New Dizziness and Diplopia After Cervical Adjustment
Danielle R., age 42, presents for a third visit for cervicogenic headaches. She has no prior vascular history, but she reports a new “whooshing” sound in her left ear and brief visual sparkles before today’s treatment. Dr. M. performs a high-velocity, low-amplitude cervical manipulation at C1–C2. Within 25 minutes, Danielle has a severe occipital headache, dizziness, diplopia, nausea, and left facial numbness. Blood pressure is 148/92; heart rate 96; she has horizontal nystagmus. Dr. M. has no written emergency protocol. He applies ice, tells her to “rest and return in two days,” and does not document the new symptoms or the manipulation. That night she calls reporting worse symptoms; he advises “give it a week.” She goes to an emergency department, where imaging shows a vertebral artery dissection. The Board later receives a complaint from her family. Dr. M.’s chart contains a signed general consent from the first visit, a one-line note for the third visit (“cervical adjustment, tolerated well”), and no referral note.
1. What should Dr. M. have done when the new symptoms appeared during and after the manipulation, and why do the earlier “whooshing” and visual symptoms matter?
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Dr. M. should have stopped and treated this as a medical emergency. New severe occipital headache, diplopia, facial numbness, nystagmus, and dizziness after cervical manipulation are red flags for vertebral artery dissection or another neurovascular injury. The pre-treatment whooshing and visual sparkles were warning symptoms that warranted deferring manipulation and screening first. The correct action is to activate emergency medical services or arrange immediate emergency department transfer, not ice and a return appointment. He should not perform further manipulation. He should document the time symptoms began, vital signs, neurologic findings, the manipulation performed, and the transfer. Advising the patient to “give it a week” after worsening symptoms is below the standard of care and exposed her to stroke risk. The Board will ask whether he recognized red flags, whether he had an emergency protocol, and whether his advice delayed care.
2. Analyze Dr. M.’s scope-of-practice and referral/co-management obligations once dissection was suspected. Could he continue chiropractic care?
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Ohio chiropractic scope includes diagnosis and chiropractic treatment, but it does not include managing a suspected arterial dissection or an acute neurovascular emergency. Once dissection is suspected, Dr. M.’s obligation is to refer emergently and co-manage with emergency medicine and neurology; cervical manipulation is contraindicated. Even before the event, the new vascular symptoms should have prompted a referral or clearance before any cervical manipulation. He should communicate with the emergency department and document the referral. Continuing care or “watchful waiting” would exceed his scope and breach the referral and co-management duty. The Board evaluates whether the licensee obtained appropriate consultation, made a timely referral, and avoided treatment outside his competence. If he wanted to remain involved, he could provide co-management only after the emergency physician cleared the patient and only for musculoskeletal issues, with clear communication.
3. What documentation and Board-reporting consequences follow? Identify what should be in the record and what the Board will likely examine.
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The record should contain a full initial history, vascular screening, informed-consent discussion, the specific manipulation, immediate post-treatment findings, vital signs, the emergency assessment, and the referral or transfer. The one-line note and missing referral note are serious documentation failures. The signed general consent from visit one does not prove informed consent for the specific cervical manipulation or its risks. The Board will examine the chart for red-flag documentation, consent, and follow-up. It may also consider whether Dr. M. made false or misleading statements to the patient and whether he cooperated with the investigation. An adverse event is not necessarily a disciplinary violation by itself, but failure to recognize, refer, document, and communicate can support gross negligence or incompetence charges. The Board could seek records, interview the patient, and use expert review.