Onset of complications following cervical manipulation due to malpractice in osteopathic treatment: A case report

Introduction

Osteopathy is a philosophy and an alternative medical practice which emphasizes the interrelationship between structure and functioning of the body, recognizing the body’s ability to heal itself; the role of the osteopath is to facilitate that process, mainly by practising manual and manipulative therapies.

The osteopathic medical philosophy is defined as the concept of healthcare that embraces the idea of the unity of the living organism’s structure (anatomy) and its functioning (physiology). According to the Glossary of osteopathic terminology of the AACOM (American Association of Colleges of Osteopathic Medicine), the following are the four major principles of osteopathic medicine. (1) The body is a unit; an integrated unit of mind, body and spirit. ¹ (2) The body possesses self-regulatory mechanisms, having the inherent capacity to defend, repair and remodel itself. (3) Structures and functions are reciprocally interrelated. (4) Rational therapy is based on consideration of the first three principles.

The regulation of non-physician manual medicine for osteopaths varies greatly according to jurisdictions. In Australia, the UK and New Zealand, the non-physician manual medicine osteopaths are regulated by statutes and practice requires registration at the relevant regulatory authority. In the European Union, there is no universal regulatory authority for the practice of osteopathy or osteopathic medicine; it is up to the country. For example, in Austria and Switzerland, osteopathic practitioners are doctors or physiotherapists who attend additional courses in osteopathy after completing their medical or practical therapy training; in France, osteopathy is a governmentally recognized profession (Decree 2007-435 relating to the acts and exercises conditions of osteopathy). In Italy, osteopathic medicine is not recognized by the national health system; the related training courses are organized by universities through postgraduate Masters or by private associations. There are no official public registers of osteopaths.

A key part of osteopathic medicine is a technique called Osteopathic Manipulative Treatment (OMT). There are many treatment techniques; OMT methods utilized may broadly be classified as follows: active method (a technique in which the person voluntarily performs a motion directed by the osteopathic practitioner); passive method (based on techniques in which the patient refrains from voluntary muscle contraction); direct method (an osteopathic treatment strategy by which the restrictive barrier is engaged and a final activating force is applied to correct somatic dysfunction); and indirect method (a manipulative technique where the restrictive barrier is disengaged and the dysfunctional body part is moved away from the restrictive barrier until tissue tension is equal in one or all planes and directions).

Recent research has found that spinal manipulation provides relief from neck ² and lower-back pain ³ ; in fact, the American College of Physicians and the American Pain Society included it as an alternative to conventional treatments in their 2007 guidelines. Additionally, US osteopathic physicians and academic researchers have conducted preliminary research to determine the efficacy of manual techniques to manage or co-manage conditions such as asthma ⁴ and acute otitis media in children. ⁵

The use of spinal manipulation has increased everywhere over the past decades and it is one of the most frequently reported complementary and alternative medicine modalities,^6,7 in part because there is a public perception that spinal manipulation is risk-free. However, this treatment appears to be associated with vascular and neurological complications. The most frequent complication is stroke, usually related to vertebral dissection, occurring during or shortly after cervical manipulation; spinal disc herniation with spinal cord compression, radiculopathy or cauda equina syndrome and other complications such as meningeal hematoma and diaphragmatic paralysis ⁸ are far less frequent.

Case

A 33-year-old woman, who consulted the osteopath on 17 May 2012, complaining of neck pain, received a treatment that included cervical spine manipulation (following the technique ‘high velocity–low amplitude’). The osteopath then prescribed analgesic and anti-inflammatory drugs. The next day, the patient developed right cervico-brachial neuralgia at C6–TI level and sensory-motor deficit in the right arm. The pain was primarily located in the right lower cervical spine and scapula, referring down the right arm to the elbow. She reported ‘numbness and tingling’ in her right posterior arm, along with significant weakness of the right upper extremity. The pain was aggravated in particular by driving and rapid neck movements.

The patient contacted the osteopath physician and reported to him the worsening of the pain after the first visit. He replied that it was the usual course after a treatment.

Because of the persistence of the symptoms, the woman consulted an orthopaedic surgeon who ordered a magnetic resonance imaging (MRI) and addressed her to a neurosurgeon. The MRI, performed on 21 May 2012, revealed at C6–C7 level an interruption of subarachnoid spaces (due to a right posterolateral disc herniation pushing back the spinal cord) and protrusion of the C4–C5 and C5–C6 discs (Figure 1). OPEN IN VIEWER

The MRI was reviewed by the orthopaedic surgeon who, agreeing with the neurosurgeon, prescribed therapy with corticosteroids and recommended anterior cervical microdiscectomy and positioning, and solid fixation of the implant (intervertebral disc spacers).

The patient underwent surgery on 25 May 2012; she was then followed by physiotherapists, and was prescribed a neck brace (Zimmer) for six weeks. An x-ray of the cervical spine performed on 4 June 2012 showed a correct positioning of vertebral implant and loss of cervical lordosis. She then began cervical stabilization training, consisting of exercises designed to train co-contraction of the cervical and scapular muscles to promote improved stability. She was followed up to four weeks later.

The patient conferred with the authors on 30 July 2012 to assess whether disc herniation had been precipitated by cervical manipulation. At the examination, the authors found restriction of neck motion (flexion and extension, rotation and lateral bending limited at ¼) with pain and sensory deficit in the right arm and II–III fingers. In the Romberg's position the patient showed lateral body oscillations. Palpation revealed contracture of the paravertebral muscles. The following MRI, on 23 October 2012, confirmed the success of surgery and the presence of disc protrusion was already apparent (MRI on 21 May 2012) (Figure 2). OPEN IN VIEWER

Discussion

The two most common techniques of osteopathic spinal handling are a ‘low velocity–high amplitude’ method (where a series of gentle and repeated motions are delivered to a joint) and a ‘high velocity–low amplitude’ method (where a sudden thrust is delivered to the involved vertebrae).

Complications of this form of treatment have been reported in the literature and sometimes they can be disabling and, on rare occasions, devastating. Minor side effects of increased pain and headache are the most common symptoms, followed by tiredness, radiating pain and dizziness, and they disappear quickly; most of these symptoms disappear within 24 hours and do not excessively affect daily activities. ⁹

Although serious complications are rare, they may occur mainly after treatment of the neck, as well as in the mid-back and lumbar spine. ¹⁰ Therefore, the knowledge of a patient’s clinical conditions is essential before starting an OMT. Osteopaths, before proceeding with a manipulation, need to study the case to assess any disease or pathologic element that could contraindicate the treatment.

In our case, osteopath behaviour was not in accordance with what is reported in WHO guidelines on manipulative treatment. In fact, the cervical pain reported by the patient to the osteopath was not previously studied through instrumental analysis, so the OMT was not justified by any diagnostic hypothesis. In addition, before proceeding with the manipulative treatment, an useful anamnesis to clarify symptoms and to highlight other pathologies that could be absolutely and relatively contraindicated to osteopathic direct (manipulation or mobilization) and/or indirect (postural exercises and breathing techniques) treatment was not conducted.

Conditions such as a vertebral bony anomaly, myelopathy, cauda equine syndrome, infections, malignancy, severe diabetes and anticoagulation therapy may be absolute contraindications and pregnancy, radicular pain and migraine relative contraindications.

Osteopaths, as other non-physician practitioners, should have the knowledge and awareness of their limitations in healthcare, so as to avoid development of complications associated with manipulations, especially the neurological type.

In this case, the osteopath did not assess pre-existing clinical conditions (torticollis by disc protrusions) and he did not recognize the severity of complications. In addition, since he is not a doctor, without suggesting radiographs or MRI or referring for orthopaedic or neurosurgeon consultation, the osteopath had improperly prescribed drugs to treat the symptoms.

This behaviour may be considered malpractice, because he does not follow WHO guidelines on safety in traditional/complementary and alternative medicine (Benchmarks for training in osteopathy: Benchmarks for training in traditional/complementary and alternative medicine. Geneva 2010, ISBN 978 92 4 159966 5). In this document, it is reported that ‘osteopathic practitioners have a responsibility to refer patients as appropriate when the patient’s condition requires therapeutic intervention that falls outside the practitioner’s competence. It is also necessary to recognize when specific approaches and techniques may be contraindicated in specific conditions’.

In conclusion, having analysed and reconstructed the event in accordance with the forensic methodology criteria on professional misconduct,¹¹ the authors identified some elements of responsibility on the part of the osteopath for the onset of disc herniation, due to the manipulation treatment. This complication, which required neurosurgery treatment, was responsible for the temporary disability evaluated at the medico-legal examination. The incidence of serious complications from cervical spine manipulation could have been lower if the osteopath had adhered to guidelines.