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Cervical Spine Adjusting Cervical Spine Adjusting and the Vertebral Artery and the Vertebral Artery

Contemporary perspectives on patient Contemporary perspectives on patient safety and protection, clinical reality safety and protection, clinical reality

and patient managementand patient management

Why?Why?

Currently the single most important issue related Currently the single most important issue related to the practice of chiropractic from a to the practice of chiropractic from a public public safety issue standpointsafety issue standpoint is associated with is associated with vertebral artery related matters.vertebral artery related matters.

Similarly, a key issue from a Similarly, a key issue from a public relations public relations perspectiveperspective is related to the practice of is related to the practice of chiropractic as associated with vertebral artery chiropractic as associated with vertebral artery related matters.related matters.

Why?Why?

The Lewis Inquest in Toronto, Ontario has The Lewis Inquest in Toronto, Ontario has provided a treasure trove of information related provided a treasure trove of information related to vertebral artery issues of interest to practicing to vertebral artery issues of interest to practicing chiropractors.chiropractors.

The recent controversy surrounding Vioxx and The recent controversy surrounding Vioxx and Accutane signals a changing public expectation Accutane signals a changing public expectation with respect to health care interventions.with respect to health care interventions.

Outcomes of the presentationOutcomes of the presentation

a. To provide the practicing chiropractor with a a. To provide the practicing chiropractor with a review of the relevant anatomy, physiology and review of the relevant anatomy, physiology and pathology associated with vertebral artery pathology associated with vertebral artery injuries and in particular vertebral artery injuries and in particular vertebral artery dissection to assure an understanding of the dissection to assure an understanding of the basic mechanisms involvedbasic mechanisms involved

b. To offer the practicing chiropractor a review b. To offer the practicing chiropractor a review of the current demographic and incidence data, of the current demographic and incidence data, the sources of the data and the strengths and the sources of the data and the strengths and weaknesses of the data associated with weaknesses of the data associated with vertebral artery injury and cervical spine vertebral artery injury and cervical spine adjustingadjusting

Outcomes of the presentationOutcomes of the presentation

c. To provide the practicing chiropractor with c. To provide the practicing chiropractor with current thoughts on the appropriate procedures current thoughts on the appropriate procedures to be used before the initiation of cervical spine to be used before the initiation of cervical spine adjusting and the recommended procedures in adjusting and the recommended procedures in the event a patient demonstrates signs of VBAI the event a patient demonstrates signs of VBAI before, during or after a care encounterbefore, during or after a care encounter

d. To provide the practicing chiropractor with d. To provide the practicing chiropractor with the current perspectives on VAD in progress and the current perspectives on VAD in progress and the clinical warning signs of the patient who the clinical warning signs of the patient who presents in a potentially compromised state as presents in a potentially compromised state as well as the most appropriate response theretowell as the most appropriate response thereto

Let’s Take It from the Top!Let’s Take It from the Top!

1. Gross anatomy review1. Gross anatomy review

2. Histology of blood vessels review2. Histology of blood vessels review3. Review of basic pathology mechanisms:3. Review of basic pathology mechanisms:

a. Injury and inflammationa. Injury and inflammation

b. Clotting and thrombus formationb. Clotting and thrombus formationc. Embolic. Embolid. Ischemiad. Ischemia

Gross Anatomy ReviewGross Anatomy Review

1. Arterial circulation:1. Arterial circulation:a. Origin of Vertebral arteriesa. Origin of Vertebral arteries

b. Course of the Vertebral arteriesb. Course of the Vertebral arteriesc. Distal distribution from the Vertebral c. Distal distribution from the Vertebral

arteriesarteriesd. Common anomalies of the Vertebral d. Common anomalies of the Vertebral

artery(ies)artery(ies)

1. Arterial Circulation1. Arterial Circulation

a. Origin of the a. Origin of the Vertebral arteries:Vertebral arteries:

i. The left and the i. The left and the right Vertebral right Vertebral arteries arise from the arteries arise from the Subclavian artery.Subclavian artery.ii. They arise proximal ii. They arise proximal to the Thyrocervical to the Thyrocervical trunk and distal to the trunk and distal to the Common Carotid Common Carotid artery.artery.


b. Course of the b. Course of the Vertebral arteries:Vertebral arteries:

i. The Vertebral i. The Vertebral arteries are divided arteries are divided into four segments as into four segments as they ascend the they ascend the cervical spinecervical spine

I. From the I. From the Subclavian artery to the Subclavian artery to the transverse foramen of transverse foramen of C5/C6C5/C6


i. The Vertebral arteries i. The Vertebral arteries are divided into four are divided into four segments as they ascend segments as they ascend the cervical spinethe cervical spine

II. Within the II. Within the transverse foramina from transverse foramina from C5/C6-C2C5/C6-C2



iii. From the superior of iii. From the superior of C2 foramen to the duraC2 foramen to the dura



iv. From the dura iv. From the dura

forwardforward


c. Distal distribution from the Vertebral c. Distal distribution from the Vertebral arteriesarteriesi. From the Subclavian artery the Vertebral i. From the Subclavian artery the Vertebral arteries continue to unite and form the Basilar arteries continue to unite and form the Basilar arteryarteryii. Prior to the junction of the right and left ii. Prior to the junction of the right and left Vertebral arteries forming the Basilar artery the Vertebral arteries forming the Basilar artery the Posterior Inferior Cerebellar artery (PICA) is Posterior Inferior Cerebellar artery (PICA) is given off.given off.


d. Common anomalies of the Vertebral d. Common anomalies of the Vertebral artery(ies)artery(ies)i. Approximately ten percent of patients have i. Approximately ten percent of patients have some form of anomaly in their Vertebral some form of anomaly in their Vertebral artery(ies).artery(ies).

ii. Compression of the Vertebral artery(ies) is ii. Compression of the Vertebral artery(ies) is seen in 5% of the population in a neutral seen in 5% of the population in a neutral position and the same in rotationposition and the same in rotation..


d. Common anomalies of the Vertebral d. Common anomalies of the Vertebral artery(ies)artery(ies)iii. Unilateral or bilateral absence of the Vertebral iii. Unilateral or bilateral absence of the Vertebral ArteryArteryiiii. Variations in arterial diameter, average 4.3 iiii. Variations in arterial diameter, average 4.3 mm on the right, 4.7mm on the leftmm on the right, 4.7mm on the leftv. Segment I, tortuous vessel in 39% of v. Segment I, tortuous vessel in 39% of specimensspecimens


d. Common anomalies of the Vertebral d. Common anomalies of the Vertebral artery(ies)artery(ies)vi. The origin of the Vertebral Artery varies in vi. The origin of the Vertebral Artery varies in 3.5% of cases3.5% of casesvii. In 5%-20% of specimens the Posterior vii. In 5%-20% of specimens the Posterior Inferior Cerebellar Arteries have an extra dural Inferior Cerebellar Arteries have an extra dural origin approximately 1 cm. proximal to dural origin approximately 1 cm. proximal to dural penetration.penetration.


d. Common anomalies of the Vertebral d. Common anomalies of the Vertebral artery(ies)artery(ies)viii. 7% of Vertebral arteries cannot be imaged viii. 7% of Vertebral arteries cannot be imaged due to the depth of the tissuedue to the depth of the tissueix. Contralateral rotation can cause alterations in ix. Contralateral rotation can cause alterations in blood flow at the C1-C2 level on MRAblood flow at the C1-C2 level on MRAx. A change in excess of 56% is needed to x. A change in excess of 56% is needed to detect alterations using Doppler imagingdetect alterations using Doppler imaging

2. Histology of blood vessels review2. Histology of blood vessels review

a. The Vertebral arteries a. The Vertebral arteries are comparable in size are comparable in size and design to the Renal and design to the Renal arteries or some of the arteries or some of the smaller Coronary arteries.smaller Coronary arteries.b. They exhibit the typical b. They exhibit the typical 3 layer pattern from 3 layer pattern from inside out of a tunica inside out of a tunica intima, tunica media and intima, tunica media and a tunica adventitia.a tunica adventitia.

Adventitia

Media

Intima

3. Review of basic pathology 3. Review of basic pathology mechanisms:mechanisms:

a. Injury and inflammationa. Injury and inflammationi. Arteriopathy may arise from heritable i. Arteriopathy may arise from heritable conditions such as Marfan’s Disease, Ehler conditions such as Marfan’s Disease, Ehler Danlos Syndrome-type IV and VI, autosomal Danlos Syndrome-type IV and VI, autosomal dominant polycystic kidney disease, or dominant polycystic kidney disease, or osteogenesis imperfecta type I (yielding cystic osteogenesis imperfecta type I (yielding cystic medial degeneration)medial degeneration)ii. Arteriopathy may also arise from ii. Arteriopathy may also arise from fibromuscular hyperplasiafibromuscular hyperplasia


b. Clotting and thrombus formationb. Clotting and thrombus formationi. Arterial damage, particularly involving the i. Arterial damage, particularly involving the tunica intima will yield the start of increased tunica intima will yield the start of increased localized clotting and thereby thrombus localized clotting and thereby thrombus formation.formation.ii. Arterial flow changes can result from ii. Arterial flow changes can result from histological changes as well as from mechanical histological changes as well as from mechanical changes in the vessel.changes in the vessel.

Intimal dissection with blood flow beneath the intimaand associated thrombus formation


c. Embolic. Embolii. Emboli present in three primary forms-liquid, i. Emboli present in three primary forms-liquid, solid or gaseous. The thrombus at the site of solid or gaseous. The thrombus at the site of arterial damage is invariably the source of arterial damage is invariably the source of emboli yielding ischemic stroke from the emboli yielding ischemic stroke from the Vertebral artery.Vertebral artery.


d. Ischemiad. Ischemiai. The degree of ischemia resultant from an i. The degree of ischemia resultant from an embolism is the consequence of the size of the embolism is the consequence of the size of the embolism, the location of the embolism and the embolism, the location of the embolism and the presence/absence of collateral circulation to the presence/absence of collateral circulation to the affected area.affected area.

From the Basics to the AdvancedFrom the Basics to the Advanced

1. Mechanisms (origins) of Vertebral 1. Mechanisms (origins) of Vertebral artery dissectionartery dissection2. Types of Vertebral artery dissections2. Types of Vertebral artery dissections3. Pathophysiology of various dissections 3. Pathophysiology of various dissections to the Vertebral arteryto the Vertebral artery4. Sequellae of dissections the Vertebral 4. Sequellae of dissections the Vertebral arteryartery

1. Mechanisms (origins) of 1. Mechanisms (origins) of Vertebral Artery DissectionVertebral Artery Dissection

a. The literature indicates that VAD arises a. The literature indicates that VAD arises spontaneously, from trivial movement, minor spontaneously, from trivial movement, minor trauma or major trauma.trauma or major trauma.b. The following have been cited in the literature b. The following have been cited in the literature as preceding a VAD- Judo, yoga, ceiling painting, as preceding a VAD- Judo, yoga, ceiling painting, nose blowing, hypertension, oral contraceptive nose blowing, hypertension, oral contraceptive use, sexual activity, receiving anesthesia, use of use, sexual activity, receiving anesthesia, use of resuscitation activities, receiving a shampoo, resuscitation activities, receiving a shampoo, vomiting, sneezing, chiropractic care.vomiting, sneezing, chiropractic care.

2. Types of Vertebral Artery 2. Types of Vertebral Artery Dissections Dissections

a. Dissections arise from an intimal tear. a. Dissections arise from an intimal tear. Yielding an intramural hematoma and they Yielding an intramural hematoma and they have been identified as subintimal or have been identified as subintimal or subadventital.subadventital.i. Subintimal dissections tend to result in i. Subintimal dissections tend to result in stenosis of the arterystenosis of the arteryii. Subadventital dissections tend to result ii. Subadventital dissections tend to result in aneurysm formation. in aneurysm formation.

3. Pathophysiology of Dissections 3. Pathophysiology of Dissections of the Vertebral Arteryof the Vertebral Artery

a. An expanding hematoma in the wall of a. An expanding hematoma in the wall of the Vertebral Artery is the root of the the Vertebral Artery is the root of the problem. The intramural hematoma can problem. The intramural hematoma can arise from hemorrhage of the vasa arise from hemorrhage of the vasa vasorum within/associated with the tunica vasorum within/associated with the tunica media or from the development of an media or from the development of an intimal flap in the lumen of the vessel.intimal flap in the lumen of the vessel.

3. Pathophysiology of Dissections 3. Pathophysiology of Dissections of the Vertebral arteryof the Vertebral artery

b. The consequences of the evolution of b. The consequences of the evolution of the hematoma include the following:the hematoma include the following:i. It seals off, remains small and is largely i. It seals off, remains small and is largely asymptomaticasymptomaticii. An expanding hematoma of a subintimal ii. An expanding hematoma of a subintimal nature occludes the vessel yielding ischemia and nature occludes the vessel yielding ischemia and a subsequent infarctiona subsequent infarctioniii. A lesion of a subadventitial nature yields an iii. A lesion of a subadventitial nature yields an aneurysm that is prone to rupture through the aneurysm that is prone to rupture through the adventitia yielding a subdural hematomaadventitia yielding a subdural hematoma

Subintimal v. SubadventitialSubintimal v. Subadventitial

Vessel lumen

Aneurysm

3. Pathophysiology of Dissections 3. Pathophysiology of Dissections of the Vertebral arteryof the Vertebral artery

b. The consequences of the evolution of b. The consequences of the evolution of the hematoma include the following:the hematoma include the following:iv. The intimal disruption results in an iv. The intimal disruption results in an alteration of normal hemodynamics, the alteration of normal hemodynamics, the creation of a thrombogenic environment, creation of a thrombogenic environment, the formation of a thrombus and the the formation of a thrombus and the potential generation of emboli.potential generation of emboli.

4. Sequellae of various forms of 4. Sequellae of various forms of injury to the Vertebral arteryinjury to the Vertebral artery

a. The effects of altered arterial flow a. The effects of altered arterial flow through the Vertebral artery as a result of through the Vertebral artery as a result of a dissection can yield few or minimal a dissection can yield few or minimal symptoms, transient ischemic attacks due symptoms, transient ischemic attacks due to the altered circulation, development of to the altered circulation, development of thrombi and emboli potentially yielding thrombi and emboli potentially yielding ischemia and/or infarction.ischemia and/or infarction.

Vertebral Artery DissectionVertebral Artery Dissection

1. Mechanisms of origin1. Mechanisms of origin

2. Incidence of VAD2. Incidence of VAD3. Morbidity and mortality associated with 3. Morbidity and mortality associated with VADVAD

4. Predisposing factors4. Predisposing factors5. Theorized predisposing factors5. Theorized predisposing factors6. Predictors of VAD6. Predictors of VAD


1. Mechanism of origin1. Mechanism of origini. According to Haldeman et al. Spine 1999 Apr i. According to Haldeman et al. Spine 1999 Apr 15;24(8):785-9415;24(8):785-94

I. 43% of are spontaneous in natureI. 43% of are spontaneous in nature

II. 31% were associated with cervical spine II. 31% were associated with cervical spine manipulationmanipulation

III. 16% from trivial traumaIII. 16% from trivial traumaIIII. 10% from major traumaIIII. 10% from major trauma


1. Mechanism of origin1. Mechanism of originii. ii. According to Beaudry and Spence (The Canadian According to Beaudry and Spence (The Canadian Journal of Neurological Sciences, V. 30, No. 4, November Journal of Neurological Sciences, V. 30, No. 4, November 2003, pp. 320-304) 2003, pp. 320-304)

I. The most common cause of traumatic Vertebrobasilar I. The most common cause of traumatic Vertebrobasilar ischemia is motor vehicle accidents.ischemia is motor vehicle accidents.

II. Of 80 cases that presented over 20 years to a single II. Of 80 cases that presented over 20 years to a single neurovascular practice, 70 were related to MVAs, 5 to industrial neurovascular practice, 70 were related to MVAs, 5 to industrial injuries, 5 associated with chiropractic. Consideration was offered injuries, 5 associated with chiropractic. Consideration was offered that some of the cases that were related to chiropractors were also that some of the cases that were related to chiropractors were also involved in MVAs further confounding the matter.involved in MVAs further confounding the matter.


2. Incidence of VAD 2. Incidence of VAD (Schievink, NEJM (Schievink, NEJM 3/22/01)3/22/01)

a. For every 100,000 strokes of any origin a. For every 100,000 strokes of any origin there will be one stroke associated with a there will be one stroke associated with a Vertebral artery dissectionVertebral artery dissectionb. Dissections account for 10%-25% of all b. Dissections account for 10%-25% of all ischemic strokes in young or middle aged ischemic strokes in young or middle aged personspersonsc. Less than 5% result in death and about c. Less than 5% result in death and about 75% have a good recovery75% have a good recovery


2. Incidence of VAD2. Incidence of VADdd. VAD and CAD account for 2.6 per 100,000. VAD and CAD account for 2.6 per 100,000

e. Cervical dissections are the underlying e. Cervical dissections are the underlying etiology in 20% of ischemic strokes in patient etiology in 20% of ischemic strokes in patient 30-45 years of age.30-45 years of age.f. Female to male ratio: 3:1 (disputed)f. Female to male ratio: 3:1 (disputed)g. Average age: VAD-40, CAD-47 (disputed)g. Average age: VAD-40, CAD-47 (disputed)


2. Incidence of VAD2. Incidence of VADhh. From the literature:. From the literature:

i. 1 in 5,000 adjustments cause a i. 1 in 5,000 adjustments cause a stroke stroke (Norris, (Norris, SPONTADS,SPONTADS, unpublished)unpublished)

ii. 1 in 20,000 adjustments cause a stroke (Vickers, ii. 1 in 20,000 adjustments cause a stroke (Vickers, BMJ, 1999)BMJ, 1999)iii. 1.3 in 100,000 patients (Rothwell, Stroke, 2001)iii. 1.3 in 100,000 patients (Rothwell, Stroke, 2001)


2. Incidence of VAD2. Incidence of VADhh. From the literature:. From the literature:

iv. 1 in 1 million adjustments (Hosek et al, JAMA, iv. 1 in 1 million adjustments (Hosek et al, JAMA, 1981)1981)v. 1 in 2 million adjustments (Klougart et al, JMPT, v. 1 in 2 million adjustments (Klougart et al, JMPT, 1996)1996)vi. 1 in 5.85 million cervical spine vi. 1 in 5.85 million cervical spine adjustments adjustments

(Carey et al, CMAJ, 2001) (Carey et al, CMAJ, 2001)

2. Incidence of VAD2. Incidence of VADii. Discussion of range of incidence data from the . Discussion of range of incidence data from the literature:literature:

i. The Rothwell data involves all patients who i. The Rothwell data involves all patients who experienced a stroke within 7 days of a chiropractic experienced a stroke within 7 days of a chiropractic

office visitoffice visitii. The Carey data reflects claims filed for a stroke ii. The Carey data reflects claims filed for a stroke following chiropractic carefollowing chiropractic careiii. It is likely that among the Rothwell data there iii. It is likely that among the Rothwell data there were unrelated strokes and among the Carey data were unrelated strokes and among the Carey data there were unreported claims-therefore 1-2/per there were unreported claims-therefore 1-2/per million million


3. Morbidity and mortality associated with 3. Morbidity and mortality associated with VADVADa. “The reported death rate from dissections of a. “The reported death rate from dissections of the carotid and vertebral arteries is less than 5 the carotid and vertebral arteries is less than 5 percent.” Schievink, NEJM, 2001percent.” Schievink, NEJM, 2001b. “VAD has been associated with a 10% b. “VAD has been associated with a 10% mortality rate in the acute phase.” E. Lang, M.D. mortality rate in the acute phase.” E. Lang, M.D. Department of Family Medicine, McGill Department of Family Medicine, McGill University; University;


4. Predisposing factors4. Predisposing factorsa. Please see the heritable conditions noted a. Please see the heritable conditions noted previously.previously.b. “approximately 5 percent of patients with b. “approximately 5 percent of patients with spontaneous dissection of the carotid or spontaneous dissection of the carotid or vertebral artery have at least one family member vertebral artery have at least one family member who has had a spontaneous dissection of the who has had a spontaneous dissection of the aorta or its main branches.” (Schievink, NEJM aorta or its main branches.” (Schievink, NEJM 2001)2001)


5. Theorized predisposing factors:5. Theorized predisposing factors:a. One case-control study in 1989 suggested a. One case-control study in 1989 suggested migraine was a risk factor for cervical artery migraine was a risk factor for cervical artery dissection (D’Anglejan, Headache, 1989)dissection (D’Anglejan, Headache, 1989)b. Hyperhomocysteinemia as reported by b. Hyperhomocysteinemia as reported by Pezzini, J Neurology, 2002Pezzini, J Neurology, 2002c. Previous respiratory infection together with c. Previous respiratory infection together with other neurological symptomsother neurological symptoms


6. Predictors of VAD6. Predictors of VADa. “Thus, given the current state of the a. “Thus, given the current state of the literature, it is impossible to advise patients or literature, it is impossible to advise patients or physicians about how to avoid vertebrobasilar physicians about how to avoid vertebrobasilar artery dissection when considering cervical artery dissection when considering cervical manipulation or about specific sports or manipulation or about specific sports or exercises that result in neck movement or exercises that result in neck movement or trauma.” (Haldeman et al, Spine 1999)trauma.” (Haldeman et al, Spine 1999)

Clinical Pearl Number OneClinical Pearl Number One

Current thinking holds that the Current thinking holds that the majority of patients who develop majority of patients who develop frank symptoms of a vertebral frank symptoms of a vertebral artery dissection following artery dissection following chiropractic care were in the chiropractic care were in the process of dissection when they process of dissection when they presented for care.presented for care.

In Support of this IdeaIn Support of this Idea

Did the SMT Practitioner Cause the Arterial Did the SMT Practitioner Cause the Arterial Injury?Injury?Terrett, Chiropractic Journal of Australia, Vol. 32, Terrett, Chiropractic Journal of Australia, Vol. 32, No. 3, 9/2003, pp. 99-110No. 3, 9/2003, pp. 99-110Manipulation of the Neck and Stroke: time for Manipulation of the Neck and Stroke: time for more rigorous evidencemore rigorous evidenceBreene, Medical Journal of Australia, Vol. 176, Breene, Medical Journal of Australia, Vol. 176, 15 Apr 2002, pp.364-36515 Apr 2002, pp.364-365Spinal manipulative therapy is an independent Spinal manipulative therapy is an independent risk factor for vertebral artery dissectionrisk factor for vertebral artery dissectionSmith, Neurology, Vol. 60, pp. 1424-1428Smith, Neurology, Vol. 60, pp. 1424-1428

The Other Side of the QuestionThe Other Side of the Question

Spinal Manipulative Therapy is an Independent Spinal Manipulative Therapy is an Independent Risk Factor for Vertebral Artery DissectionRisk Factor for Vertebral Artery Dissection

Smith, Neurology, 2003, Vol. 60, pp. Smith, Neurology, 2003, Vol. 60, pp. 1424-14281424-1428

Pre-adjustment screening testsPre-adjustment screening tests

We were all taught “George’s Test”, We were all taught “George’s Test”, “DeKlynes Test” and other tests for “DeKlynes Test” and other tests for Vertebral artery competency.Vertebral artery competency.

You have been told by many people from You have been told by many people from your teachers, to your colleagues, to your your teachers, to your colleagues, to your professional liability carrier, to your risk professional liability carrier, to your risk management consultants to use these management consultants to use these provocative tests—provocative tests—Don’tDon’t..


George’s Test or DeKlyne’s Test yield an George’s Test or DeKlyne’s Test yield an unacceptable percentage of false positives unacceptable percentage of false positives and of false negatives. It tells you nothing and of false negatives. It tells you nothing reliable.reliable.

For the patient who is a VAD-in-progress For the patient who is a VAD-in-progress the testing may be enough to make a bad the testing may be enough to make a bad situation worse.situation worse.


In March 2004 all of the clinic directors of In March 2004 all of the clinic directors of all of the U.S. chiropractic colleges and all of the U.S. chiropractic colleges and programs agreed to abandon the teaching programs agreed to abandon the teaching of and use of of and use of provocativeprovocative testing of this testing of this nature.nature.

At the same meeting the presidents/deans At the same meeting the presidents/deans accepted the recommendation of the clinic accepted the recommendation of the clinic directors.directors.


Bottomline: There are no reliable or safe Bottomline: There are no reliable or safe tests that will rule out a VAD-in-progress. tests that will rule out a VAD-in-progress. There are no tests that will identify a There are no tests that will identify a patient at risk for VAD.patient at risk for VAD.

Your best evaluative tools are: Your ears Your best evaluative tools are: Your ears and your gut.and your gut.

What is a Person to Do?What is a Person to Do?

If there are no clear-cut predisposing If there are no clear-cut predisposing factors suggesting VAD, andfactors suggesting VAD, andIf there are no testing procedures helpful If there are no testing procedures helpful in ruling out potential VAD patients, andin ruling out potential VAD patients, and

If the great majority of VAD-in-progress If the great majority of VAD-in-progress patients present with musculoskeletal patients present with musculoskeletal complaints, then,complaints, then,

What is a person to do?What is a person to do?

What is a Person to Do?What is a Person to Do?

Look, listen, ask and thinkLook, listen, ask and think

Look for What?Look for What?

Five “Ds”Five “Ds”– DizzinessDizziness– Drop attacksDrop attacks– DiplopiaDiplopia– DysarthriaDysarthria– DysphagiaDysphagia

AndAnd– AtaxiaAtaxia

Three “Ns”Three “Ns”– NauseaNausea– NumbnessNumbness– NystagmusNystagmus

Perspective on the 5 D’s, 3 N’s and the A!Perspective on the 5 D’s, 3 N’s and the A!

Many patients present to chiropractors exhibiting Many patients present to chiropractors exhibiting one or more of these symptoms, many patients one or more of these symptoms, many patients seek care for these symptoms, the presence of seek care for these symptoms, the presence of these symptoms, in and of themselves-may or these symptoms, in and of themselves-may or MAY NOT be an indication of a possible VAD-in-MAY NOT be an indication of a possible VAD-in-progress, rather it is the constellation of progress, rather it is the constellation of symptoms (dizziness, nausea and diplopia for symptoms (dizziness, nausea and diplopia for example), the uniqueness of the symptom (drop example), the uniqueness of the symptom (drop attacks for example) and the degree/severity of attacks for example) and the degree/severity of the symptoms that should draw the clinician’s the symptoms that should draw the clinician’s attentionattention

Listen for What?Listen for What?

Slurred speechSlurred speech GiddinessGiddiness A change in voice A change in voice

patternpattern Lack of context in Lack of context in

speechspeech Inappropriate Inappropriate

reactions to reactions to situationssituations

One characteristic, One characteristic, almost almost pathognomonic pathognomonic phrase from your phrase from your patient-whether they patient-whether they be an old or a new be an old or a new patient, getting their patient, getting their first adjustment or first adjustment or their 100their 100thth……

Clinical Pearl Number TwoClinical Pearl Number Two

The phraseThe phrase::““I have a pain in my I have a pain in my neck and (or) head neck and (or) head unlike anything I have unlike anything I have ever had beforeever had before.”.”

Clinical Pearl Number ThreeClinical Pearl Number Three

For those patients who experienced a For those patients who experienced a VAD, on follow-up 50% had a recent VAD, on follow-up 50% had a recent appearance of a new chief complaint appearance of a new chief complaint of upper quadrant neck pain (occipital of upper quadrant neck pain (occipital area) and/or the hemicranium. The area) and/or the hemicranium. The pain was described as throbbing, pain was described as throbbing, steady or sharp, the “thunderclap” steady or sharp, the “thunderclap” headache.headache.

Pain referral common to Vertebral Pain referral common to Internal Carotid

Ask What?Ask What?

DC: Tell me some more about this pain.DC: Tell me some more about this pain.

DC: Were you doing anything before you DC: Were you doing anything before you experienced the pain, or did it come out of experienced the pain, or did it come out of the blue?the blue?

DC: How do you feel otherwise? Light DC: How do you feel otherwise? Light headed? A little dizzy? Etc.headed? A little dizzy? Etc.

Think About What?Think About What?

Stopping cold in your tracks when you Stopping cold in your tracks when you have heard have heard TheThe phrase. phrase.

Taking a step back, slowing down and Taking a step back, slowing down and paying close attention to everything about paying close attention to everything about this patient.this patient.

Moving cautiously, discretion is the better Moving cautiously, discretion is the better part of valor.part of valor.

Think About What?Think About What?

In the presence of a patient who In the presence of a patient who expresses non-traumatic or post-whiplash expresses non-traumatic or post-whiplash neck pain as a new chief complaint, who neck pain as a new chief complaint, who refers to the pain as unlike anything they refers to the pain as unlike anything they have ever had before, who is exhibiting have ever had before, who is exhibiting other neurological symptoms referral for other neurological symptoms referral for evaluation of possible VAD before evaluation of possible VAD before adjusting is strongly recommended.adjusting is strongly recommended.

When a Patient Shows Signs of When a Patient Shows Signs of Possible VAD following an Possible VAD following an

AdjustmentAdjustment

Your management of the situation and Your management of the situation and your documentation of the situation are your documentation of the situation are the most important issues in reducing the most important issues in reducing morbidity and mortality as well as in morbidity and mortality as well as in limiting or reducing liability.limiting or reducing liability.



Your recognition of the post-adjustment Your recognition of the post-adjustment symptomatic picture is critical. You cannot symptomatic picture is critical. You cannot assume because a VAD is extremely rare it assume because a VAD is extremely rare it won’t or didn’t happen.won’t or didn’t happen.

Keep your antenna up!Keep your antenna up!



If the patient shows any of the 5 D’s, an A If the patient shows any of the 5 D’s, an A or any of the 3 N’s pay attention or any of the 3 N’s pay attention immediately.immediately.

If the symptoms are mild monitor them for If the symptoms are mild monitor them for their decrease or their resolution, if severe their decrease or their resolution, if severe consider emergency services immediatelyconsider emergency services immediately

What symptoms should be What symptoms should be monitored?monitored?

Each situation will require a different Each situation will require a different response, but in general the clinician response, but in general the clinician should be monitoring the patient’s vital should be monitoring the patient’s vital signs as well as the specific neurological signs as well as the specific neurological response that has drawn attention.response that has drawn attention.

The availability of baseline vitals will cause The availability of baseline vitals will cause this data to be more meaningful.this data to be more meaningful.



If the symptoms are very transient, limited If the symptoms are very transient, limited and resolve quickly take a position of and resolve quickly take a position of “watchful waiting”. “watchful waiting”. Consider the area adjusted, the type of Consider the area adjusted, the type of adjustment given and if an alternate adjustment given and if an alternate approach would be in order.approach would be in order.Do not readjust the patient at that timeDo not readjust the patient at that time

When a Patient Shows Signs of When a Patient Shows Signs of Possible VAD following and Possible VAD following and


If the symptoms do NOT resolve monitor If the symptoms do NOT resolve monitor the patient, stay with the patient—no the patient, stay with the patient—no matter how stacked up the waiting room matter how stacked up the waiting room is.is.

Watch for the development of additional Watch for the development of additional symptoms, note the mental status, degree symptoms, note the mental status, degree of confusion if any, etc.of confusion if any, etc.

Do not readjust the patient at that timeDo not readjust the patient at that time



If the symptoms persist, or if the If the symptoms persist, or if the symptoms worsen seek emergency symptoms worsen seek emergency services support. Monitor the patient while services support. Monitor the patient while waiting for support services.waiting for support services.

Do not readjust the patient at that time.Do not readjust the patient at that time.

Why Not Readjust?Why Not Readjust?

IF the patient is experiencing a VAD there IF the patient is experiencing a VAD there is no form of adjustment that will is no form of adjustment that will minimize the consequences of the minimize the consequences of the dissection and the introduction of another dissection and the introduction of another force may serve to create emboli and force may serve to create emboli and increase the likelihood of an ischemic increase the likelihood of an ischemic event.event.

Why Can’t I Wait and See What Why Can’t I Wait and See What Happens?Happens?

If the patient has experienced a VAD, and If the patient has experienced a VAD, and if the VAD has resulted in a thrombus if the VAD has resulted in a thrombus being formed and emboli being thrown it being formed and emboli being thrown it will result in cerebellar or brainstem will result in cerebellar or brainstem ischemia. Emergency pharmaceutical ischemia. Emergency pharmaceutical intervention, i.e. tPA, is most effective in intervention, i.e. tPA, is most effective in the first 90 minutes, moderately effective the first 90 minutes, moderately effective for three hours and possible effective for for three hours and possible effective for up to six hours-time is of the essence.up to six hours-time is of the essence.

Professional Liability ComplicationsProfessional Liability Complications

1. Your failure to recognize what is going on, to 1. Your failure to recognize what is going on, to write it off as a “normal” or “typical reaction to write it off as a “normal” or “typical reaction to an adjustment”.an adjustment”.2. Your failure to monitor and document the 2. Your failure to monitor and document the progress of the patient following the onset of the progress of the patient following the onset of the problem, as well as to document your thought problem, as well as to document your thought processes regarding the situation.processes regarding the situation.3. Your failure to manage the situation properly 3. Your failure to manage the situation properly and in a timely manner.and in a timely manner.

Professional Liability ComplicationsProfessional Liability Complications

4. Readjusting the patient4. Readjusting the patient

5. Sending the patient home if in an 5. Sending the patient home if in an unstable or fragile stateunstable or fragile state6. Taking a casual approach to seeing 6. Taking a casual approach to seeing another provider- “you might want to…”another provider- “you might want to…”7. Failing to document what went on, 7. Failing to document what went on, what you were thinking, what you did, what you were thinking, what you did, being less than honest and explicit in the being less than honest and explicit in the record.record.

Tomorrow MorningTomorrow Morning

1. There is no need to be fearful of 1. There is no need to be fearful of delivering a competent cervical spine delivering a competent cervical spine adjustmentadjustment2. Pay close attention to the responses of 2. Pay close attention to the responses of patients following cervical spine patients following cervical spine adjustmentsadjustments3. Do NOT assume it couldn’t happen in 3. Do NOT assume it couldn’t happen in my officemy office


4. Have a plan for what you would do if…, 4. Have a plan for what you would do if…, keep emergency numbers handy, discuss keep emergency numbers handy, discuss the possible scenario with your staff, plan the possible scenario with your staff, plan and respond to the plan don’t react to a and respond to the plan don’t react to a problemproblem5. Document, document, document5. Document, document, document6. Understand the mechanisms involved 6. Understand the mechanisms involved and respond accordinglyand respond accordingly


7. Evaluate your procedures in general, are you 7. Evaluate your procedures in general, are you asking the questions you should be asking, are asking the questions you should be asking, are you and your staff attuned to catching subtle you and your staff attuned to catching subtle changes in your patients, does your staff have changes in your patients, does your staff have mechanisms to let you know about things they mechanisms to let you know about things they see in patients?see in patients?8. Act in the best interests of the patient, always 8. Act in the best interests of the patient, always in all ways-this is ultimately in your best interest in all ways-this is ultimately in your best interest as wellas well

This lecture has been developed as an This lecture has been developed as an instructional guide. The information contained instructional guide. The information contained herein is based on sources believed to be herein is based on sources believed to be generally correct, however, because of variances generally correct, however, because of variances in state statutes, educational philosophy, in state statutes, educational philosophy, professional assiduity, and court opinions the professional assiduity, and court opinions the Association of Chiropractic Colleges assumes no Association of Chiropractic Colleges assumes no responsibility as to the accuracy or scope of the responsibility as to the accuracy or scope of the suggestions offered in a particular circumstance. suggestions offered in a particular circumstance. Legal counsel should be consulted for optimal Legal counsel should be consulted for optimal guidance. The opinions expressed in this lecture guidance. The opinions expressed in this lecture are exclusively those of the author.are exclusively those of the author.

Copies of this presentation in PowerPoint Copies of this presentation in PowerPoint are available, as are any of the articles are available, as are any of the articles referenced in this presentation. If you referenced in this presentation. If you desire to receive any of this information desire to receive any of this information contact Dr. Clum at:contact Dr. Clum at:

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