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The report of Dr Beck et al that a spinal chiropractic manipulation may lead to intracranial hypotension opens a debate between internal/genetic forces versus external/epigenetic events in the aetiology of dural tears.1 Considering that only 20% of patients with basilar fractures resulting in a dural tear experience CSF leakage,2 one could question how an external force from a physiological movement of the neck, which when delivered by hand generates only a minute fraction of the forces needed to fracture a bone, could tear a “healthy” dura. However, internal weakness of the dura has been noted, suggesting that an underlying hereditary disorder of connective tissue (HDCT) may exist in patients with CSF leakage.1,3 Dr Beck accurately reports that microfibrillinapthy is quite common in these patients, yet we are left with a quite tertiary or “general” examination to eliminate connective tissue disorders.1
The most widely used method to test the hypermobility of joints is to test whether the patient can perform a series of nine manoeuvres (Beighton score), which is included in the revised (Brighton 1998) criteria for the diagnosis of benign joint hypermobility syndrome (BJHS)/Ehlers-Danlos Type III (EDS III).3 I used the Beighton and Brighton hypermobility index in 118 consecutive patients that entered my clinic over a 5 month period. Of the 69 patients under 45 years of age (34F; 35M), 39% demonstrated BJHS (53%; 26% respectively) an extremely high percentage compared with that in other specialties. Furthermore, as summarised in table 1, I was able to identify eight patients with characteristics of Marfan syndrome, a condition that carries the highest risk for dural weakness.1,3,5 Interestingly, four of the patients with marfanoid habitius did not demonstrate BJHS. None of these patients suffered negative reactions from chiropractic manipulations.
Chronic musculoskeletal pain is a common manifestation of HDCT patients, with back or neck pain dominating the lives of many patients with Marfan and Ehlers-Danlos syndromes,3,5 leading them to seek care from specialists such as chiropracters. I suggest that as there exists within the chiropractic patient population a high prevalence of HDCT, the conclusion that external forces from a spinal chiropractic manipulation alone can lead to intracranial hypotension via a dural tear may be premature, and that patient selection from within this specific patient group, without testing of their genetic loads, certainly biases the conclusions of the studies.
Owing to the varied organ systems affected in patients with HDCT (heart, bone, ocular, skin), many different specialists tend to examine these patients.3,5 I propose a standardised examination for the detection and reporting of suspected patients with HDCT that would improve cross speciality communication and improve our knowledge of the role that HDCT plays in the pathogenesis of dural tears and neurovascular accidents.
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