Cervical spine manipulation (a high velocity, low amplitude, end range thrust manoeuvre) is a common treatment option for mechanical neck pain yet may carry the potential for serious neurovascular complications, specifically vertebral artery dissection and subsequent vertebrobasilar stroke. The non-superiority of manipulation to alternative treatments, coupled with concerns regarding safety, renders cervical spine manipulation unnecessary and inadvisable.

The controversy surrounding the association between manipulation and neurovascular complications is longstanding and not fully resolved, partly because it is difficult to obtain conclusive evidence on rare adverse events. What can be accepted is that the incidence of vertebral artery dissection is low, with estimates between 1 (95% confidence interval 0.5 to 1.4) and 1.7 (1.1 to 2.3) per 100 000 person years in the United States.1 The estimates for stroke resulting from vertebral artery dissection are lower still, ranging from 0.75 to 1.12 per 100 000 person years,2 and many are unlikely to be the result of cervical …