When presented with a case of cervical artery stroke allegedly associated with Chiropractic cervical spine manipulation, malpractice attorneys often want to argue direct causation. However, research studies have found that a direct cause and effect relationship between cervical spine manipulation and cervical artery stroke is not established. Malpractice attorneys should instead consider arguing the Doctor of Chiropractic’s failure to diagnose an ongoing cervical artery dissection (CAD) event and refer the patient for emergency medical care. Doctors of Chiropractic often fail to perform the history and physical examination necessary to diagnose and refer a patient with an ongoing cervical artery dissection event.
Mechanism of Cervical Artery Stroke
A tear in the inner lining of a cervical artery is referred to as a “dissection”. A dissection may be spontaneous or caused by trauma. A blood clot formed over the area of dissection may subsequently be dislodged and block a smaller artery that supplies the brain, causing a stroke. Alternatively, the blood clot may not dislodge, but may become so large it blocks the cervical artery itself, causing a stroke. The cervical arteries under consideration in this article are the vertebral artery and the carotid artery.
Direct Cause & Effect Relationship
The type of trauma that has been associated with cervical artery dissection is significant trauma such as motor vehicle accidents and the athletic injuries. A direct cause and effect relationship between cervical spine manipulation and cervical artery dissection/stroke is not supported by research. For example:
“VBA (vertebrobasilar artery) stroke is a very rare event in the population. The increased risks of VBA stroke associated with Chiropractic and PCP visits is likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke. We found no evidence of excess risk of VBA stroke associated Chiropractic care compared to primary care.”1
“We found no excess risk of carotid artery stroke after Chiropractic care. Associations between Chiropractic and PCP visits and stroke were similar and likely due to patients with early dissection-related symptoms seeking care prior to developing their strokes.”2
“The medical literature does not support a clear causal relationship between CMT (Chiropractic Manipulative Therapy) and ICAD (Internal Carotid Artery Dissection). Reported cases are exceedingly scarce, and none support clear cause and effect.”3
Failure to Diagnose & Refer
Even though it is not possible to prove direct causation in these cases, failure to diagnose and refer may be present on the part of the Doctor of Chiropractic. Cervical arterial dissection causes neck pain which feels the same as neck pain caused by musculoskeletal conditions. Therefore, many patients seek Chiropractic care for what they assume is musculoskeletal condition in their neck.
The Doctor of Chiropractic is under a duty to examine and diagnose a patient, and make the appropriate referral, if necessary. A common scenario is that the Doctor of Chiropractic initially fails to diagnose the condition properly and performs cervical spine manipulation on a patient with an ongoing arterial dissection. In most cases of cervical spine manipulation being done in the presence of a cervical arterial dissection, manipulation is uncomfortable and ineffective, but there is not an immediate stroke event following manipulation. For this reason, it is imperative that the Doctor of Chiropractic re-evaluate treatment on each visit.
If cervical spine manipulation is uncomfortable and symptoms do not show improvement, the Doctor should re-evaluate their diagnosis and consider that the patient’s neck pain may not be musculoskeletal in nature. They should then perform further evaluation and refer the patient for emergency medical care if they suspect an ongoing cervical artery dissection event. If they do not do so, they have breached the standard of care for the Chiropractic profession and are guilty of failure to diagnose and refer.
Objection to Duty to Diagnose 1
Opposing counsel may argue that diagnosis of cervical artery dissection is outside the scope of practice of a Doctor of Chiropractic. This is not the case. However, the details of Chiropractic scope of practice vary from state to state, so an attorney should always review the scope of practice for Chiropractic in the involved state. Here are a few examples:
Utah Chiropractic Scope of Practice
The state of Utah defines Chiropractic scope of practice broadly:
“Practice of chiropractic” means a practice of a branch of the healing arts: that involves examining, diagnosing, treating, correcting, or prescribing treatment for any human disease ailment, injury, infirmity, deformity, pain, or other condition, or the attempt to do so. 4
Arizona Chiropractic Scope of Practice
Arizona has a neuromusculoskeletal scope of practice. Cervical artery dissection and stroke are neurological disorders and would fall underneath a neuromusculoskeletal scope of practice. Arizona defines Chiropractic scope of practice as follows:
A Doctor of Chiropractic is a portal of entry health care provider who engages in the practice of health care that includes:
- The diagnosis and correction of subluxations, functional vertebral or articular dysarthrosis or neuromuscular skeletal disorders for the restoration and maintenance of health.
- Physical and clinical examinations, diagnostic x-rays and clinical laboratory procedures that are limited to urine collection, finger pricks or venipuncture in order to determine the propriety of a regimen of Chiropractic care or to form a basis for referral of patients to other licensed health care professionals, or both.5
Oregon Chiropractic Scope of Practice
Oregon also has neuromusculoskeletal scope of practice. Oregon defines Chiropractic scope of practice as follows:
“Chiropractic” is defined as: The chiropractic diagnosis, treatment and prevention of body dysfunction; correction, maintenance of the structural and functional integrity of the neuro-musculoskeletal system and the effects thereof or interferences therewith by the utilization of all recognized and accepted chiropractic diagnostic procedures and the employment of all rational therapeutic measures as taught in approved chiropractic colleges.6
Georgia Chiropractic Scope of Practice
Georgia hold Doctors of Chiropractic to same standard of care as any primary healthcare provider. Georgia defines Chiropractic scope of practice as follows:
The Doctor of Chiropractic has the responsibility as a primary healthcare provider to examine, establish a diagnosis/clinical impression, render treatment and/or referral, commensurate with his/her findings.7
Texas Chiropractic Scope of Practice
Texas limits Chiropractic scope of practice to musculoskeletal disorders. In this case, the Doctor of Chiropractic is not under a duty to diagnose a neurological condition. However, they are still under a duty to determine if Chiropractic treatment is appropriate and to refer to the appropriate medical provider when necessary.
Texas defines Chiropractic scope of practice as follows:
A person practices chiropractic under this chapter if the person: uses objective or subjective means to diagnose, analyze, examine, or evaluate the biomechanical condition of the spine and musculoskeletal system of the human body. 8
Texas also states that a Doctor of Chiropractic is licensed to: “Differentiate a patient or condition for which Chiropractic treatment is appropriate from a patient or condition that is in need of care from a medical or other class of provider.” Furthermore, a Doctor of Chiropractic can render: “An opinion that a patient or condition is in need of care from a medical or other class of provider” and make a “referral of patients to appropriate health care providers”.9
California Scope of Practice
The state of California defines Chiropractic scope of practice as follows:
…a duly licensed chiropractor may treat any condition, disease, or injury in any patient, including a pregnant woman, and may diagnose, so long as such treatment or diagnosis is done in a manner consistent with chiropractic methods and techniques and so long as such methods and treatment do not constitute the practice of medicine by exceeding the legal scope of chiropractic practice as set forth in this section.10
Objection to Duty to Diagnose 2
Opposing counsel may argue that Doctors of Chiropractic are not trained to diagnose a cervical artery dissection. This is not the case. All accredited Chiropractic colleges train DC’s in the history and physical examination procedures necessary to make the diagnosis.11 If imaging is needed to confirm the diagnosis, magnetic resonance angiography (MRA) or computer tomography angiography (CTA) are the imaging studies of choice. Doctors of Chiropractic can order MRA and CTA examinations.
However, while the diagnosis of a cervical artery dissection is within the scope of practice of a Doctor of Chiropractic, treatment of a cervical artery dissection is outside their scope of practice, and a stroke can occur at any time when an ongoing cervical artery dissection is present. A stroke could occur in the time it takes for a Doctor of Chiropractic to order MRA or CTA imaging. Instead, immediate referral to the ER is indicated, where the patient can receive imaging to confirm the diagnosis and emergency treatment which can prevent a stroke from occurring.
Case Study 1: Utah
This case involves a 50 year old male in Utah who consulted with a Doctor of Chiropractic complaining of vertigo and balance trouble. Despite the patient having a new chief complaint, and despite not having seen the patient in their office for over three months, the Doctor of Chiropractic did not perform an updated Patient History or an evaluation and management service (vital signs, range of motion, orthopedic testing, and neurological testing). He received cervical spine manipulation on that visit with no complications, but also with no relief of vertigo and balance trouble. The DC recommended the patient see their primary care physician for further evaluation.
The patient saw the Physician Assistant (PA) at his primary care office three days later. The PA felt the patient might be having some sinus trouble causing his dizziness and recommended a Flonase trial. The trial of Flonase did not provide any relief of vertigo and balance trouble.
The patient consulted with a different Doctor of Chiropractic from the same office 11 days later, with continued complaints of dizziness and balance trouble. Two days prior, the patient had a severe episode of cold sweats, weakness and dizziness. The Doctor of Chiropractic did not perform an updated Patient History or an evaluation and management service (vital signs, range of motion, orthopedic testing, and neurological testing). In fact, the DC did not even complete a treatment note for the date of service. The Doctor of Chiropractic performed a cervical spine manipulation. The patient again had no complications following the cervical spine manipulation, but again no relief of any symptoms.
The following morning, the patient experienced severe dizziness and lost consciousness. The patient was taken to a hospital where CTA imaging showed vertebral artery dissection and occlusion in the V3 and V4 segments of the left vertebral artery. The patient was diagnosed with a left cerebellar stroke with resultant quadriplegia and other related damages.
In this case, although it is not possible to prove a direct cause and effect relationship between cervical spine manipulation and the stroke, failure to diagnose and refer is present. The patient was experiencing symptoms of an ongoing vertebral artery dissection event prior to cervical spine manipulation. All three providers, two DC’s and the PA, failed to diagnose the patient with an ongoing vertebral artery dissection event and refer the patient for emergency medical care. But for the failure of these providers to properly diagnose and refer, the stroke and resultant quadriplegia would not have occurred. All three providers were named in the lawsuit.
Case Study 2: Oregon
A 33 year old male in Oregon received eight cervical spine manipulations from a Doctor of Chiropractic. The patient stated that his last cervical spine manipulation was painful and caused moderate pain in the right side of the neck which became constant. 24 days after the last cervical spine manipulation the patient began to experience vision difficulties, and then two days later suffered a right carotid artery stroke.
The patient claimed they had no neck complaints prior to the last cervical spine manipulation, but research into the patient file revealed that on the last five visits the patient complained of mild-moderate dull aching, tightness, and stiffness in his neck. These last five cervical spine manipulations were performed over a period of seven months. The Doctor of Chiropractic failed to diagnose and refer after seven months of neck pain which did not resolve with treatment.
Again in this case, it is not possible to prove direct causation, but failure to diagnose and refer for emergency medical care is present. It is likely this patient had a right carotid artery dissection begin seven months prior to the last cervical spine manipulation. But for the failure of the Doctor of Chiropractic to diagnose and refer, the patient would not have suffered the right carotid artery stroke.
Case Study 3: Georgia
A 28 year old female in Georgia presented to a Doctor of Chiropractic with complaints of neck pain on the right, headaches in the forehead area, and pain between the shoulder blades.
Despite not having seen the patient in their office for ten months, the Doctor of Chiropractic did not perform an updated Patient History or an evaluation and management service (vital signs, range of motion, orthopedic testing, neurological testing). The DC did not order or take any diagnostic imaging. The DC’s “Plan of Action” was for the patient to “call our office if symptoms reappear”, however, there was no documentation that the patient’s symptoms “disappeared”.
Two days later, the patient presented to the ER with complaints of occipital headache and episodes of nausea/vomiting with associated dizziness. CT examinations of the head and neck were performed. The patient was diagnosed with acute non-hemorrhagic right cerebellar infarct as a result of a right vertebral artery dissection event.
In this case, the Doctor of Chiropractic deviated from the accepted standard of care for the Chiropractic profession and was negligent in the following: Failure to examine the patient and establish a diagnosis/clinical impression of an ongoing right vertebral artery dissection event and render a referral of the patient to an emergency medical care facility.
Case Study 4: Texas
This case does not deal with cervical artery dissection, but it does show that Doctors of Chiropractic are under a duty to refer patients with neurological conditions, even in a state like Texas which has a musculoskeletal scope of practice.
A Texas man injured his back due to a slip and fall after jumping down from a tractor. Nine days later the patient presented for treatment to a Doctor of Chiropractic. The patient was 58 years old, had not been seen in the DC’s office for nearly a year, and had a history of trauma. No evaluation and management services (vital signs, range of motion, orthopedic testing, neurological testing) were documented. No imaging was done. There was no diagnosis of the patient’s condition, and no ICD-9 codes were documented. Documentation of treatment provided to the patient consisted of billing code S8890, described as “Maintenance Treatment”. No treatment plan was documented.
Twelve days later the patient presented to the ER with subjective complaints of urinary frequency, loss of appetite, and middle back pain that he rated at 9/10. No imaging was done. The patient was diagnosed with back pain and muscle spasm.
Five days later the patient was transported to the ER by an ambulance. The patient had subjective complaints of middle back pain that he rated 9/10, urinary frequency, loss of appetite, and constipation. Abdominal and pelvic CT examination was performed with no abnormal findings. The patient was diagnosed with a prostate infection. No prostate examination was documented.
Four days later the patient presented again for treatment with the Doctor of Chiropractic. On this visit, the patient was 58 years old, had a history of trauma, and had recently taken two trips to the ER for back pain, one via ambulance. No evaluation and management services (vital signs, range of motion, orthopedic testing, neurological testing) were documented. No imaging was done. The DC did not request and review medical records from the ER or the ambulance service.
Subjective findings documented by the DC were: “Has had kidney infection. Lots of tightness in the mid thoracic area. Causes him PN to do activity and difficulty sleeping. Has sharp, intense PN from T6-T12. Movement causes (increased) PN. Laying down prone was very painful.” Objective findings documented were: “Very tender interspinous and paraspinal T6-T12. ASTM T6-T12.” (Abbreviations used in the handwritten treatment notes were not explained.) There was no diagnosis of the patient’s condition, and no ICD-9 codes were documented. Documentation of treatment provided to the patient consisted of billing code S8890, described as “Maintenance Treatment”. No treatment plan was documented.
Two days later the patient again reported to the ER. The patient had subjective complaints of middle back pain which he described as “like electricity”. Lumbar spine MRI without contrast and abdominal x-ray imaging were performed. The patient was diagnosed with low back strain with spasm. It was recommended that the patient call in two days for a neurosurgery referral.
Three days later the patient presented again for treatment to the ER. The patient had subjective complaints of low back pain radiating down the leg bilaterally. Lumbar spine MRI without contrast was performed for the second time. The patient was diagnosed with acute bilateral low back pain with bilateral sciatica.
Two days later the patient presented again for treatment to the ER. The patient was transported to the ER by ambulance. The patient had subjective complaints of being unable to move his lower extremities and sciatica pain. Lumbar spine MRI without contrast was performed for the third time. The patient was diagnosed with flaccid paralysis of legs and lumbar herniated disc, mild.
The next day, the patient presented again for treatment the ER. The patient had subjective findings of back pain and paralysis and paresthesia of both legs. Thoracic spine MRI examination without contrast and CT chest examination with contrast were ordered. CT chest report noted a large paraspinal soft tissue mass (post-surgically diagnosed as a thoracic spine epidural abscess) centered at the level of T8 and T9 with an acute pathologic compression fracture of T8. There was a soft tissue density involving the anterior canal at this level with severe thoracic spinal canal stenosis at the level of T8.
The next day, the patient underwent a decompressive laminectomy surgical procedure at T7-T8-T9 with evacuation of an epidural abscess. The patient was eventually dismissed from the hospital with a diagnosis of lower extremity paraplegia.
The Doctor of Chiropractic breached the standard of care for the Chiropractic profession on two separate occasions by failing to determine that the patient had a thoracic paraspinal soft tissue mass and refer the patient to the appropriate medical provider. But for the DC’s failure to determine the nature of the patient’s condition and refer to a medical provider, the patient would have likely received appropriate medical/surgical care sooner, which would likely have avoided the lower extremity paraplegia.
Many providers, including the Doctor of Chiropractic, were negligent in this case. However, the negligence of the Doctor of Chiropractic is significant. The DC was the first provider the patient saw for this condition, the first chance to properly evaluate the patient, and the DC failed to do so. The DC failed again when the patient visited his office for the second time.
The Importance of History Taking
One thing the above cases have in common is the absence of proper history taking by the Doctor of Chiropractic. In each case, if the DC had done a proper history and physical examination, the patient’s injuries could have been avoided. Malpractice attorneys should always evaluate the Doctor of Chiropractic’s documentation to see if a proper history and physical examination (vital signs, range of motion, orthopedic testing, neurological testing, imaging) was done.
Chaibi and Russell have discussed the importance of taking a proper history: “History taking, especially regarding the time of symptom onset, is the single most important factor for detecting subtle symptoms of CAD; thus, primary care clinicians and, especially, manual therapists should dedicate enough time during the first consultation to allow for thorough history taking and physical examination. During history taking, follow-up of the patient’s answers in relation to his or her (new) neck pain and/or headache is extremely important to obtain sufficient knowledge and understanding, and one must not accept a simple yes or no answer. In cases with suspicion of high-risk CAD, which contain a combination of several warning signs, there should be an immediate referral to the medical emergency department.”12
Research studies have concluded that a direct cause and effect relationship between cervical spine manipulation and cervical artery stroke is not established. However, Doctors of Chiropractic may violate the standard of care for the Chiropractic profession by their failure to diagnose an ongoing cervical artery dissection event and refer for emergency medical care. History taking and physical examination are essential to diagnosing cervical artery dissection and making the appropriate referral.
About the Author
Steven Brown, DC, CICE, Dipl Ac, is an expert witness specializing in Chiropractic malpractice cases. He is Certified Independent Chiropractic Examiner with the American Board of Independent Medical Examiners, and holds Advanced Certification in Whiplash Biomechanics & Injury Traumatology from the Spine Research Institute of San Diego. Dr. Brown is located in Gilbert, Arizona and can be reached at 480-377-1226 or firstname.lastname@example.org.
- Cassidy, et al. Risk of Vertebrobasilar Stroke and Chiropractic Care. SPINE, 2008, Volume 33, Number 34, S176-S183.
- Cassidy, et al. Risk of Carotid Stroke after Chiropractic Care: A Population-Based Crossover Study. Journal of Stroke and Cerebrovascular Diseases, 2017 April, Vol 26, No. 4, 842-850.
- Haneline, Croft, et al. Association of Internal Carotid Artery Dissection & Chiropractic Manipulation THE NEUROLOGIST 9:35–44, 2003.
- Utah Chiropractic Physician Act Part 1 58-73-102.
- Arizona Revised Statues 32-925.
- Oregon Revised Statutes 684.010.
- Rules & Regulations of the State of Georgia, Department 100, Chapter 100-10.
- Texas Occupations Code, Title 3, Subtitle C, Chapter 201.
- Texas Administrative Code, Title 22, Part 3, Chapter 78, Rule 78.1.
- California Code of Regulation, Division 4, 302(a)(3)
- The Council of Chiropractic Education CCE Accreditation Standards: Principles, Process & Requirement for Accreditation. Section 2(H). January 2018.
- Chaibi & Russell. A risk–benefit assessment strategy to exclude cervical artery dissection in spinal manual-therapy: a comprehensive review, Annals of Medicine, 2019, DOI: 10.1080/07853890.2019.1590627.