Neck manipulation as a cause of stroke.

a recent publication by Krueger and Okazaki 1 describe a complication of manipulative therapy to the vertebral arteries at the atlanto-axial level.The vertebral artery is relatively fixed in the transverse foramen between Cl and C2 and between the exit from the foramen Cl and the atlanto-occipital membrane.Since rotation of the head and neck is one of the primary functions of the C1-C2 junction, it is not surprising that this has been the site of the majority of vertebral injuries leading to dissecting aneurysms and/or vertebral occlusion.Tilting of the neck also occurs largely at the C1-C2 junction and when various maneuvers including rotation, tilting, extension, and traction are added during cervical manipulation, one or both arteries may be temporarily occluded or injured leading to temporary brainstem ischemia, vascular occlusion or dissection or with distal embolization.The presence of atherosclerosis or cervical osteophytes compressing the vertebral artery seems to increase the chance of vertebral artery injury, but many of the reported patients have been young individuals with normal anatomy.