Chiropractic care involves hands-on manipulation of the spine and other joints, often used to treat common issues like neck pain, back pain, and headaches. The public’s primary concern centers specifically on the high-velocity, low-amplitude (HVLA) adjustment of the neck, known as cervical manipulation. This technique, characterized by a rapid, short thrust that can produce a “popping” sound, has been linked to the potential for serious injury. While major complications are exceptionally rare, the question of whether a chiropractor can hurt your neck requires a detailed look at the specific, albeit uncommon, risks involved.
The Primary Concern: Cervical Artery Dissection
The most serious adverse event associated with neck manipulation is Cervical Artery Dissection (CAD), which most often involves the Vertebral Artery (VAD). This injury occurs when the innermost lining of the artery wall tears, allowing blood to leak between the layers and form a clot. A piece of this clot can then travel to the brain, blocking blood flow and causing an ischemic stroke.
The vertebral arteries run through small bony canals in the cervical vertebrae, making them vulnerable to mechanical stress, particularly during rotation and extension. The V3 segment is especially susceptible to the bending forces that occur during a forceful neck manipulation, which is hypothesized to cause the initial intimal tear. This vascular injury is a leading cause of stroke in people under the age of 45.
Symptoms of an evolving VAD often mimic common neck complaints. The most telling symptom is a sudden, severe headache or neck pain described as “unlike any pain I have ever experienced before.” This pain is often felt in the back of the head or neck on the side of the dissection. Other neurological warning signs include dizziness, vertigo, double vision, slurred speech, or weakness on one side of the body. Because the dissection can cause pain before the stroke occurs, patients sometimes seek chiropractic care for the severe pain, inadvertently timing the adjustment close to the stroke event.
Statistical Context of Serious Adverse Events
Understanding the risk of serious events requires objective statistical context. Vertebral artery dissection is a very rare event in the general population, with an annual incidence of less than 1 per 100,000 persons. The estimated risk of a stroke following a chiropractic neck manipulation is extremely low, generally cited as ranging from 1 in 20,000 to 1 in 250,000 manipulations, or as low as 1 to 3 incidents per million treatments.
These numbers are complicated by the challenge of proving causation versus mere association. Large-scale population studies have investigated whether patients who see a chiropractor have an increased risk of VAD compared to those who see a primary care physician (PCP). These studies have consistently found that patients experiencing the early symptoms of VAD—neck pain and headache—are equally likely to visit a chiropractor or a PCP in the days leading up to a stroke.
This finding suggests that the dissection may have already begun, causing the pain that prompted the patient to seek care, rather than the manipulation causing the dissection. The mechanical stress of the adjustment may then exacerbate the pre-existing arterial damage. To provide perspective, the risk of a serious gastrointestinal complication from taking non-steroidal anti-inflammatory drugs (NSAIDs) for neck pain has been estimated to be significantly higher than the risk of VAD from manipulation.
Minimizing Risk Through Patient Selection and Technique
Qualified practitioners employ rigorous patient screening and technique modifications to minimize the already low risk of complications. The first line of defense is a thorough patient history that actively screens for risk factors and pre-dissection symptoms. Practitioners must look for a new, sudden onset of severe head or neck pain, especially when combined with neurological symptoms like dizziness or vertigo.
Certain pre-existing conditions are considered absolute contraindications for cervical manipulation, meaning the procedure should be strictly avoided. These include severe osteoporosis, known arterial anomalies, an increased risk of stroke, or cancer in the spine. The importance of history taking is emphasized, as traditional orthopedic screening tests for VAD have been shown to be unreliable for predicting an event.
The high-velocity, low-amplitude (HVLA) thrust is not the only option for treating the neck. Many low-force techniques offer effective alternatives that avoid the rapid rotation that may stress the vertebral artery.
Spinal Mobilization
This gentler approach uses slow, rhythmic stretching and passive movements to improve range of motion without a forceful thrust.
Instrument-Assisted Techniques
Techniques such as the Activator Method or Impulse Protocol use a small, handheld device to deliver a precise, low-force impulse to the joint.
Thompson Drop-Table Technique
This technique utilizes a specialized table section that drops slightly upon the application of a light thrust, achieving an adjustment with minimal manual force.
These alternative techniques are often preferred for patients who are nervous, have fragile bone structure, or simply prefer to avoid the “cracking” sound.