spinal manipulative therapy was defined by world health organization as  includes all procedures where the hands or mechanical devices are used to mobilize , adjust , manipulate , apply traction , massage , stimulate , or otherwise influence the spine and paraspinal tissues with the aim of influencing the patient 's health . 
cervical spine manipulation ( csm ) is one popular type of spinal manipulative therapies for the relief of cervical spine - related conditions worldwide , which is considered a high - level skill of manual therapy that demands bimanual coordinated rhythmical movements .
currently , csm has emerged as one of the leading forms of alternative and complementary treatment for neck pain from cervical spinal disease . however , serious complications of csm continue to be reported .
csm may carry the potential for serious neurovascular complications , primarily due to vertebral artery dissection ( vad ) and subsequent vertebrobasilar stroke . here
, we reported a rare case of locked - in syndrome ( lis ) due to bilaterial vad after csm treated by arterial embolectomy .
a 36-year - old right - handed man presented with numbness and weakness of limbs was transferred to emergency department in our hospital .
one day before admission , the patient suffered from mild neck pain with no focal neurological deficits and 2 hours before he visited a chiropractor and underwent csm in a private clinic .
however , during the period of csm , the patient 's pain deteriorated suddenly half an hour before admission . at that time , the patients complained numbness and hemiplegia in the right side of limbs .
the 4 main vital signs routinely monitored as follows : temperature was 37  c , heart rate was 80 beats per minute , blood pressure was 132/88  mmhg , and respiratory rate was 26 breaths per minute .
coagulation times , renal and liver function tests , and electrolytes were within normal limits .
the cervical vertebra computed tomography ( ct ) showed mild intervertebral disc hemia of c3/c4 , c4/c5 , and brain ct scan was normal .
gradually , although the patient remained conscious , he could not speak but could communicate with the surrounding by blinking or moving his eyes , and turned to complete quadriplegia , complete facial and bulbar palsy , dyspnea at 4  hours after admission .
the repeated brain ct scan showed the hyperdense basilar artery sign and cervical vertebra ct scan showed no evident abnormorlity in cervical cord .
brain ct angiography ( cta ) examination was performed at 8  hours after admission .
the patient was transferred to the intensive care unit to prepare for the emergency embolectomy with intubated but without mechanical ventilation . the cervical vertebra and brain ct scan and mri scan .
( a ) the ct scan at 4  hours after syptoms onset showed the hyperdense basilar artery sign ( the red arrow ) .
( b ) the ct scan at 4  hours after syptoms onset showed no evident abnormorlity in cervical cord .
( d ) the t2-weighted mri image at the 17th day showed the normal right verterbral artery ( white arrow ) and a high - signal fulfilling the left vertebral artery ( red arrow ) .
ct  =  computed tomography , mri  =  magnetic resonance imaging . the cta scan and dsa examination .
( a ) the cta scan showed stenosis of v3 segment and part of v4 segment of left vertebral artery , stenosis of v3 segment of right vertebral artery , thrombogenesis of v4 segment of left vertebral artery , mainly blocking of distal segment of basilar artery .
( d ) the dsa examination after emergency embolectomy showed the basilar artery recanalized , and bilateral superior cerebellar arteries and posterior cerebral artery developed . left vertebral
aortocranial digital subtraction angiography ( dsa ) under general anesthesia was performed immediately and endovascular treatment was taken as well .
a 6-fr introducer sheath was placed into the right femoral artery via a percutaneous route .
aortocranial dsa shows vertebrobasilar thrombosis , blocking left vertebral artery , and stenosis of right vertebral artery ( figure 2b , c ) .
after emergency arterial embolectomy , the basilar artery recanalized , and bilateral superior cerebellar arteries and posterior cerebral artery developed , although the left cerebellar artery has poor developed and still blocking of distal segment of left vertebral artery ( figure 2d ) .
after the operation , he was returned to intensive care unit followed by antiplatelet therapy and supportive therapy . at 17 days after his admission ,
brain magnetic resonance imaging ( mri ) scan showed pontine infarction ( figure 1c ) and axial t2-weighted showed a high - signal fulfilling the left vertebral artery ( figure 1d ) .
twenty - seven days later , after the treatments in the intensive care unit and a general ward , the patient 's physical function gradually improved and discharged but still left neurological deficit with muscle strength grade 3/5 and hyperreflexia of limbs .
the current best available evidence suggests that craniocervical arterial dissection may be of a low incidence but could be a serious complication of csm . in the present study
, we added a rare case who was presented with lis caused by bilateral vad after csm . in 1934 , a medical legal abstract 1st reported cerebrovascular accidents after csm . in 1947 , the 1st case of vad after chiropractic manipulation was described .
in particular , the force and extent of high velocity thrusts of the cervical spine , especially with rotational movement , can cause craniocervical arterial dissection in susceptible individuals .
craniocervical arterial dissection is one of important causes of unpredictability of ischemic stroke in young and middle - aged people .
although current biomechanical evidence is insufficient to establish the claim that causation between csm and craniocervical arterial dissection , clinical reports suggest that mechanical forces have a role in a considerable number of craniocervical arterial dissections and most population controlled studies have found an association between csm and vad stroke in young patients .
uncommonly , it has been reported bilateral vad after csm , resulting in the left thalamus and posterior limb of the internal capsule and the right cerebellar hemisphere infarction . in the present study , bilateral vad after csm causes bilateral pons infraction characterized by lis .
lis with a vascular etiology is a particularly severe type of lis for which the mortality is at 67% within the 1st 4 months .
the imaging modalities are available to diagnose craniocervical arterial dissection and stroke , including duplex ultrasonography , ct , cta , mri , mra , and dsa . in the present study , the cervical vertebra and brain ct scan at 1.5  hours after syptoms onset showed no evident abnormorlity , whereas the ct scan at 4  hours after syptoms onset showed the hyperdense basilar artery sign .
thus , cta is an easy available tool to choice , and dsa is the gold standard for luminal imaging .
mri with diffusion - weighted imaging should be employed in acute infarcts and follow - up of vad and vertebrobasilar stroke . up to now , no specific treatment for lis has been established . the acute treatment and intervention of patients with lis is similar to that for patients with other acute ischemic stroke of brain stem insults .
currently , thrombolysis with intravenous recombinant tissue - type plasminogen activator therapy remains the only proven effective pharmacological treatment for selected acute ischemic stroke patients within a relatively short therapeutic time window of 3 to 4.5 hours after the onset of stroke symptoms , although disappointments remain concerning modest recanalization rates and the devastating symptomatic intracranial hemorrhage . in 2015 , the treatment protocols for acute ischemic stroke have been fundamentally altered because of the updated guidelines of american heart association / american stroke association for the early management of patients with acute ischemic stroke using endovascular techniques .
this guideline concluded that certain endovascular procedures have been demonstrated to provide clinical benefit in selected patients with acute ischemic stroke . in the present study ,
the patient was gradually presented with lis due to bilaterial vad , which is associated with high mortality and serious complications .
although treatment is initiated beyond 6  hours from symptom onset , we decided to proceed with a mechanical embolectomy . at result ,
the patient was treated by arterial embolectomy and gradually recovered to antigravity power when discharged .
thus , arterial embolectomy is one of treatment choice for vertebrobasilar thrombosis due to bilateral vad after csm even in later time windows .
we acknowledged that the increased risk after csm may be an artifact of patients seeking care for neck pain resulting from existing cvd rather than the result of treatment itself , suggesting that not all stroke cases temporally related to csm have preexisting craniocervical artery dissection .
. the practitioner must be aware of this complication and should give the patient 's informed consent to csm .
the specific radiological tests such as duplex ultrasonography and mri should be used before csm to evaluate the risk of adverse events and vascular vulnerability .
in addition , csm is a high - level skill of manual therapy thus necessitating training to achieve proficiency . a well - trained practitioners may contribute to reduce the skill - related adverse events of inappropriate technique .
 abstractcervical spine manipulation ( csm ) is a commonly spinal manipulative therapies for the relief of cervical spine - related conditions worldwide , but its use remains controversial . 
 csm may carry the potential for serious neurovascular complications , primarily due to vertebral artery dissection ( vad ) and subsequent vertebrobasilar stroke . here 
 , we reported a rare case of locked - in syndrome ( lis ) due to bilaterial vad after csm treated by arterial embolectomy.a 36-year - old right - handed man was admitted to our hospital with numbness and weakness of limbs after treating with csm for neck for half an hour . 
 gradually , although the patient remained conscious , he could not speak but could communicate with the surrounding by blinking or moving his eyes , and turned to complete quadriplegia , complete facial and bulbar palsy , dyspnea at 4  hours after admission . 
 he was diagnosed with lis . 
 then , the patient was received cervical and brain computed tomography angiography that showed bilateral vad . 
 aortocranial digital subtraction angiography showed vertebrobasilar thrombosis , blocking left vertebral artery , and stenosis of right vertebral artery . 
 the patient was treated by using emergency arterial embolectomy and followed by antiplatelet therapy and supportive therapy in the intensive care unit and a general ward . 
 twenty - seven days later , the patient 's physical function gradually improved and discharged but still left neurological deficit with muscle strength grade 3/5 and hyperreflexia of limbs.our findings suggested that csm might have potential severe side - effect like lis due to bilaterial vad , and arterial embolectomy is an important treatment choice . the practitioner must be aware of this complication and should give the patients informed consent to csm , although not all stroke cases temporally related to scm have pre - existing craniocervical artery dissection . 
INTRODUCTION
CONSENT
CASE PRESENTATION
DISCUSSION