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The Naked Chiropractor
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Dr. Preston H. Long
Dr. Preston H. Long is THE expert. Consumers trust Andrew Weil for reliable information about alternative medicine, Dr. Bernie Siegel for inspiring words about mind-body connection, and Dr. Dean Ornish, for practical ways to keep their hearts healthy, but who the recognized authority on back care and the limits of chiropractic medicine?
When Simple Actions Ravage ArteriesNY Times Science section
April 3, 2001
By JANE E. BRODY
Martin Dunitz, a London publisher of medical texts, is one lucky man, if youcan call anyone who has suffered damage to one of the two arteries that feedthe brain lucky. While on a Caribbean vacation with his wife and twodaughters in St. Lucia, Mr. Dunitz went water-skiing.
Hours later he developed severe pain behind one eye and a strange distortionand numbness of his mouth and tongue that made it very difficult to eat andtalk. Not wanting to disrupt the vacation, Mr. Dunitz waited until he gothome to London to see a doctor. He even went water-skiing a second time.
Though one doctor thought he had Bell's palsy, a usually temporary paralysison one side of the face, Dr. Martin Rossor, a neurologist at the NationalHospital for Neurology and Neurosurgery in London, immediately suspectedsomething far more serious: a tear, or dissection, of the carotid arteryfeeding the brain, resulting in a leakage of blood that could easily haveprecipitated a full-blown stroke. The suspected diagnosis was confirmed bymagnetic resonance imaging, an M.R.I.
Mr. Dunitz is lucky because his arterial trauma did not result in a strokeand with about six months of treatment with anticoagulants, he is expectedto make a full recovery. Not everyone who has suffered a dissected carotidor vertebral artery has been as fortunate.
In February 1998, for example, a 20-year-old woman from Saskatchewan lapsedinto a coma on a chiropractor's table and died 24 hours later. She hadsought treatment for a stiff neck and, after neck manipulation by thechiropractor, a dissection of a vertebral artery caused an aneurysm thatinterrupted blood flow to her brain.
Likewise, a 35-year-old mother of four in Seattle suffered a strokeprecipitated by a dissected vertebral artery immediately after chiropracticmanipulation. She survived but now struggles with simple everyday tasks liketying her shoes.
An arterial dissection starts with a tear inside one of the major arteriesin the neck. This allows blood to enter the wall of the artery and split itslayers, resulting either in the formation of a clot or in an aneurysm (apouch sticking out from the blood vessel), possibly disrupting blood flow tothe brain and damaging cranial nerves.
Why Does This Happen?
Arterial dissections were once thought to be extremely rare and were usuallydetected only at autopsy. But with the aid of modern diagnostic techniqueslike CT scans and especially M.R.I.'s, neurologists are now discovering themmore often. In a report March 22 in The New England Journal of Medicine, Dr.Wouter I. Schievink of the Cedars-Sinai Neurological Institute in LosAngeles reported an annual incidence of 1 per 100,000 to 1.5 per 100,000people. While these dissections account for only about 2 percent of allnonhemorrhagic strokes, they are an important cause of stroke in young andmiddle-aged patients, accounting for as many as one-quarter of cases inthese age groups.
Chiropractic spinal manipulation, estimated to cause strokes in as many asone in 20,000 patients who undergo it, is but one possible cause. Anysudden, abrupt neck movement or extreme neck position can cause an arterialdissection in a susceptible person. Other situations include getting one'shair washed in a beauty salon (the so- called beauty-parlor stroke) ordrinking a shot of whiskey (dubbed the "bottoms-up dissection") or liftingheavy objects. A champion swimmer developed a dissected carotid from doingtoo much backstroke.
Dr. Schievink also lists precipitating events associated with hyperextensionof the neck, including "practicing yoga, painting a ceiling, coughing,vomiting and sneezing," as well as medical procedures like receivinganesthesia or being resuscitated and traumatic causes like motor vehicleaccidents or sports injuries.
An estimated one-fourth of patients who suffer an arterial dissection afterchiropractic manipulation are believed to have an underlying connectivetissue disorder or structural defect of the arterial wall that increasestheir vulnerability to arterial damage. In fact, it has been suggested thatthe early symptoms of vertebral-artery dissection, which commonly mimicmusculoskeletal neck pain, may be what prompt people like the 20-year-oldCanadian woman to visit a chiropractor in the first place.
There may also be an infectious factor in some cases, since the occurrenceof carotid and vertebral artery dissections with no apparent cause peaks inthe fall, when respiratory infections are most common.
Delay Is Dangerous
It is critically important to respond quickly to the early warning signs ofan arterial dissection. The spectrum of symptoms varies from patient topatient and is determined in part by which artery is affected. In patientswith a dissection of the internal carotid artery, for example, typicalsymptoms include pain on one side of the head, face or neck accompanied byparalysis of one eye and followed hours or days later by brain or retinalsymptoms.
Other common symptoms of arterial dissections are pain in the back of theneck or head, a constant headache that develops suddenly on one side of thehead and that may resemble a migraine, pain behind an eye, impaired abilityto taste, tinnitus (pulsing noises in an ear), temporary visual loss andtemporary loss of awareness (a kind of ministroke called a transientischemic attack).
Anyone who develops two or more such symptoms should seek medical carewithout delay and, to enhance the likelihood of a speedy and correctdiagnosis, perhaps even suggest that the doctor investigate the possibilityof an arterial dissection by performing a magnetic resonance angiogram.
Carotid and vertebral artery dissections are fatal in fewer than 5 percentof cases, and about three-fourths of patients who suffer a stroke as aresult of a dissection make a "good functional recovery," Dr. Schievinkreported. Most dissections heal without surgery, blockages gradually resolvein 90 percent of cases and one-third of aneurysms decrease in size. Thereis, however, a small risk that once there has been an arterial dissection,the disorder will occur in another artery.
Treatment involves preventing the complications of clots by administeringanticoagulants, at first intravenously and then orally for three to sixmonths. Patients must have their blood checked often to be sure it does notbecome too thin because overly thin blood can result in a hemorrhage.
When conservative treatment fails to correct the problem, a balloon may beinflated in the affected artery to compress the clot and a metal stentinserted to keep the artery open. With this modern therapy, surgery tobypass the damaged artery has become far less common.
Copyright 2001 The New York Times Company
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