Cervical myelopathy: a case report of a "near-miss" complication to cervical manipulation

Ten years of online incident reporting and learning using CPiRLS: implications for improved patient safety

BACKGROUND

Safety incident (SI) reporting and learning via incident reporting systems (IRSs) is used to identify areas for patient safety improvement. The chiropractic patient incident reporting and learning system (CPiRLS) is an online IRS that was launched in the UK in 2009 and, from time to time, has been licensed for use by the national members of the European Chiropractors' Union (ECU), members of Chiropractic Australia and a Canada-based research group. The primary aim of this project was to analyse the SIs submitted to CPiRLS over a 10-year period to identify key areas for patient safety improvement.

METHOD

All SIs reported to CPiRLS between April 2009 and March 2019 were extracted and analysed. Descriptive statistics were used to describe: (1) the frequency of SI reporting and learning by the chiropractic profession, and (2) the character of reported SIs. Key areas for patient safety improvement were developed following a mixed methods approach.

RESULTS

A total of 268 SIs were recorded on the database over the 10-year period, 85% of which originated from the UK. Evidence of learning was documented in 143 (53.4%) SIs. The largest subcategory of SIs related to post-treatment distress or pain (n = 71, 26.5%). Seven key areas for patient improvement were developed including: (1) patient trip/fall, (2) post treatment distress/pain, (3) negative effects during treatment, (4) significant post-treatment effects, (5) syncope, (6) failure to recognize serious pathology, and (7) continuity of care.

CONCLUSION

The low number of SIs reported over a 10-year period suggests significant under-reporting, however, an upward trend was identified over the 10-year period. Several key areas for patient safety improvement have been identified for dissemination to the chiropractic profession. Improved reporting practice needs to be facilitated to improve the value and validity of reporting data. CPiRLS is important in identifying key areas for patient safety improvement.

Identification of Degenerative Cervical Myelopathy in the Chiropractic Office: Case Report and a Review of the Literature

Degenerative cervical myelopathy (DCM) is a common cause of spinal cord dysfunction, yet it may be challenging to identify as it presents with variable symptoms. A 62-year-old woman presented to a chiropractor with a three-month exacerbation of neck pain, hand/finger numbness, and torso dysesthesia. She had previously seen primary care, physical therapy, rheumatology, and pain management. Previous cervical magnetic resonance imaging showed moderate cervical canal stenosis; however, previous providers had diagnosed her with radiculopathy and possible carpal tunnel syndrome yet had not requested neurosurgical consultation. On examination, the chiropractor identified sensorimotor deficits, hyperreflexia, and bilateral Hoffman reflexes, and referred the patient to a neurosurgeon for suspected DCM. The neurosurgeon performed an anterior cervical discectomy and fusion from C4-7. The patient's symptoms and disability level improved within two months of follow-up. We identified 11 previous cases in which a chiropractor suspected DCM which was then confirmed by a surgeon. Including the current case (i.e., 12 total), patients were older and mostly male; 50% had neck pain, 92% had hyperreflexia. Chiropractors referred each patient to a surgeon; 83% underwent cervical spine surgery. This case highlights the identification of DCM by a chiropractor and referral for neurosurgical evaluation with a positive outcome. Patients with previously undiagnosed DCM may present to chiropractors with varied symptoms and examination findings. DCM may contraindicate spinal manipulation and instead warrant surgery. Accordingly, chiropractors play a key role in the detection and referral of patients with misdiagnosed or overlooked DCM.

Recognition of prodromal cervical spondylotic myelopathy presenting in a U.S. Veteran referred to chiropractic for acute thoracic pain: A case report

OBJECTIVE

To highlight a patient who was referred to a VA chiropractic clinic for thoracic pain and upon physical exam was found to be myelopathic, subsequently requiring surgery.

CLINICAL FEATURES

A 58-year-old male attended a telephone interview with the VA chiropractic clinic for thoracic pain of 4 months duration; he denied neck pain, upper extremity symptoms or clumsiness of the feet or hands. At his in-person visit, he acknowledged frequently dropping items. The physical examination revealed signs of myelopathy including positive Hoffman's bilaterally, 3+ brisk patellar reflexes, and 5+ beats of ankle clonus bilaterally. He also had difficulty walking heel/toe.

INTERVENTION AND OUTCOME

Cervical and thoracic radiographs were ordered and a referral was placed to the Physical Medicine and Rehabilitation (PM&R) Clinic for evaluation of the abnormal neurologic exam and suspicion of cervical spondylotic myelopathy (CSM). He was treated for 2 visits in the chiropractic clinic for his thoracic pain, with resolution of thoracic symptoms. No treatment was rendered to the cervical spine. The PM&R physician ordered a cervical MRI which demonstrated severe central canal stenosis and increased T2 signal within the cord at C5-C6, representing myelopathic changes. The PM&R specialist referred him to Neurosurgery which resulted in a C5-6, C6-7 anterior cervical discectomy and fusion.

CONCLUSION

The importance of physical examination competency and routine thoroughness cannot be overstated. Swift identification of pathologic signs by the treating chiropractor resulted in timely imaging and surgical intervention.

Decompression for botulinum toxin-exacerbated cervical myeloradiculopathy in the setting of congenital stenosis and Arnold-Chiari I malformation

Introduction

We present a case describing the management of a woman with severe, functionally limiting cervical myeloradiculopathy in the setting of congenital cervical canal stenosis and Arnold-Chiari I malformation.

Case presentation

The subject is a 57-year-old woman with prior anterior cervical discectomy and fusion who presented with left-sided neck pain associated with radiculopathy, migraine, gait incoordination, and cervical dystonia. Cervical stenosis and Chiari malformation were confirmed using MRI. Conservative management with botulinum toxin, oral muscle relaxants, and cervical brace led to gradual exacerbation of symptoms. Due to failure of conservative management, surgical decompression with C3-C6 posterior laminoplasty was performed, resulting in complete resolution of all symptoms and markedly improved quality of life.

Discussion

This case reports a severe and nonspecific presentation of cervical myeloradiculopathy. Surgery for cervical myeloradiculopathy is controversial, and conservative therapy is initially preferred. However, in this case, conservative treatments likely led to paraspinal weakness, cervical hypermobility, and biomechanical instability, resulting in exacerbation of symptoms. Stretch/shear forces have been postulated to accelerate cervical myelopathy, and excessive cervical instability and range of motion are significant predictors of deterioration. In this case, surgical decompression with posterior cervical laminoplasty after 1 year of conservative management yielded significant pain relief and functional restoration, indicating the utility of this procedure even in the presence of Arnold-Chiari I malformation. This case illustrates that decompression can be effective for refractory cervical myeloradiculopathy associated with Chiari malformation, congenital stenosis, and prior anterior instrumentation, and highlights the potential risks of prolonged conservative management.

Upper Trunk Brachial Plexus Palsy Following Chiropractic Manipulation

Introduction

Upper trunk brachial plexus palsy can result from high-energy trauma and has never been reported following spinal manipulation.

Background

The case is presented of a patient who developed an acute brachial plexus upper trunk palsy following spinal manipulative therapy.

Discussion

Discussion is made on the incidence of complications following manipulation and recommendations to prospectively capture all serious complications.

Concluding remarks

Risks exist with spinal manipulative therapy. Neurological injury can occur. Risk assessment and re-examination should occur at every visit. Large rigorous prospective studies are required to identify the true incidence of serious complications resulting from manipulative therapy and the benefit:risk ratio.

Safe physiotherapy interventions in large cervical disc herniations

A 34-year-old woman was seen in a physiotherapy department with signs and symptoms of cervical radiculopathy. Loss of cervical lordosis and a large paracentral to intraforaminal disc prolapse (8 mm) at C5-C6 level was reported on MRI. She was taking diclofenac sodium, tramadol HCl, diazepam and pregabalin for the preceding 2 months and no significant improvement, except temporary relief, was reported. She was referred to physiotherapy while awaiting a surgical opinion from a neurosurgeon. In physiotherapy she was treated with mobilisation of the upper thoracic spine from C7 to T6 level. A cervical extension exercise was performed with prior voluntary extension of the thoracic spine and elevated shoulders. She was advised to continue the same at home. General posture advice was given. Signs and symptoms resolved within the following four sessions of treatment over 3 weeks. Surgical intervention was subsequently deemed unnecessary.