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
Some diagnostic pitfalls should be noted for this condition. Firstly, because of the unfamiliarity and rarity of the condition, there is a possibility that medical staff will fail to elicit a history of cervical manipulation. The specific questions regarding spinal manipulation were not included when the patient made his first visit to the ED, and it was not until the second visit, with the patient showing recurrent vertigo and disequilibrium, which might be the signs of VBI, that the cervical manipulation history was discovered. Secondly, this condition may show a fluctuating course. The aetiology of vertigo is classically separated into peripheral and central types. Because the neurological examination of our patient on the first visit was essentially normal, and he was a relatively young patient without any risk factors of stroke, he was discharged under the impression of peripheral vertigo. A fluctuating clinical course, as in our case, with normal findings in at certain time points in the course of the condition, may also contribute to misdiagnosis.
Some authors are of the opinion that brain ischaemia is delayed by hours or even weeks after injuries, thus the presence of such a delay provides a time window during which measures could be undertaken to prevent thromboembolism and to maintain vessel patency.8
The vertebrobasilar infarction associated with VAD may significantly contribute to disability in surviving patients, and may even have legal implications. Early diagnosis and management is therefore essential. Anticoagulation with heparin followed by warfarin is the treatment of choice. Surgical intervention is indicated only for those patients with persistent symptoms refractory to medical therapy. Endovascular treatment (balloon angioplasty followed by placement of stents) has largely supplanted surgery as the initial therapy of choice in cases where medical therapy fails or is contraindicated, and even instead of medical therapy for many asymptomatic patients.9
Smith et al
have suggested that chiropractic manipulation independently increases the risk of VAD with stroke by approximately six fold.10
Rates of VBD following cervical manipulation from 1 in 10
000 to 1 in 2 million have been reported,6,11,12
but the exact incidence is still unknown. However, this diagnosis should be considered in patients presenting with recent onset vertigo and loss of balance, and history taking should include questions on presence or absence of recent spinal manipulation.