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Not Re-X-raying Results in Misdiagnosis

Kaylee Rowe's father took her to see Joan Bauer, DC, after she landed awkwardly during a cheerleading jump. Then age 12 and an active 7th grader, Kaylee complained of low back pain, pulling to the groin muscle and an occasional limp.

Dr. Bauer palpated Kaylee'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-ray Findings

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.

Kaylee'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 Kaylee'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 Kaylee's condition had improved enough that she could return to cheerleading. She 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 Kaylee to “lay off a while.”

Kaylee'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. Kaylee's pain subsided after approximately one month.

However, Kaylee's pain worsened 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. Dr. Bauer again refused for the same reasons. She then performed a cursory examination, using the same treatment.

Kaylee Sees an MD

Kaylee's condition improved very little during the next five months. As a result, Kaylee'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 Kaylee 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.

Kaylee 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. Kaylee'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, Kaylee's Ewing’s sarcoma/osteosarcoma grew and proliferated. She 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 Kaylee permanently impaired while sitting, standing, walking and lying down. She 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 Kaylee's sciatic nerve. This lent credence to the contention that an earlier referral may have revealed Kaylee's carcinogenic condition.

Dr. Bauer’s attorney described Kaylee 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 Kaylee 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.

Further Testing

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

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