Cervical spinal manipulation (CSM), often called a neck adjustment, is a manual therapy used to treat neck pain and related issues. This procedure involves applying a high-velocity, low-amplitude (HVLA) thrust to the neck joints. The goal of this quick, controlled movement is to improve joint mobility, often resulting in an audible popping sound. Deciding whether to undergo this procedure requires carefully weighing its potential for pain relief against the small but serious risks involved.
Evaluating Pain Relief and Therapeutic Goals
Chiropractic spinal manipulation is frequently sought out as a non-pharmacological treatment for mechanical neck pain and headaches. Current scientific reviews suggest that CSM can be an effective part of a treatment plan for conditions like acute and chronic non-specific neck pain. The benefit often appears in the short-term, offering patients temporary relief and improved range of motion in the cervical spine.
For cervicogenic headaches, which originate from a problem in the neck, manipulation has been found in some systematic reviews to be a highly effective intervention for short-term pain and disability reduction. This effect is often comparable to, or sometimes superior to, other manual therapy options like mobilization. The evidence supports the idea that spinal manipulation, particularly when combined with exercise, is a reasonable approach for managing symptoms.
Many studies on efficacy focus on immediate or short-term outcomes, such as a few weeks after treatment. Furthermore, when comparing CSM to low-velocity mobilization techniques for neck pain, some research indicates that the therapeutic benefits are similar. This suggests that the high-velocity thrust may not be strictly necessary to achieve a positive outcome in all cases.
Specific Risks Associated with Cervical Adjustments
The primary concern with high-velocity cervical adjustments is the rare but serious risk of vascular injury, most notably Vertebral Artery Dissection (VAD), which can lead to stroke. The vertebral arteries are two major blood vessels that travel through the bony tunnels of the cervical vertebrae to supply blood to the brainstem and cerebellum. A dissection occurs when a small tear forms in the innermost lining of the artery wall, allowing blood to enter and separate the layers of the vessel.
This internal damage can lead to the formation of a blood clot, or thrombus, which may subsequently travel to the brain and block blood flow, resulting in an ischemic stroke. The extreme rotation and extension of the neck involved in some high-velocity techniques can mechanically stress the vertebral artery, particularly in its upper segments. While the healthy vertebral artery is resilient, an already vulnerable artery may be at risk during the procedure.
Case-control studies have identified an association between cervical manipulation and VAD, particularly in young and middle-aged patients who experience a specific type of stroke. However, experts debate whether the manipulation causes the dissection or if patients already experiencing a spontaneous dissection present with neck pain and headache, leading them to seek treatment just prior to a stroke. Regardless of the exact mechanism, the temporal association remains a serious consideration.
More common but less severe side effects include transient local pain, stiffness, or headache following the adjustment. In rare instances, the procedure could also cause soft tissue injury or nerve root compression. Since the symptoms of a developing VAD often mimic common musculoskeletal complaints, such as sudden, severe neck pain or an unfamiliar headache, distinguishing a pre-existing vascular issue from a benign neck problem can be difficult.
Patient Screening and Alternative Techniques
The decision to undergo a cervical adjustment should be based on a thorough and informed risk assessment conducted by the practitioner. A comprehensive patient history is a necessary step, which includes screening for risk factors such as recent neck trauma, pre-existing vascular conditions, or connective tissue disorders. A patient should report any new or unusual symptoms, especially a sudden, severe headache described as the “worst of their life.”
Patients should be aware of the “5 Ds and 3 Ns,” which are cardinal signs of potential vertebrobasilar insufficiency (reduced blood flow to the brainstem). These symptoms must be reported immediately, as they may warrant referral to a specialist before any manipulation is performed.
- Dizziness
- Diplopia (double vision)
- Dysarthria (slurred speech)
- Dysphagia (difficulty swallowing)
- Drop attacks
- Nausea
- Numbness
- Nystagmus (involuntary eye movement)
Patients should ask the practitioner about their training and choice of technique. Safer alternatives to the high-velocity thrust exist and should be discussed, especially for those with risk factors or who prefer a more gentle approach. Low-force or mobilization techniques, which involve slower, non-thrust movements, have demonstrated similar effectiveness for common neck pain.
Non-thrust options include instruments like the Activator, which delivers a quick, low-force impulse, or techniques like flexion-distraction, which use a specialized table to gently stretch the spine. By understanding the potential risks and recognizing the warning signs, patients can make a safe and informed choice about their neck care.