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Highlights

There is no evidence that neck manipulation can cause cervical artery dissection.
There is evidence that neck manipulation can cause stroke.
Failure to diagnose and refer dissection is more common than causation of stroke.
Attorneys should be skeptical that neck manipulation can cause cervical artery dissection.
Attorneys should pay more attention to failure to diagnose and refer dissection.

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Abstract

Research shows no convincing evidence to support a causal link between cervical spine manipulation (CSM) and cervical artery dissection (CAD). Researchers have proposed that a belief in a causal link may have significant negative consequences such as numerous episodes of litigation. The objective of this study was to review 10 malpractice cases for evidence of unnecessary litigation due to a belief in a causal link between CSM and CAD.

A Google Scholar Case Law search from 1989 to 2024 was conducted to identify the 10 most recent English-language reports of malpractice cases involving an allegation that CSM caused CAD. Although our objective was to review 10 cases, only 9 cases were found.

In all cases, causation of CAD by CSM was not supported by the evidence. In 4 out 9 cases reviewed, causation of stroke by CSM was supported by the evidence. In all 9 cases reviewed, failure to diagnose an existing CAD was more likely than not but was not alleged.

We conclude that belief in a causal link between CSM and CAD does have negative consequences such as unnecessary litigation. In all 9 cases reviewed, allegations of failure to diagnose an existing CAD would have been more likely to result in a settlement without need for a trial.

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Introduction

In a 2016 systematic literature review and meta-analysis, Church et al. found no convincing evidence that cervical spine manipulation (CSM) can cause cervical artery dissection (CAD).1 The authors concluded that the known association of neck pain both with CAD and with CSM may explain the relationship between CSM and CAD. The most common symptoms of CAD are neck pain and/or headache which prompt patients to seek CSM. Numerous other studies concur with and support their conclusions.2, 3, 4, 5, 6, 7, 8

Church et al. also noted that although research shows no convincing evidence to support a causal link between CSM and CAD, a belief in a causal link persists.1 The authors went on to propose that this continued belief in a causal link may have significant negative consequences such as numerous episodes of litigation.

Most chiropractic malpractice cases involving CAD also involve stroke. It is commonly alleged that CSM can cause CAD and stroke. Although there is no convincing evidence that CSM can cause CAD, there are plausible mechanisms of causation of stroke by CSM.9 If CSM is performed in the presence of existing CAD, the sudden neck and head movement from CSM may dislodge a loosely adherent cervical artery blood clot causing thromboembolic stroke, or suddenly reposition an already large cervical artery blood clot causing thrombotic stroke.10,11 These strokes would be of immediate onset, with ischemic symptoms occurring within seconds or minutes.

The objective of this study was to test the hypothesis of Church et al. that belief in a causal link between CSM and CAD may result in numerous episodes of litigation. We aimed to meet this objective by searching for 10 malpractice cases of stroke following CSM and evaluating for the following criteria (Table 1):

A Google Scholar Case Law search from 1989 to 2024 was conducted to identify the 10 most recent English-language court opinions involving an allegation that CSM caused CAD. The significant research on a causal relationship of CSM, CAD and stroke began to published in 1989.9 Searching since 1989 ensured that the attorneys and experts for the cases had access to this research. Search terms were “chiropractic”, “dissection”, and “stroke”. Our search yielded 58 results.

1. Court opinions were included if the Plaintiff was a patient alleging that the Defendant, a health care practitioner, caused CAD by way of performing CSM.
2. Court opinions were excluded if they did not contain sufficient case information to evaluate causation of CAD by CSM.

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Section Snippets

RESULTS
Although our objective was to review 10 cases, only 9 cases were found that met the inclusion/exclusion criteria (Table 2).

CASE 1: GOLDSTEIN V. BERENBAUM(12)
Plaintiff presented to a chiropractic physician in November 2017. The Defendant performed CSM, which did not cause any pain during or after the treatment. Plaintiff was diagnosed with bilateral vertebral artery dissections and stroke in early December 2017.

The Plaintiff alleged that CSM performed in November 2017 proximately caused the bilateral VADs and stroke diagnosed in early December 2017. The Plaintiff moved for summary judgement which was denied in this court opinion. The matter was

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Discussion Of Findings

In all cases, allegations of causation of CAD by CSM were not supported by the evidence (Table 3). Bringing these unsupported allegations of causation resulted in unnecessary litigation, as noted by Church et al.1

In the four most recent cases, the outcome of the case was not in the court opinion. In the latter 5 cases, the allegations of causation of CAD by CSM were not successful.
In 4 out of 9 cases, there was evidence for causation of stroke by CSM (Table 3). Plaintiff attorneys and

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Conclusions

We conclude that belief in a causal link between CSM and CAD does have negative consequences such as unnecessary litigation. In all 9 cases reviewed, allegations that CSM caused CAD were not supported by the evidence. Four cases showed evidence of causation of stroke by CSM, even in the absence of causation of CAD by CSM. Failure to diagnose and refer an existing CAD was more likely than not in all 9 cases but was not alleged. If the Plaintiff had argued that the Defendant failed to diagnose

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Acknowledgement

The author would like to acknowledge Dr. Peter Tuchin for the inspiration of the original concept for this study.

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