Adverse effects of spinal manipulation: a systematic review

J R Soc Med 2007;100:330-338
doi:10.1258/jrsm.100.7.330
© 2007 Royal Society of Medicine

 

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J R Soc Med 2007;100:330-338
© 2007 The Royal Society of Medicine


E Ernst


Complementary Medicine, Peninsula Medical School, Universities of Exeter
& Plymouth, 25 Victoria Park Road, Exeter EX2 4NT, UK Email:
Edzard.Ernst{at}pms.ac.uk

 




SUMMARY

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Objective To identify adverse effects of spinal manipulation.

Design Systematic review of papers published since 2001.

Setting Six electronic databases.

Main outcome measures Reports of adverse effects published between
January 2001 and June 2006. There were no restrictions according to language
of publication or research design of the reports.

Results The searches identified 32 case reports, four case series,
two prospective series, three case-control studies and three surveys. In case
reports or case series, more than 200 patients were suspected to have been
seriously harmed. The most common serious adverse effects were due to
vertebral artery dissections. The two prospective reports suggested that
relatively mild adverse effects occur in 30% to 61% of all patients. The
case-control studies suggested a causal relationship between spinal
manipulation and the adverse effect. The survey data indicated that even
seriousadverse effects are rarely reported in the medical literature.

Conclusions Spinal manipulation, particularly when performed on the
upper spine, is frequently associated with mild to moderate adverse effects.
It can also result in serious complications such as vertebral artery
dissection followed by stroke. Currently, the incidence of such events is not
known. In the interest of patient safety we should reconsider our policy
towards the routineuse of spinal manipulation.




INTRODUCTION

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Spinal manipulation or adjustment is a manual treatment where a vertebral
joint is passively moved between the normal range of motion and the limits of
its normal integrity, though a universally accepted definition does not seem
to exist.1 It is
occasionally used by osteopaths, physiotherapists and physicians, and it is
the hallmark treatment of chiropractors. Practically all chiropractors use
spinal manipulation regularly to treat low back and other musculoskeletal
pain.2 It often
involves a high velocity thrust, a technique in which the joints are adjusted
rapidly, often accompanied by popping sounds. This results in transient
stretching of joint capsules which, according to chiropractic belief, resets
the position of the spinal cord and nerves, allowing the nervous system to
function optimally and improving the body’s biomechanical
efficiency.3 The
thrust is exerted through either a long lever arm, in which force is applied
distant from the joint, or a short lever arm, when force is applied close to
the joint. Many experts see spinal manipulation as an effective form of
treating back pain:4
the evidence from randomized clinical trials (RCTs), however, remains
contradictory and often
unconvincing.5 For
conditions other than back pain, there is no good evidence for the
effectiveness of spinal
manipulation.5

Many authors have voiced doubt about the safety of spinal manipulation. A
particular concern is stroke after upper spinal manipulation. The systematic
review by Ernst and Stevinson, published in 2002, summarized safety data
available up to
2001.6 Since then,
an abundance of new evidence has emerged. The aim of this article is therefore
to identify adverse effects of spinal manipulationpublished since 2001.




METHODS

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Computerized literature searches were performed using MEDLINE (PubMed),
EMBASE, Amed, CINHAL, the British Nursing Index and the Cochrane Library up to
June 2006. The search terms used were ‘adverse effects’,
‘adverse events’, ‘arterial injury’, ‘cervical
manipulation’, ‘chiropractic’, ‘complications’,
‘manual therapy’, ‘osteopathy’, ‘risk’,
‘safety’, ‘spinal manipulation’, ‘stroke’,
‘vascular accident’, and ‘vertebral artery
dissection’. In addition, our departmental files were searched, and
other experts were consulted. The bibliographies of relevant papers were
scanned for pertinent articles. All reports, irrespective of language of
publication, which contained data about risks associated with spinal
manipulation were included, regardless of the profession of the therapist or
the research methodology used for the report. Articles from 2000 or earlier,
dual publications of the same
material7 and cases
of spinal manipulation for non-therapeutic
purposes8 were
excluded. All relevant reports were obtained in full. Key data were extracted
by the author according to predefined criteria, tabulated and also described
narratively.




RESULTS

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Case reports

The search strategy located 28 articles reporting a total of 32 case
reports (Tables 1 and
2). In 22 cases (published in
20 articles) the therapists were chiropractors
(Table
1
),928
while in 10 cases (published in nine articles) they were other health-care
professionals (Table
2
).13,2936
In the majority of cases, the problem related to upper spinal manipulations
including rotational movements. The patients were mostly young healthy
individuals treated for benign, self-limiting conditions such as neck pain or
headache. There was no clear over-representation of one sex over another.
Dissection of the vertebral arteries was the most common problem; other
complications included dural tear, oedema, nerve injury, disc herniation,
haematoma and bone fracture. The symptoms were frequently life-threatening,
though in most cases the patient made a full recovery. In the majority of
cases, spinal manipulation was deemed to be the probable cause of the adverse
effect.



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Table 1. Case reports of adverse events after spinal manipulation administered by
chiropractors



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Table 2. Case reports of adverse events after spinal manipulation performed by
non-chiropractors

 

 

Retrospective case series

Haldemann et al. analysed 64 cases in which a cerebrovascular
ischaemic event had occurred after spinal
manipulation.37 All
cases had been referred to Haldemann for medico legal review during a 16-year
period, and none had previously been reported in the medical literature. The
patients were predominantly women (mean age 39 years) who had consulted a
chiropractor for neck pain or headache. In 48 cases, the onset of the stroke
was within 30 minutes after spinal manipulation. The authors were unable to
identify any risk factors that would discriminate high risk from low risk
patients. Neurological status one year after the stroke was available for 46
patients: eight had made a full recovery, two had died, and the rest were
still suffering frompersistent neurological deficits.

Young and Chen described nine patients who were admitted for acute vertigo
after spinal manipulation by chiropractors or practitioners of Traditional
Chinese Medicine.38
Magnetic resonance angiography showed that the clinical symptoms were due to
vertebral artery occlusion (n=1), stenosis (n=1), slow blood
flow (n=1) or associated with normal findings (n=6). The
average time between spinal manipulation and onset of symptoms was 17 hours
(range1-24 hours). All patients made a full recovery after treatment.

Hansis et al. published an analysis of 57 patients who had been
referred during 28 years to the North Rhine General Medical Council for
alleged
malpractice.39 In
20 patients who had experienced a disc prolapse after spinal manipulation, the
Council attested five instances of malpractice. In six cases of bone
fractures, the Council attested one instance of malpractice. In nine cases of
cerebrovascular accidents, seven of which were due to dissection of the
vertebral artery, the Council attested malpractice four times. In 22
instances, patients had complained that spinal manipulation had no effect or
had worsened the presenting condition: the Council attested malpractice in two
of them.

Oppenheim et al. conducted a chart review of 18 patients (nine men
and nine women aged 31-72 years) who suffered non-vascular adverse effects
after receiving spinal manipulation by
chiropractors.40
The injuries occurred in the cervical (33%), thoracic (22%) and lumbar spine
(44%). In nine cases, they were associated with spinal cord injuries
(myelopathy, quadriparesis, central cord syndrome or paraparesis); two
patients experienced cauda equina syndrome; six patients developed
radiculopathy; and three patients had pathological fractures related to cancer
which the chiropractors had failed to diagnose. Sixteen patients required
surgery; half of them subsequently made an excellent recovery, and 31% a good
recovery.

Reuter et al. reported 36 cases of vertebral artery dissection
seen within three years in 13 neurological
centres.41 On
admission, 30 of these patients had neurological deficits; on discharge this
figure had decreased to 18. Spinal manipulation had been administered by
orthopaedic surgeons (50%), physiotherapists (14%), chiropractors (11%) or
other health-care professionals. In 14% of all cases, the onset of symptoms
was during treatment, while in a further 12% it was within one hour. All
patients had been treated with spinal manipulation for benign conditions such
as neck or back pain.

Prospective case series

Cagnie et al. invited 59 Belgian physiotherapists to recruit a
total of 465 new patients treated by them with spinal
manipulation.42 All
patients were subsequently asked to complete a questionnaire about adverse
effects. 61% of all patients reported at least one adverse effect, most of
which were mild and transient, such as headache (20%), stiffness (20%), local
discomfort (15%), radiating discomfort (12%) and fatigue (12%). 63% of these
patients noted more than one symptom. In 61%, the problems had started within
four hours after manipulation, and 64% had resolved within 24 hours. 21% of
post-manipulative effects were experienced as ‘severe’, and 27% of
patients felt impaired in their daily activities. No complications with
long-lasting consequenceswere reported.

Hurwitz et al. reported adverse effects documented in a randomized
controlled trial comparing spinal manipulation with spinal mobilization as
treatments of neck
pain.43 Of 280
patients, 30% reported at least one adverse effect. Patients receiving spinal
manipulation were more likely to experience adverse effects than patients
treated with mobilization, a more gentle manual technique preferred by many
osteopaths. The most frequently noted adverse effects were increase of pain,
headache, tiredness and radiating pain. 80% of the adverse effects began with
24 hours after treatment and were of moderate or medium severity. No serious
complicationswere noted.

Case-control studies

Dziewas et al. studied 126 patients with carotid or vertebral
artery
dissections.44
Compared to patients with carotid artery dissections, patients with vertebral
artery dissections more frequently reported having previously had chiropractic
upper spinal manipulation (6% versus 30%). Bilateral vertebral artery
dissection was also significantly related to a preceding chiropractic
manipulation. Five cases of carotid artery dissection were associated with
prior spinal manipulation, and all had a good clinical outcome. Fourteen cases
of vertebral artery dissection were linked to spinal manipulation, of which
ten had a good, three a moderate and one a poor clinical outcome. The authors
concluded that ‘this study emphasizes the potential dangers of
chiropractic manipulation of the cervicalspine.’

Rothwell et al. studied hospital records in Ontario to identify
all cases of vertebrobasilar accidents within a five-year
period.45 They
found 582 such cases and matched them by age and sex to four controls each who
had no history of stroke. In patients younger than 45 years, the odds of
having a vertebrobasilar accident within one week of visiting a chiropractor
were increased by a factor of five. In this age group, cases were five times
more likely to have had more than three chiropractic consultations with a
cervical diagnosis in the month before the event.

Smith et al. conducted blinded chart review and face-to-face
interviews with 51 patients under the age of 60 years from two stroke centres
in the USA.46 They
were age- and sex-matched to 100 controls. In univariate analysis, cases were
more likely than controls to have had spinal manipulation within 30 days of
the vascular accident (14% versus 3%). In multivariate analysis, vertebral
arterial dissections were independently associated with spinal manipulations
within 30 days (odds ratio [OR] 6.62). For carotid dissection, no significant
association was noted. The authors conclude that spinal manipulation ‘is
independently associated with vertebral arterial dissection, even after
controllingfor neck pain.’

A systematic review of case control studies of potential risk factors for
cervical artery dissection found ‘a strong association for manipulative
therapy’ (OR 3.8, 95% confidence interval [CI]
1.3-11).47 However,
these results were based only on two studies. The authors therefore urge
caution until furtherevidence becomes available.

Surveys

Adams and Sim posted a questionnaire about adverse effects of spinal
manipulation to 300 UK manipulative
therapists.48 Of
the respondents, 129 used spinal manipulation. Anxiety about complications was
a prominent reason for not using manipulation. Cervical rotary manipulations
were thought by some respondents to be potentially dangerous. Overall,
respondents felt ‘uncertain as to whether its benefits outweighed its
risks.’48

Dupeyron et al. surveyed 240 French doctors with a diploma in
‘manual medicine’ asking them to provide details of all
complications after spinal manipulation during the preceding two
years.52 93 such
cases were disclosed, none of which had previously been reported in the
medical literature. 69% of them related to radiculopathies and 15% to
cerebrovascular accidents, and 53% of the problems became symptomatic within
24 hours after treatment.

Egizii et al. posted questionnaires to 234 French doctors with
‘Manual Medicine’ or ‘Osteopathy’ diplomas from
Strasbourg University between 1985 and
2002.49 Responses
were obtained from 140 physicians. Most of them used spinal manipulation in
their daily practice. 24% of the respondents stated that they had caused one
or more adverse effects through spinal manipulation; no further details were
supplied.




DISCUSSION

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The case reports (Tables 1
and 2) confirm previous
reports6 associating
upper spinal manipulation with a range of complications. The most serious
problems, which some experts now describe as
‘well-recognized’,22
are vertebral artery dissections due to intimal tearing as a result of
over-stretching the artery during rotational manipulation. This seems to occur
most commonly at the level of the atlantoaxial
joint.20 Intimal
injury can be followed by intramural bleeding or pseudoaneurysm formation,
which can result in thrombosis,
embolism20 or
arterial
spasm.22

The retrospective case series (Table
3
) confirm that spinal manipulation is associated with risks such
as vascular accidents and non-vascular complications. Such adverse effects are
being reported from several countries and often have serious consequences. The
therapists involved are mostly chiropractors; this predominance is probably
due to the fact that these therapists use spinal manipulation more frequently
than other practitioners. Most of the incidents reported in case series or
surveys had not been previously reported, indicating that under-reporting may
frequentlybe high.



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Table 3. Retrospective case series of adverse events after spinal
manipulation

 

The two prospective case
series42,43
corroborate the results from several earlier
investigations50
showing that mild to moderate adverse effects occur in a large proportion of
patients receiving spinal manipulation. These adverse effects are transient
and non-serious but nevertheless seriously affect many
patients.42,50
Risk-benefit evaluations of spinal manipulation must therefore account not
justfor serious complications but also for such adverse events.

Case-control and other studies confirm that upper spinal manipulation is
associated with
risks4447
and that spinal manipulation is an independent risk factor for vertebral
artery
dissection.46 Many
chiropractors insist that a causal link is questionable or unlikely, as the
early signs of arterial dissections include neck pain, which could be the
reason for a patient to consult a chiropractor, therefore these possible
associations could be
false.23,51
Smith et al. tried to account for this particular confounder and
still found spinal manipulation to be a risk
factor.46

The three surveys disclose more complications. They suggest that many
therapists are now becoming aware of the risks of spinal
manipulation.48,49
Two of the
surveys49,52
also confirmthat under-reporting is frequently close to 100%.

It seems unfair to assess the risk of spinal manipulation as practised by
well-trained chiropractors alongside that associated with untrained therapists
(Tables 1 and
2). Chiropractors may argue
that it takes years of experience to learn the fine psychomotor control
required for skilled manipulations. Certainly skill and experience are
important, and it is relevant to differentiate between different professions,
as done in Tables 1 and
2. On the other hand, skill is
a quality not easily controlled for in such research; even some chiropractors
may be more skilled than others. Moreover, this review is aimed at evaluating
the risk of an intervention (spinal manipulation) and not that of a profession
(chiropractic). In fact, this review shows that the implicated practitioners
are not only chiropractors but also surgeons, shiatsu practitioners,
‘bonesetters’ and general practitioners
(Table 2).

Collectively, these data suggest that spinal manipulation is associated
with frequent, mild and transient adverse effects as well as with serious
complications which can lead to permanent disability or death. Yet causal
inferences are, of course, problematic. Vascular accidents may happen
spontaneously or could have causes other than spinal manipulation. A temporal
relationship is insufficient to establish causality, and recall bias can
further obscure the truth. Moreover, denominators are rarely available.
Consequently the frequency of serious adverse effects is currently unknown.
Estimates by chiropractors vary (e.g. 6.4 per 10 million manipulations of the
upper spine and 1 per 100 million manipulations of the lower
spine).53 These
figures, however, may be over-optimistic. Retrospective investigations have
repeatedly shown that under-reporting is close to
100%.13,52
This level of under-reporting would render such estimates nonsensical. At
present, there is no sufficiently large and rigorous prospective study to
generate reliable incidence figures; previous studies have failed to
investigate those patients which were lost at follow-up. This could be the
subgroup which has been harmed. It is therefore essential that future studies
followup close to 100% of the initial patient sample.

The effectiveness of spinal manipulation for most indications is less than
convincing.5 A
risk-benefit evaluation is therefore unlikely to generate positive results:
with uncertain effectiveness and finite risks, the balance cannot be positive.
Cautious attitudes towards upper spinal manipulation are therefore becoming
more widespread: ‘special caution should be exercised when performing
first-line cervical manipulation and simple, honest and easily understandable
information about there risks should be included when informed consent is
obtained.’54

Some therapists have started advocating screening patients for risk factors
before
treatment.5557
Based on cadaver studies of human vertebral arteries, Cagnie et
al
.58 have
suggested that, in the presence of arteriosclerotic changes, the stretching
and compression effects of rotational manipulation may constitute a risk
factor for vascular accidents. These authors concluded that ‘therapists
should avoid manipulative techniques at all levels of the cervical spine in
the presence of any indirect sign of arteriosclerotic disease or in the
presence of calcified arterial walls or tortuosities of the
vessel.’58
Others have suggested that high homocystein levels constitute a risk factor
for arterial
dissection.59
Spinal manipulation might therefore be contraindicated in such individuals.
The effectiveness of screening has, however, not been convincingly
demonstrated. The chiropractic profession tends to downplay the risks:
‘chiropractic services are
safe’;60
‘the healthy vertebral artery is not at risk from properly performed
chiropractic manipulative
procedures.’61
Others argue that ‘the occurrence of cerebrovascular accidents in the
chiropractic population is
0.000008%’,62
that causality is not proven or even
unlikely,61,6366
that other interventions are more risky (see
below),67 that the
mechanical forces employed for spinal manipulation are too low to cause
injury,68 or that
there is a ploy from the medical establishment to sideline
chiropractors.6971
In the light of the evidence summarized above, such attitudes do not seem to
be in the best interest of patients.

It is, of course, important to present any risk-benefit assessment fairly
and in the context of similar evaluations of alternative therapeutic options.
One such option is drug therapy. The drugs in question—non-steroidal
anti-inflammatory drugs (NSAIDs)—cause considerable problems, for
example gastrointestinal and cardiovascular
complications.72,73
Thus spinal manipulation could be preferable to drug therapy. But there are
problems with this line of argument: the efficacy of NSAIDs is undoubted but
that of spinal manipulation is not, and moreover, the adverse effects of
NSAIDs are subject to post-marketing surveillance while those of spinal
manipulation are not. Thus we are certain about the risks and benefits of the
former and uncertain about those of the latter. Finally, it should be
mentioned that other therapeutic options (e.g. exercise therapy or massage)
havenot been associated with significant risks at all.

This systematic review has several limitations. Even though the search
strategy was thorough, some relevant published articles might have been
missed. High levels of under-reporting or recall bias might distort the
overall picture generated. Publication bias could have exerted a similar
effect. For instance, it is possible that journals of complementary medicine
are unlikely to publish findings which might be considered
‘negative’.74

In conclusion, spinal manipulation, particularly when performed on the
upper spine, has repeatedly been associated with serious adverse events.
Currently the incidence of such events is unknown. Adherence to informed
consent, which currently seems less than
rigorous,75 should
therefore be mandatory to all therapists using this treatment. Considering
that spinal manipulation is used mostly for self-limiting conditions and that
its effectiveness is not well
established,5 we
should adopt a cautious attitude towards using it in routinehealth care.




Footnotes


Competing interests None declared.


Funding None.


Ethical approval Not required.


Guarantor EE.




REFERENCES

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 REFERENCES

 

  1. Vernon H, Mrozek J. A revised definition of manipulation.
    J Manip Physiol Ther2005; 28:68
    -72[Medline]
  2. Hurwitz EL, Coulter ID, Adams AH, Genovese BJ, Shekelle PG. Use of
    chiropractic services from 1985 through 1991 in the United States and Canada.
    Am J Public Health1998; 88:771
    -6[Abstract/Free Full Text]
  3. Segan C. Dictionary of Alternative
    Medicines
    . Stamford, CT: Appleton and Lange:1998
  4. Ernst E, Pittler MH. Experts’ opinions on complementary/alternative
    therapies for low back pain. J Manip Phys Ther1999; 22:87
    -90
  5. Ernst E, Canter P. A systematic review of systematic reviews of
    spinal manipulation. J Roy Soc Med2006; 99:192
    -6[Abstract/Free Full Text]
  6. Stevinson C, Ernst E. Risks associated with spinal manipulation.
    Am J Med2002; 112:566
    -70[Medline]
  7. Haldeman S, Kohlbeck FJ, McGregor M. Stroke, cerebral artery
    dissection, and cervical spine manipulation therapy. J
    Neurol
    2002;249:1098
    -104[Medline]
  8. Panagariya A, Kumawat BL, Singh R, Sukhani P. Total unilateral
    medullary syndrome—a rare complicaton of chiropractic manipulation.
    J Assoc Physicians India2004; 52:556[Medline]
  9. Jeret JS. More complications of spinal manipulation.
    Stroke2001; 32:1136
    -7
  10. Siegel D, Neiders T. Vertebral artery dissection and pontine
    infarction after chiropractic manipulation. Am J Emerg
    Med
    2001;19:172
    -3[Medline]
  11. Parwar BL, Fawzi AA, Arnold AC, Schwartz SD. Horner’s syndrome and
    dissection of the internal carotid artery after chiropractic manipulation of
    the neck. Am J Ophthalmol2001; 131:523
    -4[Medline]
  12. Schram DJ, Vosik W. Diaphragmatic paralysis following cervical
    chiropractic manipulation: case report and review.
    Complementary/Alternative Medicine for Asthma2001; 119:638
    -40
  13. Stevinson C, Honan W, Cooke B, Ernst E. Neurological complications
    of cervical spine manipulation. J Roy Soc Med2001; 94:107
    -10[Abstract/Free Full Text]
  14. Jeret JS, Bluth M. Stroke following chiropractic manipulation.
    Report of three cases and review of the literature. Cerebrovasc
    Dis
    2002;13:210
    -3[Medline]
  15. Sédat J, Dib M, Mahagne MH, Lonjon M, Paquis P. Stroke after
    chiropractic manipulation as a result of extracranial postero-inferior
    cerebellar artery dissection. J Manipulative Physiol
    Ther
    2002;25:588
    -90[Medline]
  16. Jay WM, Shah MI, Schneck MJ. Bilateral occipital-parietal
    hemorrhagic infarctions following chiropractic cervical manipulation.
    Semin Ophthalmol2003; 18:205
    -9[Medline]
  17. Menendez-Gonzalez M, Garcia C, Suarez E, Fernandez-Diaz D,
    Blazquez-Menes B. Sindrome de Wallemberg secundario a diseccion de la arteria
    vertegral por manipulacion quiropractica. Rev Neurol2003; 37:837
    -9[Medline]
  18. Wojcik W, Pawlak JK, Knaus R. Doctor! I can’t stand the noise in my
    ear! J Neurol Neurosurg Psychiatry2003; 74:55
    -9
  19. Beck J, Raabe A, Seifert V. Intracranial hypotension after
    chiropractic manipulation of the cervical spine. J Neurol Neurosurg
    Psychiatry
    2003;74:820
    -6[Free Full Text]
  20. Nadgir RN, Loevner LA, Ahmed T, Chalela J, Slawek K, Imbesi S.
    Simultaneous bilateral internal carotid and vertebral artery dissection
    following chiropractic manipulation: case report and review of the literature.
    Neuroradiol2003; 45:311
    -4[Medline]
  21. Oehler J, Gandjour J, Fiebach J, Schwab S. Beidseitge A.
    Vertebralis-dissektion nach chiropraktischer Behandlung.
    Orthopade2003; 32:911
    -3[Medline]
  22. Yokota J, Amakusa Y, Tomita Y, Takahashi S. The medial medullary
    infarction (Dejerine syndrome) following chiropractic neck manipulation.
    No To Shinkei2003; 55:121
    -5[Medline]
  23. Izquierdo-Casas J, Soler-Singla L, Vivas-Diaz E, Balaguer-Martinez
    E, Sola-Martinez T, Guimaraens-Martinez L. Diseccion vertebral como causa del
    sindrome de enclaustramiento y opciones terapeuticas con fibrinolisis
    intraarterial durante la fase aguda. Rev Neurol2004; 38:1139
    -41[Medline]
  24. Morandi X, Riffaud L, Houedakor J, Amlashi SFA, Brassier G, Gallien
    P. Caudal spinal cord ischemia after lumbar vertegral manipulation.
    Joint Bone Spine2004; 71:334
    -7[Medline]
  25. Saxler G, Barden B. Extensive spinal epidural hematoma—an
    uncommon entity following cervical chiropractic manipulation. Z
    Orthop Ihre Grenzgeb
    2004; 142:79
    -84[Medline]
  26. Tome F, Barriga A, Espejo L. Herniacion discal multiple tras
    manipulatcion quiropractica cervical. Rev Med Univ
    Navarra
    2004;48:39
    -41[Medline]
  27. Chen H-C, Hsu P-W, Lin C-Y, Tzaan W-C. Symptomatic hematoma of
    cervical ligamentum flavum. Spine2005; 30:E489
    -E491[Medline]
  28. Suh S-I, Koh S-B, Choi E-J, et al. Intracranial
    hypotension induced by cervical spine chiropractic manipulation.Spine
    2005;30:E340
    -E342[Medline]
  29. Kraft CN, Conrad R, Vahlensieck M, Perlick L, Schmitt O, Dietrich
    O. Non-cerebrovascular complication in chirotherapy manipulation of the
    cervical vertebrae. Z Orthop Grenzgeb2001; 139:8
    -11
  30. Tsuboi K. Retinal and cerebral artery embolism after
    ‘Shiatsu’ on the neck. Stroke2001; 32:2441[Free Full Text]
  31. Quintana JG, Drew EC, Richtsmeier TE, Davis LE. Vertebral artery
    dissection and stroke following neck manipulation by Native American healer.
    Neurol2002; 58:1434
    -5[Free Full Text]
  32. Chung OM. MRI confirmed cervical cord injury caused by spinal
    manipulation in a Chinese patient. Spinal Cord2002; 40:196
    -9[Medline]
  33. Gamer D, Schuster A, Aicher K, Apfelstedt-Sylla E. Horner’s
    syndrome in dissection of the carotid artery after chiropractic manipulation.
    Klin Monatsbl Augenheilkd2002; 219:673
    -6[Medline]
  34. Tseng S-H, Lin S-M, Chen Y, Wang C-H. Ruptured cervical disc after
    spinal manipulation therapy. Spine2002; 27:E80
    -E82[Medline]
  35. Licht PB, Christensen HW, Hoilund-Carlsen PF. Is cervical spinal
    manipulation dangerous? J Manip Physiol Ther2003; 26:48
    -52[Medline]
  36. Schmitz A, Lutterbey G, von Engelhardt L, von Falkenhausen M,
    Stoffel M. Pathological cervical practure after spinal manipulation in a
    pregnant patient. J Manip Physiol Ther2005; 28:633
    -6[Medline]
  37. Haldeman S, Kohlbeck FJ, McGregor M. Unpredictability of
    cerebrovascular ischemia associated with cervical spine manipulation therapy.
    Spine2002; 27:49
    -55[Medline]
  38. Young Y-H, Chen C-H. Acute vertigo following cervical manipulation.
    Laryngoscope2003; 113:659
    -62[Medline]
  39. Hansis ML, Weber B, Smentkowski U, Schrader P. Vorgeworfene
    Behandlungsfehler im Zusammenhang mit chirotherapeutischen Behandlungen.
    Orthopade2004; 33:1051
    -60[Medline]
  40. Oppenheim JS, Spitzer DE, Segal DH. Nonvascular complications
    following spinal manipulation. Spine J2005; 5:660
    -7[Medline]
  41. Reuter U, Hamling M, Kavuk I, Einhaupl KM, Schielke E. Vertebral
    artery dissections after chiropractic neck manipulation in Germany over three
    years. J Neurol2006; 253:724
    -30[Medline]
  42. Cagnie B, Vinck E, Beernaert A, Cambier D. How common are side
    effects of spinal manipulation and can these side effects be predicted?
    Man Ther2004; 9:151
    -6[Medline]
  43. Hurwitz EL, Morgenstern H, Vassilaki M, Chiang L-M. Adverse
    reactions to chiropractic treatment and their effects on satisfaction and
    clinical outcomes among patients enrolled in the UCLA neck pain study.
    J Manipulative Physiol Ther2004; 27:16
    -25[Medline]
  44. Dziewas R, Konrad C, Dräger B, et al. Cervical artery
    dissection—clinical features, risk factors, therapy and outcome in 126
    patients. J Neurol2003; 250:1179
    -84[Medline]
  45. Rothwell DM, Bondy S, Williams I. Chiropractic manipulation and
    stroke: a population-based case-control study. Stroke2001; 32:1054
    -60[Abstract/Free Full Text]
  46. Smith WS, Johnston SC, Skalabrin EJ, et al. Spinal
    manipulative therapy is an independent risk factor for vertebral artery
    dissection. Neurol2003; 60:1424
    -8[Abstract/Free Full Text]
  47. Rubinstein SM, Peerdeman SM, van Tulder MW, Riphagen I, Haldeman S.
    A systematic review of the risk factors for cervical artery dissection.
    Stroke2005; 36:1575
    -80[Abstract/Free Full Text]
  48. Adams G, Sim J. A survey of UK manual therapists’ practice of and
    attitudes towards manipulation and its complications. Physiother
    Res Int
    1998;3:206
    -27[Medline]
  49. Egizii G, Dupeyron A, Vautravers P. Spinal manipulation: survey of
    French medical physicians who graduated with the national diploma of
    osteopathy from Strasbourg University. Ann Readapt Med
    Phys
    2005;48:623
    -31. DOI:10.1016/j.annmp.2005.04.013[Medline]
  50. Ernst E. Prospective investigations into the safety of spinal
    manipulation. J Pain Sympt Manage2001; 21:238
    -42[Medline]
  51. Kier AL, McCarthy PW. Cerebrovascular accident without chiropractic
    manipulation: a case report. J Manipulative Physiol
    Ther
    2006;29:330
    -5[Medline]
  52. Dupeyron A, Vautravers P, Lecocq J, Isner-Horobeti ME.
    Complications following vertebral manipulation—a survey of a French
    region physicians. Ann Readapt Med Phys2002; 46:33
    -40
  53. Coulter ID. Efficacy and risks of chiropractic manipulation: what
    does the evidence suggest? Integ Med1998; 1:61
    -6
  54. Vautravers P. Cervical spine manipulation and the precautionary
    principle. Joint Bone Spine2000; 67:272
    -6[Medline]
  55. Mann T, Refshauge KM. Causes of complications from cervical spine
    manipulation. Aus J Physiother2001; 47:255
    -66
  56. Cagnie B, Vinck E, Cambier D. Side and adverse effects of spinal
    manipulation. Tijdschrift voor Geneeskunde2002; 58:1317
    -23
  57. Refshauge KM, Parry S, Shirley D, Larsen D, Rivett DA, Boland R.
    Professional responsibility in relation to cervical spine manipulation.
    Aus J Physiother2002; 48:171
    -9
  58. Cagnie B, Barbaix E, Vinck E, D’Herde K, Cambier D. Atherosclerosis
    in the vertebral artery: an intrinsic risk factor in the use of spinal
    manipulation? Surg Radiol Anat2006; 28:129
    -34[Medline]
  59. Thanvi B, Munshi SK, Dawson SL, Robinson TG. Carotid and vertebral
    artery dissection syndromes. Postgrad Med J2005; 81:383
    -8[Abstract/Free Full Text]
  60. Killinger LZ. Chiropractic and geriatrics: a review of the
    training, role, and scope of chiropractic in caring for aging patients.
    Clin Geriatr Med2004; 20:223
    -35[Medline]
  61. Haneline M, Triano J. Cervical artery dissection. A comparison of
    highly dynamic mechanisms: manipulation versus motor vehicle collision.
    J Manip Physiol Ther2005; 28:57
    -63[Medline]
  62. Cohn A. A review of the literature regarding stroke and
    chiropractic. J Vertebral Subluxation Res2001; 4:52
    -9
  63. Wenban A. Critical appraisal of an article about harm: chiropractic
    adjustment and stroke. J Vertebral Subluxation Res2001; 4:68
    -74
  64. Gotlib AC, Crawford JP, Injeyan HS. Sporadic hypercoagulability,
    haemodynamic alterations, and manipulation-linked stroke. Clin
    Chiropractic
    2002;9:21
    -30
  65. Haneline M, Croft AC, Frishberg BM. Association of internal carotid
    artery dissection and chiropractic. Neurol2003; 9:35
    -44
  66. Refisch A, Bischoff P. Manipulation und läsionen der
    zervikalarterien mehr als zeitliche koinzidenz? Manuelle
    Med
    2004;42:109
    -18
  67. Mirallas-Mart-nez JA. Cerebral vascular complications post-cervical
    spine manipulation (Spanish). Rehabilitation
    (Stuttgart) 2003;37:33
    -8
  68. Symons BP, Leonard T, Herzog W. Internal forces sustained by the
    vertebral artery during spinal manipulative therapy. J Manip
    Physiol Ther
    2002;25:504
    -10[Medline]
  69. World Chiropractic Alliance. WCA continues to dispel media stroke
    misinformation. Chiropr J2002; 16:13
  70. Filippi MR. Approaches to unsubstantiated criticism: an editorial
    rejoinder on the stoke (sic) issue. J Vertebral Subluxation
    Res
    2001;4:65
    -7
  71. Haneline M, Lewkovich G. Critique of the Canadian Stroke
    Consortium’s spontaneous versus traumatic arterial dissection study
    (SPONTADS). J Am Chiropr Assoc2004; 41:18
    -21
  72. Carson JL, Willett LR. Toxicity of non-steroidal anti-inflammatory
    drugs: an overview of the epidemiological evidence.
    Drugs1993; 46:243
    -8[Medline]
  73. Page J, Henry D. Consumption of NSAIDs and the development of
    congestive heart failure in elderly patients. Arch Intern
    Med
    2000;160:777
    -84[Abstract/Free Full Text]
  74. Ernst E, Pittler MH. Alternative therapy bias. Comp
    Med
    1997;385:480
  75. Langworthy JM, le Fleming C. Consent or submission? The practice of
    consent within UK chiropractic. J Manipulative Physiol
    Ther
    2005;28:15
    -24[Medline]


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