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Have You Suffered a Stroke?
Case Studies
SIGNIFICANCE OF PUBLISHED STUDIES AND CASE REPORTS
HIGHEST NECK MANIPULATION
OCCIPUT TO CERVICAL ONE (ATLAS) AND CERVICAL ONE TO CERVICAL TWO (AXIS)
Research of an issue of health care concern often begins with a search
of a medical database. This can now be done via the public internet
from available free databases or through more sophisticated research
programs, one of the best being Paperchase developed at the Beth Israel
Hospital of Harvard University in Boston.
What do we learn from such a search? Published reports in the
scientific literature allow us to stand on the very tip of the iceberg
largely unaware of the reality below. Most scientisits never take the
time and effort requried to report what they have found. Medical
Journals refuse the great majority of submissions. Thus the overall
picture of the true incidence and seriousness of an issue is simply
reflected by the medical database resource.
Yet the scientific literature does provide some insghts. How many well
respected scientific journals have addressed the issue? How consistent
year in and year out have reports been made? How many different
countries have reported on the issue? What is the degree of
specialization of those scientists publishing these studies? What is
the range of problems reported?
In regard to the issue of highest neck manipulation, occipital to
cervical one (atlas vertebrae) and cervical one to cervical two (axis
vertebrae) studies have been reported in numerous scientific journals
including, The Journal of Forensic Science, The Journal of Clinical
Pathology, The Journal of the American Medical Association, the Journal
of the Canadian Medical Association, the British Medical Journal, the
journals “Neurology: “Stroke”, “Lancet”, “Pediatrics”, The new England
Journal of Medicine, The American Journal of Emergency Medicine, etc.
etc.
The range of interest of these Journals include neurology,
neuroradiology, pathology, forensic sciences, legal publications,
family medicine, rehabilitation medicine, ophthalmology, audiology etc.
etc. Numerous prestigious hospitals and Universities across the world
have reported cases including the Mayo Clinic, Johns Hopkins Hospital,
the Claude Bernard Hospital, the Veterans Administration Medical center
in California, etc. etc.
The issue has been reported from Canada, the United States, Denmark,
Germany, Italy, Australia, Japan, England, Canada, China, South Africa,
Ireland, New Zealand, Switzerland, etc. etc. indeed worldwide.
The issue has also been reported on since the very inception of modern
medical index medicus over 60 years ago. The quality of the reports,
moving from observations and commentaries to retrospective analysis,
statistical studies and to prospective studies has been consistent.
The medical consequences of neck manipulation run the range from simple
spells of nausea to the Locked-In Syndrome to death. It happens in all
ages, from babies to people in their 80’s. It most commonly happens in
young adults in the prime of their lives.
The wide range of neurological and pathological findings in the
countless cases reported can make a pathologist shudder. The posterior
circulation supplies the very “stem” of our neurological system and any
tampering with it must be done as an absolute last resort. The sheer
volume of cases referred to neurologists for treatment and to the
Offices of Medical Examiners for pathology examination shows this not
to be the case. (Recent case Wendy V. Office of the Medical Examiner.
San Diego, California.
The neuropathological findings run the range of little or no findings
to those showing clear adventitial dissection and indeed rupture of the
entire artery. As stated by neurologist Wouter I. Schievink M.D.
“Intimal tears are notoriously difficult to identify at the time of
microscopic examination of postmortem or surgical specimens”. (NEJM
Vol. 344. No. 12).
This is why it is essential to consider in context:
A) The type of manipulation (the site of the neck manipulation, the
degree of rotation, the lack of flexion of the neck, the sitting or
standing position of the patient, etc.). In most ways chiropractic neck
manipulation is substantially different from that done by orthopractic
manual physiotherapists. See www.orthopractic.org
B) The initial clinical symptoms and neurological signs (posterior
C-1-3 neck pain, visual cortical changes, posterior cerebral artery
thrombus, etc.)
C) The radiology (classic angio-gram, or MRA or MR Imager equipped with
specific modern technical capabilities (both hardware and software) and
a Power Injector suitable for an MR suite. The images are acquired
while a Gadolinium chelate is rapidly injected intravenously.
D) The neurological clinical course, especially in those cases where an
initial C1-3 vertebral artery trauma leads eventually to PICA pathology.
The mechanism of neck manipulation involving rotational movements with
little nucal flexion result in a wide range of pathological findings.
These are most often distinct from those found in blunt trauma
injuries. With neck manipulation, the intima is primarily initially
involved as opposed to the muscularis or adventitial layers. The
muscularis and adventitia tends to be involved when a cervical
dissection extends to the intra-cranial portion of the artery, a
process that may take several days to develop.
The range of findings is reflected in the chiropractic literature
itself. Chiropractor Allan G.J. Terrett describes six types of
vertebral artery wall trauma all related to neck manipulation. (Current
Concepts in Vertebrobasilar Complications following Spinal
Manipulation” 2001. ISBN 1-892734-03-6
“In most cases of VBS following Spinal Manipulation Therapy where
angiography or autopsy findings are available, there is found to be
damage to the artery wall, one of the following mechanism may occur.
These run the gamut from:
A) Compression and/or stretching leading to subintimal hematoma. The
fenestrations of the intima unfold and may become scarred or even tear.
B) A simple intimal tear leading to an endothelial reaction. This can lead to a cascade of thrombus and embolus.
C) An intimal tear with a thrombus that restricts the lumen.
D) Vessel wall dissection, the most common type being between the endothelial layer and the internal elastica lamina.
E) Vessel wall dissection with psuedo-anurysm. The muscularis as well as the intima and internal elastic lamina are disrupted.
F) Perivascular bleeding. Cavitations of the centre of a clotted hematoma.
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