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R E V I E W Open Access
Outcomes indicators and a risk classification
system for spinal manipulation under
anesthesia: a narrative review and proposal
Dennis DiGiorgi
1*
, John L. Cerf
2
and Daniel S. Bowerman
3
Abstract
Over a period of decades chiropractors have utilized spinal manipulation under anesthesia (SMUA) to treat
chronic back and neck pain. As an advanced form of manual therapy, SMUA is reserved for the patient whose
condition has proven refractory to office-based manipulation and other modes of conservative care. Historically,
the protocols and guidelines put forth by chiropractic MUA proponents have served as the clinical compass for
directing MUA practice. With many authors and MUA advocates having focused primarily on anticipated benefit,
the published literature contains no resource dedicated to treatment precautions and contraindications. Also
absent from current relevant literature is acknowledgement or guidance on the preliminary evidence that may
predict poor clinical outcomes with SMUA. This review considers risk and unfavorable outcomes indicators in
therapeutic decision making for spinal manipulation under anesthesia. A new risk classification system is proposed
that identifies patient safety and quality of care interests for a procedure that remains without higher-level research
evidence. A scale which categorizes risk and outcome potential for SMUA is offered for the chiropractic clinician, which
aims to elevate the standard of care and improve patient selection through the incorporation of specific indices from
existing medical literature.
Keywords: Manipulation under anesthesia, Spine, Medical evidence, Risk, Contraindications, Precautions, Outcomes,
Informed consent
Background
Since the 1930’s, many forms of facilitated manipulation
of the spine have been reported in the literature, with vari-
ous anesthetic/sedative agents and techniques used [1]. In
the 1990’s, in managing patients with chronic spine
pain and related dysfunction, chiropractors began util-
izing the conscious sedation variety of manipulation
under anesthesia (MUA) [1]. During that era, the
standards and protocols of the National Academy of
MUA Physicians (NAMUAP) [2] were popularized
and relied upon by many in determining clinical eligi-
bility for MUA. A revised version of the original
NAMUAP standards and protocols was put forth in
2012, as adopted by the newly established American
Association of Manipulation Under Anesthesia Providers
(AAMUAP). That document subsequently underwent a
consensus-based review, in developing recommendations
for the contemporary practice of MUA [3].
What may render a clinical guideline useful for
individual patients is its reliance upon valid evidence in
establishing decision points and risks of care [4]. An
appraisal of risk is essential to clinical guideline develop-
ment [5–7]. Estimations of the balance of benefits
against risks or harms helps to ensure guideline credibil-
ity for stakeholders [8]. A significant limitation with
current SMUA guidelines, and the collective scientific
knowledge on this subject, is inadequate recognition of
the risk profiles and outcomes indicators that contribute
to patient selection. This limitation relates to incomplete
development of the relative/absolute contraindications
to care and several known clinical, diagnostic, and
litigation-related factors which may weigh against the
option of SMUA.
For spinal manipulation under anesthesia, what re-
mains ambiguous despite existing guidelines is when to
* Correspondence: drdigiorgi@aol.com
1
Consultant Practice- Whitestone, NY, USA
Full list of author information is available at the end of the article
© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
DiGiorgi et al. Chiropractic & Manual Therapies (2018) 26:9
DOI 10.1186/s12998-018-0177-z
move a patient toward treatment. The heterogeneity of
primary research and the presence of mostly lower-level
evidence pose inherent challenges to clinical decision
making [9]. Moreover, the current SMUA literature and
association-based protocol documents are without a cor-
responding evidence-informed resource that elucidates
risk versus benefit. Even when individual patients have
undergone all appropriate studies [10], weak levels of
evidence for SMUA can lead to uncertainty in selection,
dosing and patient safety. Although rare, sentinel events
have been reported [11–13]. It is with a rise in SMUA
utilization in the United States in recent years that a
constructive and critical analysis of these matters be-
comes essential. This paper reviews the evidence for
SMUA in establishing a scale for the chiropractic clin-
ician which categorizes risk and outcome potential. It
considers risk and unfavorable outcomes indicators in
the development of a risk classification system that iden-
tifies patient safety and quality of care interests for this
advanced form of treatment. As such, it calls for an ele-
vation in the standard of care and improved patient se-
lection through the incorporation of specific indices
from existing medical literature.
The principle of spinal adhesions
Within the existing SMUA literature, the principal
mechanism theorized for procedural effectiveness is the
disruption of soft tissue adhesions about the axial spine
[2,14–17]. In 1948, Clybourne proposed that the cases
most amenable to MUA treatment were those involving
joint adhesions, with limited movement in all directions
[14]. He posited that the careful selection of cases was
the product of an in-depth knowledge of joint anatomy
and pathology [14]. However, he acknowledged the
scope and limitations of the MUA procedure, indicating
that it was not a panacea for low back pain [14].
As the fundamental basis for SMUA, the adhesion-
disruption theory remains clinically appealing. The
term Fibrosis Release Procedures (FRP) is a broader
designation for spinal manipulation under anesthesia
which has been more recently introduced in the
chiropractic literature and within the published
AAMUAP guidelines [3]. This terminology establishes
that mobilization (stretching) is the primary manual
therapy component of the procedure.
The premise that reducing adhesions can increase
joint flexibility, decrease pain, and improve quality of life
is seemingly so elementary that utilizing approaches
which aim to accomplish the like must be therapeutically
beneficial. There is evidence, for example, that MUA for
stiff knees after total knee arthroplasty (TKA) can
significantly increase knee flexion in certain patients
when administered during the postoperative period but
within twelve weeks [18]. The circumstances by which
adhesions may develop after knee replacement are self-
evident, giving due consideration to the mode and scope
of intervention. The proliferation of scar tissue about
the knee joint is a well-known complication of TKA
[19]. However, that clinical scenario differs greatly from
one that involves the presence of chronically symptom-
atic and dysfunctional spinal joints due to repetitive pos-
tural strain, factors related to age, or a history of trauma
that excludes vertebral fracture or reconstructive surgery
after disc injury. Thus, the evidence that MUA may re-
duce TKA-related arthrofibrosis is not generalizable to
chronic spine pain patients who have been managed
non-surgically for lower-level injury or degenerative
change. In the latter patient populations, the supposition
that scar tissue explains any observed range of motion
deficits may be presumptuous.
Investigators have recognized that patient selection for
SMUA could be enhanced by knowing more about the
fibrotic adhesion concept [20]. One theory concerning
adhesion development suggests that lumbar spine hypo-
mobility may result in connective tissue adhesions of
zygapophyseal joints [21]. While increased collagen de-
position about the spine could explain the physical find-
ings of palpable joint restrictions and decreased range of
motion in chronic pain patients, there is no research
that may assist in differentiating those with intraarticular
adhesions from other manifestations of segmental dys-
function. In fact, validation of the adhesion concept and
a related clinical role for SMUA would appear to have
its greatest potential in cases of failed back surgery, in
which advanced imaging reveals fibrosis in the region of
prior intervention [16]. It has been estimated that as
much as 20% to 36% of all cases of failed back surgery
may be due to epidural fibrosis [22]. Nevertheless, for
post-fusion lumbar pain there is limited evidence for the
safety and efficacy of chiropractic treatment and no
guidelines to aid with therapeutic decision-making [23].
Clinical research is lacking to support that the many
historical accounts of successful SMUA treatment is due
to the disruption of ligamentous, musculotendinous
and/or epidural adhesions. The void of evidence in this
area does not allow one to confirm or deny the theories
that SMUA more effectively treats adhesions and that
adhesion reduction increases flexibility [1]. With various
spinal tissues known to account for pain and impaired
function, it defies clinical logic that adhesions might
serve as a pathological feature common to patients with
chronic pain. Thus, what may account for a favorable
response to SMUA treatment, and purportedly for nu-
merous diagnoses [3], has yet to be elucidated. The gen-
etic profiles that contribute to fibrosis and ligament
hypertrophy in specific spinal conditions [24,25], and how
identifying the like may assist in patient selection/rejection
for SMUA, are areas worthy of investigation. Nevertheless,
DiGiorgi et al. Chiropractic & Manual Therapies (2018) 26:9 Page 2 of 11
recent evidence suggests that stretch does not have
significant effects on joint mobility for people with or
without neurological conditions, or short-term effects
on pain or quality of life for people with non-
neurological conditions [26].
Predictors of unfavorable clinical outcomes with
SMUA
In the development of treatment protocols for SMUA
professional associations have relied upon numerous
studies from the early medical literature. Advocates for
the procedure frequently cite these same studies to sup-
port the use of SMUA for various diagnoses. In the more
recent literature are reports of the indications for
manipulation under anesthesia, including disc hernia-
tion/prolapse/protrusion/bulge, joint or spinal ankylosis,
failed low back surgery, nonresponsive muscle contrac-
tion, compression syndromes with non-osteophytic en-
trapment, and whiplash-associated disorders [27,28].
Most of these indications for care have been derived
from the syllabi of chiropractic post-graduate MUA cer-
tification courses and the promotional materials of MUA
proponents. However, numerous clinically significant
findings from the same dependent literature base have
yet to be given an appropriate level of attention. Several
clinical, diagnostic, and litigation-related indices must
now be recognized as predictors of unfavorable clinical
outcomes or for potential adverse events. These indices,
identified below, do not support the preservation of
certain patient management concepts and selection cri-
teria for SMUA, as initially developed before the era of
evidence-based medicine.
Ankylosis
Spinal ankylosis has been cited as one of the indications
for SMUA [27,28]. However, when joints are pathologic-
ally fused, normal physiologic integrity or function
cannot be expected to be restored via the stretching
and/or manipulation components of the procedure. This
requires no analysis. A case involving spine fracture and
hemothorax with MUA treatment for ankylosing spon-
dylitis has been reported [13].
Anxiety/stress
The prospective cohort study undertaken by Peterson
et al. (Level II evidence) suggests a contributory role
of anxiety and stress levels on outcome for patients
in receipt of SMUA for chronic neck or low back
pain [29]. When comparing short-term patient out-
comes after a single MUA procedure dose (at 2 and
4 weeks posttreatment), statistically significant differ-
ences were found for those improved vs not improved
when assessing for the variable of anxiety/stress [29].
Patients with higher levels of anxiety and stress,
identified by the Bournemouth Questionnaire (BQ),
had a tendency of non-responsiveness to SMUA [29].
Electromyography and nerve conduction studies
Published MUA guidelines specify that electromyog-
raphy (EMG) and/or nerve conduction studies may be
used to determine patient progress with SMUA [3].
Implied, in part, is that a positive EMG study may serve
as a diagnostic indicator for treatment. For years, MUA
advocates have put forth that the work of Mensor
showed that 83% of 600 patients with EMG-verified
radiculopathy responded well to SMUA [30]. However,
within Mensor’s published papers, there is no reporting
of an electromyographic assessment for any of the more
than 600 patients treated with SMUA [31,32]. In fact,
from the findings of one of the few studies that reaches
the highest level of published evidence to date (Level II),
SMUA in the presence of EMG-confirmed lumbar nerve
root compression led Siehl et al. to report an outcome
trend of procedural ineffectiveness, with surgery likely
required at some point [33]. Thus, current best evidence
does not support the premise that patients with a posi-
tive EMG study are appropriate candidates for SMUA.
As for nerve conduction studies, there is no primary
research evidence that may be assistive to clinicians in
revealing the appropriateness of SMUA for individual
patients with positive versus negative results. Moreover,
the potential clinical value for using either of these elec-
trodiagnostic tests in an outcomes assessment capacity
with SMUA is not supported by research.
Herniated and/or protruding/bulging discs
Greenman cited disc herniation as a relative contraindi-
cation to MUA, acknowledging that other authors had
reported only temporary improvement [34]. In looking
to the evidence for long-term effectiveness and safety of
SMUA with a specific diagnosis of disc herniation or
protrusion, Table 1provides the findings, observations,
or experience-based perspectives of numerous early
osteopathic/orthopedic investigators/practitioners.
There is no published evidence to suggest that the
modern SMUA approach [1] provides for better out-
comes for disc herniation/protrusion versus the methods
and protocols used by early osteopathic investigators.
Within the more recent chiropractic literature there are
only a few isolated retrospective case reports regarding
the sedated variety of SMUA for disc herniation [17],
protrusion/bulge [16,35,36], or degeneration [37]. In
the study conducted by Palmieri and Smoyak, some of
the 38 chronic low back pain patients who received
MUA may have had a lumbar disc condition [38]. How-
ever, the various causes of pain, which included “disc
syndrome”, were apparently obtained by demographic
questionnaire. There is no account of investigator
DiGiorgi et al. Chiropractic & Manual Therapies (2018) 26:9 Page 3 of 11
Table 1 Evidence of outcomes with SMUA for disc herniation/protrusion
Year of Publication Author/s Findings/observations/opinions Level of Research Evidence
a
1945 Poppen [11] Various forms of operative treatment were undertaken for 400 cases of
lumbar intervertebral disc herniation. The number of patients whose
treatment included MUA is not reported, but two from that group were
immediately paralyzed.
IV
1952 Wilson and
Ilfeld [78]
Manipulation of patients with symptoms of lumbar herniated disc was
performed under general anesthetic or via medication assistance. Three
of eighteen patients (17%) reported temporary relief of back and leg pain
over 48–72 h. Within ten days of the procedure, twelve patients (67%)
subsequently underwent exploratory laminectomy. For the remaining six
patients (33%) who did not undergo surgery, none had experienced any
change in symptoms after manipulation.
IV
1952 Siehl and
Bradford [79]
Good results were obtained in about a third of herniated disc cases but
with surgery opined to be required at some point. The authors reported
that longstanding disc herniation does not respond well to MUA and, “in
no case with positive myelography has there been lasting good results
from the manipulative procedure.”
IV
1953 Ewer [80] Manipulation should not be overlooked by orthopedic surgeons in that it
can offer “so much relief”in selected cases. However, it was opined that
with ruptured intervertebral discs and true sciatica, manipulation “cannot
effect a permanent cure and offers great hazards.”In the presence of space-
consuming lesions manipulation is contraindicated, as MUA “is more
dangerous and does not compensate for the risks involved.”
V
1955 Mensor [31] Two hundred five patients received MUA for lumbar intervertebral disc
syndrome, with 56 (27%) classified as immediate or delayed failures. Of
those, subsequent surgical exploration revealed that all had identifiable
pathology (an annular fragment protruding into the interspace, a ruptured
annulus with a large amount of free nuclear material in the canal, or
degeneration with freely shifting nuclear material permitting for alternating
reduction and reproduction of the protrusion).
IV
1963 Siehl [81] One hundred eighty five patients were treated with MUA for a diagnosis
of herniated nucleus pulposus. Good results were obtained for 26.4% of
patients. Overall, 95 of the 185 patients (51%) required subsequent disc
surgery.
IV
1964 Chrisman et al. [15] Twenty of 39 patients (51%) with ruptured lumbar intervertebral disc
maintained good to excellent results after MUA over three years. 10 of the
27 patients (37%) with positive myelograms had received the same benefit.
For neither group was there a change in the appearance of the myelograms
taken before and after MUA. The authors determined that those “without a
demonstrable myelographic defect consistently did better”and that
manipulation of “a very large disc protrusion”should be avoided due to
potential for harm.
IV
1971 Siehl et al. [33] Twenty one patients were treated via MUA for nerve root compression secondary
to lumbar disc herniation. Three (14%) showed clinical and EMG improvement,
nine (43%) had no EMG change but continued clinical improvement, and nine
(43%) showed worsened electromyographic changes of the legs. After 15 months,
thelattergrouphadanincreaseinclinicalsigns.Ingeneral,forthe50%ofpatients
who had improvement over the first 6 months, most progressively worsened over
the 6 month period thereafter.
II
1972 Tospon [82] In the author’s experience with 6000 MUA procedures, he reported, “.if the
patient has positive neurological, orthopedic and myelographic findings, low
back manipulation will be of no lasting benefit... it often helps temporarily, but
ultimately surgery has to be performed.”
V
b
1973 Morey [83]“Frequently it [manipulation under general anesthesia] affords relief, possibly
temporary, when there is actual disk protrusion.”
IV
1977 Scherrer [84] Ninety four patients underwent manipulation under general anesthesia for disc
herniation. Sixty percent had excellent or good results. Forty percent had poor
results. Within one year, more than half of the patients had to undergo a
hemilaminotomy.
IV
1986 Krumhansl and
Nowacek [47]
Of the two patients with myelogram evidence of frank disc herniation,
one required discectomy because of a return of pain within three weeks
of MUA.
IV
a
When applying the levels of evidence rating system for categorizing study quality, as put forth by Wright et al. and adopted by the Journal of Bone & Joint
Surgery [42], Spine, Clinical Orthopaedics and Related Research, the North American Spine Society, the American Academy of Orthopaedic Surgeons, and the
Pediatric Orthopaedic Society of North America [85]
b
The case report study design has not been rated by Wright et al. [42]. This case report, with editorializing, is being equated here with the established level
of evidence for expert opinion (Level V evidence)
DiGiorgi et al. Chiropractic & Manual Therapies (2018) 26:9 Page 4 of 11
verification of the cause of back pain via clinical examin-
ation or imaging. Moreover, as the decreased pain and
disability scores with MUA are not correlated with an
identified cause of pain, the outcomes for the “disc syn-
drome”category of patients are not evident. Elsewhere,
for the 42 chronic low back pain patients who received
medication-assisted manipulation after MRI, the pres-
ence or absence of disc pathology is not reported in re-
vealing the nature of the conditions under study [39].
For the 30 chronic neck or low back pain patients in re-
ceipt of SMUA in the prospective cohort study under-
taken by Peterson et al., there is no indication of a
verified source of pain [29].
Within the chiropractic literature is a description of the
need for provider modification or deletion of the maneu-
vers typically used with SMUA when disc herniation is
present [36]. However, clinical investigation is lacking to
support the safety and efficacy of any particular intraopera-
tive MUA technique. Also, it remains unclear as to whether
thesizeanddirectionofdiscprotrusion,thespinalregion
involved, the location and extent of annular tearing, the de-
gree of disc degeneration/desiccation, or the extent and
duration of correlating clinical signs and symptoms may
serve as prognosticators of outcome with SMUA. With con-
scious patients, there have been reports of favorable out-
comes with the utilization of selective spinal manipulation
procedures/techniques for specific MRI-confirmed lumbar
disc herniation features or positional variances [40,41].
However, in these studies it is not clear that either of the
two manipulative techniques described, chosen based on
the particular imaging feature/s, was superior to the other
such that its use specifically explained the improvements
reported [40,41]. Additional research is needed to clarify
which of the aforementioned elements, or other
discopathy-related variables, may have predictive value in
the SMUA setting. Presently, the evidence for SMUA for
disc-related conditions remains weak (mostly Level IV-V),
with overall unimpressive percentages of successful cases
reported by early authors and across larger samples of sub-
jects. By way of the research evidence hierarchy put forth
by Wright et al. [42], Fig. 1outlines the current state of the
evidence for SMUA for disc herniation/protrusion.
With potential for adverse events, the equivocal
benefit profile of SMUA in the presence of disc path-
ology reveals that it has yet to attain precise clinical val-
idation through investigative research. In the conscious
patient setting, the North American Spine Society has
found insufficient evidence to recommend for or against
manipulation for lumbar disc herniation with radiculo-
pathy, as an alternative to discectomy or to improve
functional outcomes [43]. Nonetheless, the emergence of
newer, preliminary evidence may suggest the efficacy of
spinal manipulation in conscious patients with MRI-
confirmed symptomatic lumbar herniated discs with varied
pathoanatomical features, including sequestration [41].
Similar evidence of efficacy exists for spinal manipulation
in conscious patients with symptomatic, MRI-confirmed
cervical disc herniations [44]. What remains unclear is
whether the addition of anesthesia to the manipulation ser-
vice, along with the SMUA-associated maneuvers/tech-
niques, may result in better outcomes over manipulation
alone for acute or chronic neck and low back pain due to
disc herniation/protrusion. That was not found to be true
in the comparative studies for subjects with a diagnosis of
chronic lumbosacral strain [45,46]. Thus, precaution must
be taken when contemplating SMUA for those with verified
or suspected disc-related conditions. Greater weight should
first be given to other, well-established interventions.
Obesity and soft tissue inflammation
Krumhansl and Nowacek reported that patients who are
overweight by greater than 50 pounds are not candidates
for SMUA, as the “procedure fails”due to the diffusion of
force within soft tissues [47]. Also reported was “amuch
reduced success rate”with patients who are overweight by
greater than 30 pounds. For similar reasons of impeded
maneuverability of spinal tissues, these practitioners cited
an absolute contraindication for patients who exhibit soft
tissue inflammation beyond a “mild”degree (greater than
2+, on the scale of 0–4+). A “very high”failure rate was re-
ported for inflammation beyond grade 2+, with risk for in-
jury to uninvolved soft tissues placed under the stresses of
manual therapy [47]. Thus, as described by these authors,
the physiologic indicators of obesity and inflammation
weigh against the option of SMUA treatment.
Work-related spine disorders and litigation
Mensor reported a significantly lower percentage of fa-
vorable patient outcomes with MUA for industry-related
lower back conditions versus “private patients”with similar
conditions [31]. He attributed this outcome discrepancy to
“themonetaryfactor”and the type of labor engaged in by
Fig. 1 SMUA evidence for disc herniation/protrusion
DiGiorgi et al. Chiropractic & Manual Therapies (2018) 26:9 Page 5 of 11
those in the industrial patient group [31]. Similarly,
Chrisman et al. observed comparatively poorer outcomes
for patients in receipt of SMUA for lumbar conditions who
were involved in litigation or had compensation claims
[15]. In one of the few SMUA studies to date that repre-
sents Level II evidence, Kohlbeck et al. excluded patient
participation if chronic low back pain was associated with
third-party liability or workers’compensation [39].
Barth has suggested that examinee-reported histories
are largely false when someone other than the examinee
is being blamed for the health complaints [48]. Also
cited by Barth are the influences of psychological and so-
cial factors in chronic pain presentations, especially with
legal claim involvement [49]. The variable of secondary
gain that may result in chronic pain, poor patient out-
comes, or invalid patient reporting [49–51] are not lim-
ited to those being considered for SMUA. However, as
SMUA utilization is closely associated with chronicity
after personal injury, consideration must be given to
prior investigator outcomes reporting for cases involving
litigation. In the presence of additional identifiable indi-
ces for unfavorable/adverse outcomes, the option of
SMUA treatment may not be appropriate for individual
patients with a legal claim.
Pain prone patients and candidacy for SMUA
In determining a patient’s candidacy for chiropractic
treatment of an acute or chronic musculoskeletal condi-
tion, many core principles apply. These are not unique
to clinical decision-making for SMUA. However, the
same obligation exists for SMUA as with any modality
or intervention being considered. For acute, non-specific
low back pain, clinical practice guidelines consistently
recommend patient reassurance of a good prognosis and
educational instruction on self-care and remaining active
[52]. Trajectory patterns for low back pain reveal that
acute pain is often an episode or a flare-up of an on-
going condition, but pain in excess of three months
would suggest a very different condition [53]. Once
chronic, low back pain can be more difficult to manage
and may require multimodal care [54]. Also, in the pres-
ence of widespread pain, chronic non-specific low back
pain has a poorer prognosis than if pain is present only
in the lower back [55].
Poor outcomes with conventional conservative treat-
ment can often be predicted. It is the provider’s duty to
identify potential barriers to recovery. For example,
Bigos et al. identified premorbid nonphysical factors
such as job dissatisfaction to be the best predictor of
reporting back pain at work [56]. Also, clinical predic-
tion/decision rules have been proposed for patient re-
sponsiveness to lumbar stabilization exercises [57] and
those at risk for developing chronic low back pain [58].
In these and other instances, use of clinical prediction
rules may help to determine the most appropriate course
of treatment or if manipulation should even be consid-
ered [59]. Attention to the patient history is particularly
important, as the reliability of the information gleaned
may be questionable when litigation potential or second-
ary gain are present [60,61].
Absent from the MUA literature is insight regarding
the significance of the patient’s attitudes, beliefs, and ex-
pectations of treatment. Factors such as secondary gain,
somatization, illness-behavior, and physician dependence
are essentially without mention, yet represent key com-
ponents to the management of chronic musculoskeletal
pain [54,62]. Moreover, although it is known that behav-
ioral treatment can prevent chronicity [55], related ele-
ments such as alcohol/illicit drug use may be overlooked
during the patient history and ensuing course of care. In
clinical and especially medicolegal circumstances, embel-
lishment and symptom magnification are not uncom-
mon [62]. If not recognized and addressed early on,
these factors could affect the direction and outcome of
care. Thus, a thorough clinical examination, with atten-
tion for non-physiologic responses, is paramount. Still
bearing relevance today is this AHCPR appraisal on pain
behavior and inconsistent findings:
“The patient who embellishes a medical history,
exaggerates pain drawings, or provides responses
on physical examination inconsistent with known
physiology can be particularly challenging. A
strongly positive supine straight leg raising test
without complaint on sitting knee extension and
inconsistent responses on examination raise a
suspicion that nonphysical factors may be affecting
the patient's responses. "Pain behaviors" (verbal or
nonverbal communication of distress or suffering)
such as amplified grimacing, distorted gait or
posture, moaning, and rubbing of painful body
parts may also cloud medical issues and even
evoke angry responses from the clinician.
Interpreting inconsistencies or pain behaviors as
malingering does not benefit the patient or the
clinician. It is more useful to view such behavior
and inconsistencies as the patient's attempt to
enlist the practitioner as an advocate, a plea for
help. The patient could be trapped in a job where
activity requirements are unrealistic relative to the
person's age or health. In some cases, the patient
may be negotiating with an insurer or be involved
in legal actions. In patients with recurrent back
problems, inconsistencies and amplifications may
simply be habits learned during previous medical
evaluations. In working with these patients, the
clinician should attempt to identify any psychological
or socioeconomic pressures that might be influenced
DiGiorgi et al. Chiropractic & Manual Therapies (2018) 26:9 Page 6 of 11
in a positive manner. The overall goal should always be
to facilitate the patient's recovery and avoid the
development of chronic low back disability.”[63]
One of several concerns with SMUA utilization relates to
proper patient selection beyond the factors of physical com-
plaints and findings. This may be of greatest relevance in
the personal injury setting, since patients within that setting
represent the preponderance of SMUA recipients in the
United States today. On the historical basis that spinal ma-
nipulationmaybethe“treatment of choice,”MUA propo-
nents have considered SMUA to be the logical next step for
chronic pain patients with limited response. Nonetheless,
not all patients can be expected to respond to the treatment
chosen by the attending provider. Furthermore, failure of
one option to provide for measurable and objective clinical
gains, such as conventional office-based manipulation,
would rarely support advancing the patient to the SMUA
setting. Numerous conservative treatment options exist.
Those with more robust evidence should be considered
first, as dictated by the best-interest principle [54].
Another concern relates to the circumstance of offer-
ing the option of SMUA relatively early in care. This
likely occurs more frequently than it should despite that
the procedure lies low in the hierarchy of evidence-
based treatment. As early patient advancement to SMUA
stands apart from the existing literature on patient man-
agement, additional risk/benefit issues arise. The con-
cepts that hurt isn’t always harm and that some patients
get better with or without treatment must be given ad-
equate consideration relative to the natural course of an
injury. An individual who is likely to demonstrate add-
itional improvement based on time alone may have no
need for exposure to the added risk of medication
assisted manipulation, even if that risk is minor. At
times, a particular patient may be predestined to receive
a full complement of therapeutic services and diagnostic
tests early on, only to be followed by a treatment option
of “last resort”if symptoms remain after a few weeks.
But with that is the failure to incorporate unique ana-
tomic, physiologic, and psychosocial variables in clinical
decision making. Setting the individual patient’s expecta-
tions that the only way to improve is by way of treat-
ment “x”undermines both the contemporaneous
treatment being pursued and the available alternatives.
Under these circumstances, the patient preference/value
component of the evidence-based practice model [54]
becomes prone to the influences of provider habit, pref-
erence, and assuredness for treatment “x”.
Defining levels of risk and informed consent with
SMUA
In the office setting, the risks associated with spinal
manipulative therapy (SMT) are relatively low as compared
with common modes of medical treatment [54]. However, a
recent systematic review found inadequate reporting of ad-
verse events with spinal manipulative therapy (SMT),
whether catastrophic or otherwise [64]. Swait and Finch re-
port that serious adverse events with manual treatment of
the spine appear to be rare, making it difficult to estimate
risk level [65]. They note that pre-existing pathology may
increase the risk of some events and call for enhanced
knowledge through clinician use of patient safety incident
reporting systems [65]. Cassidy et al. reported no evidence
of increased risk of vertebrobasilar artery (VBA) stroke [66]
or carotid artery stroke [67] associated with chiropractic
treatment versus primary care, suggesting coincidental
occurrence. Thus, the possibility exists for a cervical arterial
stroke to be the cause of neck pain rather than the result
of manual intervention [65–67]. Although it has been pro-
posed that neck hyperextension during intubation may
lead to vertebral artery dissection (VAD) [68], any specific
association between VAD and vascular mechanical stress
during neck manipulation under anesthesia has yet to be
studied. Cadaveric studies have shown that chiropractic
manipulation of the neck does not cause vertebral arterial
strain or internal carotid arterial strain in excess of the
strains incurred with ordinary movements [69,70]. As for
lumbopelvic spine manipulation-related cauda equina syn-
drome (CES), a recent systematic review cites it as the
most common of the serious adverse events reported but
excludes the assessment of cases involving manipu-
lated under anesthesia [71]. Nevertheless, manipulat-
ing the lumbar spine under anesthesia may present
an increased risk for CES over manipulation alone, as
per anecdotal reporting that sixteen of twenty-nine
identified CES cases involved manipulation under nar-
cosis or ether anesthesia [72].
Medical malpractice carrier statistics on adverse events
with MUA are proprietary and unavailable for analysis in
the public domain. The SMUA literature contains
mostly retrospective case reports and case series with
selective focus on the benefits of treatment. Thus, the
incidence for failed treatment or adverse events cannot
be determined. With the rate of minor to serious com-
plications remaining unknown, better case reporting and
investigative efforts on the safety profile of SMUA are
needed. For the chiropractic clinician who may not be
particularly expert on certain aspects of the individual
patient’s medical history, concurrent conditions, and
prescription/illicit drug use, clinical decision making for
SMUA should be reserved until all appropriate consulta-
tions are pursued. Any area of concern or uncertainty
identified should result in a referral to a specialist who
has the needed expertise to determine risk level and is
best positioned to provide for medical clearance.
Spinal manipulation under anesthesia brings additional
risk exposure beyond office-based conscious manipulation.
DiGiorgi et al. Chiropractic & Manual Therapies (2018) 26:9 Page 7 of 11
Prior to anesthetization, it is incumbent upon the chiro-
practor to be aware of these risks and overall patient fitness
for SMUA. For example, it is known that poor general
health increases the risks inherent to anesthesia. General
health risk categories for anesthesia have been established
by the American Society of Anesthesiologists (ASA) [73],
with which SMUA providers must be familiar when direct-
ing patients through pre-procedure screening evaluations.
Also, consideration must be given by the chiropractor to
the risks and contraindications for the manual therapy
component of the MUA procedure. These expand from
those associated with office-based manipulation. As mitiga-
tion and outcomes optimization strategies for the manual
therapy component of the MUA procedure, Table 2pro-
vides examples of clinical predictors of risk and outcome
potential. The elements therein have been placed on a scale
similar to that established by the ASA for predictors of
perioperative mortality rates, and as adopted by the Ameri-
can College of Physicians for predictors of postoperative
pulmonary and cardiac complications [74]. As with the
ASA Physical Status Classification System, it has been
shown that offering examples for each category aids with
proper patient assignment [75].
As noted across the early SMUA publications and
within the consensus statement put forth by the American
Academy of Osteopathy (AAO), the single-dose approach
is most common [9]. Under AAO criteria, if a second pro-
cedure dose is to be considered, it is usually after a three-
week period [76]. Such would permit sufficient time to
gauge the outcome of the initial procedure and to deter-
mine if it was sufficiently restorative in scope to represent
clinical endpoint. With the SMUA approach put forth by
Table 2 Manual therapy risk/outcome stratification with SMUA
SMUA
Classification
Patient profile or status Examples
b
SMUA I A normal, healthy patient with no frank clinical predictor for
unfavorable outcome or harm
A 40 year old male with a prior history of repetitive sports-related trauma
to the low back, and:
- a normal neurological examination
- MRI findings of mild multilevel lumbar disc degeneration
- a more recent history of chronic recurrent back pain with significant
debilitation, active/passive range of motion deficits, and muscle guarding
- limited response to adequate trials of office-based thrust manipulation
and other modes of conservative care
SMUA II An otherwise normal, healthy patient with a clinical predictor
or profile for unfavorable outcome but not harm
Obesity, high anxiety/stress level
a
, litigation, work-related injury, somatizer,
significantly inadequate response to an office-based trial of treatment
including thrust manipulation
SMUA III
c
A patient with identifiable signs, symptoms or a history of
comorbidity that may predict harm despite potential for
diminution/remediation of complaint
HTN Stage 1
e
, DVT, acute or chronic respiratory condition, history suggestive
of osteoporosis, current history of drug or alcohol abuse, cancer
history, night pain, unintentional weight loss, unexplained dizziness,
structural deformity, ligamentum flavum hypertrophy, lumbar disc
herniation/protrusion, positive lumbar EMG, corticosteroid use, prior
non-fusion surgery to site of treatment, spinal fusion with adjacent
segment disease, worsening of symptoms with office-based thrust
manipulation
SMUA IV
d
A patient with significant comorbidity or a history that likely
predicts unfavorable outcome and/or potential for harm
HTN Stage 2
f
, angina pectoris, unstable bleeding disorders, uncontrolled
diabetes, pain prone patient, hysteria, inflamed spinal tissues [47], joint
hypermobility/instability, unstable spondylolisthesis, severe joint sprain,
joint dislocation, advanced spondylosis with osteophytosis of or about
the spinal canal or IVF, implant instrumentation (precludes manipulation
to the site), advanced osteoporosis, multiple myeloma, joint/bone
infection, acute inflammatory arthritis/gout, positive myelogram, marked
motor signs, diastematomyelia, positive plantar reflex/clonus, ataxia
SMUA V
d
A patient with a highly significant clinical condition or comorbidity
that readily predicts unfavorable outcome, harm or death
Hypertensive Crisis
g
, advanced carotid/vertebral artery disease, unstable
aneurysm, acute abdominal pain with guarding, intracranial/intracanalicular
hematoma, recent fracture, ankylosing spondylitis, malignant bone tumor or
metastatic disease to bone, aggressive benign bone tumor, Paget’s disease,
Tuberculosis of bone, disc sequestration, Arnold Chiari malformation, spinal
cord/meningeal tumor, Cauda Equina Syndrome, bladder dysfunction,
saddle anesthesia, myelopathy, septicemia, known anesthesia allergy
a
When assessed by Bournemouth Questionnaire, as per the findings of a recent prospective cohort study (Level II evidence) [29]
b
Examples include identifiable factors of unfavorable outcome, as reported by prior investigators, as well as relative and absolute contraindications to manipulation of
unconscious patients. Contraindications and/or potential exclusion criteria are not limited to those shown
c
Modification of technique may be required with this risk category, assuming that medical clearance has been obtained via sufficient multidisciplinary input for
the specific precaution/s for harm. Examples of proper specialty input include a cardiologist for HTN Stage 1, and a vascular surgeon for DVT
d
This category represents a red flag classification for the SMUA service
e
Systolic mm Hg of 130–139 or diastolic mm Hg of 80–89 [86]
f
Systolic mm Hg of 140 or higher or diastolic mm Hg of 90 or higher [86]
g
Systolic mm Hg higher than 180 or diastolic mm Hg higher than 120 [86]
DiGiorgi et al. Chiropractic & Manual Therapies (2018) 26:9 Page 8 of 11
the AAMUAP, it has been proposed that customary use of
serial dosing provides for increased safety through gentler
treatment (with “better control of biomechanical force,”
when administered over three consecutive days) [3].
Nevertheless, each anesthesia exposure event would carry
its own separate risks, whether inherent to the anesthetic
agent or for the successive encounters during which the
unconscious patient is unable to alert the provider to a
painful and potentially injurious maneuver.
The ambulatory surgical center setting (ASC) in which
SMUA is typically performed presents its own risk con-
cerns. First, it must be established that patients are free
from mental impairment and have an intellectual status
permitting for adherence to ASC-related pre-procedural
and post-procedural instructions. Second, it is required
that patients have social support by way of a companion
for transportation/observation, in adhering to procedural
logistics and the at-home recovery period following ASC
discharge. Last, because the ASC simply does not have
the operational depth to meet that of a large medical
center, it is not as well positioned to manage patients
with poorly compensated or incompletely evaluated sys-
temic disease, issues of acute substance abuse, an abnor-
mal airway predisposing to difficult intubation, or
patients having a personal or strong family history of
anesthesia-associated malignant hyperthermia.
SMUA is an elective procedure. As a treatment option
for a non-life threatening disorder, it is scheduled in ad-
vance. This provides adequate time for informed consent
and/or patient pursuit of a second opinion from a spe-
cialist not involved in MUA. As put forth by Globe et al.
informed consent is defined as a communication process
between doctor and patient that leads to the patient
agreeing to undergo a specific intervention [54]. Material
risks of the intervention and available treatment options
should be explained to the patient, along with the risks
of no treatment [54]. It is the responsibility of the doctor
to disclose information that is known and that the
patient would find important in deciding whether to
undergo a particular procedure [77]. Clinicians who
perform spinal manipulation under anesthesia, or make
referrals for the like, are obligated to understand the
state of the evidence, procedural contraindications/risks,
and the conditions and indicators that are predictive of
adverse or unfavorable outcomes. As such, that informa-
tion may be communicated to patients as they contem-
plate which of the available treatment options to pursue.
Conclusion
This paper adds to the body of knowledge for SMUA by
evaluating the existing evidence in a unique way. It ad-
dresses outcome potential in several areas, identifies
prognostic factors for complication, and qualifies where
primary research efforts are needed for improved patient
selection. As a primer, a new risk classification system is
introduced which may serve as a guide for use in clinical
practice. No longer can treatment standards be reliant
upon anecdotal reports of satisfied patients, proclama-
tions of the various conditions amenable to SMUA,
preconceptions of permanent therapeutic benefit, a phil-
osophy that calls for serial and multiregional treatment
applications, and/or the fact that the procedure has had
a historically good safety record. As health care profes-
sionals committed to the public interest, chiropractors
who perform or make referrals for SMUA are obligated
to remain current and put forth accurate information in
the public domain on the state of the evidence, known
procedural contraindications/risks, and the conditions
and indicators that may predict an adverse or
unfavorable clinical outcome. When chiropractors lack a
comprehensive understanding of that information, or ad-
vocate for the procedure by preference, patients may be
unable to make informed decisions about their health
care options in submitting to appropriate consent. With
a new perspective on the evidence for SMUA, this ana-
lysis can assist clinicians who are seeking to identify key
decision points in care in enhancing risk management
strategies and optimizing patient outcomes.
Abbreviations
CES: Cauda equina syndrome; EMG: Electromyography; FRP: Fibrosis Release
Procedures; SMT: Spinal manipulative therapy; SMUA: Spinal manipulation
under anesthesia; VAD: Vertebral artery dissection; VBA: Vertebrobasilar
accident
Acknowledgements
Not applicable.
Funding
No funding or remuneration was provided.
Availability of data and materials
Some of the articles included in this review are distributed as open access papers.
The remainder are available from the corresponding author on reasonable
request.
Authors’contributions
DD and JLC initially collaborated on the writing project. All authors contributed
to the outline and submitted literature for inclusion. DD wrote the first draft.
Each author’s written contributions were reviewed by the others and revised
when needed until agreement was reached. All authors read and approved the
final manuscript.
Ethics approval and consent to participate
Not applicable.
Consent for publication
All authors consented to publication.
Competing interests
DD and DSB declare that they have no competing interests.
JLC is a former MUA postgraduate instructor and derives income as an MUA
lecturer and consultant.
DD holds a seat on the Editorial Advisory Board of the Official Disability
Guidelines (ODG). On a voluntary basis, DD periodically recommends articles
and develops new language for guideline inclusion on various subjects
including manipulation under anesthesia.
DiGiorgi et al. Chiropractic & Manual Therapies (2018) 26:9 Page 9 of 11
Publisher’sNote
Springer Nature remains neutral with regard to jurisdictional claims in published
maps and institutional affiliations.
Author details
1
Consultant Practice- Whitestone, NY, USA.
2
Clinical and Consultant Practice-
Jersey City, NJ, USA.
3
Clinical and Consultant Practice- Philadelphia, PA, USA.
Received: 20 November 2017 Accepted: 19 January 2018
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