Safety of cervical spine manipulation: are adverse events preventable and are manipulations being performed appropriately? A review of 134 case reports

Abstract

Background: Cervical spine manipulation (CSM) is a commonly utilized intervention, but its use remains controversial.Purpose: To retrospectively analyze all available documented case reports in the literature describing patients who had experienced severe adverse events (AEs) after receiving CSM to determine if the CSM was used appropriately, and if these types of AEs could have been prevented using sound clinical reasoning on the part of the clinician. Data sources: PubMed and the Cumulative Index to Nursing and Allied Health were systematically searched for case reports between 1950 and 2010 of AEs following CSM. Study selection: Case reports were included if they were peer-reviewed; published between 1950 and 2010; case reports or case series; and had CSM as an intervention. Articles were excluded if the AE occurred without CSM (e.g. spontaneous); they were systematic or literature reviews. Data extracted from each case report included: gender; age; who performed the CSM and why; presence of contraindications; the number of manipulation interventions performed; initial symptoms experienced after the CSM; and type of resultant AE. Data synthesis: Based on the information gathered, CSMs were categorized as appropriate or inappropriate, and AEs were categorized as preventable, unpreventable, or unknown. Chi-square analysis with an alpha level of 0.05 was used to determine if there was a difference in proportion between six categories: appropriate/preventable, appropriate/unpreventable, appropriate/unknown, inappropriate/ preventable, inappropriate/unpreventable, and inappropriate/unknown. Results: One hundred thirty four cases, reported in 93 case reports, were reviewed. There was no significant difference in proportions between appropriateness and preventability, P5.46. Of the 134 cases, 60 (44.8%) were categorized as preventable, 14 (10.4%) were unpreventable and 60 (44.8%) were categorized as 'unknown'. CSM was performed appropriately in 80.6% of cases. Death resulted in 5.2% (n57) of the cases, mostly caused by arterial dissection. Limitations: There may have been discrepancies between what was reported in the cases and what actually occurred, since physicians dealing with the effects of the AE, rather than the clinician performing the CSM, published many of the cases. Conclusions: This review showed that, if all contraindications and red flags were ruled out, there was potential for a clinician to prevent 44.8% of AEs associated with CSM. Additionally, 10.4% of the events were unpreventable, suggesting some inherent risk associated with CSM even after a thorough exam and proper clinical reasoning.

Development of a Clinical Prediction Rule to Identify Patients With Neck Pain Likely to Benefit From Thrust Joint Manipulation to the Cervical Spine

“…16,23,24 This may explain why physical therapists will report utilizing TJM in the thoracic spine more frequently than in the cervical spine in patients with neck pain, 1 despite evidence that many of these potential negative outcomes may be prevented through careful examination. 56 Recent evidence suggests that TJM to the thoracic spine may improve pain and disability in patients with neck pain. 13 Treating the thoracic spine in these patients has demonstrated benefits and involves arguably less risk but may not completely address the patient's presenting symptoms and mobility impairments.…”

Clinical reasoning for manual therapy management of tension type and cervicogenic headache

“…18 Despite the potential for post-manipulative adverse reactions, there is some evidence suggesting that, if all contraindications and red flags are ruled out, there is potential for a clinician to prevent 44.8% of adverse events associated with cervical manipulation; however, 10.4% of the events are unpreventable, suggesting an inherent risk associated with neck manipulation even after a thorough exam and proper clinical reasoning. 19 Other therapeutic strategies, e.g. massage, compression, and stretching, are targeted to treatment of soft tissues of the body.…”

Manual therapy and cervical artery dysfunction: Identification of potential risk factors in clinical encounters

“…24 However, practitioners should employ clinical reasoning with a focus on identifying patients who might be at increased risk of an adverse event following manual or exercise therapy applied to the cervical and cervicothoracic spine, or who might be presenting to a clinician with symptoms of a CeAD in progress. There is a need to identify these patient groups before applying any manual therapy interventions or prescription exercise.…”

“…3,4 In a review of 134 cases of post-manipulative adverse events, Puentedura et al 24 reason that 45% of cases were likely to be preventable if contraindications to manipulation (e.g., osteoporosis, rheumatoid arthritis, and cervical stenosis)…”