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February 2, 2017 Response to letter from Gerard W Clum, D.C. regarding case report: Vertebral artery dissection after a chiropractic neck manipulation, Proceedings (Baylor University Medical Center) 2015; 28 (1): 88- 90. Dear Dr. Clum, We appreciate your letter alerting us to the discrepancy between the estimated frequency of vertebral artery dissection following spinal manipulation and the reference cited in our discussion. We did cite the wrong reference in this portion of our discussion of this case report. The original reference for this number comes from a paper written by Andrew Vickers and Catherine Zollman entitled “The manipulative therapies: osteopathy and chiropractic”. This was published in the British Medical Journal in 1999; they provide estimates for severe adverse effects ranging from 1 in 20,000 patients to 1 in 1,000,000 patients undergoing cervical spine manipulation. 1 These authors provided no reference for those numbers. Timothy Mann quotes the same number range and includes an estimate as high as 1 in 4,500 based on abstract from JW Dunne presented at a meeting in 2000. 2,3 Rothwell and colleagues have provided an estimate based on a population-based case-controlled study published in Stroke in 2001. These authors suggest that 1.3 vertebral artery accidents occur per 100,000 persons aged <45 years within 1 week of manipulation. The 95% confidence interval for this estimate is 0.5-16.7 per 100,000. 4 The upper boundary of this confidence interval translates into 1.7 accidents per 10,000 manipulations. Consequently, our second review of this literature indicates that these numbers are difficult to obtain, and that there is a wide range in these estimates. The numbers 1 in 20,000 to 1 in million seem reasonable even though this range is extremely broad. The important point in this case report is that clinicians need to think about cervical spine trauma in young patients who present with vertebral artery dissections or aneurysms.
1. Vickers A, Zollman C. ABC of complementary medicine. The manipulative therapies: osteopathy and chiropractic. BMJ (Clinical research ed) 1999; 319 (7218): 1176-9.
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