A 42-year-old male former patient arrives at your chiropractic office with excruciating low back pain (7/10) that travels all the way down his right leg to his foot (9.5/10). According to him, the pain is scorching and severe, and it gets worse when he sits for a long time or coughs. Additionally, the patient states that he has had headaches and nausea, which he never experienced before.
He claims that although he has experienced sporadic low back pain for the past 10 years, this episode is more severe and has not gotten better with time. It is similar to the pain he had about two years ago, when he first presented at your clinic.
At that time, a spinal surgeon had recommended surgery to correct an MRI-confirmed disc herniation (sequestration) at L5. But the patient instead chose your treatment package, which included spinal manipulation, manual therapy, laser, and rehabilitation. After two months of care, the patient was discharged with little back pain (2/10), no leg pain (0/10), and good function, and was good-to-excellent on lumbar physical performance tests. You discharged him and instructed him to continue with physical endurance activities at home.
You now perform a full examination with the following findings:
Clinical Challenge
Given the positive Babinski sign with ankle clonus, what is your next step?
Discussion / Learning Points
Some chiropractors may automatically think back to the previous successful treatment package on any given patient. They may think that the neurological symptoms will resolve with time and therapy. But a positive Babinski sign, accompanied by ankle clonus, clearly indicates that upper-motor neurons are involved, which raises concerns for a serious problem. This requires immediate referral to a specialist for advanced imaging.
Although conservative treatment is effective for many lumbar disc herniations, including disc sequestrations, the warning signs in this case call for escalation.1-3 A positive Babinski sign with ankle clonus means the central nervous system is malfunctioning. This could be due to a brain tumor, spinal-cord compression, multiple sclerosis, or some other illness. This is a red flag (in contrast to peripheral radiculopathy).
The best evidence-based course of action is option B, which involves an ER MRI and a referral for a neurosurgical consultation. In this situation, postponing proper diagnosis could result in irreversible damage. Time is of the essence. This is not a time when you can send the patient for an MRI at your local radiology center in two weeks. If this is a brain tumor, it could be a glioblastoma, which is fast-growing.
This patient was diagnosed with a glioma grade II after an MRI and biopsy. A grade II glioma is a slow-growing brain tumor with cells that divide slowly, which means it has a more favorable prognosis than a glioblastoma.
This case is a sobering reminder that while conservative care can be highly effective, it is not always the right solution – especially when neurological red flags emerge. The presence of a positive Babinski sign and ankle clonus demanded immediate action, and delaying further investigation could have led to irreversible consequences. In this instance, swift action led to an early diagnosis of a brain tumor, offering the patient a fighting chance. Vigilance saves lives.
References
On Oct. 21, 2025, a judge in Florida issued a groundbreaking decision in Complete Care v State Farm, 25-CA-1063. It concerns a fact pattern that many chiropractic doctors have faced wherein an insurer, such as State Farm or Allstate, decides to simply stop paying all claims submitted by a healthcare provider.
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Recent laws in New Jersey and California represent a disturbing trend that will negatively impact a practice’s ability to collect monies from patients, as well as expose them to significant penalties if the practice does not follow the mandatory guidelines to a T. Please be aware that a similar law may be coming to your state. The time to act is before the law is passed.
Southern California University of Health Sciences has entered into an agreement with Pacific College of Health and Science whereby PCHS’ San Diego and Chicago campuses – including students, faculty, staff, and academic programs – will join SCU effective May 2026, pending regulatory approval. Founded in 1986 as Pacific College of Oriental Medicine, PCHS is not only the largest acupuncture / herbal medicine school in the U.S., but also offers integrative health curriculum in holistic nursing and massage therapy.
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