Flaws in a Recent Vertebral Artery Dissection Study by Smith et al

The recent publication by Smith et al1Smith WS Johnston SC Skalabrin EJ Weaver M Azari P Albers GW et al.Spinal manipulative therapy is an independent risk factor for vertebral artery dissection.Neurology. 2003; 60: 1424-1428Crossref PubMed Scopus (220) Google Scholar in Neurology addressing vertebral artery dissection (VAD) represents another chapter of regrettable studies that, despite serious flaws that raise substantial questions as to their internal validity, go to great lengths to selectively disparage the advisability of performing cervical manipulations as a means of patient care while obscuring the larger picture.2Lee KP Carlini WG McCormick GF Walters GW Neurologic complications following chiropractic manipulation: a survey of California neurologists.Neurology. 1995; 45: 1213-1215Crossref PubMed Scopus (186) Google Scholar, 3Bin Saeed A Shuaib A Al-Sulaiti G Emery D Vertebral artery dissection: warning symptoms, clinical features and prognosis in 26 patients.Can J Neurol Sci. 2000; 27: 292-296Crossref PubMed Scopus (155) Google Scholar, 4Hufnagel A Hammers A Schonle P-W Bohm K-D Leonhardt G Stroke following chiropractic manipulation of the cervical spine.J Neurol. 1999; 246: 683-688Crossref PubMed Scopus (143) Google Scholar, 5Norris JW Beletsky V Nadareishvilli ZG Canadian Stroke Consortium.Can Med Assoc J. 2000; 163: 38-40PubMed Google Scholar, 6Rothwell DM Bondy SJ Williams JI Chiropractic manipulation and stroke: a population-based case-control study.Stroke. 2001; 32: 1054-1060Crossref PubMed Google Scholar Larger picture in this instance means (1) the well-documented benefits of this procedure; (2) the equally well-chronicled risks of alternatives to cervical manipulation (including the use of medications, which is deeply entrenched in our society and obviously far more prevalent than any applications of manipulation); and (3) any evidence showing that the mechanisms of cervical manipulation provide trauma to the vertebrobasilar system, leading to dissections in the normal vertebral artery (VA). The fact that the Smith et al1Smith WS Johnston SC Skalabrin EJ Weaver M Azari P Albers GW et al.Spinal manipulative therapy is an independent risk factor for vertebral artery dissection.Neurology. 2003; 60: 1424-1428Crossref PubMed Scopus (220) Google Scholar study has been so extensively and immediately propagated in the printed and televised media, in contrast to the many investigations that have supported cervical manipulations with no reports of substantial side effects,7McCrory DC Penzien DB Hasselblad V Gray RN Evidence report: behavioral and physical treatments for tension-type and cervicogenic headache. Foundation for Chiropractic Education and Research, Des Moines2001: 58-61Google Scholar, 8Boline P Kassak K Bronfort G Nelson C Anderson AV Spinal manipulation vs. amiltriptyline for the treatment of chronic tension-type headaches: a randomized clinical trial.J Manipulative Physiol Ther. 1995; 18: 148-154PubMed Google Scholar, 9Hoyt WH Shaffer F Bard DA Benesler JS Blankenhorn GD Gray JH et al.Osteopathic manipulation in the treatment of muscle contraction headache.J Am Osteopath Assoc. 1979; 78: 322-325PubMed Google Scholar, 10Nilsson N A randomized controlled trial of the effect of spinal manipulation in the treatment of cervicogenic headache.J Manipulative Physiol Ther. 1995; 18: 435-440PubMed Google Scholar, 11Nilsson N Christensen HW Hartvigsen J The effect of spinal manipulation in the treatment of cervicogenic headaches.J Manipulative Physiol Ther. 1997; 20: 326-330PubMed Google Scholar, 12Parker G Tupling H Pryor D A controlled trial of cervical manipulation for migraine.Aust N Z J Med. 1978; 8: 589-593Crossref PubMed Scopus (79) Google Scholar, 13Jensen IK Nielsen FF Vosmar L An open study comparing manual therapy with the use of cold packs in the treatment of post-traumatic headache.Cephalalgia. 1990; 10: 243-250Google Scholar, 14Nelson C Bronfort G Evans R Boline P Goldsmith C Anderson AV The efficacy of spinal manipulation, amitriptyline, and the combination of both therapies for the prophylaxis of migraine headache.J Manipulative Physiol Ther. 1998; 21: 511-519PubMed Google Scholar, 15Whittingham W Ellis WB Molyneux TP The effect of manipulation [toggle recoil] for headaches with upper cervical joint dysfunction: a pilot study.J Manipulative Physiol Ther. 1994; 17: 369-375PubMed Google Scholar, 16Mootz RD Dhami MSI Hess JA Cook RD Schorr DB Chiropractic treatment of chronic episodic tension type headache in male subjects: a case series analysis.J Can Chiropr Assoc. 1994; 38: 152-159Google Scholar, 17Droz JM Crot F Occipital headaches: statistical results in the treatment of vertebrogenic headache.Ann Swiss Chiropr Assoc. 1985; 8: 127-136Google Scholar, 18Vernon HT Spinal manipulation and headaches of cervical origin.J Manipulative Physiol Ther. 1982; 5: 109-112PubMed Google Scholar, 19Wight JS Migraine: a statistical analysis of chiropractic treatment.Chiropr J. 1978; 12: 363-367Google Scholar, 20Stodolny J Chmielewski H Manual therapy in the treatment of patients with cervical migraine.Man Med. 1989; 4: 49-51Google Scholar, 21Turk Z Ratkolb O Mobilization of the cervical spine in chronic headaches.Man Med. 1987; 3: 15-17Google Scholar, 22Bove G Nilsson N Spinal manipulation in the treatment of episodic tension-type headache.JAMA. 1998; 280: 1576-1579Crossref PubMed Scopus (123) Google Scholar, 23Davis PT Hulbert JR Kassak KM Meyer JJ Comparative efficacy of conservative medical and chiropractic treatments for carpal tunnel syndrome: a randomized clinical trial.J Manipulative Physiol Ther. 1998; 21: 317-326PubMed Google Scholar, 24Froehle RM Ear infection: a retrospective study examining improvement from chiropractic care and analyzing for influencing factors.J Manipulative Physiol Ther. 1996; 19: 169-177PubMed Google Scholar, 25Fallon J The role of chiropractic adjustment in the care and treatment of 332 children with otitis media.J Clin Chiropr Pediatr. 1997; 2: 167-183Google Scholar, 26Degenhardt BF Kuchera ML Efficacy of osteopathic evaluation and manipulative treatment in reducing the morbidity of otitis media in children.J Am Osteopath Assoc. 1994; 94: 673Google Scholar, 27Klougart N Nilsson N Jacobsen J Infantile colic treated by chiropractors: a prospective study of 316 cases.J Manipulative Physiol Ther. 1989; 12: 281-288PubMed Google Scholar, 28Wiberg JMM Nordsteen J Nilsson N The short-term effect of spinal manipulation in the treatment of infantile colic: a randomized controlled trial with a blinded observer.J Manipulative Physiol Ther. 1999; 22: 517-522Abstract Full Text Full Text PDF PubMed Scopus (101) Google Scholar, 29Reed WR Beavers S Reddy SK Kern G Chiropractic management of primary nocturnal enuresis.J Manipulative Physiol Ther. 1994; 17: 596-600PubMed Google Scholar, 30Yates RG Lamping DL Abram NL Wright C Effects of chiropractic treatment on blood pressure and anxiety: a randomized, controlled trial.J Manipulative Physiol Ther. 1989; 11: 484-488Google Scholar represents a major disservice to the American public, which threatens its access to the best alternatives in health care available. This critique will be discussed from 2 vantage points, in terms of both internal flaws and its analysis in the larger context. To begin, there is no indication that the 151 dissection cases were randomly identified; only the control patients were so chosen. The fact that some demographic features of the 2 groups such as age or dimensions of the arteries involved differ implies a more basic and global characteristic pertaining to arterial dissections that lies outside cervical adjustments, a point to be discussed in detail below regarding spontaneous arterial dissections. This would seem to be particularly true because the number of patients in which spinal manipulative therapy (SMT) has been reported to occur within 30 days is just 7, compared with 3 in the control group. The differential of just 4 individuals between the 2 groups is a paltry number, indeed, on which to base association, let alone any hint of causality over the extended period of 30 days. The fact that 2 patients actually experienced a stroke or transient ischemic attack immediately after SMT is clearly more compelling, but even here the authors fail to make a distinction between stroke and transient ischemic attack, which is far more benign. The fact that strokes could happen at the time of SMT, but not necessarily reflect it as a risk factor, will be discussed below. To one's amazement, the authors excluded a larger number of patients (8) because of “iatrogenic dissection with or without stroke” than actually were listed as having a dissection within 30 days of SMT.7McCrory DC Penzien DB Hasselblad V Gray RN Evidence report: behavioral and physical treatments for tension-type and cervicogenic headache. Foundation for Chiropractic Education and Research, Des Moines2001: 58-61Google Scholar In addition to making the low number of dissection cases within 30 days of SMT appear even more absurd, the authors raise the more serious question as to exactly what had caused the “iatrogenic dissections in the first place.” By most common definitions, iatrogenic is thought to have been brought on by medical interventions, a point to be discussed in more detail below. This study bases its conclusions only on the association of a single observation (presence of VAD) with previous events recalled by the patient. There are no baseline (control) readings to accompany this. One could argue that, without a control hospital laboratory finding (eg, elevated blood urine creatinine or presence of an arterial artery occlusion), the frequencies of possible precipitating events before the primary finding and the presence of arterial artery dissection are meaningless. By the reasoning put forth in this study, we would be forced to the rather strange conclusion that patients who recall cervical manipulation before their yielding elevated urine creatinine, for example, could be used as evidence that this form of intervention is necessarily associated with the aberrant blood chemistry levels obtained. Other than SMT, the authors have produced no indication that cervical manipulations were administered to every patient listed, so their attempts to link VADs and manipulation become that much more problematic. Until an actual relationship is struck between the location and actual number of adjustments and vertebral dissections is given and until some light can be shed on the mechanisms that could produce this result, any speculation of causality of manipulation and arterial dissection gleaned from the data in this study must be greeted with only the most extreme skepticism. Furthermore, the authors appear to have given little consideration to the fact that cerebrovascular accidents (CVAs) appear to be a cumulative rather than a traumatic event. 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