Recognition of Spontaneous Vertebral Artery Dissection
Written by Editor   
Friday, April 10, 2015 12:00 AM

The purpose of this case report is to describe a patient who presented to a chiropractic physician for evaluation and treatment of neck pain and headache.  This case highlights the potential for patients with vertebral artery dissection to present with nonspecific musculoskeletal complaints. Neurological symptoms may not manifest initially, but their sudden onset indicates the possibility of an ischemic cerebrovascular event. We suggest that early recognition and emergent referral for this patient avoided potential exacerbation of an evolving pre-existing condition and resulted in timely anticoagulation treatment.

A 45-year-old white female presented to a chiropractic clinic complaining of upper back/neck pain and stiffness as well as headache and pain in the posterior portion of the right arm down to the elbow of 3 days duration. Her level of discomfort progressed in severity in the 24 hours prior to presentation, which is what prompted her appointment.

Because this was a new complaint, an updated history and examination were performed. No history of trauma was disclosed. Physical examination revealed painful and limited active range of motion in the cervical region. Palpation was provocative for tenderness. After the initial examination, therapeutic ultrasound was applied in the seated position over the suboccipital and posterior cervical musculature. While still in the seated position, soft tissue treatment was performed by a licensed massage therapist on the suboccipital and posterior cervical musculature. The patient was shown to a treatment room and was supine when the clinician entered and asked how she felt. The patient responded that her neck pain was much better, but she was more aware of her headache.

The patient was assisted to the seated posture, became dizzy, reported visual and cognitive disturbances, and had difficulty speaking. She proceeded to lose control of her right leg, which spontaneously assumed a flexion contracture. The clinician suspected a vascular etiology at this time and SMT was not performed. Paramedics were immediately summoned and the patient was transported to a local hospital with a working diagnosis of acute cerebrovascular ischemia.  Multiplanar computed tomographic and magnetic resonance imaging with contrast revealed vertebral artery dissection of the V2 segment in the right vertebral artery. Anticoagulation therapy was administered and the patient was discharged without complications after 5 days in the hospital.

Our case report emphasizes that undiagnosed VAD may present with neck pain and headache, a common presentation for patients undergoing cervical SMT. Although the presentation evolved rapidly to include neurological symptoms, those symptoms were not present initially and may not be present at all in a given case of VAD. Awareness of the non-specific symptoms of VAD is important because SMT could exacerbate the condition and lead to complications such as stroke. We suggest that emergent referral for diagnostic imaging, in the setting of suspected VAD, optimizes the likelihood of an accurate diagnosis and appropriate treatment.