Spinal manipulation therapy (SMT) is widely used worldwide to treat musculoskeletal and many other conditions. The evidence that it works for any of them is weak, non-existent, or negative. What is worse, SMT can – as we have discussed so often on this blog – cause adverse events some of which are serious, even fatal.
Spinal epidural hematoma (SEH) caused by SMT is a rare emergency that can cause neurological dysfunction. Chinese researchers recently reported three cases of SEH after SMT. 
- The first case was a 30-year-old woman who experienced neck pain and numbness in both upper limbs immediately after SMT. Her symptoms persisted after 3 d of conservative treatment, and she was admitted to our hospital. Magnetic resonance imaging (MRI) demonstrated an SEH, extending from C6 to C7.
- The second case was a 55-year-old man with sudden back pain 1 d after SMT, numbness in both lower limbs, an inability to stand or walk, and difficulty urinating. MRI revealed an SEH, extending from T1 to T3.
- The third case was a 28-year-old man who suddenly developed symptoms of numbness in both lower limbs 4 h after SMT. He was unable to stand or walk and experienced mild back pain. MRI revealed an SEH, extending from T1 to T2.
All three patients underwent surgery after failed conservative treatment and all recovered to ASIA grade E on day 5, 1 wk, and day 10 after surgery, respectively. All patients returned to normal after 3 mo of follow-up.
The authors concluded that SEH caused by SMT is very rare, and the condition of each patient should be evaluated in full detail before operation. SEH should be diagnosed immediately and actively treated by surgery.
These cases might serve as an apt reminder of the fact that SMT (particularly SMT of the neck) is not without its dangers. The authors’ assurance that SEH is VERY RARE is a little puzzling, in my view (the paper includes a table with all 17 previously published cases). There is, as we often have mentioned, no post-marketing surveillance, surgeons only see those patients who survive such complications long enough to come to the hospital, and they publish such cases only if they feel like it. Consequently, the true incidence is anyone’s guess.
As pointed out earlier, the evidence that SMT might be effective is shaky for most indications. In view of the potential for harm, this can mean only one thing:
The risk/benefit balance for SMT is not demonstrably positive.
In turn, this leads to the conclusion that patients should think twice before having SMT and should inquire about other therapeutic options that have a more positive risk/benefit balance. Similarly, the therapists proposing SMT to a patient have the ethical and moral duty to obtain fully informed consent which includes information about the risk/benefit balance of SMT and other options.
22 Responses to Spinal epidural hematoma after spinal manipulations: Report of three cases and a review of the literature
Leave a Reply to Edzard Cancel reply
This site uses Akismet to reduce spam. Learn how your comment data is processed.
“The evidence that it works for any of them is weak, non-existent, or negative”… Most clinical guidlines say otherwise but what do they know???
the question, it seems to me, is rather: WHAT DO YOU KNOW?
please show me guidelines where chiro is recommended for non-spinal problems, for instance.
Guidelines don’t recommend a profession, they recommend procedures/treatments.
according to DD Palmer, chiro is a treatment
He is dead.
oh really?
If these cases were in China that needs to be considered as a relevant factor.
Last i saw, “Chiropractic” and spinal manipulation is not regulated in China. This means anyone can call themselves a chiropractor and/or do spinal manipulation, without any professional training.
read the article; it lists 17 non-Chinese cases
I am referring to the three cases the authors reported. But sure if you want to go thru all 17 cases you can.
it was YOUR comment.
Yes, the authors reported on three cases. All three were in China. My comment was regarding spinal manipulation in China.
You brought up the 17 cases…I did not.
the authors reported on “three cases and a literature review”
they made this clear even in their title
Sigh. My comment was directed at the China cases.
“If these cases were in China…”
I know you are never wrong but “If these cases were in China…” as a comment to an SR of 17 cases is less than clear.
So the SIGH is all mine!
Right…from one reference…” 3 days prior he was given a layperson Thai massage by a friend. ”
Another reference
“ : A 38-year-old male patient was admitted to the emergency department for sudden weakness in the lower extremity after receiving a cervical spine massage.”
Another reference. First that say it was manipulation but in the case they state
“ We present the case of a 44-year-old female who presented with severe neck pain and mild quadriparesis following a coarse neck massage by an untrained person.”
Another reference…contraindication for SMT
“He was receiving anticoagulation therapy as a result of chronic atrial fibrillation.”
I can see why you didn’t want to go thru these cases.
Then the authors reference 16 which the only mention is SMT was that authors case report where he states a paraspinal muscle contusion was present.
That sounds like excessive force and thus a poor technique.
do you have a point with all this?
The devil is in the details. In this case, the references.
sure, but do you have a point?