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 Deaths after Chiropractic: A Review of Published Cases

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Deaths after Chiropractic: A Review of Published Cases

Abstract



Objective: The aim of this study was to summarise all cases in which chiropractic spinal manipulation was followed by death.
Design: This study is a systematic review of case reports.
Methods: Literature searches in four electronic databases with no restrictions of time or language.
Main outcome measure: Death.
Results: Twenty six fatalities were published in the medical
literature and many more might have remained unpublished. The alleged
pathology usually was a vascular accident involving the dissection of a
vertebral artery.
Conclusion: Numerous deaths have occurred after chiropractic manipulations. The risks of this treatment by far outweigh its benefit.
Introduction

Vascular accidents after upper spinal manipulation are a well-recognised problem (e.g.[1,2]).
Dissection of a vertebral artery, caused by extension and rotation of
the neck beyond the physiological range of motion, is thought to be the
underlying mechanism.[2]
Several deaths have been reported as a consequence. Some proponents of
chiropractic seem to believe that the critical evaluation of this
evidence amounts to a 'scare story' (Chairman of the UK General
Chiropractic Council)[3] or to 'puffing up (the evidence) out of all proportion' (President of the British Chiropractic Association).[4] A responsible approach to serious therapeutic risks, however, requires an open discussion of the facts.
In this review, I aimed to provide the basis for such a discussion by
summarising all fatalities which occurred after chiropractic spinal
manipulation and were published in the medical literature.
Methods

Electronic searches were conducted in the following electronic
databases: Medline, Embase, AMED, Cochrane Library (September 2009). No
restrictions of time or language were applied. Search terms were
chiropractic, spinal manipulation, vascular accidents, stroke, death and
fatality. In addition, our own departmental files and the
bibliographies of the articles thus located were searched. Several
experts were also contacted for further data. Case reports were included
if they provided information on human patients who had died after
receiving one or more treatments from a chiropractor. Data were
extracted from the included articles according to predefined criteria

Table 1. Published case reports of deaths after chiropractic treatments



ReferencesYear of publicationVictimType of vascular accidentTime between treatment and death
Anon[5]
1934Woman, age unknownTear in left lateral sinus2 weeks
Pratt-Thomas and Berger[6]
194732-year-old manThrombosis of basilar, left anterior-inferior cerebellar and right posterior-inferior arteries24 h
Pratt-Thomas and Berger[6]
194735-year-old womanThrombosis of posterior-inferior cerebellar artery10 h
Anon[7]
1955Woman, age unknownIntra-spinal bleeding and compression of spinal cord18 h
Ford and Clark[8]
195637-year-old manThrombosis of basilar, left-posterior cerebellar and left-posterior cerebral arteries6 h
Ford and Clark[8]
1956No information providedThrombosis of basilar arteryNo information provided
Smith and Estridge[9]
196233-year-old womanInfarct of cerebellar and brainstem3 days
Lorenz and Vogelsang[10]
197239-year-old womanThrombosis of basilar artery58 days
Schmitt[11]
197635-years-old womanInfarct of brainstem1 h
Krueger and Okazaki[12]
198025-year-old manInfarct of brainstem and cerebellum48 h
Sherman et al.[13]
198160-year-old womanDissection of vertebral artery4 days
Ali Cherif et al.[14]
198351-year-old manInfarct of medulla oblongata11 days
Nielsen[15]
198434-year-old manDissection of vertebral artery aneurysen3 h
Zak and Carmody[16]
198453-year-old manLeft vertebral, posterior-inferior and superior cerebellar artery occlusion; cerebellar infarction27 days
Modde[17]
198526-year-old womanDissection of vertebral artery1 day
Jentzen et al.[18]
198751-year-old manInfarct of cerebellum and brainstemNo information provided
Sherman et al.[20]
198737-year-old manInfarct of brainstem3 days
Mas et al.[19]
198935-year-old womanDissecting aneurysm of vertebral artery16 h
Raskind and North[21]
199047-year-old womanCerebellar haemorrheaeNo information provided
Sullivan[22]
199241-year-old womanHaemorrhage in ventricular system8 h
Haynes[23]
199436-year-old womanDissecting aneurysm of vertebral artery, thrombo-embolismNo information provided
Peters et al.[24]
199529-year-old womanInfarct of right hemisphere3 days
Klougart et al.[25]
199634-year-old manUnclearFew hours
Haldeman et al.[26]
2002Previously unpublished legal casesNo information providedNo information provided
Haldeman et al.[26]
2002Previously unpublished legal casesNo information providedNo information provided
Dziewas et al.[27]
2003No information providedNo information providedNo information provided

Results

Twenty-six fatalities were published since 1934 in 23 articles (Table 1).[5–27]

Most of the victims were relatively young; 14 were below the age of
40. There was a slight majority of female patients. The type of
complication associated with death frequently related to a vascular
accident leading to thrombosis and cerebral infarction. The time between
treatment and death ranged from 1 h to 58 days; in 10 cases, it was 1
day or less. Unfortunately, the published information was often
incomplete.
Many other fatalities seem to have remained unpublished. For
instance, the testimony of the chiropractor Preston Long for a court in
Connecticut recently listed the family names of nine victims: Mathiason,
Solsbury, Mc Cornick, Venegas, Bedenbaugh, Lewis, Fawcett, Parisien,
Standt. Long also states that 'many others [are] unknown hidden behind
legal agreements of silence'.[28]
A website names further North American fatalities: Linda Epping
(California), G. Fowden (Utah), Ronald Grainger (Alberta), John Hoffman
(Maryland), Renate Dora Labonte (Ontario), Jose Lopez (California),
Donald Pereyra (Connecticut), Elizabeth A. Roth (Ontario) and Kimberly
Lee Strohecker (Pennsylvania).[29]

Discussion


This systematic review demonstrates that numerous deaths have been
associated with chiropractic. Usually high-velocity, short-lever thrusts
of the upper spine with rotation are implicated. They are believed to
cause vertebral arterial dissection in predisposed individuals which, in
turn, can lead to a chain of events including stroke and death.[1,2,26,30]

Many chiropractors claim that, because arterial dissection can also
occur spontaneously, causality between the chiropractic intervention and
arterial dissection is not proven. However, when carefully evaluating
the known facts, one does arrive at the conclusion that causality is at
least likely (e.g.[30,31]).
Even if it were merely a remote possibility, the precautionary
principle in healthcare would mean that neck manipulations should be
considered unsafe until proven otherwise. Moreover, there is no good
evidence for assuming that neck manipulation is an effective therapy for
any medical condition.[32] Thus, the risk-benefit balance for chiropractic neck manipulation fails to be positive.
Reliable estimates of the frequency of vascular accidents are
prevented by the fact that under-reporting is known to be substantial.
In a survey of UK neurologists, for instance, under-reporting of serious
complications was 100%.[33]
Those cases which are published often turn out to be incomplete. Of 40
case reports of serious adverse effects associated with spinal
manipulation, nine failed to provide any information about the clinical
outcome.[34]
Incomplete reporting of outcomes might therefore further increase the
true number of fatalities. Obviously, the present article is not aimed
at providing incidence figures; this would require a different
methodology entirely. To date, no reliable incidence data are available.
This review is focussed on deaths after chiropractic, yet neck
manipulations are, of course, used by other healthcare professionals as
well. The reason for this focus is simple: chiropractors are more
frequently associated with serious manipulation-related adverse effects
than osteopaths, physiotherapists, doctors or other professionals. Of
the 40 cases of serious adverse effects mentioned above, 28 can be
traced back to a chiropractor and none to an osteopath.[34]
A review of complications after spinal manipulations by any type of
healthcare professional included three deaths related to osteopaths,
nine to medical practitioners, none to a physiotherapist, one to a
naturopath and 17 to chiropractors.[35]
This article also summarised a total of 265 vascular accidents of which
142 were linked to chiropractors. Another review of complications after
neck manipulations published by 1997 included 177 vascular accidents,
32 of which were fatal. The vast majority of these cases were associated
with chiropractic and none with physiotherapy.[36]
The most obvious explanation for the dominance of chiropractic is that
chiropractors routinely employ high-velocity, short-lever thrusts on the
upper spine with a rotational element, while the other healthcare
professionals use them much more sparingly.[37,38]

In conclusion, numerous deaths have been associated with chiropractic
neck manipulations. There are reasons to suspect that under-reporting
is substantial and reliable incidence figures do not exist. The risks of
chiropractic neck manipulations by far outweigh their benefits.
Healthcare professionals should advise the public accordingly.

References

  1. Ernst E. Adverse effects of spinal manipulation: a systematic review. J R Soc Med 2007; 100: 330–8.
  2. Leon-Sanchez A, Cuetter A, Ferrer G. Cervical spine
    manipulation: an alternative medical procedure with potentially fatal
    complications. South Med J 2007; 100: 201–3.
  3. Dixon P. Letter to the Editor. Adverse effects of spinal manipulation. J R Soc Med 2007; 100: 444.
  4. Lewis BJ. Letter to the Editor. Adverse effects of spinal manipulation. J R Soc Med 2007; 100: 444.
  5. Anon. Medicolegal. Malpractice: death resulting from chiropractic treatment for headache. J Am Med Assoc 1934; 103:1260, 1935; 105:1712–4, 1937; 109:233–4.
  6. Pratt-Thomas HR, Berger KE. Cerebellar and spinal injuries after chiropractic manipulation. J Am Med Assoc 1947; 133: 600–3.
  7. Anon. Medicolegal abstracts. Chiropractors: injury to spinal meninges during adjustments. J Am Med Assoc 1955; 159: 809.
  8. Ford FR, Clark D. Thrombosis of the basilar artery
    with softenings in the cerebellum and brain stem due to manipulation of
    the neck; a report of two cases with one post-mortem examination,
    reasons are given to prove that damage to the vertebral arteries is
    responsible. Bull Johns Hopkins Hosp 1956; 98: 37–42.
  9. Smith RA, Estridge MN. Neurologic complications of head and neck manipulations. JAMA 1962; 182: 528–31.
  10. Lorenz R, Vogelsang HG. Thrombosis of the basilar
    artery following chiropractic manipulation of the cervical spine. [In
    German] Thrombose der arteria basilaris nach chiropraktischen
    Manipulationen an der Halbwirbelsäule. Dtsch Med Wochenschr 1972; 97: 36–43.
  11. Schmitt HP. Rupturen und Thrombosen der Arteria vertebralis nach gedeckten mechanischen Insulten. Schweiz Arch Neurol Neurochir Psychiatry 1976; 119: 363–79.
  12. Krueger BR, Okazaki H. Vertebral-basilar distribution infarction following chiropractic cervical manipulation. Mayo Clin Proc 1980; 55: 322–32.
  13. Sherman DG, Hart RG, Easton JD. Abrupt change in head position and cerebral infarction. Stroke 1981; 12: 2–6.
  14. Ali Cherif A, Delpuech F, Habib M, Salamon G, Khalil
    R. Thrombose vertebro-basilaire apres manipulation du rachis cervical. A
    propos de deux cas. Ann de Med Phys 1983; 25: 459–65.
  15. Nielsen AA. Cerebrovascular insults caused by manipulation of the cervical spine. [In Danish]. Ugeskr Laeger 1984; 146: 3267–70.
  16. Zak SM, Carmody RF. Cerebellar infarction from chiropractic neck manipulation: case report and review of the literature. Ariz Med 1984; 41: 333–7.
  17. Modde PJ. Chiropractic Malpractice. Columbia, Maryland: Hanrow Press. 1985: 269–70, 273–5, 311–8, 322–3, 329–31, 334–7.
  18. Jentzen JM, Amatuzio J, Peterson GF. Complications
    of cervical manipulation: a case report of fatal brainstem infarct with
    review of the mechanisms and predisposing factors. J Forensic Sci 1987; 32: 1089–94.
  19. Mas JL, Henin D, Bousser MG, Chain F, Haw JJ.
    Dissecting aneurysm of the vertebral artery and cervical manipulation: a
    case report with autopsy. Neurology 1989; 39: 512–5.
  20. Sherman MR, Smialek JE, Zane WE. Pathogenesis of vertebral artery occlusion following cervical spine manipulation. Arch Pathol Lab Med 1987; 111: 851–3.
  21. Raskind R, North CM. Vertebral artery injuries following chiropractic cervical spine manipulation--case reports. Angiology 1990; 41: 445–52.
  22. Sullivan EC. Brain stem stroke syndromes from cervical adjustments. Report on five cases. J Chiropr Res Clin Invest 1992; 8: 12–6.
  23. Haynes MJ. Stroke following cervical manipulation in Perth. Chiropr J Aust 1994; 24: 42–6.
  24. Peters M, Bohl J, Thömke F, Kallen K-J, Mahlzahn K,
    Wandel E. Dissection of the internal carotid artery after chiropractic
    manipulation of the neck. Neurology 1995; 45: 2284–6.
  25. Klougart N, Leboeuf-Yde C, Rasmussen LR. Safety in
    chiropractic practice. Part I. The occurrence of cerebrovascular
    accidents after manipulation to the neck in Denmark from 1978–1988. J Manipulative Physiol Ther 1996; 19: 371–7.
  26. Haldeman S, Kohlbeck FJ, McGregor M. Unpredictability of cerebrovascular ischemia associated with cervical spine manipulation. Spine 2002; 27: 49–55.
  27. Dziewas R, Konrad C, Dräger B et al. Cervical artery
    dissection – clinical features, risk factors, therapy and outcome in
    126 patients. J Neurol 2003; 250: 1179–84.
  28. Presentation by Dr Preston Long DC to State of
    Connecticut. Connecticut State Board of Chiropractic Examiners. Hartford
    Connecticut. 25 October 2009.
  29. Anon. What's the harm in going to a chiropractor? What's the Harm 2009; http://whatstheharm.net/chiropractic.html (accessed October 2009).
  30. Ernst E. Vascular accidents after neck manipulation: cause or coincidence? Int J Clin Pract 2009; in press.
  31. Long PH. Stroke and spinal manipulation. J Quality Health Care 2004; 3: 8–10.
  32. Ernst E. Chiropractic: a critical evaluation. J Pain Symptom Manage 2008; 35: 544–62.
  33. Stevinson C, Honan W, Cooke B, Ernst E. Neurological complications of cervical spine manipulation. J Roy Soc Med 2001; 94: 107–10.
  34. Ernst E. Cerebrovascular complications associated with spinal manipulation. Phys Ther Rev 2004; 9: 5–15.
  35. Terrett AGJ. Current Concepts in Vertebrobasilar Complications following Spinal Manipulation, 2nd edn. Des Moines: JCMIC Group, 2001.
  36. Di Fabio RP. Manipulation of the cervical spine: risks and benefits. Physical Ther 1999; 79: 50–65.
  37. Alcantara J, Ohm J, Kunz D. The safety and
    effectiveness of pediatric chiropractic: a survey of chiropractors and
    parents in a practice-based research network. Explore (NY) 2009; 5: 290–5.
  38. Sweeney A, Doody C Manual therapy for the cervical
    spine and reported adverse effects: a survey of Irish Manipulative
    Physiotherapists. Man Ther 2010; 15: 32–6.

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