A Risk/Benefit Analysis of Spinal Manipulation Therapy for Relief of Lumbar or Cervical Pain

Abstract

Approximately 12 million Americans undergo spinal manipulation therapy (SMT) every year. Renewed interest in this method requires an analysis of its reported risks and possible benefits. This review describes two patients with spinal cord injuries associated with SMT and establishes the risk/benefit ratios for patients with lumbar or cervical pain. The first case is a man who underwent SMT for recurrent sciatica 4 years after chemonucleolysis. During therapy, he developed bilateral sciatica with urinary hesitancy. After self-referral, myelography demonstrated a total block; he underwent urgent discectomy with an excellent result 3 months after surgery. The second patient with an indwelling Broviac catheter and a history of lumbar osteomyelitis underwent SMT for neck pain. Therapy continued for 3 weeks despite the development of severe quadriparesis. After self-referral, he underwent an urgent anterior cervical decompression and removal of necrotic bone and an epidural abscess with partial neurological recovery. An analysis of these cases and 138 cases reported in the literature demonstrates six risk factors associated with complications of SMT. These include misdiagnosis, failure to recognize the onset or progression of neurological signs or symptoms, improper technique, SMT performed in the presence of a coagulation disorder or herniated nucleus pulposus, and manipulation of the cervical spine. Clinical trials of SMT have been summarized in several recent articles.(ABSTRACT TRUNCATED AT 250 WORDS)

Safety of Spinal Manipulation in the Treatment of Lumbar Disk Herniations: A Systematic Review and Risk Assessment

“…Powell et al, 31 after reviewing the literature, feel the risk/ benefit ratio in patients with acute midline lumbar pain is Hadler et al 43 Refer to Appendix 2 for definitions of the letters A to Q. * Studies whose primary purpose was to look at adverse reactions of spinal manipulation.…”

“…Powell et al 31 suggest the presence of a herniated nucleus pulposus as a risk factor to spinal manipulation; however, these authors seem to base their opinion on 2 cases presented and some cases of disk herniation following manipulation reviewed from the literature, without regard for the total number of spinal manipulations performed.…”

“…5,10-12,14-18 Some feel the goal of diskectomy is to provide more rapid relief of sciatica 10 or reduce pain and disability 12 in patients who have failed to resolve with conservative management, but others do not feel that failure of passive conservative care is an appropriate criterion for proceeding to surgical intervention, 11 since appropriate criteria and optimal timing of surgery are unknown. 10 [28][29][30][31] and disk herniation is the leading cause of claims against chiropractors. 32 There are no large prospective studies published on the use of spinal manipulation on patients with LDH with which to measure the outcome and complications accurately and compare with natural history or other treatments.…”

Vertebral artery strains during high-speed, low amplitude cervical spinal manipulation

“…Nevertheless, there has been increased interest over the past three decades to elucidate the possible damaging effects of SMT forces on internal tissues (Cote et al, 1994;Haldeman et al, 2001;Haldeman and Rubinstein, 1992a,b;Ianuzzi and Khalsa, 2005;Paciaroni and Bogousslavsky, 2009;Powell et al, 1993;Rubinstein, 2008;Rubinstein and Haldeman, 2001;Terrett and Kleynhans, 1980). One of the major issues of the use of SMT is its safety, especially with regards to neck manipulation and the risk of stroke (Lee et al, 1995;Paciaroni and Bogousslavsky, 2009;Rubinstein, 2008;Wuest et al, 2010).…”

Spinal Epidural Hematoma After Spinal Manipulative Therapy in a Patient Undergoing Anticoagulant Therapy: A Case Report

“…17 Risk factors for complications of SMT may include failure to recognize signs or symptoms of neurologic involvement, coagulation disorders, and manipulation of the cervical spine. 18 Normally, benign and even trivial physical movements or stimuli may be sufficient to trigger the development of SEH in susceptible individuals. Interestingly, SEH precipitated by coughing has been reported in anticoagulated patients.…”