Subject: Inquest May 7th & 8th - CCWG Info Bulletin - May 9, 2002 Information Bulletin From the Chiropractic Communications Working Group May 7th & 8th - Dr. Pollanen Takes Stand Stating that Lewis Died of Natural Causes Dr. Michael Pollanen, one of the original authors of the neuropathological autopsy report, on Lana Dale Lewis, began his testimony on Tuesday, May 7th by indicating that Ms. Lewis died of natural causes due to an advanced case of atherosclerosis. "We were wrong," Dr. Pollanen told a coroner's inquest, "In retrospect, our conclusions were erroneous." Dr. Pollanen conceded that mistakes were made in the original investigation into the cause of Ms. Lewis's death which concluded that trauma from spinal manipulative therapy (SMT) was the cause of death. Dr. Pollanen said that he changed his conclusion in the fall of 2001 after undertaking an exhaustive re- examination of the 507 microscopic slides of Ms. Lewis's vertebral arteries. Some of these slides were not reviewed when the original pathology report was written in April 1997. Dr. Pollanen outlined that there were three components to the cause of death: the immediate cause was an acute cerebellum infarction; the underlying cause was atherosclerosis; and the other significant contributing factors included hypertension and cardiovascular disease. The acute cerebellum infarction was caused by the natural progress of atherosclerosis. Dr. Pollanen testified "I am not aware of any finding which cannot be explained by atherosclerosis." He testified that Ms. Lewis's left vertebral artery could almost be described as aneurysmal in that it was dilated to the point that it was almost the same diameter as the basilar artery. In his opinion, she had stage 6 "end stage atherosclerosis" or "hardening of the arteries", with substantial plaque build-up particularly noted in her left vertebral artery. He explained that advanced atherosclerosis is strongly linked to stroke. He testified that a tear or dissection in the sub-adventitia of the left intracranial vertebral artery was consistent with the advancement of the atherosclerosis. He dated the time of the dissection as approximately three days prior to her death and as such had no relation to the SMT she had received. In his mind this was a "big ticket item" which lead him to change his opinion. Dr. Pollanen noted that Ms. Lewis's right vertebral artery also showed signs of the disease and was 70 percent occluded. Crown counsel Tom Schneider asked Dr. Pollanen if the right artery would also likely have thrown a clot and caused a stroke if the disease continued to progress. Dr. Pollanen replied that most probably it would have done so. A Chronology of the Neuro-pathological Findings in this Case The chronology in this case started in 1996 with the original autopsy performed by Drs. Deck and Pollanen. Dr. Pollanen was working under the supervision of Deck at the time, but they jointly authored the April 1997 neuropathological report. In coming to a conclusion on the cause of death, the two doctors considered both working and differential hypotheses, and while SMT was always high on the list of probabilities, diseases of the bone and artery were considered. Dr. Pollanen admitted that a thorough literature review had not been done and their conclusion was based on an incomplete examination of the slides. In December 2000, Dr. Pollanen was asked to act as the consulting neuropathologist on behalf of the coroner's office as Dr. Deck was unwell and could not take the stand. In preparation for the January 2001 start date of the inquest, Dr. Pollanen further reviewed the histological slides, conducted a literature review and prepared a subsequent report. This review did not change Dr. Pollanen's opinion and he again concluded that SMT was the most probable cause of death. In preparation for an inquest, those parties with standings engage experts to review and interpret findings on their behalf and put forward an expert opinion. These opinions and reports are then circulated to others involved in the case, including expert witnesses, for further review and consideration. It was such a report, issued in September 2001 by Dr. John Richardson, an expert witness for the family, which lead Dr. Pollanen to reconsider his findings and to conduct a thorough, meticulous, and objective re- examination of all the evidence. In his re-examination, he realized that one block of tissue was not properly aligned. He reset the sample and upon re-examination it became apparent that there was an intra-cranial adventitial dissection of the left vertebral artery which, in his estimation, was only three days old. As a result of his findings on this re-examination of the slides he wrote another report dated November 2001 in which he concluded that Ms. Lewis had died from natural causes. But he did not abandon completely his earlier work with Deck. He said Deck's theory of subtle arterial injury inside and outside the skull from chiropractic manipulation remains "a possible explanation." However, when pushed hard by Mr. Schneider, Dr. Pollanen characterized that hypothesis as "improbable." "I am not aware of any finding which cannot be explained by atherosclerosis," he said. Dr. Pollanen was questioned as to his rationale for changing his report. He said "Everything done as of October 2001 would have been the appropriate thing to do. This case must be approached with a scientific method, state of mind, and objectiveness. To do less would be pointless." "If I had it to do over again, I would do several things differently," he said of the original investigation and conclusion. Dr. Pollanen insisted that he changed his opinion based on "new evidence". He indicated "It is a fact that you would expect a dissection from SMT to be extra-cranial. It must be. There was no evidence of trauma [in this case]." Dr. Pollanen conceded that not everyone agrees with his findings. Review of Literature During the course of the day, Mr. Schneider questioned Dr. Pollanen on his review of the existing literature. Dr. Pollanen indicated that in 2000 he did a MedLine search (with studies and cases dating back to 1966) on the criteria of death by clinical neck manipulation. In total he found nine cases, eight were related to chiropractic and one was to naturopathy. In these cases the age ranged from 20 to 60, with a mean of 42 years of age and average of 50 years of age. The onset of symptoms ranged from immediate to 5 days, and the interval to death ranged from 16.5 hours to 16 days. He indicated that while he found similarities to Ms. Lewis's death, there were many differences that did not allow for direct comparisons. Mr. Schneider asked if he found any correlation between dissection and neck pain, and Dr. Pollanen indicated "...neck pain is correlated to extra-cranial dissection..." In his cross examination on May 8th, Mr. Brian Foster, lawyer for Ms. Lewis's chiropractor, questioned Dr. Pollanen on more recent literature on this subject. Dr. Pollanen indicated that in a January 2002 article published in the journal Brain a case from Tokyo was presented in which a man died from a dissection suffered as a result of a motor vehicle accident. The individual died 14 days following the accident. Pollanen noted that there were some similarities between this case and that of the Lewis case. He contacted the Tokyo doctor and requested to see the neuropathological slides. While examining the slides, Dr. Pollanen recalled a case in Toronto which was similar. It involved a 25 year old male who suffered a dissection following a snowmobile accident. This individual died 21 days later. In reviewing the slides from the two new cases, Dr. Pollanen noted that the healing process was much more advanced than that seen in Ms. Lewis's slides. This substantiated his belief that the intra- cranial dissection was fresh, not more than three days old. Dr. Pollanen felt that these two confirmed cases of dissection provided a control against which to further test his hypothesis that no dissection was present in Ms. Lewis that was old enough to be connected with the SMT she had received on August 26, 1996. This confirmed in his mind that the atherosclerosis disease process, not trauma from SMT, explained a lot of Ms. Lewis's histological findings. Dr. Pollanen is expected to continue on the stand until the end of the week. Mr. Foster will resume his cross-examination on Thursday. Background of Dr. Michael Pollanen Dr. Pollanen is an associate professor with the University of Toronto, a consultant with the Forensic Pathology Unit of the Office of the Coroner, Ontario, and a visiting medical examiner for the Office of the Chief Medical Examiner, Washington, D.C. Since 1987, he has published 51 articles in medical and scientific journals, as well as one text book. In 1995, he won a Governor General's gold medal for his Ph.D. dissertation in neuropathology. While he has an extensive background in science and considerable experience as a neuropathologist, he did not become an M.D. until 1999. He is considered to be a prominent pathologist whose services are in demand around the world, and he has been recognized as an expert witness at this inquest. Immediately prior to this inquest he was in East Timor where he was performing autopsies for the United Nations on possible torture victims. By 1996 he had performed nearly 1,000 autopsies. Media Attention The majority of the media pick-up on this issue continues to be greatest in the Ontario, and more specifically the Toronto, area. Coverage over the past few days has appeared in The Globe and Mail, Toronto Star, and Toronto Sun with headlines reading "Clogged artery blamed in death: conclusion that neck manipulation caused fatal stroke was wrong, pathologist says." "Pathologists missed clues in death: Blood pressure not chiropractic to blame, MD says." The CCWG is continuing to issue periodic press releases to the media, ensuring that a summary of the key findings can be found on the media news wire. Keeping in Contact Please contact us if there has been any change in your contact information. Reach us by fax at (416) 482-3629; e-mail at infochange@cmcc.ca; or mail at Alumni Affairs, Canadian Memorial Chiropractic College, 1900 Bayview Ave, Toronto, Ontario, M4G 3E6. In the meantime, if you have questions about this bulletin, please feel free to contact us by phone, fax or e-mail using the contact information listed in this bulletin. ------------------------------------------------------------ -------------------- The Communications Working Group is comprised of the following organizations: Canadian Chiropractic Association: Phone (416) 781-5656; Toll-free 1-800-668-2076; website www.ccachiro.org; e-mail ccachiro@ccachiro.org Ontario Chiropractic Association: Phone (905) 629-8211; Toll-free 1-877-327-2273; website www.chiropractic.on.ca; e-mail communications@chiropractic.on.ca Canadian Memorial Chiropractic College: Phone (416) 482-2340; Toll-free 1-800-669-2959; website www.cmcc.ca; e-mail communications@cmcc.ca Canadian Chiropractic Protective Association: Phone (416) 781-5656; Toll-free 1-800-668-2076; e-mail CCPAcommunications@ccachiro.org