Stroke and serious neurological adverse effects associated with conservative physical procedures directed towards the cervical spine: A critical review of Leung et al.

Introduction: Leung et al. published a systematic review concluding that serious adverse events following conservative physical procedures directed towards the cervical spine are predominantly vascular rather than neurological, and most commonly associated with neck manipulation. That conclusion depends on classification, search terms, and extraction. Objective: Our objective was to critically review the serious adverse events classification, search strategy, data extraction, and study inclusion criteria in Leung et al., with specific focus on stroke and other neurological serious adverse events. Methods: Leung et al. and its supplementary appendix were obtained from the publisher’s website. We assessed: (1) classification of strokes and related neurological serious adverse events using the Common Terminology Criteria for Adverse Events; (2) relevance and completeness of search keywords for stroke and neurological complications; (3) accuracy of stroke data extraction; and (4) potential omission of relevant studies reporting stroke as an serious adverse events. Results: Strokes and cerebrospinal fluid leaks are designated as neurological disorders under Common Terminology Criteria for Adverse Events yet were categorized as vascular events The search strategy omitted search terms such as “stroke” and related neurological keywords. Several included studies documented strokes that were not recorded as serious adverse events, while multiple eligible studies reporting stroke cases were excluded—likely due to restricted search terminology. Conclusion: The claim that vascular serious adverse events outweigh neurological serious adverse events is not supported when strokes are correctly classified as neurological outcomes and fully accounted for. A more comprehensive systematic review—employing expanded stroke-specific search terms, consistent Common Terminology Criteria for Adverse Events-based classification separating etiology from outcome, and thorough data extraction—is recommended to accurately characterize these risks and better inform clinical safety guidelines.