Research Review by Dr. Shawn Thistle©

Date:

Oct. 2006

Study Title:

Acute paraplegia following chiropractic therapy

Authors:

Wang C et al.

Publication Information:

Journal of Clinical Neuroscience 2006; 13: 578-581.

Summary:

This will be a very brief review of the most recent case report linking severe injury to proposed "chiropractic" treatment. Although previous case reports have attracted greater media attention, I feel it is important to be aware of recent publications in order to improve patient communication should the question arise, or to facilitate normal informed consent procedures.

This case involves a 44 year old man who eventually suffered complete paraplegia secondary to "paraspinal and epidural abscess" following "chiropractic therapy" for severe back pain.

Relevant points from the patient history and presentation include:
  • the patient was previously in good health
  • he had complained of right subscapular pain for about 2 weeks
  • for this pain, he had received several chiropractic treatments
  • the week before the onset of paraplegia - he presented to the emergency room 4 times due to persistent intractable pain
  • no local heat, skin changes, neurological deficit or swelling was noted
  • lab data revealed only mild leukocytosis with a shift to the left and elevated ESR (erythrocyte sedimentation rate)
  • plain film x-rays of the thoracic and lumbar spines were normal
  • 3 hours after a subsequent chiropractic treatment (no time frame stated) - he presented again to the emergency room with acute paraplegia (T5 neurological level) and abdominal distension
  • MRI was then performed revealing a paraspinal and epidural hematoma, a torn T5 interspinous ligament
  • emergency laminectomy was performed - debridement and abscess aspiration (positive Staph Aureus culture obtained)
  • after a 3 month recovery period, the patient regained bladder function with moderate residual left lower extremity paresis
The authors suggest that repetitive "blunt trauma due to chiropractic treatment" was the most likely cause of the infection, which they propose began in the paraspinal musculature.

An interesting comment in the discussion reads as follows: "Forceful massage with a hard tool, such as a wooden bar, to the back may cause damaged to the skin and soft tissue which will result in the formation of a hematoma; this serves as a nutrient-rich source for infection." [pg. 580] A strange, non-referenced statement, which they at least follow by stating that their theory regarding the etiology of this infection/abscess is just that - a theory.

Conclusions & Practical Application:

This case report does little to establish causality between the chiropractic treatment and this particular clinical outcome for the following reasons:
  1. the actual "chiropractic treatment" is never actually described, nor is it confirmed that the patient was actually treated by a chiropractor (they used other terms such as "forceful massage" - that in conjunction with the quote above suggests to me that they are quite confused about what a chiropractor is, or what we do)
  2. presenting 4 times to an emergency department likely indicates that this abscess was already in progress, and was missed by the emergency doctors, and the chiropractor
  3. none of their mechanisms of injury linking any chiropractic treatment to a paraspinal infection are referenced
They conclude that patients with localized back pain and raised inflammatory markers (ESR) require urgent MRI to rule out this type of pathology. I agree with this conclusion, and appreciate that this is an important differential for us all to consider when something just "isn't right".

I am disappointed however, that yet another poorly described case report with murky treatment details will now be added to the list in the literature of dire outcomes associated with what may or may not be chiropractic care/spinal manipulation.