Can Cervical Spine Manipulation Cause Immediate Thromboembolic Stroke?

Abstract

Aim: The aim was to perform a narrative review of the research cited in a 2025 commentary by Wilder et al. entitled, Informed Consent in Chiropractic: Commentary on Brown & Lehman’s “Informed Consent Regarding Risk of Stroke from Cervical Spine Manipulation”. Specifically, to review research cited to support there is no evidence that cervical spine manipulation (CSM) can dislodge a thrombus from an existing cervical artery dissection (CeAD) and cause immediate thromboembolic stroke.

Results: Our review found that 24 studies were referenced as part of discussions that CSM cannot cause thromboembolic stroke, and none of those 24 references rule out CSM as a potential cause of thromboembolic stroke. Wilder et al. misinterpret Brown and Lehman’s focus on stroke risk, not CeAD causation, in informed consent. Their discussion of studies supporting that CSM cannot cause CeAD is a separate discussion from whether CSM can cause stroke. Limitations were noted in three epidemiological stroke studies due to small stroke case numbers, no immediate exposure periods, failure to exclude CSM as a cause of stroke, and inapplicability to the population most at-risk for CeAD-related stroke, those under 45 years of age. Six studies acknowledge the plausibility of the thromboembolic mechanism of causation. Two practice guidelines and one animal study do not support Wilder et al.’s opinions.

Conclusion: We conclude there is no convincing evidence that CSM can cause CeAD, but when signs and symptoms of CeAD are present, the patient must be informed and referred to medical emergency because in that clinical setting, there is a risk that CSM may dislodge a thrombus and cause thromboembolic stroke. The 24 studies reviewed by Wilder et al. fail to rule out this risk, and in some cases support it. By acknowledging this risk and prioritizing informed consent, the chiropractic profession can uphold its commitment to patient-centered, evidence-based care.