Neurological Complications of Cervical Spine Manipulation

The article by Clare Stevinson and others (March 2000 JRSM, pp. 107-110) demonstrates why research should be undertaken only by those who understand the field they are investigating. Throughout, they trivialize the role of manipulation and quote selectively: an important omission is the review paper by Haldeman1, who as a neurologist and a trained manipulator is well qualified to comment. Manipulation physicians have been aware of the complications of spinal manipulation therapy for more than five decades2. The real difficulty has been in identifying suspect techniques; more than fifty cervical techniques are commonly used in today's practice. Stevinson et al. refer to a survey of California neurologists. The 91 patients reported in this paper3 did not, as they claim, have neurological defects only after cervical manipulation; this was the number who had defects after manipulation in any area—cervical, thoracic or lumbar. The US authors recognized the weaknesses of their study, including inability to verify responses and lack of information on pre-existing neurological details such as myelopathy, cauda equina syndrome, anticoagulant therapy, etc. In the British study, twenty-four respondents reported remembering 35 cases of serious neurological complication but only 16 of these cases could be remembered in enough detail to give even a scant description. A further case is totally erased from the paper. In only 2 cases is the manipulating profession identified— osteopathy and chiropractic, both professions that one of the authors, Professor Ernst, has confronted in the past. In my chiropractic clinic I regularly treat patients with serious neurological defects, including absent reflexes; these patients are always referred back to their GP for orthopaedic assessment but many of them resolve before this assessment. At present we are treating a patient who has clear upper motor neuron signs and symptoms; we suspect cervical myelopathy, and with much coaxing she has now consented to return to the hospital. When she does show up at the hospital, will she be remembered by the consultant as a cervical myelopathy who had been treated by a chiropractor or as someone who had been correctly referred back to the GP? Before assuming a causative relationship, any investigator must examine the treating practitioner's case notes. To gain anything out of a long-term prospective study, Professor Ernst and his colleagues must recruit onto their team manipulative experts from the four main fields. Some of the offending techniques have already been identified and the manipulative schools now avoid teaching rotary techniques that include cervical extension. The Institute for Musculoskeletal Research and Clinical Implementation is planning a multidisciplinary prospective trial using Canadian Stroke Consortium data as a pilot study. I am sure that they would be happy to discuss any future research if the aim was to prevent these mostly avoidable problems.

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