Vertigo and dizziness are among the commonly encountered symptoms presented by patients attending the emergency department (ED). Some of these patients, especially the elderly, have vertebrobasillar insufficiency (VBI) and even lethal cerebellar or brainstem infarct or haemorrhage. However, complications arising from chiropractic manipulation, especially vertebral artery dissection (VAD), may be seen in younger patients, causing VBI or cerebellar or brainstem infarct. This condition is rare but clinically significant, as its rarity and sometimes clinically atypical presentation can lead to misdiagnosis, with possible lethal outcome.

A 28 year old man in good health visited a chiropractor for treatment of neck pain for about 2 weeks. Following one of these chiropractic manipulation sessions, he began experiencing vertigo, and attended our ED immediately. On arrival, the symptoms had disappeared spontaneously. Physical and neurological examinations were essentially normal, and he was discharged with an appointment made for follow up at the outpatient clinic. The following day, he experienced another episode of vertigo, along with loss of balance, blurred vision, and mild numbness and weakness of the left extremities. He was again referred to our ED. Physical examination revealed a young man who appeared well, and was alert and cooperative except for an inability to tolerate sudden changes in position. Blood pressure was 146/76 mmHg, pulse rate was 90 beats/min, respiratory rate 18 breaths/min and ear temperature was 37.0°C. He denied any episodes of headache, syncope, head or neck trauma, and use of recreational drugs. Neurological examinations, including motor and sensory function, were essentially nonfocal; however, the patient could not stand or walk because of vertigo. Cerebellar tests including finger to nose, rapid alternating movement, and heel to shin were impaired on the right side. Routine laboratory studies including blood tests and electrolytes were within normal limits. Electrocardiography showed normal sinus rhythm, and cervical spine radiographs were normal. While retaking his history, we found that he had experienced several episodes of vertigo after cervical manipulation, thus, under high suspicion of cerebellar stroke associated with acute vascular injury, Doppler ultrasound of the extracranial artery was performed, which showed trickle flow over right distal vertebral artery. Magnetic resonance imaging of the brain revealed a tiny lesion over the right cerebellum with high intensity signal on T2 weighted image (fig 1A​1A),), which showed as a bright area on diffusion weighted images and dark on apparent diffusion coefficient mapping, most likely a tiny recent or acute infarction. Angiography of the vertebral artery revealed occlusion of the right distal vertebral artery near the craniocervical junction (fig 1B).

Chiropractic spinal manipulation is a popular alternative therapy for neck and back pain, which is performed by chiropractors, who tend to believe that it is not associated with relevant risks. However, in 1947, Pratt‐Thomas and Berger reported two patients who became unconscious during chiropractic adjustment and died in under 24 hours.¹ Since then, the risk factors and complications of chiropractic manipulation have been under discussion, and the opinion that chiropractic spinal manipulation is risk free has been contradicted by findings in the published literature.^2,3,4,5,6,7 The most frequently reported complication is posterior circulation stroke, usually related to VAD, occurring during or shortly after cervical manipulation.^2,3,6