By Robert A. Hayden, D.C., Ph.D., FICC
There has been much written about vertebral artery stroke risk and chiropractic manipulative therapy (CMT). VAS has a mortality exceeding 85 percent, and the survivors typi- cally experience dysfunction in multiple body systems due to involvement of the brainstem and cerebellum, so hemi- or quadriplegia, ataxia, dysphagia, dysarthria, visual distur- bances, and cranial neuropathies are possible(1). Making the diagnosis based on clinical presentation may be challenging due to the variability of manifestations.
The Cassidy study was the largest and most comprehen- sive on the issue of VAS. The focus was on 818 VAS events that appeared in over 100 million person-years. The authors found that people who experienced VAS were no more likely to have seen a chiropractor than they were to have seen their primary care provider (PCP). They concluded that VAS is
a rare event, and that CMT offered no excess risk. Further, the Cassidy study suggests that risk of VAS associated with CMT and PCP visits are most likely because many VAS patients present with neck pain and headaches(2).
The physical presentation is variable, but complicating the early recognition of VAS is the lack of any de nitive or reliable orthopedic or vascular physical exam procedure to herald its presence(3). Signs and symptoms must be interpret- ed in the context of a patient’s total medical history, after which appropriate imaging may be considered(4).
Jennifer is an athletic young lady in the prime of her 27-year life. She is well known to our clinic, having been treated for lumbar issues previously. Her medical history is largely non- contributory but for the usual childhood ailments. She is gravida II para II and has custody of her two children. She is a smoker, but denies recreational drugs. There is signi - cant stress on her as a single mother, as she is in the nal stages of a contested divorce.
She has a history of cervicalgia and cephalgia that in- tensi es with stress. Ergonomic stress was thought to be an issue, as she works in a health care facility doing the billing on a computer.
She presented on Aug. 14 with an 8/10 headache, de- scribed as sharp, aching, throbbing, and stabbing, radiating from the upper cervical spine to the right parietotemporal area. Pain was aggravated by virtually any movement, in- cluding standing, walking, looking up or down, and some- what alleviated by ceasing all motion.
Palpation revealed signi cant myospasms centered at C2 on the right. There was a loss of lordotic curve, possibly antalgic or re ective of spasticity. Foraminal compression and Valsava tests radiated pain to the temporal area, while cervical distraction reduced it slightly. Her scalp was sore
to touch. AP and lateral cervical lms showed a slightly reduced lordotic curve, good bone density, adequate and symmetric disc spacing, intact dens with 2 mm ADI space and unremarkable soft tissue.
A diagnosis of tension headache, non-intractable (G44.209) was made, and she was treated with CMT at C2 and C6 with Diversi ed adjustments, T1 with a Thompson anterior adjustment. Electrotherapy* was used to reduce myospasm and pain. A frozen gel pack was placed on the cervico-occipital area for 20 minutes with Jennifer in recum- bent position. She reported dramatic, though incomplete, relief.
A second headache occurred on Sept. 10. Clinical pre- sentation resembled the earlier episode except the severity was much less. The divorce was complete, and her affect was lighter.
On Nov. 21, she reported to the clinic with another severe headache, but an alteration in the description of the headache. Jennifer stated that when she turned her head to the right, she felt a “pop” and subsequently lost visual acuity, felt dizzy and experienced some nausea (without vomiting) for two to three hours before slow recovery. Walking was dif- cult due to the dizziness until she recovered.
The possibility of vertebra-basilar insuf ciency could not be ignored, and was discussed with her in detail. Upon deeper questioning, Jennifer revealed a key piece of history she had not considered important before: her mother had similar headaches and had a stroke at age 36. Further, her
grandmother had a stroke by age 39. Jennifer did not relish the expense of an MRA, as it would be part of her deduct- ible, but at length, when she realized the reason for my con- cern for her safety, she agreed. The order was sent to Grif n Imaging, and the radiologist was called and informed of the speci c concern.
The MRA was obtained on Nov. 21. The radiologist described the artery depicted above as hypoplastic, versus dissecting, in the distal segment. Carotid arteries were un- remarkable. Given the staccato of signs and symptoms over the previous week, I could not agree that the artery involved was not damaged and merely anomalous.
The incidence of anatomical anomalies in the vertebra- basilar system is not clear. One study in North America suggests 1 percent, while Asian studies indicate 10 percent. A Polish study showed as high as 20 percent(5). Whatever the incidence, when examining an upper cervical complaint with headaches, it is worth remembering that our assump- tions about patients’ anatomy may not be real.
On Nov. 26, a telephone consultation with a neurosur- geon resulted in her being seen the following morning. The neurosurgeon disagreed with the radiologist upon seeing the scan, stating his opinion that the artery was dissecting. She was anticoagulated and monitored. He urged her to have a CT angiogram (CTA), but she declined for nancial reasons.
I called her periodically to see how she was doing, and in one of those calls, she made another stunning revelation of history related to causality. Just prior to the onset of VAS signs, her ex-husband held her by the neck against a wall with her feet dangling, with strangulation, cervical fracture, or collapse of the airway all imminent until her children intervened.
Over the ensuing weeks, she slowly became less symp- tomatic. She curtailed her activities, but never missed work. There was a subsequent episode of dizziness on a Friday
MRA with cursor pointing to cessation of ow, distal right vertebral artery.
evening the following February. She was advised to get to a hospital and the triage nurse was called and informed of the history and potential issues. A CTA was performed at that time that showed a patent right vertebral artery with “focal area of calci cation on distal end of right vertebral artery, unusual for age.” This may represent scar tissue.
Thus, the artery recanalized. She never suffered a stroke or any permanent damage. Headaches slowly returned to her usual baseline occasional tension issues.
Vertebro-basilar strokes continue to be hurled at the chiro- practic profession despite the lack of evidence linking adjust- ment to causality. This case involves a continually unfolding history that included risk factors of female sex, cigarette smoking, family history and domestic abuse. Another fac- tor here is anatomical anomaly that may be part of the picture. Indeed, every patient we touch may have anatomi- cal “quirks” that cannot be discerned without imaging. As doctors, we must stay vigilant to every nuance of subjective, objective, verbal and non-verbal communication as well as our physical exam ndings.
2. Cassidy, J David DC, PhD; Boyle, Eleanor PhD; Côté, Pierre DC, PhD; He, Yaohua MD, PhD; Hogg-Johnson, Sheilah PhD; Silver, Frank L. MD; Bondy, Susan J. PhD Risk of Vertebrobasilar Stroke and Chiroprac- tic Care: Results of a Population-Based Case-Control and Case-Crossover Study Spine Volume 33(4S), February 15, 2008 pp S176-S183
3. Cote P, Kreitz B, Cassidy J, Thiel H: “The validity of the extension-rotation test as a clinical screening procedure before neck manipulation: a secondary analysis.” JMPT 1996;19:159.
4. Gupta, J D http://www.clinicaladvisor.com/imaging/vertebrobasilar-insuf - ciency/article/608768/
5. Fortuniak J; Bobeff E; Polguj M; Kosla K; Stefanczyk L; Jaskólski DJ Anatomical anomalies of the V3 segment of the vertebral artery in the Polish population. Eur Spine J. 2016; 25(12):4164-4170