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J Manipulative Physiol Ther. 2015 Nov-Dec;38(9):677-691. doi: 10.1016/j.jmpt.2013.05.009. Epub 2013 Jun 17.

Serious Adverse Events and Spinal Manipulative Therapy of the Low Back Region: A Systematic Review of Cases.

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Senior Lecturer, School of Psychology and Exercise Science, Murdoch University, Perth, Western Australia, Australia. Electronic address:
Postdoctoral Researcher, School of Health Professions, Murdoch University, Perth, Western Australia, Australia.
Adjunct Senior Lecturer, School of Health Professions, Murdoch University, Perth, Western Australia, Australia; Senior Research Fellow, Melbourne School of Health Sciences, The University of Melbourne, Carlton, Victoria, Australia.
Senior Researcher, Department of Epidemiology and Biostatistics, EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, the Netherlands.



The purpose of this study was to systematically search the literature for studies reporting serious adverse events following lumbopelvic spinal manipulative therapy (SMT) and to describe the case details.


A systematic search was conducted in PubMed including MEDLINE, EMBASE, CINAHL, and The Cochrane Library up to January 12, 2012, by an experienced reference librarian. Study selection was performed by 2 independent reviewers using predefined criteria. We included cases involving individuals 18 years or older who experienced a serious adverse event following SMT applied to the lumbar spine or pelvis by any type of provider (eg, chiropractic, medical, physical therapy, osteopathic, layperson). A serious adverse event was defined as an untoward occurrence that results in death or is life threatening, requires hospital admission, or results in significant or permanent disability. We included studies published in English, German, Dutch, and Swedish.


A total of 2046 studies were screened, and 41 studies reporting on 77 cases were included. Important case details were frequently unreported, such as descriptions of SMT technique, the pre-SMT presentation of the patient, the specific details of the adverse event, time from SMT to the adverse event, factors contributing to the adverse event, and clinical outcome. Adverse events consisted of cauda equina syndrome (29 cases, 38% of total); lumbar disk herniation (23 cases, 30%); fracture (7 cases, 9%); hematoma or hemorrhagic cyst (6 cases, 8%); or other serious adverse events (12 cases, 16%) such as neurologic or vascular compromise, soft tissue trauma, muscle abscess formation, disrupted fracture healing, and esophageal rupture.


This systematic review describes case details from published articles that describe serious adverse events that have been reported to occur following SMT of the lumbopelvic region. The anecdotal nature of these cases does not allow for causal inferences between SMT and the events identified in this review. Recommendations regarding future case reporting and research aimed at furthering the understanding of the safety profile of SMT are discussed.


Cauda Equina Syndrome; Injury; Intervertebral Disc Displacement; Lumbosacral Region; Manipulation; Risk; Spinal

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