Manipulation of the Cervical Spine

Original Editor - Riccardo Ugrin

Top Contributors - Riccardo Ugrin and Blessed Denzel Vhudzijena  

Introduction[edit | edit source]

The cervical spine is often a cause or a contributing cause for pain in the upper limb, in the head or in the dorsal region of the back. It is important to analyse the effectiveness and the efficiency of the manipulation techniques for manage pain. The safety and the contraindications of manipulation of the cervical spine were deeply analysed in the last decades, in order to proof the High Velocity Low Amplitude Thrust (HVLAT) as a technique to provide pain relief.

Description[edit | edit source]

The HVLAT of the cervical spine it is a technique, not a treatment. A patient can be

The clinical diagnosis, the functional and segmental restriction of range of movement and the anamnesis represent the usual care of the evaluation.

The ability to perform a successful adjustment with HVLA therapy will, at times, elicit a "popping" sound. The restrictive barrier should be engaged entirely before applying the thrust. Finally, after executing the HVLA technique, the practitioner should reassess the range of motion and the somatic dysfunction treated. A successful result would lead to approximately 70% or greater return in the restricted range of motion and/or relief of pain. [1]

Contraindications[edit | edit source]

Before doing a HVLAT of the cervical spine it is necessary proceed with a clinical anamnesis. The research of contraindication it is necessary to avoid advers neurologic and orthopedic events. The following are the major contraindications found for cervical spine manipulations.:

  • Patient refusal or worsening of symptoms with previous manipulations
  • Fractures of vertebrae: it is possible to have a fracture of vertebrae if a major trauma occours (car accident or an head injury) with cervical pain in standing position and with/without nervous system symptoms to the limbs. To make diagnosis of fracture to the cervical spine a X-ray evaluation is needed. With symptoms and without recent X-ray evaluations it is possible to discriminate the risk of fractures applying the Canadian C-Spine Rule (CCR)[2]: the CCR is a decision-making tool used to determine when radiography should be utilized in patients following trauma. It is not applicable in non-trauma cases, if the patient has unstable vital signs, acute paralysis, known vertebral disease or previous history of Cervical Spine surgery and age <16 years. 
  • Acute whiplash
  • Dislocation of the cervical vertebrae
  • Acute disc herniation. In presence of signs or symptoms of neurological impairment or radiculopathy it represent a contraindication to HVLAT. However Murphy (2006) concluded that is unlikely that a HVLAT to cervical spine would cause a healthy disc to become herniated, but it is possible that the manipulation caused preexisting asymptomatic disc herniation to become symptomatic.[3] It may be reasonable to recommend MRI or CT imaging to rule out in case of significant risk factors.[4]
  • Down syndrome[5]
  • Chiari malformation
  • Tumor/bony malignacy and Ostheoporosis. It may be reasonable to recommend MRI or CT imaging to rule out in case of significant risk factors.[4]
  • Recent cervical surgery: an HVLAT can force the arthrodesis between vertebrae causing paralysis.
  • Rheumatoid arthritis: the sinovial joints are affected in Rheumatoid arthritis. The trasverse ligament of the atlas is in close relationship with the atlanto-axial joint. The degeneration of the sinovial tissue of the joint could affect the trasverse ligament[6]. Because of that the dens is no longer anchored and an HVLAT can move up the cervical spine, causing paralysis.
  • Vascular Pathologies of the Neck: the signs and symptoms of a vascular pathology of the neck are usually the 5D and the 3N:
    1. Dysphagia,
    2. Dysarthria,
    3. Diplopia,
    4. Dizziness,
    5. Drop Attack.
    6. Nistagmo,
    7. Numbness,
    8. Nausea

Cervical Arterial Dysfunction and Cervical Spine Manipulation[edit | edit source]

In the last decades clinicians were asking if there are some relations between the Cervical Arterial Dysfunction (CAD) and Cervical Spine Manipulation. However it is not actually demonstrate that the manipulation can cause a Cervical Arterial Dysfunction (CAD). Otherwise it is possible that a patient can actually be visited during an acute dissecation of the vertebrobasilar arterial system (VBA)[7]. It represent a relative contraindication if there is a previous diagnosis of VBA insufficiency[1]

  • Lee at al (1995) in a 2 years retrospective study of CAD and HVLAT found a deep connection where 21% of patients had neurological signs occoured after a chiropratic manipulation.[8]
  • However Klougart et al (1996) did a 10 years retrospective study on the incidence of CAD after a chiropratic HVLAT finding one case of CVA appeared for every estimated 1.3 million cervical treatment sessions.[9]
  • Conversely there is a study that estimated the force needed to disrupt the Vertebrobasilar Artery (VBA). They concluded that under normal circumstances, a single typical (high-velocity/low-amplitude) SMT thrust is very unlikely to mechanically disrupt the VBA. [10] Indeed a review of literature demonstrate that HVLAT of the cervical spine performed by trained clinicians does not appear to place undue strain on the vertebral artery, and thus does not seem to be a factor in vertebrobasilar injuries.[11] Similarly a recent systematic review found no epidemiologic studies to support the hypothesis that HVLAT of the cervical spine is associated with an increased risk of internal carotid artery dissection[12].
  • Cassidy et al. in 2008 found no excess risk of VBA stroke associated chiropractic care compared to primary care. The increased risks of VBA stroke associated with chiropractic visits is likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke. [7]
  • In a more recent study Murphy[13] found that current evidence suggests that HVLAT of the cervical spine is associated with but not causally related to CADs, and it can be expected that patients with undetected vertebral artery dissection and stroke (VADS) will continue to see chiropractic physicians and it is essential that focused attention be made in an attempt at detection of this uncommon but potentially devastating disorder.
  • Controversy surrounds the dependability of vertebral artery testing before manipulation, with studies concluding that it is not possible to conclude the accuracy of pre-manipulative tests. Studies may indicate that the pre-manipulative tests do not seem reliable as a screening procedure[14].  Nevertheless, the possibility of vertebral artery disease must be entertained before performing cervical manipulation[1].

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 Elder B, Tishkowski K. Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae. [Updated 2021 Oct 10]. In: StatPearls [Internet].
  2. ↑ Stiell IG, Wells GA, Vandemheen KL, Clement CM, Lesiuk H, De Maio VJ, Laupacis A, Schull M, McKnight RD, Verbeek R, Brison R. The Canadian C-spine rule for radiography in alert and stable trauma patients. Jama. 2001 Oct 17;286(15):1841-8.
  3. ↑ Murphy DR. Herniated disc with radiculopathy following cervical manipulation: nonsurgical management. Spine J. 2006 Jul-Aug;6(4):459-63.
  4. ↑ 4.0 4.1 Oppenheim JS, Spitzer DE, Segal DH. Nonvascular complications following spinal manipulation. Spine J. 2005 Nov-Dec;5(6):660-6; discussion 666-7. .
  5. ↑ Ali FE, Al-Bustan MA, Al-Busairi WA, Al-Mulla FA, Esbaita EY. Cervical spine abnormalities associated with Down syndrome. Int Orthop. 2006;30(4):284-289.
  6. ↑ Vetter M, Oskouian RJ, Tubbs RS. “False” ligaments: a review of anatomy, potential function, and pathology. Cureus. 2017 Nov;9(11).
  7. ↑ 7.0 7.1 Cassidy JD, Boyle E, Côté P, et al. Risk of Vertebrobasilar Stroke and Chiropractic Care: Results of a Population-Based Case-Control and Case-Crossover Study. Eur Spine J. 2008;17(Suppl 1):176-183.
  8. ↑ Lee KP, Carlini WG, McCormick GF, Albers GW. Neurologic complications following chiropractic manipulation: a survey of California neurologists. Neurology. 1995 Jun;45(6):1213-5.
  9. ↑ Klougart N, Leboeuf-Yde C, Rasmussen LR. Safety in chiropractic practice, Part I; The occurrence of cerebrovascular accidents after manipulation to the neck in Denmark from 1978-1988. J Manipulative Physiol Ther. 1996 Jul-Aug;19(6):371-7.
  10. ↑ Symons BP, Leonard T, Herzog W. Internal forces sustained by the vertebral artery during spinal manipulative therapy. J Manipulative Physiol Ther. 2002 Oct;25(8):504-10.
  11. ↑ Herzog W, Leonard TR, Symons B, Tang C, Wuest S. Vertebral artery strains during high-speed, low amplitude cervical spinal manipulation. J Electromyogr Kinesiol. Oct 2012;22(5):740-746.
  12. ↑ Chung CL, Cote P, Stern P, L’Esperance G. The Association Between Cervical Spine Manipulation and Carotid Artery Dissection: A Systematic Review of the Literature. J Manipulative Physiol Ther. Jan 3 2014.
  13. ↑ Murphy DR. Current understanding of the relationship between cervical manipulation and stroke: what does it mean for the chiropractic profession?. Chiropr Osteopat. 2010;18:22. Published 2010 Aug 3.
  14. ↑ Hutting N, Verhagen AP, Vijverman V, Keesenberg MD, Dixon G, Scholten-Peeters GG. Diagnostic accuracy of premanipulative vertebrobasilar insufficiency tests: a systematic review. Man Ther. 2013 Jun;18(3):177-82.
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