After less than two months of treatment, a patient's condition deteriorates to the point of immobility. Was her spinal cord compression caused by her DC, or was it natural deterioration caused by a chronic condition?
Posted in Case Studies on Thursday, February 20, 2025
Mary Hill presented to David Mitchell, DC, on November 2, 2020, complaining of several months of low back pain that was affecting virtually all aspects of daily living. During the examination, Dr. Mitchell learned Ms. Hill had experienced numbness and tingling extending from both elbows through her forearms, wrists and into her fingers for the same period of time.
He performed an extensive examination focused on the primary complaint of low back pain, along with full spine palpation and active range of motion testing of the cervical spine. Based on his exam, Dr. Mitchell diagnosed misalignment in the cervical, thoracic and lumbar spine and carpal tunnel. Considering his diagnoses, Dr. Mitchell performed diversified adjustments in the cervical spine and drop table treatment for the lumbar area.
Prior to providing treatment, Dr. Mitchell had the patient complete intake forms which included a release section for her to sign authorizing chiropractic treatment. There was no separate informed consent document and no documentation of discussion with the patient about the diagnosis, treatment plan, risks of treatment or treatment options.
Ms. Hill returned to Dr. Mitchell as scheduled on November 6. At that time, Dr. Mitchell again provided diversified adjustments to multiple segments in the cervical spine and drop table treatment for the lumbar region. Although the patient was scheduled to return in a week, she was unable to make her November 13 appointment due to severe abdominal pain, which she was seeing a GI specialist for.
In mid-December 2020, the patient’s condition began to deteriorate with worsening low back pain as well as onset of weakness and spasticity in both lower extremities—to the point where she required use of a walker. On December 17, Ms. Hill resigned from her job as a medication aid in a group home because she was no longer able to perform the functions of the job.
In response to her evolving problems, Ms. Hill was evaluated by an orthopedic surgeon who obtained a lumbar MRI which did not identify a cause of the new neurologic changes. She was then referred to a physiatry specialist who obtained a cervical spine MRI on February 2, 2021, which showed disc protrusions at C4-7 and spinal cord compression at C4-5. Ms. Hill was promptly referred to a neurosurgeon who recommended immediate decompression surgery, which was performed on February 8, 2021. Although the surgery was successful, the patient was left with low back pain and weakness in her lower extremities requiring the use of a cane. Despite physical therapy, pain medications and injections, there was limited improvement in function. By two years post-surgery, her condition was permanent. Because of her pain and physical limitations, Ms. Hill was unable to return to work.
The Lawsuit
Within a year of her treatment with Dr. Mitchell, Ms. Hill filed a lawsuit containing a variety of allegations, including:
- Lack of informed consent
- Inadequate history
- Incomplete physical exam
- Failure to obtain X-rays or other imaging
- Performing cervical adjustments that were not indicated
The patient alleged Dr. Mitchell’s negligence caused disc protrusions that led to the spinal cord compression, need for decompression surgery and the residual deficits. The patient sought recovery for medical expenses, permanent lost wages and pain and suffering associated with the surgery and her ongoing physical limitations.
By the time the lawsuit was filed, Dr. Mitchell, who was 80 years old when he treated the patient, had passed away. As a result, there could not be testimony from Dr. Mitchell to explain his treatment notes, any informed consent discussion he had with the patient, his diagnosis, or the treatment plan. The defense would have to rely on Dr. Mitchell’s documentation in his medical chart, as well as a defense-retained chiropractic expert to explain Dr. Mitchell’s treatment based exclusively on what was documented on the medical chart.
In light of Dr. Mitchell’s passing and unavailability to defend himself against the patient’s testimony about certain aspects of the care he rendered, much of the defense focused on offering an alternative cause for Ms. Hill's spinal cord compression. The defense position was that Dr. Mitchell’s treatment did not cause the disc protrusions or spinal cord compression. Rather, this was a chronic degenerative condition getting progressively worse leading up to the patient’s treatment with Dr. Mitchell and continuing to worsen after her treatment with Dr. Mitchell to the point where she required surgery.
To support the defense causation position, the defense hired neurosurgery and neuroradiology consultants to review the cervical spine MRI and the patient’s subsequent medical records and offer an opinion whether the patient’s condition and subsequent medical course was consistent with an acute injury caused by the chiropractic treatment as alleged by Ms. Hill or an evolving chronic problem that would have necessitated spinal decompression surgery notwithstanding any treatment with Dr. Mitchell. The defense experts were of the opinion the MRI did not support the argument this was an acute process, but instead a condition that had been present for months and well before the patient’s treatment with Dr. Mitchell. The defense experts also believed that if the patient’s condition had been an acute injury, she would have had immediate symptoms following her treatment with Dr. Mitchell.
The patient and her attorney countered with their own chiropractic and neurosurgery experts who opined the MRI and patient’s subsequent medical course supported the patient’s contention this was an acute process either directly caused by Dr. Mitchell’s treatment or at least made significantly worse by Dr. Mitchell’s treatment. The patient’s chiropractic expert also offered several opinions in which Dr. Mitchell practiced below the standard of care, including failing to obtain adequate informed consent to include a thorough discussion with the patient about the risks and benefits of the proposed treatment, the patient’s diagnosis and reason for the proposed treatment and having the patient sign a thorough informed consent document. The patient’s retained chiropractic expert also opined that Dr. Mitchell’s history was incomplete, the physical exam of the cervical spine was inadequate to enable the doctor to make a diagnosis and implement a course of cervical treatment and as a result the doctor should not have performed any treatment to the cervical spine.
During the course of the lawsuit, the patient’s attorney had made a settlement demand of the doctor’s policy limits of $1,000,000 and never budged from that position. In conjunction with the doctor’s family, the NCMIC claims adjuster and defense counsel, the decision was made to take the case to trial. The doctor’s family felt strongly the doctor would have wanted to defend his care.
The Trial
The case proceeded to jury trial. The patient’s chiropractic expert testified as expected with regard to the chiropractor’s criticisms of Dr. Mitchell and the neurosurgery expert testifying that the chiropractic cervical adjustments caused the disc protrusions that led to the spinal cord compression and decompression surgery. On cross examination of the patient’s neurosurgery expert, defense counsel was able to obtain some key concessions from prior articles written by the patient’s expert inconsistent with positions testified to at trial. This seemed to undermine some of the patient’s neurosurgery expert’s credibility and the basis for his opinions. Nevertheless, this was a sympathetic plaintiff with a very real and permanent injury.
The defense chiropractic expert, who had a 40-year career as a professor at Logan Chiropractic College, testified in support of Dr. Mitchell. Even though the expert conceded Dr. Mitchell’s cervical spine exam was deficient in some respects, based on the information in the patient’s later medical records, there was nothing Dr. Mitchell could have learned at the time he was treating Ms. Hill that would have altered his diagnosis or approach to treatment. The defense neurosurgery and neuroradiology experts testified the patient’s condition was the result of an evolving chronic condition and not an acute injury caused by Dr. Mitchell.
At the close of trial, the plaintiff requested the jury return a verdict in her favor in the amount of $1,200,000 for recovery of approximately $500,000 in future lost wages and household services, and $700,000 for past and future pain and suffering. Following the four-day trial, the jury returned a verdict in favor of Dr. Mitchell.
What Can We Learn?
Show Your Work
The adage learned in math class in grade school still applies – show your work. Documentation is often the key to defending medical cases. Even if a diagnosis turns out to be incorrect, if the doctor can explain through the patient medical history and physical exam findings that the diagnosis and treatment was reasonable at the time of treatment, that can go a long way towards bolstering a defense when confronted with allegations of a misdiagnosis in a lawsuit.
Use a Thorough Informed Consent Form
An allegation of lack of informed consent is part of almost every chiropractic malpractice case. Having the patient sign a written informed consent at the time of treatment will typically help eliminate this potential allegation. Talking with the patient and verbally explaining the risks and benefits of the proposed treatment is often not enough as the patient will typically testify there was not informed consent and if the patient had known of the risks the patient would have refused treatment. The better practice is to include a thorough written informed consent, of course in line with any specific state regulations.
Perform Additional Exams When Necessary
In this case, one of the key hurdles to overcome was that the patient presented with a chief complaint of low back pain and during the course of the examination the doctor identified ancillary problems in the cervical spine. Yet, Dr. Mitchell did not perform testing to further identify the potential causes of the cervical issues. This enabled the patient’s hired expert to argue serious problems in the cervical spine were missed because of an inadequate exam. Even ancillary issues need to be thoroughly investigated. This is particularly prevalent with chiropractic treatment since many chiropractors will perform full spine exams identifying problems necessitating treatment that may not have been what brought the patient in for care.
Obtain Medical Records
In this case, obtaining all the patient’s subsequent medical records was a major component of the defense. While the patient testified her neurologic problems began much closer in time to her treatment with Dr. Mitchell which would logically suggest to laypersons a more likely causal connection, subsequent records enabled the defense to question this aspect of plaintiff’s case.
The defense pointed out the patient saw several medical providers in the weeks after she saw Dr. Mitchell and never mentioned any problems with her legs or neurologic issues until nearly eight weeks after her treatment with Dr. Mitchell. Although the patient testified she was seeing these other medical providers for problems unrelated to her neurologic issues and so did not see a need to mention it to those medical providers, given the severity of her neurologic issues as testified to by the patient, most lay jurors likely concluded that if the problems were occurring as early and as seriously as the patient contended, the patient would have addressed those problems with her medical providers.
The defense was able to use this to raise questions about the patient’s credibility which in term likely called into question some of the testimony offered by the patient about her interactions with Dr. Mitchell, particularly since he was not around to refute actions attributed to him by the patient.
Be Mindful of Language
While many jurors have experience with chiropractic treatment, including various manual manipulative therapies, the patients and the attorneys bringing these lawsuits often mischaracterize the way in which chiropractic manipulative therapies are provided using terms like “cracked,” “popped,” “forced,” and “twisted” in conjunction with testifying such maneuvers were performed violently or aggressively.
In this case, the defendant was not around to counter the patient’s testimony about the way in which the cervical manipulative therapy was performed, but the defense was able to offer testimony from an experienced chiropractic expert about the actual way in which a cervical manipulation is performed to show this therapy is not an aggressive or violent maneuver likely to cause injury as alleged by the patient and her attorney.
About the Author
Tom Smith is a founding partner of Fox Smith, LLC in St. Louis, Missouri. Tom has over 30 years' experience defending medical professionals in malpractice lawsuits and State Board matters. Tom has lectured in the areas of risk management, lawsuit prevention, trial strategy and employment practices to hospitals, medical professionals, businesses and insurers.