Chiropractic spinal manipulative therapy versus physical therapist-led exercise and the risk of cauda equina syndrome in adults with lumbar disc herniation, stenosis, or radiculopathy.

BACKGROUND: Cauda equina syndrome is a surgical emergency often caused by lumbar disc herniation. Spinal manipulative therapy is commonly used for lumbar spine disorders, but case reports have raised concerns it may precipitate cauda equina syndrome. One cohort study suggested no increased risk, although it did not focus on patients with lumbar spine disorders pertinent to cauda equina syndrome, such as disc herniation, stenosis, or radiculopathy/sciatica. OBJECTIVE: To address this evidence gap, we tested the null hypothesis that there is no increased risk of cauda equina syndrome following spinal manipulative therapy among adults with these lumbar spine disorders compared to matched controls receiving physical therapist-led therapeutic exercise (PTE). METHODS: Using a retrospective cohort design, we queried a U.S. research network (TriNetX) including patients aged ≥18 years with a lumbar spine disorder and excluding those with preexisting cauda equina syndrome, incontinence, serious spinal pathology, and recent spine surgery/injection. Data spanned 2005-2025. Patients were divided into cohorts: (1) spinal manipulative therapy administered by a chiropractor or (2) PTE without spinal manipulative therapy. Propensity score matching controlled for confounding variables. Outcomes included the risk ratio of cauda equina syndrome (primary), and bladder catheterization and bowel incontinence as additional cauda equina syndrome markers (secondary). RESULTS: After matching, there were 34,376 patients in each cohort. Comparing the spinal manipulative therapy cohort to PTE cohort, the incidence and risk of cauda equina syndrome did not significantly differ (risk ratio=0.88 [95% CI, 0.43-1.79]; p = .715). The risk of bladder catheterization (risk ratio = 0.50 [95% CI, 0.39- 0.64]; p < .001) and fecal incontinence (risk ratio = 0.50 [0.37, 0.68]; p < .001) was significantly lower in the spinal manipulative therapy cohort. CONCLUSION: Among adults with lumbar disc herniation, stenosis, and/or radiculopathy, we did not identify an association between spinal manipulative therapy and an increased risk of cauda equina syndrome.

Duke Scholars

Author Christine Goertz Orthopaedic Surgery