椎体动脉系统（VBA）中风与宫颈脊柱操纵疗法（C-SMT）之间的关联是一个有争议的话题，它在某些人中引起了强烈的情绪。
VBA系统的损坏通常会导致重大残疾或死亡。椎骨stroke死亡率超过85％。由于它涉及脑干和小脑，因此大多数幸存者都具有多血肌的多血症功能障碍，例如四肢瘫痪或偏瘫，共济失调，吞咽困难，颤音障碍，凝视异常和颅神经病变。
VBA情况很少见,这意味着更多的是unknown than is known. The knowledge vacuum magnifies the value attached to anecdotes, which are prone to the logical fallacy of post hoc ergo propter hoc (after this, therefore because of this).
The literature has many case studies documenting VBA stroke following violent neck movements that apply unusual forces to the neck. So the biological plausibility for VBA stroke following forceful neck manipulation is reasonable.
但是，从研究的角度来看，这种情况的小发病率不可避免地，建立因果关系的最常用方法是案例控制研究。案例控制研究通常是回顾性的，并以其偏见（包括召回偏见）而闻名。
In a study published today, Kosloff and colleagues have analyzed the largest health insurance data set (both commercial insurance and Medicare Advantage (MA) plans) used to investigate the association between chiropractic visits and stroke.
美国大约5％的人口中，使用了来自美国50个州中49个州（仅排除北达科他州）的3,900万人的数据。搜索了三年的数据以查找病例，这些病例都是患有VBA闭塞和狭窄中风的急性护理医院的患者（由ICD-9代码选择）。
随机选择了四个年龄和性别匹配的对照。在VBA中风之前，与脊医或初级保健医生（在美国通常是内科医生或家庭医生的医生）相遇。
这些案件包括商业健康计划中的1,159个VBA中风和MA计划中的670个中风。与先前的研究一致，在老年人群中脊椎治疗和VBA中风之间没有发现显着关联。然而，与其他案例控制研究相反，科斯洛夫及其同事也发现脊椎按摩治疗与VBA中风之间没有关联。
The authors acknowledge certain limitations of their study due to the nature of insurance claims data. These data do not code for what specific treatment was rendered or immediate responses to treatment. Thus it is not known if chiropractic manipulation was performed during any office visit and if there was any immediate adverse response. Further, the accuracy of the VBA stroke diagnoses is unknown. Finally as the authors note there is a loss of “contextual information surrounding clinical encounters between chiropractors and Primary Care Physicians and their patients.” This limits the knowledge of other known risk factors.
鉴于局限性，作者的结论是正确保留的。该数据集在脊椎按摩治疗与VBA中风之间没有显着关联，因此增加了脊椎治疗是不太可能的原因的观点。但是，这一发现并不排除脊椎按摩治疗可能在因果关系中作用的可能性。
研究加拿大人口的Cassidy及其同事在后循环中风与脊柱操纵治疗（SMT）以及后循环中风与初级保健医生的探视之间存在关联（1）。Kosloff等人在美国人群中重复了Cassidy研究，以概括加拿大的原始观察结果。我们已经表明，与对病历和神经影像学的神经科医生评论相比，Cassidy用来定义病例的ICD-9代码的宫颈动脉解剖（CAD）的阳性预测价值仅为11％（2）。Cassidy方法确定的一小部分“病例”具有感兴趣的实际疾病（CAD，有或没有中风）。相反，他们可能患有更常见的后循环疾病（裂缝，动脉粥样硬化，栓塞）。卡西迪（Cassidy）的案例识别策略引起了严重的结果错误分类，这使得SMT-CAD关联对零的估计有偏见。
Kosloff及其同事犯了同样的错误，但随后系统地将解剖患者排除在人群之外，从而加剧了错误。在安大略省，在Cassidy研究时，不使用针对解剖的ICD-9代码（443.xx）。在临床上被诊断出患有解剖的患者，将用Cassidy研究中的后循环法编码，因此将符合其研究的纳入标准。在美国，特定于解剖的代码在广泛使用中。具有临床CAD诊断的患者将用443.xx代码进行最精确的编码，而不是基于解剖的后循环代码。科斯洛夫（Kosloff）并未将解剖代码作为案例定义的一部分，因此有系统地排除了CAD患者。因此，Kosloff CAD识别策略的积极预测值甚至可能低于Cassidy观察到的阳性预测值。
Prior studies suggest vascular risk factors are not associated with CAD risk (3). That Kosloff’s subjects had non-CAD-related stroke is suggested by the higher prevalence of cardiovascular risk factors in the case group (Table 3). The depletion of dissections from the Kosloff population also explains why no association between SMT and case-status was observed even in the younger (<45y) group – a finding which has been consistently seen in other studies, including Cassidy’s, with statistically and clinically significant odds ratios.
Kosloff et al define their cases as “vertebrobasilar stroke” but then draw inferences about CAD. This is an error in logic that ignores the heterogeneity of stroke subtypes. In addition to outcome misclassification, epidemiologic studies of SMT as a trigger of CAD face other methodological challenges – low CAD incidence rates, confounding, reverse causation, misclassification of SMT exposure (including recall bias), and selection bias. Rigorously designed studies that address these hurdles are needed to provide quality evidence to resolve this critical public health question. Unfortunately, Kosloff’s study does not provide such data.
参考
（1）Cassidy JD, Boyle E, Cote P, et al. Risk of vertebrobasilar stroke and chiropractic care: results of a population based case-control and case-crossover study. Spine 2008; 33(4 Suppl):S176-S183.
（2）Cai X，Razmara A，Paulus JK，Switkowski K，Fariborz PJ，Goryachev SD，D'Avolio L，Feldmann E，Thaler DE。病例错误分类在脊柱操纵和动脉解剖的研究中。中风和脑血管疾病杂志，2014，23（8）：2031-2035，doi：10.1016/j.jstrokecerebrovasdis.2014.03.007
（3）Sidney M. Rubinstein，Saskia M. Peerdeman，Maurits W. Van Tulder，Ingrid Riphagen和Scott Haldeman。对宫颈动脉解剖的危险因素的系统评价。中风。2005;36：1575-1580，doi：10.1161/01.str.000000169919.73219.30
Thanks for share this informative blog here !!
Thanks for share this blog !! Chiropractic Health Centers are amongst the finest places when it comes to pain relief treatments.
It’s already proven that there is no significant association between chiropractic visits and vertebrobasilar stroke. Stephen Perle do a massive research about this report. Chiropractic care is there to help to eases the back pain at the same time there is no risk from other parts of the body.