Pre-Existing Predispositions to Cervical Artery Dissection

Written by: James Demetrious, DC, DABCO

Clarity

There is NO firm scientific basis for direct causality between cervical spinal manipulative therapy and cervical artery dissection (CAD). The literature indicates that pre-existing heritable and acquired connective tissue weakness are primary risk factors for the development of CAD.

Simple activities of daily living produce dissections with associated neck/head pain and subsequent neurologic sequelae. Those symptoms cause patients to seek chiropractic and medical care.

Chiropractic care is not causative.

However…

Chiropractors and primary care physicians may not identify a developing dissection because of the rarity of such events, having never seen such a rare event in practice, and inadequate reporting of clinical symptoms.

The symptoms generated by the early developing cervical artery dissection may not meet the threshold for patients to report symptoms. Too frequently, patients are not the most reliable witnesses to their symptoms. Patients often do not complete their intake and update forms. They may not recall that they had some slight visual or neurologic disturbance that was fleeting. With the best intentions, it is extraordinarily difficult to diagnose the burgeoning cervical artery dissection.

In such cases, chiropractic is wrongly blamed as causative.

Diligence

On rare occasions, patients with predispositions to arterial dissection may present for chiropractic care. For those unlikely cases, it is of vital importance that clinicians maintain caution and vigilance. In our PostGradDC online coursework, we offer insight into difficult differential diagnoses:

  1. Risk Factors: Patient histories and the identification of risk factors are of vital importance. Patients need to be carefully assessed at their first visit for heritable predispositions and during subsequent visits for acquired causes of connective tissue degradation due to fluoroquinolones.
  2. Epidemiology:  CADs typically occur in younger adults.
  3. Symptoms: Careful assessment of patient symptoms, location of pain, timing, and progression is important in the development of a difficult diagnosis.
  4. Signs: Patients’ early progression may not provide meaningful insight into the burgeoning event. There are no screening tests or direct examinations other than advanced imaging to define the developing CAD. Careful examination may or may not identify an early neurologic deficit.

Additional Means to Assess Patients

To identify possible pre-existing predispositions of connective tissue weakness, questions related to genetic connective tissue disorders, the use of fluoroquinolone medications, and specific signs and symptoms may provide important clues to a difficult diagnosis. Such information could be included on:

  1. Intake/Update Forms
  2. Office Postings

Physicians may benefit from advanced postgraduate education to improve their assessment of subtle neurologic abnormalities. Tools like the Beighton Score may provide insight into pre-existing connective tissue weakness.

Caution

The likelihood of a CAD event is rare, and the diagnosis of the early development of symptoms and signs is extraordinarily difficult. Chiropractic and primary care physicians may not be causative but must exercise due diligence to make the diagnosis, if possible.

Causality

Before blaming chiropractic as a causative factor in CAD and stroke cases, it is critically important to evaluate diagnosed patients for unidentified, pre-existing predispositions to arterial wall weakness:

  1. Did the patient have a pre-existing, genetic connective tissue disorder?
  2. Did the patient have an unidentified loose joint syndrome?
  3. Did the patient have a history of taking fluoroquinolone antibiotics?
  4. Did the patient have an underlying and pre-existing arteriopathy?
  5. Did the patient have hyper-homocysteinemia or vessel tortuosity?

Conclusion

Advanced post-graduate continuing education is vitally important to improve clinical acumen to identify an extraordinarily rare and difficult diagnosis.

For advanced continuing education, register for our Online PACE Approved PostGradDC CE coursework.

Disclaimer

The views and opinions expressed in this presentation are solely those of the author. 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.