CHAPTER 7
Clinical Presentation
of Vertebral Artery
Dissection
Vertebral artery dissection (VAD) is a tear in the wall of the vertebral artery located in the neck. This often causes an interruption of blood flow within the layers of the arterial wall, ultimately resulting in a blood clot in the artery.
Epidemiology
The overall incidence of VAD is relatively rare – roughly 1–1.5 per 100,000 (Park et al., 2008). Kim and Schulman (2009), reviewing a number of population-based studies, suggested that the average annual incidence of VAD in the United States and France was 1–1.1 per 100,000. Surprisingly, the authors also found that from 1994 to 2003, the rate of VAD incidences gradually increased approximately threefold. However, this surge in incidence rate has been attributed to the gradual increase of more sophisticated diagnostic device use such as MRI in clinical practice.
VAD is an increasingly acknowledged cause of brainstem stroke, especially in young and otherwise healthy adults under 45 years of age. In patients with VAD, the typical presentation includes severe pain in the back of the head and neck, with a recent history of injury in either of those two areas. These patients subsequently develop focal neurological deficits as a result of the brainstem or cerebellum ischaemia. The signs of a neurologic deficit may not show up unless a latent period as long as three days is passed. However, it has been reported that the symptoms can even take weeks or years to appear. Many patients present only at the onset of neurological symptoms (Fukuhara et al., 2015).
In general, headache may be the only presenting symptom of VAD. Kim and Schulman (2009) found that in 50–75% of cases a headache was present with almost half of patients reporting a completely unique type of pain, which they had never experienced before. In addition, in 40% of cases an occurrence of trauma has been reported days or weeks preceding the dissection; however, the trauma has been found to be minor 90% of the time (Debette, 2014). More than 75% of VAD patients recover completely or are left with minimal residual dysfunction. The remainder often develop a severe disability, although the mortality rate is rare – about 2% (Campos-Herrera et al., 2008).
Is Spinal Manipulation Associated with VAD?
Cervical spine manipulation (CSM) has been reported to be associated with VAD. This has been thought to result from over-stretching of the artery during rotational thrust manipulation (Nadgir et al., 2003), and dissection of the arteries has been presumed to occur at the level of the atlantoaxial joint. The incidence of VAD due to CSM, however, is considered to be rare. The calculated rate of incidence is 1 per 5.85 million cervical manipulations (Haldeman et al., 2002). Moreover, so far there is no conclusive evidence that supports a strong association between neck manipulation and stroke (Haynes et al., 2012).
Nevertheless, the risk of a vascular accident is not negligible; therefore, appropriate precautions should be taken to prevent the risk of VAD causation and/or exacerbation following CSM. The World Health Organization (2005) guidelines have defined a number of absolute to relative contraindications and red flag symptoms in which manipulation should never be performed. These include long-term anticoagulant therapy, certain blood dyscrasias, collagen diseases, congenital malformations and a prior history of a cerebrovascular accident. In addition, Vautravers and Maigne (1999) have made five recommendations to restrict the use of rotational thrust CSM in potentially at-risk populations. The French Society of Orthopaedic and Osteopathic Manual Medicine (SOFMMOO) later adopted these recommendations.
SOFMMOO Recommendations
1.Prior episodes of dizziness, headache, vertigo or nausea following CSM are an absolute contraindication to further manipulation, as these symptoms indicate a high possibility of a previous dissection with a spontaneous resolution.
2.Thrust manipulations should be avoided for acute head or neck pain that is less than 3–4 days old, as this may be caused by a spontaneous VAD.
3.Neurological examination should be done on a mandatory basis as part of the pre-manipulative tests before performing any cervical thrust manipulations.
4.Rotational thrust CSM should not be performed in women under 50 years of age. In men below the age of 50, rotational thrust CSM should be avoided during the first visit; however, it may be allowed in the subsequent visit if the patient’s condition is not improved. Use of mobilisations, MET (muscle energy techniques), soft-tissue cervical techniques and upper thoracic spine thrust manipulations are highly recommended instead of rotational thrust.
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