J Manipulative Physiol Ther 2004 (Nov); 27 (9): 574–578
Anthony J. Lisi, DC, Mukesh K. Bhardwaj, DC
Anthony J. Lisi, DC, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516; firstname.lastname@example.org
To present an evidence-based case report on the use of chiropractic high-velocity low-amplitude spinal manipulation in the treatment a postsurgical, chronic cauda equina syndrome patient.
Clinical Features: A 35-year-old woman presented with complaints of midback pain, low-back pain, buttock pain, saddle anesthesia, and bladder and bowel incontinence, all of 6 months duration. The patient was 6 months post emergency surgery for acute cauda equina syndrome due to lumbar disc herniation. She had been released from neurosurgical care with the current symptoms considered to be residual and nonprogressive.
Intervention and Outcome: The patient was treated with high-velocity low-amplitude spinal manipulation and ancillary myofascial release. After 4 treatments, the patient reported full resolution of midback, low back, and buttock pain. The patient was seen another 4 times with no improvement in her neurologic symptoms. No adverse effects were noted.
Conclusion: This appears to be the first published case of chiropractic high-velocity low-amplitude spinal manipulation being used for a patient with chronic cauda equina syndrome. It seems that this type of spinal manipulation was safe and effective for reducing back pain and had no effect on neurologic deficits in this case.
From the Full-Text Article:
This case report describes chiropractic management of a case of chronic CES, a condition that may be little known to many chiropractors. Although acute CES is well established as an absolute contraindication to and a rare but serious adverse effect of lumbar spinal manipulation, [2, 15, 16]. we uncovered no published data reporting even the use of spinal manipulation in chronic CES, let alone the appropriateness of such. It was unknown if administering spinal manipulation to this patient would be safe and effective. Therefore, we decided to search the literature for reports of chiropractic treatment of the primary components of chronic CES seen in this patient: bladder/bowel incontinence and postoperative LBP.
No published data were uncovered on chiropractic treatment of neurogenic bladder or bowel incontinence; therefore, any clinical decision regarding such could not be based on meaningful evidence.
Some data do exist regarding the prevalence of postsurgical patients in chiropractic practices, but data on the safety and effectiveness of chiropractic manipulation for postsurgical pain are scarce. In a practice-based survey, Aspergren and Burt  showed that 68 of 1939 consecutive patients (3.8%) consulting chiropractors had undergone at least 1 previous spinal surgery. However, this study included no details on the type of chiropractic treatment used or on patient outcomes. In a multisite study of chiropractic patient characteristics, Hurwitz et al9 noted that 2.3% of patients consulting a chiropractor for LBP had a history of at least 1 previous back surgery. The majority of these patients received spinal manipulative therapy and physical therapy modalities; however, outcomes were not assessed in this study. Stern et al  conducted a retrospective case series of 59 patients with low-back pain and radiating leg pain treated at a postgraduate chiropractic teaching clinic and found that 12% of cases had a history of previous low-back surgery. The history of prior surgery was associated with a less favorable outcome to treatment, which included HVLA manipulation and physiotherapy modalities.
Other published studies of chiropractic treatment of postsurgical LBP are limited to case reports. McGregor and Cassidy  presented 3 cases of sacroiliac syndrome post lumbar fusion that responded to side posture HVLA manipulation. Shaw  reported a case of back and leg pain in a patient after lumbar discectomy that improved after treatment with HVLA manipulation and physical therapy modalities. Gluck  described a case of back and leg pain in a patient after 2 lumbar discectomies who responded to flexion-distraction and extensive active rehabilitation.
Depending on the specific surgical procedure, postsurgical joints are considered a relative to absolute contraindication to HVLA manipulation.  Subsequently, administering spinal manipulation to a patient after spinal surgery requires a substantial knowledge of surgical procedures and a greater degree of diagnostic acumen and manipulative skill than is required for the management of uncomplicated LBP. Triano [35, 36]. is perhaps the only author who has described the various considerations related to chiropractic manipulation of patients after spinal surgery. Yet these considerations have not been explored in the literatue to a significant extent, and clinicians must approach such cases with heightened diligence.
In this instance, the clinician (A.J.L.) had prior experience with postoperative LBP patients, and a reasonable comprehension of the literature summarized above, yet had no experience with managing the type of profound neurologic deficits present in this case and had no relevant literature which to refer. Because other treatment options (physical therapy rehabilitation and pain medication) had been attempted and had failed, it was decided that a trial of HVLA manipulation would be a reasonable intervention for the patient's spinal pain but that such manipulation also carried a greater risk of worsening pain and/or neurologic symptoms in this case than in uncomplicated LBP patients. It was also decided that provocation testing would be used to estimate the appropriateness of any given HVLA maneuver, with the expectation that the response to manual preloading of the spine would aid in predicting whether symptoms would be lessened or increased by the maneuver. Although there is only scant published evidence supporting provocation testing, [30, 31, 36-38]. it is perhaps the only chiropractic examination procedure that attempts to evaluate the appropriateness of a proposed manipulative thrust.
The patient was fully informed of the clinician's experience, knowledge, and entire clinical thought process, and she consented to a therapeutic trial of HVLA manipulation. She reported resolution of pain within 4 treatments. Although a transient subjective improvement in sensory deficit was noticed immediately after each low-back manipulation, there was no lasting change; nor was there any change in bladder or bowel incontinence.
The rapid pain relief seen in this case is extremely atypical of the natural history of chronic CES. Thus, it seems very likely that HVLA manipulation contributed to the resolution of spinal pain in this patient; however, the potential role of natural history cannot be fully dismissed. Also, the possible contribution of a placebo response must be considered. It seems unlikely that the passive myofascial treatment used played any primary role in pain relief, because the patient had undergone numerous massage treatments in the past.
HVLA manipulation as administered in this case clearly was ineffective as a treatment for neurogenic bladder and bowel incontinence, yet it did not have any adverse effects on those problems. With the great concern a prudent chiropractor must have for acute CES, it is interesting to note that, in this case, it was safe to deliver HVLA manipulation to a patient with chronic CES.
This appears to be the first published case of chiropractic treatment of a patient with chronic CES. It seems that chiropractic HVLA spinal manipulation was safe and effective for relieving back pain in this patient and treatment seems to have had no positive or negative effect on the neurologic deficits present.