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Acute thoracic epidural hematoma following spinal manipulative therapy: Case report and review of the literature
Clinical Neurology and Neurosurgery 113 (2011) 575–577
Contents lists available at ScienceDirect
Clinical Neurology and Neurosurgery journal homepage: www.elsevier.com/locate/clineuro
Case report
Acute thoracic epidural hematoma following spinal manipulative therapy: Case report and review of the literature Tsung-Han Lee a,d , Chih-Feng Chen b , Tao-Chen Lee c , Hsiang-Lin Lee d , Cheng-Hsien Lu e,∗ a
Division of Trauma, Department of Surgery, Chang Gung Memorial Hospital - Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan Department of Radiology, Chiayi Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Chiayi, Taiwan Division of Neurosurgery, Department of Surgery, Chang Gung Memorial Hospital - Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan d Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan e Department of Neurology, Chang Gung Memorial Hospital - Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan b c
a r t i c l e
i n f o
Article history: Received 24 April 2010 Received in revised form 15 November 2010 Accepted 5 February 2011 Available online 11 March 2011
a b s t r a c t Spinal epidural hematoma is a rare complication of chiropractic manipulation. This study reports a case of thoracic spinal epidural hematoma following spinal manipulative therapy in the absence of predisposing factors. The effectiveness and safety of chiropractic treatment in chronic spinal pain and a literature review are also presented. © 2011 Elsevier B.V. All rights reserved.
Keywords: Spinal epidural hematoma Spinal manipulative therapy
1. Introduction Spinal manipulative therapy (SMT), such as chiropractic manipulation, is widely used for the treatment of different conditions and symptoms. Complications of SMT are relatively uncommon and most complications are reported after manipulation of the cervical spine. In this report, we present a case of anterior spinal cord syndrome caused by a post-SMT acute thoracic epidural hematoma. The safety and efficiency of chiropractic manipulation for neck pain is also discussed. 2. Case report A healthy 38-year-old woman was admitted to our emergency room with weakness and paresthesia in both legs. Four hours before admission, she had undergone SMT because of soreness in the neck and shoulders. The patient initially felt mild pain in the neck and upper back after undergoing therapy with high-velocity low-amplitude neck rotation and back-to-back lifting. However, progressive weakness and paresthesia in the legs developed subsequently. On arrival at the emergency room, the muscle power
∗ Corresponding author at: Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, No. 123, Dapi Road, Niaosong Shiang, Kaohsiung County 833, Taiwan. Tel.: +886 975056603, fax: +886 7 7354309. E-mail address: [email protected] (C.-H. Lu). 0303-8467/$ – see front matter © 2011 Elsevier B.V. All rights reserved. doi:10.1016/j.clineuro.2011.02.006
in both legs was grade 0. Pain sensation was impaired below the T4 dermatome on both sides. Proprioception and vibration sensations were normal. Difficulty in voiding the bladder was noted. Neurological examination revealed increased deep tendon reflexes in the right and left knees and ankles. The patient was not receiving anticoagulation therapy, and there was no laboratory evidence of a bleeding diathesis. Magnetic resonance imaging (MRI) of the thoracolumbar spine was performed 6 h after SMT (Fig. 1). At the 16th hour after SMT, laminectomy was performed from the lower C7 to the upper T8 levels, exposing an acute epidural hematoma in the T1–T7 region (Fig. 2). During surgery, the original bleeding source could not be identified. Postoperatively, the patient experienced immediate improvement in the muscle power of both legs (grade 4/5). She was able to walk independently 1 week after surgery. Approximately 2 weeks after the operation, she regained complete sphincter control. 3. Discussion Nontraumatic spinal epidural hematoma (SEH) was first described by Jackson in 1869 [1]. SEH following chiropractic manipulation is considered to occur very rarely. Although multiple theories concerning the mechanisms of action in spinal manipulation have been espoused, no single mechanism has been accepted to the exclusion of all others [2]. Spinal manipulation is the manual application of sufficient force to the spinal structures to restore normal vertebral biomechanics and
576
T.-H. Lee et al. / Clinical Neurology and Neurosurgery 113 (2011) 575–577
Fig. 1. Spinal MRI with (a) TIWI and (b) T2WI sagittal images demonstrating an intraspinal epidural hematoma from the T1 to the T6 levels. The high intensities of the lesion in both sequences imply acute hematoma. Axial T2WI image (c) shows the widest site of the hematoma at the levels of T3–T4. The spinal canal is compressed flattening (blank arrow on b and c).
thereby relieve pain [3]. All forms of manipulation are believed to affect both sources of afferent stimuli, reducing or eliminating gamma system overflow or reducing the proprioceptive input modulating gamma system function [4,5]. It has been suggested that this temporary interruption in myoelectrical activity has a persistent therapeutic effect on the periarticular muscle [6]. Several studies on the effectiveness of chiropractic treatment in chronic spine pain have been conducted [7–10]. One randomized clinical trial comparing the efficiency of medication, acupuncture, and spinal manipulation in treating chronic spinal pain showed that chiropractic was superior to the other two [7]. A later followup report showed that the long-term results were even more impressive [8]. In a large evidence-based review of the efficacy of various interventions for subacute or chronic neck pain, neck disorders with headache, and neck disorders with radiculopathy, spinal manipulation/mobilization (used in combination with exercise) was given the highest evidentiary status of having strong evidence, and it is perhaps noteworthy that not a single medical or pharmaceutical intervention earned that high of a ranking [9]. There have been a number of case reports, case series, and case-control studies implicating chiropractic manipulation as a mechanism of injury in cases of vertebral artery dissection, stroke
Fig. 2. After a laminectomy of T4, uncoagulated dark red blood (arrow) in the epidural space was exposed. (For interpretation of the references to color in this sentence, the reader is referred to the web version of the article.)
and spinal cord injury [11–17,22–30]. The occurrence of complications in SMT is related to several factors, including preexisting cervical spinal lesion and the force and torque of the manipulation [12–14,16,17]. Such manipulations may induce movements that exceed the physiologic limits of the spine [18,19]. Excessive movement of the spine may then injure the epidural veins, either by direct trauma or a sudden increase in venous pressure, resulting in a spinal epidural hematoma [20]. The incidence of complications associated with SMT is estimated at only 1 injury for every 1 to 1.5 million adjustments [16], and approximately 80% of these complications are related to the manipulation of the cervical spine [21]. One systematic review on the safety of chiropractic interventions demonstrated that most of the adverse events reported were benign and transitory; however, there are reports of complications that were life threatening, such as arterial dissection, myelopathy, vertebral disc extrusion, and epidural hematoma. The frequency of adverse events varied between 33% and 60.9%, and the frequency of serious adverse events varied from 5 strokes/0.1 million manipulations to 1.46 serious adverse events/10 million manipulations and 2.68 deaths/10 million manipulations [15]. Another recent comprehensive study implicating chiropractic manipulation in the risk of vertebrobasilar artery (VBA) stroke showed that VBA stroke is a very rare event in the population. The increased risks of VBA stroke associated with chiropractic and primary care physician visits is likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke and there was no evidence of an excess risk of VBA stroke associated chiropractic care compared to primary care [11]. Spinal epidural hematoma is a rare complication following SMT. To the best of our knowledge, only 9 cases [22–30] have been reported in the literature (Table 1), and 2 [27,29] of the cases were associated with anticoagulation therapy. Including the present patient, manipulation of the cervical spine was performed in 8 [22,23,25–28,30] of the 10 cases. Only 2 [26,30] of the 10 patients with SEH following SMT received conservative treatment. All 10 cases achieved a fair or good recovery regardless of whether they were treated with conservative treatment or surgery. Currently, MRI is the main investigative tool, and it allows a prompt diagnosis of SEH. Pan et al. reported that from the clinical point of view, most patients with SEH undergo some degree of irreversible spinal cord injury by the time the hematoma is resorbed; therefore, immediate surgical decompression remains the primary consideration in the management of patients with progressive neurological deficits [20].
T.-H. Lee et al. / Clinical Neurology and Neurosurgery 113 (2011) 575–577
577
Table 1 Summary of previously published and present cases of spinal epidural hematoma following spinal manipulative therapya . Authors and year
Age (years), sex
Location of SMT
Interval to symptom onset
Location of SEH
Treatment
Outcome
References
Zupruk, 1989 Segal, 1996 Ruelle, 1999 Tseng, 2002 Saxler, 2004 Whedon, 2006 Domenicucci, 2007 Solheim, 2007 Heiner, 2009 Present case
86, M 33, F 64, F 67, F 27, F 79, M 52, F 77, M 38, F 38, F
C C L C C C C L C C
24 h 15 min 2h Immediately Immediately Immediately Immediately Immediately 4h 4h
C2–7 C4–6 T9–11 C3–5 C–S C2–4 C3–T1 L3–4 C1–C4 T1–7
Surgical removal Surgical removal Surgical removal Surgical removal Conservative Surgical removal Surgical removal Surgical removal Conservative Surgical removal
Good Good Good Good Good Good Good Fair Fair Good
[22] [23] [24] [25] [26] [27] [28] [29] [30] This report
a
M = male; F = female; SEH = spinal epidural hematoma; SMT = spinal manipulative therapy; C = cervical spine; T = thoracic spine; L = lumbar spine; S = sacral spine.
4. Conclusion Our case serves as a reminder that chiropractic manipulation of the spine may be associated with rare and unexpected complications of which the chiropractor must be aware. In the event of a thoracic epidural hematoma, prompt surgical intervention is mandatory in order to achieve neurologic recovery. References [1] Jackson R. Case of spinal apoplexy. Lancet 1869;2:538–9. [2] Geiringer SR, Kincaid CB, Rechtien JJ. Traction, manipulation and massage. In: DeLisa JA, editor. Rehabilitation medicine principles and practice. Philadelphia: JB Lippincott Publishers; 1988. p. 279. [3] LaBan MM, Taylor RS, Manipulation:. An objective analysis of the literature. Orthop Clin North Am 1992;23:451–9. [4] Korr IM. Neural basis of the osteopathic lesion. J Am Osteopath Assoc 1947;47:191. [5] Korr IM. Proprioceptors and somatic dysfunction. J Am Osteopath Assoc 1985;74:638. [6] Korr IM. Somatic dysfunction, osteopathic manipulative treatment and the nervous system: a few facts, some theories, many questions. J Am Osteopath Assoc 1986;86:109. [7] Giles LG, Muller R. Chronic spinal pain: a randomized clinical trial comparing medication, acupuncture, and spinal manipulation. Spine 2003;28:1490–503. [8] Muller R, Giles LG. Long-term follow-up of a randomized clinical trial assessing the efficacy of medication, acupuncture, and spinal manipulation for chronic mechanical spinal pain syndromes. J Manipulative Physiol Ther 2005;28: 3–11. [9] Hurwitz EL, Carragee EJ, van der Velde G, Carroll LJ, Nordin M, Guzman J, et al. Treatment of neck pain: noninvasive interventions: results of the bone and joint decade 2000–2010 task force on neck pain and its associated disorders. Spine 2008;33(Suppl. 4):S123–152. [10] Hurwitz EL, Carragee EJ, van der Velde G, Carroll LJ, Nordin M, Guzman J, et al. Treatment of neck pain: noninvasive interventions: results of the bone and joint decade 2000–2010 task force on neck pain and its associated disorders. J Manipulative Physiol Ther 2009;32(2 Suppl):S141–175. [11] Cassidy JD, Boyle E, Côté P, He Y, Hogg-Johnson S, Silver FL, et al. Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study. Spine 2008;33(4 Suppl):S176–183. [12] Crowther ER. Missed cervical spine fractures: the importance of reviewing radiographs in chiropractic practice. J Manipulative Physiol Ther 1995;18:29–33.
[13] Davis C. Osteopathic manipulation resulting in damage to spinal cord. BMJ 1985;291:1540–1. [14] Destee A, Lesoin F, Di Paola F, Warot P. Intradural herniated cervical disc associated with chiropractic spinal manipulation. J Neurol Neurosurg Psychiatry 1989;52:1113–20. [15] Gouveia LO, Castanho P, Ferreira JJ. Safety of chiropractic interventions: a systematic review. Spine 2009;34:E405–413. [16] Powell F, Hanigan W, Olivero W. A risk/benefit analysis of spinal manipulation therapy for relief of lumbar or cervical pain. Neurosurgery 1993;33:73–9. [17] Schmidley JW, Koch T. The noncerebrovascular complications of chiropractic manipulation. Neurology 1984;34:684–5. [18] DeFranca GG. Manipulative techniques for the cervical spine. In: Murphy DR, editor. Conservative management of cervical spine syndromes. New York: McGraw-Hill Publishers; 2000, 443-467. [19] Emery MJ. Physical therapy application to lesions and syndromes. In: Bland JH, editor. Disorders of the cervical spine: diagnosis and medical management. 2nd ed. Philadelphia: WB Saunders Publishers; 1994, 291-311. [20] Pan G, Kulkarni M, MacDouhall DJ, Miner ME. Traumatic epidural hematoma of the cervical spine: diagnosis with magnetic resonance imaging. J Neurosurg 1993;68:798–801. [21] Brynin R, Yomtob C. Missed cervical spine fracture: chiropractic implications. J Manipulative Physiol Ther 1999;22:610–4. [22] Zupruk GM, Mehta Z. Brown–Sequard syndrome associated with posttraumatic cervical epidural hematoma: case report and review of the literature. Neurosurgery 1989;25:278–80. [23] Segal DH, Lidov MW, Camins MB. Cervical epidural hematoma after chiropractic manipulation in a healthy young woman: case report. Neurosurgery 1996;39:1043–5. [24] Ruelle A, Datti R, Pisani R. Thoracic epidural hematoma after spinal manipulation therapy. J Spinal Disord 1999;12:534–6. [25] Tseng SH, Chen Y, Lin SM, Wang CH. Cervical epidural hematoma after spinal manipulation therapy: case report. J Trauma 2002;52:585–6. [26] Saxler G, Barden B. Extensive spinal epidural hematoma—an uncommon entity following cervical chiropractic manipulation. Z Orthop Ihre Grenzgeb 2004;142:79–82. [27] Whedon JM, Quebada PB, Roberts DW, Radwan TA. Spinal epidural hematoma after spinal manipulative therapy in a patient undergoing anticoagulant therapy: a case report. J Manipulative Physiol Ther 2006;29:582–5. [28] Domenicucci M, Ramieri A, Salvati M, Brogna C, Raco A. Cervicothoracic epidural hematoma after chiropractic spinal manipulation therapy. Case report and review of the literature. J Neurosurg Spine 2007;7:571–4. [29] Solheim O, Jorgensen JV, Nygaard OP. Lumbar epidural hematoma after chiropractic manipulation for lower-back pain: case report. Neurosurgery 2007;61:E170–1. [30] Heiner JD. Cervical epidural hematoma after chiropractic spinal manipulation. Am J Emerg Med 2009;27, 1023.e1-2.
Contents lists available at ScienceDirect
Clinical Neurology and Neurosurgery journal homepage: www.elsevier.com/locate/clineuro
Case report
Acute thoracic epidural hematoma following spinal manipulative therapy: Case report and review of the literature Tsung-Han Lee a,d , Chih-Feng Chen b , Tao-Chen Lee c , Hsiang-Lin Lee d , Cheng-Hsien Lu e,∗ a
Division of Trauma, Department of Surgery, Chang Gung Memorial Hospital - Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan Department of Radiology, Chiayi Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Chiayi, Taiwan Division of Neurosurgery, Department of Surgery, Chang Gung Memorial Hospital - Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan d Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan e Department of Neurology, Chang Gung Memorial Hospital - Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan b c
a r t i c l e
i n f o
Article history: Received 24 April 2010 Received in revised form 15 November 2010 Accepted 5 February 2011 Available online 11 March 2011
a b s t r a c t Spinal epidural hematoma is a rare complication of chiropractic manipulation. This study reports a case of thoracic spinal epidural hematoma following spinal manipulative therapy in the absence of predisposing factors. The effectiveness and safety of chiropractic treatment in chronic spinal pain and a literature review are also presented. © 2011 Elsevier B.V. All rights reserved.
Keywords: Spinal epidural hematoma Spinal manipulative therapy
1. Introduction Spinal manipulative therapy (SMT), such as chiropractic manipulation, is widely used for the treatment of different conditions and symptoms. Complications of SMT are relatively uncommon and most complications are reported after manipulation of the cervical spine. In this report, we present a case of anterior spinal cord syndrome caused by a post-SMT acute thoracic epidural hematoma. The safety and efficiency of chiropractic manipulation for neck pain is also discussed. 2. Case report A healthy 38-year-old woman was admitted to our emergency room with weakness and paresthesia in both legs. Four hours before admission, she had undergone SMT because of soreness in the neck and shoulders. The patient initially felt mild pain in the neck and upper back after undergoing therapy with high-velocity low-amplitude neck rotation and back-to-back lifting. However, progressive weakness and paresthesia in the legs developed subsequently. On arrival at the emergency room, the muscle power
∗ Corresponding author at: Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, No. 123, Dapi Road, Niaosong Shiang, Kaohsiung County 833, Taiwan. Tel.: +886 975056603, fax: +886 7 7354309. E-mail address: [email protected] (C.-H. Lu). 0303-8467/$ – see front matter © 2011 Elsevier B.V. All rights reserved. doi:10.1016/j.clineuro.2011.02.006
in both legs was grade 0. Pain sensation was impaired below the T4 dermatome on both sides. Proprioception and vibration sensations were normal. Difficulty in voiding the bladder was noted. Neurological examination revealed increased deep tendon reflexes in the right and left knees and ankles. The patient was not receiving anticoagulation therapy, and there was no laboratory evidence of a bleeding diathesis. Magnetic resonance imaging (MRI) of the thoracolumbar spine was performed 6 h after SMT (Fig. 1). At the 16th hour after SMT, laminectomy was performed from the lower C7 to the upper T8 levels, exposing an acute epidural hematoma in the T1–T7 region (Fig. 2). During surgery, the original bleeding source could not be identified. Postoperatively, the patient experienced immediate improvement in the muscle power of both legs (grade 4/5). She was able to walk independently 1 week after surgery. Approximately 2 weeks after the operation, she regained complete sphincter control. 3. Discussion Nontraumatic spinal epidural hematoma (SEH) was first described by Jackson in 1869 [1]. SEH following chiropractic manipulation is considered to occur very rarely. Although multiple theories concerning the mechanisms of action in spinal manipulation have been espoused, no single mechanism has been accepted to the exclusion of all others [2]. Spinal manipulation is the manual application of sufficient force to the spinal structures to restore normal vertebral biomechanics and
576
T.-H. Lee et al. / Clinical Neurology and Neurosurgery 113 (2011) 575–577
Fig. 1. Spinal MRI with (a) TIWI and (b) T2WI sagittal images demonstrating an intraspinal epidural hematoma from the T1 to the T6 levels. The high intensities of the lesion in both sequences imply acute hematoma. Axial T2WI image (c) shows the widest site of the hematoma at the levels of T3–T4. The spinal canal is compressed flattening (blank arrow on b and c).
thereby relieve pain [3]. All forms of manipulation are believed to affect both sources of afferent stimuli, reducing or eliminating gamma system overflow or reducing the proprioceptive input modulating gamma system function [4,5]. It has been suggested that this temporary interruption in myoelectrical activity has a persistent therapeutic effect on the periarticular muscle [6]. Several studies on the effectiveness of chiropractic treatment in chronic spine pain have been conducted [7–10]. One randomized clinical trial comparing the efficiency of medication, acupuncture, and spinal manipulation in treating chronic spinal pain showed that chiropractic was superior to the other two [7]. A later followup report showed that the long-term results were even more impressive [8]. In a large evidence-based review of the efficacy of various interventions for subacute or chronic neck pain, neck disorders with headache, and neck disorders with radiculopathy, spinal manipulation/mobilization (used in combination with exercise) was given the highest evidentiary status of having strong evidence, and it is perhaps noteworthy that not a single medical or pharmaceutical intervention earned that high of a ranking [9]. There have been a number of case reports, case series, and case-control studies implicating chiropractic manipulation as a mechanism of injury in cases of vertebral artery dissection, stroke
Fig. 2. After a laminectomy of T4, uncoagulated dark red blood (arrow) in the epidural space was exposed. (For interpretation of the references to color in this sentence, the reader is referred to the web version of the article.)
and spinal cord injury [11–17,22–30]. The occurrence of complications in SMT is related to several factors, including preexisting cervical spinal lesion and the force and torque of the manipulation [12–14,16,17]. Such manipulations may induce movements that exceed the physiologic limits of the spine [18,19]. Excessive movement of the spine may then injure the epidural veins, either by direct trauma or a sudden increase in venous pressure, resulting in a spinal epidural hematoma [20]. The incidence of complications associated with SMT is estimated at only 1 injury for every 1 to 1.5 million adjustments [16], and approximately 80% of these complications are related to the manipulation of the cervical spine [21]. One systematic review on the safety of chiropractic interventions demonstrated that most of the adverse events reported were benign and transitory; however, there are reports of complications that were life threatening, such as arterial dissection, myelopathy, vertebral disc extrusion, and epidural hematoma. The frequency of adverse events varied between 33% and 60.9%, and the frequency of serious adverse events varied from 5 strokes/0.1 million manipulations to 1.46 serious adverse events/10 million manipulations and 2.68 deaths/10 million manipulations [15]. Another recent comprehensive study implicating chiropractic manipulation in the risk of vertebrobasilar artery (VBA) stroke showed that VBA stroke is a very rare event in the population. The increased risks of VBA stroke associated with chiropractic and primary care physician visits is likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke and there was no evidence of an excess risk of VBA stroke associated chiropractic care compared to primary care [11]. Spinal epidural hematoma is a rare complication following SMT. To the best of our knowledge, only 9 cases [22–30] have been reported in the literature (Table 1), and 2 [27,29] of the cases were associated with anticoagulation therapy. Including the present patient, manipulation of the cervical spine was performed in 8 [22,23,25–28,30] of the 10 cases. Only 2 [26,30] of the 10 patients with SEH following SMT received conservative treatment. All 10 cases achieved a fair or good recovery regardless of whether they were treated with conservative treatment or surgery. Currently, MRI is the main investigative tool, and it allows a prompt diagnosis of SEH. Pan et al. reported that from the clinical point of view, most patients with SEH undergo some degree of irreversible spinal cord injury by the time the hematoma is resorbed; therefore, immediate surgical decompression remains the primary consideration in the management of patients with progressive neurological deficits [20].
T.-H. Lee et al. / Clinical Neurology and Neurosurgery 113 (2011) 575–577
577
Table 1 Summary of previously published and present cases of spinal epidural hematoma following spinal manipulative therapya . Authors and year
Age (years), sex
Location of SMT
Interval to symptom onset
Location of SEH
Treatment
Outcome
References
Zupruk, 1989 Segal, 1996 Ruelle, 1999 Tseng, 2002 Saxler, 2004 Whedon, 2006 Domenicucci, 2007 Solheim, 2007 Heiner, 2009 Present case
86, M 33, F 64, F 67, F 27, F 79, M 52, F 77, M 38, F 38, F
C C L C C C C L C C
24 h 15 min 2h Immediately Immediately Immediately Immediately Immediately 4h 4h
C2–7 C4–6 T9–11 C3–5 C–S C2–4 C3–T1 L3–4 C1–C4 T1–7
Surgical removal Surgical removal Surgical removal Surgical removal Conservative Surgical removal Surgical removal Surgical removal Conservative Surgical removal
Good Good Good Good Good Good Good Fair Fair Good
[22] [23] [24] [25] [26] [27] [28] [29] [30] This report
a
M = male; F = female; SEH = spinal epidural hematoma; SMT = spinal manipulative therapy; C = cervical spine; T = thoracic spine; L = lumbar spine; S = sacral spine.
4. Conclusion Our case serves as a reminder that chiropractic manipulation of the spine may be associated with rare and unexpected complications of which the chiropractor must be aware. In the event of a thoracic epidural hematoma, prompt surgical intervention is mandatory in order to achieve neurologic recovery. References [1] Jackson R. Case of spinal apoplexy. Lancet 1869;2:538–9. [2] Geiringer SR, Kincaid CB, Rechtien JJ. Traction, manipulation and massage. In: DeLisa JA, editor. Rehabilitation medicine principles and practice. Philadelphia: JB Lippincott Publishers; 1988. p. 279. [3] LaBan MM, Taylor RS, Manipulation:. An objective analysis of the literature. Orthop Clin North Am 1992;23:451–9. [4] Korr IM. Neural basis of the osteopathic lesion. J Am Osteopath Assoc 1947;47:191. [5] Korr IM. Proprioceptors and somatic dysfunction. J Am Osteopath Assoc 1985;74:638. [6] Korr IM. Somatic dysfunction, osteopathic manipulative treatment and the nervous system: a few facts, some theories, many questions. J Am Osteopath Assoc 1986;86:109. [7] Giles LG, Muller R. Chronic spinal pain: a randomized clinical trial comparing medication, acupuncture, and spinal manipulation. Spine 2003;28:1490–503. [8] Muller R, Giles LG. Long-term follow-up of a randomized clinical trial assessing the efficacy of medication, acupuncture, and spinal manipulation for chronic mechanical spinal pain syndromes. J Manipulative Physiol Ther 2005;28: 3–11. [9] Hurwitz EL, Carragee EJ, van der Velde G, Carroll LJ, Nordin M, Guzman J, et al. Treatment of neck pain: noninvasive interventions: results of the bone and joint decade 2000–2010 task force on neck pain and its associated disorders. Spine 2008;33(Suppl. 4):S123–152. [10] Hurwitz EL, Carragee EJ, van der Velde G, Carroll LJ, Nordin M, Guzman J, et al. Treatment of neck pain: noninvasive interventions: results of the bone and joint decade 2000–2010 task force on neck pain and its associated disorders. J Manipulative Physiol Ther 2009;32(2 Suppl):S141–175. [11] Cassidy JD, Boyle E, Côté P, He Y, Hogg-Johnson S, Silver FL, et al. Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study. Spine 2008;33(4 Suppl):S176–183. [12] Crowther ER. Missed cervical spine fractures: the importance of reviewing radiographs in chiropractic practice. J Manipulative Physiol Ther 1995;18:29–33.
[13] Davis C. Osteopathic manipulation resulting in damage to spinal cord. BMJ 1985;291:1540–1. [14] Destee A, Lesoin F, Di Paola F, Warot P. Intradural herniated cervical disc associated with chiropractic spinal manipulation. J Neurol Neurosurg Psychiatry 1989;52:1113–20. [15] Gouveia LO, Castanho P, Ferreira JJ. Safety of chiropractic interventions: a systematic review. Spine 2009;34:E405–413. [16] Powell F, Hanigan W, Olivero W. A risk/benefit analysis of spinal manipulation therapy for relief of lumbar or cervical pain. Neurosurgery 1993;33:73–9. [17] Schmidley JW, Koch T. The noncerebrovascular complications of chiropractic manipulation. Neurology 1984;34:684–5. [18] DeFranca GG. Manipulative techniques for the cervical spine. In: Murphy DR, editor. Conservative management of cervical spine syndromes. New York: McGraw-Hill Publishers; 2000, 443-467. [19] Emery MJ. Physical therapy application to lesions and syndromes. In: Bland JH, editor. Disorders of the cervical spine: diagnosis and medical management. 2nd ed. Philadelphia: WB Saunders Publishers; 1994, 291-311. [20] Pan G, Kulkarni M, MacDouhall DJ, Miner ME. Traumatic epidural hematoma of the cervical spine: diagnosis with magnetic resonance imaging. J Neurosurg 1993;68:798–801. [21] Brynin R, Yomtob C. Missed cervical spine fracture: chiropractic implications. J Manipulative Physiol Ther 1999;22:610–4. [22] Zupruk GM, Mehta Z. Brown–Sequard syndrome associated with posttraumatic cervical epidural hematoma: case report and review of the literature. Neurosurgery 1989;25:278–80. [23] Segal DH, Lidov MW, Camins MB. Cervical epidural hematoma after chiropractic manipulation in a healthy young woman: case report. Neurosurgery 1996;39:1043–5. [24] Ruelle A, Datti R, Pisani R. Thoracic epidural hematoma after spinal manipulation therapy. J Spinal Disord 1999;12:534–6. [25] Tseng SH, Chen Y, Lin SM, Wang CH. Cervical epidural hematoma after spinal manipulation therapy: case report. J Trauma 2002;52:585–6. [26] Saxler G, Barden B. Extensive spinal epidural hematoma—an uncommon entity following cervical chiropractic manipulation. Z Orthop Ihre Grenzgeb 2004;142:79–82. [27] Whedon JM, Quebada PB, Roberts DW, Radwan TA. Spinal epidural hematoma after spinal manipulative therapy in a patient undergoing anticoagulant therapy: a case report. J Manipulative Physiol Ther 2006;29:582–5. [28] Domenicucci M, Ramieri A, Salvati M, Brogna C, Raco A. Cervicothoracic epidural hematoma after chiropractic spinal manipulation therapy. Case report and review of the literature. J Neurosurg Spine 2007;7:571–4. [29] Solheim O, Jorgensen JV, Nygaard OP. Lumbar epidural hematoma after chiropractic manipulation for lower-back pain: case report. Neurosurgery 2007;61:E170–1. [30] Heiner JD. Cervical epidural hematoma after chiropractic spinal manipulation. Am J Emerg Med 2009;27, 1023.e1-2.