A need to assess risks involved with spinal manipulation in children

Researchers are calling for the creation of a collaborative registry to assess the risk of serious injuries when treating children using spinal manipulation.

A recent study done in part by the University of Alberta in Edmonton, Canada, concludes that although serious adverse events have been identified when spinal manipulation is used to treat children, their true incidence remains unknown, and these events must be better reported. Patient safety demands a greater collaboration between the medical community and other health care professionals, the study suggests.

A team of researchers representing multiple professions that provide spinal manipulation conducted the study, the results of which were published in a recent issue of the journal Pediatrics.

They reviewed data drawn from 13 international studies conducted over a period of more than 40 years and found that adverse reactions in children appeared to be rare compared to the numbers of spinal manipulations performed. But those injuries that occurred, such as stroke and paraplegia, were serious enough to warrant further investigation and the development of an active surveillance registry to gather data about the quantity and quality of adverse events so that precise risk estimates can be made.

"Despite the fact that spinal manipulation is commonly used on children, exceedingly few serious injuries or adverse events have been reported," said Dr. Kim Humphreys, one of the study authors and dean of Graduate Education and Research at the Canadian Memorial Chiropractic College.

"We are unclear if that is because they do not occur, or because they are not reported," added lead author Dr. Sunita Vohra, an associate professor in the Department of Pediatrics at the University of Alberta and a pediatrician with the Capital Health Authority in Alberta.

In the data reviewed worldwide, 14 identified cases of direct adverse reactions following spinal manipulation in children 18 and younger were found. Nine were serious, resulting in hospitalization, permanent disability or death. Three of the nine cases involved misdiagnosed underlying pathology such as cancer of the spinal cord. Two involved moderately adverse events such as severe headache requiring medical attention, and three involved minor events such as back soreness.

An additional 20 cases were identified as delayed diagnosis and/or inappropriate delivery of spinal manipulation for serious medical conditions requiring the care of a physician. Eight of the cases involved delayed treatment of cancer and two of meningitis. Three of the eight cases resulted in death. All of the most serious adverse events occurred in children 13 and younger.

Spinal manipulation may be provided by a variety of health care providers such as physicians and physical therapists, but is most often provided by chiropractors. Children made an estimated 30 million visits to U.S. chiropractors in 1997, according to the study. While there is little Canadian data on the percentage of children receiving chiropractic care, a more recent survey of 1,800 participants in a Canadian pediatric hospital showed that 31 per cent of children had at some time received treatment from a chiropractor.

"Safety begins with communication," said Dr. Vohra. "Improved dialogue between parents and their child's doctor, about all of their child's health care practices, as well as between health care providers, is key."