Cervical arterial dissection: an overview and implications

The true incidence of cervical artery dissection is difficult to determine. Most spontaneous CADs result from a sub-adventitial tear caused by haemorrhage in the tunica media or tunica adventitia

CAD is the most catastrophic adverse event associated with cervical manipulative therapy. Cervical manipulation is one potential form of minor trauma, but the trauma can have various origins including sporting or recreational activities. Common to these activities is some degree of rotation or hyperextension of the neck or increased intra-thoracic pressure e.g. from lifting or paroxysmal coughing.

The aims of this masterclass on CAD are: to outline current research into the patho- physiology, aetiology and clinical presentation of CAD, to place the risk in context in a manipulative therapy setting and to discuss its possible clinical recognition.

The early clinical presentation of CAD typically includes neck pain or headache which may mimic migraine or a musculoskeletal disorder

Cadaver studies have shown that far greater forces than those capable of being produced by manipulation were required to cause damage to the arterial wall. However, manipulative therapy performed when a dissection is present could further damage the artery or propagate an embolus. 

It seems unlikely that either the force of the manipulative thrust or the position in which the technique is performed can cause dissection in a normal cervical artery. What cannot be ruled out is the possibility that a manipulative technique or trivial neck strain may cause dissection in a susceptible artery, extend a CAD or propagate an embolus.

CAD patients usually report their pain as unusual, different to any previously experienced. Signs include balance disturbance, ataxia, syncopes, drop attacks, dysphagia, dysarthria, and visual deficits (e.g. diplopia). Effective screening needs to identify patients with a dissection in progress and those susceptible to dissection. A patient with CAD in progress may present only with local symptoms of neck pain and headache, but alerting features are recent/acute onset of moderate to severe, quite unusual pain. 

> From: Thomas, Man Ther (2015) 8(Epub ahead of print). All rights reserved to Elsevier Ltd. Click here for the Pubmed summary.