There is not sufficient data to establish the safety of<unk> s, and the rate of adverse events is unknown.<unk>  is frequently associated with mild to moderate temporary adverse effects, and also rare serious outcomes which can result in permanent disability or death. The National Health Service in the UK notes that about half of people reported encountering adverse effects following<unk> . Adverse events are increasingly reported in randomized clinical trials of<unk>  but remain under-reported despite recommendations in the 2010 CONSORT guidelines. A 2015 Cochrane systematic review noted that more than half of the randomized controlled trials looking at the effectiveness of<unk>  for neck pain, did not include adverse effects in their reports. However, more recent reports have reported<unk>  adverse events to be rare. Risks of neck<unk>  The degree of serious risks associated with<unk>  of the cervical spine is uncertain, with little evidence of risk of harm but also little evidence of safety either. There is controversy regarding the degree of risk of vertebral artery dissection, which can lead to stroke and death, from cervical<unk> . Several deaths have been associated with this technique and it has been suggested that the relationship is causative, but this is disputed by many chiropractors who believe it is unproven. Understandably, vascular accidents are responsible for the major criticism of spinal manipulative therapy. However, it has been pointed out that "critics of manipulative therapy emphasize the possibility of serious injury, especially at the brain stem, due to arterial trauma after cervical<unk> . It has required only the very rare reporting of these accidents to malign a therapeutic procedure that, in experienced hands, gives beneficial results with few adverse side effects". In very rare instances, the manipulative adjustment to the cervical spine of a vulnerable patient becomes the final intrusive act which results in a very serious consequence. Edzard Ernst found that there is little evidence for efficacy and some evidence for adverse effects, and due to that, the procedure should be approached with caution, particularly forceful<unk>  of the upper spine with rotation. A 2007 systematic-review found correlations of mild to moderate adverse effects and less frequently with cervical artery dissection, with unknown incidence. A 2016 systematic-review found the data supporting a correlation between neck<unk>  and cervical artery dissection to be very weak and that there was no convincing evidence for causation. Potential for incident under-reporting Statistics on the reliability of incident reporting for injuries related to<unk>  of the cervical spine vary. The RAND study assumed that only 1 in 10 cases would have been reported. However, Edzard Ernst surveyed neurologists in Britain for cases of serious neurological complications occurring within 24 hours of cervical<unk>  by various types of practitioners; 35 cases had been seen by the 24 neurologists who responded, but none of the cases had been reported. He concluded that under-reporting was close to 100%, rendering estimates "nonsensical." He therefore suggested that "clinicians might tell their patients to adopt a cautious approach and avoid the type of<unk>  for which the risk seems greatest: forceful<unk>  of the upper spine with a rotational element." The NHS Centre for Reviews and Dissemination stated that the survey had methodological problems with data collection. Both NHS and Ernst noted that bias is a problem with the survey method of data collection. A 2001 study in the journal Stroke found that vertebrobasilar accidents (VBAs) were five times more likely in those aged less than 45 years who had visited a chiropractor in the preceding week, compared to controls who had not visited a chiropractor. No significant associations were found for those over 45 years. The authors concluded: "While our analysis is consistent with a positive association in young adults... The rarity of VBAs makes this association difficult to study despite high volumes of chiropractic treatment." The NHS notes that this study collected data objectively by using administrative data, involving less recall bias than survey studies, but the data were collected retrospectively and probably contained inaccuracies. Mis-attribution problems Studies of stroke and<unk>  do not always clearly identify what professional has performed the<unk> . In some cases this has led to confusion and improper placement of blame. In a 1995 study, chiropractic researcher Allan Terrett, DC, pointed to this problem: :"The words chiropractic and chiropractor have been incorrectly used in numerous publications dealing with<unk> T injury by medical authors, respected medical journals and medical organizations. In many cases, this is not accidental; the authors had access to original reports that identified the practitioner involved as a nonchiropractor. The true incidence of such reporting cannot be determined. Such reporting adversely affects the reader's opinion of chiropractic and chiropractors." This error was taken into account in a 1999 review of the scientific literature on the risks and benefits of<unk>  of the cervical spine (MCS). Special care was taken, whenever possible, to correctly identify all the professions involved, as well as the type of<unk>  responsible for any injuries and/or deaths. It analyzed 177 cases that were reported in 116 articles published between 1925 and 1997, and summarized: : "The most frequently reported injuries involved arterial dissection or spasm, and lesions of the brain stem. Death occurred in 32 (18%) of the cases. Physical therapists were involved in less than 2% of the cases, and no deaths have been attributed to MCS provided by physical therapists. Although the risk of injury associated with MCS appears to be<unk> all, this type of therapy has the potential to expose patients to vertebral artery damage that can be avoided with the use of mobilization (non-thrust passive movements)." In Figure 1 in the review, the types of injuries attributed to<unk>  of the cervical spine are shown, and Figure 2 shows the type of practitioner involved in the resulting injury. For the purpose of comparison, the type of practitioner was adjusted according to the findings by Terrett. The review concluded: : "The literature does not demonstrate that the benefits of MCS outweigh the risks. Several recommendations for future studies and for the practice of MCS are discussed."
Spinal manipulation
Spinal mobilization
Epidural steroid injection
Spinal precautions
Spinal decompression
Brachial plexus block
Paracervical block
Nerve block