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

BackgroundContradictions 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.ObjectivesTo 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.MethodsThe 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.ResultsFour 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.DiscussionThere 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.ConclusionThere 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.