This week’s think like a doctor column in the NYT is great. It asks the question, if a woman goes to a chiropractor, gets her neck manipulated, and within hours and for the succeeding four years she’s had symptoms of severe headaches and a pulsatile sound in her ears, what is the diagnosis?
You can guess what mine is…
It’s a great case because it comes with an excellent set of images and reports on this woman’s case. But what I can’t get over is that the most obvious problem here is that the woman was seeing a chiropractor. The most obvious conclusion of the piece is that this was malpractice.
Neck manipulation in chiropractic is a known source of serious neurologic injury. An excellent review at sciencebasedmedicine goes over the major issues. Briefly, rapidly turning someone’s neck has the potential to cause injury to the vertebral artery as it travels through the transverse processes in the neck on the way to the brain, it may cause you to dislodge plaques from those arteries or the carotid causing embolic stroke, it may cause dissections of those arteries, or it may cause local damage to the cervical vertebra or discs. A systematic review of injuries in the literature actually estimates the occurrence of these problems related to manipulation is highly under-reported as they are estimates from case reports in the literature.
Worse, it comes out in the comments that this woman was getting chiropractic care (cough, gag) by this quack to treat her for pain from a leg length discrepancy. Not neck pain, the one reason for manipulation that chiropractors insist it has benefit in, but lower body pain from a physical cause outside the spine. They just threw that neck manipulation in there for good luck, and boy did she hit the jackpot.
So, a chiropractor, practicing a form of quackery invented by a grocer with delusions of grandeur in 1895, performed an unnecessary and dangerous manipulation of a woman’s neck that resulted in years of pain. Why isn’t this a discussion of malpractice? Even their own data would suggest that routine neck manipulation in the absence of a neck complaint would be inappropriate.
I think the reason is, if you’re a quack, and you have quack treatments, you tend to perform all your treatments on every patient all the time because they’re all mostly worthless anyway. The theory that alt-med selects for highly ineffective treatments has been advanced before and I think this is an example. Neck pain? Let me twist your neck. Leg pain? Let me twist your neck. Foot pain? Let me twist your neck. Since the intervention is usually without effect, positive or negative, it’s just performed by rote. This poor lady was just the lottery winner that likely got some vascular injury as a result of the manipulation. Other treatments, like physical therapy, stretching, therapeutic massage, might have been equal or superior without incurring this risk of causing extremely morbid injury.
I actually don’t have a clue to the final answer to this case. I suspect the neck manipulation caused a vascular injury to result in these symptoms, but it’s not clear based on the imaging exactly which structure was injured. The usual injury from manipulation would have resulted in dissection of the carotid or vertebral arteries, however, based on imaging these are patent, and there is not evidence of a large hemispheric stroke, or of Wallenberg syndrome you would expect from those injuries, or of a local stroke from an embolus. Maybe she has a sigmoid sinus diverticulum as a result? I don’t get how that would happen instantly during the manipulation though. The pulsatile tinnitus is the key, but while I have a differential I don’t have a diagnosis I’d put money on. Possibly an arteriovenous fistula? It could happen acutely, but I would expect that would also have been visible on imaging.
It’s a good mystery. Check it out.