Critical Review: Cervical Spine Manipulation and Vertebral Artery Dissection – A Rebuttal Grounded in Current Evidence

Written by: James Demetrious, DC, DABCO

Board Certified Chiropractic Orthopedist

A recent article criticizing cervical chiropractic manipulation presents an emotionally compelling but scientifically selective narrative that links spinal manipulation to vertebral artery dissection (VAD) and stroke. By focusing heavily on rare but dramatic anecdotal events while neglecting broader epidemiological data, the article ultimately promotes a skewed understanding of chiropractic safety.

A balanced review of medical literature from the past ten years demonstrates that the risk of VAD after cervical spine manipulation is not only exceedingly rare but indistinguishable from risks associated with visits to primary care physicians. This review corrects misconceptions, clarifies the epidemiology of VAD, and supports the role of chiropractic care as a safe and effective conservative option for neck pain.

The Epidemiology of VAD and Chiropractic Care: Clarifying Association vs. Causation

Central to the article’s claims is the assertion that cervical spinal manipulation causes vertebral artery dissections that lead to stroke. This idea has circulated for decades but has been repeatedly refuted by high-quality research.

Cassidy et al.’s landmark 2008 case-control and case-crossover study of over 9 million person-years of data found no increased risk of VAD following chiropractic visits compared to visits to primary care physicians (PCPs) for similar complaints (Cassidy et al., 2008). Although this study precedes the 10-year scope, it is critical in laying the foundation for subsequent research.

Cassidy JD, Boyle E, Côté P, et al. Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study. Spine (Phila Pa 1976). 2008;33(4 Suppl):S176-83.

More recent analyses have affirmed and expanded upon Cassidy’s findings. In 2015, researchers from the Department of Neurosurgery, Penn State Hershey Medical Center performed a systematic review published in CMAJ Open and concluded that while case reports of VAD after spinal manipulation exist, they cannot establish causation. Importantly, patients with undiagnosed VAD often present with headache and neck pain—symptoms for which they may consult chiropractors or PCPs. As such, the temporal relationship between manipulation and stroke does not confirm causation.

Church EW, Sieg EP, Zalatimo O, et al. Systematic review and meta-analysis of chiropractic care and cervical artery dissection: No evidence for causation. CMAJ Open. 2015;3(2):E244–E256.

In 2021, another major review by D’Souza et al., published in Cureus, similarly concluded that while VAD is a serious condition, the incidence following chiropractic care is exceedingly rare and not causally linked in most instances. The authors emphasized that while vigilance is necessary, the overall safety profile of cervical spine manipulation remains acceptable when performed by trained professionals.

D’Souza RS, Jimenez A, Chappidi MR, et al. Cervical Arterial Dissections and Association With Cervical Spinal Manipulation Therapy: A Systematic Review. Cureus. 2021;13(1):e12594.

Biomechanics and Arterial Integrity: Misconceptions About Force and Damage

The article suggests that the vertebral artery is vulnerable to tearing under the forces applied during chiropractic adjustments. However, biomechanical studies contradict this. Herzog et al. (2012) evaluated the strain on the vertebral artery during cervical spinal manipulation and compared it with normal daily neck movements. They found that cervical manipulations placed less strain on the vertebral arteries than turning the head to check a blind spot while driving.

Herzog W, Symons B, Leonard T, Ng L. Vertebral artery strains during high-speed, low-amplitude cervical spinal manipulation. J Electromyogr Kinesiol. 2012;22(5):740–746.

This biomechanical evidence supports the conclusion that properly delivered cervical manipulation does not subject vertebral arteries to dangerous levels of mechanical stress and cannot reasonably be held responsible for the initiation of VAD in healthy arteries. Further research related to susceptible populations is difficult due to the rarity of this event.

Clinical Practice Standards and Risk Mitigation in Chiropractic Care

While the article implies that chiropractic care is poorly regulated and prone to negligence, modern chiropractic education and clinical protocols reflect a high standard of care. Chiropractors are trained to identify red flags suggestive of VAD, such as recent onset of neck pain with headache, neurological deficits, or signs of cranial nerve involvement. They are also trained in triage and appropriate referral when symptoms suggest vascular pathology.

A 2018 publication by Puentedura et al. in Physiotherapy Theory and Practice proposed a clinical framework for screening patients at risk of cervical artery dissection. These risk mitigation strategies are widely adopted by evidence-based chiropractors and align with practices in physiotherapy and medical care.

Puentedura EJ, Louw A, et al. A clinical reasoning framework for patients presenting with neck pain. Physiother Theory Pract. 2018;34(8):621–633.

Moreover, informed consent and clinical diligence are essential components of responsible chiropractic practice. Like any medical discipline, rare adverse outcomes may occur, but they do not reflect the norm or justify vilifying an entire profession.

Comparative Risk: Chiropractic vs. Medical Interventions

The article praises surgical intervention for cervical pathology, noting a successful anterior cervical discectomy and fusion (ACDF). However, the risks of ACDF—including dysphagia, hoarseness, hardware failure, and adjacent segment disease—are well documented. A 2021 review in Neurosurgical Focus found complication rates for ACDF ranging from 13% to 19%, depending on patient factors and surgical complexity.

Wilson JR, Tetreault LA, et al. Complications and adverse events of cervical spine surgery for degenerative disease. Neurosurg Focus. 2021;50(5):E16.

In contrast, a 2019 review by Corso et al. in Musculoskeletal Science and Practice concluded that cervical spine manipulation is associated with a very low rate of serious adverse events (less than 1 per million manipulations), making it safer than many commonly prescribed drugs and surgical procedures.

Corso M, Cancelliere C, et al. Safety of spinal manipulative therapy: a systematic review and best practice recommendations. Musculoskelet Sci Pract. 2019;42:1–13.

Important Note: Research indicates that chiropractic care does not cause dissections. In our general population, unrelated to chiropractic treatment, around 2.3 to 9 out of every 100,000 individuals experience cervical artery dissections each year. Many of these cases arise spontaneously and are often challenging to diagnose. To improve patient safety, it is crucial for both medical providers and patients to communicate pertinent information regarding previous trauma, hereditary conditions, medical history, and current medications to chiropractors. This collaboration is vital for identifying individuals who may be at risk for dissection, thrombosis, embolism, or stroke.

Conclusion: A Call for Balance and Evidence-Based Perspective

While the article presents compelling stories of harm, it does so by selecting extreme and rare outcomes while ignoring broader data demonstrating the safety and utility of cervical spinal manipulation. It conflates anecdote with evidence and commits a fundamental logical error: post hoc ergo propter hoc (after this, therefore because of this).

In contrast, modern chiropractic care—when guided by evidence, clinical reasoning, and patient-centered practice—represents a safe, cost-effective, and non-invasive approach to managing neck pain.

To suggest that cervical manipulation has no ethical place in healthcare ignores both the clinical outcomes and the scientific data from the past decade. Like any intervention, it must be delivered judiciously and with proper assessment. But when these standards are met, cervical spinal manipulation remains a valuable and responsible tool in the healthcare landscape.

PostGradDC offers advanced post-graduate chiropractic continuing education. Our founder, Dr. James Demetrious, is an internationally distinguished board-certified chiropractic orthopedist, educator, author, and editor. Register for 10-hour, Cervical Artery Dissection Certification© at PostGradDC.com.

Disclosure

The information provided in this article and all PostGradDC coursework should not be considered standards of care. We offer this information for educational purposes only. This information is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or qualified healthcare provider with any questions you may have regarding medical conditions or treatment.