An Etiologic Model to Help Explain the Pathogenesis of Cervical Artery Dissection: Implications for Cervical Manipulation

We present a theoretical etiologic model of cervical artery dissection for the purpose of coalescing our present understanding of its pathogenesis. Although the notion of an underlying arteriopathy and a trigger are universally accepted concepts, we propose in our model that dissection is a product of an underlying (genetic) predisposition, triggered specifically by risk factors associated with environmental exposure, with or without trivial trauma. Given the widespread daily occurence of neck movements and sporting activities, it seems unlikely that trivial trauma, in the absence of other triggers and an underlying arteriopathy, is sufficient to cause dissection. This concept has significant implications for practitioners of spinal manipulation. This may represent a paradigm shift because the model suggests that stroke following manipulation is unlikely in otherwise healthy individuals. Although this model is consistent with current published case-control studies on cervical artery dissection, further research is necessary to accept or refute it as a tenable hypothesis.