Protecting Chiropractic from Bad Science and Bias

Written by: James Demetrious, DC, DABCO

Board Certified Chiropractic Orthopedist

Following is a critical assessment of the article titled “Status migrainosus as the only manifestation of vertebral artery dissection due to osteopathic neck manipulation” by Romozzi et al. (2025), with annotated references and counterpoints that dispute the assertion that chiropractic or osteopathic spinal manipulation is a direct cause of cervical artery dissection (CAD):

Critical Assessment and Rebuttal

1. Misuse of Temporal Association as Causation

The article relies on a single case report of vertebral artery dissection (VAD) following neck manipulation. However, temporal proximity does not establish causality. Many case reports lack sufficient biomechanical or diagnostic evidence to support manipulation as the true etiology of the dissection.

Cassidy et al. (2008) conducted the largest case-control study to date and found that patients were just as likely to see a primary care physician as a chiropractor before a VAD-related stroke, suggesting that patients were already experiencing symptoms of dissection when they sought care—not that the care caused the dissection [Cassidy JD et al., Spine, 2008].

“This suggests that the association between chiropractic visits and vertebrobasilar artery stroke is likely due to patients with early dissection-related symptoms seeking care for headache and neck pain.”

2. Reliance on Low-Level Evidence and Anecdotal Reports

Romozzi et al. cite Ernst (2007), a widely criticized review, as a key support for their claim. Ernst’s paper aggregates case reports without a systematic approach to eliminate reporting bias or establish causality.

Triano et al. (2014) outlined that low-level evidence such as anecdotal reports and uncontrolled case studies cannot establish risk or causal inference in healthcare interventions [Triano JJ et al., JMPT, 2014].

“Case reports inherently suffer from selection bias, confirmation bias, and lack of denominator data for risk assessment.”

3. Diagnostic Ambiguity and Migrainous Predisposition

The patient had a 10-year history of migraine, which is itself a known risk factor for spontaneous arterial dissection.

Daghlas et al. (2022) confirmed that migraine, particularly without aura, is independently associated with increased risk of cervical artery dissection, likely due to underlying vascular connective tissue vulnerability [Daghlas I et al., Neurology Genetics, 2022].

“The genetic architecture of migraine may overlap with vascular dysfunction and increase predisposition to spontaneous dissection.”

4. Unsupported Generalizations About Chiropractic Technique

The authors describe “osteopathic” manipulation but link their conclusions to general chiropractic high-velocity, low-amplitude (HVLA) techniques without defining the actual procedure used. This conflates multiple manual therapy disciplines and misattributes risk.

Whedon et al. (2015) found no increased risk of cervical artery dissection or stroke associated with chiropractic spinal manipulation in a population-based analysis [Whedon JM et al., J Manipulative Physiol Ther., 2015].

“When adjusted for confounders, no significant association between cervical spine manipulation and vertebrobasilar stroke was found.”

5. Lack of Biomechanical Plausibility

Biomechanical studies suggest that the strain placed on vertebral arteries during cervical manipulation is significantly below the failure threshold necessary to cause dissection.

Herzog et al. (2012) used cadaveric models and demonstrated that even forceful chiropractic adjustments do not produce arterial strain sufficient to cause damage [Herzog W et al., JMPT, 2012].

“Our data indicate that vertebral artery strains during cervical spinal manipulation are lower than those encountered during normal daily activities.”

6. Literature Oversight: Absence of Balanced Review

Romozzi et al. do not cite major epidemiologic studies or systematic reviews that exonerate cervical manipulation as a significant causal factor, creating an unbalanced portrayal of risk.

Church et al. (2016) conducted a systematic review and concluded that the quality of evidence supporting cervical manipulation as a cause of dissection is very low, and most data are speculative [Church EW et al., Cureus, 2016].

“Current evidence is insufficient to establish a definitive causal relationship between cervical manipulative therapy and cervical artery dissection.”

Conclusion

The case presented by Romozzi et al. (2025) is anecdotal, lacks mechanistic validation, and overstates the risk of cervical manipulation by inferring causality based solely on timing. The patient’s history of migraine—a known risk factor—along with the lack of a control or comparator arm, limits the generalizability of this report.

The continued citation of low-level evidence to support claims of chiropractic-induced stroke misguides public perception and distracts from the more critical issue of recognizing early dissection symptoms, which often masquerade as common musculoskeletal complaints.

References

1. Cassidy JD, Boyle E, Côté P, et al. (2008). Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study. Spine, 33(4):S176–S183. https://doi.org/10.1097/BRS.0b013e3181644600
2. Triano JJ, et al. (2014). Manipulation-induced injuries: data synthesis and classification. JMPT, 37(7):498–512.
3. Daghlas I, et al. (2022). Migraine, stroke, and cervical arterial dissection. Neurology Genetics, 8(1).
4. Whedon JM, Mackenzie TA, Phillips RB, Lurie JD. (2015). Risk of stroke after chiropractic spinal manipulation in Medicare B beneficiaries aged 66 to 99 years with neck pain. JMPT, 38(2):93–98.
5. Herzog W, et al. (2012). Vertebral artery strains during high-speed low amplitude cervical spinal manipulation. JMPT, 35(9):617–622.
6. Church EW, Sieg EP, Rea GL, Glantz MJ, Kaszuba MC. (2016). Systematic review of chiropractic spinal manipulation and cervical artery dissection. Cureus, 8(2):e498.

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Disclosure

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