Preventing neurovascular complications of cervical spine manipulation

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Abstract
Neurovascular complications of cervical spine manipulation are an unusual but potentially devastating outcome of this treatment. The risk of a serious complication is difficult to estimate due to a lack of prospective studies, but is likely to be less than one incident per 50,000 manipulations. Most complications involve trauma to the vertebral artery in the atlanto-axial region, however the internal carotid artery is also vulnerable. Pathological evidence suggests that previous trauma and arteriopathies predispose the artery to intimal damage. The degree of ischaemic insult is greatly dependent on compensatory collateral circulation. The detection of patients at risk of such complication largely relies upon eliciting dizziness on physical examination testing utilizing cervical rotation and extension manoeuvres. Recent research indicates that the validity of predictive testing procedures is questionable and neurovascular compromise can occur despite negative testing. Some suggestions for enhancing the specificity and sensitivity of premanipulative testing are discussed.

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