• Wilder J
• Demetrious J
• Conway P
• Graber D
• Tuchin P

• Carotid Artery, Internal, Dissection
• Informed Consent
• Open Access Document
• Stroke

Background: A recent article by Brown and Lehman [2025] advocates for the universal inclusion of cervical artery dissection (CAD) and stroke risk in informed consent for cervical spine manipulation (CSM). Their narrative review appears to rely on anecdotal and low-level evidence, raising concerns regarding its validity and potential impact on clinical and legal standards.

Objective: To critically evaluate the scientific, ethical, and legal foundations of Brown and Lehman’s 2025 recommendations and to propose alternative recommendations based on current evidence-based standards and informed consent jurisprudence.

Methods: A detailed appraisal of the papers cited in Brown and Lehman's review was conducted. High-level evidence, including epidemiologic studies, systematic reviews, and biomechanical analyses, was contrasted against the narrative sources used by the authors. Legal and ethical standards surrounding informed consent across U.S. jurisdictions were also reviewed.

Results: Brown and Lehman's article may exhibit confirmation bias, selective citation, and a reliance on case reports, commentaries, and narrative reviews that do not support the concept of universal informed consent related to CSM, CAD, and stroke. Major epidemiological and biomechanical studies appear to contradict their claims. Their review did not include contrary evidence, may have misinterpreted key studies, and contained logical inconsistencies. Legal analysis reveals that informed consent standards vary by jurisdiction, with no legal mandate for blanket disclosure of statistically unproven risks such as CAD post-CSM.

Conclusion: The conclusions presented in the Brown-Lehman review article appear to be based primarily on low-level evidence, including narrative reports, commentaries, and case series, which may not meet the threshold necessary to guide clinical standards or establish legal norms. Their recommendation for universal disclosure of CAD risk in informed consent, despite the absence of causative evidence, raises important considerations regarding clinical relevance and medicolegal implications. Informed consent practices should be aligned with the best available evidence, applicable jurisdictional statutes, and professional standards. Chiropractors are encouraged to consult current clinical guidelines, review applicable laws and rules, and seek legal counsel when determining appropriate disclosures within the informed consent process.

Author keywords: Cervical spine manipulation, cervical artery dissection, informed consent, chiropractic, medico-legal standards, narrative review, causation, stroke risk

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