Two years ago, I was invited to watch while one of my patients had lumbar disc surgery. While I was scrubbing with the orthopedic spine surgeon, we were discussing testifying in malpractice cases. First, we discussed stroke following manipulation; then he began describing visual loss as a complication of spinal surgery. I have been practicing for 12 years, yet I have never heard of this. He and four of his colleagues had published a paper on this phenomenon in the journal Spine in June 1997. Since that time, he had been asked to review several cases, and later provided me with a copy of the article.
The article estimated the occurrence of bilateral or unilateral visual loss or blindness to be one case per 100 spinal surgeons per year. The article also related that various other surgeries result in blindness. In fact, visual loss may occur in one percent of all surgical patients. This appears to be as frequent - if not more so - as stroke following manipulation, yet have you ever seen this reported on national television?
The exact cause of blindness, secondary to spinal surgery, is not known, making screening for potential problems difficult. Several procedures were recommended in the Spine article as precautions, however, none of these procedures has proved effective. This is similar to stroke following cervical adjustment. We do not know the exact mechanism and screening for potential problems. A variety of procedures have been recommended for pre-adjustment screening (history questions, screening tests), but none have proven to be effective, either.
Procedures for screening patients prior to cervical adjustment are usually unable to identify a specific pathology (low specificity), or to produce a low number of false negative and false positive findings (low sensitivity). This can lead to doctors choosing to skip these procedures in order to move on to more productive tests. This is reasonable, but risky, because of the double standard applied to chiropractic care described above. If a stroke occurs, and screening was not performed, the malpractice charges will include failure to perform an appropriate history and examination, which then leads to an improper diagnosis and the rendering of inappropriate treatment. The plaintiff's attorney will then find a chiropractor who will "swear on his mama's grave" that failure to perform the screening tests violated the standards of care.
In my opinion, current screening procedures are not the standard of care, and should be performed anyway. Screening procedures can be efficiently incorporated into routine examinations; they are noninvasive, low-risk and inexpensive. This can also be said for other procedures that help identify ominous conditions and contraindications to the chiropractic adjustment. If a doctor screens a patient prior to adjustment, and a stroke does occur, at least the doctor tried. The argument that the doctor failed to screen the patient properly is weakened or defeated.
I would wager that if current screening procedures for cardiovascular accidents were as invasive as a myelogram or as expensive as an MRI, they would never meet insurance precertification or coverage requirements due to their poor specificity and sensitivity. The use of these procedures prior to chiropractic care would be impractical and difficult to establish as necessary. Fortunately, current cardiovascular screening tests are noninvasive, low-risk and inexpensive. For now, they are the best we have. Their use will help protect chiropractors, and occasionally identify a patient at risk.
- Myers M, Hamilton S, Bogosian A, Smith C, Wagner T. Visual loss as a complication of spine surgery. Spine June 15, 1997;22(12).
K. Jeffrey Miller,DC,DABCO
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