Upper Cervical Manipulation in a Patient with Osteoporosis and a Prior TIA
Dr. Marcus L. treats a 68-year-old woman with 3 weeks of neck pain. Her intake notes list osteoporosis (T-score −2.8), warfarin use, and a transient ischemic attack two years ago. Dr. L. performs a high-velocity, low-amplitude rotational manipulation of the upper cervical spine. He does not discuss the risk of vertebral artery injury, alternatives such as gentle mobilization, or the option to refer. His note reads: 'CC: neck pain. TX: adjust. Pt tolerated well.' Two days later the patient is hospitalized with a vertebral artery dissection. Her daughter files a Board complaint alleging she was never told of the risks. Dr. L. says, 'Adjustments are routine; consent is implied.' The patient's INR was 3.1 on the day of treatment.
1. Did Dr. L. obtain valid informed consent? Explain.
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No. Informed consent for a high-velocity upper cervical manipulation requires a discussion of material risks-including vertebral artery injury-benefits, alternatives (e.g., gentle mobilization, referral, medication management), and the opportunity to ask questions, followed by the patient's agreement.
'Implied consent' may cover routine touching or emergency care, not a procedure with known serious risks in a patient with osteoporosis, warfarin use, an INR of 3.1, and a prior TIA. Dr. L.'s statement that 'adjustments are routine' does not satisfy the standard. The consent discussion should be documented, including the risks discussed and the patient's questions.
A reasonable patient in this position would likely consider vertebral artery injury and bleeding risk material. The absence of any documented discussion supports the daughter's complaint.
2. How does the documentation affect the Board's review and any malpractice defense?
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The note 'CC: neck pain. TX: adjust. Pt tolerated well' is inadequate. It does not record the risk factors, the consent discussion, the technique used, the patient's response beyond 'tolerated well,' or any post-treatment instructions.
In a Board review or malpractice case, the absence of documentation makes it difficult to rebut the patient's claim that risks were never discussed. The Board may infer that no informed consent occurred. Dr. L. should not add late entries as if made contemporaneously; he may add a clearly dated addendum if appropriate, but the original record must remain intact.
He should also document the INR, his consideration of alternatives, and any communication with the patient's prescribing physician. Poor documentation can turn a defensible clinical judgment into an indefensible record.
3. What standard-of-care and disciplinary issues arise from treating a patient with these risk factors?
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The standard of care requires a chiropractor to recognize contraindications and modify or decline treatment when risk factors are present, or refer for medical evaluation. Osteoporosis, anticoagulation with an INR of 3.1, and prior TIA are material risk factors for cervical manipulation. The Board may evaluate whether Dr. L. performed an adequate history, considered alternatives, and used an appropriate technique.
If expert review shows a departure from the standard, the Board may allege gross or repeated negligence, failure to keep adequate records, and unprofessional conduct. Dr. L. should expect an investigation, a chance to respond, and possible sanctions such as reprimand, probation, suspension, or additional education. He should obtain counsel and preserve all records.
He should also consider whether the patient's hospitalization triggers any reporting obligation and whether his malpractice insurer requires notice.