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Show ' Journal of Neuro- Ophthalmology 20( 4): 236- 239, 2000. © 2000 Lippincott Williams & Wilkins, Inc., Philadelphia The Neuro- ophthalmologic Complications of Cervical Manipulation Michael W. Devereaux, MD Cervical manipulation, specifically chiropractic manipulation, is an important cause of vertebrobasilar and occasionally carotid distribution strokes. Neuro- ophthalmologic findings are a common and at times relatively isolated feature of cervical manipulation- induced stroke. A case of chiropractic- induced occipital lobe infarction with homonymous hemianopsia is reported, and the literature regarding neuro- ophthalmologic findings is reviewed. Key Words Cervical manipulation- Chiropractic- Extracranial arterial dissection- Hemianopsia- Stroke. Neurologic complications secondary to neck manipulation, specifically chiropractic manipulation, are known to neurologists but not well known to the public. The major categories of injury include stroke, myelopathy, and cervical radiculopathy. The frequency, although debated, may be greater even than that stated in the literature ( 1- 16). Neuro- ophtiialmologic complications are almost always the result of ischemia/ infarction secondary to injury to one or both vertebral arteries and far less frequently to a carotid artery ( 17,18). Most often, the neuro- ophthalmologic findings appear as part of a constellation of findings indicative of a major stroke, usually in the brain stem, most often in the lateral medullary tegmentum ( Wallenberg syndrome) ( 3- 16). Occasionally, however, relatively isolated neuro-ophthalmologic symptoms and signs may occur after chiropractic cervical manipulation. The cause may be missed unless the patient is carefully questioned. This is particularly true because there may be a long time between the manipulation and the cerebrovascular event ( 16,19,20). We have documented four patients with post-chiropractic vertebrobasilar distribution events at University Hospitals of Cleveland ( UHC) who were cared for by two members of the Department of Neurology in the last 5 years. One patient had an isolated neuro-ophthalmologic presentation. Manuscript received May 5, 2000; accepted July 25, 2000. From the Department of Neurology, University Hospitals of Cleveland, Case Western Reserve University, Ohio. Address correspondence and reprint requests to Michael W. Devereaux, MD, Department of Neurology, University Hospitals of Cleveland, 11100 Euclid Avenue, Cleveland, OH 44106. CASE A 34- year- old healthy woman with a 2- week history of neck pain had three chiropractic treatments during this period. On the drive home from the third treatment, she noted that she could not see well to the right. She saw her ophthalmologist the next day, and he identified a right visual field disturbance. She was admitted to UHC later that same day. There was no history of visual disturbance, migraine headache, or smoking. She was not taking birth- control pills. The only past medical problem was asthma. Results of the neurologic examination were normal, with the exception of a dense right congruous homonymous hemianopsia. Diagnostic tests: Magnetic resonance imaging ( MRI): Left occipital lobe ischemic infarct Magnetic resonance angiography ( MRA): Right vertebral artery dissection at the CI level and occlusion of the calcarine branch of the left posterior cerebral artery. She was anticoagulated with heparin and sent home 4 days later on warfarin. A follow- up visit, 4V2 months after discharge, indicated a persistent right homonymous hemianopsia. Diagnostic tests: MRI: 2- cm area of encephalomalacia, left occipital lobe MRA: Normal, with exception of slight irregularity of right vertebral artery lumen Anticoagulation was stopped and aspirin started. Approximately 16 months after the stroke, I spoke to her by telephone, and she still had a right visual field disturbance ( her lawyer would not permit a follow- up visit). DISCUSSION The vertebral arteries pass through the transverse foramina of the first six vertebrae of the highly mobile cervical spine, which permits approximately 160° of rotation, most of which occurs between the skull and the 236 THE NEURO- OPHTHALMOLOGIC COMPLICATIONS OF CERVICAL MANIPULATION 237 C3 vertebra. Approximately 90° of this rotation occurs between the axis and the atlas at the level of the atlas loop of the vertebral artery. Neck manipulation, particularly a combination of rotation and tilting, stretches the vertebral artery, producing a shearing force on this segment at the level of the atlantoaxial joint. This may result in an intimal tear with resultant occlusion of the lumen, thrombus formation, and embolization ( 9,17,21,22). A pseudo- aneurysm also may form in the vessel wall, producing occlusion ( Fig. 1) ( 5,8,23). Brown and Tatlow ( 23) angiographically showed occlusion of the vertebral artery in 5 of 41 cadavers subjected to simultaneous full head extension and 90° of rotation to the side opposite the occlusion. This indicates how potentially susceptible the vertebral arteries may be to head/ neck manipulation. Repeated neck manipulation also may produce subclinical changes in the vertebral arteries ( 16,19,20). The accumulation effect then may result in a subsequent stroke at a later date ( 16,19,20). Carotid artery dissection also may occur with neck rotation secondary to compression of the internal carotid artery against an upper cervical vertebra ( 9,17,18). Vertebrobasilar, and less commonly, carotid artery distribution vascular events can be the result of nonthera-peutic mechanical injury to the neck ( Table 1) as well as therapeutic neck manipulation ( Table 2). Therapeutic neck and back manipulation is an ancient art ( 29,30). The best known modern iterations, chiropractic and osteopathy, are both late nineteenth century American, midwest-ern inventions ( 31). Osteopathic manipulation in theory relieves symptoms by improving circulation to the spine, whereas chiropractic manipulation works by reducing subluxations that cause nerve- root compression. In 1895, Daniel David Palmer, a dry goods grocer and later a magneto- therapist on a quest to discover a unified concept to explain human illness, by chance manipulated a " vertebra racked from its normal position," on Harvey Lillard, a janitor claiming deafness for 17 years ( 30). The deafness was relieved. Palmer subsequently theorized that all disease is the result of interference with the body's " innate intelligence" by misaligned vertebrae ( 30). He coined the term chiropractic from the Greek Neck Manipulation I Intimal Tear Pseudo- aneurysm *" Occlusion i Thrombus I Embolization FIG. 1. Pathophysiology of vertebral artery injury. TABLE 1. Vertebrovasilar stroke: nontherapeutic mechanical causes Head positioning during medical procedures/ treatment Surgery ( 21) Cervical traction ( 24) Emergency recuscitation ( 21) Perimetry ( 25) Exercise Yoga ( 8,21) Calisthenics ( neck exercises) ( 8,21) Recreation/ sports activities Wrestling ( 8,21) Swimming ( 8,21) Football ( 26) Archery ( 8,21) Skiing ( 21) " Overhead" activities Work ( 8,11,21) Stargazing ( 21) Other Driving ( backing up) ( 8,21) Accidents ( 8,21) Sleeping ( unusual position) ( 8,21) cheiro ( hand) praktekas ( practice) and founded the Palmer School of Chiropractic in Davenport, Iowa. The chiropractor uses different manipulations and mobilization techniques. The most common are a low- velocity, high- amplitude method consisting of a series of gentle and repeated motions delivered to a point, and a high-velocity, low- amplitude method consisting of a sudden thrust delivered to the involved vertebrae ( 1,29). No studies have indicated which method is more likely to cause arterial injury ( 1,32). Neuro- ophthalmologic symptoms and signs may be the most prominent and sometimes the primary manifestation of a cerebrovascular insult after chiropractic manipulation ( Table 3). The most common are visual- field disturbances secondary to occipital lobe strokes, as is the case with my patient, ( 6,8,11,33- 35) Frisoni and Anzola ( 11) reported that 5% of the 72 cases they reviewed had occipital strokes. Quadrantanopias, hemianopias, and bilateral visual field disturbances also occur. Horner syndrome, in the absence of Wallenberg syndrome, also may occur ( 8,33,36). Grayson ( 36) theorized that in one case cervical manipulation produced direct injury to a white ramus comrnunicans with a resultant Horner syndrome. Two cases of internuclear ophthalmoplegia ( INO) after cervical manipulation have been reported ( 37,38); both had other neurologic findings. In addition, Sherman TABLE 2. Therapeutic- induced stroke Chiropractic Osteopathy Naturopaths ( 15) Allopaths ( occasional) ( 15,27) Physical therapists ( 8,15,27) Kung Fu practitioners ( 15) Barbers ( India) ( 28) Friend/ spouse ( 8,15) Self ( 8,15,21) J Neuro- Ophthalmol, Vol. 20, No. 4, 2000 238 M. W. DEVEREAUX TABLE 3. Neuro- ophthalmologic complications of chiropractic manipulation Visual field loss Horner syndrome Nystagmus Abducens palsy Internuclear ophthalmoplegia Gaze palsy Central retinal artery occlusion Painful ophthalmoplegia et al. ( 8) reported a case of INO as a result of head turning while backing up a car. Other complications of manipulations include sixth nerve palsy ( 8), gaze palsy ( 8,27), painful ophthalmoplegia ( 39), central retinal artery occlusion ( 40), and relatively isolated nystagmus ( 11,12). Does the therapeutic benefit of cervical manipulation justify the complication rate? The first problem in answering this questions is that the rate of complication is not fully established ( 15,32,41- 43). Only approximately 200 cases of cerebrovascular events have been reported, but a survey conducted on a small number of California neurologists adds 56 strokes to this number ( 1). I strongly suspect, based on the literature and personal experience, that a large number of cases are recognized but not reported. Probably additional cases of stroke exist in which the temporal relationship with chiropractic manipulation has gone unrecognized. With regard to low back chiropractic manipulation, a few studies have attempted to show benefit. The metaanalysis by Shekelle et al. ( 44) is often cited, but the benefit was minimal at best, and the results have been challenged ( 43). Other studies have shown essentially no benefit ( 45,46). Regarding benefit from cervical manipulation for neck pain and headache, a meta- analysis by Hurwitz et al. ( 42) concluded by stating, " cervical spine manipulation and mobilization probably provides at least some short- term benefits for some patients with neck pain and headache", hardly a ringing endorsement. Barr ( 47), commenting on this study, stated that there are " no convincing data to support manual therapy." CONCLUSION Stroke is a well- described consequence of chiropractic manipulation. Neuro- ophthalmologic disorders may be the primary and occasionally the sole manifestation of chiropractic- induced cerebrovascular injury. The frequency of chiropractic- induced stroke is uncertain but probably more common than currently appreciated. Patients presenting with stroke, particularly if relatively young; without stroke risk factors; and with evidence of vertebral artery dissection by MRA, should be questioned about recent chiropractic manipulation. 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