MD, PhD, MAE, FMedSci, FRSB, FRCP, FRCPEd.

Spinal cord injury after manual manipulation of the cervical spine is rare and has never been described as resulting from a patient performing a self-manual manipulation on his own cervical spine. This seems to be the first well-documented case of this association.

A healthy 29-year-old man developed Brown-Sequard syndrome immediately after performing a manipulation on his own cervical spine. Brown-Sequard syndrome is characterized by a lesion in the spinal cord which results in weakness or paralysis (hemiparaplegia) on one side of the body and a loss of sensation (hemianesthesia) on the opposite side.

Imaging showed large disc herniations at the levels of C4-C5 and C5-C6 with severe cord compression. The patient underwent emergent surgical decompression. He was discharged to an acute rehabilitation hospital, where he made a full functional recovery by postoperative day 8.

The authors concluded that this case highlights the benefit of swift surgical intervention followed by intensive inpatient rehab. It also serves as a warning for those who perform self-cervical manipulation.

I would add that the case also serves as a warning for those who are considering having cervical manipulation from a chiropractor. Such cases have been reported regularly. Here are three of them:

A spinal epidural hematoma is an extremely rare complication of cervical spine manipulation therapy (CSMT). The authors present the case of an adult woman, otherwise in good health, who developed Brown-Séquard syndrome after CSMT. Decompressive surgery performed within 8 hours after the onset of symptoms allowed for complete recovery of the patient’s preoperative neurological deficit. The unique feature of this case was the magnetic resonance image showing increased signal intensity in the paraspinal musculature consistent with a contusion, which probably formed after SMT. The pertinent literature is also reviewed.

Another case was reported of increased signal in the left hemicord at the C4 level on T2-weighted MR images after chiropractic manipulation, consistent with a contusion. The patient displayed clinical features of Brown-Séquard syndrome, which stabilized with immobilization and steroids. Follow-up imaging showed decreased cord swelling with persistent increased signal. After physical therapy, the patient regained strength on the left side, with residual decreased sensation of pain involving the right arm.

A further case was presented in which such a lesion developed after chiropractic manipulation of the neck. The patient presented with a Brown-Séquard syndrome, which has only rarely been reported in association with cervical epidural hematoma. The correct diagnosis was obtained by computed tomographic scanning. Surgical evacuation of the hematoma was followed by full recovery.

Brown-Séquard syndrome after spinal manipulation seems to be a rare event. Yet, nobody can provide reliable incidence figures because there is no post-marketing surveillance in this area.

33 Responses to Brown-Sequard syndrome after upper spinal manipulation

  • Aaaaand que in our resident DC claiming the patient was no chiropractor! 😀

    • LOL yes or possibly distracting, sorry, drawing attention to the side effects of paracetamol as ‘context’.

    • Well, the pertinent question is: would most chiropractors have performed the cervical manipulation and/or in the manner in which he did and would the outcome have been the same?

  • If one reads the cases where enough information is provided it appears, in most cases, there were contraindications to the manipulation (and/or poor technique) which was associated with the serious AE.

    “Of the 134 cases, 60 (44.8%) were categorized as preventable, 14 (10.4%) were unpreventable and 60 (44.8%) were categorized as ‘unknown’.” February 2012 The Journal of manual & manipulative therapy 20(2):66.

    • You should try to provide a link to your references DC. Here, let me help you:

      https://www.tandfonline.com/doi/full/10.1179/2042618611Y.0000000022

      You should also try to consider the whole story, not just copy the part you think supports what you want to be true.
      All things considered, in reality 100% of these cases were preventable, taking into account that cervical spinal manipulation has not been shown to have any demonstrable inherent efficacy but demonstrable risks and should therefore never be used, especially not in patients with symptoms from the head and neck. Concurrent vascular or disc lesionsand other conditions, which may be aggravated by csm, can never be ruled out.

      • I provided information on the topic, which is AE.

        • Is death an AE?

          You omitted: “Death resulted in 5·2% (n = 7) of the cases, mostly caused by arterial dissection.”

          • But did the cSMT cause the dissection or was it pre-existing?

          • As Björn Geir said to ‘DC’:

            You should also try to consider the whole story, not just copy the part you think supports what you want to be true.

            All things considered, in reality 100% of these cases were preventable, taking into account that cervical spinal manipulation has not been shown to have any demonstrable inherent efficacy but demonstrable risks and should therefore never be used, especially not in patients with symptoms from the head and neck. Concurrent vascular or disc lesionsand other conditions, which may be aggravated by csm, can never be ruled out.

          • But did the cSMT cause the dissection or was it pre-existing?

            Why do you ask? Such a question cannot be answered after the fact like in this case and so many other. What is known here is that following cervical manipulation a patient succumbed to the complications of cervical artery injury.
            Here is a question that can be answered based on current state of knowledge.
            Any patient with non specific neck/head pain may have a pre-existing arterial lesion. There is no clinical test that can rule this out without special imaging techniques and the signs and symptoms of such a condition are often very subtle and non-specific. Anyone with such symptoms may also have healthy vessels. Neck manipulation of any kind in a patient with pre-existing arterial lesion may dislodge a clot or cause dissection in a vessel that otherwise would have had the chance to heal. Do you think that csm is indicated when pre existing arterial lesion has not been ruled out?

          • Bjorn: I understand your point of view. I don’t even disagree with you on some/most of your points.

            However, how about we cut to the end.

            The only feasible way I can see to cause a potential shift in policy or procedure change (at least within chiropractic) regarding cSMT and VAD/stroke is via quality research. That is the reality.

            I have had many conversations with researchers, DCs, MDs, DOs, etc over the years on this topic. I think I have a good grasp on the current evidence and the barriers to further research said topic.

            It’s one of the reasons i recently submitted a research proposal on the general topic (the importance which could extend well beyond cSMT).

            I think the impression within this group is that I don’t care or downplay the topic. The former is far from the truth. I do however look at the current evidence and, in spite of its gaps, it is what current policy and procedures are based upon (kind
            of, in part).

            Now this blog is not solution oriented nor do I expect it to be. But I could get into feasibility of Doppler US, HINTs, ocular exam, etc, but again, quality research is lacking just as quality research is lacking on potential benefits (the other half).

            Now I anticipate someone picking something out of the above comments and make it into something it’s not or bashing chiropractors, whatever. After 20 plus years of dealing with skeptics and skeptic wannabes I doubt it will be anything new to me and honestly replying to such cheap shots isn’t worthy of my time (Pete).

            Regardless, Bjorn, I have always appreciated and respected your views and insights. Take care.

          • Note to ‘DC’: I particularly dislike the quacks who risk putting people in wheelchairs, even killing people, by using theatrical placebos to line their pockets.

            “However, how about we cut to the end.”

            Good idea:
            STOP USING CERVICAL SPINE MANIPULATION FORTHWITH, BECAUSE THE TOTALITY OF EVIDENCE DOES NOT SHOW THAT THE BENEFITS OUTWEIGH THE RISKS.

            Björn Geir wrote “Any patient with non specific neck/head pain may have a pre-existing arterial lesion.”

            A chiropractor is not medically qualified to diagnose any actual medical condition, let alone a pre-existing arterial lesion.

          • Pete: A chiropractor is not medically qualified to diagnose any actual medical condition

            Diagnosis: the making of a judgment about the exact character of a disease or other problem, esp. after an examination, or such a judgment (Cambridge)

            “Chiropractic physicians use diagnostic tests and procedures and are authorized to make and interpret radiographs (x-rays) in all jurisdictions. Most states also allow D.C.s to order and interpret magnetic resonance imaging (MRI) and computed tomography (CT) examinations. Doctors of chiropractic are trained to do phlebotomy (draw blood) and to interpret blood and serum chemistry tests, obtain swabs for microbial culture and other clinical laboratory procedures; most states allow for these laboratory procedures under the chiropractic law. Some states allow chiropractic physicians to order and/or perform other diagnostic procedures such as electromyography (EMG), electrocardiography (ECG or EKG), positron emission tomography (PET), bone scan, sonography (ultrasound), and other tests. Gender specific diagnostic procedures and examinations such as prostate exams, pelvic exams, Papanicolaou tests and breast exams are permitted in many jurisdictions. Details regarding the specific allowances in each state are determined by law, regulation or board ruling.” http://www.discoverchiropractic.org/pdf/Chiropractic-physician-scope-and-practice.pdf

            Interpret: to describe the meaning of something; examine in order to explain: (Cambridge)

            Now please step aside and let the adults talk.

          • ‘DC’ has been posting comments on this website, for several years, because chiropractic is a branch of SCAM (and it is characterized as pseudoscience); it is not a branch of medicine.

            A DC degree is a means of pretending to be a doctor, to gain a modicum of the “prestige” and societal recognition these frauds think they so richly deserve but with none of the real leg work.
            — Michael Kenny
            https://edzardernst.com/2018/07/the-royal-college-of-chiropractics-pathetic-attempt-at-re-inventing-chiropractic/#comment-104686

            An anonymous nymshifting sock puppet, ending their comment with “Now please step aside and let the adults talk.” is pathetic.

            I might be mistaken but DC systematically tries to distract from the fact that chiropractic does not generate more good than harm and that there is a continuous flow of evidence suggesting it does, in fact, the exact opposite. He (I presume he is male) might not even do this consciously in which case it would suggest to me that he is full of quasi-religious zeal and unable to think critically about his own profession and creeds.
            https://edzardernst.com/2022/04/comments-by-a-chiropractor-insights-into-quasi-religious-zeal/

          • As I wait to see if Bjorn responds to my comments to him….

            Pete: DC’ has been posting comments on this website, for several years,

            True, not sure how long it’s been

            Pete: because chiropractic is a branch of SCAM

            True in that chiropractic is typically considered a complementary health profession.

            Pete: (and it is characterized as pseudoscience);

            Some of chiropractic, or more specifically what some chiropractors claim, can be classified as pseudoscience.

            Pseudoscience: a system of thought or a theory that is not formed in a scientific way (Cambridge).

            Pete: it (chiropractic) is not a branch of medicine.

            True. Complementary health professions are not considered a “branch of medicine” that’s why they are called complementary.

          • Pete: it (chiropractic) is not a branch of medicine.
            True. Complementary health professions are not considered a “branch of medicine” that’s why they are called complementary.

            Therefore, as Pete mentioned earlier:

            A chiropractor is not medically qualified to diagnose any actual medical condition

          • R. It hinges on what he means by “medically qualified”.

            If he means that chiropractors aren’t qualified because they weren’t educated in a medical school, that means PTs, dentists, osteopaths, etc also aren’t “medically qualified.”

            If that is his point, it’s a silly and superficial statement. Something I’ve come to expect from Pete and I have no interest is the laborious journey of attempting to determine what he meant.

          • DC,

            When someone criticizes chiropractic, rather than addressing the criticism, you often respond with “what about so and so profession…”. Just an observation, that is all.

          • ‘DC’ to Björn: “I provided information on the topic, which is AE.”

            Pete to ‘DC’: “Is death an AE? You omitted: ‘Death resulted in 5·2% (n = 7) of the cases, mostly caused by arterial dissection.’”

            ‘DC’ to Pete: “But did the cSMT cause the dissection or was it pre-existing?”

            Pete to ‘DC’:
            QUOTE
            Björn Geir wrote “Any patient with non specific neck/head pain may have a pre-existing arterial lesion.”

            A chiropractor is not medically qualified to diagnose any actual medical condition, let alone a pre-existing arterial lesion.
            END of QUOTE

            So, who is responsible for:
            • diagnosing a pre-existing arterial lesion?
            • any AEs, including death, following spinal manipulation by a chiropractor?

            I specifically wrote “by a chiropractor” because the sock puppet ‘DC’ is impersonating a chiropractor in this thread, and ‘DC’ provided a long list of diagnostics in the paragraph starting “Chiropractic physicians use diagnostic tests and procedures…“.

            Professor Ernst has highlighted the tragedy that can, and sadly does, result from patients who mistake chiropractors for physicians.

            On Saturday 02 April 2022 at 16:58, I wrote:
            QUOTE
            @ ‘DC’, You are off-topic, and wrong.

            Is a chiropractor qualified and licenced, to diagnose and treat an actual medical condition, such as a herniated disc?

            No, doing so would be (depending on jurisdiction):
            • practising medicine without a medical licence
            • health fraud
            • medical fraud
            • quackery

            A note for the readers:

            If you are in doubt who to trust, the promoter or the critic of chiropractic, I suggest you ask yourself a simple question: who is more likely to provide impartial information, the chiropractor who makes a living by his trade, or the academic who has researched the subject for the last 30 years?”
            — Chiropractic: Not All That It’s Cracked Up to Be, by Edzard Ernst

            https://edzardernst.com/2022/03/lumbar-disc-herniation-treated-with-scam-10-year-results-of-an-observational-study/#comment-138482
            END of QUOTE

          • RD: When someone criticizes chiropractic, rather than addressing the criticism, you often respond with “what about so and so profession…”. Just an observation, that is all.

            Yes, I do that at times.

            I am more than capable of criticizing chiropractic (better than most here), it is just that many others here already do that so what benefit is it if I just repeat what they say?

            As a healthcare provider I have to consider the various options for my patients. That means looking at the strengths and weaknesses of other approaches by other professions. Granted, that is not the purpose of this blog but I think it’s a more balanced approach when making healthcare decisions and the readers of this blog should be made aware of the limitations of those approaches as well so they can make an informed decision.

          • “I am more than capable of criticizing chiropractic (better than most here)”
            And by Jove, I am not pompous!

          • Pete: Is a chiropractor qualified and licenced, to diagnose and treat an actual medical condition, such as a herniated disc?

            Is a Physical Therapist?

            “The majority of herniated disks do not require surgery, and respond best to physical therapy. Physical therapists design personalized treatment programs to help people with herniated disks regain normal movement, reduce pain, and get back to their regular activities.” https://www.choosept.com/guide/physical-therapy-guide-herniated-disk

          • “I am more than capable of criticizing chiropractic (better than most here)”
            And by Jove, I am not pompous!

            Reality.

            Having had discussions and debates across the continuum of the profession for the past 20 plus years.

            Having been to chiropractors, across the spectrum of treatments, for the past 50 years.

            So yes, looking at this from the inside allows me a better perspective than those who rely on Google.

          • you seem to me like an absurd caricature of a man who thinks he can identify reality

          • DC says:

            I am more than capable of criticizing chiropractic (better than most here), it is just that many others here already do that so what benefit is it if I just repeat what they say?
            Having had discussions and debates across the continuum of the profession for the past 20 plus years.
            Having been to chiropractors, across the spectrum of treatments, for the past 50 years.
            So yes, looking at this from the inside allows me a better perspective than those who rely on Google.

            Granted, that is not the purpose of this blog but I think it’s a more balanced approach…

            DC,

            In that case, we should absolutely hear your criticisms of chiropractic. A Chiropractor’s criticism certainly adds to the discussion. As you said it yourself, you have a better perspective and that makes you a better critic of chiropractic than most people here. I have been following this blog for a few years now; I haven’t seen many chiropractors (those who clearly identify as one) commenting here as often as you do. Therefore, I doubt you’d be repeating yourself.

            It comes off as disingenuous when you often resort to whataboutism (in the name of “balanced approach”) while claiming that you have a better perspective with regards to criticizing chiropractic.

          • From six years ago, when ‘DC’ was ‘Doc Dale’ (amongst other nyms):

            EE to DD: “please explain”

            DD: “Doesn’t matter. In my twenty plus years of discussions with chiro skeptics I’ve only come across one that I consider truly objective in his analysis. It appears no one here has reached that level. I’ll continue my search for such people elsewhere.”

            EE: “I am so glad I found someone who claims to be able to judge who is and who isn’t objective.
            my congratulations!”

            DD: “It’s not that hard to determine if someone is honestly striving to be objective.”

            And:

            Björn Geir: “Yes. We all know the levels of absurdity health care has reached in many US hospitals and institutions. We can also easily see that the infestation of chiropractic over there has not contributed to the general state of health. It seems we constantly have to remind our stateside commenter friends and trolls that the world is much bigger than the US. If Dale who thinks he’s a Doc had read my comment with an open mind, he would have noted that I said the ‘world over’.

            Chiropractic is actually a rare distraction if you count globally.
            It seems the majority of mankind can very well do without it 😉”

            DD: “bG: If Dale who thinks he’s a Doc had read my comment with an open mind, he would have noted that I said the ‘world over’.

            I know what you wrote.

            Apparently you are not open to an intelligent discussion…looks to be par for the so-called skeptics on EE blog. Take care.”

            EE: “don’t you just love it when a so-called doc calls you a so-called sceptic?”

            Six years of this arrogant sh1te. Good grief!

          • Ernst: you seem to me like an absurd caricature of a man who thinks he can identify reality

            reality: the state of things as they are, rather than as they are imagined to be (Cambridge)

            I don’t have to imagine.

  • On a related note.
    I stumbled upon this frightful history:

    https://web.archive.org/web/20141113073606/https://scottslockedin.com/Book_Details.html

    tonight and bought the Kindle version of Scott’s book on Amazon.
    As I have so often pointed out, if cervical manipulation was a drug, it would have been removed from the market long ago.

    • Were there contraindications to the second adjustment? Yes, it appears so, based on the information given in that story.

      • From the same source that ‘DC’ quoted on Tuesday 12 April 2022 at 12:07:

        Conclusions

        This review showed that, if all contraindications and red flags were ruled out, there was potential for a clinician to prevent 44·8% of AEs associated with CSM. Additionally, 10·4% of the events were unpreventable, suggesting some inherent risk associated with CSM even after a thorough exam and proper clinical reasoning. [my emphasis]

        • “In fact, most medical injuries are the result either of the inherent risk in the practice of medicine, or due to system errors,…” Int J Gen Med. 2013; 6: 49–56.

          • An interesting reference there, DC, but not for the relevance you seem to find in it.
            You forgot again to provide a proper internet link:
            https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3576054/

            If you want to quote this paper, I think this one is way more relevant to the ongoing discussion of the seriously questionable risk/benefit ratio of cervical spinal manipulation and the chiropractic community’s attitude towards the safety issues raised:

            Rather than being motivated by money, most health care practitioners tend to be motivated by professional or moral ideals to deliver high quality care and to “do no harm.”

          • Sure, we could get into the differences of inherent risks. However, my main interest from this paper is two fold.

            1. There appears to a need to better educate those who perform cSMT on the contraindications to cSMT. This could potentially prevent a majority of cases. Such education crosses all professions who use cSMT.

            2. Some of those cases that were considered unpreventable may not always be unpreventable. There may be risks factors that have yet to be discovered. That was the basis of my research proposal.

            We both understand the problems but I suspect we differ on the solutions.

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