Incidence of serious adverse effects following lumbar spinal manipulative techniques performed on adults: 
 a systematic review | The International Academy of Osteopathy IAO

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Incidence of serious adverse effects following lumbar spinal manipulative techniques performed on adults: 
 a systematic review


Author: Mens, Michiel, BSc. Ost. (London)
Supervisor: Barrix, David, MSc. Ost. (University of Applied Sciences)

Background: Low back pain is a very common musculoskeletal complaint where spinal manipulative techniques (SMT) are an often-used treatment option by many different practitioners and its use has increased in the past several decades. Evidence suggests positive effects following SMT for reducing acute and chronic low back pain and pain threshold and potentially on other conditions. However, a balanced assessment of interventions using SMT requires an analysis of both benefits and harms.
SMT have a large mechanical impact on the spinal column. It is therefore appropriate to investigate to what extent these techniques are safe before implementing these techniques in official guidelines and primary care. This can be done by collecting data regarding serious adverse effects following lumbar manipulations.

Question: What is the incidence of serious adverse effects of spinal manipulative techniques in the lumbar spine?

Objective: The purpose of this thesis is to search the literature for studies reporting serious adverse effects following lumbar SMT, including both observational and experimental studies, to describe the case details and to make a risk estimation.

Methods: A systematic search was conducted in PubMed, ISI Web of Science and The Cochrane Library in January, 2016. A serious adverse effect was defined as an unfavourable outcome that occurs during or occurred after SMT, and that resulted in death, was life-threatening, required patient hospitalization or prolongation of existing hospitalization, resulted in persistent or significant disability/incapacity or resulted in any other medically important condition, and where the causal relation
between the intervention and the event is at least a reasonable possibility. Only individuals of 18 years or older who experienced a severe adverse effect following SMT applied to the lumbar spine by any type of provider were included. Studies discussing the effects of SMT under anesthesia, SMT performed on children or discussing the temporary side effects following SMT were excluded.

Results: In total, 8.493 studies were screened, and 74 studies were identified in the peer-reviewed literature. This study included 36 case reports, 13 retrospective studies, 8 prospective studies, 2 randomized controlled trials and 15 reviews, reporting on 142 serious adverse effects in 105 years (1911-2016). Radiculopathies (85 cases, 67,5%) and cauda equina syndrome (33 cases, 26,2%) accounted for the majority of the serious adverse effects that could be attributed to lumbar SMT. Less frequently, vertebral fractures (7 cases, 5,6%) and vascular complications (6 cases, 4,8%) could be identified. Based on the data of the prospective studies, serious adverse effects are estimated to occur in less than 0,09% of the patients that undergo SMT in the lumbar area or in less than 0,02% (95% CI) of the lumbar SMT.

Conclusions: Our review was comprehensive. however, classifying the serious adverse effects and SMT-providers was difficult because of a lack in consistency of reporting by the primary studies. However, based on the available data, one can cautiously conclude that serious adverse effects following osteopathic lumbar SMT, performed on adults, are rare.