Risk Assessment of the Cervical Spine: A visit to the graveyard & directions for the future

That old chestnut the 'vertebral artery test' has been with us in Physiotherapy for nearly 4 decades, and yet still the arguments rage on about its clinical use. 

Confusion is never helpful in a clinical (or any) situation, so I've tried to make sense of the background, the logic and ongoing discussion regarding the use of 'the test that refused to die'.

Inspired by the recent debates within the literature, I've put together 3 SHORT FILMS.

Film I, discusses the history of the development and early use of the test. Film II uses some case studies to test the test, and then Film III, takes to the graveyard of old worn out tests, and attempts to offer some logical directions for the future for ALL clinicians working with neck pain, headache, dizziness and visual disturbances.

The key message, is that risk assessment of the cervical spine is relevant for ALL clinicians and NOT (as previously suggested) just for those who practice manual therapy. 

What we know from medico-legal cases is that delays to diagnosis and appropriate management can occur for a range of reasons. It may focus the mind to know that some medico-legal cases I've worked on, have involved assessment of the cervical spine (without intervention).

Hopefully, these films and the case studies contained within them will help to guide clinicians with their problem solving and clinical reasoning, in the quest for safe and efficient practice.

I. The Vertebral Artery Test - A SHORT FILM (Part I)

A short educational film about the long and tortuous history of the 'vertebral artery test', of interest to any clinician who manages patients with cervical spine issues.

II. The Vertebral Artery Test Part II: Risk assessment of the cervical spine

Part II of III, taking a look at the vertebral artery test from the perspective of NON manual therapists. Putting things into context using 4 case scenarios, with regard to risk assessment of the cervical spine. The video covers the umbrella concept of 'cervical arterial dysfunction'.

III. Cervical Spine Risk Assessment: Directions For The Future 

    A SHORT FILM (Part III)

Part III of the vertebral artery videos, takes us to the graveyard of tired old clinical tests, and moves on to offer some directions for the future for risk assessment of the cervical spine. A consideration of blood pressure, cranial nerve examination and sensorimotor testing is incorporated into the clinical case studies that provide background for the video/vlog.

Find more detail at: https://www.trustme-ed.com/lectures/cervical-arterial-dysfunction-moving-forward-with-alan-taylor/alan-taylor-part-3 Look out for the 'Cervical Spine: Risk & Rehabilitation online resources from Alan Taylor & Roger Kerry ... coming soon.

Author: Alan J Taylor is a writer and critic who tries to think about stuff . He works as a Physiotherapist, University Assistant Professor and Medico-Legal expert witness whilst maintaining a small clinical work load. The views contained in this blog are his own and are not linked to any organisation or institution.  He once rode the Tour of Britain and worked as a cycling soigneur. He still enjoys riding a bicylce through the leafy lanes of Nottinghamshire and Derbyshire. In a World full of conflict and division ... like Bukowski, he 'writes to stay sane'.

Death following a neck injury: What can we learn from the case of Katie May?

This commentary was originally written as a general interest article for publication on a Web news page. For one reason or another it was not published ... So here it is, in a modified Blog format.

Katie May, a 34 year old Playboy model and entrepreneur, died on February 4th 2016 following a stroke. Whilst the details are sketchy, media reports of a neck injury during a photo shoot raises questions as to how a fit healthy 34 year old, could go from an apparent neck strain to a fatal stroke in a matter of days. This report takes look at the mechanisms of early stroke and considers what we can learn from the case.

Neck pain is a common complaint that is thought to affect around 10-13% of the population. However, most patients do not have a life threatening condition. That said the cervical blood vessels can be susceptible to injury. This was illustrated graphically by the tragic death of Australian Cricketer Phillip Hughes. Hughes died from a sub arachnoid haemorrhage (bleed to the brain) following a blunt injury to a blood vessel in his neck from a cricket ball.

The blood flow to the brain is carried by two small vessels at the back of the neck called vertebral arteries, and two larger vessels at the front, called the carotid arteries. The carotids carry around of 80% of the blood flow to the brain. It is well known that any of these blood vessels can be injured by trauma or affected by disease. It is well known that the early presenting symptoms of arterial dissection may be neck pain or headache and that ischaemic symptoms may not develop until later.

A complex anatomical region ... https://www.flickr.com/photos/thomasfisherlibrary/12288500023

So, how could an apparently fit, healthy female, suffer a stroke leading to death at the age of 34?

The complete picture of exactly what happened in this case remains unknown, but we can learn from past experience. There are a number of potential scenarios.

One scenario is that like Phillip Hughes, Katie May had perfectly HEALTHY blood vessels that were injured internally (arterial dissection) by an ‘awkward’ fall during a photo shoot. What happened thereafter remains open to speculation. At that point ANY intervention whether it was advice (to keep moving), pain management/education or manual therapy/manipulation, may have ended with the same outcome.

It remains unexplained how some dissection pathologies resolve yet others go on to lead to stroke or death. It is thought that this may relate to variety of intrinsic conditions linked to connective tissue disorders and clotting factors. In addition, extrinsic factors may also play their part. A failure to recognise the signs and symptoms (assuming there were any) of a developing pathology in accident and emergency, at the GP practice, or under the care of a musculoskeletal therapist (Physiotherapist, Osteopath, Chiropractor) may be also be associated with fatal consequences. A common medico-legal scenario, is a delay to appropriate triage, in order to commence a trial of management or specific treatment.

 
 Thrombotic stroke - image en.wikipedia.org550 × 800Search by image 

A second scenario of many, is where a person develops musculoskeletal neck pain insidiously or via a minor trauma and seeks the attention of a manipulative therapist, such as a Chiropractor, Osteopath or Physiotherapist. Katie May Tweeted that she was going to see her Chiropractor, though no detail has been released. However, the wave of assumption and speculation implicating Chiropractors, could well be entirely unfounded as this single case study clearly illustrates. 

The status of the blood vessels at the time of ANY consultation, may be either healthy OR unhealthy. Unfortunately, without sophisticated equipment, there is no way of knowing whether vessels may be ‘weak’ or suffering from underlying disease such as fibromuscular dysplasia or atherosclerosis (rare in the younger patient). This is one of the reasons that manipulation in particular, has been called into question. At best the science remains equivocal. A recent systematic review found no association and suggested that, "the relative risk of ICA dissection after cervical spine manipulation compared with other health care interventions for neck pain, back pain, or headache is unknown". However, critics argue that spinal manipulation to the neck may injure vessels, leading to stroke.

Neck manipulation has many descriptions, but generally involves a high velocity manoeuvre, outside the control of the patient, which may produce a click or crack. There is evidence to suggest that for acute/subacute neck pain, cervical manipulation provides better pain relief and functional improvement than medications such as varied combinations of NSAIDs, analgesics and muscle relaxants. However, the caveat is that this benefit, may not be entirely risk free. Furthermore, it is suggested that the actual number of adverse events (injury, stroke, death) may be massively under reported. 

 

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Could the risk be reduced?

The debate on the safety of manipulation has not been helped by the lack of agreement on the risk of blood vessel injury following treatment. Some reports suggest ratios between one in 50 ,000 to one in nearly 6 million manipulations, though as mentioned, many question the accuracy of this data, citing up to 100% under-reporting. A review of 134 case reports, published in 2012, said, “there was potential for a clinician to prevent 44.8% of adverse events (such as stroke or death) associated with manipulation”. The authors suggested, “10.4% of the events were unpreventable”. Interestingly, the patients who died had continued or excessive spinal manipulation, despite the fact that they were not responding to treatment, or their symptoms were worsening.

Despite RCT reports that in apparently healthy vessels, manipulation to the atlanto-

axial joint does NOT appear to increase mechanical stress on the vertebral artery, it remains unknown what the affect might be on diseased, weak or already dissecting vessels (vertebral or carotid).

As it stands, scientific knowledge can neither accurately quantify the risk associated with neck manipulation, nor establish an unequivocal link between manipulation and adverse events. A 2016 physiotherapy publication, a profession that has been prominent in the field of neck risk assessment, suggested that, at best, “early recognition of injury to blood vessels” may reduce the occurrences of inappropriate treatment. This raises the important question of what exactly is 'inappropriate treatment'? Whilst manipulation may have been demonised by some, it is important to understand that blindly defaulting to ANY favoured intervention in the absence of sound clinical examination and risk assessment ... may lead to adverse outcomes in the presence of arterial injury.

Could tragic events like this be prevented?

Disappointingly, the complexity of the human body and mind, dictates that the answer will vary from case to case and clinician to clinician. It remains essential for ALL CLINICIANS to retain an index of suspicion for arterial injury in cases of trauma, be cognisant of ‘red flags’ and apply appropriate clinical reasoning and examination procedures. A default to, a single school of thought or approach (whatever that may be), may lead to delays to triage, inappropriate management and potential medico-legal consequences. 

Atypical, worsening presentations, with OR without subtle ischaemic symptoms may alert the clinician to the presence of arterial injury. The diagnosis of arterial dissection rests on a careful clinical history, physical examination, and targeted ancillary investigations. Clinicials should be cognisant that delay may be fatal.

What do we all have to learn from cases like this?

1. Retain an index of suspicion for vascular injury in trauma cases. 

2. Know your anatomy and pathophysiology.

3. Hurt does = harm, in some cases. 

4. Examine and question the patient in detail.

5. Have, and retain vigilance for ‘Red Flags'.

6. A DELAY to appropriate management, is a common root cause in many medico-legal cases.

 ... There is NEVER absolute certainty

 

HT to Woody  Guthrie for being an inspiration -  "It's a folk singers critical thinkers job to comfort disturbed people and to disturb comfortable people"

Author: Alan J Taylor is a writer and critic who thinks about stuff and works as a Physiotherapist, University Assistant Professor and Medico-Legal expert witness ... The views contained in this blog are his own and are not linked to any organisation or institution. Like Bukowski, he 'writes to stay sane'.

You'll find him mostly on Twitter https://twitter.com/TaylorAlanJ

Understanding cervical arterial dysfunction (CAD) for clinicians

 

The publication of the succinctly titled;

‘International framework for examination of the cervical region for potential of Cervical Arterial Dysfunction prior to Orthopaedic Manual Therapy intervention’ (Rushton, et al 2013)

... has highlighted the need for manual therapy clinicians to be cognisant with cervical arterial dysfunction (CAD). 

BUT what is that? … and what does it mean to clinicians?

Let us start ... by dealing with what it is NOT

Dissection of an artery

1. Cervical arterial dysfunction is NOT cervical arterial dissection! That may seem obvious to some, but both acronyms are now in common usage and therefore some confusion may arise. The term dissection is specific to dissection events (see image) and therefore narrow. Cervical arterial dysfunction is a broader term which is all-encompassing of a range of pathologies which may affect the cervico-cranial vasculature. 
2. CAD is NOT vertebro-basilar insufficiency (VBI). However, it does incorporate it - as one of the component parts of a wider system based approach to thinking about haemodynamics and ischaemia
3. Above all, CAD is NOT (in isolation) dissection of the vertebral artery. That would simply be a continuation of the narrow thought process which lead us to believe that a single test i.e. the vertebral artery test, could somehow allow us to decide whether cervical manipulation was ‘safe’ or not! That outdated concept has thankfully been de-bunked once and for all, as we move closer to science based practice.

So what is cervical arterial dysfunction then…?

CAD is a consideration of ALL of the potential arterial dysfunctions, which may present to, or ensue from a manual therapy intervention.

CAD is simply a way of thinking about an age old problem in a different way, and more importantly asking ourselves different questions about this familiar problem – linked to RISK and cervical spine management. The emphasis has moved firmly away from just ‘manipulation’, into a consideration of movement per se. This clearly widens the thinking into a consideration of ASSESSMENT (which incorporates movement) as well as intervention, which may incorporate ANY form of manual therapy or exercise prescription. This is then combined with a consideration of ALL of the potential structures and vascular 'dysfunctions'. Thinking is no longer constrained by one structure or pathology.

So why the shift from VBI and vertebral artery dissection …?

Well first of all, there is a lot more to the cervical vasculature than the vertebro-basilar system and there is a lot more to the range of pathologies than just dissection. Dissection or damage to the intimal wall of a vessel is a commonly cited vascular ‘injury’ thought to be associated with cervical spine manipulation in particular. However, an understanding of the basic science of haemodynamics allows us to incorporate many more conditions and pathologies into the paradigm. 

There are a range of reasons why blood vessels may be compromised in the cervico-cranial region, from pre-existing underlying anatomical anomalies, vasospasm, atherosclerotic disease, through to arteritis (i.e. temporal). All of these may lead in different ways, to potential ischaemia which may manifest and a variety of ways, ranging from PAIN, through to blindness, stroke or at worst death.

 Some direction for clinicians:

• Develop an understanding that there is more to cervical spine risk assessment than a consideration of ‘VBI’ or dissection of the vertebral artery.
• Consider a ‘systems based’ approach, incorporating the whole cervical vascular system, including the carotid vasculature (and branches) and the whole range of potential pathologies (NOT just dissection).
• Develop awareness, that whilst commonly cited vascular risk factors have not been shown to be associated with dissection pathologies, they are strongly correlated with atherosclerosis, hypertension and stroke … This is ‘system based thinking’.
• Develop increased awareness that neck pain and headache may be the early signs of pre-existing vascular dysfunction.
• Develop an index of suspicion for cervico-cranial vascular pathology, particularly in cases of acute trauma or non-resolving/worsening conditions.
• Enhance subjective/objective examination by including vascular risk factors such as hypertension, and procedures such as blood pressure, cranial nerve testing and eye examination.
• Consider carefully the ORDER of your examination in the presence of potential vascular ‘red flags’.
• Expand manual therapy teaching and practice to include haemodynamic principals and their relationship to movement, handling, anatomy and biomechanics.

Despite all this … when all is said and done, the 64m dollar question still seems to be … Should clinicians perform a ‘vertebral artery test’?

Answer … there is little to support it's use as a stand alone test. Its sensitivity and specificity are very poor AND its clinical utility is of little value. It has been argued that it should be retained from a 'medico-legal' perspective, but that contention would most likely be destroyed by any half competent barrister.

Note - that cranial nerve and blood pressure testing are additional objective measures to incorporate into the physical examination. Both feature prominently in the IFOMPT framework.

See:
Cranial nerve testing

Blood pressure testing

 

For a more detailed description of this paradigm change see:

A ‘system based’ approach to risk assessment of the cervical spine prior to manual therapy (Taylor & Kerry 2010) http://www.sciencedirect.com/science/article/pii/S1746068910000532

‘International framework for examination of the cervical region for potential of Cervical Arterial Dysfunction prior to Orthopaedic Manual Therapy intervention’ (Rushton, et al 2013)

http://www.sciencedirect.com/science/article/pii/S1356689X13001926

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Haemodynamics - A 'system based approach'