Manipulation Under Anesthesia

Manipulation Under Anesthesia

Manipulation Under Anesthesia

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Most people are familiar with either Osteopathic manipulation or Chiropractic treatments, and frequently talk about having their back “cracked”. The purpose of this entry is not to discuss the efficacy of manipulation as a whole, but to rather focus on one specific type of treatment. Manipulation Under Anesthesia (MUA) has been used by physicians and chiropractors with the theory being that the anesthesia will result in a loss of conscious guarding from a patient, therefore leading to a better manipulation. This procedure is generally not covered by insurance and many practitioners are charging very high fees for the service, sometimes more than the cost of actual spine surgery.

The efficacy of this procedure, however, is very controversial. I personally performed a search of the medical literature using PubMed which comprises more than 26 million citations for biomedical literature from MEDLINE, life science journals, and online books. It is maintained by the US National Library of Medicine at the NIH and is also considered one of the most respected search engines for medical literature which is used daily by thousands of medical professionals. Essentially, this is the ‘go to’ place to find answers to questions in the medical literature. I queried ‘Manipulation Under Anesthesia’ in effort to assess the quality of the data behind this treatment.

Unfortunately, there is a paucity of published studies on this treatment within this database. In addition, the studies which have been published consist primarily of case reports and expert opinions, which are considered the lowest level of impact/reliability in the medical literature, ‘Level 4 or 5’. This is in contrast to the typical large, placebo controlled, double-blinded studies which are generally given the highest ‘Level 1’ rating. One of the best articles I came across was actually published in the chiropractic literature. Dennis DiGiorgi wrote an excellent commentary regarding the indications for and data regarding Manipulation Under Anesthesia (Spinal Manipulation Under Anesthesia: A Narrative Review of the Literature and Commentary. Chiropractic & Manual Therapies, 21:14, 2013). In this review, he highlights the points made above regarding the lack of literature and the low quality of evidence supporting the routine use of Manipulation Under Anesthesia. According to the article, MUA should only be used in patients with chronic symptoms who have failed conservative treatments as part of a comprehensive treatment plan, including post-procedure rehabilitation. It is not meant to be performed as a stand-alone therapy. There is also no evidence to support treating the entire body, rather the procedure should only be performed on just the symptomatic region if at all.

As an Osteopathic Physician, I was trained in various types of manipulation during medical school. I was taught that there are a few different types of ‘barriers’ to consider when performing manipulation. The most important of these is the ‘anatomic barrier’. The anatomic barrier is the physical barrier created by the integrity of the supporting ligaments, bones, etc. Moving a joint though the anatomic barrier will likely result in permanent compromise to the structural integrity of the joint or even a fracture. Most of the time, a conscious patient is able to protect themselves from reaching the anatomic barrier by ‘guarding’ themselves before it is reached. My concern is that since this guarding is eliminated during anesthesia, the manipulation may inadvertently cross the anatomic barrier and result in structural damage.

My recommendation is to approach this treatment with caution and skepticism until quality data is available which can either support or refute it. Ideally, this data would include a comparison to other less costly treatments, such as physical therapy.

Citations

  • Feuerstein C, Weil L Jr, Weil LS Sr, Klein EE, Argerakis N, Fleischer AE. Joint Manipulation Under Anesthesia for Arthrofibrosis After Hallux Valgus Surgery. J Foot Ankle Surg. 2016 Jan-Feb;55(1):76-80. PubMed PMID: 26256296

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Author and Contributor to www.Spine-Health.com – July, 2015

www.Spine-Health.com/author/john-h-shim-md-facs

Chief of Surgery, Mease Countryside and Mease Dunedin Hospitals, Safety Harbor and Dunedin, Florida. 2014-2016.

Orthopaedic Section Chief Mease Countryside Hospital; Safety Harbor, Florida Mease Dunedin Hospital; Dunedin, Florida.2008-2013

Board Member Morton Plant Mease Research Council

Co-Director of Mease Neuro-Ortho Spine Center Mease Dunedin Hospital; Dunedin, Florida.

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2016 Spine Surgeons to Know list – January 2016

2014 Spine Specialists to know list – September 2014

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The information provided on this website does not provide or should be considered medical advice. It is not a substitute for diagnosis or treatment of any condition. The information provided is for informational purposes only. You should not rely solely on the information provided on this website in making a decision to pursue a specific treatment or advice. You should consult directly with a professional healthcare provider.

As a condition of using the information on this website, ShimSpine and its physicians are not responsible for any advice, diagnosis, treatment or outcome you may obtain.

ShimSpine.com is completely self-funded. No outside funds are accepted or used. This website does not utilize paid advertising as a source of revenue.
Outpatient Spine Surgery Considerations. www.Spine-Health.com. January 2016.

What is Spinal Stenosis? www.Spine-Health.com. October 2015.

Surgeon insights on the Changing Landscape of Orthopedic Care. OrthopedicToday. June 2014

Chapter 33: Interspinous Spacers. Shim JH, Mazza JS, Kim DH Published in Minimally Invasive Percutaneous Spinal Techniques. Elsevier Health Sciences, Philadelphia, Pennsylvania. (Published 2011)

Chapter 35: Minimally Invasive Percutaneous Lumbar Fusion Technique.Shim JH, Mazza JS, Kim DH Published in Minimally Invasive Percutaneous Spinal Techniques. Elsevier Health Sciences, Philadelphia, Pennsylvania. (Published 2011)

March 2010 Minimally Invasive Transforaminal Lumbar Interbody Fusion American Academy of Orthopaedic Surgeons Annual Meeting New Orleans, Louisiana February 2010

February 2010 A Review of Dynamic Stabilization in the Lumbar Spine Selby Spine Symposium; Park City, Utah

November 2009 Lumbar Spinal Stenosis Community Based Lecture; Tampa, Florida

September 2009 Instructor/Proctor Minimally Invasive Lumbar Cadaver Lab; Tampa, Florida

February 2009 New Spinal Technology: Cervical Disc Replacement and Interspinous Spacers. Selby Spine Symposium; Park City, Utah

February 2008 The Degenerative Spine: The Role of Dynamic Lumbar Stablization and Interspinous Spacers Selby Spine Symposium; Park City, Utah

October 2008 Emerging Technology and Techniques in Spinal Surgery Orthopaedics in the 21st Century Symposium; Morton Plant Mease Healthcare; Largo, Florida

September 2007 Emerging Technology in Spinal Surgery Orthopaedics in the 21st Century Symposium; Morton Plant Mease Healthcare; Largo, Florida

October 2006 Emerging Technology and Techniques in Spinal Surgery Orthopaedics in the 21st Century Symposium; Morton Plant Mease Healthcare; Largo, Florida

May 2005 The Role of Kyphoplasty in the Treatment of Vertebral Compression Fractures Mease Neurosciences Symposium; Clearwater, Florida
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