European Spine Journal

, Volume 27, Issue 7, pp 1526–1537 | Cite as

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

  • Cesar A. Hincapié
  • George A. Tomlinson
  • Pierre Côté
  • Y. Raja Rampersaud
  • Alejandro R. Jadad
  • J. David Cassidy
Original Article



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.


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.


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.


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.


Chiropractic Intervertebral disc displacement Risk Low back pain Primary health care Epidemiologic methods 



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 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.

Compliance with ethical standards

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 (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.

Data sharing

No additional data available.

Supplementary material

586_2017_5325_MOESM1_ESM.pdf (139 kb)
Supplementary material 1 (PDF 140 kb)
586_2017_5325_MOESM2_ESM.pdf (65 kb)
Supplementary material 2 (PDF 65 kb)


  1. 1.
    Vos T, Flaxman AD, Naghavi M, Lozano R, Michaud C et al (2012) Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 380:2163–2196CrossRefPubMedGoogle Scholar
  2. 2.
    Hoy D, Brooks P, Blyth F, Buchbinder R (2010) The epidemiology of low back pain. Best Pract Res Clin Rheumatol 24:769–781CrossRefPubMedGoogle Scholar
  3. 3.
    Hoy D, March L, Brooks P, Blyth F, Woolf A et al (2014) The global burden of low back pain: estimates from the Global Burden of Disease 2010 study. Ann Rheum Dis 73:968–974CrossRefPubMedGoogle Scholar
  4. 4.
    Cassidy JD, Cote P, Carroll LJ, Kristman V (2005) Incidence and course of low back pain episodes in the general population. Spine 30:2817–2823CrossRefPubMedGoogle Scholar
  5. 5.
    Hincapié CA, Cassidy JD, Côté P (2008) Is a history of work-related low back injury associated with prevalent low back pain and depression in the general population? BMC Musculoskelet Disord 9:22CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Kent PM, Keating JL (2005) The epidemiology of low back pain in primary care. Chiropr Osteopat 13:13CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Walker BF (2000) The prevalence of low back pain: a systematic review of the literature from 1966 to 1998. J Spinal Disord 13:205–217CrossRefPubMedGoogle Scholar
  8. 8.
    Andersson GB (1998) Epidemiology of low back pain. Acta Orthop Scand Suppl 281:28–31CrossRefPubMedGoogle Scholar
  9. 9.
    Genevay S, Atlas SJ, Katz JN (2010) Variation in eligibility criteria from studies of radiculopathy due to a herniated disc and of neurogenic claudication due to lumbar spinal stenosis: a structured literature review. Spine 35:803–811CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    van der Windt DA, Simons E, Riphagen, II, Ammendolia C, Verhagen AP et al (2010) Physical examination for lumbar radiculopathy due to disc herniation in patients with low-back pain. Cochrane Database Syst Rev 17:CD007431Google Scholar
  11. 11.
    Vroomen PC, de Krom MC, Wilmink JT, Kester AD, Knottnerus JA (2002) Diagnostic value of history and physical examination in patients suspected of lumbosacral nerve root compression. J Neurol Neurosurg Psychiatry 72:630–634CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Deyo RA, Loeser JD, Bigos SJ (1990) Herniated lumbar intervertebral disk. Ann Intern Med 112:598–603CrossRefPubMedGoogle Scholar
  13. 13.
    Weber H (1994) The natural history of disc herniation and the influence of intervention. Spine 19:2234–2238CrossRefPubMedGoogle Scholar
  14. 14.
    Koes BW, van Tulder MW, Peul WC (2007) Diagnosis and treatment of sciatica. BMJ 334:1313–1317CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Côté P, Cassidy JD, Carroll L (2001) The treatment of neck and low back pain: who seeks care? who goes where? Med Care 39:956–967CrossRefPubMedGoogle Scholar
  16. 16.
    Hurwitz EL, Chiang LM (2006) A comparative analysis of chiropractic and general practitioner patients in North America: findings from the joint Canada/United States Survey of Health, 2002–03. BMC Health Serv Res 6:49CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Hurwitz EL, Coulter ID, Adams AH, Genovese BJ, Shekelle PG (1998) Use of chiropractic services from 1985 through 1991 in the United States and Canada. Am J Public Health 88:771–776CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Senstad O, Leboeuf-Yde C, Borchgrevink C (1997) Frequency and characteristics of side effects of spinal manipulative therapy. Spine 22:435–440CrossRefPubMedGoogle Scholar
  19. 19.
    Leboeuf-Yde C, Hennius B, Rudberg E, Leufvenmark P, Thunman M (1997) Side effects of chiropractic treatment: a prospective study. J Manipulative Physiol Ther 20:511–515PubMedGoogle Scholar
  20. 20.
    Ferreira ML, Ferreira PH, Latimer J, Herbert R, Maher CG (2003) Efficacy of spinal manipulative therapy for low back pain of less than three months’ duration. J Manipulative Physiol Ther 26:593–601CrossRefPubMedGoogle Scholar
  21. 21.
    Bronfort G, Haas M, Evans RL, Bouter LM (2004) Efficacy of spinal manipulation and mobilization for low back pain and neck pain: a systematic review and best evidence synthesis. Spine J 4:335–356CrossRefPubMedGoogle Scholar
  22. 22.
    Chou R, Huffman LH, American Pain S, American College of P (2007) Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med 147:492–504CrossRefPubMedGoogle Scholar
  23. 23.
    Furlan AD, Yazdi F, Tsertsvadze A, Gross A, Van Tulder M et al (2012) A systematic review and meta-analysis of efficacy, cost-effectiveness, and safety of selected complementary and alternative medicine for neck and low-back pain. Evid Based Complement Alternat Med 2012:953139CrossRefPubMedGoogle Scholar
  24. 24.
    Paige NM, Miake-Lye IM, Booth MS, Beroes JM, Mardian AS et al (2017) Association of spinal manipulative therapy with clinical benefit and harm for acute low back pain: systematic review and meta-analysis. JAMA 317:1451–1460CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Gorrell LM, Engel RM, Brown B, Lystad RP (2016) The reporting of adverse events following spinal manipulation in randomized clinical trials-a systematic review. Spine J 16:1143–1151CrossRefPubMedGoogle Scholar
  26. 26.
    Santilli V, Beghi E, Finucci S (2006) Chiropractic manipulation in the treatment of acute back pain and sciatica with disc protrusion: a randomized double-blind clinical trial of active and simulated spinal manipulations. Spine J 6:131–137CrossRefPubMedGoogle Scholar
  27. 27.
    McMorland G, Suter E, Casha S, du Plessis SJ, Hurlbert RJ (2010) Manipulation or microdiscectomy for sciatica? A prospective randomized clinical study. J Manipulative Physiol Ther 33:576–584CrossRefPubMedGoogle Scholar
  28. 28.
    Bronfort G, Hondras MA, Schulz CA, Evans RL, Long CR et al (2014) Spinal manipulation and home exercise with advice for subacute and chronic back-related leg pain: a trial with adaptive allocation. Ann Intern Med 161:381–391CrossRefPubMedGoogle Scholar
  29. 29.
    Boucher P, Robidoux S (2014) Lumbar disc herniation and cauda equina syndrome following spinal manipulative therapy: a review of six court decisions in Canada. J Forensic Leg Med 22:159–169CrossRefPubMedGoogle Scholar
  30. 30.
    Hincapié CA, Cassidy JD, Côté P, Rampersaud YR, Jadad AR et al (2017) Chiropractic spinal manipulation and the risk for acute lumbar disc herniation: a belief elicitation study. Eur Spine J 38:677–691. doi: 10.1007/s00586-017-5295-0 CrossRefGoogle Scholar
  31. 31.
    Hebert JJ, Stomski NJ, French SD, Rubinstein SM (2013) Serious adverse events and spinal manipulative therapy of the low back region: a systematic review of cases. J Manipulative Physiol TherGoogle Scholar
  32. 32.
    Maclure M, Fireman B, Nelson JC, Hua W, Shoaibi A et al (2012) When should case-only designs be used for safety monitoring of medical products? Pharmacoepidemiol Drug Saf 21(Suppl 1):50–61CrossRefPubMedGoogle Scholar
  33. 33.
    Salas M, Hofman A, Stricker BH (1999) Confounding by indication: an example of variation in the use of epidemiologic terminology. Am J Epidemiol 149:981–983CrossRefPubMedGoogle Scholar
  34. 34.
    Crawford CM, Hannan RF (1999) Management of acute lumbar disk herniation initially presenting as mechanical low back pain. J Manipulative Physiol Ther 22:235–244CrossRefPubMedGoogle Scholar
  35. 35.
    Whitaker HJ, Hocine MN, Farrington CP (2009) The methodology of self-controlled case series studies. Stat Methods Med Res 18:7–26CrossRefPubMedGoogle Scholar
  36. 36.
    Whitaker HJ, Farrington CP, Spiessens B, Musonda P (2006) Tutorial in biostatistics: the self-controlled case series method. Stat Med 25:1768–1797CrossRefPubMedGoogle Scholar
  37. 37.
    Faciszewski T, Broste SK, Fardon D (1997) Quality of data regarding diagnoses of spinal disorders in administrative databases. A multicenter study. J Bone Jt Surg Am 79:1481–1488CrossRefGoogle Scholar
  38. 38.
    Peul WC, van den Hout WB, Brand R, Thomeer RT, Koes BW et al (2008) Prolonged conservative care versus early surgery in patients with sciatica caused by lumbar disc herniation: two year results of a randomised controlled trial. BMJ 336:1355–1358CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Peul WC, van Houwelingen HC, van der Hout WB, Brand R, Eekhof JA et al (2005) Prolonged conservative treatment or ‘early’ surgery in sciatica caused by a lumbar disc herniation: rationale and design of a randomized trial [ISRCT 26872154]. BMC Musculoskelet Disord 6:8CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Farrington CP, Whitaker HJ, Hocine MN (2009) Case series analysis for censored, perturbed, or curtailed post-event exposures. Biostatistics 10:3–16CrossRefPubMedGoogle Scholar
  41. 41.
    Hua W, Sun G, Dodd CN, Romio SA, Whitaker HJ et al (2013) A simulation study to compare three self-controlled case series approaches: correction for violation of assumption and evaluation of bias. Pharmacoepidemiol Drug Saf 22:819–825CrossRefPubMedGoogle Scholar
  42. 42.
    Kunhert R, Whitaker HJ (2012) adSCCS: Case series analysis for censored, perturbed or curtailed post-event exposures [computer program]. R package version 1.5Google Scholar
  43. 43.
    R Development Core Team (2012) R: a language and environment for statistical computing. In. R Foundation for Statistical Computing, Vienna, AustriaGoogle Scholar
  44. 44.
    Hincapié CA (2015) Chiropractic care and risk for acute lumbar disc herniation: a mixed methods approach [Doctoral Thesis]. University of Toronto, Toronto. Available from: Accessed 20 Sept 2016
  45. 45.
    Cassidy JD, Boyle E, Côté P, He Y, Hogg-Johnson S et al (2008) Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study. Spine 33:S176–S183CrossRefPubMedGoogle Scholar
  46. 46.
    Hartvigsen L, Kongsted A, Hestbaek L (2015) Clinical examination findings as prognostic factors in low back pain: a systematic review of the literature. Chiropr Man Therap 23:13CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    Al Nezari NH, Schneiders AG, Hendrick PA (2013) Neurological examination of the peripheral nervous system to diagnose lumbar spinal disc herniation with suspected radiculopathy: a systematic review and meta-analysis. Spine J 13:657–674CrossRefPubMedGoogle Scholar
  48. 48.
    Koes BW, van Tulder M, Lin CW, Macedo LG, McAuley J et al (2010) An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. Eur Spine J 19:2075–2094CrossRefPubMedPubMedCentralGoogle Scholar
  49. 49.
    Dagenais S, Tricco AC, Haldeman S (2010) Synthesis of recommendations for the assessment and management of low back pain from recent clinical practice guidelines. Spine J 10:514–529CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany 2017

Authors and Affiliations

  1. 1.Injury Prevention Research Office, Division of Neurosurgery, Li Ka Shing Knowledge InstituteSt. Michael’s HospitalTorontoCanada
  2. 2.Graduate Education and Research ProgramsCanadian Memorial Chiropractic CollegeTorontoCanada
  3. 3.Division of Epidemiology, Dalla Lana School of Public HealthUniversity of TorontoTorontoCanada
  4. 4.Toronto General Research Institute and Department of MedicineUniversity Health NetworkTorontoCanada
  5. 5.Faculty of Health SciencesUniversity of Ontario Institute of TechnologyOshawaCanada
  6. 6.UOIT-CMCC Centre for Disability Prevention and RehabilitationTorontoCanada
  7. 7.Division of Orthopaedic SurgeryToronto Western HospitalTorontoCanada
  8. 8.Institute for Global Health Equity and Innovation, Dalla Lana School of Public HealthUniversity of TorontoTorontoCanada
  9. 9.Centre for Global eHealth InnovationUniversity Health NetworkTorontoCanada

Personalised recommendations