Journal of Manipulative and Physiological Therapeutics
Review of LiteratureSafety of Spinal Manipulation in the Treatment of Lumbar Disk Herniations: A Systematic Review and Risk Assessment
Introduction
The lifetime prevalence of symptomatic herniated disks is estimated at 1% to 3%,1., 2. although anatomic evidence of disk herniation is said to be found in 20% to 40% of imaging tests among asymptomatic persons. 3., 4. Most clinically relevant herniations occur between the ages of 30 and 50 but can also occur in adolescents and older people.5 Two percent to 5% of patients seeking help are thought to suffer from a disk herniation,6 while others think that in about 40% of low back pain (LBP) patients the cause is internal disk disruption.7 Conservative care, or natural history, is beneficial in more than 50% of patients with disk herniation and sciatica6., 8., 9. and is associated with a low complication rate.6 Ten percent of LBP patients account for more than 80% of the total health care and social costs. It is estimated that the 1% to 2% of low back pain patients who undergo surgery for disk herniation account for as much as one third of the costs, yet the evidence for most surgical procedures is still unclear.10 Surgery has not been proven to be more effective than conservative care11 and has a complication rate of 24%, almost half of which are major complications.12
Even though 70% of patients will recover adequately, 30% of patients with lumbar radiculopathy in one study continued to have back pain, reduced capacity in work, and restriction of leisure activities, and 19% were still out of work after 1 year in both the nonsteroidal anti-inflammatory drug (NSAID) and control groups.13 Because the natural history of lumbar disk herniation (LDH) is favorable in the majority of patients, the goal of care must be to accelerate recovery beyond natural history itself, improve the quality of life during and after the recovery process,11 and provide relief when natural history is not favorable. Any treatment that can be shown to do this safely and cost-effectively should be utilized more often.
There is a general consensus among contemporary orthopedists that for most patients with LDH, a trial of conservative treatment is preferable initially over surgical intervention.5., 10., 11., 12., 14., 15., 16., 17., 18. Some feel the goal of diskectomy is to provide more rapid relief of sciatica10 or reduce pain and disability12 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 Conservative treatment of LDH by medical doctors and physical therapists usually does not include spinal manipulation,11., 12., 18., 19., 20. while chiropractors commonly treat LDH with spinal manipulation. The efficacy and the risk of this treatment are not known; however, a number of case studies show spinal manipulation to be effective in the treatment of LDH, even after other treatments have failed to provide relief.2., 6., 14., 21., 22., 23., 24., 25., 26., 27. There is evidence that spinal manipulation has a beneficial effect on pain, straight-leg raising (SLR), range of motion, size of disk herniation, neurologic symptoms, and H-reflex. Detractors, however, suggest spinal manipulation is responsible for causing disk herniations and cauda equina syndrome (CES),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. Estimates of the risk of causing LDH or CES with lumbar spinal manipulation performed for any reason range from one in 1 million to one in over 100 million.30., 33., 34. CES consists of neurogenic bowel and bladder disturbances (usually urinary retention), saddle anesthesia, bilateral leg weakness, and sensory changes33 and is the most serious sequela of LDH. It has been reported to occur in 1% to 16% of all reported cases of LDH.35 Manipulation of any sort is contraindicated in the presence of CES,16 as this represents a surgical emergency. The only estimate of the risk of spinal manipulation in patients presenting with probable LDH calculated the risk to be between 0% and 5%.6 The purposes of this article are to review the literature and to estimate the risk of spinal manipulation causing a clinically worsened disk herniation or CES in a patient presenting with LDH.
Section snippets
Methods
Databases, including MEDLINE and MANTIS, were searched from 1966 to present. Search terms included lumbar disk herniation, intervertebral disk, back pain, cauda equina syndrome, spinal manipulation, and complications. References from articles retrieved were reviewed for additional articles. Tables of contents of some journals were reviewed for relevant articles.
Papers were included if they discussed lumbar spinal manipulation and lumbar disk herniation, CES, or other complications of lumbar
Discussion
Many authors recommend the use of spinal manipulation in the treatment of LDH,2., 6., 8., 14., 16., 21., 22., 23., 24., 25., 26., 54. while some recommend against it,5., 31., 49. and disk herniation is the most common claim against chiropractors.32 Therefore, it is important to estimate the risk of serious complications of spinal manipulation in the treatment of LDH using the best available evidence. The serious complications that spinal manipulation could cause in a patient with LDH are a
Conclusion
Evidence-based care, as the term implies, bases the care a patient is given on the best evidence available in the research literature. The risk of spinal manipulation causing a clinically worsened disk herniation or CES in a patient presenting with LDH has been calculated to be less than 1 in 3.7 million manipulations.
Definitive treatment for LDH is currently unknown, but conservative care options should be exhausted prior to surgical treatment. Spinal manipulation is often left out of the
Acknowledgements
This paper was written as partial requirement for Masters of Applied Science Degree in Musculoskeletal Management, Royal Melbourne University and Southern California University of Health Sciences.
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