AHA/ASA advises to discuss risk of cervical arterial dissection before neck manipulation

The American Heart Association (AHA) and the American Stroke Association (ASA) have published a scientific statement in which they advise that patients be informed of the statistical association between cervical arterial dissection (CD) and cervical manipulative therapy (CMT), before they undergo manipulation of the cervical spine.

CD is an important cause of ischaemic stroke in young and middle-aged patients, and often occurs in the upper cervical spine. In some forms of CMT, a high or low amplitude thrust is applied to the cervical spine by a healthcare professional. Some studies have linked this type of therapy to CD.

This AHA/ASA statement aimed to review the current state of evidence on the diagnosis and management of CDs and their statistical association with CMT.

Case-control and other articles suggest an epidemiological association between CD, particularly vertebral artery dissection, and CMT. It is unclear whether this implies a causal relationship of CMT leading to CD, or whether pre-existing CD in these patients has not been recognised previously. Diagnosis of CD depends on a thorough history, physical examination and targeted additional investigations. Patients with CD may present with unilateral headaches, posterior cervical pain or cerebral or retinal ischaemia (transient ischemic attack or strokes). These may be reasons for these patients to seek help at a medical professional who performs manipulative therapy.

Currently available biomechanical evidence is insufficient to claim that CMT causes CD, although clinical reports suggest that mechanical forces play a role in a considerable number of CDs. The incidence of CMT-associated CD in patients who have previously received CMT is unclear and probably low. Causality is furthermore difficult to prove. However, practitioners should more often consider the option of CD as an underlying cause of presenting symptoms, and patients should be informed of the existing association between CD and CMT, before they receive cervical manipulation.

The statement also discusses specifics of diagnosis, treatment, prognosis and management options for patients with extracranial CD.

Find the AHA/ASA statement online