Outcomes Indicators and a Risk Classification System for Spinal Manipulation Under Anesthesia: A Narrative Review and Proposal
SOURCE: Chiropractic & Manual Therapies 2018 (Mar 8); 26: 9
Dennis DiGiorgi, John L. Cerf, and Daniel S. Bowerman
Consultant Practice
Whitestone, NY, USA.
Over a period of decades chiropractors have utilized spinal manipulation under anesthesia (SMUA) to treat chronic back and neck pain. As an advanced form of manual therapy, SMUA is reserved for the patient whose condition has proven refractory to office-based manipulation and other modes of conservative care. Historically, the protocols and guidelines put forth by chiropractic MUA proponents have served as the clinical compass for directing MUA practice.
With many authors and MUA advocates having focused primarily on anticipated benefit, the published literature contains no resource dedicated to treatment precautions and contraindications. Also absent from current relevant literature is acknowledgement or guidance on the preliminary evidence that may predict poor clinical outcomes with SMUA. This review considers risk and unfavorable outcomes indicators in therapeutic decision making for spinal manipulation under anesthesia.
A new risk classification system is proposed that identifies patient safety and quality of care interests for a procedure that remains without higher-level research evidence. A scale which categorizes risk and outcome potential for SMUA is offered for the chiropractic clinician, which aims to elevate the standard of care and improve patient selection through the incorporation of specific indices from existing medical literature.
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KEYWORDS: Contraindications; Informed consent; Manipulation under anesthesia; Medical evidence; Outcomes; Precautions; Risk; Spine
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Background
Since the 1930’s, many forms of facilitated manipulation of the spine have been reported in the literature, with various anesthetic/sedative agents and techniques used. [1] In the 1990’s, in managing patients with chronic spine pain and related dysfunction, chiropractors began utilizing the conscious sedation variety of manipulation under anesthesia (MUA). [1] During that era, the standards and protocols of the National Academy of MUA Physicians (NAMUAP) [2] were popularized and relied upon by many in determining clinical eligibility for MUA. A revised version of the original NAMUAP standards and protocols was put forth in 2012, as adopted by the newly established American Association of Manipulation Under Anesthesia Providers (AAMUAP). That document subsequently underwent a consensus-based review, in developing recommendations for the contemporary practice of MUA. [3]
What may render a clinical guideline useful for individual patients is its reliance upon valid evidence in establishing decision points and risks of care. [4] An appraisal of risk is essential to clinical guideline development. [5-7] Estimations of the balance of benefits against risks or harms helps to ensure guideline credibility for stakeholders. [8] A significant limitation with current SMUA guidelines, and the collective scientific knowledge on this subject, is inadequate recognition of the risk profiles and outcomes indicators that contribute to patient selection. This limitation relates to incomplete development of the relative/absolute contraindications to care and several known clinical, diagnostic, and litigation-related factors which may weigh against the option of SMUA.
For spinal manipulation under anesthesia, what remains ambiguous despite existing guidelines is when to move a patient toward treatment. The heterogeneity of primary research and the presence of mostly lower-level evidence pose inherent challenges to clinical decision making. [9] Moreover, the current SMUA literature and association-based protocol documents are without a corresponding evidence-informed resource that elucidates risk versus benefit. Even when individual patients have undergone all appropriate studies [10], weak levels of evidence for SMUA can lead to uncertainty in selection, dosing and patient safety. Although rare, sentinel events have been reported. [11-13] It is with a rise in SMUA utilization in the United States in recent years that a constructive and critical analysis of these matters becomes essential. This paper reviews the evidence for SMUA in establishing a scale for the chiropractic clinician which categorizes risk and outcome potential. It considers risk and unfavorable outcomes indicators in the development of a risk classification system that identifies patient safety and quality of care interests for this advanced form of treatment. As such, it calls for an elevation in the standard of care and improved patient selection through the incorporation of specific indices from existing medical literature.
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