Outcomes From Magnetic Resonance Imaging–Confirmed Symptomatic Cervical Disk Herniation Patients Treated With High-Velocity, Low-Amplitude Spinal Manipulative Therapy: A Prospective Cohort Study With 3-Month Follow-Up
Cynthia K. Peterson, RN, DC, M.Med.Ed,
Christof Schmid, DC, Serafin Leemann, DC,
Bernard Anklin, DC, B. Kim Humphreys, DC, PhD
Professor, Department of Chiropractic Medicine,
Faculty of Medicine, Orthopedic University Hospital Balgrist,
University of Zürich, Zürich, Switzerland.
OBJECTIVE: The purpose of this study was to investigate outcomes of patients with cervical radiculopathy from cervical disk herniation (CDH) who are treated with spinal manipulative therapy.
METHODS: Adult Swiss patients with neck pain and dermatomal arm pain; sensory, motor, or reflex changes corresponding to the involved nerve root; and at least 1 positive orthopaedic test for cervical radiculopathy were included. Magnetic resonance imaging-confirmed CDH linked with symptoms was required. Baseline data included 2 pain numeric rating scales (NRSs), for neck and arm, and the Neck Disability Index (NDI). At 2 weeks, 1 month, and 3 months after initial consultation, patients were contacted by telephone, and the NDI, NRSs, and patient’s global impression of change data were collected. High-velocity, low-amplitude spinal manipulations were administered by experienced doctors of chiropractic. The proportion of patients responding “better” or “much better” on the patient’s global impression of change scale was calculated. Pretreatment and posttreatment NRSs and NDIs were compared using the Wilcoxon test. Acute vs subacute/chronic patients’ NRSs and NDIs were compared using the Mann-Whitney U test.
RESULTS: Fifty patients were included. At 2 weeks, 55.3% were “improved,” 68.9% at 1 month and 85.7% at 3 months. Statistically significant decreases in neck pain, arm pain, and NDI scores were noted at 1 and 3 months compared with baseline scores (P < .0001). Of the subacute/chronic patients, 76.2% were improved at 3 months.
CONCLUSIONS: Most patients in this study, including subacute/chronic patients, with symptomatic magnetic resonance imaging-confirmed CDH treated with spinal manipulative therapy, reported significant improvement with no adverse events.
Symptomatic compression of a cervical nerve root occurs in approximately 83.2 of every 100000 persons and is caused by disk herniations, degenerative spondylosis, or a combination of the  . Degenerative stenosis leading to narrowing of the intervertebral foramen is reported to be the most common cause of nerve root compression. The C6 and C7 nerve roots are most frequently involved, often resulting in severe pain and disability. [1, 2] Symptoms can arise from the nerve root compression, inflammation, or both and include pain in a radicular distribution, paresthesias in a dermatomal pattern, decreased relevant reflex, and weakness of the muscles innervated by the nerve root. 
Patients with radiculopathy from cervical disk herniations (CDHs), the second most common cause of cervical nerve root compression, typically have acute neck pain with associated arm pain following the distribution of the involved nerve root, although the arm pain may be the predominant symptom. [3, 4]However, it is important to recognize that disk protrusions are also a common finding on magnetic resonance imaging (MRI) scans of asymptomatic people. [5-7]One study found that 63% of asymptomatic athletic males older than 40 years had protruding disks in the cervical spine. In another study, disk protrusion with demonstrable spinal cord compression was noted in 7.6% of asymptomatic subjects over the age of 50 years. However, extruded disk herniations and cord compression are unusual findings in asymptomatic individuals. 
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The treatment of patients with cervical radiculopathy is often surgical if conservative therapies fail. [2-4, 8]Conservative treatments of patients with CDH are not well described or studied but may include lifestyle changes, pain medications, physiotherapy, epidural steroid injections, or spinal manipulative therapy (SMT). [2, 3, 8, 9-12]Like most of the conservative treatments other than epidural steroid injections, the research evidence supporting SMT as a treatment for CDHs is lacking. Three systematic reviews on manipulation for various neck disorders found insufficient evidence to support this therapy for patients with neck pain and radiculopathy. [9-11]However, it is known that some doctors of chiropractic (DCs) and other manual therapists treat CDH patients with SMT in spite of the lack of supporting evidence. [11, 13]Therefore, the purpose of this study is to investigate the clinical outcomes of patients with cervical radiculopathy from MRI-confirmed CDH who are treated with high-velocity, low-amplitude SMT in an outpatient chiropractic practice.