Epidemiology Vertebrobasilar artery insufficiency

Vertebrobasilar artery insufficiency

Vertebrobasilar artery insufficiency The cervical arteries are most vulnerable when the head is rotated. 2,3

Vertebral arteries emerge from the cervical foramina, run along the grooves in the superior aspects of the posterior arch of the atlas and then through the posterior atlanto-occipital membrane before entering the dura.

Sex Slightly more often for women than for men 84 > 67.1
Age Mean age was 38.1
Pain location Neck / Occiput
Pain sensation / Symptoms Classic Cardinal Signs of Vertebrobasilar Compromise: Five Ds and Three Ns

Dizziness, Drop attacks, Diplopia, Dysarthria, Dysphagia, Ataxia of gait, Nausea, Numbness(ipsilateral face and/or contralateral body) and Nystagmus4

Blood flow According to Chrost(1984) and Hillen and Fonville(1980) there is a reduction in blood flow in the vertebral artery during physiologic movement of the cervical spine even in the absence of any anomaly or pathology. Rotation of the cervical spine seems to have a particularly marked effect in reducing blood flow in the contralateral(opposite side) vertebral artery (by lengthening the artery).

According to Hillen and Fonville(1980) side bending gives a relatively small reduction in blood flow during side bending. According to Hillen and Fonville (1980) and Penning(1978), flexion and extension of the cervical spine gives no reduction in blood low (Does not lengthen the artery).4

 

Reduction in blood flow According to Chrost, referenced by Gutmann and Biedermann (1984)4

Movement ipsilateral contralateral
Flexion and Extension 0% 0%
Side bending 10% 0%
Rotation 20% 75%
Flexion, rotation 55% 55%
Extension, rotation 50% 75%
Flexion, side bending, contralateral rotation 30% 95%
History of injury The most common site of injury to the vertebral artery caused by cervical spine manipulation appears to be at the site of the atlanto-occipital joint, this is where the artery changes its vertical course to a horizontal course.2,3

Interruption of the flow in one of the vertebral arteries or the basilar artery can result in signs and symptoms related to the dependent parts of the central nervous system.2

Literature
  1. Willem J.J. Assendelft. Complications of Spinal Manipulation A Comprehensive Review of the literature. The journal of Family Practice, 1996 May;42(5):475-80.
  2. Thiel HW. Gross morphology and pathoanatomy of the vertebral arteries. J Manipulative Phsyiol Ther 1991; 14:133-41
  3. Terrett AGJ. Vascular accidents from cervical spine manipulation: the mechanisms. Am Chiropractic Assoc J 1988; 22(5):59-74
  4. Orthopaedic Manual Therapy Diagnosis: Spine and Temporomandibular Joints – Aad Van der El

 

Physical Examination

Purpose of the test of Kleyn Nieuwenhuyse*

Exclusion of a possible problem with the vertebral artery, in the cervical spine.
* This is a premanipulatieve test, this means that this test is performed before a mobilization / manipulation of the CWK in the end-point is carried out, for safety of the patient.

Description test kleyn Nieuwenhuyse

Starting position: patient lies on his or her back
Starting Position therapist: Located at the head or at the side of the patient.
The headand neck ofthe patient are brought in extensionand rotation by the therapist. Thetherapist holdsthis position,at least 30seconds.

Please ensure that when a left rotation the permeability of a right a.vertebralis is tested. The left artery is concluded, the right artery is examined whether it has sufficiently permeable to take over the function.

  1. De Kleyn A, Nieuwenhuyse AC. Schwindelanfälle und Nystagmus beieiner bestimmten Stellung des Kopfes. Acta Otolaryngologica 1927;11:155-157

 

 Evidence Based Practice

Title, Author, Year Article Article Quality Specificity Sensetivity
1 Coté et. Al. the validity of the extension-rotation test as a clinical screening procedure before neck manipulation: a secondary analysis. Journal of manipulative and physiological therapeutics 19 (3) 1-11 Diagnostic accuracy study QUADAS 8/14 0.67-0.96 Extension-rotation

(with rotation to the left)

0.0-0.23
1 Coté et. Al. the validity of the extension-rotation test as a clinical screening procedure before neck manipulation: a secondary analysis. Journal of manipulative and physiological therapeutics 19 (3) 1-11 Diagnostic accuracy study QUADAS 8/14 0.49-0.81

Extension-rotation

(with rotation to the right)

0.00-0.46
2 Sakaguchi et. Al. (2003) mechanical compression of the extracranial vertebral artery during neck rotation. Neurology 2003 (61) 845-847 Diagnostic accuracy study QUADAS 7/14 0.97-0.99

Extension-rotation

 

0.10-0.38
3 Li Yi-Kai et. Al. (1999) changes and implications of blood flow velocity of the vertebral artery during rotation and extension of the head. Journal of manipulative and physiological therapeutics 22(2) 91-95 Diagnostic accuracy study QUADAS 6/14 0.75-1.00

Extension-rotation

 

0.03-0.20
4 B. Petersen et al. (1996)

Basilar artery blood flow during head rotation in vertebrobasilar ischemia. Acta Neurol Scand. 1996;94(294):301

Diagnostic accuracy study QUADAS 9/14 0.97-0.99

Only rotation

0.18-0.9

 

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