Ramos et al. reported a case of a 48-year-old patient with undiagnosed ankylosing spondylitis who experienced pathologic cervical fracture, spinal cord injury, vertebral artery dissection, and cerebellar strokes after spinal manipulative therapy. In response, Drs. Trager and García astutely note that a virtually identical case report was published in the journal Internal and Emergency Medicine. The editors investigated the concerns of duplicate publication and confirmed that this was the case. We contacted the authors of both papers and the editor of Internal and Emergency Medicine, and both journals issued a notice of duplicate publication explaining the outcome of the investigation.¹ In addition, Drs. Trager and García express concerns that the patient's care was discordant with chiropractic standards and question whether the initial treating provider was a formally trained, licensed chiropractor. In another response, Dr. Kolberg et al. report that the Brazilian Chiropractic Association found no evidence that the provider in question was a formally trained chiropractor (the editors have not investigated this). They call for the regulation of the chiropractic profession in Brazil, arguing that spinal manipulation is safe when performed by a trained chiropractor. Whereas such dramatic adverse outcomes after spinal manipulation may indeed be rare, the potential cerebrovascular risks of spinal manipulation are well appreciated by neurologists. Nevertheless, we may expect that such reports continue to generate debate about the role of such manipulation, particularly in the cervical area.

拉莫斯等人。报道了一例未确诊的强直性脊柱炎患者，48 岁，脊柱手法治疗后出现病理性颈椎骨折、脊髓损伤、椎动脉夹层和小脑卒中。作为回应，Drs。Trager 和 García 敏锐地注意到，几乎相同的病例报告发表在《内科和急诊医学》杂志上。编辑们对重复发表的担忧进行了调查，并确认确实如此。我们联系了两篇论文的作者和Internal and Emergency Medicine的编辑，两家期刊都发布了重复发表的通知，解释了调查结果。¹此外，博士。Trager 和 García 表示担心患者的护理不符合脊椎治疗标准，并质疑最初的治疗提供者是否是经过正式培训、获得许可的脊椎治疗师。在另一个回应中，科尔伯格博士等人。报告称，巴西脊椎治疗协会没有发现任何证据表明该提供者是受过正式培训的脊椎治疗师（编辑尚未对此进行调查）。他们呼吁对巴西的脊椎治疗师进行监管，认为由训练有素的脊椎按摩师进行脊柱推拿是安全的。尽管脊柱推拿术后如此严重的不良后果可能确实很少见，但神经科医生对脊柱推拿的潜在脑血管风险表示赞赏。尽管如此，