t the October 2004 ASA Annual Meeting held in Las Vegas, Nevada, Reference Committee 3 considered a report dealing with the involvement of anesthesiologists in the provision of services for patients undergoing chiropractic manipulation. Testimony from the Committee on Practice Parameters and others supported the development of a practice alert. While he was ASA President, Roger W. Litwiller, M.D., established a task force to review the issue, which was chaired by John C. Rowlingson, M.D. Other members of the task force were Jeffrey L. Apfelbaum, M.D. (Committee on Ambulatory Surgical Care), Karen B. Domino, M.D. (Committee on Professional Liability), Jack L. Moore, M.D. (Committee on Standards of Care), Casey D. Blitt, M.D., (Committee on Patient Safety and Risk Management), and James P. Rathmell, M.D. (Committee on Pain Medicine).

The task force clarified that the basis for manipulation under anesthesia (MUA) is that fibrotic changes in peri- and intra-articular tissues unduly restrict motion and cause pain. Sedation is proposed as being necessary to provide analgesia, reduce muscle tone and limit “protective reflexes” so that effective manipulation of the joint/spine can be provided. Although there are specific patient selection criteria as well as documented contraindications for this procedure, these may not be strictly followed by all practitioners, raising concerns about the accuracy of identifying the most suitable patients for this therapy. Even though sedation with midazolam and propofol is often used, reports that mention the use of sufentanil and muscle relaxants suggest that there may not be universal protocols that have been rigorously studied.

The task force noted that one consequence of this practice is a significant medical liability issue when MUA is performed by a chiropractor with the anesthesiologist providing analgesia/sedation or general anesthesia. It was emphasized that the preanesthetic evaluation does not suffice for the workup that results in the selection of appropriate patients for MUA. Rather a physician actively involved in the patient’s care should make the selection choice for a specific pathologic condition. The designated “qualified assistant” and the chiropractor carry a low level of liability coverage compared to the anesthesiologist, so a “deep pockets” situation could easily arise in the event of an adverse outcome. Literature review includes reports of vascular injury, stroke, spine and disc lesions and neural injuries such as radiculopathy, myelopathy and cauda equina syndrome associated with MUA. The actual risk of these undesirable outcomes is not truly known since these events are most likely under-reported. This reality plus the fact that some descriptions of MUA include the provision of needle-based interventional therapies such as trigger-point and epidural steroid injections in the sedated patient would seem to conflict with ASA’s proud history of advocating so earnestly for patient safety. Minnesota’s 2003 Adverse Health Care Events Reporting Law lists 27 reportable events in which number “17” is listed as “patient death or serious disability due to spinal manipulative therapy.”

Although the task force recommended that a formal practice alert be promulgated, Dr. Rowlingson, as chair of the task force, and I, as Chair of the Committee on Practice Parameters, felt that this brief article accomplishes the spirit of what was requested and provides a nidus of information to the membership. Doctors beware.

James F. Arens, M.D., is Professor, Department of Anesthesiology, M.D. Anderson Cancer Center, Houston, Texas. He was ASA President in 1989..

John C. Rowlingson, M.D., is Professor of Anesthesiology and Director of Pain Medicine Services, University of Virginia School of Medicine, Charlottesville, Virginia.