Myelopathy following manipulation of the neck

Myelopathy is defined as any neurologic deficit related to the spinal cord. When due to trauma, it is known as (acute) spinal cord injury. When caused by inflammatory, it is known as myelitis. Disease that is vascular in nature is known as vascular myelopathy.

The symptoms of myelopathy include:

• Pain in the neck, arm, leg or lower back
• Muscle weakness
• Difficulty with fine motor skills, such as writing or buttoning a shirt
• Difficulty walking
• Loss of urinary or bowel control
• Issues with balance and coordination

The causes of myelopathy include:

• Tumours that put pressure on the spinal cord
• Bone spurs
• A dislocation fracture
• Autoimmune diseases like multiple sclerosis
• Congenital abnormality
• A traumatic injury

This review presents a series of cases with cervical spine injury and myelopathy following therapeutic manipulation of the neck, and examines their clinical course and neurological outcome.

Its authors conducted a search for patients who developed neurological symptoms due to cervical spinal cord injury following neck SMT in the database of a spinal unit in a tertiary hospital between the years 2008 and 2018. Patients with vertebral artery dissections were excluded. Patients were assessed for the clinical course and deterioration, type of manipulation used and subsequent management.

A total of four patients were identified, two men and two women, aged between 32 and 66 years. In three patients neurological deterioration appeared after chiropractic adjustment and in one patient after tuina therapy. The patients had experienced symptoms within one day to one week after neck manipulation. The four patients had signs of:

1. central cord syndrome,
2. spastic quadriparesis,
3. spastic quadriparesis,
4. radiculopathy and myelomalacia.

Three patients were managed with anterior cervical discectomy and fusion while one patient declined surgical treatment.

The authors note that their data cannot determine whether the spinal cord dysfunction was caused my the spinal manipulations or were pre-existing problems which were aggravated by the treatments. They recommend that assessment for subjective and objective evidence of cervical myelopathy should be performed prior to cervical manipulation, and suspected myelopathic patients should be sent for further workup by a specialist familiar with cervical myelopathy, such as a neurologist, a neurosurgeon or orthopaedic surgeon who specializes in spinal surgery. They also state that manipulation therapy remains an important and generally safe treatment modality for a variety of cervical complaints. Their review, the authors stress, does not intend to discard the role of spinal manipulation as a significant part in the management of patients with neck related symptoms, rather it is meant to draw attention to the need for careful clinical and imaging investigation before treatment. This recommendation might be medically justified, yet one could argue that it is less than practical.

This paper from Israel is interesting in that it discloses possible complications of cervical manipulation. It confirms that chiropractors are most frequently implicated and that – as in our survey – under-reporting is exactly 100% (none of the cases identified by the retrospective chart review had been previously reported).

In light of this, some of the affirmations of the authors are bizarre. In particular, I ask myself how they can claim that cervical manipulation is a ‘generally safe’ treatment. With under-reporting at such high levels, the only thing one can say with certainty is that serious complications do happen and nobody can be sure how frequently they occur.