Worsening symptoms. Unusual treatment circumstances. Sparse documentation. A massive disc herniation. Sometimes, it's not one decision that creates a difficult case — it's stacking factors.
Posted in Case Studies on Wednesday, August 26, 2026
Amy Paul had a long history of neck, shoulder and low back complaints when she first saw chiropractor Dr. Sue Macklane in 2017. At the time, her low back pain was relatively minor, and treatment focused primarily on her neck and shoulders.
Amy continued seeing Dr. Macklane periodically over the next several years. She also sought care from a primary care physician who practiced homeopathic medicine, including seven injections of bee venom into her buttocks for her low back pain. The treatments didn't relieve her symptoms.
By January 2021, Amy's complaints had become more significant. She reported persistent left hip and low back pain, and Dr. Ken Scarpino, an independent contractor who worked in Dr. Macklane's office, documented several abnormal findings, including a positive straight-leg raise and weakness in the left extensor hallucis.
Dr. Scarpino's differential diagnosis included several possibilities, including a disc problem. He treated Amy with adjustments, massage, heat and active release techniques.
Amy returned to Dr. Macklane several times that month. Her records, however, did not clearly indicate whether her symptoms were improving, worsening or staying the same.
After another gap in treatment, Amy returned in July 2021. Her pain was now centered around the left sacroiliac joint and buttock, with pain radiating down the back of her thigh toward her knee and calf. She asked Dr. Macklane whether she should have an X-ray.
Dr. Macklane explained that an X-ray wouldn't be particularly useful and that an MRI would be needed to properly visualize the spine. But she advised Amy against having an MRI because, in her opinion, the results wouldn't change her treatment. She also told Amy she could save the approximately $2,000 cost of the MRI.
Dr. Macklane treated Amy again five days later. Her pain level had not changed.
An Unusual House Call
Amy wasn't getting the relief she wanted, so she contacted Dr. Scarpino, who made a house call. He brought his portable adjustment table and some celery extract that he believed could help inhibit pain signals. When Dr. Scarpino arrived, she stood up to greet him but was unable to walk as she was in so much pain.
Dr. Scarpino normally required new patients to complete intake paperwork, and although he brought the forms with him, Amy said she was in too much pain to fill them out and would complete them later.
Amy told Dr. Scarpino that her back pain had been worsening for more than a year. Sitting, lying down and almost any movement made it worse. She described pain in her back, left buttock and posterior thigh.
Despite the severity and duration of her symptoms, Dr. Scarpino proceeded with treatment, including several grades of spinal mobilization and high-velocity, low-amplitude chiropractic manipulation. Amy didn't complain during the treatment.
Before leaving, Dr. Scarpino asked her to call the next day with an update, but otherwise planned to see her at his office that Saturday. The next morning, Amy called to report severe aching pain in her perineum.
Another Unusual Decision
Dr. Scarpino went back to the house. He helped Amy into his car and drove her to his office himself, with Amy lying down in the front passenger seat under a blanket. When they arrived, she was hunched forward at approximately a 45-degree angle and needed assistance getting into the office.
Dr. Scarpino had her lie on the treatment table and performed a brief massage. Several times, when he applied pressure to her lower back, Amy told him it was too painful. He reduced the pressure or moved to another area and applied heat packs, but did not perform chiropractic manipulation that day.
On the way home, Dr. Scarpino stopped and bought Amy a bottle of women's multivitamins. He advised her to take the vitamins, along with Advil and hot baths, reassuring her that she would be okay. That reassurance would later become one of many details examined in the malpractice claim.
The Patient's Condition Deteriorates
The following morning, Amy woke screaming in pain and was experiencing numbness and tingling in both legs. A friend drove her to the emergency room, where Amy reported numbness involving her buttocks, thighs and perineum.
A stat MRI revealed a massive L5-S1 disc herniation that virtually obliterated the thecal sac and was impinging on the S1 nerve root. Amy was diagnosed with cauda equina syndrome and underwent emergency L5-S1 surgery that same day and she spent three days in the hospital.
After her catheter was removed, she had significant urinary problems and went home wearing diapers. Although her condition eventually improved, she continued to experience urinary symptoms and other problems she attributed to the injury.
Amy later claimed that she experienced bladder dysfunction, altered sexual function, numbness, pain and other symptoms that affected her quality of life and ability to work as a dancer.
The Lawsuit
In 2022, Amy sued both Dr. Macklane and Dr. Scarpino. She alleged that Dr. Macklane failed to recognize her worsening symptoms, diagnose the disc herniation and refer her for appropriate medical evaluation or imaging.
She alleged that Dr. Scarpino failed to recognize the same condition and should not have treated her without additional evaluation or consultation. She also claimed that he treated her without proper equipment and failed to obtain informed consent.
The case presented significant challenges for both doctors — but for very different reasons.
Concern #1: Conflicting MRI Information
Dr. Macklane had treated Amy over a prolonged period, despite limited improvement. Her testimony about when an MRI was appropriate became an issue during litigation.
She testified that Amy wasn't really a candidate for an MRI during the January-to-July 2021 period. Yet she also testified that she had recommended one because Amy was somewhat noncompliant. That recommendation wasn't documented in the chart.
Her defense attorney ultimately believed the plaintiff's counsel could persuade a jury that Dr. Macklane had failed to recognize the developing disc herniation because she didn't order appropriate diagnostic testing or referrals.
Concern #2: Lack of Documentation
Dr. Scarpino faced a different problem: his documentation. His entire chart for Amy consisted of one handwritten page on a blank sheet of paper. There were no completed intake forms. There were no billing records. His telephone conversations with Amy weren't documented. He recalled being paid in cash.
And after the July 28 house call, he added a notation to his record stating that bowel and bladder dysfunction would be a red flag for treatment, followed by the words, "which she denies." The plaintiff argued that this was added after Dr. Scarpino learned about Amy's diagnosis and surgery.
Dr. Scarpino denied that he should have obtained an MRI before treating Amy. He believed several diagnoses were possible, including sacroiliac dysfunction, piriformis syndrome, lumbar subluxation and a disc problem. But he acknowledged that he hadn't discussed the risks of treatment with Amy.
The defense's chiropractic expert had difficulty supporting the care. He described the MRI as showing one of the largest disc herniations he had ever seen. He didn't believe the herniation itself had been caused by chiropractic treatment and thought it had developed over time.
However, he couldn't rule out the possibility that Dr. Scarpino's July 28 manipulation triggered the final worsening of the condition.
And he identified several factors that could make Dr. Scarpino appear unprofessional to a jury:
- Making a house call
- Driving the patient to and from his office
- Treating without completed intake paperwork
- Maintaining extremely limited clinical notes
- Accepting cash without billing documentation
None of those details, standing alone, necessarily established negligence. Together, however, they created a difficult story for the defense.
The Result
After being sued, Dr. Scarpino promptly reported the claim to NCMIC. While Dr. Macklane ultimately accepted an offer for her $500,000 policy limit, Dr. Scarpino's $1 million policy limit gave him more room to continue defending the case.
At mediation, the plaintiff initially demanded Dr. Scarpino's full $1 million policy limit. But NCMIC's claims representative and defense team argued that Dr. Macklane bore significantly more responsibility for the progression of Amy's condition. The defense emphasized that the disc herniation appeared to have developed over time and that Amy had experienced persistent symptoms without meaningful improvement before Dr. Scarpino ever treated her.
The mediator ultimately came to agree that Dr. Macklane was substantially more culpable. After negotiations, Dr. Scarpino settled for less than half of what Dr. Macklane had paid. NCMIC's total legal defense expenses were approximately $142,000.
What Can We Learn?
Don't treat on autopilot. When a patient's symptoms aren't improving or are deteriorating, it's time to stop and reassess. A treatment plan that made sense months ago may no longer make sense when the clinical picture changes.
Pay attention to red flags. Significant changes in pain, neurological symptoms or other concerning complaints should prompt careful consideration of whether additional evaluation or referral is appropriate.
Document your clinical reasoning. A chart should tell the story of what you found, what you considered, what you did and why. If a patient's condition is changing, document those changes and your response to them.
Unusual circumstances deserve extra care. House calls, transporting patients, treating outside the normal office setting or accepting cash may be legitimate in some circumstances. But they can also create additional questions during a claim. Know your practice's policies and document what happened.
Never alter a record after the fact. If you need to correct a record, follow appropriate procedures. A record that appears to have been changed after an adverse event can undermine your credibility—even if the original care was appropriate.
Independent contractors need clear expectations. If you work with independent contractors, make sure everyone understands expectations for documentation, billing, treatment outside the office and communication with the practice.
Make sure you have adequate coverage. A strong defense requires time, expertise and resources. Adequate policy limits can provide your attorney with more options when deciding whether to settle or take a case to trial.
The Bottom Line
This case wasn't defined by one moment. It was a series of decisions, missed opportunities and unusual circumstances that gradually made the defense more difficult.
When a patient's clinical picture changes, don't keep treating on autopilot. Reassess. Recognize the red flags. Document your reasoning. And make sure your practice has the coverage and support to protect you when a challenging case becomes a claim.
Although this case study is based on a real case, names, dates and details have been changed to protect patient and doctor privacy.