Objective: Renal cell carcinoma accounts for 3% of adult malignancy and 95% of neoplasms arising from the kidney. One third of the patients have metastatic disease at the time of presentation and are asymptomatic with the diagnosis being made incidentally from a radiologic study obtained for other reasons. Typically, skeletal metastases are purely lytic. It is common for cases of back pain to be managed in chiropractic clinics. The diagnosis of metastatic disease is to be considered as a differential, especially in an aging population. Clinical Features: A 69-year-old man experienced back pain after a twisting movement while working. He presented for chiropractic care 2 weeks later. He had a 10-year history of low back pain and a 2-month history of weakness at the knee. Plain film radiography was assessed as negative for pathology by a medical radiologist and a chiropractic radiologist. Interventions and Outcomes: After 6 visits of care using atlas orthogonal adjusting, the outcome assessment revealed improvement in the pain but a regression in strength of the right quadriceps and peroneus muscles. The patient was referred for a magnetic resonance imaging study, which revealed a mass on the kidney and a large erosive bone lesion of the L4 vertebrae. The diagnosis of renal cell carcinoma was later confirmed. Conclusion: Progressive muscle weakness is one of the "red flag" signs in a back pain case. Advanced imaging is necessary to detect occult diseases processes such as renal cell carcinoma. The chiropractor's role as primary care clinician includes the process of clinical reasoning and appropriate referral when the clinical picture becomes unclear and/or "red flag" signs appear.

Objective: This case report describes chiropractic treatment for a patient diagnosed with bow hunter syndrome with transient vision loss (TVL). Clinical Features: A 39-year-old woman presented to a chiropractic clinic with hand and arm numbness that began after she was injured in a motor vehicle collision 18 months earlier. The primary symptom was TVL that began 3 days after the motor vehicle collision. At that time, she had been diagnosed with bow hunter syndrome using dynamic angiography findings. She had previously declined surgery recommended by her attending neurosurgeon at a local hospital. Intervention and Outcome: The patient was treated using atlas orthogonal chiropractic technique for 8 visits over a 6-week period. Examination before and the after the initial treatment included cervical radiographic analysis and vascular ultrasound measurement of the right and the left vertebral artery (VA). After the initial spinal manipulation, there was an improvement in blood flow volume of 8.2% in the left VA and 22.2% in the right VA. There was improvement of the symptom of TVL and a measured reduction of rotational misalignment of the first and second cervical vertebra on the radiographic views. After 6 weeks, the patient's perception of TVL was absent. Conclusion: A patient with TVL improved under chiropractic care using atlas orthogonal technique.