MD, PhD, FMedSci, FRSB, FRCP, FRCPEd.

Spinal manipulation has been associated with a wide range of serious complications. Usually, they occur after neck manipulations. Neurologists from Morocco just published a case-report of a patient suffering a subdural haematoma after lumbar spinal manipulation.

A previously healthy 23 years-old man was receiving spinal manipulation for chronic back pain by a physiotherapist when he experienced a knife-like low back pain and lower limbs radiculalgia. The manipulation consisted on high velocity pression in the lumbar region while the patient was in prone position. He woke up the next morning with a weakness of both lower limbs and sensation of bladder fullness.

On presentation to the emergency department, 24 hours after the manipulation, the neurological examination found a cauda equina syndrome with motor strength between 2/5 and 3/5 in the left lower limb, 4/5 in the right lower limb, an abolition of the patellar and Achilles reflexes, a saddle hypoesthesia and a tender bladder. The general examination was normal. Magnetic resonance imaging (MRI) of the lumbar spine was performed promptly and showed intradural collection extending from L2 to L3 level with signal intensity consistent with blood. There were no adjacent fractures, disc or ligament injuries. Routine blood investigations were normal.

The patient underwent an emergency operation via L2-L3 laminectomy. The epidural space had no obvious abnormalities but the dura mater was tense and bluish. After opening the dura, a compressive blood clot was removed completely. The origin of the bleeding could not be determined. At the end of the intervention, nerve roots appeared free with normal courses. Subsequently, the patient’s the motor function of lower limbs gradually returned. He was discharged without neurological deficits 6 days postoperatively. At 6-months’ follow-up, the neurological examination was totally normal.

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Subdural haematoma is a rare occurrence. As a complication after spinal manipulation, it seems to be ever rarer. Our case-series of serious adverse effects after chiropractic manipulation did include such a case, albeit not at the lumbar level (as far as I remember):

To obtain preliminary data on neurological complications of spinal manipulation in the UK all members of the Association of British Neurologists were asked to report cases referred to them of neurological complications occurring within 24 hours of cervical spine manipulation over a 12-month period. The response rate was 74%. 24 respondents reported at least one case each, contributing to a total of about 35 cases. These included 7 cases of stroke in brainstem territory (4 with confirmation of vertebral artery dissection), 2 cases of stroke in carotid territory and 1 case of acute subdural haematoma. There were 3 cases of myelopathy and 3 of cervical radiculopathy. Concern about neurological complications following cervical spine manipulation appears to be justified. A large long-term prospective study is required to determine the scale of the hazard.

The big problem with adverse events of this nature is that their true incidence is essentially unknown. The  two cases of subdural haematoma mentioned above seem to be the only two reported in the medical literature. But, as there is no monitoring system, the true figure is anybody’s guess.

20 Responses to Spinal subdural haematoma after lumbar spinal manipulation

  • Interesting, well documented case. This is especially troubling since coagulation profile was normal, no AV malformation was detected during decompression and nothing suggest a collagen vascular disorder.

    I am not familiar with the physiotherapy technique where high velocity low amplitude trust is given to the lumbar spine in the prone position so it is hard to comment. However it appears whatever technique was used it increased the spinal canal pressure in a compressive manner.

    As for the incidence of cervical subdural haematoma following SMT I suggest you look at a review by Gouveia (2009) as I recall there were more than 2 cases mentioned there. When you go back to the case reports you find all had predisposing conditions.

  • EE…Our case-series…

    From the original 323 letters posted, 239 responses were received 􏰀response rate 74%). One letter was returned undelivered. Of the 239 responders, 5 indicated that they were retired and no longer receiving referrals. 210 respondents had no cases to report during the speci®ed time-frame (one year).

  • In UK there is monitoring in place for physiotherapy treatments?

  • Surely one can calculate how many spinal manipulations were done during that time frame for those areas.

    • feel free to try!
      but you have no denominator – remember: 100% underreporting

      • You have the reports in your paper. What was it, 35 cases over the course of a year?

        • are you a bit slow in the uptake?
          there is no monitoring system
          we merely contacted neurologists,
          patients might have gone to other doctors, e.g. GPs etc.
          they might not have consulted anyone
          some might have died
          not all neurologists responded
          some might have forgotten cases
          HOW DO YOU CONSTRUCT A RELIABLE DENOMINATOR FROM THAT?

          • You construct it from the data you can obtain.

            If there were 5 million spinal adjustments delivered during that year for those service areas…

            35 serious AE reported by neurologists:5 million SMT

            Not that tough of a question if you have the data.. And it was your study. Maybe you just dont like the answer?

          • any meaningful figure of this nature must refer to AEs occurred rather that AEs picked up haphazardly with our survey.

          • Im just going off what your survey found and was curious of any ratio that could be determined.

            Although i would be surprised that a significant number of serious neurological cases would not end up in a neurologist office at some point.

            Of course having a complete case history would have been informative as well.

          • would be surprised that a significant number of serious neurological cases would not end up in a neurologist office at some point.
            yes, be surprised!
            many don’t come to the neurologist
            the mild ones go to GPs
            the serious one to the pathologist

          • Well, at least we got the haphazard.

  • True the design was not aimed to that end… however I know one prospective study that was designed exactly for that purpose (thiel 2007.) but of course we can dismiss every study when the results do not suit us…

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