Date: Sat, 24 May 1997 12:45:57 -0400 From: Jerry Vonderharr Subject: Medscape Good article in Medscape this week regarding trauma to vertebral artery in flexion/distraction trauma. Summary: Prior to this study, we had treated 1629 patients with cervical spine injuries without evaluating their vertebral vessels. A small subset of these patients presented with, or later developed, symptoms that in retrospect may have been related to a vertebral artery injury. The findings in this study may support vertebral vessel valuation in selected cases, particularly in patients with flexion distraction and flexion compression injuries who have neurologic symptoms that do not correlate with the presenting bone and soft-tissue injuries noted on standard trauma imaging series. Recognizing that vertebrobasilar ischemia can cause devastating consequences underscores the value of this noninvasive screening tool. These patients may benefit from the treatment of these vessel injuries in the peritrauma period. ----------------------- Date: Sat, 17 May 1997 11:17:45 -0500 (CDT) From: Mike Carstensen Subject: Re: Medscape discussion of vertebral artery injury following C/S trauma At 07:47 AM 5/17/97 -0400, you wrote: >While we are on this topic, I am curious how many DCs out there perform >the full George's test, which includes bilateral BP, bilateral pulse, >auscultation for subclavian bruits, as well as a functional vascular >test. I perform a full George's test on every patient that I plan on treating with cervical/upper thoracic manipulation......not because I feel it is a good predictor of vertebral artery injury, but because I don't ever want to get caught with my pants down in court. It's a small investment in time with each patient. OTOH, just because it is the accepted standard, doesn't mean it's the right thing to do. I am curious to know how many of our colleges have adopted the information put forth by Terret into their curricula. Dr. Michael Carstensen ---------------------------- Date: Sat, 17 May 1997 16:46:48 -0500 From: "Noel A. Taylor" Subject: Re: Medscape discussion of vertebral artery injury following C/S trauma >While we are on this topic, I am curious how many DCs out there perform >the full George's test, which includes bilateral BP, bilateral pulse, >auscultation for subclavian bruits, as well as a functional vascular >test. I have been told by several attorneys that George's test is the >standard of care in the community. However, Terret notes that taking >bilateral blood pressure is not useful, except for revealing a >subclavian steal syndrome, and VBS following SMT has never been >reported in a patient with the subclavian steal syndrome.(p.30) My training in differential diagnosis supported use of bilateral BP in connection with consideration of possible coarctation in the aortic arch. >Likewise, Terret notes that auscultating the neck for bruits is equally >worthless, since no arterial bruits are detected after arterial damage >and it would be highly unlikely that a bruit would have been detected >prior to the arterial trauma. I would also ask why would we be >listening for possible problems in the carotid arteries when the >vessels in question are the vertebral arteries? Again, within the Phys-Di coursework at Logan, bruits at the carotid bifurcations are indicative of probable generalized arterial plaquing, which is itself a risk factor for VBAI sequellae from HVLA extension/rotation adjusting of the c-spine due to the higher risk of 1) intimal tearing in less-elastic-than-non-plaqued plaqued vertebral arteries and 2) consideration of plaque generated emboli. >Terret concludes that "the taking of bilateral blood pressure, and listening for bruits, leads the practitioner into a false feeling that they are doing a relevant vertebrobasilar screening examination."(p.30) Therefore, he does not recommend either of these procedures. Again, I was not taught this illusion, but instead the rationale I've stated above. Please note that the term SMT covers many different forms of cervical adjusting, some of which have no stress effects upon the vertebral arteries. I would be very pleased to see more appropriate terminology applied to such discussions in Terret and elsewhere, including this list. Finally, in response to the original question about use of the testing protocol, I find that performing all portions of George's Test on each new patient provides useful information whether or not I am considering HVLA cervical adjusting. I also agree with Dr. Carstensen that such a standard of care is good medicolegal practice in the absence of any superior VBAI-related protocol. --Noel ---------------------------- Date: Sat, 17 May 1997 14:01:25 -0700 From: "William Cockburn D.C., B.C.F.E." To: "Noel A. Taylor" Subject: Re: Medscape discussion of vertebral artery injury following C/S trauma Noel, What do you think of the small doppler units. I prefer auscultation, but the documentary value of doppler may be helpful. Bill William Cockburn, D.C., D.A.B.F.E. --------------------------- From: "Dr. Mark Bodnar" Subject: Medscape discussion of vertebral artery injury following C/S trauma Date: Thu, 15 May 1997 23:11:12 -0300 This is a question of the day from Medscape. It is interesting to note that the article does not identify extension rotation the most risky mechanism of injury. Any opinions as to the relevance? * What are the clinical consequences of vertebral artery injury following neck trauma? * The mechanism of injury to the vertebral artery by closed trauma involves stretching and tearing of the intima with subsequent mural thrombosis, clot propagation, and occlusion. Unilateral occlusion of the vertebral artery rarely results in a neurologic deficit because of collateral supply through the contralateral vertebral and posterior inferior cerebellar arteries. However, extracranial compression of the vertebral artery may cause neurologic symptoms, depending on the acuteness of the occlusion as well as on preexisting conditions such as atherosclerosis, the absence of anastomotic channels, and the absence of a contralateral vertebral artery. * Signs of vertebral insufficiency may be manifested by speech deficits, diplopia, blurred vision, and dysphagia. The time course of brainstem ischemia secondary to vertebral artery occlusion is variable, ranging from a few hours to 33 days. Vertebral artery occlusion may even result in death. * What forms of neck trauma are more likely to cause vertebral artery injury? * Vertebral artery damage (all unilateral) was demonstrated by MRA in 12 of 61 patients (19.7%) with cervical spine trauma in a study recently published in Medscape Orthopedics and Sports Medicine Topic Area. Of the 12 injuries, seven were the result of flexion distraction injuries, and three were the result of flexion compression injuries. One resulted from an extension compression injury, and one from a posteriorly displaced odontoid fracture secondary to a hyperextension force. * The findings in this study may support vertebral vessel evaluation in selected cases, particularly in patients with flexion distraction and flexion compression injuries who have neurologic symptoms that do not correlate with the presenting bone and soft-tissue injuries noted on standard trauma imaging series. * Vertebral Artery Injuries Associated With Cervical Spine Trauma: A Prospective Analysis * Authors: Jerome M. Cotler, MD, Alexander R. Vaccaro, MD, Frank B. Giacobetti, MD, James C. Farmer, MD * Abstract: A prospective study of 61 patients sustaining cervical spine trauma examined the incidence of vertebral artery injuries and the associated mechanism of injury. Damage to the vertebral arteries (all unilateral) was demonstrated by magnetic resonance angiography in 12 of the 61 patients (19.7%), and 9 of those 12 had either flexion distraction or flexion compression injuries. The findings of this study may support the need for vertebral vessel evaluation in selected cases of flexion distraction or flexion compression injuries with neurologic symptoms that do not correlate with the presenting bone and soft-tissue injuries. [Comp Orthop 11(2):12-15,22-23,32, 1996. (c) 1996 SCP Communications, Inc.] * Key words: Vertebral artery injury * Magnetic resonance imaging (MRI) * Magnetic resonance angiography (MRA) * Cervical spine injury Mark Bodnar, D.C. Bedford, Nova Scotia, Canada ----------------------------- Date: Fri, 16 May 1997 08:56:14 -0400 (EDT) Subject: Re: Medscape discussion of vertebral artery injury following C/S trauma Reply-To: DACBR131@aol.com In a message dated 97-05-16 04:39:06 EDT, drbodnar@ns.sympatico.ca (Dr. Mark Bodnar) writes: << * What forms of neck trauma are more likely to cause vertebral artery injury? >> I consulted a few years ago in a malpractice case where a chiropractor had performed bilateral rotary manipulation in a 20 something female. Described by the patient as the most forceful manipulation she had ever experienced (she had be to 2 others previously). By the time she had driven from his office to the mall (some 20 minutes) she had become dysphagic and had lost control of her left arm. Hospitalized with a presumed stroke. DSA demonstrated bilateral stenosis of the vertebral arteries. Initially they weren't sure if this was congenital stenosis or acquired. Over 5-6 weeks in hospital her symptoms gradually improved and she regained full function. Eventually DSA demonstrated patent vessels. Therefore, it was considered the manipulation resulted in bilateral vasospasm. Gary M. Guebert, D.C., DACBR(tm) ------------------------- Date: Sat, 17 May 1997 07:47:08 -0400 (EDT) Subject: Re: Medscape discussion of vertebral artery injury following C/S trauma Reply-To: LHBWeitz@aol.com Good points Mike. In fact, Terret also points out that although "at first glance there does appear to be a prediliction for SMT accidents in the 30 to 45 year age group... Closer analysis does not reveal any greater risk in any one age range....The increased number of accidents reported in the 30 to 45 year age group appears simply to be reflection of the age group most likely to seek the services of SMT." pp 10,11. While we are on this topic, I am curious how many DCs out there perform the full George's test, which includes bilateral BP, bilateral pulse, auscultation for subclavian bruits, as well as a functional vascular test. I have been told by several attorneys that George's test is the standard of care in the community. However, Terret notes that taking bilateral blood pressure is not useful, except for revealing a subclavian steal syndrome, and VBS following SMT has never been reported in a patient with the subclavian steal syndrome.(p.30) Likewise, Terret notes that auscultating the neck for bruits is equally worthless, since no arterial bruits are detected after arterial damage and it would be highly unlikely that a bruit would have been detected prior to the arterial trauma. I would also ask why would we be listening for possible problems in the carotid arteries when the vessels in question are the vertebral arteries? Terret concludes that "the taking of bilateral blood pressure, and listening for bruits, leads the practitioner into a false feeling that they are doing a relevant vertebrobasilar screening examination."(p.30) Therefore, he does not recommend either of these procedures. Ben Weitz, D.C., C.C.S.P. LHBWeitz@aol.com << >Never mind trauma, the first question coming to mind ....was she on oral contraceptives and/or a smoker? These appear to be significant factors in the age group 20's - 35! Further comments would be appreciated. According to Terret's monograph on Vertebrobasilar Stroke Following Manipulation (1996): It appears that there is no relationship between oral contraceptives, SMT and VAD. (page 23) Although chronic smoking appears to increase the risk of cerebral stroke, it does not appear to increase the risk of post SMT VBS(pg24) >> fs