Cervical Arterial Dysfunction – update your skills

Cervical arterial dysfunction (CAD) is the most serious risk associated with osteopathy and any other manual therapy.  There has been much debate over the years about how practitioners should screen for risks – presenting symptoms and provocative testing.  The IJOM contains an excellent article presenting the latest evidence-based assessment knowledge for cervical arterial dysfunction.

Practitioners must be aware that it’s not just cervical manipulation that should be considered a risk but all cervical movement can be provocative.

This article is a summary of information from the IJOM article.  Please read the full article for informed, evidence-based practice.  http://www.sciencedirect.com/science/article/pii/S1746068916000250 Free access through the GOsC ozone

CAD includes dysfunction of the internal carotid artery and/or vertebral artery.

Age groups:  It can affect all age groups – internal carotid artery dissection is  more common in 34-54 years and vertebral artery dissection in those over 55 years.

Causes: 61% spontaneous, 30% trivial trauma, 9% cervical spine manipulation


Neck or facial pain, usually unilateral headache and sometimes Horner’s syndrome.

(Horner’s syndrome = partial ptosis, miosis and hemifacial anhidrosis)

Headache is usually fronto-temporal but may be occtipital – constant, steady ache, throbbing or sharp, N.B. commonly “unlike anything experienced previously”

Risk Factors

Connective tissue disease, hyperhomocysteinemia, alpha-1 antitrypsin deficiency, fibromuscular dysplasia, Ehlers-Danlos syndrome

Post-partum women Rare but may be relevant with other risk factors
Acute onset unilateral cervical spine pain Less than 1 week duration (49-88%)

80% pain in head or neck – cervical artery

92% head and neck pain – vertebral artery

Acute onset occipital, frontal, supraorbital or temporal headache New or different type of headache

Especially with ptosis, facial numbness and ataxia

Current or past history of migraine (especially without aura) Especially risk factor in under 33 years  and females
Family history of migraine
History of cervical spine trauma (including minor or trivial trauma) Trivial trauma e.g. sneezing or sporting activities 12-34% Cervical artery

RTA or very heavy exercise or physical activity

Onset may be up to 5 days later

Whether HVLA is enough trauma is unlikely could be just movement testing

Onset of pain related to sudden cervical movement Such as head banging at a rock concert
Tiniitus (especially pulsating)
History of hypertension and risk factors for cardiovascular disease Includes (not exclusively) hypertension, hypercholesterolaemia, type 2 diabetes mellitus, smoking and body mass index >25 kg/m2
Recent upper and/or lower respiratory infection (within previous week) Cervical artery dissection association although the mechanism is unclear.
Upper and/or lower extremity neurological symptoms and ataxia 65% upper extremity weakness, 50% lower extremity weakness, cervical radiculopathy and ataxia – common with VAD


Signs and Symptoms of Vertebral Artery Dysfunction  (may not be present with ICAD)

Minor mechanical trauma to the neck Dysphasia Dizziness Unsteadiness or ataxia
Occipital headaches Diplopia Dysarthria Numbness (facial, upper extremity, lower extremity)
Cervical spine pain Nystagmus Drop attacks


Red Flags

Onset of new complaint under age 20 or over 50 years Unexplained weight loss Constant and severe extremity pain Frequent nausea and/or vomiting
Persistent night pain Past history of malignancy Swelling in the extremities and abdomen with history of injury Fever and/or night sweats
Constant unremitting pain Shortness of breath Changes in colour of hands/feet Recent onset headache with no previous history
Pain that does not change with position or movement Constant unexplained fatigue Frequent or severe abdominal pain Sudden onset severe neck pain (with no history of injury or trauma)
Loss of appetite Chest pain Changes in bladder function Changes in vision, speech and/or hearing
Changes in balance and coordination


Progressive neurological symptoms


Neurological symptoms over more than one dermatome


Bilateral neurological symptoms


Sudden weakness



Examinations that may be necessary:

High number risk factors or high severity – refer for further investigation and management

Moderate number or moderate severity – monitor and possible avoidance of treatment

Low number of risk factors or low severity – caution with selection of manual therapy techniques and constant monitoring for new or changing symptoms

Cranial Nerves and co-ordination tests are required for all risk factors.

Upper Cervical Stability Tests and extremity neurological tests – if there is a history of trauma and upper and lower neurological symptoms and ataxia

Cardiovascular and respiratory tests as indicated

Any positive findings on clinical examination need referral for further investigation and no manual therapy or exercise prescription.  If clinical examinations are negative proceed with awareness of risk factors and monitoring for changes.

Screening tests

These are not considered valid.  The emphasis is on identification of risk factors in the clinical history and understanding the risks associated with the cervical arterial system.


A dissection of the carotid or vertebral arteries causes a stroke.  Patients will be treated with thrombolysis, antithrombotic or anticoagulation treatments.  Ongoing ischaemia may require surgery and stenting.

In conclusion

Cervical spine symptoms present the highest risk for adverse events from manual therapy.  Care should be taken with anyone presenting with cervical spine symptoms.  Consideration to risk factors should be given not just before manipulation but with examination and other techniques and exercises involving cervical spine movements.  Nevertheless this should not lead practitioners to be full of fear but to practice equipped with good procedures for identifying patients at risk and performing an appropriate clinical examination to have confidence in formulating a treatment plan.  Serious adverse events with manual therapy are rare, osteopathic statistics puts the risk at 1 in 36079.  This article provides a summary to help equip you to practice with safety and confidence.

I recommend you read the article yourself in addition to this summary version, it’s an excellent overview of this area of practice.  http://www.sciencedirect.com/science/article/pii/S1746068916000250


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