Cassidy was the seminal article establishing the idea that there was no greater risk of vertebral dissection under chiropractic care in comparison to medical care for patients presenting with neck pain and headache. Kosloff was a repeat of essentially the Cassidy model using US data in a much larger pool and came up with even stronger results than Cassidy did. Finally, Church that was pub- lished in 2016 is very interesting because it comes from a team of neurosur- geons at the Penn State Institute of Neurosciences. They conclude that there is no causal relationship between cervical spine adjusting and vertebral artery is- sues. Now I'm going to take a step aside from that discussion and just look at some basic numbers so we get a handle on this thing. The natural history of vertebral artery dissection is approximately 1 case per 100,000 population per year. If we assume in the United States we have a population of 350 million people and this occurs at a rate of 1 per 100,000. That means on an annual basis in the US, there'll be 3,500 arterial dissection cases. Now if we make the assumption that we as chiropractors see the above 10% of the population, then that feeds 10% or 35 of 3500 or 350 of these phenomenon would likely cross paths with a chiropractor. Now this assumes a very perfect even distribution across the pop- ulation, a perfect distribution among the chiropractic community. We know that's not real. Just as an illustration, let's walk through this. Stay with me as I walk through this. We start off with 3500 cases in the United States. 10% of the patients see a chiropractor. 350 of these potentially have a chance to cross paths with a chiropractor. We know from the literature that the fatality rate with arterial dissection is ap- proximately 5%. 5% of 350 is about 17 to 18 cases. We know that in the natural history of this thing, that 17 to 18 of these cases will cross paths with a chiro- practor and a fatality situation whether the chiropractor ever touched them or not. It's important for us to have that background and that data and look at it. Then when we look at the Cassidy study, then we appreciate the fact that Cas- sidy found no greater incidents of vertebral artery dissection for persons under chiropractic care in comparison to persons under primary medical care. Kosloff and Elton repeated the same study, the same model, 2015. It came out with an even stronger result. I would suggest to you that Cassidy, Kosloff and Church are 3 pieces of litera- ture that every chiropractor should have. Every chiropractor should have read and every chiropractor should have virtually dedicated to memory. These are critical to understanding this problem in understanding the context of how it interfaces with the chiropractic world. Next slide, please. Now in terms of what to do differently in your office, let me review some of the basics that we know should be attended to. First relative to patient history. When a patient pre- sents with headache and neck pain, don't simply take it as headache and neck pain. Explore it more fully. Figure out how the patient is describing the pain.
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