Abstract
As exhibited throughout the medical literature over many decades, there is a lack of uniformity in the manner in which spine pain patients have historically qualified for and received manipulation under anesthesia (MUA). Also, for different professions that treat the same types of spinal conditions via the same means, fundamental MUA decision points vary within the published protocols of different professional associations. The more recent chiropractic literature communicates that the evidence to support the efficacy of MUA of the spine remains largely anecdotal. In addition, it has been reported that the types of spinal conditions most suitable for MUA are without clear-cut consensus, with various indications for MUA of the low back resting wholly upon the opinions and experiences of MUA practitioners. This article will provide a narrative review of the MUA literature, followed by a commentary about the current lack of high quality research evidence, the anecdotal and consensus basis of existing clinical protocols, as well as related professional, ethical and legal concerns for the chiropractic practitioner. The limitations of the current medical literature related to MUA via conscious/deep sedation need to be recognized and used as a guide to clinical experience when giving consideration to this procedure. More research, in the form of controlled clinical trials, must be undertaken if this procedure is to remain a potential treatment option for chronic spine pain patients in the chiropractic clinical practice.
Highlights
manipulation under anesthesia (MUA) has been reported in the medical literature since the 1930’s [1]
Inspection of the literature reveals that medicine assisted manipulation (MAM) [2], across its varied forms- manipulation under general anesthesia or conscious/deep sedation (MUA), manipulation under joint anesthesia (MUJA) or manipulation under epidural anesthesia/epidural steroid injection (MUEA/Manipulation under epidural steroid injection (MUESI))has been used to treat a host of musculoskeletal conditions [1,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30]
The evidence of treatment efficacy remains limited [119], with published studies that are generally weak in their methodological quality [2] and consistently varied across multiple domains which do not permit comparative analysis toward generalization [15]
Summary
MUA has been reported in the medical literature since the 1930’s [1]. Inspection of the literature reveals that medicine assisted manipulation (MAM) [2], across its varied forms- manipulation under general anesthesia or conscious/deep sedation (MUA), manipulation under joint anesthesia (MUJA) or manipulation under epidural anesthesia/epidural steroid injection (MUEA/MUESI)has been used to treat a host of musculoskeletal conditions [1,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30]. By applying the levels of evidence schema introduced nearly a decade ago by Wright et al [41] as a method to rate the more commonly cited or relied upon published clinical studies on MAM, the quality of research evidence can be gauged by way of a contemporary standard (Table 2) It is through this process that the lack of high quality supportive scientific evidence for spinal MUA is revealed. Positive outcomes for pain, patient work status and medication use were reported in the large MUA retrospective case series conducted by West, et al [31] Those results are of uncertain value due to confounding factors with the study design. Perhaps of greatest significance, this same study had been previously published, alternatively citing that 20 of the 177 patients in the treatment
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