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Chiropractic care and risk for acute lumbar disc herniation: a population-based self-controlled case series study

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Abstract

Purpose

Chiropractic care is popular for low back pain, but may increase the risk for acute lumbar disc herniation (LDH). Low back pain is a common early (prodromal) symptom of LDH and commonly precedes LDH diagnosis. Our objective was to investigate the association between chiropractic care and acute LDH with early surgical intervention, and contrast this with the association between primary care physician (PCP) care and acute LDH with early surgery.

Methods

Using a self-controlled case series design and population-based healthcare databases in Ontario, Canada, we investigated all adults with acute LDH requiring emergency department (ED) visit and early surgical intervention from April 1994 to December 2004. The relative incidence of acute LDH with early surgery in exposed periods after chiropractic visits relative to unexposed periods was estimated within individuals, and compared with the relative incidence of acute LDH with early surgery following PCP visits.

Results

195 cases of acute LDH with early surgery (within 8 weeks) were identified in a population of more than 100 million person-years. Strong positive associations were found between acute LDH and both chiropractic and PCP visits. The risk for acute LDH with early surgery associated with chiropractic visits was no higher than the risk associated with PCP visits.

Conclusions

Both chiropractic and primary medical care were associated with an increased risk for acute LDH requiring ED visit and early surgery. Our analysis suggests that patients with prodromal back pain from a developing disc herniation likely seek healthcare from both chiropractors and PCPs before full clinical expression of acute LDH. We found no evidence of excess risk for acute LDH with early surgery associated with chiropractic compared with primary medical care.

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Acknowledgements

We thank Dr. Heather Whitaker and Dr. Ronny Kuhnert for their advice about the self-controlled case series design and analysis of this study. We acknowledge the Ontario Ministry of Health and Long-Term Care for support with data acquisition.

Author information

Authors and Affiliations

  1. Injury Prevention Research Office, Division of Neurosurgery, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Canada

    Cesar A. Hincapié

  2. Graduate Education and Research Programs, Canadian Memorial Chiropractic College, Toronto, Canada

    Cesar A. Hincapié

  3. Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada

    Cesar A. Hincapié & J. David Cassidy

  4. Toronto General Research Institute and Department of Medicine, University Health Network, Toronto, Canada

    George A. Tomlinson

  5. Faculty of Health Sciences, University of Ontario Institute of Technology, Oshawa, Canada

    Pierre Côté

  6. UOIT-CMCC Centre for Disability Prevention and Rehabilitation, Toronto, Canada

    Pierre Côté

  7. Division of Orthopaedic Surgery, Toronto Western Hospital, Toronto, Canada

    Y. Raja Rampersaud

  8. Institute for Global Health Equity and Innovation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada

    Alejandro R. Jadad

  9. Centre for Global eHealth Innovation, University Health Network, Toronto, Canada

    Alejandro R. Jadad

Authors
  1. Cesar A. Hincapié
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  2. George A. Tomlinson
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  5. Alejandro R. Jadad
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  6. J. David Cassidy
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Contributions

CAH conceived and designed the study, acquired, processed, and analysed the data, interpreted the results, and drafted and revised the paper. GT designed the study, analysed the data, interpreted the results, and revised the paper. PC and JDC conceived and designed the study, interpreted the results, and revised the paper. YRR and ARJ designed the study, interpreted the results, and revised the paper. CAH acts as guarantor.

Corresponding author

Correspondence to Cesar A. Hincapié.

Ethics declarations

Funding sources

Canadian Institutes of Health Research (Grant ID: 200902KPD-205299-111612), Canadian Chiropractic Research Foundation, and Canadian Chiropractic Protective Association.

Ethical approval

This study was approved by the research ethics board at the University Health Network (REB #09-0668-AE).

Conflict of interest

All authors have completed the ICMJE uniform disclosure form at http://www.icmje.org/coi_disclosure.pdf (available from the corresponding author) and declare: CAH was funded by a Fellowship Award in the Area of Knowledge Translation from Canadian Institutes of Health Research (Grant ID: 200902KPD-205299-111612), and Canadian Chiropractic Research Foundation, PC is funded by a Canada Research Chair in Disability Prevention and Rehabilitation at the University of Ontario Institute of Technology, the study received additional support from the Canadian Chiropractic Protective Association; PC consults for European Spine Society, National Judicial Institute of Canada, Canadian Memorial Chiropractic College, Canadian Chiropractic Protective Association, Society of Musculoskeletal Manual Practitioners of Saskatchewan, Société des experts en évaluation médico-légale du Québec, YRR consults for Medtronic, outside the submitted work; no other relationships or activities that could appear to have influenced the submitted work. The funders played no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.

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Hincapié, C.A., Tomlinson, G.A., Côté, P. et al. Chiropractic care and risk for acute lumbar disc herniation: a population-based self-controlled case series study. Eur Spine J 27, 1526–1537 (2018). https://doi.org/10.1007/s00586-017-5325-y

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  • DOI: https://doi.org/10.1007/s00586-017-5325-y

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