MD, PhD, FMedSci, FSB, FRCP, FRCPEd

The purpose of this paper by Canadian chiropractors was to expand practitioners’ knowledge on areas of liability when treating low back pain patients. Six cases where chiropractors in Canada were sued for allegedly causing or aggravating lumbar disc herniation after spinal manipulative therapy were retrieved using the CANLII database.

The patients were 4 men and 2 women with an average age of 37 years. Trial courts’ decisions were rendered between 2000 and 2011. The following conclusions from Canadian courts were noted:

  1. informed consent is an on-going process that cannot be entirely delegated to office personnel;
  2. when the patient’s history reveals risk factors for lumbar disc herniation the chiropractor has the duty to rule out disc pathology as an aetiology for the symptoms presented by the patients before beginning anything but conservative palliative treatment;
  3. lumbar disc herniation may be triggered by spinal manipulative therapy on vertebral segments distant from the involved herniated disc such as the thoracic spine.

The fact that this article was published by chiropractors seems like a step into the right direction. Disc herniations after chiropractic have been reported regularly and since many years. It is not often that I hear chiropractors admit that their spinal manipulations carry serious risks.

And it is not often that chiropractors consider the issue of informed consent. One the one hand, one hardly can blame them for it: if they ever did take informed consent seriously and informed their patients fully about the evidence and risks of their treatments as well as those of other therapeutic options, they would probably be out of business for ever. One the other hand, chiropractors should not be allowed to continue excluding themselves from the generally accepted ethical standards of modern health care.

6 Responses to Disc herniation after chiropractic

  • Edzard,
    You’d be quite surprised – I inform each and every patient of the risks of chiropractic care, to the best possible estimate available (difficult given there are few AERs and how effective these are is up for debate), and advise them of their treatment options. They are encouraged to think about it before they pursue their treatment. Having said that, spinal manipulation is not the only treatment offered at my clinic – often it is completely inappropriate and I will not perform it, often to the disappointment of some patients who have regularly experienced chiropractic care.
    RC

  • Good article.
    My informed consent also includes the possibility of aggravating a disc. It is mandatory in Australia when discussing risks with the patient!

  • Professor Ernst wrote: “…it is not often that chiropractors consider the issue of informed consent. One the one hand, one hardly can blame them for it: if they ever did take informed consent seriously and informed their patients fully about the evidence and risks of their treatments as well as those of other therapeutic options, they would probably be out of business for ever. One the other hand, chiropractors should not be allowed to continue excluding themselves from the generally accepted ethical standards of modern health care.”

    Indeed. Unfortunately theroguechiropractor and Thinking_Chiro appear to be the exception to rule:
    http://www.sciencebasedmedicine.org/whack-em-hardwhack-em-once-and-stroke/#comment-125985

    Professor Ernst wrote: “It is not often that I hear chiropractors admit that their spinal manipulations carry serious risks.”

    And when they do – and appear to cause them – you have to wonder how many of the adverse events make it into the medical literature. For example:

    QUOTE
    “…there is no reliable reporting system for harms experienced by chiropractic patients in the UK. This state of affairs is made all the more disconcerting by the content of a draft document on revalidation which was commissioned recently by the GCC (which, after it was dropped briefly, it was told to reinstate). Its purpose was to provide an analysis of the risks and benefits of chiropractic, with the aim of establishing if there was a business case for revalidation. In section 5.72 of the document, the British Chiropractic Association admits that its members have caused patient rib fracture injuries, but in sections 5.13 (along with the McTimoney Chiropractic Association), and 5.64, the Scottish Chiropractic Association have apparently ignored the request for details of patient incidents and complaints.”

    The above is lifted from here http://tinyurl.com/pdrsu89 (referenced)

  • My professional indemnity insurer and the national registration board require informed consent and it is checked as part of the forms I fill out every year on renewal for both. You should push for something similar in the UK!
    There is also a current topic being discussed at the moment in Australia in regards to adverse event reporting which is also relevant.
    https://www.mja.com.au/insight/2014/7/support-chiropractor-reporting

  • I reviewed over 6,000 chiropractic files where I looked for an Informed Consent in written form and found only two.

  • In Reply to Preston Long:
    Informed consent has been compulsory in Australia for all health care providers since 2000. I have a signed consent in every file going back to 1995, following recommendations from the registration board and COCA at that time. I am currently on my 6th version. It is regularly updated!

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