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.
1. You probably know this comic, but I post it just for good luck:
2. This may be hair-splitting semantics, but I would say that "malpractice" requires some form of treatment that is usually somehow effective if "well practiced", but that has be "practiced badly" this time â and I would therefore dispute that his was a case of malpractice.
If someone opens a "shoot people in the abdomen" practice and a patient dies, did the patient die because the doctor didn't shot properly this time, which one could expect of him, making it a case of malpractice? No, I would say "shooting people in the abdomen" isn't evidence based form of treatment in the first place. I think we wouldn't let people open such a practice in the first place â so what is the evidence for chiropractics agains?
I would never see a chiropractor. But given all the other stresses people put on their necks, from accidents such as headbumps, from purposeful athletics such as whacking soccer balls, and from just craning one's head in odd positions when performing various kinds of mechanical labor, it puzzles me that the risk from a chiropractor would be much greater than the risks from these other kinds of use/abuse. Of course, this is not excuse for the chiropractor, who is imposing that risk, likely on those more susceptible to injury, under false pretense or treating disease. It's more a general lament that we each carry so much haphazard anatomy.
Malpractice is practice below the community standard of care. The community is limited to providers in the same specialty. For example, if a family practice doc misses a rare disease that a skilled subspecialist might identify, that's not malpractice. So, unless the neck was manipulated in a way that was worse than what other chiropracters do, it's not malpractice.
Gotta love lawyers and lawmakers.
I think the main danger in the chiropractic manipulation of the neck is the nature of the motion - it's a fast, violent jerk of the neck, often past the point of normal motion. It can cause shearing injuries, much more dangerous than the slow build-up of soreness caused by holding your head in an odd position.
There was a Canadian study that showed the dangers and severe injuries that can follow such manipulations. It lead a group of neurologists to issue a statement that such manipulations should be outlawed. http://www.chirobase.org/15News/neurol.html
I was rather surprised to see this study that says that visiting a chiropractor reduces neck pain better that medication. Thoughts? I would assume that the risk of neurologic injury would outweigh any of those benefits.
Most studies I have seen demonstrate an equivalence between chiropractic, massage, and physical therapy. I would not actually recommend NSAIDS or pain killers for neck pain except in the very short term because the data suggests people tend to keep using them and they are drugs with known complications including GI bleeds. The study you're referring to here I actually read when it came out in one of my email alerts. The article you link emphasizes the chiropractic > drugs part of it. But I would emphasize the exercise = chiropractic part of it. Excercises were equivalent to spinal manipulation, and I doubt they carry the risk of injury that neck manipulation has.
The actual risk of one of these injuries during manipulation is difficult to estimate from the literature. I have seen estimates between 1:100,000 to 1:5,000,000 but as the systematic review cited in the article suggests, there is likely significant under-reporting of these injuries. Some chiropractors have hence argued that neck manipulation is therefore low relative risk for the potential short term relief of pain they can demonstrate in studies. However, these injuries can be so morbid I would disagree, especially as safer alternatives are known. At the very least informed consent should be obtained and documented with a discussion of risks.
Here's the solution
I think one problem is that many physicians see nothing wrong with chiropractic treatments (in fact, I've personally seen otherwise competent physicians recommend it to their patients). With med schools being increasingly quackery-friendly, this problem is just going to get worse.
I swear by chiropractic (although I do NOT accept claims that it is 'medical treament'!).
I developed my taste for it after sustaining near-debilitating cervical compression in a car accident. Medications did not help. Since then, I have had adjustments to (successfully) alleviate sciatica and to relieve discomfort from spinal misalignments caused various misadventures. And yes, I have had numerous cervical manipulations; every time, I notice that a piece of my face "comes back" after having been (retrospectively) slightly numb. Quackery? As far as being "medicine", yes; as far as being dangerous, look up "iatrogenic".
Wow I'm really glad I read this article. My wife has been telling me she wants to go see a chiropractor. I think we'll try and find an alternative solution to her aches! :-)
I swear by chiropractic (although I do NOT accept claims that it is 'medical treament'!). .
wctube: What are you getting at?
wctube is a copy and paste spambot copying djlactin. According to Google, 'wctube.com' is a p0rn site.
FYI, the vertebral arteries do not pass through the spinous processes
they pass through the transverse foramen in the cervical vertebrae...you might want to dust up on your general anatomy before going into surgery
Quite correct. I always flub those two processes for some reason. Don't worry, I know my anatomy, but in general surgery we don't operate on the spine, or bones in general, so sometimes my precision in bony-anatomy wanes.
my brother wast 30 years old in perfect health when a chiropractor named michael riden adjusted his neck causing a massive stroke. the quack didnt call 911 to get help. he wanted my brother to go home and REST. if my brother had had a neon sign the signs of a stroke couldnt have been more evident. i knew what was wrong as soon as i saw him! my brther suffered 2 days in ICU then died! chiropractors are not proven. and to me there wanna be doctors that couldnt pass the test! they need to be stopped!