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Case Report

Clinical Pain 2023; 22(2): 122-126

Published online December 31, 2023 https://doi.org/10.35827/cp.2023.22.2.122

Copyright © Korean Association of Pain Medicine.

Cervical Myelopathy after Neck Manipulation

도수 치료 이후 발생한 경추 척수 병증

Jin Sun Kang, Sung Hoon Lee, Ki Hong Won, Tae Ki Choi, Su Min Lee, Eun Young Kang, Hyun Kyung Lee, Youn Kyung Cho

진선ㆍ이성훈ㆍ원기홍ㆍ최태기ㆍ이수민ㆍ강은영ㆍ이현경ㆍ조윤경

Department of Rehabilitation Medicine, Kwangju Christian Hospital, Gwangju, Korea

광주기독병원 재활의학과

Correspondence to:이성훈, 광주시 남구 양림로 37 ㉾ 61661, 광주기독병원 재활의학과
Tel: 062-650-5167, Fax: 062-671-7447
E-mail: starhoon3@hanmail.net

Received: January 30, 2023; Revised: June 5, 2023; Accepted: June 15, 2023

Spinal manipulation therapy (SMT) is commonly used to treat various musculoskeletal pains; however, it is associated with several complications. Mild complications resolve quickly; however, on rare occasions, they may cause severe complications that persist indefinitely. Here, we present a case of cervical myelopathy caused by a spinal manipulation. A 52-year-old man with a history of cervical radiculopathy at C4–7 underwent manipulation, performed by an unlicensed practitioner. After the manipulation, he explained abrupt muscle weakness in all four extremities. He was diagnosed with cervical myelopathy and had to undergo emergency surgery. Through this case, we aim to emphasize the role of doctors, with regard to spinal manipulation. Physicians must supervise the pre-evaluation of patients, manipulation, and post-manipulation monitoring, and the complications of SMT should be immediately reported.

KeywordsMyelopathy, Neck manipulation

Manipulation is defined by the International Federation of Manual Medicine as “the use of hands in the patient management process using instructions and maneuvers to maintain maximal, painless movement of the musculoskeletal system and postural balance”.1 Spinal manipulation therapy (SMT) is widely used to treat low back pain and neck pain; its efficacy has been demonstrated in numerous randomized controlled trials.2,3 Typical SMTs include mobilization and thrust. Mobilizations make use of low velocity, small-, or large-amplitude passive movement techniques within the patient’s range of motion and control, whereas thrust uses high-velocity impulses applied to a synovial joint over short amplitude at or near the end of the passive or physiological range of motion.3 SMT can sometimes be associated with complications, including stroke, myelopathy, radiculopathy, vertebral artery dissection, or even death. The complications are usually mild, but they can also lead to severe and permanent disability occasionally.4-7 In Korea, recently, the number of people undergoing manual therapy for musculoskeletal disorders has increased, as have the reports of post-manual therapy side effects.8 Due to the current increase in the elderly population, the demand for treating musculoskeletal disorders is on the rise. However, a dangerous trend of discriminatory prescription of SMT without awareness of clear indications and contraindications and without monitoring by doctors, particularly musculoskeletal specialists, is observed. If this trend continues, the prevalence of complications is bound to increase. Therefore, this review aimed to report the myelopathy that occurred in our patient after SMT, raise awareness of this issue, which has been reported worldwide, alarm the doctors about the current practice of indiscri-minate prescription of manual therapy, and consider the risk of complications arising from it.

A 52-year-old man with a height of 173 cm and a weight of 70 kg presented to our emergency department with rapidly progressive quadriparesis. He had no underlying disease other than multiple cervical herniated intervertebral discs at C4/5, C5/6, and C6/7 (Fig. 1-A and 1-B). One day before he experienced the symptoms of quadriparesis, he had undergone manipulation therapy with thrusting at a massage shop from an unlicensed therapist without a doctor’s prescription to obtain relief from chronic neck pain. Before the therapy, his only symptom was pain without any motor weakness. After the manipulation therapy, however, he experienced an abrupt onset of bilateral weakness in all four extremities, leading to an inability to walk and severe numbness in both hands. Neurological examination revealed areflexia in the elbows, abdomen, and knees, along with hypoesthesia below the C5 dermatome, particularly in the C8-T1 dermatome. He also experienced weakness in all four limbs, with the upper limbs being more severely affected than the lower limbs. The manual muscle test (MMT) revealed a strength grade of 2 of 5 and 3 of 5 for the bilateral upper and lower extremities, respectively. He also complained of progressive difficulty in voiding and defecating.

Figure 1.Cervical spine magnetic resonance imaging (MRI) performed 3 months before the onset of symptoms. Sagittal and axial MRI showed multilevel herniated intervertebral discs from C4 to C7 and severe right central disc extrusion of C4/5 (A and B). After symptom onset, they indicate compressive myleopathy at C4/5 (C and D).

Compared to the cervical magnetic resonance imaging (MRI) performed three months ago, the current MRI scan confirmed spinal cord compression and surrounding edema due to the progression of C4/5 central disc herniation (Fig. 1-C and 1-D). An emergency anterior cervical decompression fusion at the level of C4/5 was performed (Fig. 2).

Figure 2.Cervical spine MRI and X-ray performed after surgery. C-spine lateral view (A) and anterioposterior view (B). Sagittal MRI and axial MRI of the same patient at the C4/5 level obtained indicated that the cord compression at C4/5 had resolved (C and D).

Immediately after the surgery, MMT improved to 3 of 5 and 4 of 5 for the bilateral upper and lower extremities, respectively. A nerve conduction study, median somatosensory evoked potentials (SEP), and needle electromyo-graphy (EMG) were performed one week after surgery. The examination indicated normal findings; however, motor evoked potentials (MEP) and tibial SEP were not performed (Table 13). The patient was eager to resume walking and wanted to return to work. Three days after the surgery, he was initiated on comprehensive rehabilitation therapy to restore muscle strength and balance through sequential performance of hip extensor strengthening, stepping, and treadmill walking exercises supervised by a well-trained physical therapist to improve endurance. Additionally, the patient was trained to improve his independence in activities of daily living, including using chopsticks and having a bath. After rehabilitation therapy for three weeks, MMT improved to 4 of 5 for the bilateral upper and lower extremities. His Functional Independence Measure score improved to 108 of 126, and he achieved independence in activities of daily living.

Table 1 Results of Nerve Conduction Studies

NerveDSL (ms)S Amp (μV)DML (ms)M Amp (μV)NCV (m/s)
Median R2.2352.79.967
Median L2.4313.21172
Ulnar R2.1212.28.456
Ulnar L2.1372.2861
Tibial R3.321.150
Tibial L3.32552
Peroneal R35.551
Peroneal L3.34.960
Superficial peroneal R2.616
Superficial peroneal L2.816
Sural R2.321
Sural L2.216

DSL: distal sensory latency, S Amp: sensory amplitude, DML: distal motor latency, M Amp: motor amplitude, NCV: nerve conduction velocity, R: right, L: left.


Table 2 Latencies of Somatosensory Evoked Potential Study

P19 latency (ms)P23 latency (ms)
RightLeftRightLeft
Median nerve19.219.823.823.7

Table 3 Results of the Needle Electromyography

MuscleSpontaneousMUAPRecruitment pattern
FibPSWDurationAmplitude
APB. RNoneNoneNormalNormalNormal
APB. LNoneNoneNormalNormalNormal
BB. RNoneNoneNormalNormalNormal
BB. LNoneNoneNormalNormalNormal
PT. RNoneNoneNormalNormalNormal
PT. LNoneNoneNormalNormalNormal
C5 paraspinal RNoneNoneNormalNormalNormal
C5 paraspinal LNoneNoneNormalNormalNormal
C6 paraspinal RNoneNoneNormalNormalNormal
C6 paraspinal LNoneNoneNormalNormalNormal
C7 paraspinal RNoneNoneNormalNormalNormal
C7 paraspinal LNoneNoneNormalNormalNormal

Fib: fibrillation, PSW: positive sharp wave, MUAP: motor unit action potential, APB: abductor pollicis brevis, BB: biceps brachii, PT: pronator teres, R: right, L: left.

Herein, the patient had a history of cervical spondylosis and C4-5 disc herniation. A combination of forced rotatory and extension maneuvers executed during cervical spine manipulation seemed to have caused an extreme excursion of the vertebrae, which can manifest in the form of direct contusion and-/or ischemia of the spinal cord.9 Thrust is contraindicated in patients with central disc herniation.6 If the patient had approached a musculoskeletal specialist, he would have been recommended alternative treatment modalities or surgery other than thrust, and the above disaster could have been prevented. This case suggests the role that should be played by doctors in situations, where the number of claims for actual expenses and those for complaints of manual treatment are increasing every year. Doctors, particularly musculoskeletal specialists, must be completely functional in all areas of manual therapy. First, subjective and objective evaluations should precede manual therapy for patients. Absolute contraindications to manual therapy or red flag groups must be identified after considering the patient’s complaints, previously diagnosed diseases, family history, physical examination and imaging tests and must be performed under the guidance of a doctor. Symptoms that arise during or after treatment must be addressed by the doctor through prompt and appropriate measures, thereby ensuring the patient’s recovery. Finally, in the event of the occurrence of adverse events (AEs), the doctors should reduce the incidence of complications in the future through active accident reporting.

Flexion and extension movements of the cervical spine involve sliding movements of a vertebra over the one below it, and normal flexion or extension reduces the anteroposterior diameter of the cervical canal. Meanwhile, in a previous case reported by Murphy et al.,10 a patient with a cervical disc problem progressed to cervical myelopathy naturally, even without manipulation. Hence, in patients with stenosis of the spinal canal or vertebral instability, cervical SMT can lead to severe cord injury. Acute fracture, acute soft tissue injury, dislocation, osteoporosis, vertebral instability, and vertebral artery abnormalities are some of the other contraindications to manipulation. Smoking, cervical trauma, recent infection, hypertension, migraine, a low cholesterol level, and a low body mass index are the additional risk factors associated with AEs.11 Previously, it has been reported that strictly excluding patients with known contraindications and red flags from receiving manipulation could reduce AEs by 44%.12

SMT can generally be performed for various etiologies of neck and lumbar pain, if not contraindicated. A limitation in normal joint movement is called a restriction barrier. Use of hands to eliminate these barriers can help restore the normal range of motion. Thrust and mobilization are useful, but there are other techniques, such as soft tissue technique and direct myofascial release, and appropriate treatment is decided by the physical therapist. There are other considerations to reduce complications. Currently, the prevalence of AEs following SMT has not been clearly established. Assendelft et al.13 reported that post spinal manipulation complications are usually underreported, owing to the inability of the physician to recall the cases, leading to misses of minor cases. Moreover, in Korea, treatment modalities, such as Chuna therapy, chiropractic treatment, and manual therapy, are mixed and have an underdeveloped complication reporting management system. Clarifying the concepts of manual therapy and allowing it to be performed by a qualified therapist can help manage the risk.

Only seven cases of complications arising from SMT have been reported in Korea, as evident from the Korea Citation Index and journals related to manual therapy, including Annals of Rehabilitation Medicine and Clinical Pain. These cases have reported central retinal artery occlusion, posterior inferior cerebellar artery infarction, vertebral fracture, accessory nerve injury, cauda equina syndrome, atlantoaxial subluxation, and myelopathy as complications of cervical SMT.11,14-19 Compared to the previous domestic report, the case of our patient was not a rare one; however, he already had cervical spondylosis, C4-5 herniated disc, multilevel disc bulging and cervical foraminal stenosis due to uncovertebral joint hypertrophy, contraindicating manual therapy. Through this case report, we emphasized the importance of a physician’s role as a commander and reiterated the importance of recognizing contraindications and indications of SMT.

  1. James WA, Ronald BT, Brendon SR, James EE. Manipulation, Traction, and Massage. In: David XC, editor. Braddom’s Physical medicine and Rehabilitation, 6th ed. Philadelphia: Elsevier; 2022. p. 316-37.
    CrossRef
  2. Bronfort G, Haas M, Evans RL, Bouter LM. Efficacy of spinal manipulation and mobilization for low back pain and neck pain: a systematic review and best evidence synthesis. Spine J 2004;4:335-56.
    Pubmed CrossRef
  3. Rubinstein SM, de Zoete A, van Middelkoop M, Assendelft WJJ, de Boer MR, van Tulder MW. Benefits and harms of spinal manipulative therapy for the treatment of chronic low back pain: systematic review and meta-analysis of randomised controlled trials. BMJ 2019;364:l689.
    Pubmed KoreaMed CrossRef
  4. Khalil S, Alon G, Gilad R, Morsi K, Ran L, Zvi L. Acute presentation of cervical myelopathy following manipulation therapy. Isr Med Assoc J 2019;21:542-5.
    Pubmed
  5. Kapur PL, Walter GC, Georges FM, Gregory WA. Neurologic complications following chiropractic manipulation: A survey of California neurologists. Neurology 1995;45:1213-5.
    Pubmed CrossRef
  6. David GM, Nevan GB, Frank JT, Christopher MB, Steven EG, Christopher GC, et al. Complications of cervical spine manipulation therapy: 5-hear retrospective study in a single group practice. Neurosurg Focus 2002;13:1-8.
  7. Clare S, Will H, Brian C, Edzard E. Neurological complications of cervical spine manipulation. J R Soc Med 2001;94:107-10.
    Pubmed KoreaMed CrossRef
  8. Korea Customer Agency. Problems and improvement plans of non-insured medical treatment (manipulation treatment, etc.) [Internet]. Eumseong-gun (KR): Korea Customer Agency; 2018 [cited 2018 Aug 28]. https://www.kca.go.kr/smartconsumer/sub.do?menukey=7301&mode=view&no=1002691771.
  9. Puentedura EJ, March J, Anders J, Perez A, Landers MR, Wallmann HW, et al. Safety of cervical spine manipulation: are adverse events preventable and are manipulations being performed appropriately? A review of 134 case reports. J Man Manip Ther 2012;20:66-74.
    Pubmed KoreaMed CrossRef
  10. Murphy DR, Beres JL. Cervical myelopathy: a case report of a “near-miss” complication to cervical manipulation. J Manipulative Physiol Ther 2008;31:553-7.
  11. Yoon SM, Lee KS, Doh JW, Bae HG, Park SI, Yun IG. Cervical spine fracture following non-authorized manipulation - A case report. Ann Rehabil Med 2001;25:896-900.
  12. Bailes JE, Petschauer M, Guskiewicz KM, Marano G. Management of cervical spine injuries in athletes. J Athl Train 2007;42:126-34.
    Pubmed KoreaMed CrossRef
  13. Assendelft WJ, Bouter LM, Knipschild PG. Complications of spinal manipulation - A comprehensive review of the literature. J Fam Pract 1996;45:475-80.
  14. Kwon YW, Kim JM. Cauda equina syndrome after spinal manipulative therapy: A case report. Ann Rehabil Med 1999;23:439-43.
  15. Jang YJ, Chun JW, Kim HC. A case of central retinal artery occlusion after chiropractic manipulation of the neck. Korean J Opthalmol 2012;26:132-4.
    Pubmed KoreaMed CrossRef
  16. Jeong DK, Hwang SK. A case of posterior inferior cerebellar artery infarction after cervical chiropractic manipulation. Korean J Neurotrauma 2018;14:159-63.
    Pubmed KoreaMed CrossRef
  17. Yoon JR, Kim YK, Chung ME. Spinal accessory nerve injury induced by manipulation therapy: A case report. Ann Rehabil Med 2018;42:773-8.
    Pubmed KoreaMed CrossRef
  18. Park CH, Chun DJ, Lee SJ, Kwon BS, Kim SC. Atlantoaxial subluxation caused by spinal manipulation: A case report. Ann Rehabil Med 2001;25:720-3.
  19. Kim MS, Cho HE, Paek MC, Park JH. Complication of the cervical thrust technique in a patient with athetoid cerebral palsy. Clin Pain 2022;21:38-40.
    CrossRef

Article

Case Report

Clinical Pain 2023; 22(2): 122-126

Published online December 31, 2023 https://doi.org/10.35827/cp.2023.22.2.122

Copyright © Korean Association of Pain Medicine.

Cervical Myelopathy after Neck Manipulation

Jin Sun Kang, Sung Hoon Lee, Ki Hong Won, Tae Ki Choi, Su Min Lee, Eun Young Kang, Hyun Kyung Lee, Youn Kyung Cho

Department of Rehabilitation Medicine, Kwangju Christian Hospital, Gwangju, Korea

Correspondence to:이성훈, 광주시 남구 양림로 37 ㉾ 61661, 광주기독병원 재활의학과
Tel: 062-650-5167, Fax: 062-671-7447
E-mail: starhoon3@hanmail.net

Received: January 30, 2023; Revised: June 5, 2023; Accepted: June 15, 2023

Abstract

Spinal manipulation therapy (SMT) is commonly used to treat various musculoskeletal pains; however, it is associated with several complications. Mild complications resolve quickly; however, on rare occasions, they may cause severe complications that persist indefinitely. Here, we present a case of cervical myelopathy caused by a spinal manipulation. A 52-year-old man with a history of cervical radiculopathy at C4–7 underwent manipulation, performed by an unlicensed practitioner. After the manipulation, he explained abrupt muscle weakness in all four extremities. He was diagnosed with cervical myelopathy and had to undergo emergency surgery. Through this case, we aim to emphasize the role of doctors, with regard to spinal manipulation. Physicians must supervise the pre-evaluation of patients, manipulation, and post-manipulation monitoring, and the complications of SMT should be immediately reported.

Keywords: Myelopathy, Neck manipulation

INTRODUCTION

Manipulation is defined by the International Federation of Manual Medicine as “the use of hands in the patient management process using instructions and maneuvers to maintain maximal, painless movement of the musculoskeletal system and postural balance”.1 Spinal manipulation therapy (SMT) is widely used to treat low back pain and neck pain; its efficacy has been demonstrated in numerous randomized controlled trials.2,3 Typical SMTs include mobilization and thrust. Mobilizations make use of low velocity, small-, or large-amplitude passive movement techniques within the patient’s range of motion and control, whereas thrust uses high-velocity impulses applied to a synovial joint over short amplitude at or near the end of the passive or physiological range of motion.3 SMT can sometimes be associated with complications, including stroke, myelopathy, radiculopathy, vertebral artery dissection, or even death. The complications are usually mild, but they can also lead to severe and permanent disability occasionally.4-7 In Korea, recently, the number of people undergoing manual therapy for musculoskeletal disorders has increased, as have the reports of post-manual therapy side effects.8 Due to the current increase in the elderly population, the demand for treating musculoskeletal disorders is on the rise. However, a dangerous trend of discriminatory prescription of SMT without awareness of clear indications and contraindications and without monitoring by doctors, particularly musculoskeletal specialists, is observed. If this trend continues, the prevalence of complications is bound to increase. Therefore, this review aimed to report the myelopathy that occurred in our patient after SMT, raise awareness of this issue, which has been reported worldwide, alarm the doctors about the current practice of indiscri-minate prescription of manual therapy, and consider the risk of complications arising from it.

CASE REPORT

A 52-year-old man with a height of 173 cm and a weight of 70 kg presented to our emergency department with rapidly progressive quadriparesis. He had no underlying disease other than multiple cervical herniated intervertebral discs at C4/5, C5/6, and C6/7 (Fig. 1-A and 1-B). One day before he experienced the symptoms of quadriparesis, he had undergone manipulation therapy with thrusting at a massage shop from an unlicensed therapist without a doctor’s prescription to obtain relief from chronic neck pain. Before the therapy, his only symptom was pain without any motor weakness. After the manipulation therapy, however, he experienced an abrupt onset of bilateral weakness in all four extremities, leading to an inability to walk and severe numbness in both hands. Neurological examination revealed areflexia in the elbows, abdomen, and knees, along with hypoesthesia below the C5 dermatome, particularly in the C8-T1 dermatome. He also experienced weakness in all four limbs, with the upper limbs being more severely affected than the lower limbs. The manual muscle test (MMT) revealed a strength grade of 2 of 5 and 3 of 5 for the bilateral upper and lower extremities, respectively. He also complained of progressive difficulty in voiding and defecating.

Figure 1. Cervical spine magnetic resonance imaging (MRI) performed 3 months before the onset of symptoms. Sagittal and axial MRI showed multilevel herniated intervertebral discs from C4 to C7 and severe right central disc extrusion of C4/5 (A and B). After symptom onset, they indicate compressive myleopathy at C4/5 (C and D).

Compared to the cervical magnetic resonance imaging (MRI) performed three months ago, the current MRI scan confirmed spinal cord compression and surrounding edema due to the progression of C4/5 central disc herniation (Fig. 1-C and 1-D). An emergency anterior cervical decompression fusion at the level of C4/5 was performed (Fig. 2).

Figure 2. Cervical spine MRI and X-ray performed after surgery. C-spine lateral view (A) and anterioposterior view (B). Sagittal MRI and axial MRI of the same patient at the C4/5 level obtained indicated that the cord compression at C4/5 had resolved (C and D).

Immediately after the surgery, MMT improved to 3 of 5 and 4 of 5 for the bilateral upper and lower extremities, respectively. A nerve conduction study, median somatosensory evoked potentials (SEP), and needle electromyo-graphy (EMG) were performed one week after surgery. The examination indicated normal findings; however, motor evoked potentials (MEP) and tibial SEP were not performed (Table 13). The patient was eager to resume walking and wanted to return to work. Three days after the surgery, he was initiated on comprehensive rehabilitation therapy to restore muscle strength and balance through sequential performance of hip extensor strengthening, stepping, and treadmill walking exercises supervised by a well-trained physical therapist to improve endurance. Additionally, the patient was trained to improve his independence in activities of daily living, including using chopsticks and having a bath. After rehabilitation therapy for three weeks, MMT improved to 4 of 5 for the bilateral upper and lower extremities. His Functional Independence Measure score improved to 108 of 126, and he achieved independence in activities of daily living.

Table 1 . Results of Nerve Conduction Studies.

NerveDSL (ms)S Amp (μV)DML (ms)M Amp (μV)NCV (m/s)
Median R2.2352.79.967
Median L2.4313.21172
Ulnar R2.1212.28.456
Ulnar L2.1372.2861
Tibial R3.321.150
Tibial L3.32552
Peroneal R35.551
Peroneal L3.34.960
Superficial peroneal R2.616
Superficial peroneal L2.816
Sural R2.321
Sural L2.216

DSL: distal sensory latency, S Amp: sensory amplitude, DML: distal motor latency, M Amp: motor amplitude, NCV: nerve conduction velocity, R: right, L: left..



Table 2 . Latencies of Somatosensory Evoked Potential Study.

P19 latency (ms)P23 latency (ms)
RightLeftRightLeft
Median nerve19.219.823.823.7


Table 3 . Results of the Needle Electromyography.

MuscleSpontaneousMUAPRecruitment pattern
FibPSWDurationAmplitude
APB. RNoneNoneNormalNormalNormal
APB. LNoneNoneNormalNormalNormal
BB. RNoneNoneNormalNormalNormal
BB. LNoneNoneNormalNormalNormal
PT. RNoneNoneNormalNormalNormal
PT. LNoneNoneNormalNormalNormal
C5 paraspinal RNoneNoneNormalNormalNormal
C5 paraspinal LNoneNoneNormalNormalNormal
C6 paraspinal RNoneNoneNormalNormalNormal
C6 paraspinal LNoneNoneNormalNormalNormal
C7 paraspinal RNoneNoneNormalNormalNormal
C7 paraspinal LNoneNoneNormalNormalNormal

Fib: fibrillation, PSW: positive sharp wave, MUAP: motor unit action potential, APB: abductor pollicis brevis, BB: biceps brachii, PT: pronator teres, R: right, L: left..


DISCUSSION

Herein, the patient had a history of cervical spondylosis and C4-5 disc herniation. A combination of forced rotatory and extension maneuvers executed during cervical spine manipulation seemed to have caused an extreme excursion of the vertebrae, which can manifest in the form of direct contusion and-/or ischemia of the spinal cord.9 Thrust is contraindicated in patients with central disc herniation.6 If the patient had approached a musculoskeletal specialist, he would have been recommended alternative treatment modalities or surgery other than thrust, and the above disaster could have been prevented. This case suggests the role that should be played by doctors in situations, where the number of claims for actual expenses and those for complaints of manual treatment are increasing every year. Doctors, particularly musculoskeletal specialists, must be completely functional in all areas of manual therapy. First, subjective and objective evaluations should precede manual therapy for patients. Absolute contraindications to manual therapy or red flag groups must be identified after considering the patient’s complaints, previously diagnosed diseases, family history, physical examination and imaging tests and must be performed under the guidance of a doctor. Symptoms that arise during or after treatment must be addressed by the doctor through prompt and appropriate measures, thereby ensuring the patient’s recovery. Finally, in the event of the occurrence of adverse events (AEs), the doctors should reduce the incidence of complications in the future through active accident reporting.

Flexion and extension movements of the cervical spine involve sliding movements of a vertebra over the one below it, and normal flexion or extension reduces the anteroposterior diameter of the cervical canal. Meanwhile, in a previous case reported by Murphy et al.,10 a patient with a cervical disc problem progressed to cervical myelopathy naturally, even without manipulation. Hence, in patients with stenosis of the spinal canal or vertebral instability, cervical SMT can lead to severe cord injury. Acute fracture, acute soft tissue injury, dislocation, osteoporosis, vertebral instability, and vertebral artery abnormalities are some of the other contraindications to manipulation. Smoking, cervical trauma, recent infection, hypertension, migraine, a low cholesterol level, and a low body mass index are the additional risk factors associated with AEs.11 Previously, it has been reported that strictly excluding patients with known contraindications and red flags from receiving manipulation could reduce AEs by 44%.12

SMT can generally be performed for various etiologies of neck and lumbar pain, if not contraindicated. A limitation in normal joint movement is called a restriction barrier. Use of hands to eliminate these barriers can help restore the normal range of motion. Thrust and mobilization are useful, but there are other techniques, such as soft tissue technique and direct myofascial release, and appropriate treatment is decided by the physical therapist. There are other considerations to reduce complications. Currently, the prevalence of AEs following SMT has not been clearly established. Assendelft et al.13 reported that post spinal manipulation complications are usually underreported, owing to the inability of the physician to recall the cases, leading to misses of minor cases. Moreover, in Korea, treatment modalities, such as Chuna therapy, chiropractic treatment, and manual therapy, are mixed and have an underdeveloped complication reporting management system. Clarifying the concepts of manual therapy and allowing it to be performed by a qualified therapist can help manage the risk.

Only seven cases of complications arising from SMT have been reported in Korea, as evident from the Korea Citation Index and journals related to manual therapy, including Annals of Rehabilitation Medicine and Clinical Pain. These cases have reported central retinal artery occlusion, posterior inferior cerebellar artery infarction, vertebral fracture, accessory nerve injury, cauda equina syndrome, atlantoaxial subluxation, and myelopathy as complications of cervical SMT.11,14-19 Compared to the previous domestic report, the case of our patient was not a rare one; however, he already had cervical spondylosis, C4-5 herniated disc, multilevel disc bulging and cervical foraminal stenosis due to uncovertebral joint hypertrophy, contraindicating manual therapy. Through this case report, we emphasized the importance of a physician’s role as a commander and reiterated the importance of recognizing contraindications and indications of SMT.

Fig 1.

Figure 1.Cervical spine magnetic resonance imaging (MRI) performed 3 months before the onset of symptoms. Sagittal and axial MRI showed multilevel herniated intervertebral discs from C4 to C7 and severe right central disc extrusion of C4/5 (A and B). After symptom onset, they indicate compressive myleopathy at C4/5 (C and D).
Clinical Pain 2023; 22: 122-126https://doi.org/10.35827/cp.2023.22.2.122

Fig 2.

Figure 2.Cervical spine MRI and X-ray performed after surgery. C-spine lateral view (A) and anterioposterior view (B). Sagittal MRI and axial MRI of the same patient at the C4/5 level obtained indicated that the cord compression at C4/5 had resolved (C and D).
Clinical Pain 2023; 22: 122-126https://doi.org/10.35827/cp.2023.22.2.122

Table 1 Results of Nerve Conduction Studies

NerveDSL (ms)S Amp (μV)DML (ms)M Amp (μV)NCV (m/s)
Median R2.2352.79.967
Median L2.4313.21172
Ulnar R2.1212.28.456
Ulnar L2.1372.2861
Tibial R3.321.150
Tibial L3.32552
Peroneal R35.551
Peroneal L3.34.960
Superficial peroneal R2.616
Superficial peroneal L2.816
Sural R2.321
Sural L2.216

DSL: distal sensory latency, S Amp: sensory amplitude, DML: distal motor latency, M Amp: motor amplitude, NCV: nerve conduction velocity, R: right, L: left.


Table 2 Latencies of Somatosensory Evoked Potential Study

P19 latency (ms)P23 latency (ms)
RightLeftRightLeft
Median nerve19.219.823.823.7

Table 3 Results of the Needle Electromyography

MuscleSpontaneousMUAPRecruitment pattern
FibPSWDurationAmplitude
APB. RNoneNoneNormalNormalNormal
APB. LNoneNoneNormalNormalNormal
BB. RNoneNoneNormalNormalNormal
BB. LNoneNoneNormalNormalNormal
PT. RNoneNoneNormalNormalNormal
PT. LNoneNoneNormalNormalNormal
C5 paraspinal RNoneNoneNormalNormalNormal
C5 paraspinal LNoneNoneNormalNormalNormal
C6 paraspinal RNoneNoneNormalNormalNormal
C6 paraspinal LNoneNoneNormalNormalNormal
C7 paraspinal RNoneNoneNormalNormalNormal
C7 paraspinal LNoneNoneNormalNormalNormal

Fib: fibrillation, PSW: positive sharp wave, MUAP: motor unit action potential, APB: abductor pollicis brevis, BB: biceps brachii, PT: pronator teres, R: right, L: left.


References

  1. James WA, Ronald BT, Brendon SR, James EE. Manipulation, Traction, and Massage. In: David XC, editor. Braddom’s Physical medicine and Rehabilitation, 6th ed. Philadelphia: Elsevier; 2022. p. 316-37.
    CrossRef
  2. Bronfort G, Haas M, Evans RL, Bouter LM. Efficacy of spinal manipulation and mobilization for low back pain and neck pain: a systematic review and best evidence synthesis. Spine J 2004;4:335-56.
    Pubmed CrossRef
  3. Rubinstein SM, de Zoete A, van Middelkoop M, Assendelft WJJ, de Boer MR, van Tulder MW. Benefits and harms of spinal manipulative therapy for the treatment of chronic low back pain: systematic review and meta-analysis of randomised controlled trials. BMJ 2019;364:l689.
    Pubmed KoreaMed CrossRef
  4. Khalil S, Alon G, Gilad R, Morsi K, Ran L, Zvi L. Acute presentation of cervical myelopathy following manipulation therapy. Isr Med Assoc J 2019;21:542-5.
    Pubmed
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Korean Association of Pain Medicine

Vol.22 No.2
December 2023

eISSN: 2765-5156

Frequency: Semi Annual

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