Editorial

Spinal Manipulation: Risks vs. Benefits

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

Abstract

“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 al2 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 1 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.

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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.