Chiropractic spinal manipulative therapy versus physical therapist-led exercise and the risk of cauda equina syndrome in adults with lumbar disc herniation, stenosis, or radiculopathy.

The study relies on electronic health record codes, which may not capture the nuance of clinical decision-making or exclude patients who were referred to emergency care before treatment. The number of CES events was very low (14 in the SMT group and 16 in the PTE group), leading to wide confidence intervals and limited precision. The study could not determine the specific techniques or force levels used in spinal manipulation, nor the specific exercises prescribed by physical therapists. Patients with serious spinal pathology or suspected CES were likely excluded or referred elsewhere, potentially selecting for a lower-risk population. The secondary outcomes of bladder catheterization and fecal incontinence were lower in the SMT group, but the authors caution this is likely due to confounding factors in the PTE group rather than a protective effect of SMT.

Funding was provided by the National Institutes of Health and the Elisabeth Severance Prentiss Foundation. One author (Robert J. Trager) receives royalties from two texts on sciatica. Other authors declared no competing interests.

Do not interpret the significantly lower rates of bladder catheterization and fecal incontinence in the SMT group as evidence that spinal manipulation protects against these issues. The authors state these outcomes are not specific to cauda equina syndrome and the difference likely reflects baseline health differences between the cohorts rather than a treatment effect.