As part of their educational process, practitioners of manipulative procedures are made aware of the possible association between neck manipulation and cerebrovascular accidents[i] (CVAs) as well as what to do in the event a CVA occurs during treatment.[ii] For any litigation considered regarding a stroke that closely follows spinal manipulation, the starting point for retained counsel is to ask what else could have caused or contributed to the stroke. Screening issues to consider include the following:
According to reported statistics, CVAs are not the most common cause of litigation against chiropractors but cerebrovascular accidents are the most serious and widely publicized because such events can and do result in permanent neurological deficits or death.[iii]
The Mercy Guidelines, written for chiropractors and published in 1993, indicated that complications in a chiropractic office setting may be attributed to any of the following: misdiagnosis; presence of coagulation dyscrasias; cervical manipulation; presence of a herniated nucleus pulposus; or, improper technique application.[iv] The Guidelines also listed the six most common malpractice claims made to NCMIC during the year of 1990. CVAs accounted for 6% of those claims.[v] The same Guidelines indicated that there had been a "rapid growth of literature on manipulation-induced accidents.[vi] This statement was confirmed by more recent statistics kept by NCMIC which have indicated that, as of 2009, claims pertaining to CVAs associated with manipulation had risen to 13.3% of claims made. When questioned, litigation department representatives from NCMIC were not able to provide an explanation for the increase in the number of claims related to CVAs.
One answer accounting for what has become a "routine" diagnosis is that the diagnosis of cervical artery dissection has become more common due to advances in imaging capabilities. Another reason is the growing awareness of cervical artery dissections among all healthcare professionals.[vii]
Many chiropractors have been shown to embrace the 2008 study entitled Risk of Vertebrobasilar Stroke and Chiropractic Care, as refuting claims that stroke was related to or associated with spinal manipulation. [viii] This study attempted to estimate the risks associated with chiropractic visits as compared to visits with general medical provider. The conclusion of the study follows:
"VBA stroke is a very rare event in the population. The risk of VBA stroke associated with a visit to a chiropractor's office appears to be no different from the risk of VBA stroke following a visit to an MD's office. The incidence of VBA stroke associated with chiropractic and primary care physician visits is likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke. The study found no evidence of excess risk of VBA stroke associated with chiropractic care compared to primary physician care."
The authors of the study added a note of caution:
"Our result should be interpreted cautiously and placed into clinical perspective. We have not ruled out neck manipulation as a potential cause of some VBA strokes." [ix]
This cautionary note appears to reduce the desired shelter from allegations of a causal relationship between manipulation of the cervical spine and subsequent stroke.
Informed consent is to provide any and all pertinent information that a careful practitioner would provide so that the information would be within the understanding of any reasonable patient.[x] From a legal perspective a conundrum exists for the provider of manipulative procedures. Does he or she acknowledge the literature detailing the risks and possibilities of stroke following manipulation and have the patient sign informed consent, or ignore the widely disseminated warnings as a statistical improbability and not provide the patient with known risks of manipulation.
1. A new or sudden onset of head/neck/face pain "unlike any previously experienced."
2. Signs and symptoms of vertebrobasilar ischemia include double vision; dizziness; drop attacks (sudden numbness); dysarthria; dysphagia; ataxia of gait; nausea; numbness;and nystagmus.[xi]
3. Signs and symptoms of carotid artery ischemia to include: confusion, dysphagia, headache, anterior neck and/or facial pain, hemiparesis or monoparesis, or visual disturbances.
4. A history of connective tissue disease, migraine, recent infection in an individual less than 45 years of age, as well as a history of trivial trauma.
Retrospectively reviewed chiropractic files frequently reveal that practitioners take a casual, if not hurried, approach to begin treatment. The examination process is too frequently limited to an estimate of spinal ranges of motion before manipulative care is begun. The records rarely provide evidence of a thorough past medical, family or social history or a review of systems. The documented examination seldom provides substantive neurological findings or even a check of vital signs.[xii] [xiii]
Practitioners are aware that an MRI, MRA or angiography are the most comprehensive imaging tools to view the anatomic integrity of a vessel or the flow of blood within the vessel when suspicions of an unfavorable outcome may be pending. Practitioners are also aware that plain film studies provide little predictive value regarding a CVA.
The practitioner's "plan of care" deserves close inspection. Clinical notes are of equal importance to determine whether symptomatic improvement was being delivered. Absent evidence of clinical improvement, an argument can be made that a change in treatment, such as referral to another health care provider, should have taken place.
Counsel should have the billing procedures of the practitioner reviewed. Frequently, the billing statements provide a wealth of information of the practitioner's practice behaviors such as requiring pre-payment for a specified, but unsupported program of care with the forfeiture of payment if not completed. Such arrangements are more entrepreneurial than clinical in nature.
Strokes following manipulation do occur.[xiv] Practitioners of manipulative procedures, by their education, represent learned intermediaries and it is the practitioner who decides whether the therapeutic value of a prescribed treatment outweighs any potential adverse reactions.
These cases are aggressively defended on all three hurdles of professional malpractice cases: deviation of the standard of care, causation, and damages. It is critical for prosecution of the case to obtain qualified chiropractic expert opinions on standard of care.
[i] Current Concepts in Vertebrobasilar Complications Following Spinal Manipulation, Terrett A,
NCMIC Chiropractic Solutions, copyright 2001, Forward, page 7
[ii] Ibid, Chapter 7, pages 81-82.
[iii] Op Cit, Forward, page 7.
[iv] Shekelle et al. 1991
[v] Guidelines for Chiropractic Quality Assurance and Practice Parameters, copyright 1993, Chapter 12 - Contraindications and Complications, page 170.
[vi] Guidelines for Chiropractic Quality Assurance and Practice Parameters, Aspen Publication, Haldeman S, Chapman-Smith D, Petersen D, Jr., copyright 1993, Chapter 12 Contraindications and Complications, page170.
[vii] Epidemiology of Cervical Artery Dissection, Wouter Schievink, Vladimir Roiter, Maxine Dunitz
Neurological Institute of Neurology, Cedars-Sinai Medical Center Los Angeles, California, USA.
[viii] Connecticut State Board of Chiropractic Examiner's Hearing on Informed Consent for Chiropractic Procedures, January 5 - 22, 2010.
[ix] Cassidy JD, et al. Risk of Vertebrobasilar Stroke and Chiropractic Care, Spine 2008; 33(45):176 183.
[x] Chiropractic Standards of Practice and Quality of Care, Vear Herbert, An Aspen Publication,copyright 1992, Chapter 13 - Standards of Practice in Third-Party Relationships, page 253.
[xi] Current Concepts in Vertebrobasilar Complications Following Spinal Manipulation, Terrett A, NCMIC Chiropractic Solutions, copyright 2001, page 37.
[xii] Mokri B, Houser OW, Sandok BA, Piepgras DG. Spontaneous dissections of the vertebral arteries. Neurology 1988; 38(6):880-885.
[xiii] Chiras J, Marciano S, VegaMolina J. Spontaneous dissecting aneurysm of the extracranial vertebral artery (20 cases). Neuroradiology 1985; 27:327-333.
[xiv] Current Concepts in Vertebrobasilar Complications Following Spinal Manipulation, Terrett A, NCMIC Chiropractic Solutions, copyright 2001, page 9.
Robert A. Bailey, DC, DABFP, CICE, DABCC, CIRE, has been practicing Chiropractic since 1977. A graduate of Logan College of Chiropractic in St. Louis, Missouri, Dr. Bailey is certified by the American Board of Independent Medical Examiners (ABIME) and holds Diplomate status from the American Board of Forensic Professionals (ABFP) and the American Board of Chiropractic Consultants (ABCC). He is certified in disability evaluations through the National Association of Disability Evaluating Professionals (NADEP).
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