractic negligence for over 20 years, I have been involved in more than 900 cases throughout North America. Of the cases reviewed, more than 400 involved allegations of a cerebrobasilar injury caused by chiropractic cervical manipulation. In all but a few of these situations, the chiropractor violated the standard of care and a causal relationship to the treatment and resulting injury was apparent. A stroke, arterial dissection or other vascular damage associated with chiropractic treatment is a tragic, life-altering situation for all parties involved.
Vertebrobasilar accidents account for just over five percent of the malpractice suits filed each year, but they are among the most serious. These injuries frequently result in permanent neurological deficit, psychological trauma, quadriplegia and/or death. Many of these lawsuits result in settlements well in excess of a million dollars. This alone is a compelling reason to maintain higher limits of liability coverage.

Overall, the chiropractic profession has downplayed the risk of stroke through cervical manipulation. Early studies and opinions felt that the risk was minimal, and that cervical manipulation has not been conclusively proven to cause vascular accidents. More recent information and studies suggest the risk of stroke due to cervical manipulation is still very low, but higher than past information would indicate. One problem encountered researching this subject is the lack of complete, concise, accurate data from which to draw accurate conclusions. The number of patients under chiropractic treatment has increased dramatically in recent years, without a corresponding rise in manipulation induced strokes. Hopefully this indicates that even with more exposure, improved chiropractic education, screening procedures and increased awareness may be starting to have a positive effect.

In 1972, Maigne suggested, "there is probably less than one death of this nature out of several tens-of-millions of manipulations". In 1982, Cyriak stated, " this risk works out to about one in 10 million manipulations, and is no argument against manipulation reduction in suitable cases." In 1981, Hosek, et al. suggested, "we may form a conservative likelihood estimator by looking at the ratio of vertebrobasilar injuries to adjustments performed. This ratio would be 100 injuries per/100 million adjustments, about one in a million." In 1983, Gutmann concluded. "There are two to three serious incidents involving the vertebrobasilar system in one million manipulations to the upper cervical spine. " In 1985, Dvorak and Orelli stated that, "following an inquiry amongst the members of the Swiss Medical Group for Manual Medicine, it was calculated that there were slight neurological complications in one in 40,000; and one important complication in 400,000 cervical manipulations." Current studies estimate that one out of every two practitioners will have a patient suffer a serious cerebrovascular injury in his or her professional lifetime.

Recent high publicity deaths of young adults in Canada from cervical manipulation prompted a population-based case-control study. The results from this study have prompted some medical experts to conclude that the risk of a vertebrobasilar injury from cervical manipulation may be as high as 1.3 incidents per 100,000 cervical manipulations. In March 2001 the New England Journal of Medicine estimated that the incidence of vertebral or carotid artery dissections may even be as high as one incident per 20,000 cervical manipulations. As more information is obtained the risk factors have steadily increased.

My experience as a forensic expert leads me to conclude that the risk of stroke from cervical manipulation is much greater than current literature suggests. In some cases I have reviewed, people died as a direct result of cervical spinal manipulation. In almost all of these cases dealing with vascular injuries, the incident could have been avoided or lessened with a proper history, through examinations with vascular screening, avoidance of rotation and extension during cervical manipulation and/or closer monitoring of post treatment progress.

Recognizing the increased risk is just the first step. The next issue is how do these vascular injuries occur, and what are some of the risk factors? The vertebral arteries are where the vast majority of cervical manipulation injuries occur, with a smaller number affecting the carotid arteries. Injuries occur from either direct trauma to the vessel wall or through subsequent vaso-spasm following treatment. Research and current data suggest that manipulative thrusts utilizing rotation and/or extension of the upper cervical spine is the type of maneuvers most likely to cause a vascular injury or stroke. Damage to the arterial wall through stretching, kinking, tearing or direct trauma can cause sufficient damage to disrupt vascular flow to certain areas of the brain, resulting in ischemia. Damage to the inner vessel wall, the intima, may result in a dissection or tearing of the vessel wall. This damage can initiate the clotting response with subsequent embolus formation altering blood flow to the brain. Signs and symptoms of ischemia usually occur during or shortly after upper cervical manipulation.
The demographics of cerebrovascular injury with cervical manipulation indicate that middle aged men and women in the 30-45 age group are in the highest risk group. For years it was incorrectly assumed that this type of stroke risk was higher in the elderly, due to vascular degenerative changes and athrosclerosis. The most common presenting symptoms of patients suffering dissections and strokes are severe headache, neck pain and cervical muscle spasms. 

Dr. Edward Sullivan published an excellent article in the 1988 edition of Chiropractic Economics entitled "Screening Prior to Cervical Adjustments Can Prevent Strokes." Dr. Sullivan recommends the following screening procedure prior to performing cervical manipulation:

Part 1 - High risk categories noted in the history
1. Hypertension

2. Transient ischemic attacks
3. Smoking (length of time is important)

4. Whiplash or cervical strain/sprain

5. Family history of strokes

6. Medications affecting hemodynamics (antihypertensives, oral contraceptives or regular aspirin use)
7. Arteriosclerosis

8. Cardiovascular disease

9. Diabetes

10. Cervical spine spondylosis or spurring
11. Constant headaches (several days duration)
12. Migraines
13. Known congenital arterial cervical anomaly (absent vertebral artery etc.)

14. Cervical arterial surgery
15. Radiographic evidence of atlanto-occipital ligament ossification or a cervical anomaly ( spina bifida, posterior ponticle etc.)
16. Upper Respiratory Infection (recent or present)

Part 2 - Symptomatic Systems Review
1. Diplopia

2. Bilateral blurred vision

3. Monocular blindness

4. Ataxia

5. Tinnitis

6. Hearing loss in one or both ears

7. Slurred speech

8. Dizziness

9. Difficulty in swallowing

10. Loss of consciousness

11. Temporary lack of understanding

12. Drop attacks without loss of consciousness

13. Numbness of loss of sensation anywhere in the body

14. Weakness, loss of coordination or strength anywhere in the body

Part 3 - Hypertension, subclavian, and carotid artery: stenosis/occlusion
Checking bilateral blood pressures; noting significant discrepancy
Palpate and measure bilateral radial pulse; checking for weakness or absence
Auscultate for bruits and palpate; Bilateral supraclavicular fossas and carotid bifurcations

Part 4 - Vertebrobasilar artery functional maneuver test (George's Test)
Have the patient rotate his/her head as far to the right as possible and hyperextend the neck for 3-5 seconds. Observe for signs of ischemia, if negative proceed to the left side.
The most common signs of vertebrobasilar ischemia include: Dizziness; nausea; nystagmus; blurred vision; syncope; slurred speech; weakness; parasthesia; and numbness.



If the patient has a positive George's Test do not perform a cervical adjustment. If the history and review of systems place the patient in a high-risk category, referral to an appropriate medical specialist may be indicated. If the patient exhibits signs of ischemia during or following cervical manipulation do not re-adjust the patient. Observe the patient closely, periodically monitoring vitals while checking the progression of the ischemic signs and symptoms. If the ischemia persists or becomes more pronounced, immediately transport the patient to the nearest hospital.

The above screening procedures combined with comprehensive history taking and physical examinations are highly effective in preventing cerebrovascular incidents, as evidenced by the experience at the National University of Health Sciences and the Canadian Memorial Chiropractic College in their outpatient clinics. Several millions of cervical adjustments have been given at these accredited chiropractic schools without a single reported vertebrovascular incident. The obvious conclusion is that cervical manipulation remains a safe effective procedure with minimal side effects when forceful cervical adjustments utilizing rotation and/or extension are avoided, and the standards of care are followed.

BIBLIOGRAPHY
(1) Koes BW, Assendelft WJJ, van der Heijden GJMG et al. Spinal manipulation and mobilization for back and neck pain; a blinded review. British Medical Journal 1991 November 23:303(6813): 1296-1303.
(2) Manga P, Angus DE, Swan WR. Effective management of low back pain: it's time to accept the evidence. Journal of the Canadian Chiropractic Association 1993 December; 37(4):221-229.
(3) Shekelle PG, Adams AH, Chassin MR et al. The appropriateness of spinal manipulation for low-back pain: project overview and literature review. Santa Monica, CA: RAND, 1991. (Presents results of the first stage of the "RAND Study") (WB 905 A6522 1991).
Shekelle PG, Adams AH, Chassin MR et al. The appropriateness of spinal manipulation for low-back pain: indications and ratings by a multidisciplinary expert panel. Santa Monica, CA: RAND, 1991. (Presents results of the second stage of the "RAND Study") (WB 905 A652 1991).