cervical spine adjusting and the vertebral artery

Cervical Spine Cervical Spine Adjusting and the Adjusting and the Vertebral Artery Vertebral Artery

Contemporary Perspectives on Contemporary Perspectives on Patient Safety and Protection, Patient Safety and Protection,

Clinical Reality and Patient Clinical Reality and Patient ManagementManagement

Why understand this?Why understand this?

Currently the single most important issue Currently the single most important issue related to the practice of chiropractic from related to the practice of chiropractic from a a public safety issue standpointpublic safety issue standpoint is is associated with vertebral artery related associated with vertebral artery related matters.matters.

Similarly, a key issue from a Similarly, a key issue from a public public relations perspectiverelations perspective is related to the is related to the practice of chiropractic as associated with practice of chiropractic as associated with vertebral artery related matters.vertebral artery related matters.

Why understand this?Why understand this?

The Lewis Inquest in Toronto, Ontario The Lewis Inquest in Toronto, Ontario has provided a treasure trove of has provided a treasure trove of information related to vertebral artery information related to vertebral artery issues of interest to practicing issues of interest to practicing chiropractors.chiropractors.

The recent controversy surrounding The recent controversy surrounding Vioxx and Accutane signals a Vioxx and Accutane signals a changing public expectation with changing public expectation with respect to health care interventions.respect to health care interventions.

Today’s OutcomesToday’s Outcomes

To provide the practicing chiropractor To provide the practicing chiropractor with:with:

• A review of the relevant anatomy, physiology and A review of the relevant anatomy, physiology and pathology associated with vertebral artery injuries, pathology associated with vertebral artery injuries, particularly vertebral artery dissection, to assure particularly vertebral artery dissection, to assure an understanding of the basic mechanisms an understanding of the basic mechanisms involvedinvolved

• A review of the current demographic and incidence A review of the current demographic and incidence data, the sources of the data, and the strengths data, the sources of the data, and the strengths and weaknesses of the data associated with and weaknesses of the data associated with vertebral artery injury and cervical spine adjustingvertebral artery injury and cervical spine adjusting

Today’s OutcomesToday’s Outcomes

• Current thoughts on the appropriate Current thoughts on the appropriate procedures to be used before the initiation procedures to be used before the initiation of cervical spine adjusting and the of cervical spine adjusting and the recommended procedures in the event a recommended procedures in the event a patient demonstrates signs of VAD before, patient demonstrates signs of VAD before, during, or after a care encounterduring, or after a care encounter

• Current perspectives on VAD in progress and Current perspectives on VAD in progress and the clinical warning signs of the patient who the clinical warning signs of the patient who presents in a potentially compromised state, presents in a potentially compromised state, as well as the most appropriate response as well as the most appropriate response theretothereto

A 30,000 foot perspective!A 30,000 foot perspective!

U.S. population: 300,000,000U.S. population: 300,000,000 Strokes in a year in the U.S.: 700,000Strokes in a year in the U.S.: 700,000 VAD occurs at a rate of: 1/100,000 pop.VAD occurs at a rate of: 1/100,000 pop. VADs annually in the U.S.: 3,000VADs annually in the U.S.: 3,000 % of pop. To visit a DC in U.S.: 10%% of pop. To visit a DC in U.S.: 10% # of VAD patients likely to see a DC: # of VAD patients likely to see a DC:

300300 60,000 DCs in U.S., if evenly 60,000 DCs in U.S., if evenly

distributed then 1/200distributed then 1/200

Stroke OverviewStroke Overview

700,000 strokes annually700,000 strokes annually 80% are ischemic (clot related)80% are ischemic (clot related) 20% are hemorrhagic (bleed related)20% are hemorrhagic (bleed related) 3,000 VADs per year3,000 VADs per year 1 of every 233 strokes is related to a 1 of every 233 strokes is related to a

VADVAD 75% of VAD related strokes make a good 75% of VAD related strokes make a good

recoveryrecovery 5% of VAD related strokes result in death5% of VAD related strokes result in death

Review: Anatomy, Physiology Review: Anatomy, Physiology & Pathology of Vertebral & Pathology of Vertebral

ArteriesArteries1. Gross anatomy 1. Gross anatomy

2. Histology2. Histology

3. Mechanism of Basic Pathology:3. Mechanism of Basic Pathology:

a. Injury and inflammationa. Injury and inflammation

b. Clotting and thrombus formationb. Clotting and thrombus formation

c. Embolic. Emboli

d. Ischemiad. Ischemia

1. Gross Anatomy Review1. Gross Anatomy Review

Arterial circulation of the vertebral Arterial circulation of the vertebral arteries:arteries:

a. Origina. Origin

b. Courseb. Course

c. Distributionc. Distribution

d. Common anomalies d. Common anomalies

Arterial CirculationArterial Circulation

a. Origin of the a. Origin of the Vertebral arteries:Vertebral arteries:

• Arise from the Arise from the Subclavian arteries Subclavian arteries bilaterallybilaterally

• Arise proximal to the Arise proximal to the Thyrocervical trunk Thyrocervical trunk and distal to the and distal to the Common Carotid Common Carotid arteryartery

Course of the Vertebral Course of the Vertebral ArteriesArteries

Divided into 4 Divided into 4 segments as they segments as they ascend the cervical ascend the cervical spine:spine:

Segment ISegment I: Rises : Rises from the Subclavian from the Subclavian artery to the artery to the transverse foramen of transverse foramen of C6C6


Segment IISegment II: Within : Within the transverse the transverse foramina from C6-foramina from C6-C2C2


Segment IIISegment III: From : From the superior of C2 the superior of C2 foramen to the foramen to the duradura


Segment IVSegment IV: From : From the dura into the the dura into the craniumcranium


c. Distribution from the Vertebral c. Distribution from the Vertebral arteries:arteries:

• From the Subclavian arteries, the From the Subclavian arteries, the Vertebral arteries ascend to ultimately Vertebral arteries ascend to ultimately unite and form the Basilar artery.unite and form the Basilar artery.

• The Posterior Inferior Cerebellar artery The Posterior Inferior Cerebellar artery (PICA) arises prior to the junction of the (PICA) arises prior to the junction of the right and left Vertebral arteries forming right and left Vertebral arteries forming the Basilar artery.the Basilar artery.


d. Common anomalies:d. Common anomalies:

Approximately 10% of patients have some form Approximately 10% of patients have some form of anomaly in their Vertebral artery(ies).of anomaly in their Vertebral artery(ies).

• Unilateral or bilateral absence of the Vertebral Unilateral or bilateral absence of the Vertebral arteryartery

• Origin of the Vertebral arteries varies in 3.5% of Origin of the Vertebral arteries varies in 3.5% of casescases

• The PICAs have an extra dural origin in 5-20% of The PICAs have an extra dural origin in 5-20% of cases: arising approximately 1 cm proximal to dural cases: arising approximately 1 cm proximal to dural penetrationpenetration


Anomalies, continued:Anomalies, continued:

• Contralateral rotation can cause alteration in Contralateral rotation can cause alteration in blood flow at the C1-C2 level on MRAblood flow at the C1-C2 level on MRA

• Compression of the Vertebral artery(ies) is Compression of the Vertebral artery(ies) is seen in 5% of the population in both a seen in 5% of the population in both a neutral position and in rotationneutral position and in rotation

• Variations in arterial diameter (average 4.3 Variations in arterial diameter (average 4.3 mm on the right, 4.7 mm on the left)mm on the right, 4.7 mm on the left)


Anomalies, continued:Anomalies, continued:

• Segment 1 is tortuous in 39% of specimensSegment 1 is tortuous in 39% of specimens

• 7% of Vertebral arteries cannot be imaged 7% of Vertebral arteries cannot be imaged with sonography due to the depth of the with sonography due to the depth of the tissuetissue

• A change in excess of 56% is needed to A change in excess of 56% is needed to detect alterations using Doppler imagingdetect alterations using Doppler imaging

2. Histology of Blood 2. Histology of Blood VesselsVessels

• The Vertebral arteries The Vertebral arteries are comparable in size are comparable in size and design to the renal and design to the renal arteries or some of the arteries or some of the smaller coronary smaller coronary arteries.arteries.

• They exhibit the typical They exhibit the typical 3 layer pattern from 3 layer pattern from inside out: tunica inside out: tunica intima, tunica media intima, tunica media and tunica adventitia.and tunica adventitia.

Adventitia

Media

Intima

3. Mechanism of Basic 3. Mechanism of Basic PathologyPathology

a. Injury and Inflammationa. Injury and Inflammation

Arteriopathy may arise from Arteriopathy may arise from conditions such as:conditions such as:

• Marfan’s DiseaseMarfan’s Disease• Ehler Danlos Syndrome-types IV and VIEhler Danlos Syndrome-types IV and VI• Autosomal Dominant Polycystic Kidney Autosomal Dominant Polycystic Kidney

DiseaseDisease• Osteogenesis Imperfecta Type I (yielding Osteogenesis Imperfecta Type I (yielding

cystic medial degeneration)cystic medial degeneration)• Fibromuscular HyperplasiaFibromuscular Hyperplasia


b. Clotting and thrombus formationb. Clotting and thrombus formation

•Arterial damage, particularly involving Arterial damage, particularly involving the tunica intima, will yield the start of the tunica intima, will yield the start of increased localized clotting and thereby increased localized clotting and thereby thrombus formation.thrombus formation.

•Arterial flow changes can result from Arterial flow changes can result from histological changes as well as from histological changes as well as from mechanical changes in the vessel.mechanical changes in the vessel.


Intimal dissection with blood flow beneath the intimaand associated thrombus formation


c. Embolic. Emboli

• Emboli present in three primary forms:Emboli present in three primary forms:• Liquid—amniotic fluidLiquid—amniotic fluid• Solid—excessive clottingSolid—excessive clotting• Gaseous—Caisson’s DiseaseGaseous—Caisson’s Disease

• The thrombus at the site of arterial damage The thrombus at the site of arterial damage is invariably the source of emboli yielding is invariably the source of emboli yielding ischemic stroke from the Vertebral artery.ischemic stroke from the Vertebral artery.


d. Ischemiad. Ischemia

•The degree of ischemia resultant from an The degree of ischemia resultant from an embolism is the consequence of the size embolism is the consequence of the size and location of the embolism, as well as and location of the embolism, as well as the presence/absence of collateral the presence/absence of collateral circulation to the affected area.circulation to the affected area.

From the Basics to the From the Basics to the AdvancedAdvanced

1. Mechanisms/origins of 1. Mechanisms/origins of Vertebral Vertebral artery dissection artery dissection (VAD)(VAD)

2. Types of VAD2. Types of VAD

3. Pathophysiology of VAD3. Pathophysiology of VAD

4. Sequellae of VAD4. Sequellae of VAD

1. Mechanisms/origins of VAD1. Mechanisms/origins of VAD

The literature indicates that VAD arises The literature indicates that VAD arises spontaneously, from trivial movement, spontaneously, from trivial movement, minor trauma or major trauma.minor trauma or major trauma.

The following have been cited in the The following have been cited in the literature as preceding VAD: judo, yoga, literature as preceding VAD: judo, yoga, ceiling painting, nose blowing, ceiling painting, nose blowing, hypertension, oral contraceptive use, hypertension, oral contraceptive use, sexual activity, receiving anesthesia, use sexual activity, receiving anesthesia, use of resuscitation activities, receiving a of resuscitation activities, receiving a shampoo, vomiting, sneezing, adjustive or shampoo, vomiting, sneezing, adjustive or manipulative procedures.manipulative procedures.

2. Types of VAD 2. Types of VAD

Dissections arise from an intimal Dissections arise from an intimal tear, yielding an intramural tear, yielding an intramural hematoma, which is then identified hematoma, which is then identified as subintimal or subadventitial.as subintimal or subadventitial.

•Subintimal dissections tend to result Subintimal dissections tend to result in stenosis of the arteryin stenosis of the artery

•Subadventitial dissections tend to Subadventitial dissections tend to result in aneurysm formationresult in aneurysm formation


The root of the problem is an The root of the problem is an expanding hematoma in the wall of expanding hematoma in the wall of the Vertebral Artery as a result of:the Vertebral Artery as a result of:

•hemorrhage of the vasa vasorum hemorrhage of the vasa vasorum within/associated with the tunica within/associated with the tunica media media

•development of an intimal flap in the development of an intimal flap in the lumen of the vessellumen of the vessel

Subintimal vs. Subintimal vs. SubadventitialSubadventitial

Vessel lumen

Aneurysm


The evolution of the hematoma The evolution of the hematoma may include the following:may include the following:

• It seals off, remains small and is largely It seals off, remains small and is largely asymptomaticasymptomatic

• An expanding hematoma of a An expanding hematoma of a subintimalsubintimal nature occludes the vessel, yielding ischemia nature occludes the vessel, yielding ischemia and subsequent infarctionand subsequent infarction

• A lesion of a A lesion of a subadventitialsubadventitial nature yields an nature yields an aneurysm that is prone to rupture through the aneurysm that is prone to rupture through the adventitia, yielding a subdural hematomaadventitia, yielding a subdural hematoma


The consequences of an intimal The consequences of an intimal disruption may include: disruption may include:

•alteration of normal hemodynamicsalteration of normal hemodynamics•creation of a thrombogenic environmentcreation of a thrombogenic environment• formation of a thrombusformation of a thrombus•potential generation of embolipotential generation of emboli

4. Sequellae of VAD4. Sequellae of VAD

The effects of altered arterial flow The effects of altered arterial flow through the Vertebral artery as a through the Vertebral artery as a result of a dissection can yield:result of a dissection can yield:

•Few or minimal symptomsFew or minimal symptoms•Transient ischemic attacksTransient ischemic attacks•Development of thrombi and emboliDevelopment of thrombi and emboli•Potential for ischemia and/or infarctionPotential for ischemia and/or infarction

VAD in LiteratureVAD in Literature

1. Mechanisms of origin1. Mechanisms of origin

2. Incidence2. Incidence

3. Morbidity and mortality3. Morbidity and mortality

4. Predisposing factors4. Predisposing factors

5. Theorized predisposing factors5. Theorized predisposing factors

6. Predictors of VAD6. Predictors of VAD

Vertebral Artery DissectionVertebral Artery Dissection

1. Mechanism of origin1. Mechanism of origin

According to Haldeman et al. Spine 1999 According to Haldeman et al. Spine 1999 Apr 15;24(8):785-94 (Based on cases Apr 15;24(8):785-94 (Based on cases reported in scientific literature):reported in scientific literature):

• 43% of are spontaneous in nature43% of are spontaneous in nature• 31% are associated with cervical spine 31% are associated with cervical spine

manipulationmanipulation• 16% from trivial trauma16% from trivial trauma• 10% from major trauma10% from major trauma


1. Mechanism of origin1. Mechanism of originAccording to Beaudry and Spence (The According to Beaudry and Spence (The Canadian Journal of Neurological Sciences, Canadian Journal of Neurological Sciences, V. 30, No. 4, November 2003, pp. 320-304) V. 30, No. 4, November 2003, pp. 320-304)

• The most common cause of traumatic Vertebrobasilar The most common cause of traumatic Vertebrobasilar ischemia is motor vehicle accidents.ischemia is motor vehicle accidents.

• Of 80 cases that presented over 20 years to a single Of 80 cases that presented over 20 years to a single neurovascular practice, 70 were related to MVAs, 5 to neurovascular practice, 70 were related to MVAs, 5 to industrial injuries, 5 associated with chiropractic. industrial injuries, 5 associated with chiropractic. Consideration was offered that some of the cases Consideration was offered that some of the cases that were related to chiropractors were also involved that were related to chiropractors were also involved in MVAs, further confounding the matter.in MVAs, further confounding the matter.


2. Incidence of VAD 2. Incidence of VAD (Schievink, NEJM 3/22/01)(Schievink, NEJM 3/22/01)

• Approximately 3,000 of the 700,000 reported Approximately 3,000 of the 700,000 reported strokes yearly are VADs.strokes yearly are VADs.

• Dissections account for 10-25% of all ischemic Dissections account for 10-25% of all ischemic strokes in young or middle aged persons.strokes in young or middle aged persons.

• VAD and CAD account for 2.6 per 100,000 VAD and CAD account for 2.6 per 100,000 strokes.strokes.

• Female to male ratio: 3:1 (disputed)Female to male ratio: 3:1 (disputed)• Average age: VAD—40, CAD—47 (disputed)Average age: VAD—40, CAD—47 (disputed)


2. Incidence of VAD—Reported Numbers2. Incidence of VAD—Reported Numbers• 1 in 5,000 adjustments cause a 1 in 5,000 adjustments cause a stroke stroke

(Norris, SPONTADS, unpublished)(Norris, SPONTADS, unpublished)• 1 in 20,000 adjustments cause a stroke (Vickers, 1 in 20,000 adjustments cause a stroke (Vickers,

BMJ, 1999)BMJ, 1999)• 1.3 in 100,000 patients (Rothwell, Stroke, 2001)1.3 in 100,000 patients (Rothwell, Stroke, 2001)• 1 in 1 million adjustments (Hosek et al, JAMA, 1 in 1 million adjustments (Hosek et al, JAMA,

1981)1981)• 1 in 2 million adjustments (Klougart et al, JMPT, 1 in 2 million adjustments (Klougart et al, JMPT,

1996)1996)• 1 in 5.85 million cervical spine adjustments 1 in 5.85 million cervical spine adjustments

(Carey et al, CMAJ, 2001)(Carey et al, CMAJ, 2001)


2. Incidence of VAD—2. Incidence of VAD—Discussion Discussion

• The Rothwell data involves all patients who The Rothwell data involves all patients who experienced a stroke within 7 days of a experienced a stroke within 7 days of a chiropractic office visitchiropractic office visit

• The Carey data reflects claims filed for a The Carey data reflects claims filed for a stroke following chiropractic carestroke following chiropractic care

• It is likely that among the Rothwell data there It is likely that among the Rothwell data there were unrelated strokes and among the Carey were unrelated strokes and among the Carey data there were unreported claimsdata there were unreported claims

• Safe number: 1/1-2 million adjustmentsSafe number: 1/1-2 million adjustments


4. Predisposing factors4. Predisposing factors

•Aforementioned heritable conditionsAforementioned heritable conditions•““approximately 5 percent of patients approximately 5 percent of patients

with spontaneous dissection of the with spontaneous dissection of the carotid or vertebral artery have at least carotid or vertebral artery have at least one family member who has had a one family member who has had a spontaneous dissection of the aorta or spontaneous dissection of the aorta or its main branches.” (Schievink, NEJM its main branches.” (Schievink, NEJM 2001)2001)


5. Theorized predisposing factors5. Theorized predisposing factors

• Migraine—One case-control study in 1989 Migraine—One case-control study in 1989 suggested that migraine was a risk factor for suggested that migraine was a risk factor for cervical artery dissection (D’Anglejan, cervical artery dissection (D’Anglejan, Headache, 1989)Headache, 1989)

• Hyperhomocysteinemia—reported by Hyperhomocysteinemia—reported by Pezzini, J Neurology, 2002Pezzini, J Neurology, 2002

• Previous respiratory infection together with Previous respiratory infection together with other neurological symptomsother neurological symptoms


6. Predictors of VAD6. Predictors of VAD

““Thus, given the current state of the Thus, given the current state of the literature, it is impossible to advise literature, it is impossible to advise patients or physicians about how to avoid patients or physicians about how to avoid vertebrobasilar artery dissection when vertebrobasilar artery dissection when considering cervical manipulation or about considering cervical manipulation or about specific sports or exercises that result in specific sports or exercises that result in neck movement or trauma.” (Haldeman et neck movement or trauma.” (Haldeman et al, Spine 1999)al, Spine 1999)

Clinical Pearl Number OneClinical Pearl Number One

Current thinking holds that the Current thinking holds that the majority of patients who majority of patients who develop frank symptoms of a develop frank symptoms of a vertebral artery dissection vertebral artery dissection following chiropractic care following chiropractic care were in the process of were in the process of dissection when they dissection when they presented for care.presented for care.

In Support of this IdeaIn Support of this Idea

• Did the SMT Practitioner Cause the Arterial Did the SMT Practitioner Cause the Arterial Injury? Terrett, Chiropractic Journal of Injury? Terrett, Chiropractic Journal of Australia, Vol. 32, No. 3, 9/2003, pp. 99-110Australia, Vol. 32, No. 3, 9/2003, pp. 99-110

• Manipulation of the Neck and Stroke: time Manipulation of the Neck and Stroke: time for more rigorous evidence. Breene, Medical for more rigorous evidence. Breene, Medical Journal of Australia, Vol. 176, 15 Apr 2002, Journal of Australia, Vol. 176, 15 Apr 2002, pp.364-365pp.364-365

• Spinal manipulative therapy is an Spinal manipulative therapy is an independent risk factor for vertebral artery independent risk factor for vertebral artery dissection. Smith, Neurology, Vol. 60, pp. dissection. Smith, Neurology, Vol. 60, pp. 1424-14281424-1428

Against this IdeaAgainst this Idea

• Spinal Manipulative Therapy is an Spinal Manipulative Therapy is an Independent Risk Factor for Vertebral Independent Risk Factor for Vertebral Artery Dissection. Smith, Neurology, 2003, Artery Dissection. Smith, Neurology, 2003, Vol. 60, pp. 1424-1428Vol. 60, pp. 1424-1428

For the Practicing DCFor the Practicing DC

• Pre-adjusting screening testsPre-adjusting screening tests

• Pre and post adjustment indicators of Pre and post adjustment indicators of VADVAD• Abnormal behavior/speechAbnormal behavior/speech• Pathognomonic complaintPathognomonic complaint• Pain patternsPain patterns

• Important Steps to followImportant Steps to follow

Pre-adjustment screening Pre-adjustment screening tests?tests?

We were all taught “George’s Test”, We were all taught “George’s Test”, “DeKlynes Test” and other tests for “DeKlynes Test” and other tests for Vertebral artery competency.Vertebral artery competency.

Regardless of what your teachers, Regardless of what your teachers, colleagues, professional liability carriers, colleagues, professional liability carriers, risk management consultants have told risk management consultants have told you about these provocative tests—you about these provocative tests—DO DO NOT DO THEMNOT DO THEM..

Pre-adjustment screening Pre-adjustment screening teststests

• Yield an unacceptable percentage of false positives Yield an unacceptable percentage of false positives and false negativesand false negatives

• Offer no reliable informationOffer no reliable information• May be enough to make a bad situation worse for May be enough to make a bad situation worse for

the patient who has a VAD in progressthe patient who has a VAD in progress• Were included in provocative testing that was Were included in provocative testing that was

abandoned by all of the clinic directors of U.S. abandoned by all of the clinic directors of U.S. chiropractic programs (which was supported by all chiropractic programs (which was supported by all of the presidents/deans of the schools) in March of the presidents/deans of the schools) in March 20042004

• Bottom Line: There are no reliable or safe Bottom Line: There are no reliable or safe tests that will rule out a VAD in progress and tests that will rule out a VAD in progress and there are no tests that will identify a patient there are no tests that will identify a patient at risk for VAD.at risk for VAD.

What is a Person to Do?What is a Person to Do?

• There are no clear-cut predisposing There are no clear-cut predisposing factors suggesting VAD…factors suggesting VAD…

• There are no testing procedures helpful There are no testing procedures helpful in ruling out potential VAD patients…in ruling out potential VAD patients…

• The great majority of VAD-in-progress The great majority of VAD-in-progress patients present with musculoskeletal patients present with musculoskeletal complaints…complaints…

What is a person to do?What is a person to do?

What is a Person to Do?What is a Person to Do?

Look, listen, ask and Look, listen, ask and thinkthink

Look and Listen for:Look and Listen for:

Five “Ds”Five “Ds”– DizzinessDizziness– Drop attacksDrop attacks– DiplopiaDiplopia– DysarthriaDysarthria– DysphagiaDysphagia

AndAnd– AtaxiaAtaxia

Three “Ns”Three “Ns”– NauseaNausea– NumbnessNumbness– NystagmusNystagmus

Perspective on the 5 D’s, 3 N’s and the Perspective on the 5 D’s, 3 N’s and the A!A!

• Many patients present to chiropractors Many patients present to chiropractors exhibiting one or more of these symptomsexhibiting one or more of these symptoms

• Many patients seek care for these symptomsMany patients seek care for these symptoms• The presence of these symptoms, in and of The presence of these symptoms, in and of

themselves, may or MAY NOT be an indication themselves, may or MAY NOT be an indication of a possible VAD-in-progressof a possible VAD-in-progress

• The constellation of symptoms (dizziness, The constellation of symptoms (dizziness, nausea and diplopia for example), the nausea and diplopia for example), the uniqueness of the symptom (drop attacks for uniqueness of the symptom (drop attacks for example) and/or the degree/severity of the example) and/or the degree/severity of the symptoms should draw the clinician’s attentionsymptoms should draw the clinician’s attention

Look and Listen for:Look and Listen for:

Slurred speechSlurred speech GiddinessGiddiness A change in voice A change in voice

patternpattern Lack of context in Lack of context in

speechspeech Inappropriate Inappropriate

reactions to reactions to situationssituations

One characteristic, One characteristic, almost almost pathognomonic pathognomonic phrase from your phrase from your patient-whether patient-whether they be an old or a they be an old or a new patient, new patient, getting their first getting their first adjustment or their adjustment or their 100100thth……

Clinical Pearl Number TwoClinical Pearl Number Two

The phraseThe phrase::““I have a pain in my I have a pain in my neck and (or) head neck and (or) head unlike anything I unlike anything I have ever had have ever had

beforebefore.”.”

Clinical Pearl Number ThreeClinical Pearl Number Three

For those patients who For those patients who experienced a VAD, on follow-up experienced a VAD, on follow-up 50% had a recent appearance of a 50% had a recent appearance of a new chief complaint of upper new chief complaint of upper quadrant neck pain (occipital quadrant neck pain (occipital area) and/or the hemicranium. The area) and/or the hemicranium. The pain was described as throbbing, pain was described as throbbing, steady or sharp: the “thunderclap” steady or sharp: the “thunderclap” headache.headache.

Pain referral common to Vertebral Pain referral common to Internal Carotid

Ask QuestionsAsk Questions

DC: Tell me some more about this pain.DC: Tell me some more about this pain.

DC: Were you doing anything before DC: Were you doing anything before you experienced the pain, or did it you experienced the pain, or did it come out of the blue?come out of the blue?

DC: How do you feel otherwise? Light DC: How do you feel otherwise? Light headed? A little dizzy? Etc.headed? A little dizzy? Etc.

Think About What?Think About What?

Stopping cold in your tracks when Stopping cold in your tracks when you have heard you have heard TheThe phrase. phrase.

Taking a step back, slowing down Taking a step back, slowing down and paying close attention to and paying close attention to everything about this patient.everything about this patient.

Moving cautiously, discretion is the Moving cautiously, discretion is the better part of valor.better part of valor.

Think About What?Think About What?

In the presence of a patient who:In the presence of a patient who:•expresses non-traumatic or post-whiplash expresses non-traumatic or post-whiplash

neck pain as a new chief complaint…neck pain as a new chief complaint…•refers to the pain as unlike anything they refers to the pain as unlike anything they

have ever had before…have ever had before…• is exhibiting other neurological is exhibiting other neurological

symptoms… symptoms…

……Referral for evaluation of possible VAD Referral for evaluation of possible VAD before adjusting is strongly recommended.before adjusting is strongly recommended.

VAD Symptoms Following an VAD Symptoms Following an AdjustmentAdjustment

• Your management and documentation of Your management and documentation of the situation are the most important the situation are the most important issues in reducing morbidity and mortality, issues in reducing morbidity and mortality, as well as in limiting or reducing liability.as well as in limiting or reducing liability.

• Your recognition of the post-adjustment Your recognition of the post-adjustment symptomatic picture is critical. You symptomatic picture is critical. You cannot assume that because VAD is cannot assume that because VAD is extremely rare that it won’t, didn’t or can’t extremely rare that it won’t, didn’t or can’t happen in your office.happen in your office.

What Should I Do?What Should I Do?

• Any of 5 D’s, the A, or any of the 3 N’s should Any of 5 D’s, the A, or any of the 3 N’s should cause you to pay attention immediately.cause you to pay attention immediately.

• If the symptoms are mild, monitor them for If the symptoms are mild, monitor them for their decrease or their resolutiontheir decrease or their resolution

• If severe, consider emergency services If severe, consider emergency services immediatelyimmediately

• Each situation will require a different Each situation will require a different responseresponse• Always monitor the patient’s vitals, as well as Always monitor the patient’s vitals, as well as

specific neurological responses that drew attentionspecific neurological responses that drew attention• Availability of baseline vitals will allow this data to Availability of baseline vitals will allow this data to

be more meaningfulbe more meaningful


• If the symptoms are very transient, If the symptoms are very transient, limited and resolve quickly, take a limited and resolve quickly, take a position of “watchful waiting”position of “watchful waiting”

• Consider the area adjusted, the type of Consider the area adjusted, the type of adjustment given, and if an alternate adjustment given, and if an alternate approach would be in orderapproach would be in order

• Do not readjust the patient at this timeDo not readjust the patient at this time


• If the symptoms do NOT resolve quickly, If the symptoms do NOT resolve quickly, monitor the patient and stay with the monitor the patient and stay with the patient, no matter how the waiting room is patient, no matter how the waiting room is stacked.stacked.

• Watch for the development of additional Watch for the development of additional symptoms, note the mental status, degree symptoms, note the mental status, degree of confusion if any, etc.of confusion if any, etc.

• If symptoms persist, or if they worsen, seek If symptoms persist, or if they worsen, seek emergency services support. Monitor the emergency services support. Monitor the patient while waiting for support services.patient while waiting for support services.

• Do not readjust the patient at this time.Do not readjust the patient at this time.

Why Not Readjust?Why Not Readjust?

IF the patient is experiencing a IF the patient is experiencing a VAD, there is no form of adjustment VAD, there is no form of adjustment that will minimize the consequences that will minimize the consequences of the dissection, and the of the dissection, and the introduction of another force may introduction of another force may serve to mobilize thrombi and serve to mobilize thrombi and create emboli, increasing the create emboli, increasing the likelihood of an ischemic event.likelihood of an ischemic event.

Importance of Immediate Importance of Immediate ActionAction

• VAD—>thrombus—>emboli—> VAD—>thrombus—>emboli—> cerebellar or brainstem ischemiacerebellar or brainstem ischemia

• Emergency pharmaceutical Emergency pharmaceutical intervention, i.e. tPA, is most intervention, i.e. tPA, is most effective in the first 90 minutes, effective in the first 90 minutes, moderately effective for three moderately effective for three hours and possibly effective for up hours and possibly effective for up to six hoursto six hours

• Time is of the essence!Time is of the essence!

Professional Liability Professional Liability ComplicationsComplications

• Failure to recognize what is going on, to write it off Failure to recognize what is going on, to write it off as a “normal” or “typical reaction to an adjustment”as a “normal” or “typical reaction to an adjustment”

• Failure to monitor and document the progress of the Failure to monitor and document the progress of the patient following the onset of the problem, as well patient following the onset of the problem, as well as to document your thought processes regarding as to document your thought processes regarding the situationthe situation

• Failure to manage the situation properly and in a Failure to manage the situation properly and in a timely mannertimely manner

• Readjusting the patientReadjusting the patient• Sending the patient home if in an unstable/fragile Sending the patient home if in an unstable/fragile

statestate• Taking a casual approach to seeing another providerTaking a casual approach to seeing another provider• Being less than honest and explicit in the recordBeing less than honest and explicit in the record

Tomorrow MorningTomorrow Morning

• Do not be fearful of delivering a competent Do not be fearful of delivering a competent cervical spine adjustmentcervical spine adjustment

• Pay close attention to the responses of Pay close attention to the responses of patients following cervical spine patients following cervical spine adjustmentsadjustments

• Do not assume, “it couldn’t happen in my Do not assume, “it couldn’t happen in my office”office”

• Evaluate your procedures: are you asking Evaluate your procedures: are you asking the right questions? Does your staff the right questions? Does your staff understand the mechanisms involved and understand the mechanisms involved and know what kinds of subtle changes to look know what kinds of subtle changes to look for?for?

Tomorrow MorningTomorrow Morning

• Include your staff in a plan for what you Include your staff in a plan for what you would do if… (emergency numbers, would do if… (emergency numbers, possible scenarios with action plans so possible scenarios with action plans so that you react to plans, not problems)that you react to plans, not problems)

• Document, document, documentDocument, document, document• Understand the mechanisms involved Understand the mechanisms involved

and respond accordinglyand respond accordingly• Act in the best interest of your patient, Act in the best interest of your patient,

always and in all ways—this is always and in all ways—this is ultimately in your best interest as well.ultimately in your best interest as well.

DisclaimerDisclaimer

This lecture has been developed as an This lecture has been developed as an instructional guide. The information instructional guide. The information contained herein is based on sources contained herein is based on sources believed to be generally correct, however, believed to be generally correct, however, because of variances in state statutes, because of variances in state statutes, educational philosophy, professional educational philosophy, professional assiduity, and court opinions the Association assiduity, and court opinions the Association of Chiropractic Colleges assumes no of Chiropractic Colleges assumes no responsibility as to the accuracy or scope of responsibility as to the accuracy or scope of the suggestions offered in a particular the suggestions offered in a particular circumstance. Legal counsel should be circumstance. Legal counsel should be consulted for optimal guidance. The consulted for optimal guidance. The opinions expressed in this lecture are opinions expressed in this lecture are exclusively those of the author.exclusively those of the author.

FinisFinis

Copies of this presentation in Copies of this presentation in PowerPoint are available, as are any of PowerPoint are available, as are any of the abstracts of the articles referenced the abstracts of the articles referenced in this presentation. If you desire to in this presentation. If you desire to receive any of this information contact receive any of this information contact Dr. Clum at:Dr. Clum at:

[email protected]

Let us know the abstract(s) you wish, your Let us know the abstract(s) you wish, your postal address and telephone number!postal address and telephone number!

cervical spine adjusting and the vertebral artery

Documents

vertebral artery origin

vertebral artery injury

vertebral artery injuries

vertebral artery dissection

vertebral artery issues

vertebral arteryies

subclavian arteries

arterial circulation