Abstract:

Cervical spine manipulation (CSM) performed in the presence of vertebral artery dissection (VAD) has been implicated in immediate thromboembolic stroke. We report a 27-year-old male who developed immediate ischemic symptoms after CSM, with imaging confirming bilateral VAD and bilateral cerebellar infarctions. Craniectomy and decompression were required; despite rehabilitation, the patient remains permanently disabled.

Using an intuitive forensic approach, we determined that the VAD was most likely pre-existing from minor neck trauma sustained one week earlier in a mosh pit, compounded by fibromuscular dysplasia. A 3-step medicolegal causation analysis established that the immediate stroke was caused by CSM as more likely than not (biological plausibility, temporality, and absence of a more probable alternative explanation). Two breaches in the standard of care were identified: failure to diagnose and refer suspected VAD prior to manipulation, and failure to recognize and urgently refer acute stroke symptoms.

Clinical examination strategies to exclude VAD before CSM, coupled with improved training in vascular differential diagnosis for chiropractic physicians, could have prevented this outcome and can prevent future cases. This case underscores the importance of thorough history-taking, vitalsign assessment, and recognition of VAD red flags in chiropractic practice.