Spinal Manipulation Under Anesthesia
DESCRIPTION
Spinal manipulation performed either with an individual sedated or under anesthesia (i.e., manipulation under anesthesia [MUA]) is intended to overcome the conscious protective reflex mechanism, which may have limited the success of prior attempts of spinal manipulation for the treatment of back pain. In MUA, a low velocity/high amplitude technique may be used in contrast to the high velocity/low amplitude technique that is used in the typical chiropractic/osteopathic adjustment. A single session of MUA may be offered, followed by a series of outpatient chiropractic/osteopathic sessions, or a series of up to 5 sessions of MUA may be offered, also followed by outpatient chiropractic/osteopathic sessions. In some instances the MUA may be accompanied by corticosteroid injections.
POLICY
Spinal manipulation under anesthesia is considered investigational.
ADDITIONAL INFORMATION
As with any treatment of pain, controlled clinical trials are considered particularly important to isolate the contribution of the intervention and to assess the extent of the expected placebo effect. As of 2007, a search of the published medical literature did not identify any controlled clinical trials. Several case series were identified, which included individuals with cervical, thoracic and lumbar back pain, treated according to varying protocols. In 1999, the largest case series, West and colleagues reported on 177 individuals with back pain who had failed prior therapy. The individuals were treated with 3 sequential manipulations under intravenous sedation, followed by 4-6 weeks of further chiropractic spinal manipulation. At 6 month follow up there was a 60% improvement in visual analogue score (VAS). However, this uncontrolled study cannot isolate the contribution of the manipulation under anesthesia compared to the placebo effect, the effect of continued chiropractic therapy, or the natural history of the condition. Other small case series focused on the use of manipulation in conjunction with corticosteroid injections. Similarly, this literature does not permit scientific interpretation.
Spinal manipulation under anesthesia does not meet the following technology evaluation criteria:
The technology must have final approval from the appropriate government regulatory bodies.
The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes.
The technology must improve the net health outcome.
The technology must be as beneficial as any established alternatives.
The improvement must be attainable outside the investigational settings.
SOURCES
BlueCross BlueShield Association. Medical Policy Reference Manual. (1:2006). Spinal manipulation under anesthesia (8.01.40). Retrieved May 8, 2007 from BlueWeb.
Cremata, E., Collins, S., Clauson, W., Solinger, A. B., & Roberts, E. S. (2005). Manipulation under anesthesia: A report of four cases. Journal of Manipulative and Physiological Therapeutics, 28 (7), 526-533. Abstract retrieved May 8, 2007 from PubMed database.
ECRI Institute. Health Technology Information Service. Windows on Medical Technology. (2003, February). Manipulation under anesthesia for low-back pain. Retrieved November 5, 2003 from ECRI Institute.
Kohlbeck, F. J., & Haldeman, S. (2002). Medication-assisted spinal manipulation. Spine, 2 (4), 288-302. Abstract retrieved November 5, 2003 from PubMed database.
Palmieri, N. F. & Smoyak, S. (2002). Chronic low back pain: A study of the effects of manipulation under anesthesia. Journal of Manipulative and Physiological Therapeutics, 25 (8), 8-17. Abstract retrieved May 8, 2007 from PubMed database.
West, D. T., Mathews, R. S., Miller, M. R., & Kent, G. M. (1999). Effective management of spinal pain in one hundred seventy-seven patients evaluated for manipulation under anesthesia. Journal of Manipulative and Physiological Therapeutics, 22 (5), 299-308.
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EFFECTIVE DATE |
6/14/2007 |
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