321 - Wallenberg Syndrome Following Cervical Traction and Manipulation: A Case Report

We describe a case of a 39-year-old male with a history of whiplash injury and migraine who had right vertebral artery (VA) dissection with subsequent lateral medullary infarct after chiropractic sessions. He visited a chiropractor for treatment of neck pain and underwent cervical manipulation and traction. A few days later, he developed neck pain, right facial numbness, and imbalance. Later, he experienced nausea, diplopia, dysphagia, dysphonia, and slurred speech. 

Neurological examination revealed diminished pain and temperature in the left arm and leg, impaired right facial sensation, mild right facial droop, and left horizontal nystagmus. Finger to nose, heel to shin, and rapid alternating movement were impaired on the right side. Tendon reflexes and muscle tone were normal. Magnetic resonance imaging (MRI) showed an acute lateral medullary infarct. MR and CT angiography revealed right VA dissection (V2, V3 segments). He was started on dual antiplatelet therapy and high-dose statin.

Discussions:

Wallenberg syndrome, also known as lateral medullary syndrome or posterior inferior cerebellar artery syndrome (PICA), is commonly caused by VA dissection in younger patients. Chiropractic manipulation and/or traction have been reported to be an independent risk factor for developing VA dissection due to intimal tearing as a result of overstretching the artery. Initial symptoms are headache, neck pain, and dizziness. The diagnosis is usually established with MRI, MRA, and CT angiography. Initial treatment is usually heparin, followed by warfarin or antiplatelet therapy. Early diagnosis is crucial to prevent stroke and disability.

Conclusions: Cervical manipulation and/or traction can place the VAs at risk of dissection. We should consider this possibility, especially for patients presenting with an acute onset of dizziness and loss of balance with a recent history of cervical manipulation and/or traction.