MD, PhD, FMedSci, FSB, FRCP, FRCPEd

case report

I just came across this article which I find remarkable in several ways. Here is the abstract:

OBJECTIVE:
The purpose of this report is to describe 2 patients with coronary artery disease presenting with musculoskeletal symptoms to a chiropractic clinic.
CLINICAL FEATURES:
A 48-year-old male new patient had thoracic spine pain aggravated by physical exertion. A 61-year-old man under routine care for low back pain experienced a secondary complaint of acute chest pain during a reevaluation.
INTERVENTION AND OUTCOME:
In both cases, the patients were strongly encouraged to consult their medical physician and were subsequently diagnosed with coronary artery disease. Following their diagnoses, each patient underwent surgical angioplasty procedures with stenting.
CONCLUSION:
Patients may present for chiropractic care with what appears to be musculoskeletal chest pain when the pain may be generating from coronary artery disease necessitating medical and possibly emergency care.

I FIND THIS REMARKABLE FOR AT LEAST 3 REASONS:

  1. I don’t remember coming across the term ‘medical physician’ before. It is clear what the author meant by it. But it is also quite clear that such phraseology is nonsensical. My Oxford Dictionary defines ‘physician’ as: “A person qualified to practise medicine, especially one who specializes in diagnosis and medical treatment as distinct from surgery.” Therefore, a ‘medical physician’ would be ‘a medical person qualified to practise medicine.’ This begs the question why this term is used in a chiro-journal. The answer is probably quite simple: they want to arrive at a point where we all accept that there are two types of physicians: medical and chiropractic. But, using again my dictionary, this would be not just a little confusing. A chiropractic physician would be ‘a chiropractor qualified to practice medicine.’ And for that you need to go not to chiro-college but to medical school.
  2. The two case reports are remarkable in themselves, I find. They show that “patients may present for chiropractic care with what appears to be musculoskeletal chest pain when the pain may be generating from coronary artery disease necessitating medical and possibly emergency care.” The remarkable thing about this is that such basic knowledge ever merited a mention and publication in a journal. It should be clear to anyone who is in healthcare! I even know shop assistants who have called an ambulance because a customer suffered from what might have been misdiagnosed as a muscular problem in the left arm but was in truth due to coronary hear disease. The fact that chiros and editors of their journals feel that it worthy of publication seems a bit worrying and begs the question: how many other elementary things about the human body (known even to shop assistants) are unknown to the average chiro?
  3. Lastly, I must praise the chiro-profession for the progress they now seem to start making. About 120 years ago, DD Palmer, the founding father of chiropractic, famously treated a man with coronary heart disease by adjusting his spine. The author of the above article did not do that! Yes, progress was painfully slow, but the above article seems to indicate that at least some chiros have come around to agreeing with real physicians that the Palmer-gospel is based on little more than wishful thinking.

This sad story was reported across the world. It is tragic and, at the same time, it makes me VERY angry. A women lost her life after giving birth due to the incompetence of her midwife. On this website, we learn the following gruesome details:

Many question the culpability of Australian midwife Gaye Demanuele in the wake of the investigations into the death of Caroline Lovell during her home birth in 2012. And while Demanuele played a major role in Lovell’s passing, a closer look may show the real culprit: homeopathy. In January 2012, Demanuele, an outspoken home birth advocate, served as senior midwife in Lovell’s home birth. After giving birth, Lovell experienced severe blood loss and begged to call an ambulance. According to the investigating coroner, Demanuele refused several times, never checking her patient’s blood pressure or effectively monitoring her blood loss. Demanuele instead tried a homeopathic “remedy” to relieve Lovell’s anxiety. Only after Lovell fainted in a pool of her own blood and went into cardiac arrest was she taken to a hospital, where she died 12 hours later…

We know that many midwifes are besotted with alternative medicine. Their love-affair with quackery had to lead to serious harm sooner or later. This story is thus tragic and awful – but it is not surprising.

What makes me angry, is the complete lack of critical comment from homeopaths and their professional organisations. Where are the homeopaths who state clearly and categorically that the use of homeopathic remedies in the situation described above (and indeed in midwifery generally) is not based on sound evidence? In fact, it is criminal charlatanry!

Homeopaths are usually not lost for words.

Where is the homeopathic organisation stating that a bleeding patient does not need homeopathy?

How should we interpret this deafening silence?

Does it mean that those homeopaths who quietly tolerate charlatanry are themselves charlatans?

If so, would this not be 100% of them?

Cervical spine manipulation (CSM) is a popular manipulative therapy employed by chiropractors, osteopaths, physiotherapists and other healthcare professionals. It remains controversial because its benefits are in doubt and its safety is questionable. CSM carries the risk of serious neurovascular complications, primarily due to vertebral artery dissection (VAD) and subsequent vertebrobasilar stroke.

Chinese physicians recently reported a rare case of a ‘locked-in syndrome’ (LIS) due to bi-lateral VAD after CSM treated by arterial embolectomy. A 36-year-old right-handed man was admitted to our hospital with numbness and weakness of limbs after receiving treatment with CSM. Although the patient remained conscious, he could not speak but could communicate with the surrounding by blinking or moving his eyes, and turned to complete quadriplegia, complete facial and bulbar palsy, dyspnoea at 4 hours after admission. He was diagnosed with LIS. Cervical and brain computed tomography angiography revealed bi-lateral VADs. Aorto-cranial digital subtraction angiography showed a vertebro-basilar thrombosis which was blocking the left vertebral artery, and a stenosis of right vertebral artery. The patient underwent emergency arterial embolectomy; subsequently he was treated with antiplatelet therapy and supportive therapy in an intensive care unit and later in a general ward. After 27 days, the patient’s physical function gradually improved. At discharge, he still had a neurological deficit with muscle strength grade 3/5 and hyperreflexia of the limbs.

The authors concluded that CSM might have potential severe side-effect like LIS due to bilaterial VAD, and arterial embolectomy is an important treatment choice. The practitioner must be aware of this complication and should give the patients informed consent to CSM, although not all stroke cases temporally related to CSM have pre-existing craniocervical artery dissection.

Informed consent is an ethical imperative with any treatment. There is good evidence to suggest that few clinicians using CSM obtain informed consent from their patients before starting their treatment. This is undoubtedly a serious violation of medical ethics.

So, why do they not obtain informed consent?

To answer this question, we need to consider what informed consent would mean. It would mean, I think, conveying the following points to the patient in a way that he or she can understand them:

  1. the treatment I am suggesting can, in rare cases, cause very serious problems,
  2. there is little good evidence to suggest that it will ease your condition,
  3. there are other therapies that might be more effective.

Who would give his or her consent after receiving such information?

I suspect it would be very few patients indeed!

AND THAT’S THE REASON, I FEAR, WHY MANY CLINICIANS USING CSM PREFER TO BEHAVE UNETHICALLY AND FORGET ABOUT INFORMED CONSENT.

We all hope that serious complications after chiropractic care are rare. However, this does not mean they are unimportant. Multi-vessel cervical dissection with cortical sparing is an exceptional event in clinical practice. Such a case has just been described as a result of chiropractic upper spinal manipulation.

Neurologists from Qatar published a case report of a 55-year-old man who presented with acute-onset neck pain associated with sudden onset right-sided hemiparesis and dysphasia after chiropractic manipulation for chronic neck pain.

Magnetic resonance imaging revealed bilateral internal carotid artery dissection and left extracranial vertebral artery dissection with bilateral anterior cerebral artery territory infarctions and large cortical-sparing left middle cerebral artery infarction. This suggests the presence of functionally patent and interconnecting leptomeningeal anastomoses between cerebral arteries, which may provide sufficient blood flow to salvage penumbral regions when a supplying artery is occluded.

The authors concluded that chiropractic cervical manipulation can result in catastrophic vascular lesions preventable if these practices are limited to highly specialized personnel under very specific situations.

Chiropractors will claim that they are highly specialised and that such events must be true rarities. Others might even deny a causal relationship altogether. Others again would claim that, relative to conventional treatments, chiropractic manipulations are extremely safe. You only need to search my blog using the search-term ‘chiropractic’ to find that there are considerable doubts about these assumptions:

  • Many chiropractors are not well trained and seem mostly in the business of making a tidy profit.
  • Some seem to have forgotten most of the factual knowledge they may have learnt at chiro-college.
  • There is no effective monitoring scheme to adequately record serious side-effects of chiropractic care.
  • Therefore the incidence figures of such catastrophic events are currently still anyone’s guess.
  • Publications by chiropractic interest groups seemingly denying this point are all fatally flawed.
  • It is not far-fetched to fear that under-reporting of serious complications is huge.
  • The reliable evidence fails to demonstrate that neck manipulations generate more good than harm.
  • Until sound evidence is available, the precautionary principle leads most critical thinkers to conclude that neck manipulations have no place in routine health care.

While some chiropractors now do admit that upper neck manipulations can cause severe problems, many of them simply continue to ignore this fact. It is therefore important, I think, to keep alerting both consumers and chiropractors to the risks of spinal manipulations. In this context, a new article seems relevant.

Danish doctors reported a critical case of bilateral vertebral artery dissection (VAD) causing embolic occlusion of the basilar artery (BA) in a patient whose symptoms started after chiropractic Spinal manipulative therapy (cSMT). The patient, a 37-year-old woman, presented with acute onset of neurological symptoms immediately following cSMT in a chiropractic facility. Acute magnetic resonance imaging (MRI) showed ischemic lesions in the right cerebellar hemisphere and occlusion of the cranial part of the BA. Angiography demonstrated bilateral VADs. Symptoms remitted after endovascular therapy, which included dilatation of the left vertebral artery (VA) and extraction of thrombus from the BA. After 6 months, the patient still had minor sensory and cognitive deficits.

The authors concluded that, in severe cases, VAD may be complicated by BA thrombosis, and this case highlights the importance of a fast diagnostic approach and advanced intravascular procedure to obtain good long-term neurological outcome. Furthermore, this case underlines the need to suspect VAD in patients presenting with neurological symptoms following cSMT.

I can already hear the excuses of the chiropractic fraternity:

  • this is just a case report,
  • the risk is very rare,
  • some investigations even deny any risk at all,
  • the risk of many conventional treatments is far greater.
However, these excuses are lame for a number of reasons:
  • as there are no functioning monitoring systems, nobody can tell with certainty how big the risk truly is,
  • the precautionary principle in health care compels us to take even the slightest of suspicions of harm seriously,
  • the risk/benefit principle compels us to ask whether the demonstrable benefits of neck manipulations outweigh its suspected risks.

The last point is perhaps the most important: AS FAR AS I CAN SEE, THERE IS NO INDICATION FOR NECK MANIPULATIONS FOR WHICH THE BENEFIT IS SUFFICIENTLY CERTAIN TO JUSTIFY ANY SUCH RISKS.

Hurray, I can hear the Champagne corks popping: this month is ‘National Chiropractic Months’ in the USA – a whole month! This has depleted my stock of the delicious fizz already in the first three days.

Now that my bottles are empty (is there a chiropractic cure for a hang-over?), I must find other ways to celebrate. How about a more sober look at what has been published in the medical literature on chiropractic during the last few days?

A quick look into Medline identifies several articles of interest. The very first one is a case-report:

Spinal epidural hematoma (SEH) occurring after chiropractic spinal manipulation therapy (CSMT) is a rare clinical phenomenon. Our case is unique because the patient had an undiagnosed cervical spinal arteriovenous malformation (AVM) discovered on pathological analysis of the evacuated hematoma. Although the spinal manipulation likely contributed to the rupture of the AVM, there was no radiographic evidence of the use of excessive force, which was seen in another reported case. As such, patients with a known AVM who have not undergone surgical intervention should be cautioned against symptomatic treatment with CSMT, even if performed properly. Regardless of etiology, SEH is a surgical emergency and its favorable neurological recovery correlates inversely with time to surgical evacuation.

This is important, I think, in more than one way. Many chiropractors simply deny that their manipulations cause serious complications of this nature. Yet such cases are being reported with depressing regularity. Other chiropractors claim that excessive force is necessary to cause the damage. This paper seems to refute this notion quite well, I think.

But let’s not be inelegant and dwell on this unpleasant subject; it might upset chiros during their month of celebration.

The next article fresh from the press is a survey – chiropractors are very fond of this research tool, it seems. It produced a lot of intensely boring data – except for one item that caught my eye: the authors found that ‘virtually all Danish chiropractors working in the primary sector made use of manipulation as one of their treatment modalities.’

Why is that interesting? Whenever I point out that there is no good evidence that chiropractic manipulations generate more good than harm, chiropractors tend to point out that they do so much more than that. Manipulations are not administered to all their patients, they say. This survey is a reminder (there is plenty more evidence on this issue) of the fact that the argument is not very convincing.

Another survey which has just been published in time for the ‘celebratory month’ is worth mentioning. It reports the responses of patients to questions about chiropractic by providing the ‘positive angle’, e.g.: ‘Most (61.4%) respondents believed that chiropractic care was effective at treating neck and back pain…’ Just for the fun of it, I thought it might be worth doing the opposite: 39% did not believe that chiropractic care was effective at treating neck and back pain… If we use this approach, the new survey also indicates that about half of the respondents did not think chiropractors were trustworthy, and 86% have not consulted a chiropractor within the last year.

Oh, so sorry – I did not mean to spoil the celebrations! Better move on then!

A third survey assessed the attitudes of Canadian obstetricians towards chiropractic. Overall, 70% of respondents did not hold a positive views toward chiropractic, 74% did not agree that chiropractic had a role in treatment of non-musculoskeletal conditions, 60% did not refer at least some patients for chiropractic care each year, and comments of the obstetricians revealed concerns regarding safety of spinal manipulation and variability among chiropractors.

And now I better let you get on with your well-deserved celebrations and look for another bottle!

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On this blog, we have repeatedly discussed the risks of acupuncture. Contrary to what we often hear, there clearly is potential for harm. Acupuncture is, of course most popular in China where it has been used for thousands of years. Therefore the Chinese literature, which is not easy to access for non-Chinese speakers and therefore often disregarded by Western researchers, might hold treasures of valuable information on the subject. It follows that a thorough review of this information might be helpful. A recent paper by Chinese scientists has tackled this issue.

The objective of this review was to determine the frequency and severity of adverse complications and events in acupuncture treatment reported from 1980 to 2013 in China. All first-hand case reports of acupuncture-related complications and adverse events that could be identified in the scientific literature were reviewed and classified according to the type of complication and adverse event, circumstance of the event, and long-term patient outcome. The selected case reports were published between 1980 and 2013 in 3 databases. Relevant papers were collected and analyzed by 2 reviewers.

Over the 33 years, 182 incidents were identified in 133 relevant papers. Internal organ, tissue, or nerve injury is the main complications of acupuncture especially for pneumothorax and central nervous system injury. Adverse effects also included syncope, infections, hemorrhage, allergy, burn, aphonia, hysteria, cough, thirst, fever, somnolence, and broken needles.

The authors of this review concluded that qualifying training of acupuncturists should be systemized and the clinical acupuncture operations should be standardized in order to effectively prevent the occurrence of acupuncture accidents, enhance the influence of acupuncture, and further popularize acupuncture to the rest of the world.

This is a bizarrely disappointing article followed by a most strange conclusion. The authors totally fail to discuss the most important issue and they arrive at conclusions which, I think, make little sense.

The issue to discuss here is, of course, under-reporting. We know that under-reporting in the Western literature is already huge. For every complication reported there could easily be 10 or even 100 that go unreported. There is no monitoring system for adverse effects, and acupuncturists have no incentive to publish their mistakes. Accurate and realistic prevalence data are therefore anybody’s guess.

In China, under-reporting is likely to be one or two orders of magnitude bigger. I say this because close to zero % of all Chinese papers on acupuncture report negative findings. For China, TCM is a huge export business, and the interest in reporting adverse effects is close to zero.

Seen from this perspective, it seems at first glance laudable that the Chinese authors dared to address this thorny issue. In the text of the article, they even mention that the included complications resulted in a total of 25 fatalities! This seems courageous. But one only needs to read the full article to get a strong suspicion that the authors are either in denial about the real figures, or their paper is a deliberate attempt to ‘white-wash’ acupuncture from its potential to do harm.

In 2010, we published a very similar review of the Chinese literature (unsurprisingly, it was not cited by the authors of the new paper). At the time, we found almost 500 published cases of serious adverse events and stated that we suspect that underreporting of such events in the Chinese-language literature is much higher than in the English-language literature.

The truth is that nobody knows how frequent adverse events of acupuncture truly are in China – or most other countries, for that matter. I believe that, before we “further popularize acupuncture to the rest of the world”, it would be ethical and necessary to 1) state this fact openly and 2) do something about it.

Much has been written on this blog and elsewhere about the risks of spinal manipulation. It relates almost exclusively to the risks of manipulating patients’ necks. There is far less on the safety of thrust joint manipulation (TJM) when applied to the thoracic spine. A new paper focusses on this specific topic.

The purpose of this review was to retrospectively analyse documented case reports in the literature describing patients who had experienced severe adverse events (AE) after receiving TJM to their thoracic spine.

Case reports published in peer reviewed journals were searched in Medline (using Ovid Technologies, Inc.), Science Direct, Web of Science, PEDro (Physiotherapy Evidence Database), Index of Chiropractic literature, AMED (Allied and Alternative Medicine Database), PubMed and the Cumulative Index to Nursing and Allied Health (CINHAL) from January 1950 to February 2015.

Case reports were included if they: (1) were peer-reviewed; (2) were published between 1950 and 2015; (3) provided case reports or case series; and (4) had TJM as an intervention. The authors only looked at serious complications, not at the much more frequent transient AEs after spinal manipulations. Articles were excluded if: (1) the AE occurred without TJM (e.g. spontaneous); (2) the article was a systematic or literature review; or (3) it was written in a language other than English or Spanish. Data extracted from each case report included: gender; age; who performed the TJM and why; presence of contraindications; the number of manipulation interventions performed; initial symptoms experienced after the TJM; as well as type of severe AE that resulted.

Ten cases, reported in 7 articles, were reviewed. Cases involved females (8) more than males (2), with mean age being 43.5 years. The most frequent AE reported was injury (mechanical or vascular) to the spinal cord (7/10); pneumothorax and hematothorax (2/10) and CSF leak secondary to dural sleeve injury (1/10) were also reported.

The authors point out that there were only a small number of case reports published in the literature and there may have been discrepancies between what was reported and what actually occurred, since physicians dealing with the effects of the AE, rather than the clinician performing the TJM, published the cases.

The authors concluded that serious AE do occur in the thoracic spine, most commonly, trauma to the spinal cord, followed by pneumothorax. This suggests that excessive peak forces may have been applied to thoracic spine, and it should serve as a cautionary note for clinicians to decrease these peak forces.

These are odd conclusions, in my view, and I think I ought to add a few points:

  • As I stated above, the actual rate of experiencing AEs after having chiropractic spinal manipulations is much larger; it is around 50%.
  • Most complications on record occur with chiropractors, while other professions are far less frequently implicated.
  • The authors’ statement about ‘excessive peak force’ is purely speculative and is therefore not a legitimate conclusion.
  • As the authors mention, it is  hardly ever the chiropractor who reports a serious complication when it occurs.
  • In fact, there is no functioning reporting scheme where the public might inform themselves about such complications.
  • Therefore their true rate is anyone’s guess.
  • As there is no good evidence that thoracic spinal manipulations are effective for any condition, the risk/benefit balance for this intervention fails to be positive.
  • Many consumers believe that a chiropractor will only manipulate in the region where they feel pain; this is not necessarily true – they will manipulate where they believe to diagnose ‘SUBLUXATIONS’, and that can be anywhere.
  • Finally, I would not call a review that excludes all languages other than English and Spanish ‘systematic’.

And my conclusion from all this? THORACIC SPINAL MANIPULATIONS CAN CAUSE CONSIDERABLE HARM AND SHOULD BE AVOIDED.

Proponents of alternative medicine regularly stress the notion that their treatments are either risk-free or much safer than conventional medicine. This assumption may be excellent for marketing bogus treatments, however, it neglects that even a relatively harmless therapy can become dangerous, if it is ineffective. Here is yet again a tragic reminder of this undeniable fact.

Japanese doctors reported the case of 2-year-old girl who died of precursor B-cell acute lymphoblastic leukaemia (ALL), the most common cancer in children.

She had no remarkable medical history. She was transferred to a hospital because of respiratory distress and died 4 hours after arrival. Two weeks before her death, she had developed a fever of 39 degrees C, which subsided after the administration of a naturopathic herbal remedy. One week before death, she developed jaundice, and her condition worsened on the day of death.

Laboratory test results on admission to hospital showed a markedly elevated white blood cell count. Accordingly, the cause of death was suspected to be acute leukaemia. Forensic autopsy revealed the cause of death to be precursor B-cell ALL.

With the current advancements in medical technology, the 5-year survival rate of children with ALL is nearly 90%. However, in this case, the child’s parents had opted for naturopathy instead of evidence-based medicine. They had not taken her to a hospital for a medical check-up or immunisation since she was an infant. If the child had received routine medical care, she would have a more than 60% chance of being alive 5 years after diagnosis of ALL.

The authors of this case-report concluded that the parents should be accused of medical neglect regardless of their motives.

Such cases are tragic and infuriating in equal measure. There is no way of knowing how often this sort of thing happens; we rely entirely on anecdotes because systematic research is hardly feasible.

While anecdotes of this nature have their obvious limitations, they are nevertheless important. They can serve as poignant reminders that alternative remedies might be relatively harmless, but this does not necessarily apply to all alternative practitioners. Moreover, they should make us redouble our efforts to inform the public responsibly about the all too often trivialized risks of alternative medicine.

If you ask a chiropractor, you will probably be told that chiropractic spinal manipulation is a safe treatment. Unfortunately this is not quite true, as regular readers of this blog will appreciate. About half of all patients suffer mild to moderate adverse effects after chiropractic treatments and, in addition, many instances of much more serious complications have been documented, including rare cases of Horner syndrome. It results from an interruption of the sympathetic nerve supply to the eye and is characterized by the classic triad of miosis (ie, constricted pupil), partial ptosis, and loss of hemifacial sweating (ie, anhidrosis).

Danish neurologists recently reported the case of a 60-year-old man with no relevant medical history who was admitted to the Department of Neurology with drooping of his right upper eyelid and an ipsilateral contracted pupil, combined with pain, weakness, and numbness in his upper right limb.

The patient had experienced thoracic back pain of moderate intensity with radiating right-sided belt-like chest pain for 7 days. When the discomfort suddenly intensified, he sought chiropractic treatment. Following manipulations of the thoracic and cervical spine, the pain intensity initially lessened. Approximately one hour after chiropractic treatment, the patient experienced the eye and upper limb symptoms described above, for which he sought medical assistance three days later.

A detailed neurologic examination revealed moderate right-sided ptosis and miosis, no facial anhidrosis, decreased strength of the intrinsic and opponens muscles of the right hand, and reduced cutaneous sensation corresponding to the T1 dermatome, with inability to discriminate pain and light touch. The remaining clinical examination, routine blood tests, and vital parameters were unremarkable.

Brain CT scan and CT angiography including the aortic arch and neck vessels were performed and ruled out cerebral stroke and carotid artery dissection, respectively. As clinical signs of Horner syndrome and a concomitant radiating pain to the medial arm were considered suggestive of either a lower brachial plexopathy, i.e., due to a Pancoast tumor, or a radiculopathy, chest X-ray and electroneurography (ENG) were performed. No apical pulmonary pathology was detected. ENG of the right medial cutaneous antebrachial nerve demonstrated a normal sensory action potential (SAP), consistent with the lesion being located proximally to the dorsal spinal root ganglion, thus suggestive of a spinal nerve root lesion. A subsequent MRI of the thoracic spine showed a para-median herniation of the T1-T2 intervertebral disc compressing the right T1 spinal nerve root.

The patient received no surgery, and follow-up examination 6 months later revealed near-complete recovery, with only mild paraesthesia in the T1 segment of his right arm and a subtle ptosis remaining.

Horner syndrome due to a herniated thoracic disc has only been reported 6 times in the English language literature, though never preceded by chiropractic manipulation.

One of the most frequent causes of Horner syndrome is carotid artery dissection, which may occur spontaneously or due to local trauma to the neck region. Chiropractic manipulation as an independent risk factor for neck artery dissection and a consequent stroke is a controversial topic, though multiple cases of Horner syndrome due to ICA dissections subsequent to chiropractic manipulation have been reported. In the patient described here, an ICA dissection was considered unlikely due to the concomitant prominent radiating medial brachialgia and was furthermore ruled out by a CT angiogram of the neck vessels.

This patient experienced the onset of a Horner syndrome and ipsilateral upper limb symptoms shortly after chiropractic treatment, suggesting the cervico-thoracic manipulation as the cause of or at least worsening factor in the T1-T2 disc herniation. Several cases of disc herniations following chiropractic treatment have been reported.

While the definite pathophysiologic mechanism to explain this patient’s Horner syndrome remains unclear, it seems, according to the authors of this case-report, evident that manipulations as a minimum altered the configuration of an already existing disc protrusion.

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