Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress 2023 EHA Congress 2023 ASCO Annual Meeting
Clinical Collections
Advances in Alzheimer’s

At a glance: The ONWARDS insulin icodec trials

A round-up of the ONWARDS phase 3 clinical trials evaluating the novel weekly insulin icodec in people with diabetes.
ADVANCED SEARCH
Log in
Top
Chiropractic & Manual Therapies
Published in: Chiropractic & Manual Therapies 1/2018

Open Access 01-12-2018 | Review

Outcomes indicators and a risk classification system for spinal manipulation under anesthesia: a narrative review and proposal

Authors: Dennis DiGiorgi, John L. Cerf, Daniel S. Bowerman

Published in: Chiropractic & Manual Therapies | Issue 1/2018

Login to get access

Abstract

Over a period of decades chiropractors have utilized spinal manipulation under anesthesia (SMUA) to treat chronic back and neck pain. As an advanced form of manual therapy, SMUA is reserved for the patient whose condition has proven refractory to office-based manipulation and other modes of conservative care. Historically, the protocols and guidelines put forth by chiropractic MUA proponents have served as the clinical compass for directing MUA practice. With many authors and MUA advocates having focused primarily on anticipated benefit, the published literature contains no resource dedicated to treatment precautions and contraindications. Also absent from current relevant literature is acknowledgement or guidance on the preliminary evidence that may predict poor clinical outcomes with SMUA. This review considers risk and unfavorable outcomes indicators in therapeutic decision making for spinal manipulation under anesthesia. A new risk classification system is proposed that identifies patient safety and quality of care interests for a procedure that remains without higher-level research evidence. A scale which categorizes risk and outcome potential for SMUA is offered for the chiropractic clinician, which aims to elevate the standard of care and improve patient selection through the incorporation of specific indices from existing medical literature.
Literature
1.
Dagenais S, Mayer J, Wooley JR, Haldeman S. Evidence-informed management of chronic low back pain with medicine-assisted manipulation. Spine J. 2008;8(1):142–9.CrossRefPubMed
2.
Gordon RC. An evaluation of the experimental and investigational status and clinical validity of manipulation of patients under anesthesia: a contemporary opinion. J Manip Physiol Ther. 2001;24(9):603–11.CrossRef
3.
4.
5.
Cates JR, Young DN, Bowerman DS, Porter RC. An independent AGREE evaluation of the occupational medicine practice guidelines. Spine J. 2006;6(1):72–7.CrossRefPubMed
6.
Cates JR, Young DN, Guerriero DJ, Jahn WT, Armine JP, Korbett AB, Bowerman DS, Porter RC, Sandman T, King RA. An independent assessment of chiropractic practice guidelines. J Manip Physiol Ther. 2003;26(5):282–6.CrossRef
7.
Cates JR, Young DN, Guerriero DJ, Jahn WT, Armine JP, Korbett AB, Bowerman DS, Porter RC, Sandman TD, King RA. Independent guideline appraisal summary report for vertebral subluxation in chiropractic practice (CCP) guidelines. J Chiropr Med. 2002 Spring;1(2):72–4.CrossRefPubMedPubMedCentral
8.
Field MJ, Lohr KN, editors. Clinical practice guidelines: directions for a new program. Institute of Medicine (US) committee to advise the public health service on clinical practice guidelines. Washington: National Academies Press (US); 1990.
9.
DiGiorgi D. Spinal manipulation under anesthesia: a narrative review of the literature and commentary. Chiropractic Man Ther. 2013;21(1):14.
10.
Pauker SG, Kassirer JP. Therapeutic decision making: a cost-benefit analysis. N Engl J Med. 1975;293(5):229–34.CrossRefPubMed
11.
Poppen JL. The herniated intervertebral disk- an analysis of 400 verified cases. NEJM. 1945;232(8):211–5.CrossRef
12.
13.
14.
Clybourne HE. Manipulation of the low back region under anesthesia. J Am Osteopath Assoc. 1948;48(1):10–1.PubMed
15.
Chrisman OD, Mittnacht A, Snook GA. A study of the results following Rotatory manipulation in the lumbar Intervertebral-disc syndrome. J Bone Joint Surg Am. 1964;46:517–24.CrossRefPubMed
16.
Davis CG, Fernando CA, da Motta MA. Manipulation of the low back under general anesthesia: case studies and discussion. Journal of the Neuromusculoskeletal System. 1993;1(3):126–34.
17.
Herzog J. Use of cervical spine manipulation under anesthesia for management of cervical disk herniation, cervical radiculopathy, and associated cervicogenic headache syndrome. J Manipulative Physiol Ther. 1999;22(3):166–70.
18.
Vanlommel L, Luyckx T, Vercruysse G, Bellemans J, Vandenneucker H. Predictors of outcome after manipulation under anaesthesia in patients with a stiff total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2017;25(11):3637–3643.
19.
Cheuy VA, JRH F, Paxton RJ, Bade MJ, Zeni JA, Stevens-Lapsley JE. Arthrofibrosis associated with Total knee Arthroplasty. J Arthroplast. 2017;32(8):2604–11.CrossRef
20.
Morningstar MW, Strauchman MN. Manipulation under anesthesia for patients with failed back surgery: retrospective report of 3 cases with 1-year follow-up. J Chiropr Med. 2012;11(1):30–5.CrossRefPubMedPubMedCentral
21.
Cramer GD, Henderson CN, Little JW, Daley C, Grieve TJ. Zygapophyseal joint adhesions after induced hypomobility. J Manip Physiol Ther. 2010;33(7):508–18.CrossRef
22.
Epter RS, Helm S 2nd, Hayek SM, Benyamin RM, Smith HS, Abdi S. Systematic review of percutaneous adhesiolysis and management of chronic low back pain in post lumbar surgery syndrome. Pain Physician. 2009;12(2):361–78.PubMed
23.
Daniels CJ, Wakefield PJ, Bub GA, Toombs JD. A narrative review of lumbar fusion surgery with relevance to chiropractic practice. J Chiropr Med. 2016;15(4):259–71.CrossRefPubMedPubMedCentral
24.
Sun C, Tian J, Liu X, Guan G. MiR-21 promotes fibrosis and hypertrophy of ligamentum flavum in lumbar spinal canal stenosis by activating IL-6 expression. Biochem Biophys Res Commun. 2017;490(3):1106–11.CrossRefPubMed
25.
Xu YQ, Zhang ZH, Zheng YF, Feng SQ. MicroRNA-221 regulates hypertrophy of Ligamentum Flavum in lumbar spinal Stenosis by targeting TIMP-2. Spine. 2016;41(4):275–82.CrossRefPubMed
26.
Harvey LA, Katalinic OM, Herbert RD, Moseley AM, Lannin NA, Schurr K. Stretch for the treatment and prevention of contractures. Cochrane Database Syst Rev. 2017;9:1.
27.
Morningstar MW, Strauchman MN. Management of a 59-year-old female patient with adult degenerative scoliosis using manipulation under anesthesia. J Chiropr Med. 2010;9(2):77–83.CrossRefPubMedPubMedCentral
28.
Taber DJ, James GD, Jacon A. Manipulation under anesthesia for lumbopelvic pain: a retrospective review of 18 cases. J Chiropr Med. 2014;13(1):28–34.CrossRefPubMedPubMedCentral
29.
Peterson CK, Humphreys BK, Vollenweider R, Kressig M, Nussbaumer R. Outcomes for chronic neck and low back pain patients after manipulation under anesthesia: a prospective cohort study. J Manip Physiol Ther. 2014;37(6):377–82.CrossRef
30.
31.
Mensor MC. Non-operative treatment, including manipulation, for lumbar intervertebral disc syndrome. J Bone J Surg. 1955;37A:925–36.CrossRef
32.
Mensor MC. Non-operative treatment, including manipulation, for lumbar intervertebral-disc syndrome. J Bone Joint Surg Am. 1965;47-A:1073–4.CrossRef
33.
Siehl D, Olson DR, Ross HE, Rockwood EE. Manipulation of the lumbar spine with the patient under general anesthesia: evaluation by electromyography and clinical-neurologic examination of its use for lumbar nerve root compression syndrome. J Am Osteopath Assoc. 1971;70:433-440.
34.
Greenman PE. Manipulation with the patient under anesthesia. J Am Osteopath Assoc. 1992;92(9):1159–60. 1167-70PubMed
35.
Hughes BL. Management of cervical disk syndrome utilizing manipulation under anesthesia. J Manip Physiol Ther. 1993;16(3):174–81.
36.
Cremata E, Collins S, Clauson W, Solinger AB, Roberts ES. Manipulation under anesthesia: a report of four cases. J Manip Physiol Ther. 2005;28(7):526–33.CrossRef
37.
Davis CG. Chronic cervical spine pain treated with manipulation under anesthesia. Journal of the Neuromusculoskeletal System. 1996;4(3):102–15.
38.
Palmieri NF, Smoyak S. Chronic low back pain: a study of the effects of manipulation under anesthesia. J Manip Physiol Ther. 2002;25(8):E8–E17.CrossRef
39.
Kohlbeck FJ, Haldeman S, Hurwitz EL, Dagenais S. Supplemental care with medication-assisted manipulation versus spinal manipulation therapy alone for patients with chronic low back pain. J Manip Physiol Ther. 2005;28(4):245–52.CrossRef
40.
Peterson CK, Leemann S, Lechmann M, Pfirrmann CW, Hodler J, Humphreys BK. Symptomatic magnetic resonance imaging-confirmed lumbar disk herniation patients: a comparative effectiveness prospective observational study of 2 age- and sex-matched cohorts treated with either high-velocity, low-amplitude spinal manipulative therapy or imaging-guided lumbar nerve root injections. J Manip Physiol Ther. 2013;36(4):218–25.CrossRef
41.
Ehrler M, Peterson C, Leemann S, Schmid C, Anklin B, Humphreys BK. Symptomatic, MRI confirmed, lumbar disc Herniations: a comparison of outcomes depending on the type and anatomical axial location of the hernia in patients treated with high-velocity, low-amplitude spinal manipulation. J Manip Physiol Ther. 2016;39(3):192–9.CrossRef
42.
Wright JG, Swiontkowski MF, Heckman JD. Introducing levels of evidence to the journal. J Bone Joint Surg Am. 2003;85-A(1):1–3.CrossRefPubMed
43.
Kreiner DS, Hwang SW, Easa JE, Resnick DK, Baisden JL, Bess S, Cho CH, MJ DP, Dougherty P 2nd, Fernand R, Ghiselli G, Hanna AS, Lamer T, Lisi AJ, Mazanec DJ, Meagher RJ, Nucci RC, Patel RD, Sembrano JN, Sharma AK, Summers JT, Taleghani CK, Tontz WL Jr, Toton JF. An evidence-based clinical guideline for the diagnosis and treatment of lumbar disc herniation with radiculopathy. Spine J. 2014;14(1):180–91.CrossRefPubMed
44.
Peterson CK, Pfirrmann CW, Hodler J, Leemann S, Schmid C, Anklin B, Humphreys BK. Symptomatic, magnetic resonance imaging-confirmed cervical disk Herniation patients: a comparative-effectiveness prospective observational study of 2 age- and sex-matched cohorts treated with either imaging-guided indirect cervical nerve root injections or spinal manipulative therapy. J Manip Physiol Ther. 2016;39(3):210–7.CrossRef
45.
Bremner RA. Manipulation in the management of chronic low backache due to lumbosacral strain. Lancet. 1958;4;1(7010):20–1.CrossRef
46.
Bremner RA, Simpson M. Management of chronic Iumbosacral strain. Lancet. 1959;28;2(7109):949–50.CrossRef
47.
Krumhansl BR, Nowacek CJ. Manipulation under anesthesia. In: Grieve GP, editor. Modern manual therapy of the vertebral column. Edinburgh: Churchill Livingstone; 1986. p. 777–86.
48.
Barth RJ. Claimant-reported history is not a credible basis or clinical for administrative decision making. AMA Guides Newsletter September/October. 2009:1–7.
49.
Barth RJ. Chronic pain: fundamental scientific considerations, specifically for legal claims. AMA Guides Newsletter. January/February. 2013:1–18.
50.
Carragee EJ. Validity of self-reported history in patients with acute back or neck pain after motor vehicle accidents. Spine J. 2008;8(2):311–9.CrossRefPubMed
51.
Kumar N, Wijerathne SI, Lim WW, Barry TW, Nath C, Liang S. Resistive straight leg raise test, resistive forward bend test and heel compression test: novel techniques in identifying secondary gain motives in low back pain cases. Eur Spine J 2012;21(11):2280-2286.
52.
Weiner SS, Weiser SR, Carragee EJ, Nordin M. Managing nonspecific low back pain: do nonclinical patient characteristics matter? Spine. 2011;36(23):1987–94.CrossRefPubMed
53.
Kongsted A, Kent P, Axen I, Downie AS, Dunn KM. What have we learned from ten years of trajectory research in low back pain? BMC Musculoskelet Disord 2016;17:220.
54.
Globe G, Farabaugh RJ, Hawk C, Morris CE, Baker G, Whalen WM, Walters S, Kaeser M, Dehen M, Augat T. Clinical practice guideline: chiropractic Care for low Back Pain. J Manip Physiol Ther. 2016;39(1):1–22.CrossRef
55.
Krismer M, van Tulder M. Low back pain Group of the Bone and Joint Health Strategies for Europe project. Strategies for prevention and management of musculoskeletal conditions. Low back pain (non-specific). Best Pract Res Clin Rheumatol. 2007;21(1):77–91.CrossRefPubMed
56.
Bigos SJ, Battié MC, Spengler DM, Fisher LD, Fordyce WE, Nachemson AL HT, Wortley MD. A prospective study of work perceptions and psychosocial factors affecting the report of back injury. Spine. 1991;16(1):1–6.CrossRefPubMed
57.
Hicks GE, Fritz JM, Delitto A, SM MG. Preliminary development of a clinical prediction rule for determining which patients with low back pain will respond to a stabilization exercise program. Arch Phys Med Rehabil. 2005;86(9):1753–62.CrossRefPubMed
58.
Mehling WE, Ebell MH, Avins AL, Hecht FM. Clinical decision rule for primary care patient with acute low back pain at risk of developing chronic pain. Spine J. 2015;15(7):1577–86.CrossRefPubMedPubMedCentral
59.
Flynn T, Fritz J, Whitman J, Wainner R, Magel J, Rendeiro D, Butler B, Garber M, Allison S. A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine. 2002;27(24):2835–43.CrossRefPubMed
60.
Don AS, Carragee EJ. Is the self-reported history accurate in patients with persistent axial pain after a motor vehicle accident? Spine J. 2009;9(1):4–12.CrossRefPubMed
61.
Barth RJ. Determining injury-relatedness, work-relatedness, and claim-relatedness. AMA Guides Newsletter. 2012:1–10.
62.
Feinberg SD, Brigham CR, Ensalada L. Assessing impairment and disability in the pain patient. AMA Guides Newsletter January/February. 2016:3–10.
63.
Bigos S, Bowyer O, Braen G, et al. Acute Low Back Problems in Adults. Clinical Practice Guideline No. 14. AHCP0R publication no. 95–0642. Rockville: MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services; 1994.
64.
Gorrell LM, Engel RM, Brown B, Lystad RP. The reporting of adverse events following spinal manipulation in randomized clinical trials-a systematic review. Spine J. 2016;16(9):1143–51.CrossRefPubMed
65.
66.
Cassidy JD, Boyle E, Côté P, He Y, Hogg-Johnson S, Silver FL, Bondy SJ. Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study. J Manip Physiol Ther. 2009;32(2 Suppl):S201–8.CrossRef
67.
Cassidy JD, Boyle E, Côté P, Hogg-Johnson S, Bondy SJ, Haldeman S. Risk of carotid stroke after chiropractic care: a population-based case-crossover study. J Stroke Cerebrovasc Dis. 2017;26(4):842–50.CrossRefPubMed
68.
Testai FD, Gorelick PB. An unusual cause of vertebral artery dissection: esophagogastroduodenoscopy. Stroke Res Treat. 2010;2010.
69.
Wuest S, Symons B, Leonard T, Herzog W. Preliminary report: biomechanics of vertebral artery segments C1-C6 during cervical spinal manipulation. J Manip Physiol Ther. 2010;33(4):273–8.CrossRef
70.
Herzog W, Tang C, Leonard T. Internal carotid artery strains during high-speed, low-amplitude spinal manipulations of the neck. J Manip Physiol Ther. 2015;38(9):664–71.CrossRef
71.
Hebert JJ, Stomski NJ, French SD, Rubinstein SM. Serious adverse events and spinal manipulative therapy of the low back region: a systematic review of cases. J Manip Physiol Ther. 2015;38(9):677–91.CrossRef
72.
Shekelle PG, Adams AH, Chassin MR, Hurwitz EL, Brook RH. Spinal manipulation for low-back pain. Ann Intern Med. 1992;117(7):590–8.CrossRefPubMed
73.
Owens WD, Felts JA, Spitznagel EL Jr. ASA physical status classifications: a study of consistency of ratings. Anesthesiology. 1978;49(4):239–43.CrossRefPubMed
74.
Qaseem A, Snow V, Fitterman N, Hornbake ER, Lawrence VA, Smetana GW, Weiss K, Owens DK, Aronson M, Barry P, Casey DE Jr, Cross JT Jr, Fitterman N, Sherif KD, Weiss KB. Clinical efficacy assessment Subcommittee of the American College of physicians. Risk assessment for and strategies to reduce perioperative pulmonary complications for patients undergoing noncardiothoracic surgery: a guideline from the American College of Physicians. Ann Intern Med. 2006;44(8):575–80.CrossRef
75.
Hurwitz EE, Simon M, Vinta SR, Zehm CF, Shabot SM, Minhajuddin A, Abouleish AE. Adding examples to the ASA-physical status classification improves correct assignment to patients. Anesthesiology. 2017;126(4):614–22.CrossRefPubMed
76.
American Academy of osteopathy consensus statement for osteopathic manipulation of somatic dysfunction under anesthesia and conscious sedation. The American Academy of Osteopathy Journal. 2005;15(2):26–7.
77.
78.
Wilson JN, Ilfeld FW. Manipulation of the herniated intervertebral disc. Am J Surg. 1952;83(2):173–5.CrossRefPubMed
79.
Siehl D, Bradford WG. Manipulation of the low back under general anesthesia. J Am Osteopath Assoc. 1952;52(4):239–42.PubMed
80.
81.
Siehl D. Manipulation of the spine under general anesthesia. J Am Osteopath Assoc. 1963;62:881–7.
82.
Tospon HN. Manipulation of the lumbar spine under anesthesia. The Orthop. 1972;9:4.
83.
Morey LW Jr. Osteopathic manipulation under general anesthesia. J Am Osteopath Assoc. 1973;73(2):116–27.PubMed
84.
Scherrer H. Hernia of intervertebral disc: treatment by manipulation under general anesthesia. Z Orthop Ihre Grenzgeb. 1977;115(5):772–8. [abstract]PubMed
85.
86.
Metadata
Title
Outcomes indicators and a risk classification system for spinal manipulation under anesthesia: a narrative review and proposal
Authors
Dennis DiGiorgi
John L. Cerf
Daniel S. Bowerman
Publication date
01-12-2018
Publisher
BioMed Central
Published in
Chiropractic & Manual Therapies / Issue 1/2018
Electronic ISSN: 2045-709X
DOI
https://doi.org/10.1186/s12998-018-0177-z

Other articles of this Issue 1/2018

Chiropractic & Manual Therapies 1/2018 Go to the issue

Review

Unravelling functional neurology: a critical review of clinical research articles on the effect or benefit of the functional neurology approach

Research

Changes in pain knowledge, attitudes and beliefs of osteopathy students after completing a clinically focused pain education module

Research

Impact of the workforce distribution on the viability of the osteopathic profession in Australia: results from a national survey of registered osteopaths

Hypothesis

Spontaneous cervical artery dissection: a fluoroquinolone induced connective tissue disorder?

Commentary

Chiropractic in Global Health and wellbeing: a white paper describing the public health agenda of the World Federation of Chiropractic

Research

Spinal manipulation in the treatment of patients with MRI-confirmed lumbar disc herniation and sacroiliac joint hypomobility: a quasi-experimental study