Chiropractic Care and Cervical Artery Dissection: NO EVIDENCE OF CAUSATION
Written by: James Demetrious, DC, DABCO
Recently, a neurosurgeon criticized the chiropractic profession in a biased manner that deflects from the substantial morbidity and mortality rates associated with medical care.
Neurosurgeons should remember that neurosurgery is the leading cause of medical malpractice in the United States. Medical researchers and physicians from the Department of Neurological Surgery and Pritzker School of Law at Northwestern University report:
“Neurosurgeons are more likely to face a malpractice claim than any other physician (19.1% annually).” 
As published in the Journal of the American Medical Association, Stanford University Professor of Orthopedic Surgery, Eugene Carragee, MD reported:
“Patients having a complex fusion had almost a 2-day longer hospital stay than those having decompression alone. Complex fusion operations resulted in average hospital charges ($80,888) more than 3 times as those for decompressions alone ($23,724).” 
“Financial incentives to hospitals and surgeons for more complex procedures may play a role as may desires of surgeons to be local innovators.” 
Other members of the medical profession should remember that an estimated 250,000–400,000 people die each year in the US due to medical errors, which are listed 3rd as a leading cause of death behind heart disease and cancer.
Ironically, prescribed fluoroquinolone antibiotics have been identified by Demetrious and subsequently confirmed by other authors to cause cervical artery dissection (CAD) due to iatrogenic connective tissue degradation. [3,4,5,6]
Bias and Evidence-Poor Rhetoric
Biased attacks upon chiropractic are too often published with a consistency of purpose that seeks to harm a great profession. In the guise of propriety, authors incorrectly assert harm through a temporal association of unsubstantiated CAD strain mechanisms.
In contrast, chiropractic physicians seek to help patients by recognizing the pre-existing heritable and acquired conditions that predispose them to dissection and stroke:
- The temporal relationship of the CAD events have been vetted in highly powered systematic reviews. [7,8,9,10,11]
- Vessel strain has been carefully evaluated, revealing no excess risk to high velocity-low amplitude manipulation of the cervical spine. [12,13,14,15]
- Arteriopathies and fibromuscular dysplasia have been associated with CAD. [16,17]
- Heritable connective tissue disorders and acquired fluoroquinolone degradation have been identified as root causes for dissection, and yet authors and experts conveniently neglect to discuss these mechanisms. [3,4,5,6]
Highly Powered and Conclusive Research from a Respected Source
Church et al. are esteemed investigators at the Department of Neurosurgery at the Penn State Hershey Medical Center. In a systematic review and meta-analysis of chiropractic care, the authors report:
“There is no convincing evidence to support a causal link [of chiropractic to CAD], and unfounded belief in causation may have dire consequences.” 
An Honest Medical Opinion
When questioned whether cervical spinal manipulation for mechanical neck pain should be abandoned because its risks outweighed its benefits, K. Daniel Riew, MD, an internationally esteemed professor of orthopedic surgery reported:
“Most patients can receive spinal manipulation. If they ever have severe spinal cord compression, then I do not recommend it. However, I have seen thousands of patients who have undergone chiropractic spinal manipulation, and I can count on one hand, the number of patients who have been harmed by it – there are many more patients who have been harmed by bad spinal operations.” 
Chiropractic Saves Lives
Keeney of Dartmouth Medical School, Department of Orthopaedics et al. reported:
“42.7% of workers who first saw a surgeon had surgery, in contrast to only 1.5% of those who saw a chiropractor.” 
Consider the reduction of morbidity, mortality, and cost, if patients first sought chiropractic care before medical interventions.
Highly powered medical research concludes that chiropractic care is evidence-based, safe, and effective. Research indicates that chiropractors do not cause CADs. CADs are rare events that produce symptoms, causing patients to seek chiropractic, medical and ancillary care.
In contrast to those who wish to inappropriately assign blame, a more meaningful effort should be made to better identify pre-existing predispositions, symptoms, and examination findings that suggest a burgeoning CAD for emergent medical care. It is through this means that we can save lives.
For advanced continuing education, register for our Online PACE Approved PostGradDC CE coursework:
Cervical Artery Dissection: Risk Factors
Cervical Artery Dissection: Diagnosis
Cervical Artery Dissection due to Fluoroquinolones
Chiropractic Case Management: Medical Error
- Larkin et al. Neurosurg Focus 49 (5):E2, 2020.Church E W, Sieg E P, Zalatimo O, et al. (February 16, 2016) Systematic Review and Meta-analysis of Chiropractic Care and Cervical Artery Dissection: No Evidence for Causation. Cureus 8(2): e498. DOI 10.7759/cureus.498.
- Carragee EJ. JAMA 2010 Apr 7;303(13):1309-10. doi: 10.1001/jama.2010.402.
- Demetrious J. Chiropractic and Manual Therapy 2018 26:22.
- Del Zotto et al. Eur J Neurol 2019 26(7):1028-1031.
- Harada et al. Intern Med. 2021 60(17):2863-2865.
- Wang et al. Arch Cardiovasc Dis Suppl 2023 15(1):112-113.
- Cassidy et al. Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study. Spine. 2008;33(4 Suppl):S176-83.
- Cassidy et al. J Stroke Cerebrovac Dis. 2017 26(4):842-850.
- Kosloff et al. Chiropractic and Manual Therapies 2015 23:19.
- Chung et al. JMPT 2015;38(9: 672-676.
- Whedon et al. Spine 2015 40:264-270.
- Quesnele et al. JMPT 2014 37(1): 22-31.
- Yelverton et al. JMPT 2020 43(2): 144-151.
- Herzog et al. J Electromyog Kinesiol 2012 22:740-746.
- Piper et al. Clin Biomech 2014 29:1099-1107.
- Bonacina et al. Trends in Cardiovascular Medicine 2022 32(2):103-109.
- Pfefferkorn et al. Stroke 2011 42:1563-1568.
- Church E W, Sieg E P, Zalatimo O, et al. (February 16, 2016) Systematic Review and Meta-analysis of Chiropractic Care and Cervical Artery Dissection: No Evidence for Causation. Cureus 8(2): e498. DOI 10.7759/cureus.498
- Riew D. Spinal News International 24, 2012.
- Keeney et al. Spine (Phila Pa 1976). 2013 May 15; 38(11): 953–964.
The views and opinions expressed in this presentation are solely those of the author. The information is not offered as a standard of care, as research and care evolve. We offer this only to educate and inform. Patients should seek the care of their doctors regarding their conditions.
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. For current, evidence-based, and clinically intuitive CE Coursework, attain your advanced training at PostGradDC.com.