What are the absolute contraindications to cervical spinal manipulation (CSM)?

From the Guidelines

Cervical spinal manipulation (CSM) is absolutely contraindicated in patients with certain medical conditions that pose a significant risk of severe harm.

Key Contraindications

• Spinal fusion [ 1 ]: Patients with spinal fusion are at high risk of spine fractures, spinal cord injury, and paraplegia following CSM, particularly of the cervical spine.
• Advanced spinal osteoporosis [ 1 ]: Advanced osteoporosis of the spine increases the risk of fractures and other severe complications with CSM.
• Acute fractures or dislocations of the cervical spine: These conditions require immediate medical attention and stabilization, making CSM unsafe.
• Severe osteoporosis or osteopenia: Similar to advanced spinal osteoporosis, severe osteoporosis or osteopenia increases the risk of fractures with CSM.
• Rheumatoid arthritis with cervical instability: Cervical instability due to rheumatoid arthritis can lead to severe complications, including spinal cord injury, with CSM.
• Recent cervical spine surgery: Patients who have recently undergone cervical spine surgery should avoid CSM to prevent disrupting the surgical site and causing further injury.
• Presence of a pacemaker or other implanted electrical devices: The presence of implanted electrical devices can pose a risk of interference or damage with CSM.
• Vertebral or carotid artery dissection: These conditions can lead to severe and potentially life-threatening complications, including stroke, with CSM.
• Cervical spondylolisthesis or spondylosis with instability: Instability in the cervical spine due to these conditions can increase the risk of severe harm with CSM.
• Infection or inflammation of the cervical spine, such as osteomyelitis or discitis: CSM can exacerbate these conditions and lead to further complications.
• Tumors or metastatic disease affecting the cervical spine: The presence of tumors or metastatic disease can weaken the cervical spine and increase the risk of fractures or other severe complications with CSM.
• Patients taking anticoagulant medications, such as warfarin, with an INR greater than 3.0, or those taking novel oral anticoagulants like apixaban or rivaroxaban: These medications can increase the risk of bleeding and other complications with CSM. In general, caution should be exercised when considering CSM in patients with a history of stroke, transient ischemic attack, or other cerebrovascular disease.

From the Research

Absolute Contraindications to Cervical Spinal Manipulation (CSM)

• The provided studies do not explicitly list absolute contraindications to CSM, but they do discuss the importance of recognizing cervical instability and the potential risks associated with CSM 2, 3, 4.
• Cervical instability is a significant concern, as it can lead to severe neurologic compromise, including paralysis or death 2.
• The studies suggest that a thorough physical examination, including a neurological evaluation, should be performed prior to manipulation to identify potential contraindications 3, 4.
• The presence of certain conditions, such as segmental kyphosis, significant loss of disc height, bridging osteophytes, and prior cervical spine surgery, may be considered relative contraindications to CSM 5.
• Cervical arterial dissection (CAD) is a potential adverse event associated with CSM, and women may be at higher risk for CAD 6.

Potential Contraindications to CSM

• Cervical instability, as measured by radiographic instability, is a potential contraindication to CSM 2.
• Prior cervical spine surgery, segmental kyphosis, and significant loss of disc height may be considered relative contraindications to CSM 5.
• The presence of certain symptoms, such as nausea or vertigo, after prior manipulation may be considered a contraindication to future spinal manipulations 3.

Importance of Pre-Manipulative Screening

• Pre-manipulative cervical instability and arterial integrity tests appear to be unreliable in identifying patients at risk for adverse events 6.
• A thorough physical examination, including a neurological evaluation, is essential to identify potential contraindications to CSM 3, 4.
• Patient characteristics, such as age and gender, may not be reliable predictors of adverse events associated with CSM 6.