Case ReportManipulation Under Anesthesia for Lumbopelvic Pain: A Retrospective Review of 18 Cases
Introduction
Low back pain (LBP) is a common, costly problem that afflicts 60% to 90% of the population at some point during adulthood,1, 2 with 1 in 4 people experiencing back pain at any given time. Thirty percent of people who experience acute LBP, which is defined as pain lasting less than 4 weeks,3 will transition to a chronic LBP, a painful state lasting longer than 12 weeks.4 Although prevalence estimates vary across studies from 5% to 90%, careful estimates suggest that 15% of all cases of LBP are facetogenic, that is, arising from zygapophyseal (Z) joints.5 Roughly 25% of patients with LBP have pain due to sacroiliac joint pathology.6 Despite these estimates, the cause of nonspecific LBP remains unknown in a majority of cases.
The use of high-velocity, low-amplitude (HVLA) manipulation of the spine has been shown to reduce pain and improve function in both acute and chronic back pain when compared to sham manipulation.7, 8, 9 By directing the manual thrust past the physiologic barrier, direct HVLA manipulation differs from indirect nonthrust manual therapy by the associated audible release of the articular surface during HVLA manipulation, referred to as cavitation. The effects of cavitation at the spinal Z-joint have been studied extensively.10, 11, 12, 13 The audible separation of these joints is associated with release of tissue adhesions, stimulation of the afferent nerve to the Z-joint and spinal muscles, and reflex neurologic and possibly immunologic sequelae and inflammatory chemical down-regulation.10, 11, 12, 13, 14
There are a percentage of patients in whom cavitation of the spinal facet joint is not possible because of spasm, guarding, and inhibitory mechanisms15, 16, 17 despite meeting clinical criteria for its use.18, 19, 20 Manipulation under anesthesia (MUA) is a pain management procedure using passive stretches combined with spinal manipulation under conscious sedation or general anesthesia with the goal of relieving musculoskeletal pain. The MUA procedure generally consists of sedation, mobilization/stretching/traction, manipulation, and post-MUA care.15, 16, 17, 21, 22, 23, 24, 25, 26, 27, 28, 29 Anesthesia minimizes pain, muscle spasm, and protective guarding that may occur during manipulation. Manipulation on a sedated patient is purported to enhance the practitioner’s ability to break apart adhesions and repair segmental dysfunction,11, 15, 17, 30 leading to increased ligament, tendon, muscle, and articular flexibility.22
Manipulation under anesthesia has been used as an intervention for back pain in some form for more than 80 years.31 Although it was the mainstay of orthopedists prior to the mid-1960s,24, 32 today, MUA is most commonly performed by doctors of chiropractic and medical pain management specialists33, 34 and is reported to have improved techniques and safer, rapid-acting anesthetics with short half-lives.17, 23
Manipulation under anesthesia is routinely used for pain of various etiologies. Indications include disk herniation/prolapse/protrusion/bulge, joint or spinal ankylosis, failed low back surgery, nonresponsive muscle contraction, compression syndromes with nonosteophytic entrapment, and whiplash-associated disorders.26 The procedure is generally reserved for patients who are responsive to noninvasive spinal manipulation techniques but who continue to experience pain and/or reduced mobility. A clinical justification for MUA has been suggested by the National Academy of Manipulation Under Anesthesia Physicians,28 as well as the International Academy of MUA Physicians35 and the National Association of MUA Physicians.36
The purpose of this case series is to study the effects of chiropractic MUA for patients with lumbopelvic (lumbar spine, sacroiliac and/or pelvic, hip) pain in an outpatient ambulatory/hospital-based setting.
Section snippets
Data Collection
This case series based upon a retrospective chart review was deemed exempt under 45 CFR 46.101(b)(4) from the United Health Services Hospitals Institutional Review Board. Patient charts from visits between June 23, 2010, and August 29, 2011, were reviewed by an independent reviewer invited by the authors to the practice. Charts were reviewed for patients treated at United Health Services Outpatient Ambulatory Surgical Center, Johnson City, NY, and Binghamton General Hospital, Binghamton, NY.
Results
Manipulation under anesthesia was used to treat chronic LBP in 30 reviewed cases. Twelve cases were excluded because of concomitant musculoskeletal pain complaints or insufficient ODI data. Of the 18 included patient cases, 8 were male and 10 were female. Ages ranged from 29 to 60 years, with a mean age of 45. Diagnosed conditions fell within the recognized categories of conditions responsive to MUA as listed in Fig 1. The majority of patients (13 of 18; 72%) had 3 MUA treatments. Three
Discussion
This study described the results from 18 patients who underwent single or multiple MUAs to treat chronic lumbar back pain. No patient reported any complications. All patients had improvements in ODI scores, and the mean ODI score decreased significantly after MUA. In 16 of 18 cases, ODI scores were at least 8 points lower after MUA. Because a change of 5 to 9 points on the ODI is considered clinically meaningful,41 all but 2 patients in this sample had a true reduction in LBP disability after
Limitations
There were inherent limitations in this study. A referral bias could lead to referral of patients with more chronic pain, which could affect results. Referral of patients who were highly motivated could also influence results. The small study size contributes to a selection or referral bias. Reviews of case series are the least methodologically robust epidemiological study because they are at risk for several types of bias such as case selection bias.43 All past cases were considered, and only
Conclusions
This report describes the treatment of 18 patients with chronic lumbopelvic back pain using single or multiple MUAs. Sixteen of the 18 patients had clinically meaningful reduction in LBP disability, and the mean ODI score decreased after MUA for all patients. No complications were reported.
Funding Sources and Conflicts of Interest
No funding sources or conflicts of interest were reported for this study.
Acknowledgment
The authors thank Dr. Michael T. Sapko for his editorial assistance with this manuscript.
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