Spinal manipulation: risks vs. benefits.

"Cervical Spine Manipulation: An Alternative Medical Procedure with Potentially Fatal Complications" (1), in this issue of the Southern Medical Journal details the tragic events that occurred with a young female after her procedure. It requires a critical analysis pertaining to the risks and benefits associated with cervical spine manipulation techniques. For the purpose of this editorial, the term manipulation will refer specifically to high velocity low amplitude thrust procedures. Inherent limitations associated with a case report preclude one from concluding that the cerebellar infarct sustained by this patient was the direct result of the cervical manipulation. However, a number of studies have reported that cervical spine manipulation procedures have been associated with adverse events including vertebral artery dissection (VAD). (2) In a review of the literature, Haldeman et al (2) found that of all the reported incidents of vertebral artery dissection, occlusion, or both identified from 1966 to 1993, 30% were associated with cervical spinal manipulation. Fortunately, most reports have estimated the risks of VAD to be extremely low (6 in 10 million); (3) however, some estimates have been reported to be as high as I in 400,000. (4) In addition, VADs can occur spontaneously and typically present with a first onset of neck pain or headaches; (5) hence, the possibility exists that a VAD might be present before the individual seeks care for their neck pain.

Historically, screening procedures used in an attempt to identify patients at risk for an adverse event with the use of cervical manipulation have been widely advocated, accepted as standard of care, and routinely used in clinical practice. (6) However, studies to date have largely failed to substantiate the ability of currently available screening procedures to identify at-risk patients before treatment. (7) Although the reported risks of an adverse event is extremely low, based on the continued publication of case reports similar to that presented by Dr. Leon-Sanchez and colleagues in this issue, clinicians should consider alternative treatment options to cervical spine thrust manipulation for the management of patients with neck pain or headaches. It has been demonstrated that thrust manipulation directed at the cervical spine is no more beneficial than nonthrust procedures in the management of patients with neck pain, and manipulation results in a higher prevalence of side effects. (8) It is possible, however, that a subgroup exists for whom cervical manipulation may result in larger clinical improvements than nonthrust techniques directed to the cervical spine. Further research is warranted to clarify the existence and size of this subgroup, with careful attention given to the risks and benefits.

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It has been demonstrated that physical therapists are concerned about the risks associated with thrust manipulation and only a small percentage incorporate such techniques into clinical pratice. (9) However, despite the fatal occurrence in the case report by Dr. Leon-Sanchez and colleagues and the reported risks associated with cervical spine manipulation, these risks cannot be extrapolated to manipulation techniques directed at the thoracic and lumbar spine. In fact, recently, evidence has begun to emerge suggesting that dramatic therapeutic benefits can occur with thoracic spine thrust manipulation in patients with mechanical neck pain while reducing the inherent risks associated with thrust procedures targeting the cervical spine. (10) This evidence suggests that thoracic spine manipulation may be a more prudent choice of initial intervention for patients with mechanical neck pain. However, the risks of cervical thrust manipulation cannot be viewed in isolation from the risks associated with competing therapies such as NSAIDs and in some cases cervical spine surgery. For example, the risks associated with the use of NSAIDs occur in the order of 7,600 deaths annually. (11)

Similar to the argument for the use of manipulation targeting the thoracic spine (benefits outweigh the potential risks), a similar case can be made for the use of thrust procedures directed at the lumbopelvic region. The primary risk associated with an adverse event in the lumbar spine has been reported to be cauda equina syndrome (approximately I in 6 million manipulations). In addition, a clinical prediction rule has been developed and validated, (12) demonstrating that a particular subgroup of patients with low back pain will respond rapidly and dramatically to thrust techniques directed at the lumbopelvic region. It has also been established that patients with low back pain who do not receive manipulation directed at the lumbopelvic region may experience a worsening in disability. (13) In lieu of the benefits of spinal manipulative techniques directed at the lumbar spine and minute inherent risks associated with these procedures, clinicians who identify the proper subgroup of patients likely to benefit from these techniques should incorporate them into clinical practice with confidence that the benefits outweigh the risks.

Current evidence does not support that the benefits of cervical spine manipulation for the management of any non-musculoskeletal condition including asthma, (14) otitis media, (15) or infatile colic (15) outweigh the potential risks. The limited evidence for thrust techniques in the management of musculoskeletal conditions including neck pain and headaches should be weighed within the context of competing treatments including medications or surgical intervention. A risk assessment comparing cervical manipulation and NSAIDs in the management of neck pain concluded that NSAIDs have a significantly greater rate of serious complications including death. (16) However, the tragic event that occurred in the case reported by Dr. Leon-Sanchez and colleagues suggest that the potential risks associated with cervical thrust procedures should be considered in light of the potential benefits and weighed against competing interventions. It should be recognized that the inherent risks associated with thrust manipulation directed at the cervical spine should not be extrapolated to the thoracic and lumbar regions. In fact, the aforementioned evidence suggests that clinicians should incorporate thoracic spine thrust manipulation for the management of patients with neck pain and lumbopelvic thrust manipulation in patients with low back pain into clinical practice.

References

1. Leon-Sanchez A, Cuetter A, Ferrer G. Cervical spine manipulation: an alternative medical procedure with potentially fatal complications. South Med J 2007;100:201-203.

2. Haldeman S, Kohlbeck F, McGregor M. Risk factors and precipitating neck movements causing vertebrobasilar artery dissection after cervical trauma and spinal manipulation. Spine 1999;24:785-794.

3. Hurwitz EL, Aker PD, Adams AH, et al. Manipulation and mobilization of the cervical spine. A systematic review of the literature. Spine 1996;21:1746-1759.

4. Magarey ME, Rebbeck T, Coughlan B, et al. Pre-manipulative testing of the cervical spine review, revision and new clinical guidelines. Man Ther 2004;9:95-108.

5. de Sousa JE, Halfon MJ, Bonardo P, et al. Different pain patterns in patients with vertebral artery dissections. Neurology 2005;64:925-926.

6. Refshauge KM, Parry S, Shirley D, et al. Professional responsibility in relation to cervical spine manipulation. Aust J Physiother 2002;48:171-179.

7. Childs JD, Flynn TW, Fritz JM, et al. Screening for vertebrobasilar insufficiency in patients with neck pain: manual therapy decision-making in the presence of uncertainty. J Orthop Sports Phys Ther 2005;35:300-306.

8. Hurwitz EL, Morgenstern H, Vassilaki M, et al. Adverse reactions to chiropractic treatment and their effects on satisfaction and clinical outcomes among patients enrolled in the UCLA Neck Pain Study. J Manipulative Physiol Ther 2004;27:16-25.

9. Adams G, Sim J. A survey of UK manual therapists' practice of and attitudes towards manipulation and its complications. Physiother Res Int 1998;3:206-227.

10. Cleland JA, Childs JD, McRae M, et al. Immediate effects of thoracic manipulation in patients with neck pain: a randomized clinical trial. Man Ther 2005;10:127-135.

11. Tamblyn R, Berkson L, Dauphinee WD, et al. Unnecessary prescribing of NSAIDs and the management of NSAID-related gastropathy in medical practice. Ann Intern Med 1997;127:429-438.

12. Childs JD, Fritz JM, Flynn TW, et al. A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study. Ann Intern Med 2004;141:920-928.

13. Childs JD, Flynn TW, Fritz JM, et al. A perspective for considering the risks and benefits of spinal manipulation in patients with low back pain. Man Ther 2006;11:316-320.

14. Balon JW, Mior SA. Chiropractic care in asthma and allergy. Ann Allergy Asthma Immunol 2004;93:S55-S60.

15. Ernst E. Chiropractic manipulation for non-spinal pain--a systematic review. N Z Med J 2003;116:U539.

16. Dabbs V, Lauretti WJ. A risk assessment of cervical manipulation vs. NSAIDs for the treatment of neck pain. J Manipulative Physiol Ther 1995;18:530-536.

Joshua A. Cleland, PT, PhD, OCS, FAAOMPT

From the Department of Physical Therapy, Franklin Pierce College, Concord, NH; Rehabilitation Services, Concord Hospital, Concord, NH; and Regis University Manual Therapy Fellowship Program, Denver, CO.

Reprint requests to Joshua A. Cleland, PT, PhD, OCS, FAAOMPT, Physical Therapy Program, Franklin Pierce College, 5 Chenell Drive, Concord, NH 03301. Email: [e-mail]

Accepted October 17, 2006.