Trager Robert J, Baumann Anthony N, Perez Jaime A, Dusek Jeffery A, Perfecto Romeo-Paolo T, Goertz Christine M
Connor Whole Health, University Hospitals Cleveland Medical Center, Cleveland, Ohio, United States of America.
Department of Family Medicine and Community Health, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States of America.
PLoS One. 2024 Mar 11;19(3):e0299159. doi: 10.1371/journal.pone.0299159. eCollection 2024.
Cauda equina syndrome (CES) is a lumbosacral surgical emergency that has been associated with chiropractic spinal manipulation (CSM) in case reports. However, identifying if there is a potential causal effect is complicated by the heightened incidence of CES among those with low back pain (LBP). The study hypothesis was that there would be no increase in the risk of CES in adults with LBP following CSM compared to a propensity-matched cohort following physical therapy (PT) evaluation without spinal manipulation over a three-month follow-up period.
A query of a United States network (TriNetX, Inc.) was conducted, searching health records of more than 107 million patients attending academic health centers, yielding data ranging from 20 years prior to the search date (July 30, 2023). Patients aged 18 or older with LBP were included, excluding those with pre-existing CES, incontinence, or serious pathology that may cause CES. Patients were divided into two cohorts: (1) LBP patients receiving CSM or (2) LBP patients receiving PT evaluation without spinal manipulation. Propensity score matching controlled for confounding variables associated with CES.
67,220 patients per cohort (mean age 51 years) remained after propensity matching. CES incidence was 0.07% (95% confidence intervals [CI]: 0.05-0.09%) in the CSM cohort compared to 0.11% (95% CI: 0.09-0.14%) in the PT evaluation cohort, yielding a risk ratio and 95% CI of 0.60 (0.42-0.86; p = .0052). Both cohorts showed a higher rate of CES during the first two weeks of follow-up.
These findings suggest that CSM is not a risk factor for CES. Considering prior epidemiologic evidence, patients with LBP may have an elevated risk of CES independent of treatment. These findings warrant further corroboration. In the meantime, clinicians should be vigilant to identify LBP patients with CES and promptly refer them for surgical evaluation.
马尾综合征（CES）是一种腰骶部外科急症，在病例报告中已发现其与整脊脊柱推拿（CSM）有关。然而，由于腰痛（LBP）患者中CES的发病率较高，因此难以确定是否存在潜在的因果关系。研究假设是，与在三个月随访期内接受物理治疗（PT）评估但未进行脊柱推拿的倾向匹配队列相比，接受CSM治疗的LBP成年患者发生CES的风险不会增加。
对美国一个网络（TriNetX公司）进行查询，搜索在学术健康中心就诊的超过1.07亿患者的健康记录，数据范围为搜索日期（2023年7月30日）之前的20年。纳入年龄在18岁及以上的LBP患者，排除既往有CES、尿失禁或可能导致CES的严重病理情况的患者。患者分为两个队列：（1）接受CSM的LBP患者；（2）接受PT评估但未进行脊柱推拿的LBP患者。倾向评分匹配控制了与CES相关的混杂变量。
倾向匹配后，每个队列有67220名患者（平均年龄51岁）。CSM队列中CES的发病率为0.07%（95%置信区间[CI]：0.05 - 0.09%），而PT评估队列中为0.11%（95%CI：0.09 - 0.14%），风险比和95%CI为0.60（0.42 - 0.86；p = 0.0052）。两个队列在随访的前两周内CES发生率均较高。
这些发现表明CSM不是CES的危险因素。考虑到先前的流行病学证据，LBP患者发生CES的风险可能独立于治疗而升高。这些发现需要进一步证实。同时，临床医生应警惕识别患有CES的LBP患者，并及时将他们转诊进行手术评估。
