Talk:Vertebral artery dissection

WP:DUE, manipulation and VAD

We state 16–28% of VAD may be due to manipulation. Thus most are not. They occur spontaneously at a rate of 1 to 1.5 per 100,000. They may occur in possibly 1 per 100,000 neck manipulations. And 1% of serious neck trauma cases. Thus well much literature agrees that manipulation is a possible cause it does not appear to be the main cause.

I agree with JFD that it should not be mentioned in the lead but dealt with in the body of the article. Ernst is a well know and respected researcher of alt med. Thus his reviews are appropriate. But based on my editorial judgment belongs in the body of the article. My COI is on my user page. Doc James (talk · contribs · email) 02:25, 1 December 2010 (UTC)

IIRC, the Canadian study concluded it was a the major cause in individuals under 45 years of age. Otherwise I agree that it doesn't have to be mentioned in the lead, at least not until it is properly developed in the body. Then we can see if it's worth mentioning in the lead. -- Brangifer (talk) 02:53, 1 December 2010 (UTC)

Can you give a link for that? Does it give a percentage? How did it come to this conclusion? Doc James (talk · contribs · email) 06:18, 1 December 2010 (UTC)

I did find the "under 45" figure many places, probably quoting from this Stroke reference: Rothwell DM, Bondy SJ, Williams I. Case control study of chiropractic manipulation and stroke. Stroke 2001 (5) 1054-1060. Some places say it's a "major cause" and others a "leading cause". I'll refactor my comment above to soften it.

Here is a statement from 62 Canadian neurologists where they express concern that "patients with posterior circulation strokes under the age of 45 are 5 times more likely than controls to have visited a chiropractor within one week of the event 14." You can read their statement and the references they use:

• Statement of Concern to the Canadian Public from Canadian Neurologists Regarding the Debilitating and Fatal Damage Manipulation of the Neck May Cause to the Nervous System

Interestingly, this published statement was issued at a time when a major lawsuit was being filed by a family whose daughter, Laurie Jean Mathiason, had died after a neck manipulation. Immediately following the manipulation, she convulsed on the table and her head actually began turning blue. She went into a coma and died. The lawyers for the Canadian Chiropractic Association were on their toes and very aggressive. When this statement was published, each of the neurologists was contacted by those lawyers and threatened with a lawsuit if they didn't retract their support for the statement. Brangifer (talk) 07:43, 1 December 2010 (UTC)

Is any of this immediately relevant here? We are already discussing it as one of the causes in a fair amount of detail, ensuring NPOV by stating that there is an opposing view. From the above sources, is there anything that is going to make this article better? JFW | T@lk 10:06, 1 December 2010 (UTC)

Reviews

A few more reviews to flesh out the article:

• Redekop GJ (2008). "Extracranial carotid and vertebral artery dissection: a review". Can J Neurol Sci. 35 (2): 146–52. PMID 18574926. {{cite journal}}: Unknown parameter |month= ignored (help)
• Caplan LR (2008). "Dissections of brain-supplying arteries". Nat Clin Pract Neurol. 4 (1): 34–42. doi:10.1038/ncpneuro0683. PMID 18199995. {{cite journal}}: Unknown parameter |month= ignored (help)
• Goyal MS, Derdeyn CP (2009). "The diagnosis and management of supraaortic arterial dissections". Curr. Opin. Neurol. 22 (1): 80–9. PMID 19165955. {{cite journal}}: Unknown parameter |month= ignored (help)
• Nedeltchev K, Baumgartner RW (2005). "Traumatic cervical artery dissection". Front Neurol Neurosci. 20: 54–63. doi:10.1159/000088149. PMID 17290111.
• Campos-Herrera CR, Scaff M, Yamamoto FI, Conforto AB (2008). "Spontaneous cervical artery dissection: an update on clinical and diagnostic aspects". Arq Neuropsiquiatr. 66 (4): 922–7. PMID 19099146. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)

The last one is freely available. Doc James (talk · contribs · email) 02:39, 1 December 2010 (UTC)

I don't want more reviews currently. We already have Kim and LancetNeurol. I might use Nedeltchev to inform the trauma-related content and I will have a look at Goyal to make sure it covers the same ground as our present sources. JFW | T@lk 10:04, 1 December 2010 (UTC)

The source you overlooked is now part of the Prognosis section. QuackGuru (talk) 06:47, 6 December 2010 (UTC)

I didn't overlook it. It does not currently distinguish between mortality and poor outcome. JFW | T@lk 06:55, 6 December 2010 (UTC)

Would you like me to delete the Prognosis section with the reference you objected to because it does not currently distinguish between mortality and poor outcome. QuackGuru (talk) 06:58, 6 December 2010 (UTC)

I have not read these reviews. Just to get an idea of weight, how much attention is paid in these reviews to the discussion of spinal manipulation? DigitalC (talk) 02:07, 6 December 2010 (UTC)

A little, just like the article in its current form. LancetNeurol avoids the discussion altogether, but Kim has a paragraph on it. JFW | T@lk 06:36, 6 December 2010 (UTC)

Ernst-death once more

QuackGuru (talk · contribs) reinserted content quoted from "Ernst-death" despite my continuing objections and a de facto lack of consensus. There are two points that we are presently sourcing to this study. Firstly, that there have been 26 deaths reported in the literature since 1937 attributable to chiropractic and that this is unacceptably high for a modality of limited proven benefit. Secondly, that there is "underreporting" of VAD events. Let me pick apart these two claims and explain my ongoing objections against including this content in this article.

Deaths from chiropractic - we know that VAD may result from chiropractic, and we know that VAD can lead to death. There is no suggestion in any source that VAD resulting from chiropractic carries a higher risk of death than VAD from another cause. The fact that chiropractic can kill is a criticism that needs to be discussed in the context of the alleged benefits of chiropractic, and I suggest that the study is discussed in the chiropractic article.

Underreporting - we are presently quoting propulation-based studies from the Mayo clinic and from France (both fairly reliable sources of data). We are also presently quoting the concerns from the Lancet Neurol that people with very mild symptoms may never undergo a definitive investigation and therefore remain without a diagnosis; whether the prognosis in this population is particularly bad is unknown, nor do we know if they should be considered for anticoagulation or antiplatelet treatment. The kind of "underreporting" that Ernst-death is referring to is the fact that not every death from chiropractic-related VAD has been submitted to a peer-reviewed medical journal. That has absolutely nothing to do with the actual incidence. All that is implied is "we suspect that chiropractic has killed more than 26 people but we can't prove it yet". I don't think this is the kind of fact that we can reasonably cite as factual.

I want to stop this article from turning into a WP:COATRACK to bash chiropractic. At the same time I totally agree that chiropractic is without an evidence base and that there are real harms attached to the treatment. JFW | T@lk 07:33, 5 December 2010 (UTC)

Ernst identifies spinal manipulation as a possible or likely cause for VBA stroke. Other studies show similar rates of VBA stroke between the regular population and chiropractic patients, suggesting a pre-existing condition to be the cause. Given the unresolved ambiguity in this area, and their only tangential relevance to this article, a full reference to the Ernst study seems like undue Weight. This issue is thoroughly detailed at both Chiropractic and Spinal manipulation, where it can be addressed fully. We should only give it brief mention and provide links for deeper investigation. The alternative is a full review of studies from the last decade regarding SM/VBA correlation and causality in this article. Either way, I agree QG's edits are not ready to stand by themselves, nor is there consensus for them to do so.

Also, QG added this information with the edit comment, 'copyedit', which it clearly was not. QG, making controversial changes which have been disputed on talk pages and labeling them as copyedits is as close as I've seen you come to doing something blatantly blockable. Since you know where most of the lines with regard to that are, please add it to your list. It's one thing for you to have a COI or a SPA, or a POV--all of those I can live with--but if the continuous tendentious editing wasn't enough, that kind of blatant deception is. Please do not it. Ocaasi (talk) 08:18, 5 December 2010 (UTC)

There is consensus for this change. QuackGuru (talk) 08:31, 5 December 2010 (UTC)

How so? I don't think it belongs as is, neither does Jdfwolff. Because you seem to think otherwise, consensus is something that emerges from the opinions of multiple editors, not just whatever you would prefer it to be. While there's talk page discussion of this going on, please don't add back the material. Ocaasi (talk) 08:35, 5 December 2010 (UTC)

Also, QG, a discussion at Wikiproject Medicine does not mean consensus here. If you want to add the material on this article page, you'll have to get consensus among the editors working on the article, not just over there. Ocaasi (talk) 09:15, 5 December 2010 (UTC)

There is no consensus at all. Several editors have objected to your approach, including myself and VAPhD. I want you to address my points from the above post: whether discussion of deaths is proportionate, and whether underreporting is a separate issue from underdiagnosis. I don't intend to engage in any further discussion unless you (QG) have shown to be addressing my points. JFW | T@lk 10:34, 5 December 2010 (UTC)

There is no consensus at all to delete a recent syatematic review. Uninvolved editors want the source restored. See Wikipedia talk:WikiProject Medicine#Vertebral artery dissection. The text I added as a compromise is sourced in accordance with V. The underreporting sourced. We know that VAD may result from chiropractic is also sourced. It is not our job to conduct our own review of the source.

"What’s known Chiropractic upper spinal manipulation has repeatedly been associated with arterial dissection followed by stroke and, in some cases, death."

"What’s new The article is the first systematic review of all fatalities reported in the medical literature. Twenty-six deaths are on record and many more seem to have remained unpublished."

"Vascular accidents after upper spinal manipulation are a well-recognised problem (e.g. 1,2). Dissection of a vertebral artery, caused by extension and rotation of the neck beyond the physiological range of motion, is thought to be the underlying mechanism(2)."

"This systematic review demonstrates that numerous deaths have been associated with chiropractic. Usually high-velocity, short-lever thrusts of the upper spine with rotation are implicated. They are believed to cause vertebral arterial dissection in predisposed individuals which, in turn, can lead to a chain of events including stroke and death (1,2,26,30)."

"Reliable estimates of the frequency of vascular accidents are prevented by the fact that underreporting is known to be substantial."

E Ernst (2010). "Deaths after chiropractic: a review of published cases". Int J Clinical Practice. 64 (8): 1162–1165. doi:10.1111/j.1742-1241.2010.02352.x. PMID 20642715.

(The compromise is sourced.) "A systematic review stated that the risk of death from manipulations to the neck, typically associated with vertebral artery dissection, by far outweighs the benefits; 26 fatalities are recorded in the medical literature since 1934, and many more seem to remain unpublished."

(The compromise is sourced.) "The frequency for accurate estimates of vascular accidents involving vertebral artery dissection are impeded by the suspected substantial underreporting." QuackGuru (talk) 04:32, 6 December 2010 (UTC)

QG, this is not a V or an RS issue but a Weight issue. Systematic reviews are reliable per MEDRS, and everything you included can be sourced: Weight is not about either of those issues, however. It is about whether and how much of those verifiable, reliably-sourced pieces should be included. You'll have to address the actual arguments presented to you, not refutations of objections that haven't been made. Ocaasi (talk) 05:00, 6 December 2010 (UTC)

See WP:WEIGHT: Neutrality requires that each article or other page in the mainspace fairly represents all significant viewpoints that have been published by reliable sources, in proportion to the prominence of each viewpoint. Giving due weight and avoiding giving undue weight means that articles should not give minority views as much of or as detailed a description as more widely held views.

A recent systematic review is a significant viewpoint that has been published by a reliable source. QuackGuru (talk) 05:04, 6 December 2010 (UTC)

That would be true if it were a systematic review about the article's subject as opposed to about a systematic review about a minor aspect of the article. Then different considerations apply, because context matters when considering Weight. A viewpoint is not inherently significant solely because it is reliable. Nor are all aspects of a review relevant; nor do they have to be included with the maximum amount of words or attention.

NPOV is about relative balance within articles as well as the presentation of specific sources. No one has suggested not using Ernst at all, just using Ernst in proportion to the attention that one important review--in a controversial area which addresses a likely but unproven (and possibly underreported) cause of a small subset of overall VBA incidents--should receive. The place for significant detail about this is not here, but at Chiropractic and Spinal Manipulation, unless you also want to include the several studies that question the CSM/VBA connection and call on the need for further research. Keep it short and neutral or expanded but balanced. Either way is ok with me. Ocaasi (talk) 05:42, 6 December 2010 (UTC)

"Vascular accidents after upper spinal manipulation are a well-recognised problem (e.g. 1,2). Dissection of a vertebral artery, caused by extension and rotation of the neck beyond the physiological range of motion, is thought to be the underlying mechanism(2)."

This is not a minor cause according to the recent sytematic review. Vascular accidents after neck manipulation is a well-recognised problem. QuackGuru (talk) 05:50, 6 December 2010 (UTC)

Ernst identifies vascular accidents as a recognized problem for CSM, but not that manipulation is a major source vascular accidents in general. These are different in scope, and significance in one is different than in the other.

There are other reasons why shorter is better here. For one, there are studies which question whether a pre-existing condition causes people to seek out Chiropractors, resulting in a misattribution of causality. And if we want to give a detailed coverage of Ernst, then we have to do it for Spine 2008 ("VBA stroke is a very rare event in the population. The increased risks of VBA stroke associated with chiropractic and PCP visits is likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke. We found no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care."), JMPT 2005 ("Perceived causation of reported cases of cervical artery dissection is more frequently attributed to chiropractic manipulative therapy procedures than to motor vehicle collision related injuries, even though the comparative biomechanical evidence makes such causation unlikely. The direct evidence suggests that the healthy vertebral artery is not at risk from properly performed chiropractic manipulative procedures."), and Spine 2009 ("There is no robust data concerning the incidence or prevalence of adverse reactions after chiropractic. Further investigations are urgently needed to assess definite conclusions regarding this issue.")... and it just gets long for this article. Ocaasi (talk) 06:35, 6 December 2010 (UTC) Missed one Neurologist 2008] ("Weak to moderately strong evidence exists to support causation between CMT and VAD and associated stroke. Ultimately, the acceptable level of risk associated with a therapeutic intervention like CMT must be balanced against evidence of therapeutic efficacy. Further research, employing prospective cohort study designs, is indicated to uncover both the benefits and the harms associated with CMT." Ocaasi (talk) 10:49, 6 December 2010 (UTC)

If you want to include other sources they must meet MEDRS. QuackGuru (talk) 06:53, 6 December 2010 (UTC)

Oh they do. Certainly Spine does and JMPT is reliable for spinal manipulation. After proposing a mediocre 2009 primary study as MEDRS but dismissing a quality review from Spine, I'm not sure if you are actually applying MEDRS or just using it for justification. Can you explain the differences between Ernst 2010, Spine 2008 and 2009, and the 2009 Chiropractic student study you cited at Chiropractic? Ocaasi (talk) 08:03, 6 December 2010 (UTC)

Ernst 2010 is a recent systematic review. The 2009 study is the best source available for that study on specifc treatment techniques and on students especially for hand/wrist injuries sustained by chiropractors. If there was a better source we would use that. You did not delete the 2010 Belguim study that was not a review. QuackGuru (talk) 08:19, 6 December 2010 (UTC)

The Belgium study was actually relevant to the section because it discussed treatment techniques, not the risk of injuries to chiropractic students a chiropractic college. As for the JMPT injury study, the only relevant piece is "Diversified, Gonstead, and upper cervical adjusting techniques were perceived to be the most injury-related." If you have other sourced information relating to those techniques (descriptive as well as research), we could add that piece. It really doesn't need a whole paragraph, though, especially from a lower quality MEDRS source, but I wouldn't object to it. Ocaasi (talk) 09:53, 6 December 2010 (UTC)

(←) The current version does not hide the fact that spinal manipulation can cause VAD. We still need to expand the "prognosis" section to explain that VAD can lead to death. That way, the reader will understand that spinal manipulation can give you VAD, and that VAD can kill.

You keep on going on about the fact that "Ernst-death" is WP:MEDRS. I don't dispute that, and neither do I dispute any of the statements of fact. But I think that it constitutes WP:WEIGHT because we are actually talking about a rare event, even if we take underreporting of 100% into consideration. JFW | T@lk 06:36, 6 December 2010 (UTC)

I think that it constitutes WP:WEIGHT because we are actually using a recent systematic review. Do you have a specific response to "Vascular accidents after upper spinal manipulation are a well-recognised problem (e.g. 1,2)." QuackGuru (talk) 06:53, 6 December 2010 (UTC)

We are already saying that, both in the introduction and in the "causes" section. We even give a figure of 16-28%, suggesting that manipulative therapy is responsible for a very significant proportion of cases. I don't think we can inflate this figure further. JFW | T@lk 06:59, 6 December 2010 (UTC)

Manipulative therapy is responsible for a very significant proportion of cases. We should include the systematic review per WEIGHT. QuackGuru (talk) 07:03, 6 December 2010 (UTC)

But we are already saying that! JFW | T@lk 07:26, 6 December 2010 (UTC)

(The compromise.) "A systematic review stated that the risk of death from manipulations to the neck, typically associated with vertebral artery dissection, by far outweighs the benefits; 26 fatalities are recorded in the medical literature since 1934, and many more seem to remain unpublished."

(The compromise.) "The frequency for accurate estimates of vascular accidents involving vertebral artery dissection are impeded by the suspected substantial underreporting."

I think the 2010 systematic review constitutes WP:WEIGHT because manipulative therapy is responsible for a very significant proportion of cases and vascular accidents after neck spinal manipulation are a well recognised issue. QuackGuru (talk) 07:35, 6 December 2010 (UTC)

What source establishes that manipulative therapy is responsible for a significant proportion of vascular accidents? Ernst reports that SM can be dangerous or even fatal but that actual incidents are very rare (even with underreporting). Also, Spine 2007 disputes Ernst, as does JMPT 2005 and, and Spine 2009 affirms that the data regarding chiropractic and adverse events is really not very good at all, and further research is urgently needed. Ernst's findings are credible for a risk analysis, but they don't broadly establish significance related to VBA, just an association, a presumed cause, and evidence of underreporting. Ocaasi (talk) 08:03, 6 December 2010 (UTC)

Hey. Looked what somehow got in the article. "Chiropractic and other forms of neck manipulation have been linked to vertebral artery dissection (16–28% of cases in hospital-based studies).[1]" It seems you forgot to delete it. Thanks. It seems 16–28% is a significant proportion of vascular accidents. You are doing your own review of the systematic review rather than helping to improve the article. The systematic review does say "Chiropractic upper spinal manipulation has repeatedly been associated with arterial dissection followed by stroke and, in some cases, death." I show this source is relevant to this article. QuackGuru (talk) 08:19, 6 December 2010 (UTC)

I hadn't found the 16-28%, nor would I have removed it. It is significant although not overwhelming, also considering the general rarity of VBA incidents. Again, I didn't say Ernst shouldn't be mentioned, only that it be proportional or balanced. Spine 2008 addresses the issue of preexisting conditions that could explain the CSM/VBA correlation and Spine 2009 concludes that adverse incident data still for spinal manipulation still lacks quality. I see that as a dispute among reliable sources. And the Weight concern is still there: including, "Chiropractic and other forms of neck manipulation have been linked to vertebral artery dissection (16–28% of cases in hospital-based studies)" seems close to sufficient. As long as we include a mention of underreporting, and perhaps the lack of quality data, we should be covered. I'd also argue we should include Spine 2008 and JMPT 2005 which found that the forces experienced during SM are less than other traumas known not to cause VBAs in healthy individuals. Ocaasi (talk) 10:16, 6 December 2010 (UTC)

The 16-28% figure has been in the "causes" section since I added it on 25 November (diff). I stand by its inclusion and have no intention to remove it. JFW | T@lk 15:29, 6 December 2010 (UTC)

• My 2 cents: As a review of the case studies, not exactly Cochrane level of evidence, but it is a peer reviewed review of the literature. I think the one sentence on the incidence and likely under-reporting is appropriate here - if we are explicitly clear that we are speaking of the under-reporting of serious complications like death. The other section about deaths does not appear appropriate for the "Trauma" section - if and when the "Prognosis" section is expanded, a one liner there would probably be the right WP:WEIGHT; language about "risks out weight benefits" seems somewhat out of place here, and probably more appropriate in the chiropractic article. Yobol (talk) 15:15, 6 December 2010 (UTC)

But what do you mean by "underreporting"? Is there any evidence that VAD due to chiropractic is more lethal than VAD due to any other cause? JFW | T@lk 15:29, 6 December 2010 (UTC)

No, nor do I think such language would be appropriately sourced to Ernst 2010. Any discussion of under-reporting from this source would have to be specific to deaths from chiropractic manipulation. How about move the mention of "under-reporting" and combine it with the deaths section, and place both in the Prognosis section? Yobol (talk) 15:36, 6 December 2010 (UTC)

I made this change for now. QuackGuru (talk) 18:55, 6 December 2010 (UTC)

QG, there are several contrasting viewpoints in this section about how to handle its Weight, and they are approaching a consensus. While it's being discussed, it should be on the talk page. For now, you should take it out and paste it as a proposal in a new section. Ocaasi (talk) 19:05, 6 December 2010 (UTC)

• Since QuackGuru's viewpoint seems amply clear, I would be very interested to see how this discussion would progress if QuackGuru would abstain from commenting for, say, 24 or 48 hours. A suggestion only, at this point. MastCell ^Talk 19:18, 6 December 2010 (UTC)

• Hee hah! LMFAO! You all may wonder why I haven't been contributing here lately. As long as QG is involved with his special method of making edits of controversial material before a consensus is reached, I find it pointless. I hate getting involved because he can keep this circus going for months on end. Let me know when he's been effectively contained. Until then I can't afford losing my 2 cents repeatedly. -- Brangifer (talk) 20:21, 6 December 2010 (UTC)

Proposal

To be placed in the prognosis section (the epidemiology section would be inappropriate as it discussing a complication and good incidence rates are not available):

Deaths due to chiropractic manipulation to the neck, which is thought to be associated with vertebral artery dissection, have been documented in the medical literature, with 26 fatalities since 1934 reported by one review. There is likely under-reporting in the literature of the true incidence of death associated with VAD due to manipulation, although no reliable data on incidence is available. (ref to ernst-death)

I think this is appropriately weighted, without getting in too much details about chiropractic. Thoughts? Yobol (talk) 15:21, 7 December 2010 (UTC)

Why is this relevant to the subject of prognosis? JFW | T@lk 22:33, 7 December 2010 (UTC)

Death being a possible complication, it might be relevant here. What section do you think it fits better in? Yobol (talk) 22:38, 7 December 2010 (UTC)

Have you read even a single one of my posts above? Why should chiropractic-related VAD be any more lethal than other forms of VAD? JFW | T@lk 23:51, 7 December 2010 (UTC)

I never said it could, and I do not know the relevance of that question to my question as to where to place this information. Are you saying we shouldn't use this information if we can't prove VAD related manipulation is more likely to be complicated by death? Yobol (talk) 23:58, 7 December 2010 (UTC)

Don't you think it comes close to WP:WEIGHT to say something along the lines of "you know, VAD related to chiropractic can also kill, and there have been 26 cases reported over >60 years, but we think there may be more"? JFW | T@lk 00:07, 8 December 2010 (UTC)

Presumably we would have other information in the prognosis section to provide proper balance. Otherwise, I don't see anything obviously WP:UNDUE about my proposal. Could you elaborate on your objection? Yobol (talk) 00:10, 8 December 2010 (UTC)

The source doesn't say anything new. All other sources already state that chiropractic can cause VAD, and that VAD can kill. What is new here? The underreporting is only suspected; it presumes that every fatality from a disease is submitted to a registry or published in the medical literature. I have restated this again and again, and I'm still not hearing a good reason why this study needs to be given such emphasis. JFW | T@lk 06:29, 8 December 2010 (UTC)

This is uniquely different from other "diseases", where the connection between cause and effect are usually noted by a physician or coroner. Here we have a traumatic cause that is often separated by days and even weeks from the actual stroke or death. This means that it is rare to connect the two. It pretty much only happens when the VAD occurs dramatically in immediate connection with the cervical manipulation. Even then, chiropractors will deny there is any causation in spite of immediate convulsions, foaming at the mouth, and the head turning blue. That has actually happened! That's why underreporting is a problem to a degree not found with other conditions, where the connection between cause and stroke/death is noted. Here the VAD might be noted, but the real cause isn't even guessed. -- Brangifer (talk) 07:10, 8 December 2010 (UTC)

In that sense it is no different from any other types of trauma, which may be remote. Again, the evidence for underreporting is very circumstantial. JFW | T@lk 07:33, 8 December 2010 (UTC)

The information is not "new"? We have other sources documenting the number of deaths noted in the literature from chiropractic manipulation and that this is likely underreported as to the true incidence? I don't understand how you can say it's not "new" if the information isn't in the WP article already.

And I guess I'm not seeing that this information is getting any more "emphasis" than any other piece of information; if you have any other reviews that look at the literature I would expect it to get as much weight as this one. It's two short sentences. Yobol (talk) 14:37, 8 December 2010 (UTC)

Proposal 2

Serious adverse events including 26 deaths since 1934 have been associated with spinal manipulation to the neck, and vertebral artery dissection or stroke is a suspected cause (neurologist 2008, ernst 2010). Uncertainty remains due to both significant under-reporting of manipulation-related trauma (ernst 2010) as well as the possibility of patients seeking out chiropractors because a pre-existing verterbral artery condition (spine 2008). Evidence suggests healthy vertebral arteries are not at risk from proper manipulation (JMPT 2005), however better data is needed to understand the connection (spine 2009).

-Spine 2008 "VBA stroke is a very rare event in the population. The increased risks of VBA stroke associated with chiropractic and PCP visits is likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke. We found no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care."

-JMPT 2005 "Perceived causation of reported cases of cervical artery dissection is more frequently attributed to chiropractic manipulative therapy procedures than to motor vehicle collision related injuries, even though the comparative biomechanical evidence makes such causation unlikely. The direct evidence suggests that the healthy vertebral artery is not at risk from properly performed chiropractic manipulative procedures."

-Spine 2009 "There is no robust data concerning the incidence or prevalence of adverse reactions after chiropractic. Further investigations are urgently needed to assess definite conclusions regarding this issue."

-Neurologist 2008] "Weak to moderately strong evidence exists to support causation between CMT and VAD and associated stroke. Ultimately, the acceptable level of risk associated with a therapeutic intervention like CMT must be balanced against evidence of therapeutic efficacy. Further research, employing prospective cohort study designs, is indicated to uncover both the benefits and the harms associated with CMT." Ocaasi (talk) 14:29, 8 December 2010 (UTC)

The current article is a WEIGHT violation for not including the relevant 2010 systematic review. There are two different proposals on the talk page and most editors want to include at least something from the reference. QuackGuru (talk) 02:45, 21 December 2010 (UTC)

Cochrane

Having cited Menon as a treatment trial showing (essentially) equipoise between antiplatelets and anticoagulation, I thought I'd have a look at Cochrane to see if they might have reviewed this. Unfortunately the only review is doi:10.1002/14651858.CD000255.pub2, which only covers carotid dissection. JFW | T@lk 14:46, 12 December 2010 (UTC)

The 2007 American stroke guideline (doi:10.1161/STROKEAHA.107.181486) devotes little space to arterial dissection, and seems to discourage anticoagulation but without discussing the evidence! JFW | T@lk 22:48, 12 December 2010 (UTC)

Strangely, the 2009 imaging guideline for stroke seems to suggest that DSA should be performed rather than CT/MRI to confirm or exclude dissection. No idea how this advice is followed in practice. doi:10.1161/STROKEAHA.108.192616 JFW | T@lk 22:56, 12 December 2010 (UTC)

Almost done...

Having expanded the article significantly in the last few days, I'm just taking stock of what we still need to do before it might be ripe for reassessment (class B or GA, depending mostly on whether I have the time).

•  Done Signs and symptoms - could still expand on the lateral medullary syndromes, but sources are rather quiet about it
  • Decided not to go into too much detail. Very odd that so little is told in the sources about the actual deficit, as well as the causes for deterioration (i.e. what do people with VAD die of - aspiration pneumonia?)
•  Done Causes - pretty complete I'd say, unless a consensus emerges on Ernst-death
•  Done Mechanism - could still mention more about aneurysm formation
•  Done Diagnosis - pretty complete
•  Done Treatment - pretty complete, could still expand a bit on surgery, but this is an unusual intervention
•  Done Prognosis - pretty complete
•  Done Epidemiology - pretty complete
•  Done History - could still expand but unsure what other landmarks there are still to discuss

I've reviewed Goyal and Derdeyn 2009 (reference above). It doesn't add much to the present content but goes into a lot of detail about aneurysms. The relative relevance of each statement is a bit lost on me. The same applies to PMID 18309525, which is currently not cited, another neurosurgical paper that mostly deals with dissecting aneurysms. I will give both papers another read over the next few days and decide if there's anything we are not saying. JFW | T@lk 17:32, 13 December 2010 (UTC)

Submitting for GA. JFW | T@lk 17:51, 16 December 2010 (UTC)

Thanks for your hard work. Ocaasi (talk) 19:07, 16 December 2010 (UTC)

You're welcome. JFW | T@lk 19:17, 16 December 2010 (UTC)