Knowing When to Quit

In 2002, I published an article in Dynamic Chiropractic describing a discussion I had with an orthopedic surgeon while watching him perform spinal surgery.¹ The patient he operated on had a tremendous amount of facial swelling, especially around the eyes, just after the procedure. When I asked about this, the surgeon said it was normal and then told me blindness is a common side effect of spinal surgery. In fact, he directed me to an article he published in Spine that stated one out of every 100 spinal surgeons reported a case of unilateral or bilateral blindness following surgery.² While I consider myself to be well-read on vascular complications related to spinal care, I had never heard of blindness following spinal surgery.

The article compared the statistics of postsurgical blindness to those with a stroke following an adjustment. I did my own comparison - of the media coverage each receives. While a stroke following an adjustment occurs less often than blindness following spinal surgery, chiropractors get more negative media coverage than spine surgeons. No surprise there!

I mention this because recently, I was reading Bourdillon's Spinal Manipulation, which states that anxiety is the first and most common sign of cerebral vascular insufficiency.³ I had never heard of this, either. There was no reference listed. I immediately wondered what the reference was and why anxiety isn't listed as a positive sign for the many vertebrobasilar tests we have all studied.

The Anxious Patient: Know When to Back Off

The second thing to cross my mind when reading that textbook pertained to experiences I had with two patients when I was in practice. On two occasions, a patient became anxious almost instantly and requested not to be adjusted. I was preparing to deliver a diversified cervical adjustment that involved head rotation. The episodes stand out in my mind, as they were very different from other experiences I have had with anxious patients.

We have all experienced patients who were nervous, hesitant and unsure during their initial visits. I once had a truck driver twice my size tear up while I was examining him. He said he was afraid I was going to hurt him. Like most anxious patients, he was that way from the start and it took a few visits for him to calm down. The two patients who came to mind after learning of anxiety due to cerebral vascular insufficiency were not anxious until I turned their heads in preparation for the adjustment.

In each of the two situations, the anxiety was immediate and alarming. Both times, I stopped what I was doing and discussed alternatives. This included discontinuation of care for one patient and using another technique for the other. I was not aware of the anxiety factor at that time and I now wonder if these were cases of cerebral vascular insufficiency associated with vertebral artery compromise.

While searching for the answer to this question, I found a case report in Aviation, Space and Environmental Medicine that documents a situation similar to the two cases I had experienced.⁴ The case report involved a 28-year-old fighter pilot. Over an 18-month period, he experienced anxiety that included strange feelings, concern over the welfare of his radar intercept officer, flushing, nausea and the intense need to immediately land the aircraft. The last six months of symptoms also included "shooting stars" in his peripheral vision, dizziness and disorientation. The symptoms were precipitated by head turning (primarily to the left) and G-force maneuvers, and were relieved with straightening the head. Magnetic resonance cerebral angiogram showed the pilot had a dominant right vertebral artery with a hypoplastic left vertebral artery.

This case study referenced an article from JAMA that described 20 similar patients. Eighteen of those patients had hypoplastic vertebral arteries and two had partial vertebral artery occlusions. As with the fighter pilot, rotation of the head caused signs and symptoms. However, it was not the only head position to produce symptoms.

 Could the two patients I encountered have had hypoplastic or occluded vertebral arteries? There's no way to know at this point, but they were interesting case scenarios and now raise interesting questions. Another interesting question is whether the sudden onset of anxiety is "most common," as stated in Bourdillon's Spinal Manipulation, or "unusual," as stated in the aerospace journal article.

Drop Attacks: Know When to Refer

The sudden anxiety due to cerebral vascular insufficiency reminds me of another clinical condition: drop attacks. In drop attacks, congenital and/or pathological conditions of the carotid and vertebral arteries decrease cerebral blood. When the patient rotates the head, cerebral blood decreases further and causes them to collapse. This situation is often referred to as "collapsing without losing consciousness." There is no loss of consciousness because head position changes as a result of the fall. Cerebral blood flow improves fast enough to prevent the patient from passing out. Barring injury from the fall, the patients recover within minutes.

I encountered two patients suffering from drop attacks during 17 years of private practice. The first patient entered the office requesting help for dizziness. He related that when he turned his head, he became dizzy and had fallen twice. He had never "fainted." The symptoms had only been present for a few weeks. When asked the patient to describe the first episode, he stated, "I am a factory manager and a few weeks ago I was walking through the factory and someone called my name. I turned my head to see who was calling me and suddenly I was lying on the factory floor. I didn't pass out, but my head was spinning." Turning his head to back his car out had resulted in a similar scenario. Referral for imaging was initiated immediately following the history without further evaluation. The history was a textbook description of a drop attack.

The second patient also entered requesting help for dizziness. She had just completed eight weeks of physical therapy for inner ear dysfunction. The patient's history was very suggestive of an inner ear disorder, but drop attacks were also a possibility. In this incidence, I started an exam, first performing Hautant's test. The test was grossly positive, the exam was stopped and a referral was made. In both cases, studies confirmed vascular disease of the carotid and vertebral arteries.

Know When to Quit

So, what is my point in relating these situations? All of these cases emphasize the concept of knowing when to quit. The anxious patients requested that I stop, and I stopped. We discussed alternatives and the patients made the final decision whether to continue. I did not recognize what was occurring at the time, but I stopped and did not attempt to talk the patient into proceeding with care.

Patients must be given the information necessary to make a decision about accepting or denying care. They either take it or leave it. At times, it is obvious that the patient is making the wrong decision by declining care. Still, right or wrong, the decision has to be respected. A patient should not be talked into care if they are unsure. Occasionally, we hear of a doctor who proceeds regardless of the patient's wishes, literally assaulting the patient with care. In these cases, it sounds like the doctor is the one who has cerebral vascular insufficiency.

In the drop attack cases, knowing when to quit was a result of recognizing history and examination results that pointed to the possibility of ominous pathology. While ominous pathologies causing spinal and spinal-related conditions have occurrence rates between 1 and 5 percent, the conditions are not negligible. Think about this: Seeing 300 new patients in a year means three to 15 of those patients may have ominous conditions. Patients with ominous conditions do enter the average chiropractic office. We must be alert to this possibility in every patient. And here's my final point: While everyone is subluxated at some point, there are cases in which referral is definitely a higher priority than adjusting.

References

1. Miller KJ. Exam techniques should seek to identify or rule out ominous conditions and contraindications to the chiropractic adjustment. Dynamic Chiropractic, Sept. 24, 2002.
2. Myers M, Hamilton S, Bogosian A, et al. Visual loss as a complication of spine surgery. Spine, June 15, 1997;22(12).
3. Isaacs E, Bookhout M. Bourdillon's Spinal Manipulation, 6th Edition. 2002, p. 112.
4. Krentz MJ, Hopkins III EW, Moore JL. Panic with a twist: an unusual presentation of combined psychiatric and neurologic symptoms in a tactical jet aviator. Aviat Space Environ Med, 1997;68(3): 217-20.