Considerations for Spinal Manipulation Under Anesthesia

Spinal manipulation under anesthesia (MUA), also referred to as medication-assisted manipulation (MAM), involves putting a patient with chronic neck or back pain under anesthesia (and/or other medications) while a doctor manipulates the spine. The hope is that the treatment increases range of motion and decreases pain—but does it work?

See Chronic Pain As a Disease: Why Does It Still Hurt?

This page discusses the differences between manipulation under anesthesia vs. traditional manipulation, the goals of MUA treatment for spine pain, and what current research indicates about the treatment.

See Spinal Manipulation: High-Velocity Low-Amplitude (HVLA)

Anesthesia Effects During Manipulation

The use of anesthesia and other medications during spinal MUA aims to:

• Sedate the pain-perceiving nerves that have been irritated due to spinal dysfunction
• Achieve complete muscle relaxation (no more conscious or unconscious muscle guarding to avoid more pain)
• Shut off the muscle spasm cycle, if present

In modern spinal MUA procedures, propofol (Diprivan) and midazolam (Versed) are common anesthetics used. ¹ Gordon R, Cremata E, Hawk C. Guidelines for the practice and performance of manipulation under anesthesia. Chiropr Man Therap. 2014;22(1):7. Other anesthetics and/or medications may be used during the procedure, depending on the patient’s specific needs and treatment.

It is possible for anesthesia to cause complications during or after spinal MUA, which can range from mild to life-threatening. For example, some potential side effects of propofol include slowed breathing, fast or slow heart rate, skin changes or itching around the intravenous (IV) needle, muscle pain, and others. ² Diprivan patient information including side effects. RxList Web site. Accessed December 4, 2017. One study reported about 1 in 60,000 people experienced an allergic reaction to propofol, but estimates vary in the medical literature. ³ Hepner DL, MC Castells. Anaphylaxis during the perioperative period. Anesthesia & Analgesia. 2003; 97(5): 1381-95.

The Proposed Goals of MUA for Spinal Pain

Some potential patient benefits of MUA that have been reported include:

• Breaking up or stretching excessive scar tissue (fibrous adhesions) both in and around the spinal joints.
• Decreasing chronic muscle spasm.
• Overcoming the hypersensitivity of injured areas to enable the patient to continue with other treatments, such as physical therapy, traditional manual manipulation, or exercise.
• Stretching persistent shortened muscles, ligaments, and tendons.
• Decreasing pain related to fibromyalgia.
• Relieving pain and radiating symptoms from damaged intervertebral discs. ⁴ Herzog J. Use of cervical spine manipulation under anesthesia for management of cervical disk herniation, cervical radiculopathy, and associated cervicogenic headache syndrome. J Manipulative Physiol Ther. 1999, 22 (3): 166-70.

See Understanding Spinal Manipulation

Other benefits from spinal MUA have also been reported, such as relief from cervicogenic headache stemming from the neck.

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Effectiveness of Manipulation Under Anesthesia for Spinal Pain

Most of the evidence for manipulation under anesthesia for spinal pain involves case studies and anecdotal evidence, rather than large randomized controlled trials typically required for high-quality scientific evidence. While some practitioners and patients report satisfactory benefits from the procedure, more studies are needed to evaluate whether manipulation under anesthesia is better than the placebo effect. ¹ Gordon R, Cremata E, Hawk C. Guidelines for the practice and performance of manipulation under anesthesia. Chiropr Man Therap. 2014;22(1):7. ^{, 5} Digiorgi D. Spinal manipulation under anesthesia: a narrative review of the literature and commentary. Chiropr Man Therap. 2013;21(1):14

Manipulation under anesthesia for some other areas of the body, including the shoulder, are covered by insurance more often than when the procedure is done for the spine, as many insurance companies still consider this application to be experimental. Spinal MUA is more likely to be covered by insurance under medical benefits rather than chiropractic benefits.

When performed by certified professionals in a hospital or other medical environment, manipulation under anesthesia is currently considered a relatively safe procedure. ¹ Gordon R, Cremata E, Hawk C. Guidelines for the practice and performance of manipulation under anesthesia. Chiropr Man Therap. 2014;22(1):7. ^{, 5} Digiorgi D. Spinal manipulation under anesthesia: a narrative review of the literature and commentary. Chiropr Man Therap. 2013;21(1):14 The American Medical Association’s Current Procedural Terminology Publication lists a CPT code of 22505 for manipulation under anesthesia for any region of the spine. ⁶ AAPC Coder Web site. Accessed December 5, 2017.