Chiropractic After Surgery

Chiropractic is a well-studied and accepted treatment for people with chronic low back and neck pain. (1,2,3)  A common misconception about chiropractic is that it is inappropriate or even dangerous after spinal surgery.  Is chiropractic manipulation appropriate after surgery ?  My opinion is, yes, it most definitely is…under the right circumstances.

There are no studies or reports available to date that would suggest that chiropractic is dangerous after surgery.  The overall research on safety (4,5,6) and effectiveness of manipulation, has been well documented for decades.  Serious side-effects are very rare.

As of now (August-2011), there are no randomized controlled trials specifically researching spinal manipulation on post-surgical back pain patients.  Unfortunately, chiropractic research facilities are not funded well enough to do large research studies on post-surgical back pain.  But, there are some small studies to learn from.

A study appeared in the chiropractic profession’s leading journal, the Journal of Manipulative and Physiological Therapeutics in July 2011.  In it, 32 cases over a period of ten years were reviewed from one chiropractic practice.  All the patients had undergone a lumbar discectomy, fusion and/or laminectomy.  The average pre and post treatment pain scores were reduced 64% and no adverse events were reported. (7)

Many patients still have pain after back surgery (8) and may not be getting relief from medication or other forms of therapy.  Chiropractic may be the only option left that can help.  But, post-surgery patients are more technically difficult to treat.  If you have had surgery, you are going to need to ask some questions of your chiropractor prior to undergoing a course of treatment.  Most of these questions can be answered by the doctor or staff member over the phone.

Does the doctor have training in treating post-surgical patients ?

This is important, because some chiropractic schools and technique courses include training on handling post-surgical cases (9,10,11,12) and some do not.

My experience is that chiropractors who do not have training or experience in treating post-surgical cases, will not attempt to do so.  However, they probably will not refer you to someone who does, simply because they may not know where to send you.  So it might pay to do some calling around, or searching on the internet.

How much experience does he/she have in treating people after spinal surgery ?

You would like it to be someone who has experience.  It can be difficult for a chiropractor to get experience treating post-surgical cases.  Most patients are unaware that chiropractic can be an option for them.  Many have been warned not to see a chiropractor by their well-meaning, but misinformed surgeon.  So, there aren’t that many patients who will seek out chiropractic after surgery.

I was fortunate, because I was able to see several post-surgical cases while I was doing my clinical internship atPalmerChiropracticUniversity.  In this situation I worked under the supervision of Larry Swank DC, DABCO, FACO, who helped me a great deal.  I also learned from Howard Pettersson DC, a technique instructor and author of several chiropractic technique books.  They taught me what areas I should treat, to avoid rotation of the spine, how much force to use, what soft-tissue techniques to use, and so forth.

Once I treated a few of these cases successfully, Larry found more patients for me to work with.  By the time I graduated, I was very comfortable working on post-surgical cases and had many success stories.  (I owe a lot to Howard and Larry, and my patients do too.)

Chiropractors who have post-surgical experience usually get it by working with another doctor.  They either learn in an academic setting, or in association with a more experienced doctor.

It doesn’t take many post-surgical patients to get good at treating them, as long as the training is sound.  The doctor needs to have understanding and experience with certain considerations, or the patient may become quite sore afterward.  I have never seen a serious complication from post-surgical manipulation, but I have seen cases where pain was aggravated due to an inexperienced doctor choosing an inappropriate procedure.

Are there post-surgical cases that a chiropractor should not treat ?

This is important for a number of reasons.  First and foremost, it relates to the answers given to the questions above.  If you have training and experience in treating post-surgical cases, you will know what types of surgeries respond and what types don’t.

A chiropractor experienced with post surgical cases can look at x-rays or MRI’s and tell whether or not you are a candidate for treatment.

Spinal fusion patients will often get symptom relief from chiropractic treatments, above and below the area of fusion.  However, if the fusion itself is not aligned so that it will compliment the alignment changes the chiropractor wants to make, the patient will not respond.

This is especially true in situations where the cervical or lumbar spine is fused into a kyphosis (reversed curve).  If the cervical or lumbar spine is fused into a kyphosis, the patient will not respond to treatment.

Patients with lumbar laminectomies can get a good deal of relief from having gentle manipulation performed on the involved area.  However, some chiropractic techniques call for the doctor placing his hands on the spinous process or lamina in order to render the procedure.  Since these pieces of bone were removed in the surgery, the chiropractor can not use these techniques. The doctor will have to switch to other contact points.

One or two level cervical laminectomy patients will respond to gentle manipulation in the region and treatment designed to correct forward head posture. I don’t treat patients with three or more cervical laminectomies due to issues with spinal instability.

Discectomies don’t have any special considerations other than using lighter force techniques in the involved area.

I have never worked on a patient with an artificial disc replacement, kyphoplasty or vertebroplasty.

A study published in April 2010 in Chiropractic Osteopathy (13) reported on eight post-disc arthroplasty (disc replacement) patients that received chiropractic care.  The study reported no serious adverse events.  However, it describes short term benign side-effects (increased pain) commonly after treatment.  These patients were all treated in the side-posture position.  This position is used when the doctor wants to use a rotation movement in the procedure.  In my experience, rotation of the spine in post-operative cases should be avoided.  It will tend to aggravate symptoms, which is what happened in this study.  The JMPT study sited in the beginning of this article, did not use rotational methods. (7)

I have treated patients with healed compression fractures in the thoracic and lumbar spine and given them some short lasting relief of pain.  I use anterior spinal manipulation which helps lift the rib cage up and back.  This takes some pressure off the area, but due to the nature of compression fractures, which tip the spine forward, the relief only lasts a few days.

The kyphoplasty or vertebroplasty should stop the forward tipping and provide relief.  If it hasn’t, it is probably because the surgery has failed to stop the tipping.  Therefore, I would expect someone with a kyphoplasty or vertebroplasty to get short lived relief similar to my experience with compression fracture treatment, from anterior spinal manipulation.  The short term relief aspect should be explained to the patient prior to initiating treatment.

How soon after surgery should spinal manipulation be performed ?

I have never used spinal manipulation on a patient less than six months after surgery.  Most of the patients I treat, wander around the health care system looking for answers for years.  So, this issue usually doesn’t come up.  I don’t know of any research on this topic, but based on my experience, I think six months would be a minimum.

The patient should let their bones and other tissues heal.  It is essential to do the recommended physical therapy to strengthen up the area.  If after six months, pain is still too much and function is not enough, then spinal manipulation may be considered.

What kind of results can be expected ?

It is not unusual to have a patient start treatment, self-rating their pain in the 8 to 10 range and ending care, in the 3 to 4 range.  These results are consistent with the available research. (4)  Oswestry or Neck pain disability index scores should drop 5 points or more, in the first 30 days of care.  (Oswestry and Neck pain disability indexes are surveys the patient fills out that score how well they are functioning)

Treatment usually involves more frequent visits in the beginning and then tapering off as symptoms improve.  A full course of treatment may take 3 or 4 months.  The research says you can expect the average number of treatments to be around 14.  But it can range between 6 and 31.  My experience is about the same.

Most patients who have had surgery, did so because their spine had a serious problem.  Becoming pain free with spinal manipulation is not realistic.  But cutting the pain down and improving function is.  Supportive visits may be necessary to keep you functioning well.

In addition to spinal manipulation, chiropractors often will provide lifestyle counseling and exercise.  Changing the diet can often help the overall health of the patient.  The Mediterranean diet combined with Omega-3 fish oil and anti-oxidant supplements can help reduce inflammation in the body. (14)  Other vitamin supplements, like vitamin D, may help with pain (15) and other symptoms and a chiropractor can help in prescribing the correct dosage.  (16)

Smoking, drinking and fried food are very damaging to spinal discs. (17)  Your chiropractor may be able to guide you to the resources necessary to eliminate these from your life.

A chiropractor can also be very helpful with ergonomic issues like correct footwear, work stations, chairs, mattresses and pillows.  These issues can be critically important to post-surgical cases.  A bad mattress or chair can cause a lot of havoc.  Having someone help you get these things right, will help with sleep, rest, work and leisure activities.

How long does it take to get results ? 

After taking your history, examining you and looking at your films your chiropractor should be able to give you an idea of when you should notice improvement.  You have to be patient, it will not happen overnight.  In general, you should notice benefits within the first 30 days of care, if not sooner.  If you don’t notice improvement in the first 30 days, chiropractic probably isn’t going to work for you.

You should notice things like decreased pain, less stiffness, better sleep and increased activity.  Anyone in pain should not lose hope, keep trying.  Chiropractic care can be extremely beneficial to people after surgery.  It can help reduce pain, improve how you function, and get you back into life.

Paul Kramer DC is a graduate ofPalmerChiropracticUniversitywith post-graduate training in spinal manipulation and chronic pain treatment.  He has been practicing inMenomonee Falls,WIsince 1994.

(1)     Spine. 2003;28(14): 1490-1502 “Chronic Spinal Pain: A Randomized Clinical Trial Comparing Medication, Acupuncture and Spinal Manipulation.”  L.G. Giles and R. Muller

(2)     JMPT 2005;28:3-11  “Long-term Follow-up of a Randomized Clinical Trail Assessing the Efficacy of Medication, Acupuncture, and Spinal Manipulation for Chronic Mechanical Spinal Pain Syndromes”  Reinhold Muller and Lynton

(3)     Spine 2004; 335-356  “Efficacy of Spinal Manipulation and Mobilization for Low Back Pain and Neck Pain:  A Systematic Review and Best Evidence Synthesis.”  Bronfort, Haas, Evans, Bouter.

(4)     JMPT 2007;30:408-418  “The Benefits Outweigh the Risks for Patients Undergoing Chiropractic Care for Neck Pain: A Prospective, Multi-center, Cohort Study.”  Rubinstein, Leboeuf-Yde, Knol, Koekkoek, Pfeifle, Tulder.

(5)     Stroke 2001;32: 1054-1060  “Chiropractic Manipulation and Stroke: A Population Based Case-Control Study”  Rothwell, Bondy, Williams, Bousser

(6)     JMPT 2004; 27:197-210  “Safety of Spinal Manipulation in the Treatment of Lumbar Disk Herniations:  A Systematic Review and Risk Assessment.”

(7)     JMPT 2011 Jul-Aug; 34(6):408-12  “Chiropractic Management of Post-Surgical Lumbar Spine Pain: a Retrospective Study of 32 Cases”  Kruse, Cambron.

(8)     SPINE 2001;26:2521-2532 “Lumbar Fusion Versus Non-Surgical Treatment fo Chronic Low Back Pain, A Multi-center Randomized Controlled Trial”  Fritzell P, Olle Hagg, Wessburg, Nordawall

(9)     Barge, Fred “Scoliosis vol. 3”  Chiropractic Technic, 1981 (and corresponding coursework)

(10)  Pierce, WV  Results.Dravosburg,PA: X-cellent X-ray Co., 1986. (and corresponding coursework )

(11)  Ward,LowellE. “The Dynamics of Spinal Stress”  SSS Press 1980 ( and corresponding coursework )

(12)  Palmer Chiropractic University Technique Department and Clinics

(13)  Chiropractic and Osteopathy 2010 Apr 21;18:7  “Chiropractic Management of Patients Post-Disc Arthroplasty: Eight Case Reports.”

(14)   Arthritis and Rheumatism vol.46, Issue 6, 2002 p.1544-1553  “Pathologic Indicators of Degradation and Inflammation in Human Osteoarthritic Cartilage are Abrogated by Exposure to Omega-3 Fatty Acids”

(15)   J Am Board Fam Med 2009;22:69-71  “Improvement of Chronic Back Pain or Failed Back Surgery with Vitamin D Repletion: A Case Series”

(16)   Integrative Medicine Vol. 9, No. 1, Feb/Mar 2010  “What Have We Learned About Vitamin D Dosing ?”

Neurosurg Focus 13 (2): August, 2002  “Pathophysiology of Lumbar Disc Degeneration: A Review of the Literature.”