How to Recognize a Cervical Artery Dissection?

Research Review by: James Demetrious, DC, DABCO

Vitally Important Research

Sometimes extraordinary research papers are published that require careful consideration and implementation. Such is the Open Access review article published in the journal Annals of Medicine by Chaibi and Russell. [1] The authors reaffirm that:

  • Manual therapy does not result in an increased risk of CAD. 
  • There is no strong evidence in the literature that manual therapy provokes CAD.

Chaibi and Russell cite high-quality research to support these conclusions:

  • The rarity of CAD also makes the provision of epidemiological evidence challenging.
  • However, several extensive cohort studies and meta-analyses have found no excess risk of CAD resulting in secondary ischaemic stroke for chiropractic SMT compared to primary care. [2, 3, 4]
  • Similarly, retrospective cohort studies have reported no association with traumatic injury to the head or neck after SMT for neuromusculoskeletal pain.
  • Studies have disproven any misconception about whether SMT strains exceed failure strains.
  • No changes in blood flow or velocity in the VA of healthy young male adults were found in various head positions and during a cervical SMT.
  • Thus, these studies support the evidence of spontaneous causality or minimally suggest very low risk for serious AEs following SMT.

Chaibi and Russell report that “History taking is the single most important factor for detecting subtle symptoms of CAD.” In their article, they provide clinicians with an updated step-by-step risk-benefit assessment strategy tool to:

  • facilitate clinicians’ understanding of CAD,
  • appraise the risk and applicability of cervical manual therapy, and
  • provide clinicians with adequate tools to detect and exclude CAD in clinical settings.

Clinical Utility

The Chaibi and Russell CAD Assessment flowchart provides a comprehensive approach to the assessment of patients:

A Newly Discovered Risk Factor by Dr. Demetrious

In 2018, I was the first to ever publish the association of fluoroquinolone antibiotics to the genesis of CAD. In my article published in Chiropractic and Manual Therapies, I provide the rationale for this association.

Two independent medical studies have confirmed my novel discovery:

  • In 2019, Del Zotto and Pezzini reported, “Fluoroquinolones may represent a novel contributing factor involved in the pathogenesis of spontaneous cervical artery dissection.” [5]
  • In 2021, Harada et al. reported, “…quinolone exposure can be a risk factor for vertebral artery dissection.” [6]

Fluoroquinolone antibiotics must be considered as an environmental iatrogenic risk factor and predisposing cause of cervical artery dissection.

A Difficult Diagnosis

Highly powered research confirms that chiropractic spinal manipulation neither increases the risk nor does it provoke CAD. The recognition of the developing, rare CAD event is extraordinarily difficult. When possible, it is incumbent upon physicians to identify the risk factors, signs, and symptoms of a developing dissection to make emergent medical referrals.

Informed Practice

As physicians, we utilize evidence-based studies and our clinical intuition to deliver the best care possible. Diagnostic and therapeutic flow charts, appropriateness criteria, and standards of care are limited by many factors. Despite our best efforts, research is sometimes incomplete and clinical circumstances often undermine our ability to help all patients.


  1. Chaibi A, Russell MB. A risk-benefit assessment strategy to exclude cervical artery dissection in spinal manual-therapy: a comprehensive review. Ann Med. 2019;51(2):118-127. DOI:10.1080/07853890.2019.1590627.
  2. Cassidy et al. DOI:
  3. Church et al. DOI: 10.7759/cureus.498.
  4. Cassidy et al. DOI: 10.1016/j.jstrokecerebrovasdis.2016.10.031.
  5. Del Zotto et al. DOI: 10.1111/ene.13917
  6. Harada et al. DOI: 10.2169/internalmedicine.6736-20. Epub 2021 Mar 22.

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The views and opinions expressed in this presentation are solely those of the author. NCMIC does not set practice standards. We offer this only to educate and inform.

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