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.