Did a Chiropractic Assistant's Actions Cause Patient's Quadriplegia?

Should a chiropractic assistant have made a referral to the emergency room instead of providing basic treatment?

Posted in Case Studies on Wednesday, April 16, 2025

The Incident

Dean Fowler, 44, presented to Salem MultiSpecialists (SMS) on August 5, 2019, and reported neck pain that had been present for the past three days and was worsening. Although he was an established patient of SMS, he had not been seen there since 2012, also presenting at that time with a complaint of severe neck pain. Range of motion was performed by the physical therapist in 2012, and Mr. Fowler was treated with electrical stimulation, ultrasound, and stretching. An MRI showed bulging disc and spondylosis at C3 – C6, along with straightening of the lordotic curve. Mr. Fowler continued to receive physical therapy treatments in 2012 for one month when he was released to Dr. Sheila Burroughs, DC, in an improved condition.

On the day of the incident, Mr. Fowler denied any trauma or injury but provided a history of recently lifting up to 300 pounds. He described the pain as sharp and constant over the neck and upper thoracic region bilaterally, extending into the upper trapezius, also bilaterally. He denied any numbness or tingling in any extremity. Aspirin was helpful, but any movement of his neck exacerbated the pain.

Dr. Burroughs noted the patient was in no distress but appeared uncomfortable. She performed cervical range of motion, found no sensory loss in the upper extremities, positive cervical compression, and positive Jackson’s compression. X-rays were performed and showed significant loss of disc height at C4/5, C5/6, and C6/7. The impression was recurrent cervical disc protrusion and possible cervical stenosis.

Mr. Fowler received a Toradol injection for the pain from Brian Andrews, MD. Dr. Burroughs recommended a cervical MRI but the patient declined, saying he did not have the financial means for that test. He was then sent to the Physical Therapy Department within SMS during this visit for conservative treatment. The passive modalities were performed by the chiropractic assistant (CA), Tyler Frost. CA Frost performed passive range of motion and stretching, but the patient was unable to tolerate due to the pain. Mr. Fowler was not seen by a Physical Therapist prior to receiving this treatment and therefore there was no PT plan of care. CA Frost then escorted Mr. Fowler to the X-ray room to be seen again by Dr. Burroughs. While Dr. Burroughs was reviewing the X-ray results with the patient, Mr. Fowler began experiencing weakness. He was taken to an exam room and was seen by Dr. Andrews. His exam found numbness and tingling throughout his body which was progressing. EMS was called and the patient was transferred to the emergency room.

Mr. Fowler was found to have suffered a C5/6 traumatic herniated nucleus pulposus; it was a large herniation causing spinal stenosis at C5/6, and an ASIA-A C6 spinal cord injury. ASIA is an impairment scale for spinal cord injuries, grading severity of neurological loss. The scale is A through E, with A being the worst. Mr. Fowler’s classification of A indicates no motor or sensory function. He underwent surgery that same day, specifically an anterior cervical discectomy at C-5/6 and anterior cervical fusion at C-5/6 with structural allograft. He underwent rehabilitation and therapy but unfortunately lost total motor and sensory function of all extremities, along with loss of bladder function.

Lawsuit

Mr. Fowler filed a lawsuit against Dr. Burroughs, CA Frost, and SMS, alleging that the only treatment that should have been administered that day was a referral to the ER. The Plaintiff alleged that no cervical stretching or exercises should have been performed without a current MRI. The Plaintiff further asserted that even if they did not send him to the ER, no physical therapy treatment should have been provided without a Physical Therapy plan of care in place. Administering physical therapy in the absence of a plan of care can be a violation of state law. Plaintiff’s theory is that the treatment administered by CA Frost was performed on a potentially unstable cervical spine and caused the patient’s neurological injuries.

The Case

The Defendants retained Chiropractic, Physical Therapy, and Neurosurgery experts. The chiropractic expert found no contraindications to light stretching as administered by CA Frost. While the Physical Therapy expert agreed that the patient should not have been treated before a Physical Therapist had developed a plan of care, he believed that the absence of a plan of care did not cause or contribute to the patient’s injuries. He strongly believed that a plan of care likely would have recommended the same treatment that was provided. The Physical Therapy and Neurosurgical experts both believed that Mr. Fowler was a “ticking time bomb” for the disc herniation, although they were surprised that he suffered a cord injury. They noted that it was a significant herniation that is typically only seen after massive trauma. Of importance, the experts believed that there were no contraindications to any of the care or assessments performed by anyone and that it was not required to obtain an MRI prior.

The Plaintiff produced a life care plan for Mr. Fowler’s future medical and rehabilitation needs in the amount of $10 million.

The Outcome

Because of the catastrophic injuries suffered by Mr. Fowler, it was determined that the best course was to avoid the possibility of a large verdict at trial. Dr. Burroughs and SMS agreed (NCMIC’s True Consent-to-settle* feature means that NCMIC will not a settle a claim without the policyholder’s authorization) and were covered by liability insurance from NCMIC for $1 million each.

Even though the lack of a physical therapy care plan was unlikely to have caused or contributed to Mr. Fowler’s injuries, the Defendants believed that a jury might find SMS negligent on that issue and that if a Physical Therapist had evaluated the patient prior to treatment, it is possible that no treatment would have been rendered by CA Frost. A jury may also have found that no treatment should have been rendered until the MRI was performed as this was ordered by Dr. Burroughs prior to any therapy, and that the patient’s inability to pay should be addressed in light of the potential emergency need for the study. The case was therefore settled for policy limits.

What Can We Learn

Physical Therapy Plan of Care. If your practice offers physical therapy, be aware of the guidelines and state laws regarding requirements for a plan of care prior to administering any treatment. It may be necessary for a patient to be seen by a Physical Therapist before a physical therapy assistant or chiropractic assistant may render care to ensure that the treatment rendered is appropriate for that patient.

Execute Orders. If a provider believes a test should be performed, such as an MRI, and the patient says he/she cannot afford the fee, it is important to discuss the situation with the patient and document that discussion. Part of the conversation should include what financial assistance may be available and other imaging options that are appropriate and less expensive. Dr. Burroughs believed an MRI was necessary enough to order that test. She should have had a conversation with the patient explaining why the test should be performed and the risks of not obtaining the imaging.

About the Author

Dede K. Zupanci focuses her practice on health care defense litigation and regulatory matters, including: chiropractic professional liability, hospital premises liability, and hospital regulations and compliance. She has represented clients in Illinois and Missouri, including metropolitan and rural hospitals, as well as chiropractors and physicians. She is a graduate of Saint Louis University (J.D.) and Southern Illinois University – Carbondale and is a member of the Illinois Association of Defense Trial Counsel, Madison County Bar Association and St. Louis Area Health Lawyers Association. Dede resides in Edwardsville, Illinois.