Patient 5 was a 76-year-old man who complained of back pain from the neck through the lumbar region several hours after chiropractic manipulation. He had a past history of a neck fracture 50 years previously. He reported progressive worsening of his pain over weeks, recently requiring the use of a walker. He had been ambulatory before his chiropractic visit that day, but shortly after returning home, he had increased pain and was no longer ambulatory. He was diagnosed with cervical cord dysfunction from a combination of cervical spondylosis, stenosis, degenerative disease, and displacement of an old nonfused unstable C2 fracture. He was treated with laminectomy, dens removal, and fusion from occiput to C4 and was discharged to a nursing home with residual quadriparesis.
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Patient 5 presents a dilemma because he clearly complained of pain and neurologic dysfunction; however, the question remains whether chiropractic manipulation qualifies as trauma. If considered trauma, this remains a protocol violation. If not, this would become an injury missed by the protocol. We believe that the paramedic should have known to immobilize this patient because he documented an acute inability to ambulate after manipulation. This patient is also concerning because he represents the only patient who had an adverse outcome with residual quadriparesis. However, the extent of neurologic dysfunction did not change between the initial paramedic evaluation and the ED evaluation. Consequently, it seems unlikely that spinal immobilization would have changed the outcome in this situation.
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Three patients with cervical injuries met none of the protocol criteria for immobilization (patients 2, 3, and 4)...[They] had no neurological deficits.
