Is Pre SMT Screening with MRI / CT on the Horizon?
By Stan Innes BAppSc(chiro), MSc(psych)

In a recent Spine Journal paper¹ 3 Neurosurgeons make the assertion after reviewing the medical records, for a 6-year period, from a suburban neurosurgical practice in New York that pre-treatment MRI or CT scanning may help identify patients with significant risk factors. They preface their paper by stating that this study was not intended to serve as a review of the value of spinal manipulation nor to criticize spinal manipulation; instead to study these patients ‘‘a posteriori,’’ with the hope of preventing future complications from spinal manipulation.

They identified 18 cases (age range 32 to 71 years, no gender dominance) whose symptoms significantly worsened during treatments. Cases were not included if only the severity of the symptoms worsened (eg, increased pain) or if delayed deterioration occurred. Patients who may have developed neurological deterioration weeks or even only days after spinal manipulation were therefore not included in this series, because that deterioration may have represented the natural history of the disease and not necessarily the direct result of the spinal manipulation. None of the patients had obtained magnetic resonance or computed tomographic (CT) imaging before the initiation of manipulative treatment, whereas some had pre-treatment X-rays performed by the chiropractors.

Six of the injuries were in the cervical spine (33%), four were in the thoracic spine (22%), and the remaining eight were in the lumbar spine (44%). The manipulations were associated with spinal cord injury (including myelopathy, quadriparesis, central cord syndrome, or paraparesis) in 9 patients (50%), cauda equina syndrome in 2 patients (11%), and radiculopathy in 6 patients (33%). Three of the patients developed signs and symptoms from pathologic fractures from previously undiagnosed metastatic tumours involving vertebral bodies. The manipulations performed on these patients were followed by the development of these new symptoms, and all three of these patients subsequently died.

16 of the 18 patients required surgery and earlier surgical intervention resulted in improved outcomes. Interestingly three of the cases presented with symptoms that were distant from the site of their subsequent manipulation and complication. Oppenheim et al noted that a different chiropractor was associated with each case and inferred that the complications identified were not the result of a specific practitioner using either improper technique or excessive force, but rather an inherent risk of the manipulative technique itself.

They then recommend the inclusion of the presence of a herniated disc as a relative and absolute contraindication to spinal manipulation. They conclude that it may be reasonable and appropriate to recommend MRI or CT imaging to help identify patients with significant risk factors, such as substantial disc herniations or occult malignancies. Prompt neurosurgical evaluation and intervention is necessary when symptoms worsen or neurological deficits develop. Further, that physicians should be aware of these risks when treating patients who are concurrently undergoing spinal manipulation.

Dr. Scott Haldeman² provided a short commentary on this article in which he begins by raising concerns over the shortcomings and methodological weaknesses of the article. He draws this section to a close by asking “If a practice with three neurosurgeons was aware of only 18 serious adverse events from 60 chiropractors over a 6-year period, the incidence of these complications is so small that it would be the envy of any other medical or surgical spinal treatment approach.”

He continues by claiming that the suggestion resulting from the study that all patients who consider spinal manipulation should have a magnetic resonance imaging scan before treatment simply cannot be supported. He notes that with approximately 10% of the entire North American population receiving chiropractic care each year, such a recommendation would produce first-year costs of over $20 billion (i.e., 30 million magnetic resonance imaging scans at $700 each). More importantly he notes that there is no evidence that such screening by advanced imaging would change the adverse event rate. Large case series have demonstrated that disc herniation without neurological deficits / red flags does not pose a contraindication to most routine forms of manipulation.

I felt he made a valid point when he asked the question of Oppenhein et al. “The authors clearly feel that the publication of this paper is serving a purpose. I ask the authors if they would feel it was equally reasonable for The Spine Journal to publish a similar paper written by chiropractors retrospectively reviewing charts to document patients who reported an adverse response to elective spine surgery and then recommended changes in the clinical practice of neurosurgery based on these few case reports”.

Haldeman concludes “I wish to reiterate that the topic of adverse events following all forms of treatment of spinal disorders is extremely important and deserves further discussion and consideration in the literature. I would urge my colleagues, however, to consider designing such studies with the methodological rigor that would yield useful data and add to the body of scientific evidence rather fanning the flames on such a pyrrhic subject”.

References:

1. Oppenhein JS, Spitzer DE, Segal DH. Nonvascular complications following spinal manipulation. The Spine Journal 2005;5(6):660-6.
2. Haldeman S. Commentary. The Spine Journal 2005;5(6):666-7.