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Table 1 Evidence of outcomes with SMUA for disc herniation/protrusion

From: Outcomes indicators and a risk classification system for spinal manipulation under anesthesia: a narrative review and proposal

Year of Publication Author/s Findings/observations/opinions Level of Research Evidencea
1945 Poppen [11] Various forms of operative treatment were undertaken for 400 cases of lumbar intervertebral disc herniation. The number of patients whose treatment included MUA is not reported, but two from that group were immediately paralyzed. IV
1952 Wilson and Ilfeld [78] Manipulation of patients with symptoms of lumbar herniated disc was performed under general anesthetic or via medication assistance. Three of eighteen patients (17%) reported temporary relief of back and leg pain over 48–72 h. Within ten days of the procedure, twelve patients (67%) subsequently underwent exploratory laminectomy. For the remaining six patients (33%) who did not undergo surgery, none had experienced any change in symptoms after manipulation. IV
1952 Siehl and Bradford [79] Good results were obtained in about a third of herniated disc cases but with surgery opined to be required at some point. The authors reported that longstanding disc herniation does not respond well to MUA and, “in no case with positive myelography has there been lasting good results from the manipulative procedure.” IV
1953 Ewer [80] Manipulation should not be overlooked by orthopedic surgeons in that it can offer “so much relief” in selected cases. However, it was opined that with ruptured intervertebral discs and true sciatica, manipulation “cannot effect a permanent cure and offers great hazards.” In the presence of space-consuming lesions manipulation is contraindicated, as MUA “is more dangerous and does not compensate for the risks involved.” V
1955 Mensor [31] Two hundred five patients received MUA for lumbar intervertebral disc syndrome, with 56 (27%) classified as immediate or delayed failures. Of those, subsequent surgical exploration revealed that all had identifiable pathology (an annular fragment protruding into the interspace, a ruptured annulus with a large amount of free nuclear material in the canal, or degeneration with freely shifting nuclear material permitting for alternating reduction and reproduction of the protrusion). IV
1963 Siehl [81] One hundred eighty five patients were treated with MUA for a diagnosis of herniated nucleus pulposus. Good results were obtained for 26.4% of patients. Overall, 95 of the 185 patients (51%) required subsequent disc surgery. IV
1964 Chrisman et al. [15] Twenty of 39 patients (51%) with ruptured lumbar intervertebral disc maintained good to excellent results after MUA over three years. 10 of the 27 patients (37%) with positive myelograms had received the same benefit. For neither group was there a change in the appearance of the myelograms taken before and after MUA. The authors determined that those “without a demonstrable myelographic defect consistently did better” and that manipulation of “a very large disc protrusion” should be avoided due to potential for harm. IV
1971 Siehl et al. [33] Twenty one patients were treated via MUA for nerve root compression secondary to lumbar disc herniation. Three (14%) showed clinical and EMG improvement, nine (43%) had no EMG change but continued clinical improvement, and nine (43%) showed worsened electromyographic changes of the legs. After 15 months, the latter group had an increase in clinical signs. In general, for the 50% of patients who had improvement over the first 6 months, most progressively worsened over the 6 month period thereafter. II
1972 Tospon [82] In the author’s experience with 6000 MUA procedures, he reported, “.if the patient has positive neurological, orthopedic and myelographic findings, low back manipulation will be of no lasting benefit... it often helps temporarily, but ultimately surgery has to be performed.” Vb
1973 Morey [83] “Frequently it [manipulation under general anesthesia] affords relief, possibly temporary, when there is actual disk protrusion.” IV
1977 Scherrer [84] Ninety four patients underwent manipulation under general anesthesia for disc herniation. Sixty percent had excellent or good results. Forty percent had poor results. Within one year, more than half of the patients had to undergo a hemilaminotomy. IV
1986 Krumhansl and Nowacek [47] Of the two patients with myelogram evidence of frank disc herniation, one required discectomy because of a return of pain within three weeks of MUA. IV
  1. aWhen applying the levels of evidence rating system for categorizing study quality, as put forth by Wright et al. and adopted by the Journal of Bone & Joint Surgery [42], Spine, Clinical Orthopaedics and Related Research, the North American Spine Society, the American Academy of Orthopaedic Surgeons, and the Pediatric Orthopaedic Society of North America [85]
  2. bThe case report study design has not been rated by Wright et al. [42]. This case report, with editorializing, is being equated here with the established level of evidence for expert opinion (Level V evidence)