Spinal manipulation in patients with disc herniation: A critical review of risk and benefit



      Contradictions in the literature exist in terms of the use of spinal manipulation in the management of disc herniation, with some authors advocating its usefulness, and others suggesting it is contraindicated.


      To determine whether there is evidence from published reports on the clinical efficacy of spinal manipulation in the management of disc herniation, and to relate this to published data on harms.


      The major databases (MEDLINE, AHMED, Cochrane and Clinical Evidence) up to February 2006 were searched, and four UK insurance companies used by osteopaths and chiropractors were approached for information on incidence of adverse events.


      Four randomised controlled trials (RCT) relevant to the clinical question of efficacy were located. Three suggested some early benefit of manipulation compared to treatment controls. One suggested no benefit, and none suggested any long-term benefit. Three were of low methodological quality however, and one of better quality had very low patient numbers. Evidence for harms is based primarily on case reports, and incidences would appear to be rare, though underreporting may be a significant problem. No data was available from the insurance companies on incidences of adverse events. Some of the research on the effects of manipulation on the disc and the role of the disc in the generation of symptoms is briefly reviewed.


      There is a lack of strong evidence to support the role of spinal manipulation in disc herniation, though some weak evidence suggests it may be beneficial in the early stages. Some of the difficulties in gaining evidence on rare events and determining causality is discussed. The underlying pathophysiological mechanisms of benefit or harm are poorly understood.


      There is an urgent need for more research in this area in order to help practitioners make decisions on benefit versus harm. It is likely to be safe when used by appropriately-trained practitioners, however some of the reports discussed highlight the importance of a thorough case history and physical examination. It would seem reasonable that patients are warned of potential risk. Clinical guidelines within the osteopathic profession on the management of disc herniation are needed, for the protection of both patients and practitioners.


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        • Andersson G.
        Epidemiology of spinal disorders.
        in: Frymoyer J.W. Ducker T.B. Hadler N.M. Kostuik J.P. Weinstein J.N. Whitecloud T.S. The adult spine: principles and practice. Raven Press, New York1997: 93-141
        • Vroomen P.C.
        • de Krom M.C.
        • Slofstra P.D.
        • Knottnerus J.A.
        Conservative treatment of sciatica: a systematic review.
        J Spinal Disord. 2000; 13: 463-469
        • Weber H.
        The natural history of disc herniation and the influence of intervention.
        Spine. 1994; 19: 2234-2238
        • Anderson B.J.
        • Brown M.D.
        • Dvorak J.
        • Herzog R.J.
        • Kambin P.
        • Malter A.
        • et al.
        Consensus summary on the diagnosis and treatment of lumbar disc herniation.
        Spine. 1996; 21: 75S-78S
        • Jordan J.
        • Konstantinou K.
        • Morgan T.S.
        • Weinstein J.
        Herniated lumbar disc.
        Clin Evid. 2005; 14: 1-14
        • Corrigan B.
        • Maitland G.D.
        Practical orthopaedic medicine.
        Butterworths, 1983
        • Brukner P.
        • Khan K.
        Clinical sports medicine.
        McGraw-Hill, 1993
        • Cyriax H.
        • Cyriax P.J.
        Cyriax's illustrated manual of orthopaedic medicine.
        2nd ed. Butterworth-Heinmann, Oxford1993
        • Cox J.M.
        • Hazen L.J.
        • Mungovan M.
        Distraction manipulation reduction of an L5 S1 disc herniation.
        J Manipulative Physiol Ther. 1993; 16: 342-345
        • BenEliyahu D.J.
        Magnetic resonance imaging and clinical follow up study of 27 patients receiving chiropractic care for cervical and lumbar disc herniations.
        J Manipulative Physiol Ther. 1996; 19: 597-606
        • Rebain R.
        • Baxter G.D.
        • McDonough S.
        The passive straight leg raising test in the diagnosis and treatment of lumbar disc herniation: a survey of United Kingdom osteopathic opinion and clinical practice.
        Spine. 2003; 28: 1717-1724
        • Jagbandhansingh M.P.
        Most common causes of chiropractic malpractice law suits.
        J Manipulative Physiol Ther. 1997; 20: 60-64
        • Oliphant D.
        Safety of spinal manipulation in the treatment of lumbar disc herniations: a systematic review and risk assessment.
        J Manipulative Physiol Ther. 2004; 27: 197-210
        • Zhao P.
        • Feng T.Y.
        The biomechanical significance of herniated lumbar intervertebral disc: a clinical comparison analysis of 22 multiple & 39 single segments in patients with lumbar intervertebral disc herniation.
        J Manipulative Physiol Ther. 1996; 19: 391-397
        • Cassidy J.D.
        • Thiel H.W.
        • Kirkaldy W.
        Side posture manipulation for lumbar vertebral disc herniation.
        J Manipulative Physiol Ther. 1993; 16: 96-103
        • Gould A.
        Manual therapy for a prolapsed intervertebral disc: a critical evaluation of two approaches.
        Br J Ther Rehab. 1995; 2: 663-668
        • Huijbregts P.A.
        Fact and fiction of disc reduction; a literature review.
        J Manipulative Physiol Ther. 1998; 6: 137-143
        • Assendelft W.J.J.
        • Morton S.C.
        • Yu Emily I.
        • Suttorp M.J.
        • Shekelle P.G.
        Spinal manipulative therapy for low-back pain.
        The Cochrane Database of Systematic Reviews. 2004; 1 (CD000447)
        • Shekelle P.G.
        • Adams A.H.
        • Chassin M.R.
        • Hurwitz E.L.
        • Brook R.H.
        Spinal manipulation for low back pain.
        Ann Intern Med. 1992; 117: 590-598
        • Koes B.W.
        • Assendelft W.J.J.
        • van der Heijden G.J.M.G.
        • Bouter L.M.
        Spinal manipulation for low back pain. An updated systematic review of randomised clinical trials.
        Spine. 1996; 21: 2860-2873
        • Coxhead C.E.
        • Meade T.W.
        • Inskip H.
        • North W.R.
        • Troup J.D.
        Multicentre trial of physiotherapy in the management of sciatic symptoms.
        The Lancet. 1981; i: 1065-1068
        • Mathews B.J.
        • Mills S.B.
        • Jenkins V.M.
        • Grimes S.M.
        • Morkel M.J.
        • Mathews W.
        • et al.
        Back pain and sciatica: controlled trials of manipulation, traction, sclerosant and epidural injections.
        Br J Rheumatol. 1987; 26: 416-423
        • Liu J.
        • Zhang S.
        Treatment of protrusion of lumbar intervertebral disc by pulling and turning manipulations.
        J Tradit Chinese Med. 2000; 20: 195-197
        • Burton A.K.
        • Tillotson K.M.
        • Cleary J.
        Single-blind randomised controlled trial of chemonucleolysis and manipulation in the treatment of symptomatic lumbar disc herniation.
        Eur J Spine. 2000; 9: 202-207
        • Farfan H.F.
        • Cosette J.W.
        • Robertson G.H.
        • Wells R.V.
        • Kraus H.
        The effects of torsion of the lumbar intervertebral joints: the role of torsion in the production of disc degeneration.
        J Bone Joint Surg. 1970; 52A: 468-497
        • Krismer M.
        • Haid C.
        • Rabl W.
        The contribution of annular fibres to torque resistance.
        Spine. 1996; 21: 2551-2557
        • Adams M.
        • Bogduk N.
        • Burton K.
        • Dolan P.
        The biomechanics of back pain.
        Churchill Livingstone, 2002 (chapter 9)
        • Slosberg M.
        Side posture manipulation for lumbar intervertebral disc herniation reconsidered.
        J Manipulative Physiol Ther. 1994; 17: 258-262
        • Deyo R.A.
        • Weinstein J.N.
        Low back pain.
        N Engl J Med. 2001; 344: 365-370
        • Jensen M.C.
        • Brant-Zawdaski M.N.
        MRI of the lumbar spine in people without back pain.
        N Engl J Med. 1994; 331: 69-73
        • Boden S.B.
        • David D.O.
        Abnormal MRI scans of the lumbar spine in asymptomatic subjects.
        J Bone Joint Surg Am. 1990; 72: 403-408
        • Weisel S.W.
        • Tsourmast N.
        A study of CT in an asymptomatic group of patients.
        Spine. 1984; 9: 549-551
        • Carragee E.J.
        • Tanner C.M.
        • Yang B.
        • Brito J.L.
        • Truong T.
        False-positive findings on lumbar discography. Reliability of subjective concordance assessment during provocative disc injection.
        Spine. 1999; 24: 2542-2547
        • Cooper G.
        Osteopathic manipulation resulting in damage to spinal cord.
        Br Med J. 1985; 291: 1540-1541
        • Schmidley J.W.
        • Koch T.
        The noncerebrovascular complications of chiropractic manipulation.
        Neurology. 1984; 34: 684-685
        • Haldeman S.
        • Rubinstein S.M.
        Cauda equina syndrome in patients undergoing manipulation of the lumbar spine.
        Spine. 1992; 17: 1469-1473
        • Eriksen K.
        Management of cervical disc herniation with upper cervical chiropractic care.
        J Manipulative Physiol Ther. 1998; 21: 51-55
        • Oppenheim J.S.
        • Spitzer D.E.
        • Segal D.H.
        Nonvascular complications following spinal manipulation.
        Spine J. 2005; 5: 660-667

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      • Comments on “Spinal manipulation in patients with disc herniation: A critical review of risk and benefit”
        International Journal of Osteopathic MedicineVol. 10Issue 1
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          The review article1 by Nicolas Snelling on the efficacy of spinal manipulation was an interesting and welcome contribution to the debate. However, I would like to take issue with some of the author's comments on the trial by Burton et al.2 in the concluding paragraph of section 3.2.4. The author states that the number of subjects was a “major weakness of the study”. However, the study detected a difference between chemonucleosis and osteopathic manipulative care at 2–6 weeks despite the low numbers (20 in each group).
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