Going to a chiropractor has become an accepted part of medical care, with about 15 percent of adults in the United States visiting one every year. Although critics claim the field lacks scientific validity, chiropractic treatments provide many people with pain relief, and a vast majority take place without incident.
But given the delicate nature of the spine — particularly the upper vertebrae of the neck — the consequences of complications can be devastating. One injury in particular, arterial dissection, in which blood vessels that supply blood from the heart to the brain are torn, is of high concern. In some cases, a patient may be unaware that an injury has occurred and the damage heals on its own. In others, a tear in the artery wall can cause a clot to form and result in a stroke and even death.
It is unclear how common the complication is following chiropractic care — one estimate says that an arterial dissection occurs in one out of 1,000 neck manipulations, another says one in 5.8 million (three of the four authors on that study worked for chiropractic associations).
Because of the severity of the injury, though, many spine specialists warn that chiropractic manipulation of the neck can be dangerous. Here’s what to know if you’re considering the treatment for your neck pain.
The risks of neck manipulation
Chiropractic manipulations involve high velocity, low amplitude movements of the spine. “We take the joint to its limited range, and we do a very quick push on that joint — that’s the high velocity aspect,” said William Lauretti, a professor of integrated chiropractic therapies at Northeast College of Health Sciences and a spokesman for the American Chiropractic Association. “But we’re moving it for a very, very small range — that’s the low amplitude.”
The concern over arterial tears is specific to manipulations of the neck. That’s partly because the neck is more mobile and thus more susceptible to injury; the torso is protected by the ribs, so the lower back doesn’t rotate as much. Major arteries that distribute blood from the heart to the brain are also threaded through the neck vertebrae, making the blood vessels there more vulnerable.
“When you turn the neck side to side, those vessels will rotate within the bone,” said Dr. Betsy Grunch, a neurosurgeon based in Gainesville, Ga. “If you turn your head quickly or rotate quickly, like a car accident or manual manipulation or sport, the vessel can get abruptly torqued.”
The most common symptoms of an arterial dissection are headaches, dizziness and vertigo; weakness, numbness or paralysis on one side can also occur.
In a widely publicized case last year, a 28-year-old graduate student at Georgia Southern University named Caitlin Jensen became dizzy and nauseated after a chiropractor manipulated her neck. The chiropractor called 911 and, at the hospital, doctors determined Ms. Jensen had tears in four blood vessels, resulting in a stroke and cardiac arrest.
Nine months later, Ms. Jensen has just started to be able to speak again, though she still cannot walk or swallow. The right side of her body was paralyzed by the injury, as were her vocal cords. Her mother, Darlene Jensen, told The New York Times that her daughter is making progress in her recovery, but that it is slow going. “It’s very encouraging when we have really good days and good therapy sessions,” Darlene Jensen said. “But then other days, when she’s struggling through something, it’s very frustrating and emotional because she just wants her life back.”
It’s virtually impossible to know how common cases like Caitlin Jensen’s are, because “there is no monitoring system to record such events,” Edzard Ernst, an emeritus professor of complementary medicine at the University of Exeter in Britain, wrote in an email. “Many patients sue the chiro and settle out of court. Many patients have a stroke and might never connect it to the manipulation.” (Darlene Jensen said the insurance company for the chiropractor paid the malpractice claim without disputing it.)
One study of over 50,000 cervical spine manipulations found that about 16 in 1,000 resulted in fainting, dizziness and lightheadedness. Other researchers have tried to assess the risk by working backward: finding people who experienced an arterial dissection and determining whether a significant proportion recently had their necks manipulated by chiropractors. For example, a small study found that 15 percent of arterial dissections occurred after a sporting activity, and 11 percent followed a chiropractic manipulation.
Several studies have shown the risk of arterial dissection and stroke to be three to 12 times higher in people who’ve recently had a neck manipulation, according to a review by the American Heart Association’s Stroke Council.
To Dr. Grunch, who treats one or two patients with the injury every year, the connection is clear: “Arterial dissection is a known complication of spinal manipulation.” So even though the risk is rare, Dr. Grunch strongly advises against having your neck manipulated by a chiropractor.
Dr. Alan Hilibrand, the chief of spine surgery at the Rothman Orthopaedic Institute in Philadelphia and a former president of the Cervical Spine Research Society, said that “there’s no smoking gun” in the scientific literature tying chiropractors to arterial dissections. But, he added, “I’m very uncomfortable” with it, and he cautioned patients that neck manipulations could be dangerous.
Are chiropractors being unfairly blamed?
Many chiropractors dispute the claim that their treatments can cause such significant harm. They point to review papers that have found no link between neck manipulations and arterial tears and research showing that people who visited a primary care doctor were just as likely to have a stroke in the weeks following the appointment as people who saw a chiropractor.
Instead, they say, a visit to a chiropractor is more often the result of an arterial dissection, not the cause of it.
“These patients have an artery that’s been injured in some way,” causing neck pain and headaches, Dr. Lauretti said. “Some of them go to their primary care doctor, some of them go to their chiropractor. If the patient has a stroke following a visit to the chiropractor, the chiropractor gets blamed.”
When a patient goes to a chiropractor for neck pain, Dr. Lauretti added, the practitioner must do a thorough examination to rule out any “red flags” before performing a neck manipulation.
Acknowledging the vulnerability of the neck, some chiropractors take a more conservative approach when treating the area. Philip Cordova, a chiropractor in Houston, said that in his office, they don’t rotate the neck very far in an effort to minimize the chance of injury. Some patients also tell him, “‘I don’t want my neck adjusted,’ and that’s not a problem,” Dr. Cordova said. “We work around that.”
The risk of complications from chiropractic treatment of other parts of the spine is extremely low, and some research suggests that the practice is as beneficial as home exercise, physical therapy and medication. As a result, many orthopedic surgeons and neurosurgeons — including Dr. Grunch and Dr. Hilibrand — will occasionally refer patients to chiropractors for issues that aren’t related to the neck.
“I think incorporating chiropractic treatment as a part of a conservative treatment plan is totally appropriate,” Dr. Grunch said.
Dr. Hilibrand agreed. “I won’t hesitate to send a patient to someone who I know,” he said. “Many of these people provide very good care.”
So what should you do about neck pain?
Accidents stemming from chiropractic manipulations are very uncommon, but because of their potential severity, it may be best to avoid the treatment if you are experiencing neck pain. Fortunately, there are several other options available.
The first line of treatment Dr. Hilibrand recommends is over-the-counter pain medications combined with physical therapy. “Eighty percent of the people with neck pain will get better after the first six weeks with just those two interventions,” he said.
If pain persists, Dr. Hilibrand said you might want to consider alternative therapies, like acupuncture or a massage technique known as myofascial release. You could even pay a visit to the chiropractor for gentler manual therapy or traction, which involves less aggressive, more controlled stretches or movements. (In instances of spinal compression, though, he said people should steer clear of chiropractors altogether.) Steroid injections can also be helpful in reducing pain and inflammation.
In some instances, surgery may be required as a last resort, but experts say that noninvasive therapies can often resolve the problem. “Most patients with acute neck or acute back pain don’t need surgery,” Dr. Grunch said. “They just need a good, well-balanced conservative treatment plan.”