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Original article
peer-reviewed

Systematic Review and Meta-analysis of Chiropractic Care and Cervical Artery Dissection: No Evidence for Causation



Abstract

Background

Case reports and case control studies have suggested an association between chiropractic neck manipulation and cervical artery dissection (CAD), but a causal relationship has not been established. We evaluated the evidence related to this topic by performing a systematic review and meta-analysis of published data on chiropractic manipulation and CAD.

Methods

Search terms were entered into standard search engines in a systematic fashion. The articles were reviewed by study authors, graded independently for class of evidence, and combined in a meta-analysis. The total body of evidence was evaluated according to GRADE criteria.

Results

Our search yielded 253 articles. We identified two class II and four class III studies. There were no discrepancies among article ratings (i.e., kappa=1). The meta-analysis revealed a small association between chiropractic care and dissection (OR 1.74, 95% CI 1.26-2.41). The quality of the body of evidence according to GRADE criteria was “very low.”

Conclusions

The quality of the published literature on the relationship between chiropractic manipulation and CAD is very low. Our analysis shows a small association between chiropractic neck manipulation and cervical artery dissection. This relationship may be explained by the high risk of bias and confounding in the available studies, and in particular by the known association of neck pain with CAD and with chiropractic manipulation. There is no convincing evidence to support a causal link between chiropractic manipulation and CAD. Belief in a causal link may have significant negative consequences such as numerous episodes of litigation.



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Original article
peer-reviewed

Systematic Review and Meta-analysis of Chiropractic Care and Cervical Artery Dissection: No Evidence for Causation


Author Information

Ephraim W. Church Corresponding Author

Department of Neurosurgery, Penn State Hershey Medical Center

Emily P. Sieg

Department of Neurosurgery, Penn State Hershey Medical Center

Omar Zalatimo

Department of Neurosurgery, Penn State Hershey Medical Center

Namath S. Hussain

Department of Neurosurgery, Loma Linda University Medical Center

Michael Glantz

Department of Neurosurgery, Penn State Hershey Medical Center

Robert Harbaugh

Department of Neurosurgery, The Pennsylvania State University


Ethics Statement and Conflict of Interest Disclosures

Human subjects: All authors have confirmed that this study did not involve human participants or tissue. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

Acknowledgements

The authors wish to thank Elaine Dean, MLS, of the Penn State Hershey Medical Center George T. Harrell Health Sciences Library, for her assistance with the systematic review.


Original article
peer-reviewed

Systematic Review and Meta-analysis of Chiropractic Care and Cervical Artery Dissection: No Evidence for Causation


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Original article
peer-reviewed

Systematic Review and Meta-analysis of Chiropractic Care and Cervical Artery Dissection: No Evidence for Causation

Ephraim W. Church">Ephraim W. Church , Emily P. Sieg">Emily P. Sieg, Omar Zalatimo">Omar Zalatimo, Namath S. Hussain">Namath S. Hussain, Michael Glantz">Michael Glantz, Robert Harbaugh">Robert Harbaugh

  • Author Information
    Ephraim W. Church Corresponding Author

    Department of Neurosurgery, Penn State Hershey Medical Center

    Emily P. Sieg

    Department of Neurosurgery, Penn State Hershey Medical Center

    Omar Zalatimo

    Department of Neurosurgery, Penn State Hershey Medical Center

    Namath S. Hussain

    Department of Neurosurgery, Loma Linda University Medical Center

    Michael Glantz

    Department of Neurosurgery, Penn State Hershey Medical Center

    Robert Harbaugh

    Department of Neurosurgery, The Pennsylvania State University


    Ethics Statement and Conflict of Interest Disclosures

    Human subjects: All authors have confirmed that this study did not involve human participants or tissue. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

    Acknowledgements

    The authors wish to thank Elaine Dean, MLS, of the Penn State Hershey Medical Center George T. Harrell Health Sciences Library, for her assistance with the systematic review.


    Article Information

    Published: February 16, 2016

    DOI

    10.7759/cureus.498

    Cite this article as:

    Church E W, Sieg E P, Zalatimo O, et al. (February 16, 2016) Systematic Review and Meta-analysis of Chiropractic Care and Cervical Artery Dissection: No Evidence for Causation. Cureus 8(2): e498. doi:10.7759/cureus.498

    Publication history

    Received by Cureus: January 26, 2016
    Peer review began: January 28, 2016
    Peer review concluded: February 08, 2016
    Published: February 16, 2016

    Copyright

    © Copyright 2016
    Church et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 3.0., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

    License

    This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract

Background

Case reports and case control studies have suggested an association between chiropractic neck manipulation and cervical artery dissection (CAD), but a causal relationship has not been established. We evaluated the evidence related to this topic by performing a systematic review and meta-analysis of published data on chiropractic manipulation and CAD.

Methods

Search terms were entered into standard search engines in a systematic fashion. The articles were reviewed by study authors, graded independently for class of evidence, and combined in a meta-analysis. The total body of evidence was evaluated according to GRADE criteria.

Results

Our search yielded 253 articles. We identified two class II and four class III studies. There were no discrepancies among article ratings (i.e., kappa=1). The meta-analysis revealed a small association between chiropractic care and dissection (OR 1.74, 95% CI 1.26-2.41). The quality of the body of evidence according to GRADE criteria was “very low.”

Conclusions

The quality of the published literature on the relationship between chiropractic manipulation and CAD is very low. Our analysis shows a small association between chiropractic neck manipulation and cervical artery dissection. This relationship may be explained by the high risk of bias and confounding in the available studies, and in particular by the known association of neck pain with CAD and with chiropractic manipulation. There is no convincing evidence to support a causal link between chiropractic manipulation and CAD. Belief in a causal link may have significant negative consequences such as numerous episodes of litigation.



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Create a free account to continue reading this article.

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Ephraim W. Church, M.D.

Department of Neurosurgery, Penn State Hershey Medical Center

For correspondence:
echurch@hmc.psu.edu

Emily P. Sieg, M.D.

Department of Neurosurgery, Penn State Hershey Medical Center

Omar Zalatimo

Department of Neurosurgery, Penn State Hershey Medical Center

Namath S. Hussain, M.D., M.B.A.

Department of Neurosurgery, Loma Linda University Medical Center

Michael Glantz

Department of Neurosurgery, Penn State Hershey Medical Center

Robert Harbaugh, M.D.

Department of Neurosurgery, The Pennsylvania State University

Ephraim W. Church, M.D.

Department of Neurosurgery, Penn State Hershey Medical Center

For correspondence:
echurch@hmc.psu.edu

Emily P. Sieg, M.D.

Department of Neurosurgery, Penn State Hershey Medical Center

Omar Zalatimo

Department of Neurosurgery, Penn State Hershey Medical Center

Namath S. Hussain, M.D., M.B.A.

Department of Neurosurgery, Loma Linda University Medical Center

Michael Glantz

Department of Neurosurgery, Penn State Hershey Medical Center

Robert Harbaugh, M.D.

Department of Neurosurgery, The Pennsylvania State University