Response to letter to the editor

First of all, we would like to highlight the fact that we had to summarise the case in accordance with the journal editorial guidelines. We nonetheless believe that the exposure was sufficiently clear to make the reader better able to understand the clinical event.

Scientific articles are meant to provide valuable information on current clinical practice, focusing on some of the problems in the management of patients and complications of treatment. The main theme of our contribution is cervical manipulation: it is of fundamental importance for the osteopath to exclude the presence of any condition that might be aggravated after a manipulative treatment. The patient’s symptomatology is disclosed in the article: this is to make it clear that the osteopath had taken responsibility for the treatment, even though little clinical data was available. The subsequent clinical history is well described: pain after the treatment, sensory deficit, the reports of the investigations performed, treatment for herniated discs and the residual damage.

In the letter, we reaffirm that the information provided to the reader would not be sufficient to verify the correctness of the osteopath’s work, thus making it meaningless to report him/her. In this regard, we would like to point out that the reason why the patient required osteopathic treatment and the information requested by the osteopath before performing the manipulation are written in the article. The symptom for which the patient was seeing the osteopath was known: a stiff neck. The osteopath should have been certain that there were no conditions that could contraindicate the treatment. The article serves the purpose of highlighting the fact that the osteopath had acted imprudently. He/she should have sent the patient to a doctor orthopaedic and/or a physical therapist to get an accurate diagnosis of the cause of the pain in order to find the best treatment. On the contrary, the osteopath did not request any further study and performed the treatment immediately. This was reckless behaviour because the causes of torticollis are copious and of varying severity, and treatment could cause a worsening of the underlying disease: vascular and nerve complications can occur after manipulative treatment, resulting in serious consequences.

The article shows how greater diligence on the part of the practitioner could have reduced or even avoided the risk of damaging the patient. This statement is also based on a document for the training of osteopathic physicians published by the World Health Organization ¹ : the bibliographic reference is authoritative and valid. In fact, if the osteopath had studied the case better, he would have noticed an anatomical-pathological framework altered by the presence of multiple disc protrusions, as shown by the MRI examination performed four days after the treatment. In this way, he/she could have decided if it was appropriate to perform the treatment, and he/she should have informed the patient about the relative risks and benefits as well.

As far as the correlation between the manipulation and the onset of symptoms are concerned, we would like to highlight how the pain appeared immediately after treatment and worsened with the passing of time. In addition, the patient did not report the occurrence of any other event (e.g. trauma) that might have led to the appearance of the complication. This means that the medico-legal criteria of causal relationship ² are met: (1) the criterion of scientific possibility-probability, because the medical literature states that a neurological complication of post-treatment is possible and likely to happen; (2) the criterion of chronological order, because the symptoms occurred shortly after the treatment; (3) the qualitative-quantitative and modal criterion, because the type of manipulation illustrated can determine these complications; (4) the topographical criterion, because the manipulation and the herniated cervical spine concern the same area; and (5) the criterion for exclusion of other causes, because there were not other conditions that could cause a hernia.

This highlights how the work of the osteopath was wrong, especially from a methodological point of view. The osteopath should have followed various steps to exclude the presence of contraindications to the treatment. The patient’s disc disease of the spine might not have been an absolute contraindication to the treatment. However, if proceeding with treatment, it should have been performed with the utmost of care. In any case, the patient should have known that the treatment could result in further complications, so that she could choose freely. In fact, we point out that the patient was not informed properly on the technique used and its possible adverse effects: the informed consent of acceptance of the procedure is actually missing.

Finally, we would like to underline the fact that the purpose of presenting this case is to stress the importance of proper methodology. This is the only way to carry out one’s work at one’s best without causing damage.

The aphorism ‘primum non nocere’ (improperly attributed to Hippocrates) indicates precisely this fundamental condition of the work of health. It is essential always to improve the health condition of the patient and act for his/her own good. This concept is currently also being developed by Daniel Sokol. ³ He describes how the work of the physician must ensure that the benefits are always higher than the potential harm: balancing harm and benefit is a not purely a clinical exercise – first do no net harm!