Cervical spine manipulation (a high velocity, low amplitude, end range thrust manoeuvre) is a common treatment option for mechanical neck pain used by chiropracters. It focuses on the neck and involves a range of high-speed manual manoeuvres that stretch, mobilise or manipulate the upper spine in order to relieve pain.
However a recent article in the BMJ has highlighted the risks of this treatment – namely it may carry the potential for serious neurovascular complications, specifically vertebral artery dissection and subsequent vertebrobasilar stroke. The authors state that the non-superiority of manipulation to alternative treatments, coupled with concerns regarding safety, renders cervical spine manipulation unnecessary and inadvisable.
The authors of one study suggested that the increased risk after chiropractic treatment may be an artefact of patients seeking care for neck pain resulting from existing vertebral artery dissection rather than the result of treatment itself. Although the results suggest that some cases of vertebrobasilar stroke may be misattributed to manipulation, this does not rule out that some patients have dissection induced by manipulation or that the clinical sequelae are worsened by manipulation in some patients with spontaneous dissection.
Most reported cases of vertebral artery dissection and stroke after manual therapy seem to have followed chiropractic care rather than osteopathy or physiotherapy, where manipulation is used less often.
The authors of this article in the BMJ state that neck manipulation should be used only if there is substantial and unique benefit associated with this technique. A Cochrane review of randomised trials of neck manipulation or mobilisation actually found that as a stand-alone treatment, the technique provides only moderate short-term pain relief.
Many of my patients regularly see a chiropractor. It is important that as healthcare professionals, we are aware of these potential complications.
Clearly more research into the pros and cons of this and other techniques with the aim of identifying safe and effective treatments needs to be undertaken.