A RISK-BENEFIT ANALYSIS OF SPINAL MANIPULATION THERAPY FOR RELIEF OF LUMBAR OR CERVICAL PAIN

APPROXIMATELY 12 MILLION Americans undergo spinal manipulation therapy (SMT) every year. Renewed interest in this method requires an analysi s of its reported risks and possible benefits. This review describes t wo patients with spinal cord injuries associated with SMT and establis hes the risk/benefit ratios for patients with lumbar or cervical pain. The first case is a man who underwent SMT for recurrent sciatica 4 ye ars after chemonucleolysis. During therapy, he developed bilateral sci atica with urinary hesitancy. After self-referral, myelography demonst rated a total block; he underwent urgent discectomy with an excellent result 3 months after surgery. The second patient with an indwelling B roviac catheter and a history of lumbar osteomyelitis underwent SMT fo r neck pain. Therapy continued for 3 weeks despite the development of severe quadriparesis. After self-referral, he underwent an urgent ante rior cervical decompression and removal of necrotic bone and an epidur al abscess with partial neurological recovery. An analysis of these ca ses and 138 cases reported in the literature demonstrates six risk fac tors associated with complications of SMT. These include misdiagnosis, failure to recognize the onset or progression of neurological signs o r symptoms, improper technique, SMT performed in the presence of a coa gulation disorder or herniated nucleus pulposus, and manipulation of t he cervical spine. Clinical trials of SMT have been summarized in seve ral recent articles. Although these reviews agreed that most trials ex hibited serious flaws, the data suggest that SMT demonstrates consiste nt effectiveness as an alternate treatment for adults with acute low b ack pain. SMT has not been shown to be superior to other conservative methods, nor to offer long-term benefits. It is concluded that the ris k/benefit ratio is acceptably low for SMT as therapy for adults with m idline low back pain of less than 1 week in duration. The ratio was un acceptably high for patients with radicular symptoms or signs associat ed with prolapsed discs and neck pain. Potential complications and unk nown benefits indicate that SMT should not be used in the pediatric po pulation.