Phrenic nerve injury: a rare but serious complication of chiropractic neck manipulation
Published Friday 20 February 2015
Neck pain is a common problem which often causes significant disability. Chiropractic manipulation has become one of the most popular forms of alternative treatment for such symptoms. This seems surprising considering that neck manipulations are neither convincingly effective nor free of adverse effects.
The current Cochrane review on this subject could not be clearer: “Done alone, manipulation and/or mobilization were not beneficial; when compared to one another, neither was superior.” In the absence of compelling evidence for efficacy, any risk of neck manipulation would tilt the risk/benefit balance into the negative.
Adverse effects of neck manipulations range from mild symptoms, such as local neck tenderness or stiffness, to more severe injuries involving the spinal cord, peripheral nerve roots, and arteries within the neck. A recent paper reminds us that another serious complication has to be added to this already long list: phrenic nerve injury.
The phrenic nerve is responsible for controlling the contractions of the diaphragm, which allows the lungs to take in and release air and make us breathe properly. The phrenic nerve is formed from C3, C4, and C5 nerve fibres and descends along the anterior surface of the scalenus anterior muscle before entering the thorax to supply motor and sensory input to the diaphragm. Its anatomic location in the neck leaves it vulnerable to traumatic injury. Phrenic nerve injury can result in paralysis of the diaphragm and often leads to deteriorating function of the diaphragm, which can lead to partial or complete paralysis of the muscle and, as a result, serious breathing problems.
Patients who experience such problems may require emergency medical treatment or surgery. Sudden, severe damage to the phrenic nerve can make it impossible for the diaphragm to contract on its own. In order to make sure that the patient can breathe, a breathing tube needs to be inserted, a process called intubation. Artificial respiration would then be required.
American neurologists published a case report of a healthy man who consulted a chiropractor for his neck pain. Predictably, the chiropractor employed cervical manipulation to treat this condition. The result was bilateral diaphragmatic paralysis.
Similar cases have been reported previously, for instance, here and here and here and here . Damage to other nerves has also been documented to be a possible complication of spinal manipulation, for instance, here and here .
The authors of this new case report conclude that physicians must be aware of this complication and should be cautious when recommending spinal manipulation for the treatment of neck pain, especially in the presence of preexisting degenerative disease of the cervical spine.
I know what my chiropractic friends will respond to this post:
I am alarmist,
I cherry-pick articles that are negative for their profession,
these cases are extreme rarities,
conventional medicine is much more dangerous.
To this I reply: Imagine a conventional therapy about which the current Cochrane review says that it has no proven effect for the condition in question. Imagine further that this therapy causes mild to moderate adverse effects in about 50% of all patients in addition to very dramatic complications which are probably rare but, as no monitoring system exists, of unknown frequency. Imagine now that the professionals using this treatment more regularly than any other clinicians steadfastly deny that the risk/benefit balance is way out of kilter.
Would you call someone who repeatedly tries to warn the public of this situation ‘alarmist’?
Would you not consider the professionals who continue to practice the therapy in question to be irresponsible?
AN other on Saturday 21 February 2015 at 09:36
I agree with Thinking Chiro that you are not being alarmist and it is important to highlight side effects of treatments particularly when there are safer and more effective forms of treatment. Just one small suggestion – if you feel that chiropractors perform a particular type of neck manipulation maybe you should put “chiropractic neck manipulation” instead of “neck manipulation” in the body of the article. However, if there is no difference between in how neck manipulation is done between the professions who use it, then maybe you should just refer to “neck manipulation”.
Also, what was the reason for not using the latest Cochrane review for neck manipulation and mobilisation? The authors conclusions were as follows:
Cervical manipulation and mobilisation produced similar changes. Either may provide immediate- or short-term change; no long-term data are available. Thoracic manipulation may improve pain and function. Optimal techniques and dose are unresolved. Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
p.s. – when i refer to professions i am referring to CAM professions not conventional professions (even though they do neck manipulation too)
Julie K Brown on Friday 01 February 2019 at 13:19
Could you help me? I am in a lot of pain, I started seeing a chiropractor after a car accident. At first , I thought I felt better, going 3 days a week for 3 months, things have turned worse,for the past 2 weeks, i have developed something like spondyititus!! I think all the manipulations and Chiropractic treatments have caused me to develop life threatening results!! Can I sue the chiropractor for malpractice? Where should I go to get help? I’m living on pain pills every 2 hours. Help!!
darwinslapdog on Saturday 21 February 2015 at 01:09
I would add to your list the response I usually get when I outline the lack of evidence for and the risks of chiropractic:
“That may be the case, but MY Chiropractor is great!. S(he) always makes me feel better”. Feeling better is never defined other than, “my back is better now”. Mind you, most of them have been seeing the Chiro for up to twenty years. Either the back is a chronic problem and a real doctor should be consulted, or they just like the Chiro who “cares” about the worried well way more than the busy MD. When they add that the Chiro told them NOT to get a flu shot, a mammogram, or some other type of normal (truly) preventative health care, I really start to get my dander up.
And let’s not forget all the useless supplements that come with the “treatment” because “everyone knows that doctors know nothing about nutrition”. What is there to know? Eat decent food in an amount that doesn’t cause you to gain weight and concentrate on the veg, fruit and whole grains/beans. Avoid overindulgence especially of processed foods. Who needs an MD for that? If you are already fat, you must eat less and there is no magic–nor can your doctor do this for you. More could be done to support people in their efforts but this takes time and who is to pay for it? Weight Watchers offers this at a reasonable price. Can any alternative practitioner demonstrate that he or she has been responsible for anyones weigh loss, let alone the maintainance of that loss for any length of time? I’d love to see such data.
Thinking_Chiro on Monday 23 February 2015 at 01:07
I was interested to find out what the chiropractors actually did to cause the adverse event.
The 2015 case report in The Neurologist is behind a paywall even when I tried to access it through the Royal Australian College of GP’s library, one of the benefits of COCA membership here is https://www.coca.com.au/professional-development/infolink-introduction/ It would be interesting to know the exact details!, the abstract gives none!
Edzard also cites similar cases from 2001, 2007, 2010 and 2011 so I looked them up and accessed the full articles. The last three all just reference the 2001 article and add chiropractic manipulation to their list of causes. So what did the 2001 article say?
“the chiropractor did a number of manipulations that the patient described as forcing his shoulders downward and turning his head laterally.”
That is not a manipulation or thrust, it is a fairly standard stretch used by physio’s, chiro’s, exercise physiologists remedial masseurs etc etc to release the levator scapulae muscle.
Thinking_Chiro on Thursday 26 February 2015 at 23:08
So a Levator Scapulae stretch that caused a traction injury to the phrenic nerve is now incorrectly labelled chiropractic manipulation! Cervical passive range of motion followed by active provocation test at end range causing phrenic nerve injury incorrectly labeled chiropractic manipulation!
Will either of these case studies help physio’s, doctors, exercise physiologists, chiro’s, specialists, remedial masseurs etc who utilise these as standard procedures avoid further adverse events? Do other papers citing these poor case studies help prevent further adverse events?
Or is it a case of its a chiropractor so he must have tried to rip the patients head off?
Charlie Murray on Thursday 05 November 2015 at 00:02
Hi i have a condition called HNA, historically i was diagnosed with brachial neuitis. This effected both my arms as well as my neck. This has left me with bilateral paralysis of the diaphragm. The thought orthe idea that manipulation may have caused a bilateral paralysis for me is a long shot. Yes there have been cases during surgery and possibly during manipulation but for bilateral paralysis to occur durring manipulation….. . For me it’s a very long shot, I live with this condition and have researched beyond belief to find a cure as well as unearthing the little known about HNA or NA that can cause BDP. ( I now have the time)
Look for the underlying cause of the pain first and foremost, there is alot to rule out as the cause before looking at the possibility of any manipulation that may be the cause. BN, HNA and NA are sudden and very painful conditions that have very rare but know causes of Diaphramic Paralysis. Initially I thought it was the morphine that was causing my breathing issues but this was only coincidental. Just food for thought from a patient and an ex engineer.
C Weaver on Monday 09 May 2016 at 05:34
I believe that a specific manipulation might have caused my phrenic nerve damage; but when I ask doctors, they will never say that it’s a possibility….the specific thing was a wooden stand placed under my upper neck near the base of my skull and the doctor then proceeded to push down repeatedly on my forehead. He said this was to improve the “curve of life” the shape the neck should be. After the treatment, for about two days, I had pretty bad, burning pain. I should have gone to ER, but didn’t. About 2 years passed and I was always short of breath, so went for check up and that’s when the doctor said she thought I had phrenic nerve damage and I did all the testing and it was confirmed. Number one question diagnosing doctor asked was if I was in an accident. I did fall and felt a sharp pain on my right side, thinking a broke a rib (didn’t, though)….I wonder if this might have been the cause; this happened a few months before diagnosis, but about two years after neck manipulation. Yes, I think I lived with this for a while, not realizing it….. Doctors don’t seem to want to say either of these two things could have caused it, instead saying it’s probably just idiopathic.
Tamara on Friday 04 January 2019 at 20:07
I Stumbled upon this article due to the following:
1) Dec2016 chiropractic manipulation of the neck let me with a Bilateral Vertebral Artery Dissection, multiple strokes, poor eye sight, and bad judge of distance and balance.
2) Dissection healed
3) 22 months later after an extensive 4×4 trip almost immediately that night I started with my numbing, pins and needles and burning in my limbs when I am sleeping or sitting funny. My symptoms vary, but they are daily.
4) 3 months later I had a nerve check in my limbs and they picked up nothing.
5) symptoms are real and continuing, pain is not prominent in my muscles during the day.
Could it be a nerve Compression of some sort? Should I see a neuro surgeon?
Any advice would be appreciated.
BAM on Wednesday 28 August 2019 at 07:31
About 4 years ago I saw a chiropractic father and then his son the next day. On both days they jerked my neck very rapidly and were pretty rough on my lower back as well. The next day I had to go to the ER because the pain was so severe. I had to keep going back everyday for two more days to the ER for pain. I couldn’t raise my arms because my trap muscles were that tight and it was very painful to try to sit down due to lower back pain and painful to move my neck. I couldn’t raise my arms for a week and needed assistance eating and drinking.
3 weeks later I could move my arms mostly without pain over my head. I tried to go back to work before me and my friends lost the apartment. The temp agency told me that if I didn’t work a full day I was fired. Eventually, the pain in my trapezeous muscles started again and I tried to rotate my entire upper body so I didn’t have to move my arms as much placing jars on the conveyor belt. I had to stop because of pain and was told by the floor manager that I wouldn’t be fired, but that I needed to go home. I was fired, had to move to my mom’s house.
A little after a month after seeing the chiropractor I was running in the yard and fell suddenly on my right knee. I tried to brush it off as if maybe I had tripped, but it didn’t feel right. Within that same week I tried taking multiple walks, but would just fall over.
The first doctor that I saw about it said that weed made me fall over. I told him that I had smokes for years and had been falling for less than a year. What is the correlation. He told me he wad telling me the correlation. Lol. I didn’t go back there. Weed would help me walk…but I was pregnant. My OB said that if the THC levels didn’t drop that I’d lose him as my OB. I would use cannabis once a month after my OB visits and finally have some relief.
A friend let me have crutches, but then I’d have my muscles give out on my right leg again and fall into the wall or doorknob…or almost the street and a bush…still better than going without crutches and falling in the middle of the street right?
Eventually, I got a wheelchair and I was so happy that I could move around without getting hurt and be safe next to streets and kids. I still smoked to walk when I could…but started to become really depressed. A lot of other crap happened and I had to move..got a new OB, new doctor and eventually new therapist..had my son and CPS didn’t care about the why of the cannabis use of course…so won’t go into that….
I stopped smoking weed and stayed wheelchair bound, but also began to see a neurologist…they said that I have myelopathy. One day I fell in his bathroom floor because the doorway was too narrow for my wheelchair…he walked pasted me and said something to me and kept walking…idr what he said. My doctor sent me to a different neurologist and they said that a combination of psychological and muscular-skellular issues cause me to fall. I stopped trying to see neurologist.
I was in physical therapy for awhile, but wasn’t getting anywear. I found CBD gel and put it on my knee and the pain was gone and I could walk sometimes, then I took CBD oil and the spasms in my leg stopped and I could walk again. Physical therapy taught me how to stand up from a chair easier too ???? Without the CBD capsules that I take to this day, I’d be back in a wheelchair with too much back pain to stand much. The only thing that I’ve ever seen like it was a video on youtube called Myoclonus in leg where a guy would fall on one leg and sometimes be able to catch himself, and sometimes he couldn’t just like me. It seems very rare…but I think the chiropractor may have damaged peripheral nerves that with stress caused me to have spasms while walking.
I’ve yet to have an accurate diagnosis from what I xan tell. I don’t believe I have myelopathy. I think it’s myoclonus and I’d love to sue if I had a proper diagnosis or and/or statement from my doctor agreeing that the chiropractor(s) caused this.
I’m 25 now and a woman. Always take people’s pain seriously. It’s not fair to invalidate someone just because you cannot feel or relate to what they’re going through.
CB on Tuesday 10 December 2019 at 19:55
In may, after an adjustment, I suddenly became short of breath. I went to an urgent care center the day after the adjustment. They first thought it was my heart, but X-rays and a follow up sniff test confirmed that it is phrenic nerve damage. I am on my way to the attorney’s office right now…