• Nunn NR
• Battiston A
• Breeze S
• Harrison J

• Manipulation, Cervical
• Open Access Document
• Vertebral Artery Dissection

Background: To the authors’ knowledge, this is the first paper to conduct a scoping review of the literature examining the reported ratios between cervical spinal adjustments or manipulation (CeSAM) and cervical vascular accidents (CeVA). This review highlights how several authors have cited pre-existing ratios in their own calculations, sometimes without recalculating based on primary data. Furthermore, the paper addresses the diverse and often inconsistent acronyms used in the literature, contextualising them within their relevant anatomical structures, particularly in relation to the cervical spine and the Circle of Willis.

Intervention: Sixteen distinct acronyms associated with cervical vascular accidents (CeVA) have been identified in the literature. This paper provides an anatomical overview of the cervical vascular system—focusing on the vertebral and carotid arteries, and the Circle of Willis—followed by an analysis of how these acronyms have been applied. All peer-reviewed publications presenting incidence or risk ratios linking CeSAM to CeVA were reviewed and synthesised. A summary table presents the primary practitioners involved in each study alongside the associated ratios reported.

Outcome: This review presents the currently available literature reporting ratios or frequencies of cervical vascular accidents in association with cervical spinal manipulation. It distinguishes between primary ratios, calculated directly from empirical data, and secondary ratios, where authors have cited figures from prior studies. Reported incidence rates in the literature vary widely, ranging from 1 per 4,500 treatments to 1 per 5.85 million manipulations. These figures are contrasted with the spontaneous incidence of cervical artery dissection in the general population, estimated between 1 and 3 per 100,000 people annually, highlighting the uncertainty and inconsistency in the data.

Conclusion: Cervical artery dissection, although rare, remains the most serious reported iatrogenic complication associated with cervical spinal manipulation. The current body of literature suggests a weak association between CeSAM and CeVA, with no definitive causal link established. Nonetheless, the frequency and interpretation of reported ratios vary widely. Moreover, the literature tends to emphasise adverse events, with insufficient reporting of positive outcomes or appropriate referrals made by Chiropractors and manual therapists. In light of the Montgomery ruling (2015), it is no longer a matter of establishing causation alone; all available information, risks, uncertainties, and benefits, must be disclosed to patients, placing the practitioner in a clearly defined advisory role.

Author keywords: Cervical vascular accident; carotid artery accident; vertebral artery accident; cervical chiropractic adjustments, osteopathic, or physiotherapy manipulation; CVA.

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