Although I’ve been telling my patients about this potentially serious health threat for many years, I’d also like to warn my readers about it as well. Especially since I came across the warning again the other day while reading research studies in the American Heart Association (AHA)’s journal, Stroke.  The warning is of particular importance to those of you who get cervical spine manipulations regularly.

Neck Manipulations and the Risk of Stroke

Spinal manipulations, done by chiropractors and other health practitioners, can be beneficial in treating back pain and other musculoskeletal injuries.  Generally, there is low risk of injury if you go to a certified, experienced practitioner.  Yet, cervical spine (neck) manipulations can be more problematic.  Even though the occurrence of stroke from neck manipulations is low, the serious risk is felt, by many doctors and researchers, to outweigh any of the possible benefits.

Having your neck manipulated puts you at high risk for something called a cervical dissection – a tear, rip, shearing of the 2 vertebral basilar arteries that run in the back of your neck. Rotating, putting pressure on, or suddenly “cracking” the neck in certain ways may cause a tear to one of these arteries.  Bleeding may occur and/or a clot.  If that clot breaks off, another condition called a vertebrobasilar artery (VBA) stroke can occur which can leave you seriously mentally and physically impaired.

Although this warning is not new (VBA’s from neck manipulations have been noted as far back as the 1930’s with chiropractic treatments),  the practice is still widespread today. Yet, when patients visit an ER, or their medical doctor, with stroke symptoms they almost always don’t report the preceding neck manipulation.  They don’t make the connection between their stroke symptoms and their neck manipulation.  Doctors, in turn, don’t consider the neck manipulation as the likely cause and look to other factors. As such, the practice of neck manipulation “gets off the hook” as a practice associated with stroke.

Some studies headed by chiropractors  (who do 90% of neck manipulations) counter that patients may come in with an undiagnosed VBA already in progress.  The patient may be there seeking relief of a headache and/or stiff neck when, in fact, they have a stroke in progress.  So, proceeding to cervical spine manipulation will only worsen the patient’s condition.  Other professionals argue back that the diagnosis of the stroke-in-evolution symptoms should have been recognized first and the patient referred immediately to an Emergency Room without any neck manipulation occurring.

For these reasons, the certainty of cause and effect of neck manipulation leading to stroke is not well documented. Yet, the motions of your neck that occur during neck manipulation can put the 2 vertebral arteries that run through your vertebral column at higher risk for injury.  Sudden, jerking movements of the neck, hyperextension, hyperflexion, or rotation of the neck, can stretch and stress the inner tissues, and impact the position of the disks of the spine.

While this is true for patients of all ages, it is particularly true, and of concern, in older, over-50 age patients who likely have some degenerative changes of the cervical spine.  Fragile cervical spinal disks may chip during vigorous manipulations and may impact the nearby arteries.

People who have atherosclerotic plaque buildup in their coronary arteries and/or have diagnosed coronary artery disease, are also at higher risk for the same condition in the VBA’s. This also elevates risk of stroke.

The Stroke report reveals that patients should be warned of these risks before allowing manipulation of their cervical spine by any health practitioner.  If you’ve ever had a cervical spine manipulation, were you informed of these risks?

An earlier study done in 2012, cited in the British Medical Journal revealed that its authors felt that neck manipulation “may carry the potential for serious neurovascular complications” and that the practice is “unnecessary and inadvisable”.

Should you have a cervical spine manipulation and have certain symptoms afterwards, or even a few days later, you’ll want to contact your doctor, an emergency room or urgent care, immediately.  Be sure to tell them that you’ve had a neck manipulation recently so that they can do specific tests to determine if the VBA’s have been affected. The following symptoms may indicate a possible VBA stroke in evolution:

1. Pain, stiffness, burning in your neck.

2. Headache.

3. Dizziness/vertigo.

4. Vision changes – seeing double and/or rapid eye movements.

5.  Trouble walking with unsteadiness.

6.  Slurred speech or inability to access words.

7.  Nausea and vomiting.

Protect Your Neck From Injury

Of course there are other situations where your neck can become injured and VBA damage may occur that can bring on a stroke. Most of these are accidental and include sports injuries, car/bike accidents, falls, etc.  Doing your best to do activities safely and with protective headgear, if indicated, can help prevent this type of injury.  Here are some things you can do everyday to protect your neck from strains and injury. They include the following:

1.  Don’t hyperextend or hyperflex your neck.  Don’t look up, down, or sideways for prolonged periods of time.  These “hyper” movements can also happen from sleeping on too high, or too low pillows. Also, falling asleep sitting up, or lying down, with your neck hyperextended to one side can cause painful muscle strains and nerve injuries.

2.  Maintain good posture while working. Sit up straight with your head aligned, instead of slouched down with your chin leading forward. Poor posture puts a strain on neck muscles and your entire spine. Sitting too long can also throw the cervical spine out of alignment causing pain and poor mobility.

3.  Maintain good sleep mechanics.  If you’ve ever woken up with a stiff neck from sleeping in a contorted position, you’ll know how easy it is for your neck to become strained during sleep.  Sleep with a pillow under your knees while you lie flat on your back to keep your neck aligned properly.  If you like to sleep on your side, you can also put a pillow between your knees to take pressure off your spine and keep it aligned. Try not to fall asleep sitting up without support for your neck.

4. Drink Enough Water.  Cervical spine disks, as well as the disks of the rest of your spine, are about 80% water.  Dehydration causes the disks to dry out and rub against each other. Be sure to drink enough water.

In summary, many people claim to have gotten relief of neck pain, poor range of motion, etc, with neck manipulations.  But, I’d have to say I agree with the authors of both the journal studies mentioned above.  I feel the risks associated with it far outweigh any real, lasting therapeutic value.

Of course, chiropractors have a completely different view and still recommend cervical spine manipulation as a valuable treatment.  I’ll let you be the judge.  But, you may want to read more at the references listed below before you make your decision.

Stay Well,
Ron Blankstein, M.D.

Neck Manipulation Risk vs Benefit, http://www.sciencebasedmedicine.org/neck-manipulation-risk-vs-benefit/

Neck Manipulation May Be Associated with Stroke, http://www.sciencedaily.com/releases/2014/08/140807163631.htm

Should Spinal Manipulation for Neck Pain Be Abandoned? http://www.sciencedaily.com/releases/2012/06/120607190827.htm

Vertebrobasilar  insufficiency http://www.ucdmc.ucdavis.edu/vascular/diseases/vertebrobasilar.html