Safety of Spinal Manipulation in the Treatment of Lumbar Disc Pathology: Current Concepts in Literature: Review 2016

CHAPTER 6

Safety of Spinal
Manipulation in the
Treatment of Lumbar
Disc Pathology

Current Concepts in Literature: Review 2016

Dr James Inklebarger

Introduction

Spinal manipulation is considered a relatively risk-free intervention for the treatment of musculoskeletal conditions when administered skilfully and accurately. The primary adverse reactions include temporary exacerbation of symptoms or new local symptoms. Serious complications of manipulation are rarely reported. However, in recent years, a number of adverse outcomes associated with lumbar spine manipulation, such as lumbar disc annular tears (LDAT), lumbar disc herniation (LDH) and degenerative disc disease (DDD), have been reported in the literature (Boucher and Robidoux, 2014). In contrast, there is also a growing body of evidence that spinal manipulation (SMT) is a safe and effective intervention for the management of acute and chronic discogenic low back pain (DLBP) (Oliphant, 2004).

It is, therefore, important to determine whether the risks associated with SMT can outweigh the benefits. Informed consent and modern clinical decision-making processes rely on the evidence base of medicine to calculate risk versus benefit ratios. The methodology can also be applied to SMT for the management of DLBP. The actual risk of serious complications, such as cauda equina syndrome (CES), LDAT and LDH, arising from lumbar manipulation can be ascertained by reviewing literature reporting adverse outcomes.

Although determining an actual risk versus benefit ratio for SMT is profoundly difficult on a global scale, the job is less strenuous when it is calculated in a selected group of people. As chiropractors in the United States represent the largest professional body of lumbar spine manipulators across the globe (Weeks, 2009), the total number of reported complications following SMT from this group can be used to determine an estimated risk associated with the therapy. However, it is fair to point out that these reports appear to have lumped chiropractors together with other spinal manipulators, such as surgeons, physiotherapists and massage therapists, as well as unskilled lay and general practitioners who may have less skill, education and experience.

Risk v Benefit Ratio for Lumbar SMT

The risk of serious complications after lumbar SMT can be estimated by excluding the minor and transient adverse reactions. This can be accomplished by making a statistical comparison between the number of serious adverse events reported in the literature and the numbers of patients receiving SMT. Many authors, including Adams and Sim (1998), Cagnie et al. (2004) and Smith et al. (1995), have attempted to put things in perspective. However, the exact rate of such adverse events is yet not known. Moreover, these estimates of risks have been reported to vary widely between studies (see Table 6.1).

Table 6.1 Rate of serious adverse events due to lumbar manipulation
Rate of complications	Nature of complication	Authors
1 per 10–100 million	CES	Shekelle et al. (1992)
1 per 286 million	CES	Haldeman and Rubinstein (1992)
1 per 1 million	CES	Assendelft, Boulter and Knipschild (1996)
1 per 100 million	CES	Coulter (1998)
1 per 3.7 million	LDH, LDAT and CES	Oliphant (2004)

The rate of serious complications after lumbar manipulation, such as LDH, LDAT and CES, have been reported in the chiropractic literature as 1 per 3.7 million (Oliphant, 2004), with the risk virtually doubling in cases where lumbar SMT was performed under anaesthesia (MUA) (Haldeman and Rubenstein, 1992). Using 40 years of United States chiropractic patient data, Oliphant calculated the occurrence of LDH/CES in patients complaining of DLBP to be 1 in 46 million (Oliphant, 2004). In contrast to this study, Haldeman and Rubinstein (1992) in an earlier study have estimated SMT-associated CES to be 1 per 286 million.

To put the relative safety of manipulation in a clearer perspective, some authors have compared the safety of lumbar SMT against the conventional therapies such as non-steroidal anti-inflammatory drugs (NSAIDs) and lumbar spine fusion (LSF). NSAIDs are known to have serious renal, gastrointestinal (gastric erosions/ulcers leading to death) and asthma-exacerbating side effects. Coulter (1998) suggests that the use of lumbar manipulation is far safer than NSAIDs, as NSAIDs are associated with 3.2 complications per 1000 patients. Furthermore, excluding some of the serious adverse effects of NSAIDs such as renal complications and asthma symptom exacerbations, Henry et al. (1993, 1996) reported that the rate of NSAIDs-associated upper gastrointestinal complications in the adult population was 147 per 100,000 patients.

LSF is a popular surgical method for the management of intractable DLBP. Over 400,000 Americans undergo this costly procedure every year. Unfortunately, LSF is associated with many complications and had a failure rate of 13.2% in a five-year follow-up (Greiner-Perth et al., 2004). Despite the high failure rate of LSF, many patients suffering severe intractable discogenic pain have reported high levels of surgical satisfaction after the procedure. Nevertheless, LSF and surgical alternatives such as artificial disc replacement are permanent life-altering interventions, and therefore should be reserved for those whose conditions have failed to improve following conservative treatment (Inklebarger, 2014).

Taken together, it can be said that the risk of serious complications due to lumbar SMT is very low. Although some case-report authors would argue otherwise (Malawski et al., 1993; Li, 1989), based on the findings in the recent literature, SMT appears to be very safe for the treatment of low back pain (LBP). In fact, SMT has repeatedly been recommended as a relatively safe and effective intervention for the management of lumbar disc diseases.

For example, Bronfort et al. (2004) in a systematic review found SMT as effective as medical care for both the short- and long-term relief of LBP-associated disc herniation. Some studies even reported high-velocity, low-amplitude thrust (HVLAT) techniques as safe procedures for expediting the recovery period of both acute and chronic LDH (Quon et al., 1989; Leemann et al., 2014).

Biomedical research utilises a more novel approach to determine adverse effects of a therapy. Not surprisingly, the safety of SMT is also ensured by damage markers analysis. In a randomised controlled trial, Achalandabaso et al

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