Red Flags and Patient Safety

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Red Flags and Patient Safety

• Contraindications to Adjustment, Necessity for
  Referral

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Background Reading

• Fundamentals of Chiropractic
• pp. 561-580
• Red Flags document on Redwood web page

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Absolute Contraindications to CMT

• Malignancies
• Bone and joint infections
• Acute myelopathy or acute cauda equina syndrome
• Acute fractures and dislocations, or healed
  fractures and dislocations with signs of
  ligamentous rupture or instability

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More Absolute Contraindications

• Acute rheumatoid, rheumatoid-like, or nonspecific
  arthropathies, including ankylosing spondylitis
  characterized by episodes of acute inflammation,
  demineralization, and ligamentous laxity with
  anatomical subluxation or dislocation
• Active juvenile avascular necrosis
• Unstable os odontoideum

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Diagnostic Danger Signs

• History of a significant trauma, such as a fall
  or auto accident
• Possible traumatic fracture
• History of osteoporosis, corticosteroid use
  (cortisone, prednisone) or endocrine disease or
  age over 50
• Possible pathologic fracture
• Recent unexplained weight loss or malaise,
  history of cancer or other serious disease
• Possible pathological fracture or metastatic
  disease

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Danger Signs (2)

• Non-mechanical pain pattern constant,
  progressive pain unrelated to movement with no
  relief with rest or severe pain during the night
• Possible metastatic disease or referred pain from
  organ pathology

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Danger Signs (3)

• Saddle anesthesia or sphincter disturbance,
  recent onset of bladder dysfunction, such as
  incontinence, increased frequency or urinary
  retention or bowel incontinence
• Possible cauda equina syndrome

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Danger Signs (4)

• Severe or progressive weakness or numbness in the
  legs or arms, particularly if it extends past the
  knee or elbow
• Possible disc herniation with true radiculopathy
• Neck pain that causes shooting pains into the
  arms or legs, or an extremely rigid neck when
  bending forward
• Possible cervical disc herniation or meningitis

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Danger Signs (5)

• History of recent bacterial infection (such as
  urinary tract infection) intravenous drug use or
  immune suppression from steroid use, transplant
  or HIV infection recent fever over 100 (in
  combination with one or more of above signs)
• Possible spinal infection or meningitis

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Danger Signs (6)

• Constant headache or neck pain accompanied by
  numbness, weakness, dizziness, nausea or vomiting
• Possible CVA or CNS tumor
• Headache or neck pain accompanied by confusion,
  visual disturbances, difficulties in speech or
  swallowing, or alteration in consciousness
• Possible CVA or CNS tumor

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Danger Signs (7)

• Severe or constant and progressive headache, or a
  sudden onset of worst headache ever.
• Possible CVA or CNS tumor

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Vertebrobasilar Ischemia

• 5 Ds And 3 Ns
• Dizziness, vertigo, or light-headedness
• Drop attacks (sudden fainting)
• Diplopia (double vision) or other visual problems
• Dysarthria (speech difficulty)
• Dysphagia (difficulty in swallowing)
• Ataxia (unsteadiness) of gait or hemiparesis
  (lack of voluntary movement on one side of the
  body)
• Nausea or vomiting
• Numbness or hemianesthesia (lack of sensation on
  one side of the body)
• Nystagmus

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Vertebrobasilar Ischemia (2)

• Another potential warning sign of stroke is the
  sudden onset of severe pain in the side of the
  neck and/or head or in the occipital region,
  particularly if it is different than any pain the
  patient has had before.
• May be referred pain from trauma to
  pain-sensitive wall of the vertebral artery, and
  may herald the onset of a dissection.

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Vertebrobasilar Ischemia (3)

• Significantly, patients may seek care at the
  chiropractors office for treatment of this type
  of pain
• It may be misdiagnosed as musculoskeletal in
  origin.

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Stroke Controversy

• Over the years, there have been rare individual
  cases of people having strokes subsequent to
  cervical adjustment/manipulation
• Is there ...
• Correlation
• Causation
• Coincidence

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Stroke Two Major Canadian Papers

• Rothwell et al (Stroke, 2001)
• Ontario medical records, 1993-1998
• 582 vertebrobasilar accidents (VBA)
• Of these, 57 saw DC in previous 365 days
• 50 million chiropractic visits
• No correlation between DC visit and stroke for
  those over age 45
• 5x greater likelihood in those under age 45 if
  saw DC within 8 days of stroke
• Difficult to study, very few cases, no
  causation shown

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Cassidy et al (Spine, 2007)

• Reviewed same Ontario records as Rothwell group
• Key new question was there a higher correlation
  for DC visit and stroke than for MD visit and
  stroke?
• Answer patient no more likely to have a stroke
  if visited a DC than if visited an MD!!
• Most likely, these stroke cases involve people
  already having (or on verge of having) a stroke
  when they arrive at doctors office (whether DC
  or MD)

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Rothwell and Cassidy References

• Cassidy JD, Boyle E, Cote P, et al. Risk of
  vertebrobasilar stroke and chiropractic care
  results of a population-based case-control and
  case-crossover study. Spine. Feb 15 200833(4
  Suppl)S176-183.
• Rothwell DM, Bondy SJ, Williams JI. Chiropractic
  manipulation and stroke a population-based
  case-control study. Stroke. May
  200132(5)1054-1060.

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Dizziness A Challenge

• May be caused by musculoskeletal lesion of the
  cervical spine
• cervical adjustment/manipulation may be helpful
• May be an early sign of vertebrobasilar
  compromise
• cervical adjustment might precipitate a
  full-scale stroke

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What to Ask Yourself?

• Does neck rotation and extension aggravate the
  dizziness?
• Are any other of the 5Ds And 3Ns present?
• Did adjustment/manipulations aggravate symptoms
  in the past?
• The presence of any of these factors may suggest
  a vascular etiology.

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What to Do?

• When in doubt, a prudent course is to treat the
  neck with other non-manipulative conservative
  methods such as soft tissue procedures, massage,
  physiological therapeutics, or non-force
  chiropractic techniques.
• If the dizziness improves under this course of
  care, it suggests a musculoskeletal, non-vascular
  etiology.

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If Worrisome Reaction

• If after a neck adjustment or manipulation a
  patient exhibits any of the key warning signs or
  symptoms (the 5Ds And 2Ns), experiences visual
  field disturbances (particularly seeing zigzag
  lines flashing lights), or experiences other
  neurological complications, do not re-manipulate
  the patient.

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Be Responsible

• If patient shows any of the signs or symptoms
  described above after a neck adjustment (or under
  any other circumstances) allow him/her to rest
  quietly.
• Observe closely.
• If the symptoms do not resolve or if they worsen,
  the patient needs to be hospitalized immediately.
  
• The emergency treatment of choice for cervical
  artery dissection is immediate anticoagulant
  therapy.

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Cauda Equina Syndrome

• Compression to the nerves running through the
  lower part of the spine the cauda equina as
  they pass through the lower part of the lumbar
  spinal canal.
• Usually from a large posteromedial disc
  herniation.
• Immediate effect can be a dramatic loss of bowel
  and bladder function.

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Cauda Equina and the Chiropractor

• Motor, sensory and reflex exam on every patient
  along with taking a good history -- to screen for
  this
• If you see it, immediately refer to neurosurgeon.
  Impress patient with urgency and possible
  permanent consequences of not going to
  neurosurgeon.

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Cauda Equina and the Chiropractor (2)

• In exceedingly rare cases, it is possible that
  cauda equina syndrome could be consequence of
  spinal manipulation.
• Likelihood rated by Shekelle at 1 per 100
  million.
• Shekelle PG et al Spinal manipulation for
  low-back pain, Ann Int Med 117(7) 590, 1992.