Cervical Spine Manipulation: Neck Relief and Brain Grief

1HealthPartners, Saint Paul, MN
2HealthPartners, Saint Paul, MN
3Creighton University, Omaha, NE

Meeting: Hospital Medicine 2009, May 14-17, Chicago, Ill.

Abstract number: 158

Case Presentation:

A 37‐year‐old woman with an unremarkable medical history was admitted with sudden onset of dizziness, aphasia, and right arm numbness and weakness. The patient's symptoms lasted approximately 45 minutes and then slowly resolved, after which she was able to call for help. A few hours before her symptoms, the patient had her usual neck stiffness, and thus she went to the chiropractor. She did have a neck manipulation, which certainly alleviated the pain. The patient denied tobacco use or history of hypertension. On physical exam, her blood pressure was 148/95, and she was afebrile. The neurologic exam was nonfocal. The patient's left‐arm numbness was still present. MRI of the brain showed 3–4 tiny foci suggestive of multifocal acute to subacute ischemic changes in the left parietal, whereas MRA of the head and neck showed bilateral internal carotid artery (ICA) dissection and markedly diminished intracranial flow throughout the left middle cerebral artery distribution. There was no evidence of dysplasia on angiography. The vertebral arteries were widely patent and within normal limits. The patient was started on a heparin drip and bridged to coumadin. A workup for a hypercoagulable state was negative. Echocardiogram did not reveal any abnormalities. The patient's symptoms completely resolved, and she was discharged home in a stable condition on coumadin with a target INR of 2–3.


Although neurological manifestations following chiropractic neck manipulation have been attributed to vertebral artery dissection and subsequent vertebrobasilar ischemia, injuries to the internal carotids arteries following spine manipulation are rarely reported. We report a patient with bilateral ICA dissection after visiting a chiropractor for neck relief. Our patient did not have known risk factors for artery dissections such as fibromuscular dysplasia, Marfan syndrome, Ehlers‐Danlos syndrome, oral contraception, and arteriosclerosis, but did admit to a history of gestational hypertension, and blood pressure was elevated on presentation. Neurological deficits after spine manipulation vary widely in timing and presentation. The dissection is thought to occur because of shear force on the wall of the vessel. Symptoms may occur within minutes or even weeks. Clinical manifestations depend on the affected cerebral circulation. Although our patient exhibited word‐finding difficulty and right‐hand numbness, which are suggestive of middle cerebral artery distribution, patients with vertebral artery involvement may present with occipital headache, neck pain, nausea, vomiting, or tinnitus. These symptoms may be transient, thus making increased awareness a priority, as such patients should not be subjected to additional cervical spine manipulation.


Serious and sometimes fatal neurological complications may occur following cervical spine manipulation. Transient neurologic symptoms may be the first manifestations. Hospitalists must be vigilant of these complications, as early recognition may prevent death.

Author Disclosure:

T. S. Hamieh, none; M. Saha, none; V. Dimov, none.

To cite this abstract:

Hamieh T, Saha M, Dimov V. Cervical Spine Manipulation: Neck Relief and Brain Grief. Abstract published at Hospital Medicine 2009, May 14-17, Chicago, Ill. Abstract 158. Journal of Hospital Medicine. 2009; 4 (suppl 1). https://www.shmabstracts.com/abstract/cervical-spine-manipulation-neck-relief-and-brain-grief/. Accessed April 25, 2019.

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