Not Re-X-raying Results in Misdiagnosis
Jan Rowe's father took her to see Joan Bauer, DC, after she landed awkwardly during a cheerleading jump. Then age 12 and an active seventh-grader, Miss Rowe complained of low back pain, pulling to the groin muscle, and an occasional limp.
Posted in Risk Management on Friday, August 10, 2018
Dr. Bauer palpated Miss Rowe’s back, and she conducted orthopedic tests that elicited positive findings at T12–L2. A “figure four” test was used to put stress on the hip joint to ensure no trauma or injury had occurred to the joint. This was negative.
X-rays were obtained and interpreted by Dr. Bauer to be consistent with lumbar subluxation with low back pain and radiculitus. Dr. Bauer’s treatment consisted of adjustments from T9–L5, with a clockwise torque using a drop table. Adjustments were also made to the pelvic girdle and ileum. The adjustments were followed by eight minutes of ultrasound at 20 watts to the T10–L1 levels.
Miss Rowe’s condition improved enough that she was able to play basketball and handball without pain. Unfortunately, her pain reoccurred three months later.
She returned to Dr. Bauer whose findings were “involvement” of the lumbar spine in the same area initially injured. A lumbosacral spine belt was prescribed for acute low back pain referred to the left groin. Dr. Bauer documented that Miss Rowe’s father had to carry her into the exam room. The exam revealed tenderness at T12–L2, radiating into the anterior part of the left leg and anterior thigh. Neurological findings were not noted, and reflex testing was not done.
After two more months of care, Dr. Bauer felt that Miss Rowe’s condition had improved enough that she could return to cheerleading. Miss Rowe saw Dr. Bauer again one year later after she suffered a recurrence of low back and groin pain. Dr. Bauer employed the same treatment and advised Miss Rowe to “lay off a while.”
Miss Rowe’s mother asked Dr. Bauer to re-X-ray her, but the DC refused, claiming it wasn’t necessary and would expose the girl to needless radiation. Miss Rowe’s pain subsided after approximately one month.
However, Miss Rowe’s pain exacerbated while cheerleading a few months later, causing her to limp. When her mother took her to see Dr. Bauer, she again requested new X-rays. Again, Dr. Bauer refused for the same reasons. Dr. Bauer then performed a cursory examination, using the same treatment.
Miss Rowe Sees MD
Miss Rowe’s condition improved very little during the next five months. As a result, Miss Rowe’s parents took her to see Tim Wang, MD, for a second opinion. They brought with them copies of the X-rays Dr. Bauer took. When Dr. Wang viewed these X-rays, he also took new X-rays and advised Miss Rowe and her parents that he saw a tumor on his films. He also told them the tumor was present on Dr. Bauer’s initial films.
Miss Rowe was immediately sent for an MRI, which revealed a malignant bone tumor involving the left ilium and invasion of the soft tissues. The differential diagnosis included Ewing’s sarcoma/osteosarcoma of the left ilium. Miss Rowe’s father sued Dr. Bauer for misdiagnosing the signs of cancer as subluxation of the lumbar vertebra and lumbar radiculoneuritis.
The lawsuit alleged that as a result of Dr. Bauer’s negligence, Miss Rowe’s Ewing’s sarcoma/osteosarcoma grew and proliferated. Miss Rowe had to undergo far more extensive treatment than if the condition was diagnosed earlier, with less assurance of preserving her life.
Excision of the cancerous growth left Miss Rowe permanently impaired while sitting, standing, walking and lying down. Miss Rowe required six months of chemotherapy administered via a catheter surgically implanted into her chest to control and destroy the cancerous growth.
Defense Team Assesses Case
The chiropractic expert consultant couldn’t justify Dr. Bauer’s failure to re-X-ray, refer for a soft tissue film or seek medical consult. The consultant also said the standard of care would have been to take additional X-rays due to the traumatic nature of the exacerbation.
The defense team’s radiological expert stated that Dr. Bauer’s film showed increased bone density on the posterior aspect of the left ilium, and this was likely secondary to a lesion on the left acetabulum. This expert also noted a possible soft density mass in the left aspect of the pelvis that may have been putting pressure on Miss Rowe’s sciatic nerve. This lent credence to the contention that an earlier referral may have revealed Miss Rowe’s carcinogenic condition.
Dr. Bauer’s attorney described Miss Rowe as a survivor—a child who surely would impress a jury. Additionally the defense team had concerns about the less-than-supportive expert opinions and the significant damages suffered by Miss Rowe and her family. After hearing the defense team’s assessment of the case, NCMIC entered into settlement discussions, and the case resolved for $850,000.
What Can We Learn?
By Jennifer Boyd Herlihy, Boston, Massachusetts, and Providence, Rhode Island
Patient History Unfortunately, Ewing’s sarcoma is an aggressive “take-no-prisoners” tumor. A critical issue in this case was the patient’s trauma recorded during the initial visit. The patient’s history suggested an X-ray be taken, and Dr. Bauer did so. However, her failure to diagnose the tumor evident on the film was significant considering the multiple episodes of mild trauma.
A young patient’s failure to respond quickly should have heightened Dr. Bauer’s clinical suspicion and triggered the need for further testing and evaluation. Dr. Bauer also overlooked other “red flags,” including repeated trauma. The doctor, at minimum, should have obtained consultation or used more sophisticated diagnostic imaging before the patient’s parents sought another opinion.
Rule Out Conditions
X-rays, in combination with CBC and ESR, may help rule out a tumor or infection in patients with acute low back problems when other clinical indicators are present. Other imaging studies, such as a bone scan, CT, or MRI, may be clinically indicated even if X-rays are negative. X-rays may be clinically indicated to rule out fractures when the patient:
- Had recent significant trauma (any age)
- Experienced recent mild trauma (the patient is over age 50)
- Has a history of prolonged steroid use
- Has a history or evidence of osteoporosis
- Is over age 70
- Is a child who may have been abused
Expertise of Others
Consider obtaining the services of a chiropractic radiologist as appropriate for the situation.
Jennifer Boyd Herlihy is healthcare defense lawyer with the firm of Adler / Cohen / Harvey / Wakeman / Guekguezian, LLP, located in Boston, Massachusetts, and Providence, Rhode Island. She represents chiropractors and other healthcare providers in matters related to their professional licenses and malpractice actions. The firm’s website is www.adlercohen.com.