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

Why This Matters

Cauda equina syndrome (CES) is a rare but serious condition that requires urgent surgical intervention. Concerns have been raised—primarily from case reports—that spinal manipulation could precipitate CES, particularly in patients with disc herniation or stenosis. This study evaluates whether those concerns are supported by large-scale clinical data.

What the Research Found

This large retrospective cohort study analyzed over 68,000 patients with lumbar disc herniation, stenosis, or radiculopathy, comparing those treated with chiropractic spinal manipulative therapy (SMT) versus physical therapist-led exercise (PTE).

Key Findings:

  • No increased risk of cauda equina syndrome with spinal manipulation
    • Risk ratio: 0.88 (no statistical difference vs exercise)
  • Secondary outcomes showed lower risk in the SMT group:
    • Bladder catheterization: ↓ 50%
    • Fecal incontinence: ↓ 50%
  • Results were controlled using propensity score matching to reduce confounding

Findings directly address a population at highest theoretical risk (disc herniation, stenosis, radiculopathy)

Clinical Takeaways

    • Recognize that spinal manipulation was not associated with an increased risk of cauda equina syndrome in a large, matched cohort
    • Be aware that prior concerns are largely based on case reports rather than population-level data
    • Consider that serious neurologic complications remain rare across treatment approaches
    • Continue to screen for red flag symptoms (bowel/bladder changes, saddle anesthesia, progressive neurologic deficit) regardless of treatment approach

Where Collaborative Spine Care May Support This

This study supports the role of conservative spine care, including spinal manipulation, as a management option for lumbar spine disorders without increased risk of catastrophic neurologic events. Collaboration across providers—including chiropractors, physical therapists, and physicians—remains essential for appropriate patient selection, monitoring, and timely referral when red flags arise.

Reference

Trager RJ, Baumann AN, Perfecto RT, Goertz CM. 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. PM&R. 2026.
DOI: http://dx.doi.org/10.1002/pmrj.70071
PubMed: https://pubmed.ncbi.nlm.nih.gov/41482869/