One chiropractic manipulation patient injury. Two case reports. Two editor’s notes.

What happens when two different groups from two different medical specialties see a patient, and then write up separate case reports?

Ask teams of doctors in the neurology and rheumatology departments of the Faculdade de Medicina, Universidade de São Paulo in Brazil. They both published case reports about a patient was injured after undergoing chiropractic spinal cord manipulation. And now both journals have editor’s notes acknowledging dual publication.

The patient’s case appeared in Neurology as “Spinal Cord Injury, Vertebral Artery Dissection, and Cerebellar Strokes After Chiropractic Manipulation” and as “Breaking the diagnosis: ankylosing spondylitis evidenced by cervical fracture following spine manipulation” in the journal Internal and Emergency Medicine. The two publications included the same figure and reported many of the same details about the patient with undiagnosed ankylosing spondylitis who experienced spinal cord injury and cerebellar strokes after experiencing  spinal cord manipulation.

The editors of both journals published notes flagging the cases, an expression of concern in Internal and Emergency Medicine and a “notice of dual publication” in Neurology

The notices are nearly identical, and state, in part:

Both case reports were written by authors from the Faculdade de Medicina, Universidade de São Paulo. The authors of the article published in Internal and Emergency Medicine were affiliated with the Department of Rheumatology, and the authors of the Neurology article were affiliated with the Department of Neurology.

The authors of both articles were contacted and asked for an explanation for the dual publication. Both teams of authors explained that they cared for the patient during the hospital admission and that they were unaware of the submission by the other team.

Although the patient was the same, as was much of the discussion, the two papers are not, the journal editors explained: 

The focus of the articles is different: one focuses on bone injury and emergency care, and the other on the neurological aspects of the case. Both author groups apologize for the duplicate submissions and agree with this statement.

The duplicate publication came to light after two chiropractors wrote to Neurology noting the similarities between the two cases, and expressing concerns that the patient in question did not receive care from a properly trained chiropractor.

In an email to Retraction Watch, Neurology journals executive editor Patricia Baskin said: 

We believe we detailed all the information in this situation of dual publication by two author groups in which each group was unaware that the other group was also writing a report about the same patient. We had encountered a similar situation in our journal in 2013, at which time we posted a similar notification

When someone notifies us of a duplicate publication, we do check with the authors and authorities of the institution to determine the circumstances surrounding the duplicate publication. In both these instances, we determined that the duplication was unintentional.

Marina Barguil Macêdo, who was the corresponding author of the article in Internal and Emergency Medicine and is now at the University of Washington, shared the statement that she and her colleagues drafted in response to the inquiry about possible duplicate publication:

We, from the Rheumatology division, were completely unaware that the Neurology division submitted a manuscript about the same case to a different journal. Our Hospital is the largest public teaching hospital of Latin America, so one patient is commonly seem by different teams, that, despite working together on case management, hold their scientific discussions separately. We truly lament this dual publication, but we cannot overemphasize it was by no means intentional.

As Baskin’s note indicates, duplicate publications on the same patient’s case by two different groups of doctors happen occasionally, and we’ve reported on a few.

In 2012, two different research groups at Myongji Hospital in Goyang, Korea submitted case studies about the same patient to different journals, first to the Journal of the Korean Society of Plastic and Reconstructive Surgeons and next to Annals of Dermatology

Unlike in the recent case from Brazil, Annals of Dermatology editors retracted their publication, as detailed in the retraction notice:

As some of the pictures in the case report in the Annals of Dermatology were utilized without any permission from the original publisher, it is a duplicate publication. Thus, the editorial board of Annals of Dermatology finally decided to retract it in full.

Two different groups at a Turkish hospital wrote in 2015 about the same 75-year old woman who developed internal bleeding after taking an anticoagulant. The first case report appeared in the Indian Journal of Pharmacology, only to be detailed once again in the Journal of Clinical Pharmacy and Therapeutics. As with the Korean case, the editors of the second publication eventually retracted it.

And in 2020, two groups of doctors at different hospitals in Iran described what they claimed was the first death of a pregnant woman from Covid-19. The second paper about the patient, in Travel Medicine and Infectious Disease, was retracted in May 2020.

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26 thoughts on “One chiropractic manipulation patient injury. Two case reports. Two editor’s notes.”

  1. If these articles were genuinely prepared and submitted independently by two different author groups, they show no text overlap and if “The focus of the articles is different: one focuses on bone injury and emergency care, and the other on the neurological aspects of the case”, is this really a case of duplicate publication? For sure, readers must be alerted to the fact that the two articles are about the same patient and contain identical images. But, strictly speaking, duplicate publication? Depending on the extent of overlap of the literature reviewed, discussion and conclusions, etc., I have to wonder whether these papers even qualify as a case of redundant publication.

    1. I agree. I don’t see any scientific issue here, nor is there anything for which the authors should apologise. In fact, accidental duplications, even if they are from specialists in the same field, can be interesting to shed light on the consistency in interpretation by independent doctors. Only if the authors were aware of each other’s work and did not mention it would there be an issue.

      I think a correction pointing out the other article would have been a more suitable course of action than an expression of concern. There is nothing here to be concerned about.

  2. I have lived with a chiropractic neck injury for almost twenty years. I have to endure painful C-spine injections 3-4 times a year. There was an unusually sharp pain during the adjustment followed by a sharp pain every time I lift my left arm to brush or wash my hair, similar to touching an electric fence. He assured me it would go away, didn’t seem concerned but didn’t attempt to treat my neck again. When it’s pinched I suffer from migraine type headaches that last for 2-3 days. It has significantly affected my quality of life- kayaking, holding grandkids and even folding laundry. I probably should have been compensated but I know he didn’t intentionally injure me. Beware

    1. I was ill for nine months after chiropractic spinal and neck adjustments. After the first one, I experienced numbness from the neck down on both sides, a burning, agonising base of spine and pain spasms down my left arm and leg. I was only able to tolerate three sessions out of six. I also experienced severe exhaustion after trying deep tissue massage to correct my side effects. It felt like the symptoms of ME. When these symptoms finally cleared up, I went on to develop costochondritis and IBS. It was as if my immune system had risen up against me.

  3. Chiropractors don’t manipulate the spinal cord. They manipulate or, as they call it, “adjust” the spine which houses the spinal cord. I’ve read articles where people had spinal cord damage from adjustments to the vertebrae, also my friends’ daughter had a cervical adjustment and had a stroke. She was only 26.

  4. I think the journal’s editors treated unfairly the authors.

    The ideal action on true dual publication is to only issue dual publication notice to the paper that was published later, and keep original research status on the first published work.

    Nevermind that the case in light discuss different subjects and were done by different disciplines.

    A much better ruling would have been to keep the first paper as is and add a notice to the second simply informing that the paper discuss the same patient.

    But no. As If doing research on 3rd world countries isnt hard enough already, a 1st world so called “chiropractor” steps in and tries to silence the medical truth of the matter: chiropractor injuries are serious and common , they represent a major health risk for people with back pain and no access to universal health care.

    1. You mention “a 1st world so called “chiropractor” – can I ask why you ignore the second author who is from Mexico, which, like Brazil, is considered a developing country?

      Also, where do you get the notion that they tried to “silence the medical truth”? The authors of the letter are apparently correct in noting that the two papers seem to deal with the same patient, which they had asked to be clarified – at no point do they call for retraction of these papers.

  5. Many clinical trials generate multiple papers from the same patients. So what? The point is, injury from cervical manipulation is not uncommon. Forty years ago, I reviewed the world literature and found hundreds of cases of stroke, vertebral artery and carotid dissection among other injuries associated with manipulation. Not much has changed with effort to downplay it.

    1. Seriously, you found hundreds of cases??—if this is for real , I doubt that they were all done by chiropractors licensed in this country (USA)…I have been adjusting necks for 25 yrs, thousands of patients and never had an serious incident—some muscle spasms and pain that went away after a few days but that’s it. Comments like yours cause unnecessary spin.

      Dr David Leonard

  6. These isolated rare incidents, majority of Chiropractic adjustment when done properly, NOT the violent rotating twisting manipulation, BUT, specific P-A or lateral Toggle with drop headpiece on the table, are very safe and beneficial.
    Chiropractic has rare related vertebral artery or spinal cord negative complications. 1:10,000,000.
    There are more incidents involving getting Hair Washed @ beauty shop,than Chiropractic.

    1. Preach! The very rare incidents are always over publicized. I will say however, someone manipulating ankylosing spondylitis is not doing their due diligence. A simple history would’ve revealed that cervical adjustments would be contraindicated in this patient. So chiropractic injury is very rare…. When the doctor is doing their due diligence.

    2. Strokes after chiropractic neck manipulation are likely more common than what’s reported in the literature. For one thing, subtle arterial dissection due to neck trauma can take time to manifest as stroke, by which time the connection to neck cracking is not obvious.

      Given that there is a lack of benefit demonstrated for chiropractic neck cracking and a chance, however small, of devastating injury associated with the practice, you should never let a chiropractor near your neck.

      1. Given that there is a lack of benefit demonstrated for chiropractic neck cracking and a chance, however small, of devastating injury associated with the practice, you should never let a chiropractor near your neck

        —–seriously???? where do you people get this information from?
        There are over 500 peer-reviewed articles that show the benefit of neck manipulation when performed by qualified chiropractors.

    3. Any source on the injury rate of hair washing?

      Regardless, a hairwash has actual benefits (clean hair), as opposed to the deceptive snake oil that is chiropractic.

  7. All medical procedures carry some risk. I have been using chiropractors for 22+ years for lower back and neck issues and never had a single issue. I’ve had steroid injection and radio ablation for lower back with mixed results. My first steroid injection was awesome. The last one didn’t help at all. Had radio ablation following dual nerve blocking test procedures, that both indicated very promising results, only to find the ablation didn’t seem to change anything 😦

    As for this case I don’t see the problem. Two different departments wrote papers on the same patient. How is that a problem?

    1. The problem is meta-analyses. If there is no way to tell from the two papers that this is the same patient, there is a risk they will be double-counted in a meta-analysis.

  8. Chiropractors don’t manipulate the spinal cord nor is there a technique to manipulate the spinal cord…..there is a smelly fish somewhere in the water here. Another restraint of trade violation by the AMA who has already paid out millions in the past for their misconceptions!

  9. Seriously, what licensed DC would perform a cervical manipulation knowing a patient suffers from AS?! People would be astounded to know the number of deaths and permanent injuries under the care of allopathic medicine performed by MD’s. Botched surgeries, abuse of opioids and related drugs, a pill for every ailment under the sun that does more harm than good to the health of patients are a daily common occurrence, yet most people accept that as normal? People, please do your fact checks before making your “opinions” heard.

    1. What physicians do and don’t do, provides no excuse for chiropractors paralyzing and killing patients through neck cracking that has no valid clinical justification.

      Far too many chiros still perform such dangerous maneuvers, as well as claiming to treat internal medical problems, “adjusting” infants and condemning vaccination. It’s long past time to get your house in order, not point fingers elsewhere.

  10. All I’m reading is chiropractors trying to defend their practices while getting defensive that people report they got hurt. I’ll never let a chiropractor touch me and I’m selective of doctors and question recommendations for meds.

  11. I can’t help but sense emotion from the respondents to this article. This is truly a tragic case whether published from an orthopedic, neurology or even a chiropractic perspective . Obviously something like this is extremely rare. If it were happening regularly I doubt the millions of people who see chiropractors every day would be taking the risk. I think we need some perspective here. As one of the MD respondents wrote there was a “association” between chiropractic manipulation and some of these tragic events such as vertebrobasilar stroke. There are numerous papers now that suggest the likelihood that people in the initial phase of the stroke (vertebral artery dissection and clot formation) experience an intense suboccipital headache. The majority of these individuals are seen by an MD just prior to their stroke. …some have a chiropractor and go to their chiropractor. The point is the stroke was already in progress and was not recognized and anticoagulant therapy was not initiated. So what JD Cassidy found in his seminal paper Feb. 2008 Spine: Conclusion: VBA stroke is a very rare event in the population. The increased risks of VBA stroke associated with chiropractic and PCP visits is likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke. We found no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care.
    If chiropractic were so dangerous why is my $3 million malpractice insurance policy less than $3,000 per year?

    1. Gee, what possible connection could there be between a chiro violently wrenching someone’s neck and that person suffering a stroke due to a tear in their neck artery?

      There remains no demonstrated clinical usefulness for chiropractic neck cracking. Devastating effects like stroke and death are completely unjustifiable in that context.

      “If chiropractic were so dangerous why is my $3 million malpractice insurance policy less than $3,000 per year?”

      Because chiros generally limit themselves to addressing aches and pains. If more chiros treated serious internal medical conditions (and some do) those malpractice rates would skyrocket.

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