Missed cervical spine fracture: chiropractic implications

Malpractice Litigation Involving Chiropractic Spinal Manipulation

OBJECTIVE

To evaluate the relationship between chiropractic spinal manipulation and medical malpractice using a legal database.

METHODS

The legal database VerdictSearch was queried using the terms "chiropractor" OR "spinal manipulation" under the classification of "Medical Malpractice" between 1988 and 2018. Cases with chiropractors as defendants were identified. Relevant medicolegal characteristics were obtained, including legal outcome (plaintiff/defense verdict, settlement), payment amount, nature of plaintiff claim, and type and location of alleged injury.

RESULTS

Forty-eight cases involving chiropractic management in the United States were reported. Of these, 93.8% (n = 45) featured allegations involving spinal manipulation. The defense (practitioner) was victorious in 70.8% (n = 34) of cases, with a plaintiff (patient) victory in 20.8% (n = 10) (mean payment $658,487 ± $697,045) and settlement in 8.3% (n = 4) (mean payment $596,667 ± $402,534). Overaggressive manipulation was the most frequent allegation (33.3%; 16 cases). A majority of cases alleged neurological injury of the spine as the reason for litigation (66.7%, 32 cases) with 87.5% (28/32) requiring surgery. C5-C6 disc herniation was the most frequently alleged injury (32.4%, 11/34, 83.3% requiring surgery) followed by C6-C7 herniation (26.5%, 9/34, 88.9% requiring surgery). Claims also alleged 7 cases of stroke (14.6%) and 2 rib fractures (4.2%) from manipulation therapy.

CONCLUSIONS

Litigation claims following chiropractic care predominately alleged neurological injury with consequent surgical management. Plaintiffs primarily alleged overaggressive treatment, though a majority of trials ended in defensive verdicts. Ongoing analysis of malpractice provides a unique lens through which to view this complicated topic.

C Spine Fracture on OPG

Maxillofacial injuries are common and they occur in a variety of situations. All patients who undergo maxillofacial or head trauma, are presumed to sustain cervical spine injuries. Identification of cervical spine injuries is essential in management of trauma, because a missed injury can result in a catastrophic spinal cord injury. Advanced Trauma Life Support (ATLS) guidelines have suggested that routine use of cervical spine radiographs may not be required in an asymptomatic patient. We are presenting here a case with a cervical spine injury with no clinical deficits, found incidentally on panoramic radiographs which were advised for evaluation of the mandibular fracture. We suggest that importance has to be given to examination of the cervical spine on the panoramic radiographs as well.

Clinical identifiers for detecting underlying closed cervical fractures

BACKGROUND

Although uncommon, closed cervical fractures (CCFs) may present in orthopedic clinical settings despite previous workup. The objective of this study was to describe the characteristics associated with missed CCF.

METHODS

The study was a retrospective database exploration of a cohort of subjects within a department of surgery with cervical pain. The sample consisted of 162 patients seen for a surgical consult for a number of cervical conditions. The examination time frame represented a clinical examination and imaging confirmation of diagnosis after an original initial visit by another provider. Descriptive and diagnostic accuracy values including sensitivity/specificity and positive/negative likelihood ratios (LR+/LR-) were calculated for each targeted variable. Clustered analyses were calculated using the patient history and situational characteristics.

RESULTS

Eleven patients in the sample were diagnosed with CCF (6.7%). Six variables were significantly associated with a missed CCF. Using these six variables, it was found that failure to exhibit a condition of 2 of the 6 variables (1 or fewer) was the strongest in ruling out the condition (LR- = 0.0; post-test probability with a negative finding = 0%), whereas a finding of 4 of 6 was the most diagnostic for ruling in the condition (LR+ = 32; post-test probability with a positive finding = 70%).

CONCLUSIONS

The findings in this sample suggest that select patient history or situational factors are still useful even after initial examination and clinicians must stay vigilant because CCFs may be missed during emergent care screens.

Acute thoracic epidural hematoma following spinal manipulative therapy: case report and review of the literature

Spinal epidural hematoma is a rare complication of chiropractic manipulation. This study reports a case of thoracic spinal epidural hematoma following spinal manipulative therapy in the absence of predisposing factors. The effectiveness and safety of chiropractic treatment in chronic spinal pain and a literature review are also presented.

Pathological Cervical Fracture after Spinal Manipulation in a Pregnant Patient

OBJECTIVE

To present the rare case of a displaced odontoid fracture after manipulative treatment.

CLINICAL FEATURES

A 37-year-old, 15-week pregnant patient was referred with acute neck pain and a diffuse paravertebral swelling that started after cervical manipulation performed by her general medical practitioner 5 days before. Because of pregnancy, a cervical spine radiographic series was not obtained before treatment. Magnetic resonance imaging revealed a displaced odontoid fracture associated with a pathological process in the vertebral body of C2 and a paravertebral hematoma on the left side from C2 to C4.

INTERVENTION AND OUTCOME

After initial halo vest immobilization, an anterior-posterior fusion of C1-C2 was performed. The histological analysis showed features of an aneurysmal bone cyst. The patient was discharged and had an undisturbed pregnancy and was without any neurological complications.

CONCLUSIONS

Because of the weakening lesion in C2, the spinal manipulation most likely caused the displaced odontoid fracture. Special imaging should be performed, preferably with magnetic resonance imaging, when a patient experiences significant new symptoms after cervical manipulation.

Chiropractic care of a patient with low back pain associated with subluxations and a Malgaigne-type pelvic fracture

OBJECTIVE

To describe the chiropractic care of a patient with a pelvic ring fracture and concomitant subluxations of multiple segments of the spinal column.

CLINICAL FEATURES

A 23-year-old male, after falling down a flight of stairs, was initially hospitalized for fractures of the pelvis. Five weeks posthospitalization, the patient initiated chiropractic care with complaints of severe low back pain with lower extremity involvement. He also complained of neck pain and occipital headache. The patient had several positive low back orthopedic tests with bilaterally absent Achilles deep tendon reflexes. The anteroposterior radiographic view revealed ununited fractures at the left superior and inferior pubic ramus, noted as a type I Malgaigne fracture. Subluxations were detected at the left innominate (ie, fracture-subluxation) and at the patient's lumbar, thoracic, and cervical spine.

INTERVENTION AND OUTCOME

The patient was cared for with contact-specific, high-velocity, low-amplitude adjustments to sites of vertebral and sacroiliac subluxations. The patient's response to care was positive, receiving great pain relief. Less than 3 months after initiating care, the patient returned to work on regular duty.

CONCLUSION

There are indications that patients suffering from the injuries described above may derive benefits from chiropractic care. The practitioner must pay careful attention to issues of biomechanical and vascular stability and adjustment modifications in these types of patients.

The pediatric spine: anatomical and dynamic considerations preceding manipulation

Spinal manipulation is effective for the treatment of many conditions, albeit not without possible complications. The incidence of subtle growth plate fractures following high-velocity techniques in children is surely under-appreciated because of the occult nature of these injuries.

Development of an evidence-based guideline for imaging in cervical spine trauma

Cervical spine trauma is a common reason for presentation to an emergency department. However, less than 5% of patients who have suffered possible neck injury actually have an injury requiring medical treatment. Nevertheless, the consequences, both for the patient and the doctor, of a missed injury are well recognized by emergency department medical staff. This results in the vast majority of these patients receiving some form of diagnostic imaging. We describe the development of an evidence-based imaging guideline for use in the patient who has suffered cervical spine trauma. The guideline aims to help clinicians determine, at the bedside, when it is appropriate to use imaging and which imaging modality should be used first. Correct utilization of the guideline should lead to a reduction in the number of imaging tests required to reach a diagnosis without adverse patient outcomes.

Missed cervical spine fracture-dislocations: the importance of clinical and radiographic assessment

OBJECTIVE

To review the case of a patient who suffered a cervical spine fracture-dislocation missed at a hospital emergency department.

CLINICAL FEATURES

A 77-year-old man involved in a motor vehicle accident was transported to a local emergency hospital where cervical spine x-ray films taken were reported as demonstrating no evidence of acute injury. The patient visited a chiropractic clinic 6 days later, where x-ray films were again obtained, finding that the patient sustained fractures of C5 and C6, as well as a bilateral facet dislocation at C5/C6. Computed tomography confirmed the fractures, and magnetic resonance imaging findings demonstrated cervical spinal cord compression and posterior spinal cord displacement.

INTERVENTION AND OUTCOME

The patient was referred for preoperative medical evaluation. He underwent C5-6 closed reduction and anterior/posterior fusion surgery and was released without complication. Patient follow-up indicated full recovery with minimal neurologic symptoms.

CONCLUSION

Cervical spine fracture-dislocations are often missed during standard radiographic examinations in emergency department settings. Chiropractors are encouraged to perform a comprehensive evaluation of patients presenting with cervical trauma even if they have had prior x-ray films reported as normal. Standard x-ray films taken at emergency department facilities are not entirely reliable for detecting or revealing cervical spine fracture-dislocations. This case stresses the importance of careful clinical assessment and imaging procedures on patients who have encountered cervical spine trauma.

Ruptured cervical disc after spinal manipulation therapy: report of two cases

STUDY DESIGN

Case reports of ruptured cervical disc after spinal manipulation therapy.

OBJECTIVES

To present the rare cases of ruptured cervical disc temporally related to spinal manipulation therapy.

SUMMARY OF BACKGROUND DATA

The complication of ruptured cervical disc was rare in the literature.

METHODS

Two patients developed cervical myelopathy or radiculopathy after spinal manipulation therapy, and magnetic resonance imaging showed herniated cervical discs at C4-C5 and C6-C7, respectively.

RESULTS

Anterior cervical discectomy was performed, and ruptured disc fragments were removed in these two patients. Both patients had good neurologic recovery after operation, and no neurologic deficits were noted after 15 and 6 months of follow-up, respectively.

CONCLUSIONS

The experience of these two patients reminds us that cervical disc rupture can occur during a course of cervical spinal manipulation. Full neurologic recovery is achievable if accurate diagnosis and prompt surgical treatment are done.