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Onset of complications following cervical manipulation due to malpractice in osteopathic treatment: A

case report
Michela Cicconi, Tatiana Mangiulli and Giorgio Bolino
Med Sci Law published online 8 January 2014
DOI: 10.1177/0025802413513451

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Med Sci Law OnlineFirst, published on January 8, 2014 as doi:10.1177/0025802413513451

Case report

Medicine, Science and the Law

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Onset of complications following cervical ! The Author(s) 2014
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DOI: 10.1177/0025802413513451

osteopathic treatment: A case report msl.sagepub.com

Michela Cicconi1, Tatiana Mangiulli1 and Giorgio Bolino1

Abstract
The aim of this study is to correlate cervical disc herniation with manipulation performed by a non-physician osteopath
on a patient complaining of neck pain. The authors report a case in which a woman treated with osteopathic spinal
manipulation developed cervical-brachial neuralgia following the cervical disc herniation. The patient then underwent
surgery and was followed by physiotherapists. A clinical condition characterized by limitation of neck mobility, with pain
and sensory deficit in the right arm and IIIII fingers, still persists. The patient consulted the authors to establish whether
cervical disc herniation could be attributed to manipulation. Adverse events or side effects of spinal manipulative therapy
are relatively common and usually benign. Most of these side effects are mild or moderate, but sometimes they can be
severe. Cervical manipulation can provoke complications less often than thoracic or lumbar manipulation. Furthermore,
many diseases can be absolutely and relatively contraindicated to osteopathic treatment. Therefore, the knowledge of a
patients clinical conditions is essential before starting a manipulative treatment; otherwise the osteopath could be
accused of malpractice. It is the authors opinion that a causeeffect relationship exists between the manipulative
treatment and the development of disc herniation.

Keywords
complications to manipulation, disc herniation, malpractice, osteopathic manipulation treatment, osteopathy

regulated by statutes and practice requires registration

Introduction at the relevant regulatory authority. In the European
Osteopathy is a philosophy and an alternative medical Union, there is no universal regulatory authority for
practice which emphasizes the interrelationship the practice of osteopathy or osteopathic medicine; it
between structure and functioning of the body, recog- is up to the country. For example, in Austria and
nizing the bodys ability to heal itself; the role of the Switzerland, osteopathic practitioners are doctors or
osteopath is to facilitate that process, mainly by prac- physiotherapists who attend additional courses in
tising manual and manipulative therapies. osteopathy after completing their medical or practical
The osteopathic medical philosophy is dened as therapy training; in France, osteopathy is a govern-
the concept of healthcare that embraces the idea of mentally recognized profession (Decree 2007-435
the unity of the living organisms structure (anatomy) relating to the acts and exercises conditions of oste-
and its functioning (physiology). According to the opathy). In Italy, osteopathic medicine is not recog-
Glossary of osteopathic terminology of the nized by the national health system; the related
AACOM (American Association of Colleges of training courses are organized by universities through
Osteopathic Medicine), the following are the four postgraduate Masters or by private associations.
major principles of osteopathic medicine. (1) The There are no ocial public registers of osteopaths.
body is a unit; an integrated unit of mind, body and A key part of osteopathic medicine is a technique
spirit.1 (2) The body possesses self-regulatory mech- called Osteopathic Manipulative Treatment (OMT).
anisms, having the inherent capacity to defend, repair
and remodel itself. (3) Structures and functions are
1
reciprocally interrelated. (4) Rational therapy is Department of Anatomic, Histologic, Medical-Legal Sciences and of
based on consideration of the rst three principles. Locomotor System, Rome University Sapienza, Rome, Italy
The regulation of non-physician manual medicine
Corresponding author:
for osteopaths varies greatly according to jurisdic- Michela Cicconi, University Sapienza, Viale Regina Elena, 336-00161
tions. In Australia, the UK and New Zealand, the Rome, Italy.
non-physician manual medicine osteopaths are Email: michelacicconi@gmail.com

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2 Medicine, Science and the Law 0(0)

There are many treatment techniques; OMT methods Because of the persistence of the symptoms, the
utilized may broadly be classied as follows: active woman consulted an orthopaedic surgeon who ordered
method (a technique in which the person voluntarily a magnetic resonance imaging (MRI) and addressed
performs a motion directed by the osteopathic prac- her to a neurosurgeon. The MRI, performed on 21
titioner); passive method (based on techniques in May 2012, revealed at C6C7 level an interruption of
which the patient refrains from voluntary muscle con- subarachnoid spaces (due to a right posterolateral disc
traction); direct method (an osteopathic treatment herniation pushing back the spinal cord) and protru-
strategy by which the restrictive barrier is engaged sion of the C4C5 and C5C6 discs (Figure 1).
and a nal activating force is applied to correct som- The MRI was reviewed by the orthopaedic surgeon
atic dysfunction); and indirect method (a manipula- who, agreeing with the neurosurgeon, prescribed ther-
tive technique where the restrictive barrier is apy with corticosteroids and recommended anterior
disengaged and the dysfunctional body part is cervical microdiscectomy and positioning, and solid
moved away from the restrictive barrier until tissue xation of the implant (intervertebral disc spacers).
tension is equal in one or all planes and directions). The patient underwent surgery on 25 May 2012;
Recent research has found that spinal manipula- she was then followed by physiotherapists, and was
tion provides relief from neck2 and lower-back prescribed a neck brace (Zimmer) for six weeks. An x-
pain3; in fact, the American College of Physicians ray of the cervical spine performed on 4 June 2012
and the American Pain Society included it as an alter- showed a correct positioning of vertebral implant
native to conventional treatments in their 2007 guide- and loss of cervical lordosis. She then began cervical
lines. Additionally, US osteopathic physicians and stabilization training, consisting of exercises designed
academic researchers have conducted preliminary to train co-contraction of the cervical and scapular
research to determine the ecacy of manual tech- muscles to promote improved stability. She was fol-
niques to manage or co-manage conditions such as lowed up to four weeks later.
asthma4 and acute otitis media in children.5 The patient conferred with the authors on 30 July
The use of spinal manipulation has increased 2012 to assess whether disc herniation had been pre-
everywhere over the past decades and it is one of cipitated by cervical manipulation. At the examin-
the most frequently reported complementary and ation, the authors found restriction of neck motion
alternative medicine modalities,6,7 in part because (exion and extension, rotation and lateral bending
there is a public perception that spinal manipulation limited at ) with pain and sensory decit in the
is risk-free. However, this treatment appears to be
associated with vascular and neurological complica-
tions. The most frequent complication is stroke, usu-
ally related to vertebral dissection, occurring during
or shortly after cervical manipulation; spinal disc her-
niation with spinal cord compression, radiculopathy
or cauda equina syndrome and other complications
such as meningeal hematoma and diaphragmatic par-
alysis8 are far less frequent.

Case
A 33-year-old woman, who consulted the osteopath
on 17 May 2012, complaining of neck pain, received a
treatment that included cervical spine manipulation
(following the technique high velocitylow ampli-
tude). The osteopath then prescribed analgesic and
anti-inammatory drugs. The next day, the patient
developed right cervico-brachial neuralgia at C6TI
level and sensory-motor decit in the right arm. The
pain was primarily located in the right lower cervical
spine and scapula, referring down the right arm to the
elbow. She reported numbness and tingling in her
right posterior arm, along with signicant weakness
of the right upper extremity. The pain was aggravated
in particular by driving and rapid neck movements.
The patient contacted the osteopath physician and
reported to him the worsening of the pain after the
rst visit. He replied that it was the usual course after Figure 1. Large cervical disc herniation compressing the
a treatment. spinal cord at C6C7.

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Cicconi et al. 3

right arm and IIIII ngers. In the Rombergs posi- previously studied through instrumental analysis, so
tion the patient showed lateral body oscillations. the OMT was not justied by any diagnostic hypoth-
Palpation revealed contracture of the paravertebral esis. In addition, before proceeding with the manipu-
muscles. The following MRI, on 23 October 2012, lative treatment, an useful anamnesis to clarify
conrmed the success of surgery and the presence of symptoms and to highlight other pathologies that
disc protrusion was already apparent (MRI on 21 could be absolutely and relatively contraindicated to
May 2012) (Figure 2). osteopathic direct (manipulation or mobilization)
and/or indirect (postural exercises and breathing tech-
niques) treatment was not conducted.
Discussion Conditions such as a vertebral bony anomaly,
The two most common techniques of osteopathic myelopathy, cauda equine syndrome, infections,
spinal handling are a low velocityhigh amplitude malignancy, severe diabetes and anticoagulation ther-
method (where a series of gentle and repeated motions apy may be absolute contraindications and preg-
are delivered to a joint) and a high velocitylow amp- nancy, radicular pain and migraine relative
litude method (where a sudden thrust is delivered to contraindications.
the involved vertebrae). Osteopaths, as other non-physician practitioners,
Complications of this form of treatment have been should have the knowledge and awareness of their
reported in the literature and sometimes they can be limitations in healthcare, so as to avoid development
disabling and, on rare occasions, devastating. Minor of complications associated with manipulations, espe-
side eects of increased pain and headache are the cially the neurological type.
most common symptoms, followed by tiredness, In this case, the osteopath did not assess pre-exist-
radiating pain and dizziness, and they disappear ing clinical conditions (torticollis by disc protrusions)
quickly; most of these symptoms disappear within and he did not recognize the severity of complications.
24 hours and do not excessively aect daily activities.9 In addition, since he is not a doctor, without suggest-
Although serious complications are rare, they may ing radiographs or MRI or referring for orthopaedic
occur mainly after treatment of the neck, as well as in or neurosurgeon consultation, the osteopath had
the mid-back and lumbar spine.10 Therefore, the improperly prescribed drugs to treat the symptoms.
knowledge of a patients clinical conditions is essential This behaviour may be considered malpractice,
before starting an OMT. Osteopaths, before proceed- because he does not follow WHO guidelines on
ing with a manipulation, need to study the case to safety in traditional/complementary and alternative
assess any disease or pathologic element that could medicine (Benchmarks for training in osteopathy:
contraindicate the treatment. Benchmarks for training in traditional/complemen-
In our case, osteopath behaviour was not in tary and alternative medicine. Geneva 2010, ISBN
accordance with what is reported in WHO guidelines 978 92 4 159966 5). In this document, it is reported
on manipulative treatment. In fact, the cervical pain that osteopathic practitioners have a responsibility to
reported by the patient to the osteopath was not refer patients as appropriate when the patients con-
dition requires therapeutic intervention that falls out-
side the practitioners competence. It is also necessary
to recognize when specic approaches and techniques
may be contraindicated in specic conditions.
In conclusion, having analysed and reconstructed
the event in accordance with the forensic methodology
criteria on professional misconduct,11 the authors
identied some elements of responsibility on the part
of the osteopath for the onset of disc herniation, due to
the manipulation treatment. This complication, which
required neurosurgery treatment, was responsible for
the temporary disability evaluated at the medico-legal
examination. The incidence of serious complications
from cervical spine manipulation could have been
lower if the osteopath had adhered to guidelines.

Funding
This research received no specic grant from any funding
agency in the public, commercial, or not-for-prot sectors.

Figure 2. Decompression at the C6C7 level and persistence Declaration of conflicting interests
of disc protrusion. The authors declare that there is no conict of interest.

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4 Medicine, Science and the Law 0(0)

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