Abstract

Object: The authors report a series of 22 patients in whom major complications developed after cervical spinal manipulation therapy (CSMT). A second objective was to estimate the regional incidence of these complications and to compare it with the very low incidences reported in the literature.
Methods: During a 5-year period, practioners at a single group neurosurgical practice in Tulsa, Oklahoma, treated 22 patients, who were markedly worse during, or immediately after, CSMT. The details of these cases are reported. The 1995 US Government National Census was used to define the regional referral population for Tulsa. The published data regarding the incidence of serious CSMT-related complications and the rate of CSMTs undertaken nationally were used to estimate the expected number of CSMT-related complications in the authors' region. The number (22 cases) reported in this series was used to estimate the actual regional incidence.
Complications in the series included radiculopathy (21 cases), myelopathy (11 cases), Brown-Séquard syndrome (two cases), and vertebral artery (VA) occlusion (one case). Twenty-one patients underwent surgery. Poor outcomes were observed in three, outcome was unchanged in one, and 17 improved. The number of patients in this series exceeded the expected number for the region.
Conclusions: Cervical spinal manipulation therapy may worsen preexisting cervical disc herniation or cause disc herniation resulting in radiculopathy, myelopathy, or VA compression. In cases of cervical spondylosis, CSMT may also worsen preexisting myelopathy or radiculopathy. Manipulation of the cervical spine may also be associated with higher complication rates than previously reported.

Introduction

Cervical spinal manipulation therapy is a common modality for the treatment of neck pain and headache with between 18 and 38 million such treatments performed yearly by US chiropractors.^[46] There are several types of spinal manipulation. One type is the high-velocity, low-amplitude thrust technique the goal of which is to provide a "sharp thrust with velocity" to induce a gap in the joint.^[15] Numerous complications have been reported from cervical spinal manipulation (Table 1).^{[2,3,5,7,9,11,12,14, 16-18,23,24,26-29,31,32,36-38,41,42,44,47,49]} Some practioners have advocated manipulation of the cervical spine in cases of MR imaging-documented cervical disc herniation.^[4] The use of general anesthesia as an adjunct to cervical spine manipulation in cases of cervical disc herniation has also been supported by some authors.^[20] Serious CSMT-related complications are reported to be rare.^{[9,10,18,21,24,35]} In other studies investiagors have found that these complications occur more frequently.^[27,28] The purpose of this study was to report the types of complications documented in a single group practice of six neurosurgeons.